記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: We sought to define the association of the systemic immune inflammation index (SII) with prognosis and adjuvant therapy benefit among patients undergoing resection of extrahepatic cholangiocarcinoma (eCCA). METHODS: The impact of SII on overall (OS) and recurrence-free survival (RFS) following resection of eCCA was assessed and compared with other inflammatory markers and traditional prognostic factors. Propensity score matching (PSM) was used to determine the impact of adjuvant therapy (AT) on OS and RFS relative to low versus high SII. RESULTS: Patients with high versus low SII had worse 5-year OS (15.9% vs. 27.9%) and RFS (12.4% vs. 20.9%) (both p < 0.01). On multivariate analysis, high SII remained associated with worse OS (HR = 1.50, 95% CI 1.20-1.87) and RFS (HR = 1.46, 95% CI 1.18-1.81). Patients with T1/2 disease and a high-SII had worse 5-year OS versus individuals with T3/4 disease and low-SII (5-year OS: T1/2 & low-SII 35.6%, T1/2 & high-SII 16.4%, T3/4 & low-SII 22.1%, T3/4 & high-SII 15.6%, p < 0.01). Similarly, 5-year OS was comparable among individuals with N0 and high-SII versus N1 and low-SII (5-year OS: N0 & high-SII 23.2%, N1 and low-SII 19.8%, p = 0.95). On PSM, AT improved OS and RFS among patients with high SII (5-year OS: 22.5% vs. 12.3%, p < 0.01, 5-year RFS: 19.0% vs. 12.5%; p = 0.01) but not individuals with low SII (5-year OS: 22.9% vs. 26.9%; p = 0.98, 5-year RFS: 18.5% vs. 19.9%; p = 0.94). CONCLUSIONS: SII was independently associated with postoperative OS and RFS following curative-intent resection of eCCA. High SII up-staged patients relative T- and N-categories and identified patients with high SII as the most likely to benefit from AT.

DOI： 10.1245/s10434-022-12058-2

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Prognostic stratification of patients with colorectal cancer liver metastasis based solely on tumor-related factors has only moderate discriminatory ability. We hypothesized that the inclusion of nontumor related factors can improve prediction of long-term prognosis of patients with colorectal cancer liver metastasis. METHODS: Nontumor related laboratory markers were assessed utilizing a training cohort from 2 U.S. institutions (n = 1,205). Factors independently associated with prognosis were used to develop a nontumor related prognostic score. The discriminatory ability, assessed by Harrell's C-statistics (C-index) and net reclassification improvement, was validated and compared with 3 commonly used tumor-related clinical risk scores: Fong clinical risk scores, m-clinical risk scores, and Genetic and Morphological Evaluation (GAME) score in an external validation cohort from 5 Asian (n = 1,307) and 3 European (n = 1,058) institutions. The discriminatory ability of nontumor related prognostic score combined with each of these 3 tumor-related prognostic scores was also estimated. RESULTS: Alkaline phosphatase (hazard ratio 1.43; 95% confidence interval, 1.11-1.84), albumin (hazard ratio 0.71; 95% confidence interval, 0.57-0.89), and mean corpuscular volume (hazard ratio 19.0, per log unit; 95% confidence interval, 4.79-75.0) were each independently associated with increased risk of death after resection of colorectal cancer liver metastasis (all P < .05). In turn, alkaline phosphatase, albumin, and mean corpuscular volume were combined to form a nontumor related prognostic score (2.942 × mean corpuscular volume + 0.399 × alkaline phosphatase-0.339 × albumin-12) × 10 (median, 16; range, 1-30). The nontumor related prognostic score had good-to-modest discriminatory ability in the external cohort (C-index = 0.58), which was comparable to the 3 established tumor-related prognostic scores (C-index: Fong clinical risk scores, 0.53, m-clinical risk scores, 0.55, GAME, 0.58). The addition of the nontumor related prognostic score to the tumor-related prognostic scores enhanced the discriminatory ability in the entire study cohort (C-index: nontumor related score+Fong, 0.60, nontumor related score+m-clinical risk scores, 0.61, nontumor related score+GAME, 0.64), as well reclassification improvement (42.5, 42.7%, and 21.2%, respectively). CONCLUSION: Nontumor related prognostic information may help improve the prognostic stratification of patients after resection of colorectal cancer liver metastasis. The nontumor related prognostic score may be combined with tumor-related prognostic tools to enhance prognostic stratification of patients with colorectal cancer liver metastasis.

DOI： 10.1016/j.surg.2022.01.030

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Pancreatectomy is the main curative therapeutic option for pancreatic neuroendocrine tumors (pNETs). Given the indolent behavior of pNETs and the relatively limited lifetime of elderly patients, the impact of primary site surgery (PSS) of pNETs on long-term outcomes among older patients has been a topic of debate. METHODS: Patients aged 70 or older with pNETs were identified in the Surveillance, Epidemiology and the End Results (SEER) database from 1998 to 2016. Propensity score matching was used to compare overall (OS) and cancer-specific survival (CSS) of patients who did versus did not undergo PSS. RESULTS: Among 2,319 elderly patients with pNETs, 942 patients (40.6%) underwent PSS, while 1,377 (59.4%) did not undergo PSS (non-PSS: NPSS). After propensity score matching (n = 433 in each group), PSS group had improved survival compared with the NPSS group (5-year OS: 53.4% vs. 37.3%; 5-year CSS: 77.2% vs. 58.1%, both p < 0.001). In contrast, subgroup analysis of individuals aged ≥ 80 revealed no difference in 5-year CSS (PSS: 69.2% vs. NPSS: 67.4%, p = 0.27). A subgroup analysis among patients who had small (≤ 2 cm) non-functional (NF) pNETs noted comparable long-term outcomes among patients who underwent PSS versus NPSS patients (5-year OS: 73.1% vs. 66.5%, p = 0.19; 5-year CSS: 98.5% vs. 95.2%, p = 0.14). CONCLUSIONS: Approximately 2 in 5 elderly patients with pNETs underwent PSS. While PSS was generally associated with prolonged OS and CSS among older patients, PSS was not associated with improved CSS among a subset of patients aged 80 or older, as well as among patients age ≥ 70 years with NF-pNET less than 2 cm.

DOI： 10.1007/s00268-021-06281-3

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Although multidisciplinary treatments including the use of adjuvant therapy (AT) have been adopted for biliary tract cancers, patients with distal cholangiocarcinoma (DCC) can still experience recurrence. We sought to characterize the incidence and predictors of early recurrence (ER) that occurred within 12 months following surgery for DCC. PATIENTS AND METHODS: Patients who underwent resection for DCC between 2000 and 2015 were identified from the US multi-institutional database. Cox regression analysis was used to identify clinicopathological factors to develop an ER risk score, and the predictive model was validated in an external dataset. RESULTS: Among 245 patients included in the analysis, 67 patients (27.3%) developed ER. No difference was noted in ER rates between patients who did and did not receive AT (28.7% vs. 25.0%, p = 0.55). Multivariable analysis revealed that neutrophil-to-lymphocyte ratio (NLR), peak total bilirubin (T-Bil), major vascular resection (MVR), lymphovascular invasion, and R1 surgical margin status were associated with a higher ER risk. A DIstal Cholangiocarcinoma Early Recurrence Score was developed according to each factor available prior to surgery [NLR > 9.0 (2 points); peak T-bil > 1.5 mg/dL (1 points); MVR (2 points)]. Cumulative ER rates incrementally increased among patients who were low (0 points; 10.6%), intermediate (1-2 points; 26.8%), or high (3-5 points; 57.6%) risk (p < 0.001) in the training dataset, as well as in the validation dataset [low (0 points); 3.4%, intermediate (1-2 points); 32.7%, or high risk (3-5 points); 55.6% (p < 0.001)]. CONCLUSIONS: Among patients undergoing resection for DCC, 1 in 4 patients experienced an ER. Alternative treatment strategies such as neoadjuvant chemotherapy may be considered especially among individuals deemed to be at high risk for ER.

DOI： 10.1245/s10434-021-09811-4

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記述言語：英語   掲載種別：研究論文（学術雑誌）   出版者・発行元：Springer Science and Business Media Deutschland GmbH  

Introduction: While tumor burden (TB) has been associated with outcomes among patients with hepatocellular carcinoma, the role of overall TB in intrahepatic cholangiocarcinoma (ICC) remains poorly defined. Methods: Patients undergoing curative-intent resection of ICC between 2000 and 2017 were identified from a multi-institutional database. The impact of TB on overall (OS) and disease-free survival (DFS) was evaluated in the multi-institutional database and validated externally. Results: Among 1101 patients who underwent curative-intent resection of ICC, 624 (56.7%) had low TB, 346 (31.4%) medium TB, and 131 (11.9%) high TB. OS incrementally worsened with higher TB (5-year OS
low TB: 48.3% vs medium TB: 29.8% vs high TB: 17.3%, p &lt
0.001). Similarly, patients with low TB had better DFS compared with medium and high TB patients (5-year DFS: 38.3% vs 18.7% vs 6.9%, p &lt
0.001). On multivariable analysis, TB was independently associated with OS (medium TB: HR = 1.40, 95% CI 1.14–1.71
high TB: HR = 1.89, 95% CI 1.46–2.45) and DFS (medium TB, HR = 1.61, 95% CI 1.33–1.96
high TB: HR = 2.03, 95% CI 1.56–2.64). Survival analysis revealed an excellent prognostic discrimination using the TB among the external validation cohort (3-year OS
low TB: 44.8%, medium TB: 29.3%
high TB: 23.3%, p = 0.03
3-year DFS: low TB: 32.7%, medium TB: 10.7%
high TB: 0%, p &lt
0.001). While neoadjuvant chemotherapy was not associated with survival across the TB groups, receipt of adjuvant chemotherapy was associated with increased survival among patients with high TB (5-year OS: 24.4% vs 13.4%, p = 0.02). Conclusion: Overall TB dictated prognosis among patients with resectable ICC. TB may be used as a tool to help guide post-resection treatment strategies.

DOI： 10.1245/s10434-020-09393-7

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

PURPOSE: The objective of the current study was to assess the therapeutic benefit of lymphadenectomy according to the extent of lymphadenectomy. METHODS: Patients undergoing colectomy for right-sided colon cancer were identified. Distribution of lymph node metastases (DLNM) of 1, 2 and 3 were defined as lymph node metastasis (LNM) in the pericolic nodes, the intermediate nodes and the front of the SMV near the origin of the major artery, respectively. The therapeutic index (TI) was calculated based on the frequency of LNM and the 5 year overall survival (OS) rate of patients with LNM. RESULTS: Among 344 patients who met the inclusion criteria, roughly half had LNM (n = 150, 43.7%). While 107 (31.1%) and 30 (8.7%) patients had DLNM1 and DLNM2, respectively, only 13 patients (3.8%) were defined as DLNM3. However, there was no significant difference in 5 year OS by DLNM (DLNM1 71.1%, DLNM2 78.7%, DLNM3 50.4%, p = 0.61). Overall, the TI of lymphadenectomy for D3 area was approximately 1/10 of the TI for D1 (1.9 vs.22.1), given the low frequency of LNM (3.8%) and poor 5 year OS of patients with LNM (50.4%). This trend was consistent irrespective of primary tumor locations. CONCLUSION: The survival benefit from central lymphadenectomy namely D3 was low among patients with right-sided colon cancers.

DOI： 10.1007/s00595-020-02084-6

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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.

DOI： 10.1007/s11605-019-04504-6

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

DOI： 10.1245/s10434-020-09194-y

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The optimal time interval to define early recurrence (ER) among patients who underwent resection of gallbladder cancer (GBC) is not well defined. We sought to develop and validate a novel GBC recurrence risk (GBRR) score to predict ER among patients undergoing resection for GBC. PATIENTS AND METHODS: Patients who underwent curative-intent resection for GBC between 2000 and 2018 were identified from the US Extrahepatic Biliary Malignancy Consortium database. A minimum p value approach in the log-rank test was used to define the optimal cutoff for ER. A risk stratification model was developed to predict ER based on relevant clinicopathological factors and was externally validated. RESULTS: Among 309 patients, 103 patients (33.3%) had a recurrence at a median follow-up period of 15.1 months. The optimal cutoff for ER was defined at 12 months (p = 3.04 × 10-18). On multivariable analysis, T3/T4 disease (HR: 2.80; 95% CI 1.58-5.11) and poor tumor differentiation (HR: 1.91; 95% CI 1.11-3.25) were associated with greater hazards of ER. The GBRR score was developed using β-coefficients of variables in the final model, and patients were classified into three distinct groups relative to the risk for ER (12-month RFS; low risk: 88.4%, intermediate risk: 77.9%, high risk: 37.0%, p < 0.001). The external validation demonstrated good model generalizability with good calibration (n = 102: 12-month RFS; low risk: 94.2%, intermediate risk: 59.8%, high risk: 42.0%, p < 0.001). The GBRR score is available online at https://ktsahara.shinyapps.io/GBC_earlyrec/ . CONCLUSIONS: A novel online calculator was developed to help clinicians predict the probability of ER after curative-intent resection for GBC. The proposed web-based tool may help in the optimization of surveillance intervals and the counselling of patients about their prognosis.

DOI： 10.1245/s10434-020-09108-y

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

DOI： 10.1245/s10434-020-09111-3

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The adoption of spleen-preserving distal pancreatectomy (SPDP) for malignant disease such as pancreatic neuroendocrine tumors (pNETs) has been controversial. The objective of the current study was to assess the impact of SPDP on outcomes of patients with pNETs. METHODS: Patients undergoing a distal pancreatectomy for pNET between 2002 and 2016 were identified in the US Neuroendocrine Tumor Study Group database. Propensity score matching (PSM) was used to compare short- and long-term outcomes of patients undergoing SPDP versus distal pancreatectomy with splenectomy (DPS). RESULTS: Among 621 patients, 103 patients (16.6%) underwent an SPDP. Patients who underwent SPDP were more likely to have lower BMI (median, 27.5 [IQR 24.0-31.2] vs. 28.7 [IQR 25.7-33.6]; p = 0.005) and have undergone minimally invasive surgery (n = 56, 54.4% vs. n = 185, 35.7%; p < 0.001). After PSM, while the median total number of lymph nodes examined among patients who underwent an SPDP was lower compared with DPS (3 [IQR 1-8] vs. 9 [5-13]; p < 0.001), 5-year overall survival (OS) and recurrence-free survival (RFS) were comparable (OS: 96.8 vs. 92.0%, log-rank p = 0.21, RFS: 91.1 vs. 84.7%, log-rank p = 0.93). In addition, patients undergoing SPDP had less intraoperative blood loss (median, 100 mL [IQR 10-250] vs. 150 mL [IQR 100-400]; p = 0.001), lower incidence of serious complications (n = 13, 12.8% vs. n = 28, 27.5%; p = 0.014), and shorter length of stay (median: 5 days [IQR 4-7] vs. 6 days [IQR 5-13]; p = 0.049) compared with patients undergoing DPS. CONCLUSION: SPDP for pNET was associated with acceptable perioperative and long-term outcomes that were comparable to DPS. SPDP should be considered for patients with pNET.

DOI： 10.1159/000506399

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: While tumor burden (TB) has been associated with outcomes among patients with hepatocellular carcinoma, the role of overall TB in intrahepatic cholangiocarcinoma (ICC) remains poorly defined. METHODS: Patients undergoing curative-intent resection of ICC between 2000 and 2017 were identified from a multi-institutional database. The impact of TB on overall (OS) and disease-free survival (DFS) was evaluated in the multi-institutional database and validated externally. RESULTS: Among 1101 patients who underwent curative-intent resection of ICC, 624 (56.7%) had low TB, 346 (31.4%) medium TB, and 131 (11.9%) high TB. OS incrementally worsened with higher TB (5-year OS; low TB: 48.3% vs medium TB: 29.8% vs high TB: 17.3%, p < 0.001). Similarly, patients with low TB had better DFS compared with medium and high TB patients (5-year DFS: 38.3% vs 18.7% vs 6.9%, p < 0.001). On multivariable analysis, TB was independently associated with OS (medium TB: HR = 1.40, 95% CI 1.14-1.71; high TB: HR = 1.89, 95% CI 1.46-2.45) and DFS (medium TB, HR = 1.61, 95% CI 1.33-1.96; high TB: HR = 2.03, 95% CI 1.56-2.64). Survival analysis revealed an excellent prognostic discrimination using the TB among the external validation cohort (3-year OS; low TB: 44.8%, medium TB: 29.3%; high TB: 23.3%, p = 0.03; 3-year DFS: low TB: 32.7%, medium TB: 10.7%; high TB: 0%, p < 0.001). While neoadjuvant chemotherapy was not associated with survival across the TB groups, receipt of adjuvant chemotherapy was associated with increased survival among patients with high TB (5-year OS: 24.4% vs 13.4%, p = 0.02). CONCLUSION: Overall TB dictated prognosis among patients with resectable ICC. TB may be used as a tool to help guide post-resection treatment strategies.

DOI： 10.1245/s10434-020-09393-7

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記述言語：英語  

In the original article, Ryan C. Fields' middle initial is missing.

DOI： 10.1245/s10434-020-08397-7

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The objective of this study was to examine whether the systemic immune inflammation index (SII) was associated with prognosis among patients following resection of intrahepatic cholangiocarcinoma (ICC). METHODS: The impact of SII on overall (OS) and cancer-specific survival (CSS) following resection of ICC was assessed. The performance of the final multivariable models that incorporated inflammatory markers (i.e. neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR] and SII [platelets∗NLR]) was assessed using the Harrell's concordance index. RESULTS: Patients with high SII had worse 5-year OS (37.7% vs 46.6%, p < 0.001) and CSS (46.1% vs 50.1%, p < 0.001) compared with patients with low SII. An elevated SII (HR = 1.70, 95% CI 1.23-2.34) and NLR (HR = 1.58, 95% CI 1.10-2.27) independently predicted worse OS, whereas high PLR (HR = 1.17, 95% CI 0.85-1.60) was no longer associated with prognosis. Only SII remained an independent predictor of CSS (HR = 1.55, 95% CI 1.09-2.21). The SII multivariable model outperformed models that incorporated PLR and NLR relative to OS (c-index; 0.696 vs 0.689 vs 0.692) and CSS (c-index; 0.697 vs 0.689 vs 0.690). CONCLUSION: SII independently predicted OS and CSS among patients with resectable ICC. SII may be a better predictor of outcomes compared with other markers of inflammatory response among patients with resectable ICC.

DOI： 10.1016/j.hpb.2020.03.011

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記述言語：英語  

In the original version of this abstract, the visual abstract is missing. The original abstract has been updated.

DOI： 10.1245/s10434-020-09315-7

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: The value of routine ICU admission after elective surgery has been debated due to the lack of robust evidence supporting its benefit, as well as the increased incurred costs. We sought to analyze outcomes of patients undergoing hepatectomy who were routinely admitted to the intensive care unit (ICU) compared with surgical ward admission. METHODS: Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database from 2010 to 2016. Routine postoperative ICU admission was defined as ICU admission for ≤ 24 h on postoperative day 0. Potential association between routine ICU admission with extended length-of-stay (LOS), failure-to-rescue, and total inpatient costs was analyzed. RESULTS: In total 7970 patients underwent hepatectomy; 37.7% (n = 3001) had routine ICU admission and 62.3% (n = 4969) surgical ward admission. Among the 3001 patients who had routine ICU admission, 1137 (37.9%) had a major and 1864 (62.1%) had a minor hepatectomy. Routine ICU admission was not associated with lower failure-to-rescue (routine ICU 4.9% vs. ward 1.8%; p < 0.001). Patients routinely admitted to the ICU had longer median LOS (routine ICU 7 days, IQR 5-15 days vs. ward 5 days, IQR 4-7 days; p < 0.001). Median payments were higher for routine ICU admission than for surgical ward admission ($50,501, IQR $34,270-$80,459 vs. $39,774, IQR $28,555-$58,270, respectively). CONCLUSION: Routine ICU admission was associated with longer LOS and higher hospital payments, yet did not translate into lower failure-to-rescue among patients undergoing hepatectomy.

DOI： 10.1007/s11605-019-04408-5

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: We sought to assess the effect of nurse-to-patient ratio on outcomes with a focus on defining whether nurse-to-patient ratio altered outcomes relative to pancreaticoduodenectomy (PD) surgeon specific volume. METHODS: Medicare SAFs from 2013-2015 were used to identify patients who underwent PD. Nurse-to-patient ratio, PD specific surgeon volume were stratified. Association of factors associated with short term outcomes was evaluated. RESULTS: Overall, 6668 patients (median age 73, IQR 68-77; 52.8% male) were identified. The median annual PD volume of surgeons in the highest volume tier was 24 (IQR 21-29), whereas surgeons in the lowest tier performed 2 PDs annually (IQR 1-3) (p < 0.001). Compared with hospitals that had the highest nurse-to-patient ratio tier, patients at hospitals with the lowest nurse-to-patient ratio tier were 26% more likely to have a complication (OR 1.26, 95% CI 1.02-1.55). Additionally, patients of surgeons in the lowest tier had 43% greater odds of suffering a complication compared to patients of surgeons in the highest tier (OR 1.43, 95% CI 1.11-1.84). However, patients who underwent a PD by a surgeon within the lowest tier had similar odds of a complication irrespective of nurse-to-patient ratio (OR 1.34, 95% CI 0.97-1.86). CONCLUSION: Compared with patients who underwent an operation by a surgeon in highest PD volume tier, patients treated by surgeons in the lowest tier had higher odds of post-operative complications which was not mitigated by a higher nurse-to-patient ratio.

DOI： 10.1007/s11605-019-04449-w

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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.

DOI： 10.1007/s11605-019-04430-7

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND/PURPOSE: The purpose of the present study was to assess long-term outcomes following liver resection for colorectal liver metastases (CRLM) with concurrent extrahepatic disease and to identify the preoperative prognostic factors for selection of operative candidates. METHODS: In this retrospective, multi-institutional study, 3820 patients diagnosed with CRLM during 2005-2007 were identified using nationwide survey data. Data of identified patients with concurrent extrahepatic lesions were analyzed to estimate the impact of liver resection on overall survival (OS) and to identify preoperative, prognostic indicators. RESULTS: Three- and 5-year OS rates after liver resection in 251 CRLM patients with extrahepatic disease (lung, n = 116; lymph node, n = 51; peritoneal, n = 37; multiple sites, n = 23) were 50.2% and 32.0%, respectively. Multivariate analysis revealed that a primary tumor in the right colon, lymph node metastasis from the primary tumor, serum carbohydrate antigen (CA) 19-9 level >37 UI/mL, the site of extrahepatic disease, and residual liver tumor after hepatectomy were associated with higher mortality. We proposed a preoperative risk scoring system based on these factors that adequately discriminated 5-year OS after liver resection in training and validation datasets. CONCLUSIONS: Performing R0 liver resection for colorectal liver metastases with treatable extrahepatic disease may prolong survival. Our proposed scoring system may help select appropriate candidates for liver resection.

DOI： 10.1002/jhbp.810

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: Safety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined. METHODS: Discharge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6-33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined. RESULTS: Nearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001). CONCLUSION: Perioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care.

DOI： 10.1007/s11605-019-04428-1

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

OBJECTIVE: The objective of the current study was to define surgical outcomes after resection of multinodular hepatocellular carcinoma (HCC) beyond the Milan criteria, and develop a prediction tool to identify which patients likely benefit the most from resection. BACKGROUND: Liver resection for multinodular HCC, especially beyond the Milan criteria, remains controversial. Rigorous selection of the best candidates for resection is essential to achieve optimal outcomes after liver resection of advanced tumors. METHODS: Patients who underwent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. Patients were categorized according to Milan criteria status. Pre- and postoperative overall survival (OS) prediction models that included HCC tumor burden score (TBS) among patients with multinodular HCC beyond Milan criteria were developed and validated. RESULTS: Among 1037 patients who underwent resection for HCC, 164 (15.8%) had multinodular HCC beyond the Milan criteria. Among patients with multinodular HCC, 25 (15.2%) patients experienced a serious complication and 90-day mortality was 3.7% (n = 6). Five-year OS after resection of multinodular HCC beyond Milan criteria was 52.8%. A preoperative TBS-based model (5-year OS: low-risk, 73.7% vs intermediate-risk, 45.1% vs high-risk, 13.1%), and postoperative TBS-based model (5-year OS: low-risk, 80.1% vs intermediate-risk, 37.2% vs high-risk, not reached) categorized patients into distinct prognostic groups relative to long-term prognosis (both P < 0.001). Pre- and postoperative models could accurately stratify OS in an external validation cohort (5-year OS; low vs medium vs high risk; pre: 66.3% vs 25.2% vs not reached, P = 0.012; post: 61.4% vs 42.5% vs not reached, P = 0.045) Predictive accuracy of the pre- and postoperative models was good in the training (c-index; pre: 0.68; post: 0.71), internal validation (n = 2000 resamples) (c-index, pre: 0.70; post: 0.72) and external validation (c-index, pre: 0.67; post 0.68) datasets. TBS alone could stratify patients relative to 5-year OS after resection of multinodular HCC beyond Milan criteria (c-index: 0.65; 5-year OS; low TBS: 70.2% vs medium TBS: 54.7% vs high TBS: 16.7%; P < 0.001). The vast majority of patients with low and intermediate TBS were deemed low or medium risk based on both the preoperative (98.4%) and postoperative risk scores (95.3%). CONCLUSION: Prognosis of patients with multinodular HCC was largely dependent on overall tumor burden. Liver resection should be considered among patients with multinodular HCC beyond the Milan criteria who have a low- or intermediate-TBS.

DOI： 10.1097/SLA.0000000000004346

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: The USA has one of the largest known income-based health disparities, with low-income adults being up to five times more likely to report being in poor health. We evaluated the association of hospital zip-code-based distressed communities index (DCI) with post-surgical outcomes following hepatopancreatobiliary (HPB) surgery. METHODS: Adults undergoing HPB surgery were identified in the National Inpatient Sample. The association between hospital socioeconomic distress and outcomes including complications, mortality, failure to rescue (FTR), and never events were compared between high-distress facilities (HDF) and low-distress facilities (LDF). RESULTS: A total of 11,119 (37.8%) patients underwent an operation at an HDF. Patients treated at HDF were younger (18-39 years, HDF: n = 1261, 11.3% vs. LDF: n = 966, 9.0%; p < 0.001), Black/Hispanic (HDF: n = 2060, 18.5% vs. LDF: n = 1440, 11.4%; p < 0.001) and in the lowest income quartile (HDF: n = 2825, 25.4% vs. LDF: n = 1116, 10.8%; p < 0.001). While complications were comparable at HDF versus LDF (HDF: n = 2483, 22.3% vs. LDF: n = 2370, 22.0%; p = 0.28), patients treated at HDF had higher odds of in-hospital mortality (OR, 1.31; 95% CI, 1.07-1.59), FTR (OR, 1.24; 95% CI, 1.02-1.52), and a never event (OR, 1.76; 95% CI, 1.29-2.39; all p < 0.001). Hospitals having advanced internal medicine services had reduced odds of mortality (OR, 0.61; 95% CI, 0.47-0.80) whereas high nurse-to-patient ratio was associated with reduced odds of a complication (OR, 0.89; 95% CI, 0.81-0.98). CONCLUSION: Approximately 40% of patients were admitted to HDF. These patients were more likely to be Black/Hispanic and underinsured. Perioperative outcomes were worse at HDF following HPB surgery.

DOI： 10.1007/s11605-019-04401-y

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

Importance: Although surgery offers the best chance of a potential cure for patients with localized, resectable intrahepatic cholangiocarcinoma (ICC), prognosis of patients remains dismal largely because of a high incidence of recurrence. Objective: To predict very early recurrence (VER) (ie, recurrence within 6 months after surgery) following resection for ICC in the pre- and postoperative setting. Design, Setting, and Participants: Patients who underwent curative-intent resection for ICC between May 1990 and July 2016 were identified from an international multi-institutional database. The study was conducted at The Ohio State University in collaboration with all other participating institutions. The data were analyzed in December 2019. Main Outcomes and Measures: Two logistic regression models were constructed to predict VER based on pre- and postoperative variables. The final models were used to develop an online calculator to predict VER and the tool was internally and externally validated. Results: Among 880 patients (median age, 59 years [interquartile range, 51-68 years]; 388 women [44.1%]; 428 [50.2%] white; 377 [44.3%] Asian; 27 [3.2%] black]), 196 (22.3%) developed VER. The 5-year overall survival among patients with and without VER was 8.9% vs 49.8%, respectively (P < .001). A preoperative model was able to stratify patients relative to the risk for VER: low risk (6-month recurrence-free survival [RFS], 87.7%), intermediate risk (6-month RFS, 72.3%), and high risk (6-month RFS, 49.5%) (log-rank P < .001). The postoperative model similarly identified discrete cohorts of patients based on probability for VER: low risk (6-month RFS, 90.0%), intermediate risk (6-month RFS, 73.1%), and high risk (6-month RFS, 48.5%) (log-rank, P < .001). The calibration and predictive accuracy of the pre- and postoperative models were good in the training (C index: preoperative, 0.710; postoperative, 0.722) as well as the internal (C index: preoperative, 0.715; postoperative, 0.728; bootstrapping resamples, n = 5000) and external (C index: postoperative, 0.672) validation data sets. Conclusion and Relevance: An easy-to-use online calculator was developed to help clinicians predict the chance of VER after curative-intent resection for ICC. The tool performed well on internal and external validation. This tool may help clinicians in the preoperative selection of patients for neoadjuvant therapy as well as during the postoperative period to inform surveillance strategies.

DOI： 10.1001/jamasurg.2020.1973

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Although KRAS mutation status is known to affect the prognosis of patients with colorectal liver metastasis, the hierarchical association between other prognostic factors and KRAS status is not fully understood. METHODS: Patients who underwent a hepatectomy for colorectal liver metastasis were identified in a multi-institutional international database. A classification and regression tree model was constructed to investigate the hierarchical association between prognostic factors and overall survival relative to KRAS status. RESULTS: Among 1,123 patients, 29.9% (n = 336) had a KRAS mutation. Among wtKRAS patients, the classification and regression tree model identified presence of metastatic lymph nodes as the most important prognostic factor, whereas among mtKRAS patients, carcinoembryonic antigen level was identified as the most important prognostic factor. Among patients with wtKRAS, the highest 5-year overall survival (68.5%) was noted among patients with node negative primary colorectal cancer, solitary colorectal liver metastases, size <4.3 cm. In contrast, among patients with mtKRAS colorectal liver metastases, the highest 5-year overall survival (57.5%) was observed among patients with carcinoembryonic antigen <6 mg/mL. The classification and regression tree model had higher prognostic accuracy than the Fong score (wtKRAS [Akaike's Information Criterion]: classification and regression tree model 3334 vs Fong score 3341; mtKRAS [Akaike's Information Criterion]: classification and regression tree model 1356 vs Fong score 1396). CONCLUSION: Machine learning methodology outperformed the traditional Fong clinical risk score and identified different factors, based on KRAS mutational status, as predictors of long-term prognosis.

DOI： 10.1016/j.surg.2020.05.019

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Patients with hepatocellular carcinoma (HCC) and portal vein hypertension assessed with platelet count (PVH-PLT; platelet count < 100,000/mL) are often denied surgery even when the disease is technically resectable. Short- and long-term outcomes of patients undergoing minimally invasive surgery (MIS) versus open resection for HCC and PVH-PLT were compared. METHODS: Propensity score matching (PSM) was used to balance the clinicopathological differences between MIS and non-MIS patents. Univariate comparison and standard survival analyses were utilized. RESULTS: Among 1974 patients who underwent surgery for HCC, 13% had a PVH-PLT and 33% underwent MIS. After 1:1 PSM, 407 MIS and 407 non-MIS patients were analyzed. Incidence of complications and length-of-stay (LoS) were higher among non-MIS versus MIS patients (both p ≤ 0.002). After PSM, among 178 PVH-PLT patients (89 MIS and 89 non-MIS), patients who underwent a non-MIS approach had longer LoS (> 7 days; non-MIS: 55% vs. MIS: 29%), as well as higher morbidity (non-MIS: 42% vs. MIS: 29%) [p <0.001]. In contrast, long-term oncological outcomes were comparable, including 3-year overall survival (non-MIS: 66.2% vs. MIS: 72.9%) and disease-free survival (non-MIS: 47.3% vs. MIS: 50.2%) [both p ≥ 0.08]. CONCLUSION: An MIS approach was associated with improved short-term outcomes, but similar long-term outcomes, compared with open liver resection for patients with HCC and PVH-PLT. An MIS approach for liver resection should be considered for patients with HCC, even those individuals with PVH-PLT.

DOI： 10.1245/s10434-020-08444-3

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) Hospital Compare star rating system has been proposed as a means to assess hospital quality performance. The current study aimed to investigate outcomes and payments among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer across hospital star rating groups. METHODS: The Medicare Standard Analytic Files (SAF) from 2013 to 2015 were used to derive the analytic cohort. The association of star ratings to perioperative outcomes and expenditures was examined. RESULTS: Among 119,854 patients, the majority underwent surgery at a 3-star (n = 34,901, 29.1%) or 4-star (n = 30,492, 25.4%) hospital. Only 12.2% (n = 14,732) were treated at a 5-star hospital. Across all procedures examined, patients who underwent surgery at a 1-star hospital had greater odds of death within 90 days than patients who had surgery at a 5-star hospital (colorectal, 1.41 [95% confidence interval {CI}, 1.25-1.60]; lung, 1.97 [95% CI 1.56-2.48]; esophagectomy, 1.83 [95% CI 0.81-4.16]; pancreatectomy, 1.70 [95% CI 1.20-2.41]; hepatectomy, 1.63 [95% CI 0.96-2.77]). A similar trend was noted for failure to rescue (FTR), with the greatest odds of FTR associated with 1-star hospitals. The median expenditure associated with an abdominal operation was $1661 more at a 1-star hospital than at a 5-star hospital (1-star: $17,399 vs 5-star: $15,738). A similar trend was noted for thoracic operations. CONCLUSION: The risk of FTR, 90-day mortality, and increased hospital expenditure were all higher at a 1-star hospital. Further research is needed to investigate barriers to care at 5-star-rated hospitals and to target specific interventions to improve outcomes at 1-star hospitals.

DOI： 10.1245/s10434-019-08088-y

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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 < 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.

DOI： 10.1007/s11605-019-04340-8

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: The objective of the current study was to comprehensively assess the change of practice in hepatobiliary surgery by determining the rates and the trends of textbook outcomes (TO) among patients undergoing surgery for primary liver cancer over time. METHODS: Patients undergoing curative-intent resection for primary liver malignancies, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) between 2005 and 2017 were analyzed using a large, international multi-institutional dataset. Rates of TO were assessed over time. Factors associated with achieving a TO and the impact of TO on long-term survival were examined. RESULTS: Among 1829 patients, 944 (51.6%) and 885 (48.4%) individuals underwent curative-intent resection for HCC and ICC, respectively. Over time, patients were older, more frequently had ASA class > 2, albumin-bilirubin grade 2/3, major vascular invasion and more frequently underwent major liver resection (all p < 0.05). Overall, a total of 1126 (62.0%) patients achieved a TO. No increasing trends in TO rates were noted over the years (ptrend = 0.90). In addition, there was no increasing trend in the TO rates among patients undergoing either major (ptrend = 0.39) or minor liver resection (ptrend = 0.63) over the study period. Achieving a TO was independently associated with 26% and 37% decreased hazards of death among ICC (HR 0.74, 95%CI 0.56-0.97) and HCC patients (HR 0.63, 95%CI 0.46-0.85), respectively. CONCLUSION: Approximately 6 in 10 patients undergoing surgery for primary liver tumors achieved a TO. While TO rates did not increase over time, TO was associated with better long-term outcomes following liver resection for both HCC and ICC.

DOI： 10.1245/s10434-020-08548-w

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery. METHODS: The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample. RESULTS: Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79). CONCLUSION: Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods.

DOI： 10.1007/s11605-019-04338-2

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Although most conventional risk prediction models have been based on preoperative information, intra- and post-operative events may be more relevant to mortality after surgery. We sought to develop a mortality risk calculator based on real time characteristics associated with hepatectomy. METHODS: Patients who underwent hepatectomy between 2014 and 2017 were identified in the ACS-NSQIP dataset. Three prediction models (pre-, intra-, post-operative) were developed and validated using perioperative data. RESULTS: Among 14,720 patients, 197 (1.3%) experienced 30-day mortality. The predictive ability of the real-time mortality risk calculator was very good based on only preoperative factors (AUC; training cohort: 0.813, validation cohort: 0.731). Incorporating intra-operative variables into the model increased the AUC (training: 0.838, validation: 0.777), while the post-operative model achieved an AUC of 0.922 in the training and 0.885 in the validation cohorts, respectively. While patients with low preoperative risk had only very small fluctuations in the estimated 30-day mortality risk during the intraoperative (Δ0.4%) and postoperative (Δ0.6%) phases, patients who were already deemed high risk preoperatively had additional increased mortality risk based on factors that occurred in the intraoperative (Δ5.4%) and postoperative (Δ9.3%) periods. CONCLUSION: A real-time mortality risk calculator may better help clinicians identify patients at risk of death at the different stages of the surgical episode.

DOI： 10.1016/j.hpb.2019.10.2446

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The 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). METHODS: Patients 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. RESULTS: Among 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). CONCLUSIONS: Patients 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.

DOI： 10.1245/s10434-020-08350-8

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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.

DOI： 10.1007/s11605-020-04720-5

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Cholecystectomy is one of the most commonly performed operations in the United States, yet it still carries up to a 6% risk of major morbidity. Lawsuits are a major source of emotional, financial, and personal stress for surgeons. We sought to characterize malpractice claims associated with gallbladder surgery as well as define contributing factors and costs with these claims. METHODS: The Westlaw database (Thomson Reuters Corporation, Toronto, Canada) was queried for jury verdicts and settlements related to cholecystectomy and malpractice between 2000 and 2018. Data were abstracted from the case files and details of the settlements, jury verdicts, and factors related to the claims were assessed. RESULTS: Among 231 cases, a plaintiff verdict was reached in 45 (19.5%) and a defendant verdict was reached in 122 (53%); other cases were either settled (n = 29, 12%), dismissed (n = 31, 13%), or denied (n = 4, 2%). Plaintiff cases often involved young (median age, 44 years [interquartile range: 35-57]) female (n = 146, 63%) patients. The attending surgeon accounted for 59% of defendants. Procedural error (49%), wrongful death (18%), or failure to treat in a timely manner (13%) were the most commonly cited reasons for litigation. Among the 134 cases where a second surgical procedure was performed, the most common types of procedures were biliary tract repair (n = 82, 61%) and bowel repair (n = 16, 12%). The total cost of the claims over the study period was $22 million with a median payout of $500,000; the median time from operative event to final disposition was over 5 years (interquartile range: 4-7). CONCLUSION: A plaintiff verdict or settlement was reached in 1 in 3 cases, and large payouts were common. Minimizing procedural error and improving care of patients after cholecystectomy complications should be emphasized.

DOI： 10.1016/j.surg.2020.04.009

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery. METHODS: The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome. RESULTS: Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53). CONCLUSION: The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.

DOI： 10.1016/j.surg.2020.02.024

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Several investigators have advocated for extending the Barcelona Clinic Liver Cancer (BCLC) resection criteria to select patients with BCLC-B and even BCLC-C hepatocellular carcinoma (HCC). The objective of the current study was to define the outcomes and recurrence patterns after resection within and beyond the current resection criteria. PATIENTS AND METHODS: Patients who underwent resection for HCC within (i.e., BCLC 0/A) and beyond (i.e. BCLC B/C) the current resection criteria between 2005 and 2017 were identified from an international multi-institutional database. Overall survival (OS), disease-free survival (DFS), as well as patterns of recurrence of patients undergoing HCC resection within and beyond the BCLC guidelines were examined. RESULTS: Among 756 patients, 602 (79.6%) patients were BCLC 0/A and 154 (20.4%) were BCLC B/C. Recurrences were mostly intrahepatic (within BCLC: 74.3% versus beyond BCLC: 70.8%, p = 0.80), with BCLC B/C patients more often having multiple tumors at relapse (69.6% versus 49.4%, p = 0.001) and higher rates of early (< 2 years) recurrence (88.0% versus 75.5%, p = 0.011). During the first postoperative year, annual recurrence was 38.3% and 21.3% among BCLC B/C and BCLC 0/A patients, respectively; 5-year OS among BCLC 0/A and BCLC B/C patients was 76.9% versus 51.6% (p = 0.003). On multivariable analysis, only a-fetoprotein (AFP) > 400 ng/mL (HR = 1.84, 95% CI 1.07-3.15) and R1 resection (HR = 2.36, 95% CI 1.32-4.23) were associated with higher risk of recurrence among BCLC B/C patients. CONCLUSIONS: Surgery can provide acceptable outcomes among select patients with BCLC B/C HCC. The data emphasize the need to further refine the BCLC treatment algorithm as well as highlight the need for surveillance protocols with a particular focus on the liver, especially for patients undergoing resection outside the BCLC criteria.

DOI： 10.1245/s10434-020-08452-3

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR). METHODS: Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3-5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined. RESULTS: Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055). CONCLUSION: Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons.

DOI： 10.1007/s11605-019-04323-9

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: Although a positive surgical margin is a known prognostic factor for recurrence, the optimal surgical margin width in the context of an R0 resection for early-stage hepatocellular carcinoma (HCC) is still debated. The aim of the current study was to examine the impact of wide (> 1 cm) versus narrow (< 1 cm) surgical margin status on the incidence and recurrence patterns among patients with T1 HCC undergoing an R0 hepatectomy. METHODS: Between 1998 and 2017, patients with T1 HCC who underwent R0 hepatectomy for stage T1 HCC were identified using an international multi-institutional database. Recurrence-free survival (RFS) was estimated, and recurrence patterns were examined based on whether patients had a wide versus narrow resection margins. RESULTS: Among 404 patients, median patient age was 66 years (IQR: 58-73). Most patients (n = 326, 80.7%) had surgical margin < 1 cm, while 78 (19.3%) patients had a > 1 cm margin. The majority of patients had early recurrences (< 24 months) in both margin width groups (< 1 cm: 70.3% vs > 1 cm: 85.7%, p = 0.141); recurrence site was mostly intrahepatic (< 1 cm: 77% vs > 1 cm: 61.9%, p = 0.169). The 1-, 3-, and 5-year RFS among patients with margin < 1 cm were 77%, 48.9%, and 35.3% versus 81.7%, 65.8%, and 60.7% for patients with margin > 1 cm, respectively (p = 0.02). Among patients undergoing anatomic resection, resection margin did not impact RFS (3-year RFS: < 1 cm: 49.2% vs > 1 cm: 58.9%, p = 0.169), whereas in the non-anatomic resection group, margin width > 1 cm was associated with a better 3-year RFS compared to margin < 1 cm (86.7% vs 47.3%, p = 0.017). On multivariable analysis, margin > 1 cm remained protective against recurrence (HR = 0.50, 95%CI 0.28-0.89), whereas Child-Pugh B (HR = 2.13, 95%CI 1.09-4.15), AFP > 20 ng/mL (HR = 1.71, 95%CI 1.18-2.48), and presence of microscopic lymphovascular invasion (HR = 1.48, 95%CI 1.01-2.18) were associated with a higher hazard of recurrence. CONCLUSION: Resection margins > 1 cm predicted better RFS among patients undergoing R0 hepatectomy for T1 HCC, especially small (< 5 cm) HCC. Although resection margin width did not influence outcomes after anatomic resection, wider margins were more important among patients undergoing non-anatomic liver resections.

DOI： 10.1007/s11605-019-04275-0

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: Disparities in health and healthcare access remain a major problem in the USA. The current study sought to investigate the relationship between patient insurance status and hospital selection for surgical care. METHODS: Patients who underwent liver or pancreatic resection for cancer between 2004 and 2014 were identified in the National Inpatient Sample. The association of insurance status and hospital type was examined. RESULTS: In total, 22,254 patients were included in the study. Compared with patients with private insurance, Medicaid patients were less likely to undergo surgery at urban non-teaching hospitals (OR = 0.36, 95%CI 0.22-0.59) and urban teaching hospitals (OR = 0.54, 95%CI 0.34-0.84) than rural hospitals. Medicaid patients were less likely to undergo surgery at private investor-owned hospitals (OR = 0.53, 95%CI 0.38-0.73) than private non-profit hospitals. In contrast, uninsured patients were 2.2-fold more likely to go to government-funded hospitals rather than private non-profit hospitals (OR = 2.19, 95%CI 1.76-2.71). CONCLUSION: Insurance status was strongly associated with the type of hospital in which patients underwent surgery for liver and pancreatic cancers. Addressing the reasons for inequitable access to different hospital settings relative to insurance status is essential to ensure that all patients undergoing pancreatic or liver surgery receive high-quality surgical care.

DOI： 10.1007/s11605-019-04288-9

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) represents a novel surgical technique which provides rapid and effective liver regeneration allowing for the resection of lesions initially deemed unresectable. The objective of this systematic review is to summarize all technical modifications of the original ALPPS approach (mALPPS) for primary liver malignancies and evaluate short- and long-term outcomes. A systematic search of the literature was conducted using PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases until July, 31 2019. The following keywords were utilized: "Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy", "ALPPS", "Portal Vein Embolization (PVE) And In Situ Split", "Portal Vein Ligation (PVL) And In Situ Split". A total of 24 studies were identified incorporating data on 83 patients who underwent a mALPPS for a primary liver malignancy. Median FLR hypertrophy after ALPPS-1 was 54% (range, 6.7-133%) and median EBL during the ALPPS 1 and ALPPS 2 stages was 200 mL (range 0-1000) and 700 ml (range 100-4000), respectively. R0 resections were achieved in all patients (100%). Most complications occurred post ALPPS- 2 (n = 33/72, 45.8%), while overall 30-day mortality was 13.3%. After a median follow up of 7 months (range 3-60), recurrence rate was 18.9%. Disease-free survival ranged from 3 to 60 months with a median of 10 months and overall survival ranged from 3 to 60 months with a median of 11 months. ALPPS with the various technical modifications offers a reasonable chance of complete tumor resection among patients with initially unresectable primary liver tumors. Further advances in patient selection, surgical techniques and perioperative management are required to minimize complications rates. Large scale prospective trials are needed to validate the role of the technical modifications of ALPPS in the treatment of patients with primary liver malignancies in an individualized setting.

DOI： 10.1016/j.suronc.2020.01.010

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: The aim of the current study is to assess rates of textbook outcome (TO) among Medicare beneficiaries undergoing hepatopancreatic (HP) surgery for cancer at dedicated cancer centers (DCCs) and National Cancer Institute affiliated cancer centers (NCI-CCs) versus non-DCC non-NCI hospitals. PATIENTS AND METHODS: Medicare Inpatient Standard Analytic Files were utilized to identify patients undergoing HP surgery between 2013 and 2017. TO was defined as no postoperative surgical complications, no 90-day mortality, no prolonged length of hospital stay, and no 90-day readmission after discharge. RESULTS: Among 21,234 Medicare patients, 8.2% patients underwent surgery at DCCs whereas 32.1% underwent surgery at NCI-CCs and 59.7% underwent an operation at neither DCCs nor NCI-CCs. Although DCCs more often cared for patients with severe comorbidities [Charlson score > 5: DCCs, 1195 (68.9%), NCI-CCs, 3687 (54.1%), others, 3970 (31.3%); p < 0.001], DCCs achieved higher rates of TO compared with NCI-CCs and other US hospitals. Interestingly, DCCs were more likely to perform surgery with a minimally invasive approach versus NCI-CCs and other US hospitals (17.0%, n = 295, vs. 12.6%, n = 856 vs. 11.9%, n = 1504, p < 0.001). On multivariable analysis, patients undergoing liver surgery at DCCs had 31% and 36% higher odds of achieving TO compared with NCI-CCs and other US hospitals, respectively. Medicare expenditure was substantially lower for patients achieving TO at DCCs compared with patients who achieved a TO at NCI-CCs. CONCLUSIONS: Even though DCCs more frequently took care of patients with high comorbidity burden, the likelihood of achieving TO for HP surgery at DCCs was higher compared with NCI-CCs and other US hospitals. The data suggest that DCCs provide higher-value surgical care for patients with HP malignancies.

DOI： 10.1245/s10434-020-08279-y

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: Scirrhous hepatocellular carcinoma (HCC) is a rare primary liver tumor characterized by extensive fibrosis and production of parathyroid hormone-related peptide. There have been conflicting reports on patient survival in scirrhous versus non-scirrhous HCC. The objective of the present study was to define the clinical features, practice patterns, and long-term outcomes of patients with scirrhous HCC versus non-scirrhous HCC in a propensity score-matched cohort. METHODS: A propensity score-matched cohort was created using data from the National Cancer Database for 2004 to 2015. A multivariable Cox proportional hazards regression analysis was performed to assess the effect of the scirrhous HCC variant on overall survival. RESULTS: Among the 70,426 patients with a diagnosis of HCC who met the inclusion criteria, 99.8% had non-scirrhous HCC (n = 70,290) whereas a small subset had scirrhous HCC (n = 136, 0.19%). While 20,330 (28.9%) patients underwent liver-directed therapy (resection, ablation, and transplantation), the majority did not (n = 50,096, 71.1%). After propensity matching, there were no difference in 1-, 3-, or 5-year overall survival among patients with scirrhous versus non-scirrhous HCC (1-year overall survival (OS), 53.7% versus 51.0%; 3-year OS, 34.6% versus 28.7%; and 5-year OS, 18.0% versus 21.0%, respectively; p = 0.52). While the scirrhous HCC variant was not associated with survival (hazard ratio [HR] 0.93, 95% CI 0.74-1.16), non-receipt of liver-directed therapy (HR 0.24, 95% CI 0.18-0.32), advanced AJCC stage (III/IV) (HR 2.14, 95% CI 1.55-2.95), and non-academic facilities (HR 0.60, 95% CI 0.49-0.73) remained associated with worse survival. CONCLUSION: Patients with the scirrhous variant had a comparable overall survival compared with individuals who had non-scirrhous HCC. Failure to receive liver-directed therapy, advanced AJCC stage (III/IV), and treatment at a non-academic facility was strongly associated with a worse long-term prognosis.

DOI： 10.1007/s11605-019-04282-1

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The objective of the current study was to define and compare rates of textbook outcomes (TO) among patients undergoing colorectal, lung, esophagus, liver, and pancreatic surgery for cancer at U.S. News & World Report (USNWR) ranked hospitals. METHODS: Medicare Inpatient Standard Analytic Files 2013-2015 were utilized to examine the relationship of TO and USNWR hospital ratings following surgery for colorectal, lung, esophageal, pancreatic, and liver cancer. TO was defined as no postoperative surgical complications, no prolonged length of hospital stay, no readmission within 90 days after discharge, and no postoperative mortality within 90 days after surgery. RESULTS: Among the 35,352 Medicare patients included in the cohort, 16,820 (47.6%) underwent surgery at honor roll hospitals, whereas 18 532 (52.4%) underwent surgery at non-honor roll hospitals. The overall proportion of patients who achieved TO was 50.1%. In examining the clinical outcomes of patients who underwent surgery, there was no difference in the odds of achieving TO at honor roll vs non-honor roll hospitals (colorectal: odds ratio [OR], 0.87; 95% confidence interval [CI], 0.69-1.10; lung: OR, 1.07; 95% CI, 0.87-1.32; esophagus: OR, 1.44; 95% CI, 0.72-2.89; liver: OR, 1.27; 95% CI, 0.87-1.84; pancreas: OR, 1.04; 95% CI, 0.67-1.62). CONCLUSION AND RELEVANCE: Patients undergoing surgery for lung, esophageal, liver, pancreatic, and colorectal cancer had comparable rates of TO at honor roll vs non-honor roll hospitals. No linear association was observed between hospital position in the rank and postoperative outcomes such as TO indicating that patients should not overly focus on the exact position within USNWR ranked hospitals. These data highlight to patients and physicians that up to one-half of patients undergoing surgery for cancer should anticipate at least one adverse outcome.

DOI： 10.1002/jso.25833

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: While patient- and hospital-level factors affecting outcomes of patients undergoing pancreatoduodenectomy (PD) have been well described separately, the relative impact of these factors on in-hospital mortality has not been comprehensively assessed. METHODS: Retrospective review of the National Inpatient Sample database (January 2004-December 2014) was conducted to identify patients undergoing PD. Factors associated with in-hospital mortality after PD were analyzed after adjusting for previously defined patient- and hospital-level risk factors. RESULTS: A total of 9639 patients who underwent a PD at 2325 hospitals were identified. Median patient age was 57 years (IQR 66-73). Overall, mortality following PD was 3.2%. When patient- and hospital-level characteristics were analyzed in the same model, patient-level characteristic associated with increased odds of in-hospital mortality included increasing patient age (OR 1.05, 95% CI 1.03-1.06/per 5 years increase), male sex (OR 1.47, 95% CI 1.16-1.86), the presence of liver disease (OR 3.03, 95% CI 1.99-4.61), chronic kidney disease (OR 1.78, 95% CI 1.18-2.68), and congestive heart failure (OR 2.48, 95% CI 1.65-3.74). The only hospital characteristic associated with odds of mortality following PD included compliance with Leapfrog volume standards (OR 0.70, 95% CI 0.54-0.92). CONCLUSION: Patient-level factors, such as advanced comorbidities, male sex, and increased age, contributed the most to increased risk of mortality after PD. Hospital volume was the only hospital-level factor contributing to risk of in-hospital mortality following PD.

DOI： 10.1007/s11605-019-04307-9

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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 (R2 = 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.

DOI： 10.1007/s11605-020-04610-w

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記述言語：英語   掲載種別：研究論文（国際会議プロシーディングス）   出版者・発行元：Elsevier Inc.  

Background: Estimating prognosis in the preoperative setting is challenging, as most survival risk scores rely exclusively on postoperative factors. We sought to develop a composite score that incorporated preoperative liver, tumor, nutritional, and inflammatory markers to predict long-term outcomes after resection of intrahepatic cholangiocarcinoma (ICC). Study Design: Patients who underwent curative-intent hepatectomy for ICC between 2000 and 2017 were identified using an international multi-institutional database. Clinicopathologic factors were assessed using bivariate and multivariable analysis and a prognostic model to estimate overall survival (OS) based only on preoperative laboratory values (LabScore) was developed and validated. Results: Among 660 patients, median OS was 43.2 months and 5-year OS rate was 42.4%. On multivariable analysis, laboratory values associated with OS included carbohydrate antigen 19-9 (hazard ratio [HR] 1.16
95% CI 1.05 to 1.27), neutrophil-to-lymphocyte ratio (HR 1.09
95% CI, 1.05 to 1.13), platelet count (HR 1.01
95% CI, 1.00 to 1.01), and albumin (HR 0.75
95% CI, 0.62 to 0.92). A weighted LabScore was constructed based on the formula: (8.2 + 1.45 × natural logarithm of carbohydrate antigen 19-9 + 0.84 × neutrophil-to-lymphocyte ratio + 0.03 × platelets – 2.83 × albumin). Patients with a LabScore of 0 to 9 (n = 223), 10 to 19 (n = 353) and ≥20 (n = 88) had incrementally worse 5-year OS rates of 54.9%, 38.2% and 21.6%, respectively (p &lt
0.001). The model demonstrated good performance in both the test (c-index 0.70) and validation cohorts (c-index 0.67), as well as outperformed individual laboratory markers, the prognostic nutritional index (c-index 0.58), and American Joint Committee on Cancer staging system (c-index 0.60). Conclusions: A preoperative LabScore was able to predict long-term outcomes of patients after resection for ICC better than American Joint Committee on Cancer staging system. The LabScore can be used to preoperatively identify patients who will benefit the most from upfront operation or alternative treatment options, including neoadjuvant chemotherapy before resection.

DOI： 10.1016/j.jamcollsurg.2019.12.025

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

DOI： 10.1245/s10434-019-08134-9

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Accurate 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). METHODS: Patients 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. RESULTS: Among 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). CONCLUSIONS: The 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.

DOI： 10.1245/s10434-019-08067-3

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The 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. METHODS: Patients 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. RESULTS: The 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. CONCLUSION: The 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.

DOI： 10.1245/s10434-019-08120-1

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator (SRC) aims to help predict patient-specific risk for morbidity and mortality. The performance of the SRC among an elderly population undergoing curative-intent hepatectomy for hepatocellular carcinoma (HCC) remains unknown. METHODS: Patients > 70 years of age who underwent hepatectomy for HCC between 1998 and 2017 were identified using a multi-institutional international database. To estimate the performance of SRC, 12 observed postoperative outcomes were compared with median SRC-predicted risk, and C-statistics and Brier scores were calculated. RESULTS: Among 500 patients, median age was 75 years (IQR 72-78). Most patients (n = 324, 64.8%) underwent a minor hepatectomy, while 35.2% underwent a major hepatectomy. The observed incidence of venous thromboembolism (VTE) (3.2%) and renal failure (RF) (4.4%) exceeded the median predicted risk (VTE, 1.8%; IQR 1.5-3.1 and RF, 1.0%; IQR 0.5-2.0). In contrast, the observed incidence of 30-day readmission (7.0%) and non-home discharge (2.5%) was lower than median-predicted risk (30-day readmission, 9.4%; IQR 7.4-12.8 and non-home discharge, 5.7%; IQR 3.3-11.7). Only 57.8% and 71.2% of patients who experienced readmission (C-statistic, 0.578; 95%CI 0.468-0.688) or mortality (C-statistic, 0.712; 95%CI 0.508-0.917) were correctly identified by the model. CONCLUSION: Among elderly patients undergoing hepatectomy for HCC, the SRC underestimated the risk of complications such as VTE and RF, while being no better than chance in estimating the risk of readmission. The ACS SRC has limited clinical applicability in estimating perioperative risk among elderly patients being considered for hepatic resection of HCC.

DOI： 10.1007/s11605-019-04174-4

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The survival benefit of lymphadenectomy among patients with gallbladder cancer (GBC) remains poorly understood. METHODS: Patients who underwent resection for GBC between 2000 and 2015 were identified from a US multi-institutional database. The therapeutic index (LNM rate multiplied by 3-year overall survival [OS]) was determined to assess the survival benefit of lymphadenectomy. RESULTS: Among 449 patients, less than half had LNM (N = 183, 40.8%). The median number of evaluated and metastatic lymph nodes (LNs) was 3 (interquartile range [IQR]: 1-6) and 1 (IQR: 0-1), respectively. 3-year OS among patients with LNM in the entire cohort was 26.8%. The therapeutic index was lower among patients with T4 (5.9) or T1 (6.0) tumors as well as carbohydrate antigen (CA19-9) ≥200 UI/mL (6.0). Of note, a therapeutic index difference ≥10 was noted relative to CA19-9 (<200: 18.7 vs ≥200: 6.0), American Joint Committee on Cancer T Stage (T1: 6.0 vs T2: 17.8 vs T4: 5.9) and number of LNs examined (1-2: 6.9 vs ≥6: 16.9). Concomitant common bile duct resection was not associated with a higher therapeutic index among patients with either T2 or T3 disease. CONCLUSION: Certain clinicopathological factors including T1 or T4 tumor and CA19-9 ≥200 UI/mL were associated with a low therapeutic index. Resection of six or more LNs was associated with a meaningful therapeutic index benefit among patients with LNM.

DOI： 10.1002/jso.25825

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: There is an ongoing debate about expanding the resection criteria for hepatocellular carcinoma (HCC) beyond the Barcelona Clinic Liver Cancer (BCLC) guidelines. We sought to determine the factors that held the most prognostic weight in the pre- and postoperative setting for each BCLC stage by applying a machine learning method. METHODS: Patients who underwent resection for BCLC-0, A and B HCC between 2000 and 2017 were identified from an international multi-institutional database. A Classification and Regression Tree (CART) model was used to generate homogeneous groups of patients relative to overall survival (OS) based on pre- and postoperative factors. RESULTS: Among 976 patients, 63 (6.5%) had BCLC-0, 745 (76.3%) had BCLC-A, and 168 (17.2%) had BCLC-B HCC. Five-year OS among BCLC-0/A and BCLC-B patients was 64.2% versus 50.2%, respectively (p = 0.011). The preoperative CART model selected α-fetoprotein (AFP) and Charlson comorbidity score (CCS) as the first and second most important preoperative factors of OS among BCLC-0/A patients, whereas radiologic tumor burden score (TBS) was the best predictor of OS among BCLC-B patients. The postoperative CART model revealed lymphovascular invasion as the best postoperative predictor of OS among BCLC-0/A patients, whereas TBS remained the best predictor of long-term outcomes among BCLC-B patients in the postoperative setting. On multivariable analysis, pathologic TBS independently predicted worse OS among BCLC-0/A (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.02-1.07) and BCLC-B patients (HR 1.13, 95% CI 1.06-1.19) undergoing resection. CONCLUSION: Prognostic stratification of patients undergoing resection for HCC within and beyond the BCLC resection criteria should include assessment of AFP and comorbidities for BCLC-0/A patients, as well as tumor burden for BCLC-B patients.

DOI： 10.1245/s10434-019-08025-z

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: 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. METHODS: A retrospective analysis of the National Cancer Database (NCDB) was conducted to identify patients with early-stage HCC who underwent partial hepatectomy in the USA from 2010 to 2013. Overall survival (OS) was compared in three cohorts: crude; stabilized inverse probability of treatment propensity score weighting (IPTW); and propensity score matching (PSM). RESULTS: Among 4027 patients included in the study, only 11.7%, (n = 473) underwent MILR. In the stabilized IPTW cohort, patients who underwent MILR versus open resection were more likely to have tumors greater than 3 cm (63.9%, n = 285 vs. 51.4%, n = 228, p < 0.001) and poorly/undifferentiated tumors (21.5%, n = 96 vs. 12.9%, n = 57, p < 0.001). Within the crude cohort, a 5-year OS was superior among patients in the open surgical group (67.8%) compared with patients who underwent MILR (56.6%) (p < 0.001). After classic PSM analysis, the 5-year OS of patients undergoing MILR and open surgery were noted to be comparable (57.3% vs 63.8%, p = 0.17; HR 1.16, 95% CI 0.92-1.45). In contrast, after applying IPTW, the 5-year OS of patients who underwent MILR (55.5%) was worse compared with patients who had an open resection (67.5%) (HR 1.46, 95% CI 1.15-1.84; p < 0.001). CONCLUSIONS: Long-term outcomes of patients undergoing MILR were comparable with patients who had open surgery when assessed by standard PSM. The use of IPTW resulted in more unbalanced groups leading to residual confounding and bias.

DOI： 10.1007/s11605-019-04221-0

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

Background: Patients with advanced hepatobiliary cancer (HBC) have a dismal prognosis and limited treatment options. Immunotherapy has been considered as a promising treatment, especially for cancers not amenable to surgery. Methods: Between 2004, and 2015, patients diagnosed with hepatocellular carcinoma (HCC), intra- and extrahepatic cholangiocarcinoma and gallbladder cancer (GBC) were identified in the National Cancer Database. Results: Among 249,913 patients with HBC, only 585 (0.2%) patients received immunotherapy. Among patients who received immunotherapy, most patients were diagnosed between 2012 and 2015, had private insurance, as well as an income ≥$46,000 and were treated at an academic facility. The use of immunotherapy among HBC patients varied by diagnosis (HCC, 67.7%; bile duct cancer, 14%). On multivariable analysis, a more recent period of diagnosis (OR 1.80, 95% CI: 1.44-2.25), median income >$46,000 (OR 1.43, 95% CI: 1.11-1.87), and higher tumor stage (stage III, OR 2.22, 95% CI: 1.65-3.01; stage IV, OR 3.24, 95% CI: 2.41-4.34) were associated with greater odds of receiving immunotherapy. Conclusions: Overall utilization of immunotherapy in the US among patients with HBC was very low, yet has increased over time. Certain socioeconomic factors were associated with an increased likely of receiving immunotherapy, suggesting disparities in access of patients with lower socioeconomic status.

DOI： 10.21037/hbsn.2019.07.01

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: An increasing number of patients require admission to a skilled nursing facility (SNF) following surgery. However, the impact of SNF quality on post-operative outcomes is unknown. METHODS: The Medicare Standard Analytic Files and Nursing Home Compare Dataset were used to define SNF utilization and determine the influence of SNF star quality ratings on outcomes following hepatectomy. RESULTS: Among 7256 Medicare beneficiaries, 918 (12.7%) required. Compared to patients discharged home, individuals discharged to SNF were older (median age: 75 [IQR 71-80] vs. 71 [IQR 68-76] years), and had a higher incidence of complications such as pulmonary failure, pneumonia, and acute renal failure during index hospitalization (all p < 0.05). Patients sent to a SNF were more likely to be readmitted within 30-days (30.1% vs. 13.4%, p < 0.001). The incidence of new complications within 30- and 90-days of discharge was similar regardless of star quality ratings (all p > 0.05). On multivariable analysis, Charlson comorbidity score ≥3 was the factor most strongly associated with 30-day readmission (OR 1.32-15.29, p = 0.016). CONCLUSION: While post-discharge outcomes were similar across SNF quality ratings, roughly one in three Medicare patients discharged to a SNF were readmitted within 30-days.

DOI： 10.1016/j.hpb.2019.05.012

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

INTRODUCTION: Data on the association of high preoperative healthcare utilization and adverse clinical outcomes are scarce. We sought to evaluate the role of annual preoperative expenditure (APE) as a surrogate for latent variables of risk for adverse short-term postoperative outcomes. METHODS: Low and super-utilizers who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, colectomy, total hip arthroplasty, total knee arthroplasty, or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files. To assess the association between APE and postoperative outcomes, multivariable logistic regression was utilized. RESULTS: Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were preoperative low- and super-utilizers, respectively. Median APE was more than 60 times higher among super-utilizers than low-utilizers ($57,160 vs. $932), as was the cost of the surgical episode ($21,141 vs. $13,179). The predictive ability of APE ranged from 0.683 (95% CI 0.678-0.687) for 90-day readmission to 0.882 (95% CI 0.879-0.886) for a complication at the index hospitalization. Among super-utilizers, the odds of a complication during the surgical episode was nearly double versus low-utilizers (OR = 1.96, 95% CI 1.89-2.04). Super-utilizers also had an increased odds of 30-day readmission (OR = 1.64, 95% CI 1.58-1.69) and mortality (OR = 2.22; 95% CI 2.04-2.42). CONCLUSION: APE was able to predict adverse postsurgical outcomes including complications during the surgical episode, readmission, and 90-day mortality. APE should be considered in the assessment of patient populations when defining risk of adverse postoperative events.

DOI： 10.1007/s00268-019-05184-8

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Considered the top 5% of healthcare utilizers, "super-utilizers" are estimated to consume as much as 40-55% of all healthcare costs. The aim of this study was to identify factors associated with switching between low- and super-utilization. METHODS: Low and super-utilizers who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), colectomy, total hip arthroplasty (THA), total knee arthroplasty (TKA), or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files. RESULTS: Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were low- or super-utilizers prior to surgery, respectively. Among patients who were super-utilizers before surgery, 23% remained super-utilizers post-operatively, yet 26.8% patients became low-utilizers after surgery. Factors associated with moving from low-to super-utilization in the pre-versus post-operative setting included AAA repair, higher Charlson, and pulmonary failure. In contrast, pre-operative super-utilizers who became low-utilizers in the post-operative setting were less likely to be African American or have undergone CABG. CONCLUSION: While 3% of pre-operative low-utilizers became super-utilizers likely due to complications, nearly one quarter of all pre-operative super-utilizers became low-utilizers following surgery suggesting success of the surgery to resolve underlying conditions associated with preoperative super-utilization.

DOI： 10.1016/j.amjsurg.2019.07.042

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Surgery is considered the only potentially curative treatment option for patients with hepatocellular carcinoma. However, the chance that patients will eventually be "cured" after liver resection for hepatocellular carcinoma remains ill defined. METHODS: Patients who underwent curative-intent hepatectomy for hepatocellular carcinoma between 1998 and 2017 were identified using an international multi-institutional database. A nonmixture cure model was used with disease-free survival as a primary measure to estimate cure fractions after matching patients with the general population by age, race, and sex. RESULTS: Among 1,010 patients, the median and 5-year disease-free survival were 2.8 years and 36.6%, respectively. The probability of being cured after hepatocellular carcinoma resection was 42.2% and the median time to cure was 3.35 years. The multivariable cure model revealed preoperative alpha-fetoprotein level, tumor size, tumor number, and margin status as independent predictors of cure. The cure fraction for patients with an alpha-fetoprotein level ≤ 10 ng/mL, largest tumor size ≤5 cm, ≤3 nodules, and R0 resection was 61.6%. In contrast, patients who had all 4 unfavorable prognostic factors (ie, alpha-fetoprotein >11 ng/mL, nodules ≥4, size >5cm, R1 resection) had a cure fraction of 15.8%. Although the probability of cure was 47.6% among Barcelona Clinic Liver Cancer-A patients, patients undergoing resection for Barcelona Clinic Liver Cancer-B hepatocellular carcinoma had a 37.6% cure fraction. Only alpha-fetoprotein levels predicted the probability of cure among Barcelona Clinic Liver Cancer-B patients. CONCLUSION: Roughly 4 in 10 patients could be considered "cured" after liver resection for hepatocellular carcinoma. Although cure was achieved more often after resection for Barcelona Clinic Liver Cancer-A hepatocellular carcinoma, surgery still provided a reasonable probability of cure among select patients with Barcelona Clinic Liver Cancer-B hepatocellular carcinoma.

DOI： 10.1016/j.surg.2019.08.010

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Over 19 million Americans have a substance abuse disorder. The current study sought to characterize the relationship between substance abuse with in-hospital outcomes following major, elective abdominal surgery. METHODS: The Nationwide Inpatient Sample was used to identify patients who underwent major abdominal surgery between 2007 to 2014. Patients with preoperative substance abuse, including alcohol, opioids, and non-opioid drugs, were identified. Propensity score matching was used to examine the association of substance abuse with perioperative outcomes. RESULTS: Among 301,659 patients, 7,925 patients (2.6%) had a history of substance abuse. Pancreatectomy was the surgical procedure with the highest proportion of patients with substance abuse history (n = 844, 4.7%). Compared with patients without a substance abuse history, patients with a substance abuse history were more likely to be younger (median age, 60 years [interquartile range (IQR) 52-69] vs 63 years [IQR 52-72]), male (n = 5,438, 67.5% vs n = 132,961, 54.7%), and be in the lowest income category (n = 2,062, 26% vs n = 64,345, 21.9%) (all P < .001). On propensity score matching, substance abuse was associated with increased odds ratio of experiencing a complication (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.55-1.82), non-home discharge (OR 1.95, 95% CI 1.76-2.16), extended length of stay (OR 1.88, 95% CI 1.76-2.02), and higher expenditure (OR 1.62, 95% CI 1.49-1.77). Stratified by the type of substance abuse, patients with history of alcohol (OR 1.57, 95% CI 1.44-1.71) and drug abuse (OR 1.26, 95% CI 1.14-1.39) were more likely to experience a complication, whereas only history of alcohol abuse was associated with higher odds ratio of in-hospital mortality (OR 1.38, 95% CI 1.07-1.79) (all P < .05). CONCLUSION: Up to 1 in 50 patients undergoing complex abdominal surgery had a substance abuse history. History of substance abuse was associated with an increased risk of adverse perioperative outcomes and higher healthcare expenditures.

DOI： 10.1016/j.surg.2019.06.018

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The impact of cirrhosis on perioperative outcomes for elderly patients undergoing hepatectomy remains not well defined. We sought to determine the influence of underlying cirrhosis and minimally invasive surgery (MIS) on postoperative outcomes among elderly patients who underwent a hepatectomy. METHODS: Patients who underwent hepatectomy 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 hepatectomy, stratified by the presence of cirrhosis and MIS, were examined. RESULTS: Among 7452 patients who underwent a hepatectomy, a minority had cirrhosis (n = 481, 6.5%) whereas the vast majority did not (n = 6971, 93.5%). Overall, median patient age was 72 years (IQR 68-76) and preoperative Charlson comorbidity score was 6 (IQR 2-8). Patients with cirrhosis were more likely to be younger (median age 71 [67-76] vs 72 [IQR 68-76] years), male (64.4% vs 50%), African American (8.1% vs 6.4%) and have a malignant diagnosis (87.1% vs 78.7%) compared to non-cirrhotic patients (all p < 0.001). There was no difference among patients with and without cirrhosis regarding type of hepatectomy or surgical approach (open vs MIS) (both p > 0.05). Patients with versus without cirrhosis had similar complication rates (24.1% vs 22.3%, p = 0.36), as well as 30-day (6.2% vs 5%, p = 0.25) and 90-day (10.4% vs 8.5%, p = 0.15) mortality. MIS reduced the length-of-stay in non-cirrhotic patients (OR 0.79, 95% CI 0.62-0.99, p < 0.05), yet was not associated with morbidity or mortality (both p > 0.05). CONCLUSION: The presence of cirrhosis did not generally impact outcomes in elderly patients undergoing hepatectomy for benign and malignant diseases. MIS hepatectomy in the elderly Medicare beneficiary population reduced LOS among patients without cirrhosis, yet was not associated with differences in morbidity or mortality.

DOI： 10.1007/s11605-019-04117-z

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Despite the popularity of the U.S. News and World Report (USNWR) hospital rankings among the general public, the relationship between hospital rankings and actual patient outcomes for major cancers remains poorly investigated. METHODS: Medicare Inpatient Standard Analytic Files were queried from 2013-2015 to assess the relationship of postoperative outcomes and Medicare expenditures among patients undergoing surgery for colorectal, lung, esophageal, pancreatic, and liver cancer at hospitals ranked in the top-50 USNWR vs hospitals ranked below 50. RESULTS: Among 94 599 patients, 13 217 vs 81 382 patients underwent surgery at a top-50 hospital versus a non-top 50 ranked hospital. Other than among patients who underwent colorectal surgery, the odds of postoperative complications were lower at top ranked vs non-top ranked hospitals (colorectal: OR, 1.46, 95% CI, 1.28-1.65; lung: OR, 0.73, 95% CI, 0.61-0.87; esophagus: OR, 0.70, 95% CI, 0.52-0.94; pancreas: OR, 0.81, 95% CI, 0.70-0.94; liver: OR, 0.85, 95% CI, 0.69-1.04). Moreover, the odds of 90-day mortality were lower at top ranked hospitals vs non-top ranked hospitals (colorectal: OR, 0.59, 95% CI, 0.48-74; lung: OR, 0.66, 95% CI, 0.53-0.82; esophagus: OR, 0.56, 95% CI, 0.40-0.80; pancreas: OR, 0.51, 95% CI, 0.40-0.65; liver: OR, 0.61, 95% CI, 0.44-0.84). Outcomes were comparable among hospitals within the top-50 rank. CONCLUSION: Mortality rates were lower at hospitals in the top-50 USNWR versus non-top ranked, yet hospitals within the top-50 USNWR rankings had comparable outcomes.

DOI： 10.1002/jso.25751

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Little data regarding the selection of nonsurgical therapies for localized intrahepatic cholangiocarcinoma (ICC) are available. METHODS: A cohort of nonsurgically managed patients with American Joint Commission on Cancer clinical stage I/II ICC in the United States from 2004 to 2013 were identified in the National Cancer Database. Overall survival (OS) was compared according to treatment options (radiofrequency ablation [RFA] vs chemoradiotherapy) using propensity-score matching. RESULTS: Among 505 patients, 86 patients were treated with RFA and 419 patients were treated with chemoradiotherapy. After propensity matching (n = 84, each group), 5-year OS was 17.6% among patients who underwent RFA vs 3.8% among patients receiving chemoradiotherapy (P < .001). On bivariate analysis, RFA was related to an OS benefit (hazard ratio, 0.46; 95% confidence interval, 0.33-0.66; P < .001). Specifially, a stage-specific subgroup analysis revealed a survival benefit in favor of RFA among stage I patients (5-year OS; RFA: 20.1% vs chemoradiotherapy: 3.7%, P < .001), whereas no difference in OS was noted among patients with stage II disease. CONCLUSION: Among ICC patients with small (≤5 cm), solitary ICC without vascular invasion, RFA was associated with better survival compared with chemoradiotherapy.

DOI： 10.1002/jso.25736

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The benefit derived from lymph node dissection (LND) in patients with pancreatic neuroendocrine tumors (pNETs) based on clinicopathological characteristics remains unclear. METHODS: Patients 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. RESULTS: Among 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). CONCLUSION: LND 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.

DOI： 10.1002/jso.25689

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Neuroendocrine liver metastases (NELM) are typically associated with high recurrence rates following surgical resection. Conditional disease-free survival (CDFS) estimates may be more clinically relevant compared to actuarial survival estimates. METHODS: CDFS was assessed using a multi-institutional cohort of patients. Cox proportional hazards models were used to evaluate factors associated with disease-free survival (DFS). Three-year CDFS (CDFS3) estimates at "x" year after surgery were calculated as CDFS3  = DFS(x + 3)/DFS(x). RESULTS: A total of 521 patients met the inclusion criteria. While actuarial 3-year DFS gradually decreased from 49% at 1 year to 39% at 5 years, CDFS3 increased over time. CDFS3 at 5 years was estimated as 89% vs actuarial 8-year DFS of 39% (P < .001). The probability of remaining disease-free at 5 years after resection increased as patients remained disease-free. For example, the probability of being disease-free for an additional 3 years was 66.3% and 88.8% for patients who lived 2 and 5 years, respectively. Overall, CDFS3 in each subgroup increased postoperatively as years elapsed, however, the impact of each prognostic factor on CDFS3 changed over time. CONCLUSION: CDFS of patients who underwent resection of NELM exponentially improved as patients survived additional years without recurrence. CDFS provides more accurate prognostic measures compared with traditional DFS measures.

DOI： 10.1002/jso.25713

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Systemic chemotherapy is the standard treatment for patients with unresectable extrahepatic cholangiocarcinoma (ECC), however, the survival benefit of chemotherapy is limited. Photodynamic therapy (PDT) has been associated with improved survival among patients with advanced ECC, yet utilization of PDT remains low. We sought to compare the outcomes of patients with unresectable ECC following treatment with PDT versus chemotherapy. METHODS: A review of the National Cancer Database was conducted to identify patients with ECC who were nonsurgically managed between 2004 and 2013. Overall survival (OS) of patients receiving PDT vs systemic chemotherapy was compared using propensity score matching. RESULTS: After propensity matching (PDT, n = 59; chemotherapy, n = 177), 5-year OS was 17.6% (95% confidence interval [CI], 9.0%-28.6%) among patients who underwent PDT vs 3.8% (95%CI, 0.4%-14.0%) among patients receiving chemotherapy (P < .001). On multivariable analysis PDT was associated with an OS benefit (hazard ratio, 0.72; 95%CI, 0.52-0.998; P = .048). Subset analysis of patients receiving PDT only (n = 45) and patients receiving chemotherapy demonstrated similar results. In subset analysis of patients undergoing PDT-only vs PDT-chemotherapy, OS was comparable. CONCLUSION: PDT was associated with a survival benefit compared with chemotherapy alone among patients with unresectable ECC.

DOI： 10.1002/jso.25773

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Few data are available regarding the management and outcomes among patients with sarcomatoid hepatocellular carcinoma (HCC) due to its rarity. METHODS: Patients diagnosed with sarcomatoid HCC from 2004 through 2015 were identified in the National Cancer Data Base. Overall survival (OS) was calculated among patients with sarcomatoid versus conventional HCC using a 1:3 propensity score matching based on sex, age, and American Joint Committee on Cancer (AJCC) stage of disease. RESULTS: The final analytic cohort included 104 patients with sarcomatoid HCC and 312 patients with conventional HCC. Patients with sarcomatoid HCC more often had a larger median tumor size (8.5 cm vs 5.4 cm; P < .001) and poorly or undifferentiated tumors (52.9% vs 13.8%; P < .001) compared with patients who had conventional HCC. 5-year OS was worse among patients with sarcomatoid versus conventional HCC (5.7% vs 30.1%; P < .001). Subgroup analysis demonstrated worse 5-year OS among patients with sarcomatoid versus conventional HCC among patients treated with either curative-intent or palliative therapies. Stage-specific subgroup analysis indicated a worse OS among patients with AJCC stage I, stage II, or stage III sarcomatoid HCC. On multivariable analysis, uninsured status, advanced AJCC stage (stage III/stage IV), and histological sarcomatoid subtype were independently associated with worse outcomes (all P < .05). CONCLUSIONS: Sarcomatoid HCC is a very rare variant of HCC, which was associated with larger tumor size and worse tumor grade on presentation. On propensity score matched analyses that controlled for known confounding factors, patients with sarcomatoid HCC had a worse stage-for-stage long-term survival compared with patients who had conventional HCC.

DOI： 10.1002/cncr.32396

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The Alliance of Dedicated Cancer Centers (DCCs) is comprised of 11 institutions that are exempt from the prospective payment system utilized by Medicare for hospital reimbursement. OBJECTIVE: The aim of this study was to compare short- and long-term outcomes of patients undergoing liver and pancreatic surgery for cancer at DCCs versus non-DCCs. METHODS: Patients who underwent a liver or pancreatic operation for a malignant indication between 2013 and 2015 were identified using the Medicare Inpatient Standard Analytic Files. Regression analyses and the Kaplan-Meier method were used to assess short- and long-term outcomes of patients at DCCs versus non-DCCs. RESULTS: Among 13,256 patients, 7.0% of patients were treated at a DCC. Median patient age and complexity of surgical procedures were comparable among DCCs and non-DCCs (all p > 0.05). Overall complications (16.5% vs. 23.6%), 90-day readmission (26.2% vs. 30.2%), and 90-day mortality (3.0% vs. 8.7%) were lower at DCCs compared with non-DCCs (all p < 0.001). In addition, long-term hazards of death among patients undergoing hepatectomy [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.54-0.75] and pancreatectomy (HR 0.66, 95% CI 0.56-0.78) were lower among patients treated at DCCs (both p <  0.05). While Medicare payments for patients undergoing pancreatic surgery (DCC: $22,200 vs. non-DCC: $22,100; p = 0.772) were comparable among DCC and non-DCC hospitals, Medicare payments for liver resection at DCCs were 13.9% lower than non-DCCs (DCC: $16,700 vs. non-DCC: $19,400; p < 0.001). CONCLUSIONS: Patients undergoing hepatopancreatic surgery at DCCs had better short- and long-term outcomes for the same/lower level of Medicare expenditure as non-DCC hospitals. DCCs provide higher-value surgical care for patients undergoing liver and pancreatic cancer operations.

DOI： 10.1245/s10434-019-07677-1

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The objective of the current study was to characterize patients with intrahepatic cholangiocarcinoma (ICC) undergoing curative-intent surgery with discordant preoperative and postoperative prediction scores and determine factors associated with prediction discrepancy. METHODS: Patients who underwent hepatectomy for ICC between 1990 and 2016 were identified in a multi-institutional international database. Preoperative and postoperative prognostic models were designed and discordant prognostic scores were identified. A multivariable logistic regression analysis was completed to determined factors associated with score discordance. RESULTS: Among 1149 patients, those who had concordant prediction scores were older (median age, 60 vs 56), and more likely to have a smaller median tumor size (6.0 vs 7.5 cm) (all P < .05). On multivariable logistic analysis, patients with higher neutrophil-lymphocyte ratio (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19), higher CEA levels (OR, 1.25; 95% CI, 1.04-1.50), larger tumors (OR, 1.10; 95% CI, 1.04-1.15) and suspicious lymph nodes (OR, 2.05; 95% CI, 1.25-3.36) were more likely to have preoperative and postoperative score discordance. Older patients had decreased odds of having score discordance (OR, 0.98; 95% CI, 0.96-0.99). Patients with score discordance had worse overall survival compared with patients with concordant scores (median:15.9 vs 21.7 months, P < .05). CONCLUSION: Score discordance may reflect an aggressive variant of ICC that would benefit from early integration of multidisciplinary treatment strategies.

DOI： 10.1002/jso.25671

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have questioned the prognostic stratification of this classification schema, as well as the proposed treatment allocation of patients with a single large tumor. METHODS: Patients who underwent curative-intent hepatectomy for histologically proven hepatocellular carcinoma (HCC) between 1998 and 2017 were identified using an international multi-institutional database. Overall survival (OS) among patients with BCLC stage 0, A, and B was examined. Patients with a single large tumor were classified as BCLC stage A1 and were independently assessed. RESULTS: Among 814 patients, 68 (8.4%) were BCLC-0, 310 (38.1%) were BCLC-A, 279 (34.3%) were BCLC-A1, and 157 (19.3%) were BCLC-B. Five-year OS among patients with BCLC stage 0, A, A1, and B HCC was 86.2%, 69.0%, 56.9%, and 49.9%, respectively (p < 0.001). Among patients with very early- and early-stage HCC (BCLC 0, A, and A1), patients with BCLC stage A1 had the worst OS (p = 0.0016). No difference in survival was noted among patients undergoing surgery for BCLC stage A1 and B HCC (5-year OS: 56.9% vs. 49.9%; p = 0.259) even after adjusting for competing factors (hazard ratio 0.83, 95% confidence interval 0.54-1.28; p = 0.40). CONCLUSION: Prognosis following liver resection among patients with BCLC-A1 HCC was similar to patients presenting with BCLC-B tumors. Surgery provided acceptable long-term outcomes among select patients with BCLC-B HCC. Designation into BCLC stage B should not be considered an a priori contraindication to surgery.

DOI： 10.1245/s10434-019-07580-9

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

DOI： 10.1245/s10434-019-07608-0

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Use of hospice services among patients with pancreatic cancer following pancreatic resection remains unknown. METHODS: Patients with pancreatic cancer who underwent resection were identified in the Medicare Standard Analytic Files. Outcomes included overall hospice use, early hospice enrollment (≥4 weeks before death), late hospice enrollment (initiation within 3 days of death), and Medicare expenditures. RESULTS: Among the 4369 deceased individuals, three-fourths of patients (n = 3252, 74.4%) used hospice at the time of death. Patients who did not use hospice were more likely to be male, have a complication on index admission and receive life sustaining treatments on subsequent admissions (P < .05). Only one-third (32.2%) of patients initiated hospice services early. Medicare expenditure during the last month of life was $10 000 lower among patients who initialized hospice services at least 1 month before death versus within 3 days of death (late: $10 581 [$5454-$17 200], early: $221 [$46-$733]; P < .001) CONCLUSION: While three-fourths of patients utilized hospice services after pancreatic resection, only one-third of patients initiated hospice services at least one-month before death. Late hospice use was associated with higher Medicare expenditures during the last month of life. Further research is needed to understand barriers to early hospice utilization.

DOI： 10.1002/jso.25623

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND AND OBJECTIVE: Financial hardship occurring as a result of cancer treatment has been termed financial toxicity and is an established side effect of the cancer treatment. We investigated the risk of financial toxicity among patients undergoing surgery for gastrointestinal cancers. METHODS: All uninsured and privately insured patients who underwent surgery for a gastrointestinal cancer were identified from the National Inpatient Sample. Publicly available government data were used estimate income, food expenditure, and average maximum out-of-pocket expenditure. Risk of financial toxicity was defined as health expenditure ≥ 40% of postsubsistence income. RESULTS: Among the 78 545 patients in the analytic cohort, 73 305 individuals had private insurance while 5240 patients were uninsured. Overall median hospital charges were $58 651 (IQR: $37 912-$95 379). Approximately 90% of uninsured and 10% of privately insured patients were at risk of financial toxicity. At the subpopulation level, patients in the lowest income quartile, undergoing emergency surgery, black or hispanic individuals, and those undergoing surgery for esophageal or colon cancer were more likely to experience catastrophic costs following surgery (P < .001). CONCLUSION: Approximately 9 in 10 uninsured and 1 in 10 privately insured patients with cancer were at risk of financial toxicity after the surgery. Targeted interventions are needed to provide financial protection to patients undergoing the cancer treatment.

DOI： 10.1002/jso.25605

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Although lymph node metastasis (LNM) is an important prognostic indicator for patients with intrahepatic cholangiocarcinoma (ICC), the benefit and indication for lymphadenectomy remain unclear. METHODS: Patients diagnosed with ICC between 1990 and 2016 were identified in the international multi-institutional dataset. To determine the survival benefit from lymphadenectomy, the therapeutic index was calculated by multiplying the frequency of LNM in a particular group of patients by the 3-year cancer-specific survival (CSS) rate of patients with LNM in that subgroup. RESULTS: Among 471 patients who met the inclusion criteria, approximately half had LNM (n = 205, 43.5%). The median number of resected and metastatic LNs were 4 [interquartile range (IQR) 2-8] and 0 (IQR 0-1), respectively. Three-year CSS in the entire cohort was 29.9%, reflecting a therapeutic index value of 13.0. The therapeutic index was lower among patients with major vascular invasion (5.4), preoperative carcinoembryonic antigen (CEA) > 5.0 (8.2), and LNM in areas other than the hepatoduodenal ligament (5.2). Of note, a therapeutic index difference of more than 10 points was noted only when examining the number of LNs harvested [1-2 (4.1) vs. 3-6 (16.1) vs. ≥ 7 (17.8)]. CONCLUSION: The survival benefit derived from lymphadenectomy was poor among patients with major vascular invasion, CEA > 5.0, and LNM in areas other than the hepatoduodenal ligament. Resection of three or more LNs was associated with the highest therapeutic value among patients with LNM.

DOI： 10.1245/s10434-019-07483-9

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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 0.93-1.19) or blood transfusions (OR 0.90, 95% CI 0.79-1.03) with EA versus conventional analgesia (CA). The odds of prolonged LOS (OR 1.16, 95% CI 1.03-1.30) were higher with EA; the odds of in-hospital mortality were higher with conventional analgesia (OR 1.90, 95% CI 1.28-2.83). 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.

DOI： 10.1016/j.hpb.2018.12.008

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The objective of the current study was to define the impact of albumin-bilirubin (ALBI) grade on short- as well as long-term outcomes among patients with intrahepatic cholangiocarcinoma (ICC). METHODS: Patients who underwent hepatectomy for ICC between 1990 and 2016 were identified using an international multi-institutional database. Clinicopathologic factors including ALBI score were assessed using bivariate and multivariable analyses, as well as standard survival analyses. RESULTS: Among 706 patients, 453 (64.2%) patients had ALBI grade 1, 231 (32.7%) ALBI grade 2, and 22 (3.1%) had ALBI grade 3. After adjusting for all competing factors, patients with ALBI grade 2/3 had higher odds of a prolonged length-of-stay (>10 days, odds ratio [OR] = 2.37, 95% confidence interval [CI]:1.47-3.80), perioperative transfusion (OR = 2.15, 95% CI:1.45-3.18) and 90-day mortality (OR = 2.50, 95% CI:1.16-5.38). Median and 5-year overall survival (OS) for the entire cohort was 41.5 months (IQR:15.7-107.8) and 39.8%, respectively. Of note, median OS incrementally worsened with increased ALBI grade: grade 1, 49.6 months (IQR:18.3-NR) vs grade 2, 29.6 months (IQR:12.6-98.4) vs grade 3, 16.9 months (IQR:6.5-32.4; P < 0.001). On multivariable analysis, higher ALBI grade remained associated with higher hazards of death (grade 2/3: hazard ratio = 1.36, 95% CI:1.04-1.78). CONCLUSION: The ALBI score was associated with both short- and long-term outcomes following resection for ICC and could prove a useful surrogate marker to identify patients at risk for adverse outcomes.

DOI： 10.1002/jso.25486

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The aim of the current study was to develop an online calculator to predict survival after liver resection for intrahepatic cholangiocarcinoma (ICC) based on the "metro-ticket" paradigm. METHODS: Between 1990 and 2016, patients who underwent liver resection for ICC were identified in an international multi-institutional database. The final multivariable model of survival was used to develop an online prognostic calculator of survival. RESULTS: Among 643 patients, actual 5-year overall survival (OS) after resection for ICC was 42.7%. On multivariable analysis, CA19-9 > 200 (hazard ratio (HR), 2.62; 95% CI, 2.01-3.42), sum of the number and largest tumor size >7 (HR, 1.88; 95% CI, 1.46-2.42), N1 disease (HR, 2.87; 95% CI, 1.98-4.16), R1 resection (HR, 1.72; 95% CI, 1.21-2.46), poor/undifferentiated tumor grade (HR, 1.74; 95% CI, 1.25-2.44), major vascular invasion (HR, 1.47; 95% CI, 1.03-2.10), and adjuvant chemotherapy (HR, 0.64; 95% CI, 0.45-0.89) were significantly associated with survival and were included in the online calculator. The predictive accuracy of the model was good to very good as the C-statistics to predict 5-year OS was 0.696 in the training dataset and 0.672 with bootstrapping resamples (n = 5000) in the test dataset. CONCLUSION: A novel, online calculator was developed to estimate the 5-year survival probability for patients undergoing resection for ICC. This tool could help provide useful information to guide treatment decision-making and inform conversations about prognosis.

DOI： 10.1002/jso.25480

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

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 (2004-2009: 8.05 months vs. 2010-2015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of ≥6 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24-1.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04-1.49, 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.

DOI： 10.1007/s00268-019-04966-4

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: The association between body mass index (BMI) and long-term outcomes of patients with ICC has not been well defined. We sought to define the presentation and oncologic outcomes of patients with ICC undergoing curative-intent resection, according to their BMI category. METHODS: Patients who underwent resection of ICC were identified in a multi-institutional database. Patients were categorized as normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2) and obese (BMI≥30 kg/m2) according to the World Health Organization (WHO) definition. Impact of clinico-pathological factors on recurrence-free survival (RFS) was assessed using Cox proportional hazards model among patients in the three BMI categories. RESULTS: Among a total of 790 patients undergoing curative-intent resection of ICC in the analytic cohort, 399 (50.5%) had normal weight, 274 (34.7%) were overweight and 117 (14.8%) were obese. Caucasian patients were more likely to be obese (66.7%, n = 78) and overweight (47.1%, n = 129) compared with Asian (obese: 18.8%, n = 22; overweight: 46%, n = 126) and other races (obese: 14.5%, n = 17; overweight: 6.9%, n = 19)(p < 0.001). There were no differences in the presence of cirrhosis (10.9%, vs. 12.8%, vs. 12.9%), preoperative jaundice (8.6% vs. 9.5% vs. 12.0%), or levels of CA 19-9 (75, IQR 24.6-280 vs. 50.9, IQR 17.9-232 vs. 43, IQR 16.9-192.7) among the BMI groups (all p > 0.05). On multivariable analysis, increased BMI was an independent risk factor for tumor recurrence (OR 1.16, 95% CI 1.02-1.32, for every 5 unit increase). CONCLUSION: Increasing BMI was associated with incremental increases in the risk of recurrence following curative-intent resection of ICC. Future studies should aim to achieve a better understanding of BMI-related factors relative to prognosis of patients with ICC.

DOI： 10.1016/j.ejso.2019.03.004

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

BACKGROUND: Para-aortic lymph node (PALN) metastasis of colorectal cancer is rare, and the treatment strategy for PALN metastasis (PALNM) is not established in contrast to liver or lung metastases. We sought to evaluate the survival outcomes and prognostic factors among patients undergoing surgery combined with extended lymphadenectomy for PALNM from left-sided colorectal cancer. METHODS: From 1992 to 2012, 322 patients who underwent PALN dissection (PALND) synchronously with primary resection, among 1819 left-sided colorectal surgical cases, were retrospectively examined. We investigated the overall survival (OS) and prognostic factors for patients with PALNM. RESULTS: Of the 322 patients, 62 (19.3%) were histologically confirmed to have PALNM. The 5-year OS in patients with and without PALNM was 19.5% and 67.0% (p < 0.001), respectively. Among patients with PALNM, on the multivariable analysis, the positive resection margin (hazard ratio (HR) 3.61; 95% confidence interval (CI) 1.85-7.06), undifferentiated histological type ((por/muc/sig), HR 4.51; 95% CI, 2.22-9.19), ≥ 4 PALNMs (HR 3.34; 95% CI 1.53-7.31), and preoperative CEA ≥ 10 ng/mL (HR 2.1; 95% CI 1.11-4.27) were significant prognostic factors. Among R0 resected cases, the 5-year OS of the 17 cases with ≤ 3 PALNM and well/moderately differentiated adenocarcinoma was 54.2%, which was comparable to that of patients undergoing PALND and diagnosed with stage IIIC (49.6%). CONCLUSION: Patients with PALNM of colorectal cancer had a poor prognosis. However, curative resection, ≤ 3 PALNM, and well/moderately differentiated histology type were associated with the long-term survival.

DOI： 10.1007/s00384-019-03294-2

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記述言語：英語  

Background: Acute iliac arterial thrombosis during surgery is very rare complication. There were few reports on this complication relative to gastroenterological surgery, and the risk has not been recognized. Case presentation: A 70-year-old man, diagnosed with a rectal cancer (adenocarcinoma of rectum) with known history heavy cigarette smoking with no known history of peripheral vascular disease underwent a laparoscopic abdominoperineal resection. He presented severe pain in the left leg in the recovery room. A computed tomography (CT) scan revealed the complete obstruction of the left common iliac artery. A successful revasculization was achieved through a thrombotectomy and percutaneous transluminal angioplasty with a stent immediately after the diagnosis. The pain in the left leg disappeared immediately after the revasculization. Conclusion: An acute arterial thrombosis is a potential complication of the laparoscopic colorectal surgery with the lithotomy position.

DOI： 10.1093/jscr/rjz020

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記述言語：英語   掲載種別：研究論文（学術雑誌）  

Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare and poorly understood ischemic colitis that occurs in the rectosigmoid colon of predominantly young, previously healthy, male patients. A 76-year-old Japanese man presented to our hospital with a 1-year history of worsening diarrhea, lower abdominal pain, and weight loss (-6 kg). Laboratory evaluation revealed white blood cell count of 13,200/μL, C-reactive protein level of 2.0 mg/dL (normal range, 0.0-0.3), and negative results for stool culture (including Clostridium difficile). Colonoscopy showed circumferential and edematous narrowing of the sigmoid colon with deep longitude ulceration. Biopsy was done and examination of the specimen demonstrated no specific ischemia. The patient was treated with bowel rest, antibiotics, and i.v. fluids; however, his symptoms worsened. Finally, sigmoidectomy was carried out. Histological examination demonstrated significant myointimal hyperplasia of mesenteric veins leading to thickening and stenosis of the venous lumen. Therefore, the final diagnosis was IMHMV. Three months following sigmoidectomy, he was asymptomatic.

DOI： 10.1111/den.12470

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記述言語：日本語   掲載種別：研究論文（学術雑誌）  

An 85-year-old man was diagnosed with mucosa-associated lymphoid tissue (MALT) lymphoma of the colon in 20XX. Although Helicobacter pylori eradication was performed as part of the treatment, it was ineffective. He was followed-up by colonoscopy for 4 years without additional treatment and there was no interval change;however, he was lost to follow-up 6 years after the first visit. Nine years after the initial diagnosis, he presented with new MALT lymphoma lesions in the stomach and small intestine. Genetic analysis showed that a biopsy specimen was positive for API2/MALT1 fusion gene, and IgH rearrangement showed monoclonal banding between colon and stomach. This suggested disseminated monoclonal API2/MALT1-positive MALT lymphoma of the colon, stomach, and small intestine. Careful attention should be paid to the appearance of multiple lesions in MALT lymphoma.

DOI： 10.11405/nisshoshi.112.270

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