Background Upfront resection with adjuvant chemotherapy remains standard for resectable pancreatic ductal adenocarcinoma (PDAC), but a quarter or more of patients never start adjuvant therapy. We assessed readiness for adjuvant therapy within 12 weeks of upfront pancreatectomy, its correlates, and how often ready patients went untreated. Methods We reviewed 114 consecutive upfront pancreatectomies for PDAC at a high-volume centre (2017-2023). The primary endpoint was clinician-documented readiness for adjuvant chemotherapy within 12 weeks; initiation was secondary. The same oncologist usually documented both, so they are not independent. A burden score counted five adverse recovery events by day 30. Results Of 107 assessed patients, 89 (83.2%, 95% CI 74.7-89.7) were ready within 12 weeks (87.3% excluding 5 who died or had metastatic disease). Readiness was 94.6% with no adverse event, 82.4% with one, and 68.8% with two or more (non-readiness vs none: OR 7.1, 95% CI 2.1-30.5). Clinically relevant pancreatic fistula alone showed no association (OR 1.15, 95% CI 0.36-3.33; 5 events), but a clinically important effect could not be excluded. The burden score had an internally estimated AUC of 0.73 (95% CI 0.59-0.85). Only 54 (50.5%) started chemotherapy within 12 weeks, including 53 of 88 ready patients. Discussion Most patients were ready for adjuvant therapy within 12 weeks, and failure to recover tracked cumulative postoperative burden by day 30. Over a third of ready patients had no documented chemotherapy start, although readiness and initiation were not independently assessed. These hypothesis-generating findings require external validation and do not compare treatment sequencing.
Severe acute respiratory distress syndrome (ARDS) after trauma can require extracorporeal support, however, the usual approach to ARDS is often complicated by associated injuries. Prone positioning may be limited by unstable fractures or other injuries, while traumatic intracranial hemorrhage and recent bleeding can make systemic anticoagulation difficult. At the same time, severe ARDS can substantially increase right ventricular afterload and lead to right ventricular dysfunction. Conventional venovenous extracorporeal membrane oxygenation (VV-ECMO) improves gas exchange and may reduce right ventricular afterload indirectly, but it still relies on native right ventricular forward flow. Veno-pulmonary (V-P) ECMO offers an alternative by combining extracorporeal gas exchange with direct right ventricular unloading. Most published experience, however, has involved conversion to V-P support after refractory right ventricular failure has already developed. This review examines the role of V-P ECMO in severe trauma-associated ARDS, focusing on right ventricular dysfunction, selection of the initial extracorporeal configuration, and anticoagulation when traumatic bleeding limits standard management. We also describe an illustrative multiply injured patient with severe ARDS, evolving right ventricular dysfunction, and traumatic subdural hemorrhage who received V-P ECMO as the initial configuration without systemic anticoagulation. Current evidence supports the feasibility of V-P ECMO but does not define when earlier direct right ventricular support is warranted. Trauma adds important constraints that make configuration and anticoagulation decisions particularly complex and deserving of further study.
Malnutrition is common among patients undergoing cancer surgery, yet guideline-recommended perioperative nutritional care is inconsistently implemented. We evaluated outpatient nutritional counseling before and after integration of a dedicated registered dietitian (RD) into a surgical oncology clinic. We conducted a retrospective cohort study of adults undergoing oncologic surgery from January 2021 through August 2025. The primary outcome was documented perioperative RD counseling; postoperative outcomes were exploratory. Among 234 surgeries, 133 preceded RD integration and 101 followed it. Counseling increased from 15.0% (20/133) to 65.3% (66/101; P < 0.001). Post-integration patients had higher odds of counseling (OR 10.65, 95% CI 5.69-19.96). Counseled patients had lower baseline BMI, suggesting preferential referral of patients at greater nutritional risk. Dedicated RD integration substantially improved access to perioperative nutritional counseling, a clinically meaningful step toward timely, individualized nutrition assessment and intervention, while identifying opportunities to strengthen referral pathways and documentation.
Objective To compare 1-year outcomes of bedside and operating-room drainage of perianal abscesses using propensity score methods to address confounding by indication. Methods This two-center retrospective cohort included 303 adults undergoing drainage of perianal or anorectal abscesses. Because all bedside procedures involved perianal abscesses, comparative analyses were restricted to 271 patients with perianal abscesses who were potentially eligible for either drainage approach (183 bedside and 88 operating room). We performed 1:1 propensity score matching, inverse probability of treatment weighting (IPTW), and doubly robust analysis using nine baseline covariates. Results Propensity score matching yielded 76 pairs. Recurrent abscess occurred in 6.6% of operating-room and 13.2% of bedside patients (OR, 0.38; 95% CI, 0.10-1.41; P = 0.147), newly diagnosed anal fistula in 10.5% and 18.4% (OR, 0.50; 95% CI, 0.19-1.33; P = 0.166), and reoperation in 11.8% and 28.9%, respectively (OR, 0.28; 95% CI, 0.10-0.75; P = 0.011). The association with lower reoperation remained significant in the IPTW (OR, 0.33; 95% CI, 0.15-0.60; P < 0.001) and doubly robust analyses (OR, 0.20; 95% CI, 0.05-0.45; P < 0.001). Recurrent abscess and anal fistula consistently favored operating-room drainage, but their doubly robust findings were exploratory and hypothesis-generating because of low events-per-variable values (2.4 and 3.5, respectively). Conclusion A reduction in the co-primary outcomes was not established in the matched or IPTW analyses; their doubly robust findings are exploratory and hypothesis-generating. Reoperation, a prespecified secondary outcome, was consistently less frequent after operating-room drainage. Further prospective studies are warranted.
