Abstract Background Current guidelines do not recommend routine sampling of lymph node stations (LNS) 16b1, 9, and 8a during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) and other periampullary cancers because prospective multicentre studies are lacking. This study evaluated the association between the involvement of these LNS and overall survival (OS). Methods This prospective multicentre study included patients undergoing pancreatoduodenectomy for PDAC, distal cholangiocarcinoma, ampullary cancer, or duodenal cancer between October 2015 and April 2020. Associations between involvement of LNS 16b1, 9, and 8a and OS were analysed using multivariable Cox regression analyses. Results Among 1218 included patients, 673 had PDAC, 228 had distal cholangiocarcinoma, 212 had ampullary cancer, and 105 had duodenal cancer. LNS 16b1 involvement was associated with worse OS in PDAC (10 versus 24 months; adjusted hazard ratio (aHR) 2.33; 95% confidence interval (c.i.) 1.62 to 3.35), distal cholangiocarcinoma (7 versus 28 months; aHR 6.95; 95% c.i. 2.88 to 16.77), ampullary cancer (9 versus 62 months; aHR 4.35; 95% c.i. 1.73 to 10.94), and duodenal cancer (13 months versus endpoint not reached; aHR 3.95; 95% c.i. 1.15 to 13.47). LNS 8a involvement was associated with worse OS in PDAC (13 versus 22 months; aHR 1.38; 95% c.i. 1.03 to 1.86), distal cholangiocarcinoma (16 versus 26 months; aHR 1.68; 95% c.i. 1.00 to 2.81), and ampullary cancer (16 versus 62 months; aHR 2.89; 95% c.i. 1.51 to 5.53). LNS 9 involvement was associated with worse OS only in ampullary cancer (4 versus 35 months; aHR 8.19; 95% c.i. 2.34 to 28.57). Conclusion LNS 16b1 involvement was associated with poor OS in PDAC and periampullary cancer. Future studies should assess routine preoperative and intraoperative sampling of LNS 16b1 and the impact of neoadjuvant treatment.
Abstract Background Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. The aim of this study was to establish clinically relevant benchmarks for elective laparoscopic cholecystectomy (ELC) to guide quality initiatives and support improvements in patient outcomes. Method The Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography provided data on patients treated with primary ELC for a benign indication between 2015 and 2023. Exclusion criteria were common bile duct stones or stents detected before surgery, suspicion of bile duct obstruction, abnormal or unperformed intraoperative cholangiogram, previous major upper abdominal surgery, concomitant surgical procedures, and robotic surgery. The Achievable Benchmark of Care methodology was used to develop intra- and postoperative benchmarks, with severe postoperative complications (Clavien–Dindo ≥ III) representing the primary outcome. During surgery, serious adverse events were defined as intestinal perforation, bile leakage, or bleeding requiring transfusion or conversion to open surgery. Postoperative outcomes were assessed up to 30 days after surgery. Logistic regression identified risk factors for severe postoperative complications. Results Overall, 48 564 patients undergoing ELCs across 81 surgical facilities were included. Among these, 69% were women. Median age was 50 (range 18–95) years and 91.4% were classified as American Society of Anesthesiologists classification ≤ II. Ten benchmarks were developed, capturing either intraoperative events (3) or postoperative complications (7). During surgery, 0.5% of the total cohort experienced a serious adverse event (median 0.3%, interquartile range 0.2–0.7% between facilities)—benchmark was 0.2%. Severe postoperative complications occurred in 1.7% of patients (median 1.6%, interquartile range 1.0–2.2% between facilities)—benchmark was 1.0%. Postoperative mortality was low (7 deaths, < 0.1%). At multivariable analysis, American Society of Anesthesiologists classification ≥ III (odds ratio 1.35, 95% confidence interval 1.05 to 1.72; P = 0.018), previous abdominal surgery (odds ratio 2.15, 1.24 to 3.75; P = 0.007), and intraoperative assessment of an altered gallbladder morphology (odds ratio 1.24, 1.01 to 1.52; P = 0.044) were independently associated with severe postoperative complications. Conclusion This study provides benchmarks for elective laparoscopic cholecystectomy. When compared with real-world performance, these benchmarks highlight potential areas for quality improvement.
Abstract Background After the Stockholm III trial, a trend towards delayed surgery after neoadjuvant short-course radiotherapy (5 × 5 Gy) for rectal cancer has emerged in Sweden, driven by the lower short-term complication rates and similar oncological outcomes. This study aimed to examine long-term oncological outcomes after neoadjuvant short-course radiotherapy, comparing direct versus delayed surgery for rectal cancer in a real-world setting. Methods A registry-based retrospective national cohort study was conducted using prospectively collected data from the Swedish Colorectal Cancer Registry. Patients with rectal cancer receiving neoadjuvant neoadjuvant short-course radiotherapy with surgery between 2016 and 2020 were analysed for oncological outcomes (local recurrence, distant metastasis) and overall survival at 3 years, comparing direct surgery, defined as surgery within 7 days after neoadjuvant short-course radiotherapy, and delayed surgery, defined as surgery after 28–90 days. The rate of patients who underwent surgery within the delayed time frame of the Stockholm III trial was also recorded. Results A total of 2080 patients were identified, of whom 1208 (58.1%) underwent direct surgery and 872 had delayed surgery. Of note, only 288 patients underwent resection 28–56 days after neoadjuvant short-course radiotherapy (within the time frame of the Stockholm III trial). Although the pathological complete response rate was higher in the delayed-surgery group compared with the direct-surgery group (6.5% versus 0.4%), 3-year local recurrence and distant metastasis rates were, respectively, 1.0% (12 patients) and 6.8% (82) in the direct-surgery group, and 3.4% (30) and 11.9% (104) in the delayed-surgery group. The adjusted hazard ratios for local recurrence and distant metastasis comparing delayed surgery with direct surgery were 3.60 (95 per cent confidence interval 1.75 to 7.39) and 2.17 (1.58 to 2.96), respectively, whereas the adjusted hazard ratio for overall survival was 1.37 (1.06 to 1.77), favouring the direct-surgery group. Conclusion In a real-world setting, the results indicate that few patients in the delayed-surgery group had surgery within the stipulated time frame. Considering this, delayed surgery was associated with a higher risk of local recurrence, distant metastasis, and reduced overall survival.
Abstract Introduction Evidence of the effects of obesity and smoking on complication-related reintervention after elective umbilical hernia mesh repair is limited. This study evaluated the association between these factors and reoperation after mesh repair. Methods A nationwide cohort of elective open umbilical hernia repairs from 2017 to 2020 was identified from prospective registration in the Danish Hernia Database. Patients were followed until 31 December 2023 through nationwide registries and complete scrutiny of operative notes associated with succeeding reinterventions. Study outcomes were reoperation for any complication, recurrence, or non-recurrence complication with special reference to the repair method. Multivariable analyses included cause-specific hazard models with adjustment for body mass index (BMI), smoking status, sex, age, and hernia size. Results Of the 2391 patients included in the study, 18.4% were smokers and 34.0% were obese (BMI > 30 kg/m2). The follow-up rate was 99.9% over a median of 4.65 years. Reoperation for any complication was increased in smokers compared with non-smokers (hazard ratio (HR) 1.68; 95% confidence interval (c.i.) 1.05 to 2.69; P = 0.032). Reoperation for non-recurrence complications was more frequent in smokers (HR 2.01; 95% c.i. 1.19 to 3.38; P = 0.009) and obese patients (HR 1.83; 95% c.i. 1.12 to 3.00; P = 0.016). Comparable risks of reoperation for hernia recurrence were found between smokers and non-smokers (HR 0.80; 95% c.i. 0.23 to 2.73; P = 0.721) and between patients with and without obesity (HR 0.73; 95% c.i. 0.26 to 2.09; P = 0.559). Conclusion Reoperation for any complication after open umbilical hernia mesh repair was more frequent in smokers, whereas no independent association was observed between patients with and without obesity. Smoking and obesity were associated with an increased risk of reoperation for non-recurrence complications, while not affecting reoperation for hernia recurrence.
Abstract Background Nipple-sparing mastectomy (NSM) offers superior cosmetic and patient-reported outcomes compared with skin-sparing mastectomy (SSM), although its oncological safety remains debated. This study evaluated recurrence and survival after NSM versus SSM in women with breast cancer receiving implant-based immediate breast reconstruction (IBR). Methods The population-based Stockholm Breast Reconstruction Database, including all women with breast cancer who underwent implant-based IBR in Stockholm from 2005 to 2015, was reviewed. Data were collected from medical chart review and the National Quality Register for Breast Cancer. The primary outcomes were long-term local recurrence (LR) rates and overall survival (OS) after NSM versus SSM. Survival probabilities and hazard ratios (HR) with their 95% confidence interval (c.i.) were estimated with a maximum 12 years of follow-up. Results Of 1687 patients registered in the database, this analysis included 1594 implant-based IBRs performed in 1537 women with primary breast cancer. Of these, 86.3% (1376 breasts) had SSM and 13.7% had NSM (218 breasts). The median follow-up was 75 months for SSM and 60 months for NSM. The use of NSM increased from 7.6% in 2005–2007 to 26.6% in 2014–2015 (P < 0.001). LR occurred in 50 breasts, 13 after NSM and 37 after SSM, with a 12-year cumulative incidence of 14.1% for NSM and 3.7% for SSM (P = 0.001). Among the 13 LRs after NSM, 4 (30.8%) were localized in or beneath the nipple–areola complex. The unadjusted HR was 3.18 (95% c.i. 1.67 to 6.03) and remained significant in the multivariable analysis (HR 2.08; 95% c.i. 1.01 to 4.28). OS did not differ significantly (HR 0.74; 95% c.i. 0.38 to 1.44). Conclusion NSM was associated with an increased risk of LR compared with SSM, whereas no significant association with OS was observed. Whether these results can be attributed to more residual breast glandular tissue needs to be evaluated in further research.
