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Competing Interests: Disclosure: Kazunari Sasaki, Jane Wang, Carsten Kamphues, Stefan Buettner, Johan Gagniere, Victoria Ardilles, Katsunori Imai, Doris Wagner, Ioannis Pozios, Dimitris Papakonstantinou, Emmanouil Pikoulis, Efstathios Antoniou, Daisuke Morioka, Inger Marie Løes, Per Eystein Lønning, Peter Kornprat, Federico N. Aucejo, Hideo Baba, Eduardo de Santibañes, Klaus Kaczirek, Richard Burkhart, Itaru Endo, Katharina Beyer, Martin E Kreis, Timothy M. Pawlik, and Georgios Antonios Margonis have no conflicts of interest/competing interests to declare.

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Background: Frailty correlates with worse postoperative outcomes and higher surgical cost, but the long-term impact on healthcare use remains ill-defined. We sought to evaluate patterns of healthcare use pre- and postsurgery among patients with gastrointestinal cancer and characterize the association with frailty., Study Design: Data on patients who underwent surgical resection for liver, biliary, pancreatic, colon and rectal cancer were obtained from the SEER-Medicare database from 2005 to 2020. Frailty was assessed using the claims-based frailty index. Group-based trajectory modeling identified clusters of patients with discrete patterns of healthcare use. Multivariable regression was performed to predict cluster membership based on preoperative factors, including frailty., Results: Among 66,684 beneficiaries, 4 distinct use trajectories based on data from 12 months before and after surgical resection were identified. After a surge in use during the month of surgical resection, most patients reverted to presurgery baseline use (low: 6,588, 9.9%; moderate: 17,627, 26.4%; and high: 29,850, 44.8%). However, a notable trajectory involving 12,619 (18.9%) patients was identified, wherein surgical resection precipitated a transition from a "low" presurgery use state to a "high" use state postsurgery. Frail patients were more likely to be among those individuals who transitioned to high users (low: 4.2% vs transition: 12.6% vs high: 7.5%; p < 0.001). On multivariable analysis incorporating preoperative variables, frailty was associated with high group trajectory membership (ref: least and moderate; highest: odds ratio 4.90, 95% CI 4.49 to 5.35; p < 0.001)., Conclusions: Patients with gastrointestinal cancer demonstrated distinct clusters of healthcare use after surgical resection. Preoperative predictive models may help differentiate different healthcare use trajectories to help tailor care for patients in the postoperative period., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Recent studies have suggested that certain combinations of KRAS or BRAF biomarkers with clinical factors are associated with poor outcomes and may indicate that surgery could be "biologically" futile in otherwise technically resectable colorectal liver metastasis (CRLM). However, these combinations have yet to be validated through external studies., Patients and Methods: We conducted a systematic search to identify these studies. The overall survival (OS) of patients with these combinations was evaluated in a cohort of patients treated at 11 tertiary centers. Additionally, the study investigated whether using high-risk KRAS point mutations in these combinations could be associated with particularly poor outcomes., Results: The recommendations of four studies were validated in 1661 patients. The first three studies utilized KRAS, and their validation showed the following median and 5-year OS: (1) 30 months and 16.9%, (2) 24.3 months and 21.6%, and (3) 46.8 months and 44.4%, respectively. When analyzing only patients with high-risk KRAS mutations, median and 5-year OS decreased to: (1) 26.2 months and 0%, (2) 22.3 months and 15.1%, and (3) not reached and 44.9%, respectively. The fourth study utilized BRAF, and its validation showed a median OS of 10.4 months, with no survivors beyond 21 months., Conclusion: The combinations of biomarkers and clinical factors proposed to render surgery for CRLM futile, as presented in studies 1 (KRAS high-risk mutations) and 4, appear justified. In these studies, there were no long-term survivors, and survival was similar to that of historic cohorts with similar mutational profiles that received systemic therapies alone for unresectable disease., Competing Interests: Disclosure. None to report., (© 2024. Society of Surgical Oncology.)

Background: Regular surveillance imaging is commonly used after curative-intent resection of most solid-organ cancers to enable prompt diagnosis and management of recurrent disease. Given the fear of cancer recurrence, surveillance may lead to distress and anxiety ("scanxiety") but its frequency, severity, and management among cancer survivors are poorly understood., Methods: A systematic review of the PubMed, Embase, CINAHL, and PsycINFO databases was conducted to evaluate existing literature on anxiety and emotional experiences associated with surveillance after curative-intent cancer surgery as well as interventions aimed at reducing scanxiety., Results: Across the 22 included studies encompassing 8693 patients, reported rates of scanxiety varied significantly, but tended to decrease as time elapsed after surgery. Qualitative studies showed that scanxiety arises from various factors innate to the surveillance experience and is most prevalent in the scan-to-results waiting period. Common risk factors for scanxiety included sociodemographic and cancer-related characteristics, low coping self-efficacy, pre-existing anxiety, and low patient well-being. Conversely, reassurance was a positive aspect of surveillance reported in several studies. Trials evaluating the impact of interventions all focused on modifying the surveillance regimen compared with usual care, but none led to reduced rates of scanxiety., Conclusions: Although scanxiety is nearly universal across multiple cancer types and patient populations, it is transient and generally limited in severity. Because existing trials evaluating interventions to reduce scanxiety have not identified effective strategies to date, future research is needed to identify interventions aimed at reducing their impact on high-risk individuals., Competing Interests: Disclosure: There are no conflict of interest., (© 2024. The Author(s).)

Background: We sought to define the survival benefit of kidney transplantation versus long-term dialysis relative to waitlist time on dialysis, social vulnerability, and age among end-stage renal transplant candidates., Methods: End-stage renal disease patients who were candidates for their first deceased donor kidney transplantation between 2008 and 2020 were identified using the US Renal Data System. Survival probabilities for patient survival were compared using the restricted mean survival times (RMSTs) across different age and social vulnerability index (SVI) ranges., Results: Among 149 923 patients, 68 795 (45.9%) patients underwent a kidney transplant and 81 128 (54.1%) remained on dialysis. After propensity-score matching (n = 58 035 in each cohort), the 5-y RMST difference between kidney transplant and dialysis demonstrated an increasing trend in mean life-years gained within 5 y of follow-up relative to advancing age (<30 y: 0.40 y, 95% confidence interval, 0.36-0.44 y versus >70 y: 0.75 y, 95% confidence interval, 0.70-0.80 y). Conversely, disparities in 5-y RMSTs remained consistent relative to social vulnerability (median 5-y RMST difference: 0.62 y comparing low versus high SVI). When considering waitlist duration, stratified analyses demonstrated increasing trends across different age groups with the largest RMST differences observed among older patients aged ≥70 y. Notably, longer waitlist durations (>3 y) yielded more pronounced RMST differences compared with shorter durations (<1 y)., Conclusions: These data underscore the survival benefit associated with kidney transplantation over long-term dialysis across various age and SVI ranges. Transplantation demonstrated a greater advantage among older patients who had a longer waitlist duration., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Benzodiazepines are the third most misused medication, with many patients having their first exposure during a surgical episode. We sought to characterize factors associated with new persistent benzodiazepine use (NPBU) among patients undergoing cancer surgery., Patients and Methods: Patients who underwent cancer surgery between 2013 and 2021 were identified using the IBM-MarketScan database. NPBU was defined as one prescription filled during the 90-180 days period after surgery by patients who were previously benzodiazepine naïve. The association of variables with perioperative benzodiazepine use and NPBU was assessed using multivariable regression., Results: Among 34,637 patients with cancer (breast: n = 5460, 15.8%; lung: n = 3479, 10.0%; esophagus: n = 384, 1.1%; gastric: n = 852, 2.5%; liver: n =502, 1.4%; biliary: n = 268, 0.8%; pancreas: n = 1290, 3.7%; colon: n = 10,838, 31.3%; rectum: n = 2566, 7.4%; prostate: n = 8998, 26.0%), most were male (n = 19,687, 56.8%) with a median age of 57 years (IQR 51-61 years). Overall, 8.8% of patients had perioperative benzodiazepine use and 7.5% of patients developed NPBU following surgery. On multivariable analyses, perioperative benzodiazepine exposure (ref. no perioperative exposure: OR 2.00, 95% CI 1.68-2.38) and higher perioperative dose of > 32.0 lorazepam milligram equivalents (LME) (ref. < 10 LME: OR 2.42, 95% CI 2.01-2.92) were independently associated with higher odds of NPBU. Notably, male patients had lower odds of NPBU versus female patients (OR 0.80, 95% CI 0.68-0.94)., Conclusions: Roughly 1 in 13 commercially insured patients developed NPBU following surgery for cancer. Judicious use of benzodiazepines among patients with high risk of misuse can mitigate NPBU to help avoid benzodiazepine-related complications such as overdose or accidental deaths., Competing Interests: Disclosures: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no funding or financial support. The authors declare no conflict of interest., (© 2024. Society of Surgical Oncology.)

Background: We sought to define whether and how hepatic ischemia/reperfusion (I/R) as manifested by perioperative aspartate aminotransferase (AST) and alanine aminotransaminase (ALT) levels impact long-term outcomes after curative-intent resection of hepatocellular carcinoma (HCC)., Patients and Methods: Intrasplenic injection of HCC cells was used to establish a murine model of HCC recurrence with versus without I/R injury. Patients who underwent curative resection for HCC were identified from a multi-institutional derivative cohort (DC) and separate external validation (VC) cohort. Perioperative changes of transaminase levels were examined relative to the recurrence-free (RFS) and overall survival (OS) among patients following HCC resection., Results: Mice exposed to hepatic I/R injury were more likely to experience tumor recurrence, as well as higher luminescence signal intensity (all p < 0.05) versus mice with no I/R injury. Relative changes between AST and ALT (sum of AST/ALT ratios, SAAR) on postoperative day (POD) 1 and POD 3 AST 1 ALT 1 and AST 3 ALT 3 were calculated using the formula: SAAR = 1 2 AST 1 ALT 1 + AST 3 ALT 3 via Fourier transform theory. Among 734 patients in DC, the median SAAR was 2.1. After adjusting for other competing risk factors, SAAR ≥ 2.0 remained strongly associated with risk of postoperative recurrence (ref. SAAR < 2.0, HR 1.32, p = 0.03), whereas SAAR ≥ 3.5 was associated with risk of postoperative mortality (ref. SAAR < 3.5, HR 1.86, p < 0.01). SAAR demonstrated good accuracy to predict postoperative recurrence (c-index 0.724, 0.731) and mortality (c-index 0.655, 0.765) in DC and VC, respectively., Conclusions: Use of routine labs such as AST and ALT can help identify patients at high risk of recurrence and mortality following HCC resection., Competing Interests: Disclosure: The authors declare no conflict of interest., (© 2024. Society of Surgical Oncology.)

Introduction: We sought to assess the variations in practice metrics and billing practices among US Medical Graduates (USMGs) and International Medical Graduates (IMGs) in surgical oncology who serve a fee-for-service population., Methods: Medicaid Services Medicare fee-for-service provider utilization and payment files were used to obtain publicly available data between January 1, 2021, and December 31, 2021. Comparisons were conducted using the t-test for parametric variables and Wilcoxon rank-sum for nonparametric variables., Results: A total of 952 surgical oncologists (IMGs: n = 102 [10.7%]) were included in the analytic cohort. The average risk score among beneficiaries treated by IMGs was higher than USMGs (1.70 [0.04] vs. 1.46 [0.02], p < 0.001) and IMGs also had a higher total number of unique codes (47.0 [IQR: 36.0-69.0] vs. 38.0 [IQR: 24.0-60.0], p < 0.05). IMG surgical oncologists had higher payment-per-service amounts ($236.56 [10.34] vs. $196.20 [$2.65]; p < 0.05), charge-per-service amounts ($1242.48 [$83.14] vs. $1014.89 [$26.13]; p < 0.05), and higher total submitted charges ($400,373.26 [$342,978.45] vs. $360,020.29 [$523,675.91]; p < 0.05). IMGs provided a higher percentage of procedural services (34.1% vs. 27.9%; p < 0.001) and treatment services (2.1% vs. 1.9%; p < 0.001) versus USMGs. Female surgical oncologists, particularly female IMGS, billed lower annual mean Medicare charges (female IMGS: $295,383 vs. male IMGs: $424,407 vs. female USMGs: $294,168 vs. male USMGs: $414,543; p < 0.001)., Conclusions: IMGs provided more procedural services, cared for patients with a higher average risk score, and performed a greater variety of procedures compared with USMGs. Consequently, IMGs had higher mean annual charges, payment-per-service, and charge-per-service amounts., (© 2024 The Author(s). World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Poor infrastructure in deprived areas may hinder access to health care, and a lack of socioeconomic resources can prevent patients from remaining at home after discharge. This study sought to assess the association between the Area Deprivation Index (ADI) and days at home within 90 days (DAH-90) after a complex operative procedure., Methods: Patients who underwent an elective operation for a gastrointestinal cancer between 2016 and 2020 were identified from the Medicare Standard Analytic Files. County-level ADI was calculated using a weighted average of ADI percentiles for each census block within a county. The association between ADI and DAH-90 and the impact of DAH-90 on 1-year expenditures and 1-year mortality were evaluated., Results: Among 72,452 patients who underwent a surgical procedure, median patient age was 75 years (interquartile range [IQR] 71-81) and 54.3% of patients had a Charlson Comorbidity Index higher than 2. A +0.2 increase in ADI was associated with 12.6% lower odds of achieving high DAH-90 (adjusted odds ratio [aOR], 0.874; 95% confidence interval [CI], 0.845-0.903) compared with low DAH-90. Notably, high DAH-90 (mean difference, -55,614$; 95% CI, -56,540$ to -54,687$) and medium DAH-90 (mean difference, -39,538$; 95% CI, -40,194$ to -38,882$) were associated with markedly decreased 1-year total expenditures, as well as lower 1-year mortality compared with patients who spent fewer days at home after surgery., Conclusions: Increasing area deprivation was associated with higher likelihood of spending fewer days at home after a complex cancer surgical procedure. Patients spending fewer days at home were far more likely to die within 1 year and experienced higher health care costs., Competing Interests: Disclosure: There are no conflicts of interest., (© 2024. Society of Surgical Oncology.)

Background and Objectives: Social and environmental injustice may influence accessibility and utilization of health resources, affecting outcomes of patients with cancer. We sought to assess the impact of socio-environmental inequalities on cancer screening and mortality rates for breast, colon, and cervical cancer., Methods: Data on cancer screening and environmental justice index social and environmental ranking (SER) was extracted from the CDC PLACES and ATSDR, respectively. Mortality rates were extracted using CDC WONDER. Screening targets were defined by Healthy People 2030., Results: Among census tracts, 14 659 were classified as "low," 29 534 as "moderate," and 15 474 as "high" SER (high SER denoting greater socioenvironmental injustice). Screening targets were achieved by 31.1%, 16.2%, and 88.6% of tracts for colon, breast, and cervical cancers, respectively. High SER tracts were much less likely to reach screening targets compared with low SER tracts for colon (OR: 0.06), breast (OR: 0.24), and cervical cancer (OR: 0.05) (all p < 0.001). Median mortality rates for low and high SER were 16.7, and 21.0, respectively, for colon, 13.4, 14.75, respectively, for breast, and 1.0, 1.6, respectively, for cervical cancer (all p < 0.05)., Conclusion: Socioenvironmental disparities negatively influence cancer screening and mortality, underscoring the need to reduce environmental injustices through measures like equitable cancer screening services., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Background: Lymphatic route is the main pathway for gastric cancer (GC) spread, and lymph node (LN) involvement is a major prognostic factor after curative resection. The aim of this study was to assess the outcomes of specific LN station dissection., Methods: Patients with locally advanced (cT2-4N0-3M0) GC who underwent multimodal treatment between 2013 and 2023 were included in the study. Patients who had not undergone gastrectomy, had early (cT1) or metastatic GC, who had undergone multiorgan resections, palliative care, had died before the end of curative-intent planned treatment, or had incomplete clinical or pathological information were excluded. The primary endpoint was the development of serious complications, and the secondary outcome was OS., Results: Mulivariable analysis revealed, that among patients who received neoadjuvant chemotherapy (NAC), it was observed that station 10 lymphadenectomy was associated with a higher risk of serious postoperative complications. (27.6 % vs 8.7 %; OR = 3.28) Among the no-NAC group, it was observed that station 13 lymphadenectomy was associated with a higher risk of serious postoperative complications. (57.1 % vs 13.2 %; OR = 6.96). Among the NAC group, a lower risk of death was observed in patients with station 8 (HR = 0.53) or 11 lymphadenectomy (HR = 0.53)., Conclusion: While D2 lymphadenectomy remains crucial, particularly in in high-volume, experienced GC centers, the necessity of a more extensive D2+ lymphadenectomy is not supported by our findings. Moreover, we aimed to highlight the importance of tailored surgical approaches and emphasize the significance of LN station dissection in influencing both short-term complications and long-term survival outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objective: To characterize the association between type of fellowship training and patient outcomes following hepatopancreatic (HP) surgery across different surgeon career stages using a national representative cohort of Medicare beneficiaries., Background: The current state of training in HPB surgery in North America is defined through three main pathways: the Complex General Surgical Oncology (CGSO), the Americas HPB Association fellowship, and the American Society of Transplant surgeons fellowship. Each pathway offers a unique perspective on HPB surgery with different number of training years, yet outcomes of graduates performing HP surgery relative to type of fellowship training have not been defined., Methods: Medicare claims were used to identify patients who underwent HP surgery for cancer between 2016-2021. The association of textbook outcomes (TO), defined as no postoperative complications, no prolonged LOS, no 90-day mortality and no 90-day readmission, relative to different fellowship pathways was examined., Results: Overall, 15,411 cancer operations (pancreatectomy: 11,003, 71.4%; hepatectomy: 4,408, 28.6%) were performed by 1,030 HPB surgeons. A total of 9,390 patients (60.9%) were operated on by a CGSO/SONC graduate, 2,315 patients (15.0%) by an HPB fellowship graduate and 3,706 (24.1%) by a transplant fellowship graduate. Patients who were operated on by an HPB fellowship graduate more frequently had a higher Charlson score (>5: 44.8% vs. 38.1%) and more frequently were operated on an urgent basis (7.7% vs. 6.1%) compared with individuals treated by CGSO/SONC graduates. After adjusting for patient, procedural, hospital, and surgeon related factors, the likelihood of TO following an HP operation by an HPB fellowship graduate was 47.7% versus 45.2% among CGSO (% difference 2.7%) and 42.8% among transplant fellowship graduates (% difference 4.9%, P=0.01). While the probability of TO was higher among surgeons having completed a dedicated HPB fellowship during early (1-7th year of independent practice, P=0.032) and middle (8-14th year, P<0.001) career stages, the probability of TO did not differ based on fellowship type among late career surgeons (>15th year, P=0.257)., Conclusions: Achievement of TO following an HP procedure was higher among surgeons who had completed a dedicated HPB fellowship, especially during early and middle career stages. Further efforts should be made to enhance HP surgery exposure and training for CGSO fellows interested in a career in HPB surgery., Competing Interests: Conflict of interest: none, (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Neoadjuvant therapy (NT) is increasingly used for gastrointestinal (GI) and hepatopancreatobiliary (HPB) cancers. Risk factors for surgical attrition during NT are poorly understood. A planned secondary analysis of patient-reported outcomes (PROs) from a prospective cohort study of patients undergoing NT was performed to identify factors associated with surgical attrition., Methods: Adult patients with GI/HPB cancer receiving NT were provided a mobile phone application administering QOL assessments every 30 days and measuring mood/symptoms until NT completion. Univariate and multivariate logistic regression were performed to determine the association between demographic, clinical characteristics, and PROs with surgical attrition (no surgery (NS) versus surgery or watchful waiting (SWW)). Mixed-effects regression models evaluated trends of QOL and symptoms between the cohorts., Results: Among 104 enrolled patients, mean age was 60.5 ± 11.5 years, 57 (55%) were male, and 95 (91%) were Caucasian. After a mean duration of 3.4 months of NT, 76 (73%) patients underwent SWW, while 28 (27%) did not (NS). Cancer type (HPB vs GI, OR 7.0, CI 2.7-19.3, p < 0.001), comorbidities (OR 1.72, CI 1.0-2.99, p = 0.05), and severe complications during NT (OR 4.2, CI 1.2-15.3, p = 0.03) were associated with NS. There were no differences between longitudinal QOL scores or PROs among patients who underwent SWW versus NS except for the lack of appetite, which was associated with NS (OR 3.6, CI 1.0-12.2, p = 0.04)., Conclusions: Among patients undergoing NT for GI/HPB malignancies, type of cancer, comorbidities, and severe complications during NT were associated with failure to undergo surgery, whereas QOL and PROs were largely not., Competing Interests: Declarations. Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the clinical scientific review committee and institutional review board of The Ohio State University (#2020C0071). Consent to Participate: Informed consent was obtained from all individual participants included in the study. Competing Interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Competing Interests: Disclosure: The authors declare no conflicts of interest.

Background: The value of serum biomarkers, particularly alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II), gains increasing attention in prognostic evaluation and recurrence monitoring for patients with hepatocellular carcinoma (HCC). This study investigated the implications of serological incomplete conversion (SIC) of these 2 biomarkers as prognostic indicators for long-term outcomes after HCC resection., Methods: A multicenter observational study was conducted on a cohort of HCC patients presenting with AFP (>20 ng/mL) or PIVKA-II (>40 mAU/mL) positivity who underwent curative-intent resection. Based on their postoperative AFP and PIVKA-II levels at first postoperative follow-up (4~8 weeks after surgery), these patients were stratified into the serological incomplete conversion (SIC) and serological complete conversion (SCC) groups. The study endpoints were recurrence and overall survival (OS)., Results: Among 1755 patients, 379 and 1376 were categorized as having SIC and SCC, respectively. The SIC group exhibited 1- and 5-year OS rates of 67.5% and 26.3%, with the corresponding recurrence rates of 53.2% and 79.0%, respectively; while the SCC group displayed 1- and 5-year OS rates of 95.8% and 62.5%, with the corresponding recurrence rates of 16.8% and 48.8%, respectively (both P < .001). Multivariate Cox regression analysis demonstrated that postoperative SIC was an independent risk factor for both increased recurrence (HR: 2.40, 95% CI, 2.04-2.81, P < .001) and decreased OS (HR: 2.69, 95% CI, 2.24-3.24, P < .001)., Conclusion: The results emphasize that postoperative incomplete conversion of either AFP or PIVKA-II is a significant prognostic marker, indicating a higher risk for adverse oncologic outcomes following HCC resection. This revelation has crucial implications for refining postoperative adjuvant therapy and surveillance strategies for HCC patients., (© The Author(s) 2024. Published by Oxford University Press.)

Introduction: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) has been introduced as a superior term to describe steatosis on a background of metabolic dysregulation and is slated to become the leading cause of HCC worldwide, as the incidence of metabolic comorbidities is increasing. As such, MASLD has evolved into an important public health issue, potentially leading to higher rates of liver mortality and end-stage liver disease. To this end, understanding the association between MASLD and HCC may allow for the identification of better interventions and novel therapeutic strategies., Areas Covered: The authors provide a review of current knowledge on HCC development among patients with MASLD, with insights into molecular pathways and current and future therapeutic strategies., Expert Opinion: MASLD has a strong association with the risk of HCC development, as metabolic comorbidities induce dysregulation in molecular pathways, leading to insulin-resistance, oxidative stress, and chronic inflammation, thus causing progression to cirrhosis and eventually to HCC. Therapeutic strategies focused on reducing diabetes-associated complications, as well as the prevalence of obesity and smoking can improve patient outcomes and reduce HCC incidence. Future studies on the molecular background of metabolic alterations may help devise new therapeutic approaches aiming to improve the current management of MASLD-HCC.

Introduction: The advanced lung cancer inflammation index (ALI), which combines inflammation and nutrition data, was recently proposed as a prognostic biomarker. We assessed the impact of ALI on overall survival (OS) among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC)., Methods: Patients who underwent surgery for ICC were identified from an international cohort. ALI was calculated as body-mass index (BMI)∗albumin/neutrophil-to-lymphocyte ratio; patients were categorized into "low-" and "high-ALI" using log-rank statistics. The impact of ALI on OS was compared against other inflammatory markers (i.e., neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], systemic immune inflammation index [SII = platelets∗NLR]) using Harrell's Concordance index (C-index) and the Akaike Information Criterion (AIC). To minimize intergroup differences, propensity score matching was employed., Results: Among 1045 patients, more than one-half of individuals underwent major hepatectomy (n = 582, 55.7 %), median tumor size was 5.5 cm (IQR, 3.8-7.8), and median ALI was 38.9 (IQR 26.5-57.2). On multivariate analysis, low ALI was an independent risk factor for worse OS (HR 1.21, 95 % CI 1.01-1.46; p = 0.04). Patients with low ALI had worse 5-year OS (36.9 % vs. 49.9 %; p < 0.001), which remained significant after PSM (36.9 % vs. 41.3 %; p = 0.039). ALI had a comparable discriminatory ability compared with NLR, PLR, and SII (C-index: 0.646 vs. 0.644 vs. 0.640 vs. 0.641, respectively), yet had a lower AIC (5475.31 vs. 5546.80 vs. 5550.45 vs. 5548.62, respectively) suggesting slightly better model fit and accuracy., Conclusions: ALI was an independent predictor of OS among patients undergoing surgery for ICC. Nutritional and inflammatory markers should be incorporated into predictive models to improve prognostic stratification., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Gastrointestinal (GI) cancer diagnosis can adversely affect the mental health (MH) of household members, including spouses and children. We sought to examine potential changes in MH claims in households following an index patient's GI cancer diagnosis., Methods: Households of patients with a GI cancer diagnosis were identified using the IBM MarketScan database (2014-2019) and matched with households of patients without cancer. MH-related visits of spouses and children were assessed in the 12 months before and after the index date of diagnosis. Changes were compared between the two cohorts using difference-in-difference (DID) analysis., Results: Among 40,650 households in the spouse analysis and 20,014 households in the child analysis, 25.1% (n = 10,210) and 26.8% (n = 5,368) were households in which there was a patient with a GI cancer. Univariable DID analysis demonstrated that households with a GI cancer had a greater increase in anxiety-related (spouses, 2.2% vs 0.7%; children, 2.0% vs 1.1%), mental illness (MI)-related (spouses, 3.2% vs 1.2%; children, 3.0% vs 1.6%), and overall MH-related visits (spouses, 3.3% vs 1.4%) versus the control group (all P < .05). In adjusted DID analysis, spouses, children, and households with a GI cancer diagnosis had a 2.1%, 1.6%, and 2.3% absolute risk increase of MI-related visits, respectively, compared with non-cancer households (all P < .05)., Conclusion: In a cohort of privately insured households, coinsured spouses and children of patients with a GI cancer diagnosis had a higher risk of MH-related claims versus households without a GI cancer diagnosis. The data highlight the importance of family counseling and psychological support when a loved one is diagnosed with cancer., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Background: Gallbladder cancer (GBC) has been associated with high rates of recurrence and dismal prognosis even after curative-intent resection. The prognostic utility of the modified albumin-bilirubin (mALBI) score among individuals undergoing curative-intent resection for GBC has not been determined., Methods: Patients who underwent radical resection for GBC between 2000 and 2022 were identified from an international, multi-institutional database. Preoperative albumin and bilirubin levels were used to calculate the mALBI score. The relationship among mALBI score, overall survival (OS), and recurrence-free survival (RFS) was examined., Results: Among 269 patients who underwent radical resection for GBC, 161 (59.9%) had mALBI grade 1, 48 (17.8%) had grade 2a, 47 (17.5%) had grade 2b, and 13 (4.8%) had mALBI grade 3. After surgery, compared with patients with a low mALBI grade (grade 1/2a), individuals with a high mALBI grade (grade 2b/3) had worse 5-year OS (54.4% vs 19.2%, respectively; P < .001) and RFS (42.0% vs 17.8%, respectively; P < .001). On multivariable analysis, after controlling for relevant clinicopathologic variables, individuals with a high mALBI score remained independently associated with higher risks of death and recurrence (OS: hazard ratio [HR], 2.38 [95% CI, 1.50-3.79]; RFS: HR, 2.12 [95% CI 1.41-3.20]) versus patients with a low mALBI score after curative-intent resection for GBC. Of note, mALBI score was associated with incrementally worse survival within T2, T3, and N+ categories, whereas classic American Joint Committee on Cancer subclassifications failed to distinguish patients with long-term survival., Conclusion: The mALBI score presents a simple, objective measure of hepatic functional reserve and may be a useful prognostic tool for patients undergoing curative-intent resection for GBC., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Background: There is significant variation in inpatient expenditures among physicians and hospitals. This study aimed to characterize the association between variation in physician spending and short-term outcomes among patients undergoing surgery for pancreatic ductal adenocarcinoma (PDAC) and colorectal cancer (CRC)., Methods: Patients who underwent surgery for PDAC and CRC from 2010 to 2020 were identified using the Surveillance, Epidemiology, and End Result-Medicare-linked database. The cohort was divided into quartiles based on adjusted physician spending, and multivariate models were used to assess the association between physician spending and patient outcomes., Results: Among 27,596 Medicare beneficiaries, 25,615 (92.8%) underwent surgery for CRC and 1981 (7.2%) underwent surgery for PDAC. Of the variations in spending, 79.9% were due to patient-level factors, 13.3% were due to hospital characteristics, and 6.8% were due to surgeon-level variables. On multivariate analysis, there was no association between physician spending and 30-day readmission (with complications: first quartile [Q1], reference; Q4: odds ratio [OR], 1.10; 95% CI, 0.86-1.41; P = .123; without complications: Q1, reference; Q3, stage IV: OR, 0.97; 95% CI, 0.68-1.40; P = .882) or between physician spending and 30-day mortality (without complications: Q1, reference; Q2, stage I: OR, 1.17; 95% CI, 0.45-3.01; P = .804). However, an increase in physician spending was associated with higher 30-day mortality among patients with complications (Q1, reference; Q4: OR, 2.28; 95% CI, 1.72-3.03; P < .001)., Conclusion: There was more variation in healthcare spending across hospitals than across individual physicians. No consistent association between variation in physician spending and patient outcomes was noted. Wasteful spending can be reduced through targeted interventions aimed at reducing variations at the physician and hospital levels., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Background: Despite improvements in intraoperative and postoperative outcomes of laparoscopic cholecystectomy (LC), spilled gallstones (SGs) after LC remain a significant yet often overlooked complication, occurring in 1% to 40% of cases. This review discusses the most recent updates regarding the risk factors, presentations, complications, diagnosis, management, and prognosis of SGs after LC., Methods: A comprehensive systematic review was conducted using MEDLINE/PubMed, Google Scholar, Cochrane Library, and the Web of Science databases, with the range of search dates being between January 2015 and July 2024, regarding SG incidence, management, and complications., Results: Risk factors for SGs after LC include intraoperative gallbladder perforation because of poor operational environment, quantity, size, and type of stone (pigment, cholesterol rich, or mixed); presence of adhesions or anatomic variations; and insufficient surgical training. Of note, 60% of SG complications are abscesses from bacterial infections, which can progress to peritonitis, fistulas, lung/liver abscesses, and choledocholithiasis. SGs were associated with delayed presentation of unexpected clinical problems, with even diagnosis. Although treatment depends on the severity of the complication, when SGs are identified through imaging, often ultrasound and computed tomography, minimally invasive approaches and antibiotic courses are viable first-line approaches., Conclusion: Although LC-associated spillage of gallstones is rare, the complications can be a serious cause of morbidity. Therefore, proper notification of operative complications, a high index of suspicion for patients with a previous history of LC, and awareness of appropriate diagnostic modalities are key variables for the early diagnosis and prevention of SG-related complications., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Background: US News and World Report (USNWR) hospital rankings influence patient choice of hospital, but their association with surgical outcomes remains ill-defined. We sought to characterize clinical outcomes and costs of surgery for colon cancer among USNWR top ranked and unranked hospitals., Methods: Using Medicare Standard Analytic Files, patients aged ≥65 years undergoing surgery for colon cancer were identified. Hospitals were categorized as 'ranked' or 'unranked' based on USNWR cancer hospital rankings. One-to-one matching was performed between patients treated at ranked and unranked hospitals, and clinical outcomes and costs of surgery were compared., Results: Among 50 ranked and 2522 unranked hospitals, 13,650 patient pairs were compared. Overall, 30-day mortality was 2.13% in ranked hospitals versus 3.68% in unranked hospitals (p < 0.0001), and the overall paired cost difference was $8159 (p < 0.0001). As patient risk increased, 30-day mortality differences became larger, with the ranked hospitals having 30-day mortality of 7.59% versus 11.84% for unranked hospitals among the highest-risk patients (p < 0.0001). Overall paired cost differences also increased with increasing patient risk, with cost of care being $72,229 for ranked hospitals versus $56,512 for unranked hospitals among the highest-risk patients (difference = $14,394; p = 0.02). The difference in cost per 1% reduction in 30-day mortality was $9009 (95% confidence interval [CI] $6422-$11,597) for lowest-risk patients, which dropped to $3387 (95% CI $2656-$4119) for highest-risk patients (p < 0.0001)., Conclusion: Treatment at USNWR-ranked hospitals, particularly for higher-risk patients, was associated with better outcomes but higher-cost care. The benefit of being treated at highly ranked USNWR hospitals was most pronounced among high-risk patients., (© 2024. The Author(s).)

Introduction: Locoregional therapies are a mainstay of treatment for patients with neuroendocrine liver metastases (NELM), yet the optimal transarterial approach remains undefined and recent studies have raised concern over the safety of transarterial chemoembolization (TACE)., Methods: Patients with NELM who underwent TACE or transarterial embolization (TAE) at a single institution between 2000-2022 were retrospectively reviewed. Propensity score matching (PSM) controlling for age, sex, bilateral disease, tumor size, lobar embolization, grade, and extrahepatic disease was utilized to compare short- and long-term outcomes., Results: Among 412 patients with NELM, 329 underwent TACE and 83 TAE. Mean age was 60.7 ± 11.1 years. Patients primarily presented with synchronous (69.2%), bilateral (84.2%), and G1 disease (48.8%) and underwent staged procedures (55.8%). Following PSM, TACE was associated with slightly worse post-procedure laboratory values, but no difference in complications compared to TAE (23.3%vs29.3%, p = 0.247). TACE was associated with improved mean PFS (21.8vs10.7 months, p = 0.002), but no difference in radiographic size, chromogranin level, or median overall survival (50.0 months vs not met, p = 0.833)., Conclusion: Among patients with NELM, TACE was associated with similar short-term outcomes and improved PFS, but no difference in OS compared to TAE. These findings highlight the need for additional research on the optimal locoregional therapy for NELM., (Copyright © 2024 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: When considering hepatectomy for elderly HCC patients, it's essential to assess surgical safety and survival benefits. This study investigated the impact of preoperative frailty, assessed with the Clinical Frailty Scale (CFS), on outcomes for octogenarians undergoing HCC hepatectomy., Methods: A retrospective cohort study of octogenarians who had hepatectomy for HCC between 2010 and 2022 at 16 hepatobiliary centers was conducted. Patients were categorized as frail or non-frail based on preoperative CFS, with frailty defined as CFS ≥5. The primary endpoints were overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS), with perioperative outcomes as secondary endpoints., Results: Among 240 octogenarians, 105 were characterized as being frail. Frail patients had a higher incidence of postoperative 30-day morbidity and postoperative 30-day and 90-day mortality versus non-frail patients. Meanwhile, 5-year OS, RFS and CSS among frail patients were lower compared with non-frail patients. Univariable and multivariable analysis revealed that preoperative frailty was an independent risk factor of postoperative 30-day morbidity (OR: 2.060), OS (HR: 2.384), RFS (HR: 2.190) and CSS (HR: 2.203)., Conclusion: Preoperative frailty, as assessed by the CFS, was strongly associated with both short-term outcomes and long-term survival among octogenarians undergoing hepatectomy for HCC. Incorporating frailty assessment into the preoperative evaluation may help optimize patient selection and perioperative care., (Copyright © 2024 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: The impact of hospital procedural volume on outcomes after hepatectomy relative to other facility-related factors remains unclear. We sought to define the comparative impact of hospital volume compared with other facility-related factors on postoperative outcomes among Medicare beneficiaries undergoing hepatectomy., Methods: Data on patients who underwent hepatectomy between 2013 and 2021 were collected from the Medicare Standard Analytic Files and linked with facility-level data from the American Hospital Association Survey databases. Hospital volume was stratified into high- (top 10%) and low-volume centers. Propensity score matching was used to account for variable imbalances in patient characteristics among high-compared with low-volume centers. Mediation analysis was employed to delineate facility-related factors responsible for the impact of hospital volume on outcomes with a specific focus on incidence of complications, in-hospital mortality, and failure to rescue., Results: The analytic cohort included 22,969 patients from 340 institutions. After propensity score matching, receipt of surgery at a high-volume center was associated with a lower likelihood of postoperative complications (39.9% vs 41.7%, P = .01), in-hospital mortality (2.2% vs 2.8%, P = .02), and failure to rescue (5.4% vs 6.5%, P = .04) versus low-volume centers. Mediation analysis revealed that hospital capacity (bed capacity and nurse-to-bed ratio) contributed the most to the variations in risk of complications and in-hospital mortality, whereas liver transplant program status had the largest impact on failure to rescue., Conclusions: Hospital volume is a significant determinant of postoperative outcomes after hepatectomy, with hospital capacity and liver transplant program status being important mediators of this effect. Centralization and optimal resource distribution are important to achieve favorable outcomes following liver resection., Competing Interests: Conflicts of interest/Disclosure The authors have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Racial and sex disparities in the incidence and outcomes of patients with intrahepatic cholangiocarcinoma (iCCA) exist, yet potential genomic variations of iCCA based on race and sex that might be contributing to disparate outcomes have not been well studied., Methods: Data from the American Association for Cancer Research Project GENIE registry (version 15.0) were analyzed to assess genetic variations in iCCA. Adult patients (age >18 years) with histologically confirmed iCCA who underwent next-generation sequencing were included in the analytic cohort. Racial and sex variations in genomic profiling of iCCA were examined., Results: The study enrolled 1068 patients from 19 centers (White, 71.9%; Black, 5.1%; Asian, 8.4%, other, 14.6%). The male-to-female ratio was 1:1. The majority of the patients had primary tumors (73.7%), whereas 23.0% had metastatic disease sequenced. While IDH1 mutations occurred more frequently in White versus Black patients (20.8% vs. 5.6%; p = 0.021), FGFR2 mutations tended to be more common among Black versus White populations (27.8% vs. 16.1%; p = 0.08). Males were more likely to have TP53 mutations than females (24.3% vs. 18.2%, p = 0.016), whereas females more frequently had IDH1 (23.3% vs 16.0 %), FGFR2 (21.0% vs. 11.3%), and BAP1 (23.4% vs. 14.5%) mutations than males (all p < 0.05). Marked variations in the prevalence of other common genomic alterations in iCCA were noted across different races and sexes., Conclusion: Distinct genomic variations exist in iCCA across race and sex. Differences in mutational profiles of iCCA patients highlight the importance of including a diverse patient population in iCCA clinical trials as well as the importance of recognizing different genetic drivers that may be targetable to treat distinct patient cohorts., (© 2024. The Author(s).)

Background: We sought to characterize the benefit of lymphadenectomy among patients undergoing curative-intent surgery for perihilar cholangiocarcinoma (pCCA) utilizing the therapeutic index., Methods: Data on patients who underwent curative-intent resection for pCCA were obtained from 8 high-volume international hepatobiliary centers. Multivariable Cox regression analysis was used to assess clinicopathological factors associated with overall survival (OS). The therapeutic index was determined to assess the therapeutic benefit of lymphadenectomy., Results: Among 341 patients, median number of lymph nodes (LNs) evaluated was 7 (IQR: 4-11). A total of 127 (37.2 %) patients underwent lymphadenectomy of station 12 only, while 146 (42.8 %) patients had LNs from stations 12 plus 8 ± 13 harvested. On multivariable analysis, lymphadenectomy of stations 12 plus 8 ± 13 was associated with improved OS (referent, station 12 only: HR 0.51, 95%CI 0.32-0.80). The therapeutic index was highest among patients who underwent LN evaluation of stations 12 plus 8 ± 13 (33.1) and had ≥6 LNs harvested (26.3)., Conclusion: At the time of surgery of pCCA, lymphadenectomy should include station 12, as well as stations 8 and 13, with the goal to evaluate ≥6 LNs to ensure optimal staging and maximize the therapeutic benefit for patients., Competing Interests: Conflicts of interest None declared., (Copyright © 2024 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Transplant recipients undergoing surgery may represent a vulnerable population because of transplant-related comorbidities as well as reliance on immunosuppressive medications. We sought to characterize the association of prior transplant status on postoperative outcomes among patients undergoing major non-transplant-related surgical procedures., Methods: Data on patients who underwent a major surgical procedure (pneumonectomy, coronary artery bypass graft, abdominal aortic aneurysm repair, Whipple, colectomy) between 2016 and 2020 were obtained from the Nationwide Readmission Database. After balancing the 2 cohorts using entropy balancing, multivariable regression models were used to assess the relationship between post-transplant status and patient outcomes., Results: Among 1,818,973 patients, 0.45% (n = 8,212) had a history of solid organ transplantation (liver: n = 1,773, 21.6%; heart/lung: n = 1,087, 13.2%; kidney/pancreas: n = 4,891, 59.6%; and multiple: n = 461, 5.6%). In the unmatched cohort, patients who had a history of organ transplant were more likely to be male (64.1% vs 57.7%) and have Medicare insurance (71.7% vs 59.3%) (both P < .001). On multivariable analysis, prior transplant recipient status was associated with higher odds of postoperative complications (odds ratio 1.30, 95% confidence interval 1.22-1.38), 30-day readmission (odds ratio 1.42, 95% confidence interval 1.31-1.54), and in-hospital mortality (odds ratio 1.20, 95% confidence interval 1.03-1.40) (all P < .05). Moreover, organ transplantation was associated with higher index hospitalization costs (14.4% difference, 95% confidence interval 14.1%-14.6%) and 30-day postdischarge costs (16.2% difference, 95% confidence interval 15.3%-17.0%) (both P < .001)., Conclusions: Prior transplant recipient status was associated with adverse clinical and financial outcomes following subsequent major surgery. Prior history of transplant may be an important factor to incorporate into risk stratification of patients undergoing subsequent major surgical procedures., Competing Interests: Conflict of Interest/Disclosure The authors declare no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The effect of "time to surgery (TTS)" on outcomes for curative-intent hepatectomy of hepatocellular carcinoma (HCC) remains debated. The interaction between tumor burden score (TBS) and TTS remains unclear. We sought to evaluate the effects of TBS and TTS on long-term HCC outcomes., Methods: Patients with HCC who underwent curative-intent hepatectomy (2000-2022) were analyzed from a multi-institutional database and categorized by TTS (≤60 or >60 days). Overall survival (OS) and cancer-specific survival were assessed., Results: Among 910 patients, median TTS estimates were 22 days in the short TTS group (n = 485) and 120 days in the long TTS group (n = 425). Patients with long TTS were older and were more likely to have American Society of Anesthesiologists class >2, diabetes mellitus, and cirrhosis. There was no difference in median TBS among patients who had short versus long TTS (4.61 vs 5.00, respectively). In addition, there was no difference in 5-year OS (70.0% vs 63.1%, respectively; P =.05). On multivariate analysis TBS (hazard ratio [HR], 1.07; 95% CI, 1.03-1.11; P <.001), log alpha-fetoprotein (HR, 1.08; 95% CI, 1.01-1.14; P =.02), and albumin-bilirubin score (HR, 2.52; 95% CI, 1.66-3.82; P <.001) were associated with OS. In contrast, TTS was not associated with OS (HR, 1.18; 95% CI, 0.78-1.77; P =.43). Interaction analysis demonstrated that TBS was asssociated with OS among patients with short TTS (HR, 1.12; 95% CI, 1.07-1.17; P <.001), but not among patients with long TTS (HR, 0.98; 95% CI, 0.91-1.05; P =.56). Among patients with low TBS (≤5), higher mortality was observed with long TTS versus short TTS (5-year OS: 82.4% vs 63.0%, respectively; P =.001); however, TTS was not associated with OS among patients with high TBS (5-year OS: 57.9% vs 63.3%, respectively; P =.92). Multivariate analysis demonstrated that long TTS was a risk factor for OS among patients with low TBS (HR, 3.12; 95% CI, 1.60-6.01; P <.001), but not among individuals with high TBS (HR, 0.57; 95% CI, 0.30-1.07; P =.08). Similar trends were observed relative to cancer-specific survival., Conclusion: TTS needs to be considered in light of patient and tumor-specific factors. Expediting TTS may be particularly important among patients with HCC and a low TBS., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Ethics approval and consent to participate: This study was performed in accordance with the Declaration of Helsinki and was approved by the Institutional Review Boards of all participating hospitals.

Background & Aims: Surgical site infection (SSI) is a common complication after hepatectomy for hepatocellular carcinoma (HCC), but its risk factors and impact on outcomes remain poorly characterized. We aimed to investigate the incidence, risk factors, and outcomes of SSI after hepatectomy for HCC and develop a prediction model., Methods: This multicenter retrospective study included patients who underwent curative-intent hepatectomy for HCC across 15 Chinese hepatobiliary centers from 2010 to 2021. SSI was defined according to Centers for Disease Control and Prevention criteria. Logistic regression identified independent risk factors for SSI. A nomogram was developed and internally validated., Results: Among 4124 patients, 393 (9.5 %) developed SSI; 76 (19.3 %) were diagnosed after discharge. SSI was associated with prolonged hospital stay (mean: 21 vs. 11 days), higher 30-day readmission (13.7 % vs. 3.2 %), and 90-day mortality (5.1 % vs. 2.9 %) (all P < 0.001). Independent risk factors for SSI were obesity (odds ratio [OR] 2.12), diabetes (OR 3.31), portal hypertension (OR 1.96), blood loss ≥400 mL (OR 1.75), open approach (OR 4.99), diaphragmatic incision (OR 2.27), major hepatectomy (OR 1.88), and operative time ≥180 min (OR 1.55). The nomogram model and online calculator (http://asapcalculate.top/Cal14&#95;en.html) demonstrated good discrimination (C-index 0.733) and calibration., Conclusions: SSI was common after hepatectomy for HCC and associated with worse short-term postoperative outcomes. The novel easy-to-use prediction calculator may facilitate individualized risk assessment and guide targeted preventive strategies. Future studies should focus on external validation and evaluating interventions in high-risk patients., Competing Interests: Declaration of competing interest Neither the entire manuscript nor any part of its content has been published or has been accepted elsewhere and this manuscript has not been submitted to any other journal. No portion of the text has been copied from other material in the literature. All of the authors in this manuscript have read and approved the final version submitted, and there are no conflicts involved in this submission., (Copyright © 2024 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: There is an ongoing debate on surgical training and its evolution to meet the demands of a complex and changing healthcare environment., Methods: A GI Surgery Summit was held in January 2024 that included prominent leaders and rising talents from the Society for Surgery of the Alimentary Tract, Society of Surgical Oncology, Association for Academic Surgery, and Society of University Surgeons. This meeting was held to address the multifaceted current and future challenges of surgery., Results: This paper addresses the topic of recruitment and training of the next generation of surgeons in the United States and abroad and reflects a collective focus on surgical education to ensure the delivery of high-quality care in an increasingly sophisticated medical and surgical landscape., Conclusion: The discussions and recommendations from the 2024 GI Surgery Summit underscore the crucial need to support diversity, embrace innovative educational frameworks, build a robust global surgical workforce, and foster a culture of wellness and support. Focusing on these key areas ensures that the future leaders of surgery are not only skilled and knowledgeable but also resilient and compassionate, ready to meet the evolving challenges of the healthcare landscape., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

Introduction: There is no consensus on the optimal surveillance interval for patients undergoing resection of colorectal liver metastases (CRLM). We sought to assess the timing and intensity of recurrence following curative-intent resection of CRLM utilizing a recurrence-free survival (RFS) hazard function analysis., Methods: Patients with CRLM who underwent curative-intent resection were identified from a multi-institutional database. The RFS hazard function was used to plot hazard rates and identify the peak of recurrence over time., Results: Among 1804 patients, the median RFS was 19.9 months. In the analytic cohort, the RFS hazard curve peaked at 5.9 months (peak hazard rate: 0.054) and gradually declined, indicative of early recurrence. In subgroup analyses, patients with high and medium tumor burden scores (TBS) had RFS hazard peaks at 4.9 months (peak hazard rate: 0.060) and 5.8 months (peak hazard rate: 0.054), respectively. In contrast, patients with low TBS had a later peak at 7.5 months, with the lowest peak hazard rate of 0.047., Conclusions: The recurrence peak for CRLM patients occurred approximately 6 months postsurgery, highlighting the need for intensified early postoperative surveillance. Patients with high TBS experienced earlier recurrence, underscoring the importance of close monitoring, particularly during the first 6 months after surgery., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Metastatic colorectal cancer is a leading cause of cancer-related death across the world. The treatment paradigm has shifted away from systemic chemotherapy alone to include targeted therapy and immunotherapy. The past two decades have been characterized by increased investigation into molecular profiling of colorectal cancer. These molecular profiles help physicians to better understand colorectal cancer biology among patients with metastatic disease. Additionally, improved data on genetic pathways allow for specific therapies to be targeted at the underlying molecular profile. Investigation of the EGFR, VEGF, HER2, and other pathways, as well as deficient mismatch repair, has led to the development of multiple targeted therapies that are now utilized in the National Comprehensive Cancer Network guidelines for colon and rectal cancer. While these new therapies have contributed to improved survival for metastatic colorectal cancer, long-term survival remains poor. Additional investigation to understand resistance to targeted therapy and development of new targeted therapy is necessary. New therapies are under development and are being tested in the preclinical and clinical settings. The aim of this review is to provide a comprehensive evaluation of molecular profiling, currently available therapies, and ongoing obstacles in the field of colorectal cancer.

Introduction: Despite cost-standardization efforts, significant variations in hospital costs persist in insurance claims. We sought to identify and quantify factors driving cost variability at hospital and cost center levels following a complex gastrointestinal surgical procedure., Methods: Individuals who underwent pancreatectomy (PA), colectomy (CO), and proctectomy (PR) were identified from the Surveillance, Epidemiology, and End Results database. Index surgery costs across 1,262 hospitals were compared, adjusting for clinical, demographic, and geographic factors. Multilevel regression modeling identified factors associated with variability in charges., Results: Among 35,908 individuals (PA: 8.2%; CO: 79.4%; PR: 12.4%), the median age was 78 years (interquartile range [IQR] 72-84), with 56.1% male. Median Medicare payments varied significantly by cancer type (CO: $21,704, PA: $26,709, PR: $21,228; p < 0.001). Operating room ($6,891, 23.82%), hospital stay ($5,931, 20.9%), and professional fees ($4,352, 15.35%) were the top cost centers, comprising 60% of total costs. Surgeons had the highest charges (PA: $2,037; CO: $2,131; PR: $2,243), followed by anesthesiologists (PA: $622; CO: $431; PR: $480). Charges for critical care specialists and pathologists were relatively low. Multilevel modeling demonstrated total charge variability was primarily influenced by patient factors (83%), followed by surgeon factors (9%) and hospital factors (8%)., Conclusions: There was marked variation in spending at the cost center level in the surgical treatment of gastrointestinal cancers. Patient factors demonstrated the greatest variability, followed by hospital and surgeon-level factors. Implementing value-based healthcare and standardized surgical protocols may improve both care quality and cost-effectiveness., Competing Interests: Disclosure The authors declare no conflict of interest., (© 2024. Society of Surgical Oncology.)

Background: Although resection is generally necessary for curative-intent treatment of most solid organ cancers, surgery is occasionally aborted due to intraoperative findings. Following aborted cancer surgery, patients have unique care needs that specialized palliative care (PC) providers may be best equipped to manage. We hypothesized that early ambulatory PC referral following aborted cancer surgery would be feasible and acceptable., Methods: This single-institution prospective clinical trial enrolled adult patients with gastrointestinal or hepatopancreatobiliary cancer with no prior PC exposure who had curative-intent oncologic surgery that was unexpectedly aborted. The primary endpoint was the completion of an ambulatory PC consultation within 30 days of enrollment. Secondary outcomes included changes in standardized measures of quality-of-life (QOL) and anxiety/depression during the 3-month follow-up., Results: Among 25 enrolled participants, the mean age was 65.3 ± 9.9 years, 68% were male, and 88% were White. The most common types of cancers were pancreatic (44%), hepatobiliary (20%), and colorectal (12%); reasons for aborting surgery were occult metastatic disease (52%) and local unresectability (36%). Only 13 of 25 (52%) met the primary endpoint of ambulatory PC within 30 days, less than the prespecified threshold of 70%. Overall, 16 (64%) patients completed ambulatory PC consultation a mean of 29.2 ± 15.8 days after enrollment. Of the 9 (36%) who did not, reasons included patient preference (n = 4), withdrawal from study (n = 1), lost to follow-up (n = 1), scheduling conflict (n = 1), and required inpatient PC before discharge (n = 2). Anxiety (4.94 ± 3.56 vs 3.35 ± 2.60, P = 0.06), depression (4.18 ± 4.02 vs 4.76 ± 3.44, P = 0.49), and QOL (82.44 ± 11.41 vs 82.03 ± 15.37, P = 0.92) scores did not significantly differ at 3-month follow-up compared to baseline., Conclusions: Barriers to early ambulatory palliative care consultation exist after aborted cancer surgery. Given the unique and complex care needs of this patient population, additional research is needed to optimize supportive care strategies., Competing Interests: Disclosure: The authors declare that they have nothing to disclose., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Disclosure Giovanni Catalano and Timothy M. Pawlik declare no conflicts of interest that may be relevant to the contents of this article.

Competing Interests: Disclosures None.