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Despite standardization, the 2016 ISGPF criteria are limited by their wider applicability and oversimplification of grade B POPF. This work applied the 2016 ISGPF grading criteria within a US academic cancer center to verify clinical and fiscal distinctions and sought to improve grading criteria for grade B POPF. The 2008–2018 cost and NSQIP data from pancreaticoduodenectomy to postoperative day 90 were merged. All POPFs were coded by 2016 ISGPF criteria. The Clavien-Dindo Classification (CD) defined complication severity. On sub-analyses, grade B POPFs were divided into those with adequate drainage and those requiring additional drainage. Chi-square, ANOVA, and Fisher’s least significant difference test were employed. Two hundred thirty-two patients were in the final analyses, 72 (31%) of whom had POPFs: 16 (7%) biochemical leaks, 54 (23%) grade B (28% required additional drainage), and 2 (1%) grade C. There was no significant difference in length of stay, CD, readmission, or cost in patients without a POPF, with biochemical leak or grade B POPF. On sub-analyses, 92% of adequately drained grade B POPFs had CD 1–2 and readmission equivalent to patients without POPF (p > 0.05). One hundred percent of grade B POPF requiring drainage had CD 3–4a, and 67% were readmitted. Cost was significantly increased in grade B POPF requiring additional drainage (p = 0.02) and grade C POPF (p

The identification of incidental pancreas cystic lesions (PCLs) has increased in recent decades with the expanded use and improved sensitivity of cross-sectional imaging. Because the overall risk of malignancy associated with PCLs is low, yet the relative morbidity of pancreatic surgery is high, evidence-based guidelines are necessary for appropriate surveillance and management. Therefore, this article provides a review of existing guidelines regarding surveillance and management of PCLs and highlights recent advances in the diagnostic evaluation of cysts and the postresection management of mucinous lesions.There are 5 main guidelines related to the management of PCLs: the American Gastrointestinal Association (AGA) guidelines, the American College of Gastroenterology (ACG) guidelines, the American College of Radiology (ACR) recommendations, the European evidence-based guidelines, and the International Association of Pancreatology (IAP)/Fukuoka guidelines. These guidelines are based on retrospective studies that do not account or control for most tumor- and patient-specific factors. These guidelines also vary in scope, recommendations for surgical resection vs surveillance, as well as duration and type of follow-up.PCL guidelines should be viewed within the context of the data limitations on which they are based. PCL subtype-specific guidelines on surveillance and treatment are needed. In the future, the integration of cyst-specific genomic analysis, as well as evolutions in advanced diagnostic tools, such as cyst fluid next-generation sequencing and EUS-guided confocal laser endomicroscopy, may also better inform treatment guidelines. Owing to the current low-quality evidence on which many guidelines are based and the inherent morbidity of pancreas surgery, it is imperative that patients with PCLs are referred to institutions with advanced diagnostics and a multidisciplinary approach to patient surveillance and management.

Cholangiocarcinoma (CCA) is the second most common biliary tract malignancy with a dismal prognosis. Surgical resection with a negative microscopic margin offers the only hope for long-term survival. However, the majority of patients present with advanced disease not amenable to curative resection, mainly due to late presentation and aggressive nature of the disease. Unfortunately, due to the heterogeneous nature of CCA as well as limitations of available chemotherapy medications, traditional chemotherapy regimens offer limited survival benefit. Recent advances in genomic studies and next-generation sequencing techniques have assisted in better understanding of cholangiocarcinogenesis and identification of potential aberrant signaling pathways. Targeting the specific genomic abnormalities via novel molecular therapies has opened a new avenue in management of CCA with encouraging results in preclinical studies and early clinical trials. In this review, we present emerging therapies for precision medicine in CCA.

BACKGROUND: Physician variation in adherence to best practices contributes to the high costs of health care. Understanding surgeon-specific cost variation in common surgical procedures may inform strategies to improve the value of surgical care. METHODS: Laparoscopic cholecystectomies at a single institution were identified over a five-year period and linked to an institutional cost database. Multiple linear regression was used to control for patient-, case-, and hospital- specific factors while assessing the impact of surgeon variability on cost. RESULTS: The final dataset contained 1,686 patients. Higher surgeon volume (reported in tertiles) was associated with decreased costs ($5,354 vs $6,301 vs $7,156, p

Background Automated data extraction from the electronic medical record is fast, scalable, and inexpensive compared with manual abstraction. However, concerns regarding data quality and control for underlying patient variation when performing retrospective analyses exist. This study assesses the ability of summary electronic medical record metrics to control for patient-level variation in cost outcomes in pancreaticoduodenectomy. Methods Patients that underwent pancreaticoduodenectomy from 2014 to 2018 at a single institution were identified within the electronic medical record and linked with the National Surgical Quality Improvement Program. Variables in both data sets were compared using interrater reliability. Logistic and linear regression modelling of complications and costs were performed using combinations of comorbidities/summary metrics. Models were compared using the adjusted R2 and Akaike information criterion. Results A total of 117 patients populated the final data set. A total of 31 (26.5%) patients experienced a complication identified by the National Surgical Quality Improvement Program. The median direct variable cost for the encounter was US$14,314. Agreement between variables present in the electronic medical record and the National Surgical Quality Improvement Program was excellent. Stepwise linear regression models of costs, using only electronic medical record–extractable variables, were non-inferior to those created with manually abstracted individual comorbidities (R2 = 0.67 vs 0.30, Akaike information criterion 2,095 vs 2,216). Model performance statistics were minimally impacted by the addition of comorbidities to models containing electronic medical record summary metrics (R2 = 0.67 vs 0.70, Akaike information criterion 2,095 vs 2,088). Conclusion Summary electronic medical record perioperative risk metrics predict patient-level cost variation as effectively as individual comorbidities in the pancreaticoduodenectomy population. Automated electronic medical record data extraction can expand the patient population available for retrospective analysis without the associated increase in human and fiscal resources that manual data abstraction requires.

INTRODUCTION. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC. METHODS. An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS). RESULTS. In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395–25,240). Median length of stay (LOS) was 8 (7–11.5) days and ICU stay was 1 (1–1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS. DISCUSSION. Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.

OBJECTIVE: To determine differences in Entrustable Professional Activity (EPA) assessments between male and female general surgery residents. SUMMARY BACKGROUND DATA: Evaluations play a critical role in career advancement for physicians. However, female physicians in training receive lower evaluations and underrate their own performance. Competency-based assessment frameworks, such as EPAs, may help address gender bias in surgery by linking evaluations to specific, observable behaviors. METHODS: In this cohort study, EPA assessments were collected from July 2018 to May 2020. The effect of resident gender on EPA entrustment levels was analyzed using multiple linear and ordered logistic regressions. Narrative comments were analyzed using Latent Dirichlet Allocation (LDA) to identify topics correlated with resident gender. RESULTS: Of the 2,480 EPAs, 1,230 EPAs were submitted by faculty and 1,250 were submitted by residents. After controlling for confounding factors, faculty evaluations of residents were not impacted by resident gender (estimate = 0.09, p = 0.08). However, female residents rated themselves lower by 0.29 (on a 0–4 scale) compared to their male counterparts (p < 0.001). Within narrative assessments, topics associated with resident gender demonstrated that female residents focus on the ‘guidance’ and ‘supervision’ they received while performing an EPA, while male residents were more likely to report ‘independent’ action. CONCLUSIONS: Faculty assessments showed no difference in EPA levels between male and female residents. Female residents rate themselves lower by nearly an entire PGY level compared to male residents. LDA-identified topics suggest this difference in self-assessment is related to differences in perception of autonomy.

Simple Summary Intrahepatic cholangiocarcinoma is the second most common primary liver malignancy. Among patients with operable disease, surgical resection is the cornerstone of therapy. Among the majority of patients who present with advanced disease treatment, systemic or targeted therapy is indicated. Recent advancements have provided more novel therapeutic approaches to a subset of patients with intrahepatic cholangiocarcinoma. Abstract Although rare, intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy and the incidence of ICC has increased 14% per year in recent decades. Treatment of ICC remains difficult as most people present with advanced disease not amenable to curative-intent surgical resection. Even among patients with operable disease, margin-negative surgical resection can be difficult to achieve and the incidence of recurrence remains high. As such, there has been considerable interest in systemic chemotherapy and targeted therapy for ICC. Over the last decade, the understanding of the molecular and genetic foundations of ICC has reshaped treatment approaches and strategies. Next-generation sequencing has revealed that most ICC tumors have at least one targetable mutation. These advancements have led to multiple clinical trials to examine the safety and efficacy of novel therapeutics that target tumor-specific molecular and genetic aberrations. While these advancements have demonstrated survival benefit in early phase clinical trials, continued investigation in randomized larger-scale trials is needed to further define the potential clinical impact of such therapy.

Increasing hospital or surgeon volume is associated with improved outcomes among patients with pancreatic cancer. Promotion of regionalized care is based on this volume-outcome association. However, other research has exposed nuances and complexities inherent to this association that should be considered when promoting regionalized care models. We herein provide a critical review of the literature on the volume-outcome association and a discussion of areas of ongoing controversy. A PubMed literature search was conducted for the years 1995–2020. Peer reviewed original research studies were selected for critical review based on study design, potential to draw meaningful conclusions from the data, and discussion of current knowledge gaps. Based on the cumulative published literature, hospital/surgeon volume and patient mortality are inversely related. However, it remains unclear whether volume is a proxy for other more causative variables inherent in high-volume centers. Interpretation of the volume-outcome association is made more difficult to interpret due to the large variation in the definition of high volume, difficulty in isolating the individual impact of surgeon versus hospital volume, challenges in quantifying health system processes related to volume, and the fact that some low-volume centers consistently achieve excellent clinical results. Implementation of true regionalized care models has been rare, likely reflecting both health system and patient level challenges. The volume-outcome association has been consistently demonstrated to be important to the care of patients with pancreas cancer. The underlying mechanism of this association to explain the overall benefit is likely multifactorial. Better understanding of what drives the volume-outcome association may increase access to optimized care for a broader range of hospital systems and patients.

Introduction: Peri-hilar cholangiocarcinoma is an aggressive bile duct cancer. Long-term survival is possible with margin-negative surgery. Historically, unresectable disease was approached with no...

We sought to derive and validate a prediction model of survival and recurrence among Western patients undergoing resection of gastric cancer. Patients who underwent curative-intent surgery for gastric cancer at seven US institutions and a major Italian center from 2000 to 2020 were included. Variables included in the multivariable Cox models were identified using an automated model selection procedure based on an algorithm. Best models were selected using the Bayesian information criterion (BIC). The performance of the models was internally cross-validated via the bootstrap resampling procedure. Discrimination was evaluated using the Harrell’s Concordance Index and accuracy was evaluated using calibration plots. Nomograms were made available as online tools. Overall, 895 patients met inclusion criteria. Age (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.17–1.84), presence of preoperative comorbidities (HR 1.66, 95% CI 1.14–2.41), lymph node ratio (LNR; HR 1.72, 95% CI 1.42–2.01), and lymphovascular invasion (HR 1.81, 95% CI 1.33–2.45) were associated with overall survival (OS; all p

We sought to derive and validate a prediction model of survival and recurrence among Western patients undergoing resection of gastric cancer.Patients who underwent curative-intent surgery for gastric cancer at seven US institutions and a major Italian center from 2000 to 2020 were included. Variables included in the multivariable Cox models were identified using an automated model selection procedure based on an algorithm. Best models were selected using the Bayesian information criterion (BIC). The performance of the models was internally cross-validated via the bootstrap resampling procedure. Discrimination was evaluated using the Harrell's Concordance Index and accuracy was evaluated using calibration plots. Nomograms were made available as online tools.Overall, 895 patients met inclusion criteria. Age (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.17-1.84), presence of preoperative comorbidities (HR 1.66, 95% CI 1.14-2.41), lymph node ratio (LNR; HR 1.72, 95% CI 1.42-2.01), and lymphovascular invasion (HR 1.81, 95% CI 1.33-2.45) were associated with overall survival (OS; all p 0.01), whereas tumor location (HR 1.93, 95% CI 1.23-3.02), T category (Tis-T1 vs. T3: HR 0.31, 95% CI 0.14-0.66), LNR (HR 1.82, 95% CI 1.45-2.28), and lymphovascular invasion (HR 1.49; 95% CI 1.01-2.22) were associated with disease-free survival (DFS; all p 0.05) The models demonstrated good discrimination on internal validation relative to OS (C-index 0.70) and DFS (C-index 0.74).A web-based nomograms to predict OS and DFS among gastric cancer patients following resection demonstrated good accuracy and discrimination and good performance on internal validation.

Introduction Surveillance care including routine physical exams and testing following gastrointestinal (GI) cancer treatment can be fiscally and emotionally burdensome for patients. Emerging technology platforms may provide a resource-wise surveillance strategy. However, effective implementation of GI cancer surveillance is limited by a lack of patient level perspective regarding surveillance. This study aimed to describe patient attitudes toward GI cancer surveillance and which care modalities such as telemedicine and care team composition best meet the patient's needs for follow-up care. Methods Focused interviews were conducted with 15 GI cancer patients undergoing surveillance following curative-intent surgery. All interviews were audio recorded, transcribed verbatim, and uploaded to NVivo. Study personnel trained in qualitative methods consensus coded 10% of data inductively and iteratively developed a codebook and code descriptions. Using all transcripts, data matrices were developed to identify themes inherent in the transcripts. Results Qualitative analysis revealed three overarching themes. First, increasing ease of access to surveillance care through telemedicine follow-up services may interfere with patients’ preferred follow-up routine, which is an in-office visit. Second, specialist providers were trusted by patients to deliver surveillance care more than primary care providers (PCPs). Thirdly, patients desired improved psychosocial health support during the surveillance period. Conclusion These novel patient-level qualitative data demonstrate that replacing conventional in-office GI cancer surveillance care with telemedicine is not what many patients desire. These data also demonstrate that his cohort of patients prefer to see specialists for GI cancer surveillance care rather than PCPs. Future efforts to enhance surveillance should include increased psychosocial support. Telemedicine implementation should be personalized toward specific populations who may be interested in fewer in-office surveillance visits.

Despite standardization, the 2016 ISGPF criteria are limited by their wider applicability and oversimplification of grade B POPF. This work applied the 2016 ISGPF grading criteria within a US academic cancer center to verify clinical and fiscal distinctions and sought to improve grading criteria for grade B POPF.The 2008-2018 cost and NSQIP data from pancreaticoduodenectomy to postoperative day 90 were merged. All POPFs were coded by 2016 ISGPF criteria. The Clavien-Dindo Classification (CD) defined complication severity. On sub-analyses, grade B POPFs were divided into those with adequate drainage and those requiring additional drainage. Chi-square, ANOVA, and Fisher's least significant difference test were employed.Two hundred thirty-two patients were in the final analyses, 72 (31%) of whom had POPFs: 16 (7%) biochemical leaks, 54 (23%) grade B (28% required additional drainage), and 2 (1%) grade C. There was no significant difference in length of stay, CD, readmission, or cost in patients without a POPF, with biochemical leak or grade B POPF. On sub-analyses, 92% of adequately drained grade B POPFs had CD 1-2 and readmission equivalent to patients without POPF (p 0.05). One hundred percent of grade B POPF requiring drainage had CD 3-4a, and 67% were readmitted. Cost was significantly increased in grade B POPF requiring additional drainage (p = 0.02) and grade C POPF (p 0.01).This analysis did not confirm an incremental increase in morbidity and cost with POPF grade. Sub-analyses enabled accurate clinical and cost distinctions in grade B POPF; adequately drained grade B POPF are low risk and clinically insignificant.

INTRODUCTION: National Comprehensive Cancer Network guidelines recommend that sentinel lymph node biopsy (SLNB) be discussed with patients with thin melanoma at higher risk for lymph node metastasis (T1b or T1a with positive deep margins, lymphovascular invasion, or high mitotic index). We examined the association between SLNB and resource utilization in this cohort. METHODS: We conducted a retrospective cohort study of patients that underwent wide local excision for higher risk thin melanomas from 2009 to 2018 at a tertiary care center. Patients who underwent SLNB were compared to those who did not undergo SLNB with regard to resource utilization, including total hospital cost. RESULTS: A total of 70 patients were included in the analysis and 50 patients (71.4%) underwent SLNB. SLNB was associated with increased hospital costs ($6700 vs. $3767; p < .01) and increased operative time (68.5 vs. 36.0 min; p < .01). This cost difference persisted in multivariable regression (p < .01). Of patients who underwent successful SLN mapping, 3 out of 49 patients had a positive SLN (6.1%). The cost to identify a single positive sentinel lymph node (SLN) was $47,906. CONCLUSION: In patients with a higher risk of thin melanoma, SLNB is associated with increased cost despite a low likelihood of SLN positivity. These data better inform patient-provider discussions as the role of SLNB in thin melanoma evolves.

Introduction Previous studies on readmission cost in pancreaticoduodenectomy patients use estimated cost data and do not delineate etiology or cost differences between early and late readmissions. We sought to identify relationships between postoperative complication type and readmission timing and cost in pancreaticoduodenectomy patients. Methods Hospital cost data from date of discharge to postoperative day 90 were merged with 2008–2018 NSQIP data. Early readmission was within 30 days of surgery, and late readmission was 30 to 90 days from surgery. Regression analyses for readmission controlled for patient comorbidities, complications, and surgeon. Results Of 230 patients included, 58 (25%) were readmitted. The mean early and late readmission costs were $18,365 ± $20,262 and $24,965 ± $34,435, respectively. Early readmission was associated with index stay deep vein thrombosis (p

Background Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery. Approach The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC). Adaptation was accomplished using a modification of the Replicating Effective Programs (REP) model, which has four phases: (1) preconditions, (2) preimplementation, (3) implementation, and (4) maintenance and evolution. A random sample of five patients each month was selected to complete a phone survey regarding patient satisfaction. Preimplementation planning allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. The adapted protocol specifically addressed surgical issues such as nutrition, fever, ostomy output, dehydration, drain character/output, and wound appearance. After protocol launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. Outcomes Survey responders reported 100% overall satisfaction with the transitional care program. Key Insights The adaptable nature of sC-TraC may allow for low-resource hospitals, such as rural or inner-city medical centers, to use the methodology provided in this study for implementation of local phone-based transitional care protocols. In addition, as the C-TraC program has begun to disseminate nationally across US Department of Veterans Affairs (VA) hospitals and rural health settings, sC-TraC may be implemented using the existing transitional care infrastructure in place at these hospitals.

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous throm-boembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.

Background Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol. Study Design The intervention includes in-person enrollment of patients. Follow-up protocolized phone calls by specially trained surgical C-TraC nurses addressed medication management, clinic appointments, operation-specific concerns, and identification of red-flag symptoms. Enrollment criteria included pancreatectomy, gastrectomy, operative small bowel obstruction or perforation, ostomy, discharge with a drain, in-hospital complication, and clinician discretion. Engaged patients participated in the first phone call, which was within 48 to 72 hours of discharge and continued every 3 to 4 days. Patients completed the program once they and surgical C-TraC nurse agreed that no additional follow-up was needed or the patient was readmitted. Results Two hundred and twelve patients were enrolled, October 2015 through April 2016, with a mean age of 56 years (range 19 to 89 years); 33% of patients were 65 years or older. Surgery sites included colon (46%), small bowel (16%), pancreas (12%), multivisceral (9%), liver (4.5%), retroperitoneum/soft tissue (4.5%), gastric (4%), biliary (2%), and appendix (1.5%). Refusal rate was 1% and engagement was 95%. At initial call, 47% of patients had at least 1 medication discrepancy (range 0 to 6). Mean number of calls from provider to patient was 3.2 (range 0 to 20, median 3). Conclusions A phone-based transitional care protocol for surgical patients is feasible, with

Evidence suggests that operative delay of up to 24 h is not associated with adverse outcomes among patients undergoing emergent appendectomy. However, the fiscal implication of operative delay is not well described in adults. We sought to examine the effect of delayed appendectomy on clinical outcomes and hospital cost.We conducted a retrospective cohort study of patients undergoing nonelective laparoscopic appendectomy from 2014 to 2018 at both a tertiary care center and an affiliated short-stay hospital. Using a unique data set constructed from merged electronic health record and patient-level hospital financial data, patients with delayed surgery, defined as 12 h from emergency department (ED) arrival to operation, were compared with patients who underwent surgery within 12 h. Patient-specific variables were analyzed for their association with resource utilization, and subsequent multivariable linear regression was performed for total hospital cost.1372 patients underwent laparoscopic appendectomy during the study period. 938 patients (68.3%) underwent surgery within 12 h of ED arrival, and 434 patients (31.6%) underwent delayed surgery. Delayed cases had longer length of stay (44.6 ± 42.5 versus 34.5 ± 36.5 h, P 0.01) and increased total hospital cost ($9326 ± 4691 versus $8440 ± 3404, P 0.01). The cost difference persisted on multivariable analysis (P 0.01). There were no significant differences between delayed cases and nondelayed cases for operative time, intraoperative findings, including rate of perforation, or postoperative complications.Although safe, delayed appendectomy is associated with an increased length of stay and increased total hospital costs compared with appendectomy within 12 h of reaching the ED.

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous thromboembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.

Background A 5 cm margin is advocated for distal gastric adenocarcinoma (GAC). The optimal proximal resection margin (PM) length for proximal GAC is not established. Methods Patients who underwent curative-intent resection for proximal GAC from 2000 to 2012 at 7 centers in the US Gastric Cancer Collaborative were included. PM length was sequentially dichotomized and analyzed at 0.5 cm increments (0.5–6.5 cm). Outcomes after negative margin (R0) and positive microscopic margin (R1) resections were compared. Primary endpoints were local recurrence (LR) and overall survival (OS). Results All patients (n = 162) had R0 distal margins. 151 (93.2%) had an R0-PM with mean length of 2.6 cm (median:1.7 cm; range:0.1–15 cm). A greater PM distance was not associated with LR or OS. An R1-PM was associated with higher N-stage (N3:73% vs. 26%; P = 0.007) and increased LR (HR6.1; P = 0.009) but not associated with decreased OS. On multivariate analysis, an R1-PM was also not independently associated with LR. Conclusions For resection of proximal gastric adenocarcinoma, proximal margin length is not associated with local recurrence or overall survival. An R1 margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing resection of proximal gastric adenocarcinoma, efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned. J. Surg. Oncol. 2015 111:203–207. © 2015 Wiley Periodicals, Inc.

Background Jejunostomy feeding tubes (J-tubes) are often placed during resection for gastric adenocarcinoma (GAC). Their effect on postoperative complications and receipt of adjuvant therapy is unclear. Methods Patients who underwent curative-intent resection of GAC at seven institutions of the U.S. Gastric Cancer Collaborative from 2000 to 2012 were identified. The associations of J-tubes with postoperative complications and receipt of adjuvant therapy were determined. Results Of 837 patients, 265 (32%) received a J-tube. Patients receiving J-tubes demonstrated greater incidence of preoperative weight loss, lower BMI, greater extent of resection, and more advanced TNM stage. J-tube placement was associated with increased infectious complications (36% vs. 19%; P

The American Cancer Society projects there will be over 22,000 new cases, resulting in nearly 11,000 deaths, related to gastric adenocarcinoma in the US in 2014. The aim of the current study was to find clinicopathologic variables associated with disease-free survival (DFS) and overall survival (OS) following curative resection of gastric adenocarcinoma, and create a nomogram for individual risk prediction. A nomogram to predict DFS and OS following surgical resection of gastric adenocarcinoma was constructed using a multi-institutional cohort of patients who underwent surgery for primary gastric adenocarcinoma at seven major institutions in the US between January 2000 and August 2013. Discrimination and calibration of the nomogram were tested by C-statistic, Kaplan–Meier curves, and calibration plots. A total of 719 patients who underwent surgery for primary gastric adenocarcinoma were included in the study. Using the backward selection of clinically relevant variables with Akaike information criteria, age, sex, tumor site, depth of invasion, and lymph node ratio (LNR) were selected as factors predictive of OS, while age, tumor site, depth of invasion, and LNR were incorporated in the prediction of DFS. A nomogram was constructed to predict OS and DFS using these variables. Discrimination and calibration of the nomogram revealed good predictive abilities (C-index, DFS 0.711; OS 0.702). Independent predictors of recurrence and death following surgery for primary gastric adenocarcinoma were used to create a nomogram to predict DFS and OS. The nomogram was able to stratify patients into prognostic groups, and performed well on internal validation.

There are no validated methods to preoperatively identify patients with increased risk of discharge to skilled nursing facilities following resection of gastric cancer. We sought to identify preoperative predictors of non-home discharge to optimize transition of care to skilled nursing facility. Patients who underwent resection of gastric cancer from 2000 to 2012 from seven participating institutions of the US Gastric Cancer Collaborative were analyzed. Fisher’s exact tests, Student t tests, and logistic regression analyses identified preoperative variables associated with non-home discharge. A prediction tool was created and validated through c-indices. Survival analysis was conducted according to the methods of Kaplan and Meier. Out of the 918 patients identified, 93 (10 %) were discharged to nonhome location. Univariate analysis identified advancing age, American Society of Anesthesiology (ASA) score, hypertension, decreasing preoperative albumin, and lack of neoadjuvant chemotherapy as risk factors for non-home discharge (NHD). Multivariable analysis identified advanced age (odds ratio (OR) = 1.07, 95 % confidence interval (CI) = 1.04–1.10, p

A proximal margin distance of 5 cm is advocated for resection of gastric adenocarcinoma (GAC). We assessed the prognostic value of proximal margin (PM) distance on survival outcomes after resection of distal GAC.All patients who underwent resection of distal GAC (antrum/body) from 2000 to 2012 at seven institutions of the U.S. Gastric Cancer Collaborative were included. Patients with positive distal margins or macroscopic residual disease were excluded. The prognostic value of PM distance (assessed in 0.5-cm increments) on overall (OS) and recurrence-free survival (RFS) was assessed by Kaplan-Meier and multivariate regression analysis.A total of 465 patients underwent resection of distal GAC. Of these, 435 had R0 resections; 30 patients had a positive PM. 143 patients had stage I, and 322 had stage II-III tumors. Median follow-up was 44 months. Average PM distance was 4.8 cm. Median OS for patients with PM of 3.1-5.0 cm (n = 110) was superior to patients with PM ≤ 3.0 cm (n = 176) (48.1 vs. 29.3 months; p = 0.01), while a margin5.0 cm (n = 179) offered equivalent survival to PM 3.1-5.0 cm (50.6 months, p = 0.72). The prognostic value of margin distance was stage specific. On multivariate analysis of stage I patients, PM 3.1-5.0 cm remained associated with improved OS [hazard ratio (HR), 0.16; 95 % confidence interval (95 % CI), 0.04-0.60; p = 0.01]. In stage II-III, neither PM 3.1-5.0 cm nor PM5.0 cm was significantly associated with OS; OS was dictated by T stage and nodal involvement.The prognostic value of proximal margin distance after resection of distal gastric cancer appears stage specific. In stage I, a 3.1- to 5.0-cm proximal margin is associated with the same improved OS as a5.0-cm margin. In stage II-III disease, other adverse pathologic factors more strongly impact survival than proximal margin distance.

103 Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins by additional gastric resection after a positive proximal margin frozen section (FS) is unknown. Methods: The US Gastric Cancer Collaborative includes all patients who had resection of GAC at 7 institutions by oncologic surgeons from 2000-2012. Intraoperative proximal margin FS data were classified as R0 or R1 based on final permanent section (PS); positive distal margins were excluded. Primary aim was to evaluate the impact on local recurrence (LR) of converting a positive proximal margin FS to an R0 final margin by additional resection. Secondary endpoints were recurrence-free (RFS) and overall survival (OS). Results: Of 860 pts, 520 had a proximal margin FS; 67 were positive. Of these 67, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 pts (86%), R1 in 25 (5%), and R1 converted to R0 in 48 (9%). Median FU was 44 mos. Although LR was decreased in the converted R1 to R0 group compared to the R1 group (10% vs 32%, p=0.01), when accounting for other pathologic variables on multivariate (MV) analysis, R1 to R0 conversion was not associated with decreased LR. Median RFS was similar between the R1 to R0 and R1 cohort (37 vs 31 mos; p=0.6) compared to 110 mos for the R0 group. Median OS was similar between the R1 to R0 conversion and R1 groups (36 vs 26 mos; p=0.14) compared to 50 mos for the R0 group. On MV analysis, increasing T-stage and positive lymph nodes were associated with worse OS; R1 to R0 conversion of the proximal margin was not associated with improved OS (p=0.5; Table). Conclusions: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection does not decrease local recurrence or improve recurrence-free or overall survival. This may guide decisions regarding the extent of resection. [Table: see text]

The impact of adjuvant chemotherapy and chemo-radiation therapy in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio on the relative benefit of adjuvant chemotherapy or chemo-radiation therapy among patients having undergone curative-intent resection for gastric cancer.Using the multi-institutional US Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of lymph node ratio on overall survival among patients who received chemotherapy or chemo-radiation therapy was evaluated.Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based chemo-radiation therapy, whereas the remaining 141 (19.6%) received chemotherapy. Median overall survival was 40.9 months, and 5-year overall survival was 40.3%. According to lymph node ratio categories, 5-year overall survival for patients with a lymph node ratio of 0, 0.01-0.10,0.10-0.25,0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse overall survival included involvement of the gastroesophageal junction (hazard ratio 1.8), T-stage (3-4: hazard ratio 2.1), lymphovascular invasion (hazard ratio 1.4), and lymph node ratio (0.25: hazard ratio 2.3; all P .05). In contrast, receipt of adjuvant chemo-radiation therapy was associated with an improved overall survival in the multivariable model (versus resection alone: hazard ratio 0.40; versus chemotherapy: hazard ratio 0.45, both P .001). The benefit of chemo-radiation therapy for resected gastric cancer was noted only among patients with lymph node ratio0.25 (versus resection alone: hazard ratio R 0.34; versus chemotherapy: hazard ratio 0.45, both P .001). In contrast, there was no noted overall survival benefit of chemotherapy or chemo-radiation therapy among patients with lymph node ratio ≤0.25 (all P .05).Adjuvant chemotherapy or chemo-radiation therapy was utilized in more than one-half of patients undergoing curative-intent resection for gastric cancer. Lymph node ratio may be a useful tool to select patients for adjuvant chemo-radiation therapy, because the benefit of chemo-radiation therapy was isolated to patients with greater degrees of lymphatic spread (ie, lymph node ratio0.25).

Postoperative complications (POCs) can negatively impact survival after oncologic resection. POCs may also decrease the rate of adjuvant therapy completion. We evaluated the impact of complications on gastric cancer survival and analyzed the combined effect of complications and adjuvant therapy on survival. We analyzed 824 patients from 7 institutions of the U.S. Gastric Cancer Collaborative who underwent curative resection for gastric adenocarcinoma between 2000 and 2012. POC were graded using the modified Clavien–Dindo system. Survival probabilities were estimated using the method of Kaplan and Meier and analyzed using multivariate Cox regression. Median follow-up was 35 months. The overall complication rate was 41 %. The 5-year overall survival (OS) and recurrence-free survival (RFS) of patients who experienced complications were 27 and 23 %, respectively, compared with 43 and 40 % in patients who did not have complications (p

This study utilized a multi-institutional database to evaluate risk factors for readmission in patients undergoing curative gastrectomy for gastric adenocarcinoma with the intent of describing both perioperative risk factors and the relationship of readmission to survival.Patients who underwent curative resection of gastric adenocarcinoma from 2000 to 2012 from seven academic institutions of the US Gastric Cancer Collaborative were analyzed. In-hospital deaths and palliative surgeries were excluded, and readmission was defined as within 30 days of discharge. Univariate and multivariable logistic regression analyses were employed and survival analysis conducted.Of the 855 patients, 121 patients (14.2 %) were readmitted. Univariate analysis identified advanced age (p 0.0128), American Society of Anesthesiology status ≥3 (p = 0.0045), preexisting cardiac disease (p 0.0001), hypertension (p = 0.0142), history of smoking (p = 0.0254), increased preoperative blood urea nitrogen (BUN; p = 0.0426), concomitant pancreatectomy (p = 0.0056), increased operation time (p = 0.0384), estimated blood loss (p = 0.0196), 25th percentile length of stay (7 days, p = 0.0166), 75th percentile length of stay (12 days, p = 0.0256), postoperative complication (p 0.0001), and total gastrectomy (p = 0.0167) as risk factors for readmission. Multivariable analysis identified cardiac disease (odds ratio (OR) 2.4, 95 % confidence interval (CI) 1.6-3.3, p 0.0001), postoperative complication (OR 2.3, 95 % CI 1.6-5.4, p 0.0001), and pancreatectomy (OR 2.2, 95 % CI 1.1-4.1, p = 0.0202) as independent risk factors for readmission. There was an association of decreased overall median survival in readmitted patients (39 months for readmitted vs. 103 months for non-readmitted). This was due to decreased survival in readmitted stage 1 (p = 0.0039), while there was no difference in survival for other stages. Stage I readmitted patients had a higher incidence of cardiac disease than stage I non-readmitted patients (58 vs. 24 %, respectively, p = 0.0002).Within this multi-institutional study investigating readmission in patients undergoing curative resection for gastric cancer, cardiac disease, postoperative complication, and concomitant pancreatectomy were identified as significant risk factors for readmission. Readmission was associated with decreased overall median survival, but on further analysis, this was driven by differences in survival for stage I disease only.

Limited data exist on the prognosis of preoperative Helicobacter pylori (H. pylori) infection in gastric adenocarcinoma (GAC). Patients who underwent curative-intent resection for GAC from 2000 to 2012 at seven academic institutions comprising the United States Gastric Cancer Collaborative were included in the study. The primary end points of the study were overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS). Of 559 patients, 104 (18.6 %) who tested positive for H. pylori were younger (62.1 vs 65.1 years; p = 0.041), had a higher frequency of distal tumors (82.7 vs 71.9 %; p = 0.033), and had higher rates of adjuvant radiation therapy (47.0 vs 34.9 %; p = 0.032). There were no differences in American Society of Anesthesiology (ASA) class, margin status, grade, perineural invasion, lymphovascular invasion, nodal metastases, or tumor-node-metastasis (TNM) stage. H. pylori positivity was associated with longer OS (84.3 vs 44.2 months; p = 0.008) for all patients. This relationship with OS persisted in the multivariable analysis (HR 0.54; 95 % CI 0.30–0.99; p = 0.046). H. pylori was not associated with RFS or DSS in all patients. In the stage 3 patients, H. pylori was associated with longer OS (44.5 vs 24.7 months; p = 0.018), a trend of longer RFS (31.4 vs 21.6 months; p = 0.232), and longer DSS (44.8 vs 27.2 months; p = 0.034). Patients with and without preoperative H. pylori infection had few differences in adverse pathologic features at the time of gastric adenocarcinoma resection. Despite similar disease presentations, preoperative H. pylori infection was independently associated with improved OS. Further studies examining the interaction between H. pylori and tumor immunology and genetics are merited.

A 5 cm margin is advocated for distal gastric adenocarcinoma (GAC). The optimal proximal resection margin (PM) length for proximal GAC is not established.Patients who underwent curative-intent resection for proximal GAC from 2000 to 2012 at 7 centers in the US Gastric Cancer Collaborative were included. PM length was sequentially dichotomized and analyzed at 0.5 cm increments (0.5-6.5 cm). Outcomes after negative margin (R0) and positive microscopic margin (R1) resections were compared. Primary endpoints were local recurrence (LR) and overall survival (OS).All patients (n = 162) had R0 distal margins. 151 (93.2%) had an R0-PM with mean length of 2.6 cm (median:1.7 cm; range:0.1-15 cm). A greater PM distance was not associated with LR or OS. An R1-PM was associated with higher N-stage (N3:73% vs. 26%; P = 0.007) and increased LR (HR6.1; P = 0.009) but not associated with decreased OS. On multivariate analysis, an R1-PM was also not independently associated with LR.For resection of proximal gastric adenocarcinoma, proximal margin length is not associated with local recurrence or overall survival. An R1 margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing resection of proximal gastric adenocarcinoma, efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned.

Background Our objective was to use a human factors and systems engineering approach to understand contributors to surgical readmissions from a patient and provider perspective. Previous studies on readmission have neglected the patient perspective. To address this gap and to better inform intervention design, we evaluated how transitions of care relate to and influence readmission from the patient and clinician perspective using the Systems Engineering Initiative for Patient Safety (SEIPS) model. Study design Patients readmitted within 30 days of discharge after complex abdominal surgery were interviewed. A focus group of inpatient clinician providers was conducted. Questions were guided by the SEIPS framework and content was analyzed. Data were collected concurrently from the medical record for a mixed-methods approach. Results Readmission occurred a median of 8 days (range 1 to 25 days) after discharge. All patients had follow-up scheduled with their surgeon, but readmission occurred before this in 72% of patients. Primary readmission diagnoses included infection, gastrointestinal complications, and dehydration. Patients (n = 18) and clinician providers (n = 6) identified a number of factors during the transition of care that may have contributed to readmission, including poor patient and caregiver understanding; inadequate discharge preparation for home care; insufficient educational process and materials, negatively affected by electronic health record design; and inadequate care team communication. Conclusions This is the first study to use a human factors and systems engineering approach to evaluate the impact of the quality of the transition of care and its influence on readmission from the patient and clinician perspective. Important targets for future interventions include enhancing the discharge process, improving education materials, and increasing care team coordination, with the overarching theme that improved patient and caregiver understanding and engagement are essential to decrease readmission and postdischarge health care use.

The prognostic effect of perioperative blood transfusion on recurrence and survival in patients undergoing resection of gastric adenocarcinoma (GAC) remains controversial.All patients who underwent resection for GAC from 2000 to 2012 at the 7 institutions of the US Gastric Cancer Collaborative were identified. The effect of transfusion on recurrence-free (RFS) and overall survival (OS) in the context of adverse clinicopathologic variables was examined by univariate and multivariate regression analyses.Of 965 patients, 765 underwent curative intent R0 resection. Median follow-up was 44 months; 30-day mortalities were excluded. Median estimated blood loss (EBL) was 200 mL, and 168 patients (22%) received perioperative allogeneic blood transfusions. Transfused patients were less likely to receive adjuvant therapy (44% vs 56%; p = 0.01). Transfusion was associated with significantly decreased median RFS (13.5 vs 37.2 months, p0.001). Median OS was similarly decreased in patients receiving transfusions (18.6 vs 49.8 months, p0.001). On multivariate analysis, transfusion remained an independent risk factor for decreased RFS (hazard ratio [HR] 1.63; 95% CI 1.13 to 2.37; p = 0.010) and decreased OS (HR 1.79; 95% CI 1.21 to 2.67; p = 0.004), regardless of EBL or need for splenectomy. Timing (intraoperative vs postoperative) and volume of transfusion did not alter the negative prognostic effect of transfusion on survival.Perioperative allogeneic blood transfusion is associated with decreased RFS and OS after resection of gastric cancer, independent of adverse clinicopathologic factors. This supports the judicious use of perioperative transfusion during resection of gastric cancer.

Conflicting data exist on the prognostic implication of signet-ring cell (SRC) histology in gastric adenocarcinoma (GAC). All patients who underwent curative-intent resection of GAC from the seven institutions of the U.S. Gastric Cancer Collaborative between 2000 and 2012 were included. Primary end points were recurrence-free survival (RFS) and overall survival (OS). Stage-specific analyses were performed. A total of 768 patients met the inclusion criteria. SRC was present in 40.6 % of patients and was associated with female sex (52.9 vs. 38.6 %; p

The effect of routine drainage after abdominal surgery with enteric anastomoses is controversial. In particular, the role of peritoneal drain (PD) placement after total gastrectomy for adenocarcinoma is not well established. Patients who underwent total gastrectomy for gastric adenocarcinoma (GAC) at seven institutions from the US Gastric Cancer Collaborative, from 2000 to 2012, were identified. The association of PD placement with postoperative outcomes was analyzed. Overall, 344 patients were identified and 253 (74 %) patients received a PD. The anastomotic leak rate was 9 %. Those with PD placement had similar American Society of Anesthesiologists score, tumor size, TNM stage, and the need for additional organ resection when compared with their counterparts. No difference was observed in the rate of any complication (54 vs. 48 %; p = 0.45), major complication (25 vs. 24 %; p = 0.90), or 30-day mortality (7 vs. 4 %; p = 0.51) between the two groups. In addition, no difference in anastomotic leak (9 vs. 10 %; p = 0.90), the need for secondary drainage (10 vs. 9 %; p = 0.92), or reoperation (13 vs. 8 %; p = 0.28) was identified. On multivariate analysis, PD placement was not associated with decreased postoperative complications. Subset analysis, stratified by patients who did not undergo concomitant pancreatectomy (n = 319) or those who experienced anastomotic leak (n = 31), similarly demonstrated no association of PD placement with reduced complications or mortality. PD placement after total gastrectomy for GAC is associated with neither a decrease in the frequency and severity of adverse postoperative outcomes, including anastomotic leak and mortality, nor a decrease in the need for secondary drainage procedures or reoperation. Routine use of PDs is not warranted.

To determine pathologic features associated with recurrence and survival in patients with lymph node-negative gastric adenocarcinoma.Multi-institutional retrospective analysis.Lymph node status is among the most important predictors of recurrence after gastrectomy for gastric adenocarcinoma. Pathologic features predictive of recurrence in patients with node-negative disease are less well established.Patients who underwent curative resection for gastric adenocarcinoma between 2000 and 2012 from 7 institutions of the US Gastric Cancer Collaborative were analyzed, excluding 30-day mortalities and stage IV disease. Competing risks regression and multivariate Cox regression were used to determine pathologic features associated with time to recurrence and overall survival. Differences in cumulative incidence of recurrence were assessed using the Gray method (for univariate nonparametric analyses) and the Fine and Gray method (for multivariate analyses) and shown as subhazard ratios (SHRs) and adjusted subhazard ratios (aSHRs), respectively.Of 805 patients who met inclusion criteria, 317 (39%) had node-negative disease, of which 54 (17%) recurred. By 2 and 5 years, 66% and 88% of patients, respectively, experienced recurrence. On multivariate competing risks regression, only T-stage 3 or higher was associated with shorter time to recurrence [aSHR = 2.7; 95% confidence interval (CI), 1.5-5.2]. Multivariate Cox regression showed T-stage 3 or higher [hazard ratio (HR) = 1.8; 95% CI, 1.2-2.8], lymphovascular invasion (HR = 2.2; 95% CI, 1.4-3.4), and signet ring histology (HR = 2.1; 95% CI, 1.2-3.6) to be associated with decreased overall survival.Despite absence of lymph node involvement, patients with T-stage 3 or higher have a significantly shorter time to recurrence. These patients may benefit from more aggressive adjuvant therapy and postoperative surveillance regimens.

Objective: To compare the prognostic performance of American Joint Committee on Cancer/International Union Against Cancer seventh N stage relative to lymph node ratio (LNR), log odds of metastatic lymph nodes (LODDS), and N score in gastric adenocarcinoma. Background: Metastatic disease to the regional LN basin is a strong predictor of worse long-term outcome following curative intent resection of gastric adenocarcinoma. Methods: A total of 804 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. The relative discriminative abilities of the different LN staging/scoring systems were assessed using the Akaike’s Information Criterion (AIC) and the Harrell’s concordance index (c statistic). Results: Of the 804 patients, 333 (41.4%) had no lymph node metastasis, whereas 471 (58.6%) had lymph node metastasis. Patients with ≥N1 disease had an increased risk of death (hazards ratio = 2.09, 95% confidence interval: 1.68–2.61; P < 0.001). When assessed using categorical cutoff values, LNR had a somewhat better prognostic performance (C index: 0.630; AIC: 4321.9) than the American Joint Committee on Cancer seventh edition (C index: 0.615; AIC: 4341.9), LODDS (C index: 0.615; AIC: 4323.4), or N score (C index: 0.620; AIC: 4324.6). When LN status was modeled as a continuous variable, the LODDS staging system (C index: 0.636; AIC: 4304.0) outperformed other staging/scoring systems including the N score (C index: 0.632; AIC: 4308.4) and LNR (C index: 0.631; AIC: 4225.8). Among patients with LNR scores of 0 or 1, there was a residual heterogeneity of outcomes that was better stratified and characterized by the LODDS. Conclusions: When assessed as a categorical variable, LNR was the most powerful manner to stratify patients on the basis of LN status. LODDS was a better predicator of survival when LN status was modeled as a continuous variable, especially among those patients with either very low or high LNR.

Survival estimates following surgical resection of gastric adenocarcinoma are traditionally reported as survival from the date of surgery. Conditional survival (CS) estimates, however, may be more clinically relevant by accounting for time already survived. We assessed CS following surgical resection for gastric adenocarcinoma. We analyzed 807 patients who underwent resection for gastric adenocarcinoma from 2000 to 2012 at seven participating institutions in the U.S. Gastric Cancer Collaborative. Cox proportional hazards models were used to evaluate factors associated with overall survival. Three-year CS estimates at “x” year after surgery were calculated as follows: CS3 = S(x+3)/S(x). Overall 1-, 3-, and 5-year overall survival rates after gastric resection were 42, 34, and 30 %, respectively. Using CS estimates, the probability of surviving an additional 3 years given that the patient had survived at 1, 3, and 5 years were 56, 71, and 82 %, respectively. Patients with higher risk at baseline (i.e., stage III or IV disease, lymphovascular invasion) demonstrated the greatest increase in CS over time. Survival estimates following surgical resection of gastric adenocarcinoma is dynamic; the probability of survival increases with time already survived. Patients with worse prognostic features at the time of surgery had the greatest increases in CS over time. Conditional survival estimates provide important information about the changing probability of survival over time and should be used among patients with resected gastric adenocarcinoma to guide subsequent follow-up strategies.

Use of perioperative chemotherapy (CTx) alone versus chemoradiation therapy (cXRT) in the treatment of resectable gastric cancer remains varied. We sought to define the utilization and effect of CTx alone versus cXRT on patients having undergone curative-intent resection for gastric cancer.Using the multi-institutional US Gastric Cancer Collaborative database, we identified 505 gastric cancer patients between 2000 and 2012 who received perioperative therapy in addition to curative-intent resection. The impact of perioperative therapy on survival was analyzed by the use of propensity-score matching of clinicopathologic factors among patients who received CTx alone versus cXRT.Median patient age was 62 years, and most patients were male (58.2 %). Most patients had a T3 (38.7 %) or T4 (36.8 %) lesion and lymph node metastasis (73.4 %). A total of 211 (42.8 %) patients received perioperative CTx alone, whereas the remaining 294 (58.2 %) patients received cXRT. Factors associated with receipt of cXRT were younger age (odds ratio, 1.93) and lymph node metastasis (odds ratio, 4.02; both P 0.05). At a median follow-up of 28 months, the median overall survival (OS) was 33.4 months, and the 5-year OS was 36.7 %. Factors associated with worse overall survival included large tumor size [hazard ratio (HR), 1.83], T3 (HR 2.96) or T4 (HR 4.02) tumors, and lymph node metastasis (HR 1.57; all P 0.05). In contrast, receipt of cXRT was associated with improved long-term OS (CTx alone, 20.9 months; cXRT, 46.7 months; HR 0.51; P 0.001).cXRT was utilized in 58 % of patients undergoing curative-intent resection for gastric cancer. With propensity score-matched analysis, cXRT was an independent factor associated with improved recurrence-free survival and OS.