BACKGROUND Current guidelines recommend excisional/complete biopsy for melanoma diagnosis, owing to high rates of residual disease found at wide local excision (WLE) after partial biopsy techniques. We sought to determine any survival disadvantage associated with the presence of residual invasive melanoma in the WLE after diagnosis with a partial biopsy technique. STUDY DESIGN Data were examined from Multicenter Selective Lymphadenectomy Trials I and II (MSLT-I and -II), 2 large melanoma trials. Patients diagnosed with excisional/complete biopsy were excluded. Clinicopathologic characteristics, melanoma-specific survival (MSS), distant disease-free survival (DDFS), and disease-free survival (DFS) of those with residual invasive melanoma in the definitive WLE and those with no residual melanoma were compared. Matched pairing was used to reduce variability between groups. RESULTS From 1994 through 2014, 3,939 patients were enrolled in these trials and 874 (22%) were diagnosed using partial biopsy techniques. Of these, 399 (46%) had residual tumor in the WLE. Only 6 patients had residual tumor in their WLE resulting in T-upstaging of their tumor. Match-pairing formed two cohorts (1:1) of patients with and without residual invasive tumor after WLE. A total of 514 patients were paired; 288 (56%) males, 148 (28.8%) aged 60 or older, 192 (37.4%) with truncal melanomas, 214 (41.6%) had Breslow thickness 2 mm or greater, and 376 (73.2%) had positive sentinel nodes. Kaplan-Meier analysis showed no statistical difference in 10-year MSS (73.6% ± 3.3% vs 73.9% ± 3.7%, p = 0.891), DDFS (68.7% ± 3.4% vs 65.3% ± 4.0%, p = 0.548), or DFS (59.6% ± 3.7% vs 59.4% ± 3.9%, p = 0.783). CONCLUSIONS Survival in patients with primary melanoma does not appear to be worse in patients who undergo a partial biopsy technique and are later found to have residual invasive tumor in the WLE specimen.

BackgroundEsophagectomy is a complex operation in which outcomes are profoundly influenced by operative experience and volume. We report the effects of experience and innovation on outcomes in minimally invasive esophagectomy.MethodsEsophageal resections for cancer from 2007 to 2016 at Levine Cancer Institute at Carolinas Medical Center (Charlotte, NC) were reviewed. During this time, three changes in technique were made to improve outcomes: vascular evaluation of the gastric conduit to improve anastomotic healing (beginning at case #63), one-stage approach to permit access to abdomen and chest through one draped surgical field (case #82), and adoption of a lung-protective anesthetic protocol (case #101). Mortality, operative time, complications, and length of stay were analyzed relative to these interventions using GLM regression.Results200 patients underwent minimally invasive esophagectomy. There were no mortalities at 30days, and no change in mortality rate at 60 and 90days. Anastomotic leak decreased significantly after the introduction of intraoperative vascular evaluation of the gastric conduit (3.6 vs 19.4%). Operative time decreased with adoption of a one-stage approach (416 vs 536min). Pulmonary complications decreased coincident with a change in anesthetic technique (pneumonia 6 vs 28%). Lymph node harvest increased over time. Length of stay was driven primarily by complications and decreased with operative experience.ConclusionsPostoperative complications, operative time, and length of stay decreased with case experience and alterations in surgical and anesthetic technique. We believe that adoption of the techniques and technology described herein can reduce complications, reduce hospital stay, and improve patient outcomes.

Background and Objectives Stage IV colorectal cancer is often treated with palliative chemotherapy with the primary tumor in place. Low rates of unplanned surgical intervention (due to obstruction or perforation) have been reported. We examined a large national dataset to determine the rate of unplanned surgical intervention in these patients. Methods Surveillance Epidemiology and End Results-Medicare were queried for patients with metastatic colorectal cancer receiving chemotherapy (1998-2013). Patient who underwent planned surgery to the primary or metastasectomy were excluded. The primary outcome was the need for nonelective surgery. Time to surgery or death was measured. Conditional analyses were performed to determine the risk of surgical intervention at 6-month, 1-, and 2-year after diagnosis. Results The analytic cohort consisted of 4692 patients (median age = 75). At 24 months, 80% of the patients had died. The overall unplanned intervention rate was 12%. The probability of requiring unplanned surgery between 6 and 12 months was 8.1%; 12 and 24 months = 6.7%, and >24 months = 5.3%. Males, those with right-sided tumors, and older patients were less likely to require surgery. Conclusions Patients treated with palliative chemotherapy who are not resected upfront are unlikely to require unplanned surgery. Prophylactic surgery to reduce the risk of perforation or obstruction may not be necessary.

Optimal nutrition after esophagectomy is challenging due to alterations in eating, both from the tumor and during surgical recovery. Enteral nutrition via feeding tube is commonly used. The impact of feeding tubes on post-esophagectomy outcomes was examined in a large national data set.

INTRODUCTION:The standard technique for Ivor Lewis minimally invasive esophagectomy involves a two-stage approach necessitating repositioning mid-procedure.TECHNIQUE:We describe our technique for a one-stage hand-assisted minimally invasive esophagectomy that allows sequential access to the chest and abdomen within the same surgical field, eliminating the need for repositioning. The patient is positioned in a "corkscrew" configuration with the abdomen supine and the chest rotated to the left to allow access to the right chest. The abdomen and chest are prepped into a single operative field. This technique allows sequential access to the abdomen for gastric mobilization, chest for division of the esophagus, abdomen for construction of the gastric conduit, and chest for intrathoracic anastomosis.CONCLUSION:This approach enables extracorporeal construction of the conduit, which helps ensure a clear distal margin on the specimen and facilitates conduit length by placing the stomach on stretch during stapling.

Current National Comprehensive Cancer Network guidelines for resectable small bowel neuroendocrine tumors (NETs) recommend regional lymphadenectomy. However, no consensus exists on the optimal nodal harvest.

163 Background: Locally advanced gastric adenocarcinoma (GACa) is optimally treated with a combination of surgery, chemotherapy (CHEMO) and radiation (RT). Utilization of therapies can vary with institutional practices. Methods: The NCDB was queried for pts with GACa who had RO resection (2006-2012). Pts with metastatic disease, incomplete pathologic staging, and incomplete CHEMO or RT sequencing data were excluded. Pts were divided into groups by treatment regimen: G1: perioperative CHEMO; G2: adjuvant CHEMO±RT; G3: neoadjuvant CHEMORT; G4: other adjunctive regimens; G5: surgery only. Pts who received neoadjuvant therapy were staged using clinical TNM; those who did not or had incomplete clinical staging were staged using pathologic TNM. 3 subsets were created: LOCAL: T0-2N0, LOCALLY ADV: T3-4N0, REGIONAL: N+. Chi-square, univariate, multivariable with stepwise selection, and Cochran-Armitage time trend analyses were performed. Results: N = 12946: G1 = 1099, G2 = 4771, G3 = 180, G4 = 244 and G5 = 6652. The percentage of pts receiving adjunctive therapy was determined for each subset: LOCAL = 17.2%, LOCALLY ADV = 59.8%, and REGIONAL = 66.0%. Use of adjunctive therapy increased from 2006: 44% to 2012: 53% (p < 0.01). Use of perioperative CHEMO increased from 2006: 4% to 2012: 18% (p < 0.01). Factors affecting use of adjunctive therapy on multivariable analysis are: age (p < 0.01), race (p < 0.01), income (p < 0.01), insurance (p < 0.01), comorbidity score (p < 0.01), and facility volume (p = 0.01). Conclusions: Though utilization of adjunctive therapy is increasing, a large proportion of pts with resectable GACa do not receive recommended adjunctive therapy. This study highlights disparities in utilization of optimal multimodality care. National efforts to expand access to care are necessary to improve outcomes in resectable GACa. [Table: see text]

Objective: This retrospective review seeks to establish a predictive model for patients who may benefit from intraoperative feeding tube (FT) placement at the time of pancreaticoduodenectomy (PD) to decrease length of hospitalization, improve postoperative nutrition, or prevent post-PD abdominal procedures. Methods: PD procedures performed by a quaternary hepatopancreaticobiliary (HPB) referral center from January 1, 2008, to July 31, 2015, were analyzed. Factors correlating with FT placement and delayed gastric emptying (DGE) were examined with univariate and multivariate analysis. Models predicting FT requirement and DGE were devised. Results: In all, 407 patients underwent PD: 336 (82.6%) patients had no feeding tube placed, while 71 (17.4%) underwent concomitant tube placement and 27 (8%) required tube placement within 90 postoperative days. Ninety-three patients (22.9%) developed DGE. The strongest predictors of FT requirement were increasing age (p=.002) and surgical blood loss (p=.003), American Society of Anesthesiologists (ASA) classification of V (p=.003), and occurrence of lymphovascular invasion (p=.016). Predictive models for tube placement within 90 days of PD (ROC: 0.637) and DGE (ROC: 0.655) were derived. Conclusion: This review of patients undergoing PD identifies factors influencing FT placement, however, models for FT and DGE had moderate overall predictive ability. Low rates of Grade C DGE and POPF in this dataset may contribute to the models' moderate predictive capacities. Expansion of this study with a larger sample size is planned to develop more effective predictive models for intraoperative FT placement at the time of PD.

726 Background: Definitive chemoradiotherapy (CHEMORT) is the treatment of choice for anal squamous cell carcinoma (SCC), while surgery is typically reserved for salvage therapy. Patients (pts) who are frail due to advanced age or medical comorbidities often have difficulty completing therapy. Methods: The NCDB was queried for pts with anal SCC (2004-2012). Pts < 50 years, and those with in situ or metastatic disease, or with incomplete CHEMORT treatment data were excluded. The primary outcome was completion of CHEMORT. Secondary outcome was requirement of salvage surgical therapy. Statistical analyses include Chi-square, univariate and multivariable logistic regression. Results: N = 11918. 5907 (49.5%) did not complete recommended CHEMORT. 9862 (82.8%) received CHEMO, 6011 (61.0%) of whom completed RT with dosage > 45Gy. Factors significantly associated with failure to complete therapy on multivariable analysis include: older age at diagnosis, higher Charlson-Deyo score, earlier year of diagnosis, male gender, and earlier clinical T and N stages (Table 1). 41.7% of pts who did not complete CHEMORT required salvage surgical therapy, versus 25.1% of pts completing CHEMORT (OR: 2.14 95% CI [1.97, 2.31], p < 0.01). Conclusions: Approximately half of pts older than 50 years of age with anal SCC failed to complete definitive CHEMORT. This study highlights the negative impact of frailty on the ability of pts to receive optimal therapy, resulting in more operative interventions. Medical optimization of older pts with more comorbidities in order to improve utilization of CHEMORT is one possible area of improvement in the management of anal SCC. [Table: see text]

Objective: Adjuvant chemotherapy (CHEMO), with or without radiation (RT), improves survival for patients with resectable pancreatic adenocarcinoma (PACa). Utilization of adjunctive therapies can vary with institutional practices and disparities in care. Methods: The NCDB was queried for patients with PACa undergoing pancreaticoduodenectomy (2006–2012). Patients with metastatic disease, incomplete pathologic staging, and incomplete CHEMORT sequencing data were excluded. Patients were grouped by treatment regimen: G1=neoadjuvant CHEMO, G2=neoadjuvant CHEMORT, G3=adjuvant CHEMO, G4=adjuvant CHEMORT, and G5=surgery alone. Patients who received neoadjuvant therapy were staged using clinical TNM, and those who did not or who lacked complete clinical staging were staged using pathologic TNM. Subsets were created based on AJCC stage. Statistical analyses included Chi-square, univariate, multivariable modeling and Cochran-Armitage time trend. Results: N=6845: G1=273, G2=402, G3=1831, G4=2122, G5=2217. The percentage of patients receiving adjunctive therapy was determined for each subset: Stage 1=499/944 (52.9%), Stage 2A=919/1379 (66.6%), Stage 2B=3034/4304 (70.5%), Stage 3=176/218 (80.7%). Utilization of any adjunctive therapy increased from 2006–2012 (62.8–72.1%, p<0.0001), as did use of neoadjuvant CHEMO (6.5–12.3%, p<0.0001). Adjunctive therapy was less frequently administered to patients who were earlier stage in addition to those who were older, lower income, uninsured, those with higher Charlson-Deyo score, and those cared for in higher-volume facilities (all p<0.05 on multivariate analysis). Conclusion: Though utilization of adjunctive therapy is increasing, a large proportion of patients with resectable PACa do not receive recommended adjunctive therapy. This study highlights disparities in utilization of optimal multimodality care. National efforts to expand access to care are necessary to improve outcomes in pancreatic head adenocarcinoma.Table 1Adjunctive treatment group by AJCC staging subset.Neoadjuvant Chemo N (row%)Neoadjuvant ChemoRT N (row%)Adjuvant Chemo N (row%)Adjuvant ChemoRT N (row%)Surgery alone N (row%)Total N (row%)T0-2N043(4.6)110(11.7)176(18.6)170(18.0)445(47.1)944(100)T3N061(4.4)145(10.5)347(25.2)366(26.5)460(33.4)1379(100)T0-3N167(1.6)157(3.6)1287(29.9)1523(35.4)1270(29.5)4304(100)T4N0-115(6.9)77(35.3)21(9.6)63(28.9)42(19.3)218(100)Total1862.7%489(7.1)1831(26.7)2122(31.0)2217(32.4)6845(100) Open table in a new tab

BACKGROUND:This study compares clinical and cost outcomes of robot-assisted laparoscopic (RAL) and open longitudinal pancreaticojejunostomy (LPJ) for chronic pancreatitis.METHODS:Clinical and cost data were retrospectively compared between open and RAL LPJ performed at a single center from 2008-2015.RESULTS:Twenty-six patients underwent LPJ: 19 open and 7 RAL. Two robot-assisted cases converted to open were included in the open group for analysis. Patients undergoing RAL LPJ had less intraoperative blood loss, a shorter surgical length of stay, and lower medication costs. Operation supply cost was higher in the RAL group. No difference in hospitalization cost was found.CONCLUSIONS:Versus the open approach, RAL LPJ performed for chronic pancreatitis shortens hospitalization and reduces medication costs; hospitalization costs are equivalent. A higher operative cost for RAL LPJ is mitigated by a shorter hospitalization. Decreased morbidity and healthcare resource economy support use of the robotic approach for LPJ when appropriate.

Journal of Surgical OncologyVolume 116, Issue 7 p. 960-960 RESPONSE TO LETTER TO THE EDITOR Letter response: Reporting of mitotic rate in cutaneous melanoma Patrick D. Lorimer MD, Patrick D. Lorimer MD Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorEmily Benham MD, Emily Benham MD Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorKendall Walsh BA, Kendall Walsh BA Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorYimei Han MS, Yimei Han MS Department of Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NCSearch for more papers by this authorMeghan R. Forster MD, Meghan R. Forster MD Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorTerry Sarantou MD, FACS, Terry Sarantou MD, FACS Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorRichard L. White Jr MD, FACS, Richard L. White Jr MD, FACS orcid.org/0000-0001-6559-8312 Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorJoshua S. Hill MD, Joshua S. Hill MD joshua.hill@carolinashealthcare.org Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this author Patrick D. Lorimer MD, Patrick D. Lorimer MD Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorEmily Benham MD, Emily Benham MD Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorKendall Walsh BA, Kendall Walsh BA Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorYimei Han MS, Yimei Han MS Department of Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NCSearch for more papers by this authorMeghan R. Forster MD, Meghan R. Forster MD Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorTerry Sarantou MD, FACS, Terry Sarantou MD, FACS Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorRichard L. White Jr MD, FACS, Richard L. White Jr MD, FACS orcid.org/0000-0001-6559-8312 Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this authorJoshua S. Hill MD, Joshua S. Hill MD joshua.hill@carolinashealthcare.org Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NCSearch for more papers by this author First published: 01 December 2017 https://doi.org/10.1002/jso.24815Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume116, Issue7December 1, 2017Pages 960-960 RelatedInformation

Objective: This study examined the outcomes of microwave ablation (MWA) for the management of hemorrhage from ruptured liver tumors. Though resection is often considered the preferred treatment for ruptured hepatic tumors, rapid coagulative necrosis induced by MWA may obviate the need for immediate resection in physiologically challenged patients. While management protocols exist for specific tumors, a global hemodynamic, oncologic, and hepatic functional assessment may be better suited to the range of pathology seen in modern hepatobiliary practice. Methods: Patients treated for bleeding liver tumors at a single institution from January 1, 2008 to September 30, 2015 were retrospectively analyzed using standard statistical methods. Tumor characteristics, interventions, and operative outcomes are reported. Results: Eighteen patients underwent surgical intervention for bleeding tumors; 12 (66.7%) presented with ruptured HCC, 5 (27.8%) with ruptured hepatic adenoma, and one melanoma liver metastasis. Ten patients (55.6%) underwent hepatic artery embolization (HAE); this was unsuccessful in 3 cases. Laparotomy was reserved for hemodynamically unstable patients (n = 6, 33%). Hemostasis was obtained with MWA in 14 cases (77.8%); the remaining tumors were resected without performing ablation. One ablation was converted to resection after hemostasis was achieved. No reoperation occurred for bleeding following MWA. Conclusion: MWA is an effective modality for controlling hemorrhage from ruptured liver tumors. Hemorrhage control without emergent hepatectomy allows resuscitation and planned intervention should further liver-directed therapy be required. An algorithmic approach to bleeding liver tumors is proposed based on review of this experience and published disease process-specific algorithms (Figure 1).

3608 Background: The current standard of care in locally advanced rectal cancer is neoadjuvant chemoradiation and R0 resection. An optimal radiation-surgery interval (RSI) has not been established. A small institutional dataset showed RSI > 49 days improved pathologic complete response (pCR) rates and disease free survival. However, in a national dataset, RSI greater than 60 days was associated with increased rates of positive margins and impaired overall survival. Because pCR is associated with improved survival, we used a national database to evaluate the relationship between RSI, pCR and survival after neoadjuvant therapy for rectal cancer. Methods: The NCDB was queried for cases 2004-2013 of AJCC stage II or III rectal adenocarcinoma that underwent neoadjuvant radiation followed by radical resection. We excluded patients with missing and outlier RSI. pCR was defined as ypT0N0M0. Chi-square, univariate, multivariable Cox model, and Cochran-Armitage time trend analyses were performed. Results: 23475 patients were identified. 7901 (33.7%) had RSI ≥60 days. pCR occurred in 1766 (11.3%) of the < 60 group and 1174 (14.9%) of the ≥60 group (p < 0.001). RSI ≥60 days has increased over time, from 22.1% in 2004 to 45.4% in 2013 (p < 0.001), as have pCR rates, from 8.4% in 2004 to 14.2% in 2013 (p < 0.001). Multivariable Cox model of the total cohort showed that RSI ≥60 days (HR = 1.11, 95% CI = 1.04-1.19) and residual disease (HR = 2.04, 95% CI = 1.78-2.34) were associated with increased mortality. Subgroup analysis of patients with pCR showed RSI ≥60 days was not associated with worse survival (HR = 1.07, 95% CI = 0.82-1.41). However, analysis of patients with residual disease showed RSI ≥60 days was associated with worse survival (HR = 1.13, 95% CI = 1.06-1.21). Conclusions: In a large national database, RSI ≥60 days worsens survival in patients who have residual disease after neoadjuvant therapy for locally advanced rectal cancer, while there is no difference in those with pCR. Emphasis should be placed on identifying patients who are unlikely to have pCR and to prioritize resection in these patients within 60 days of completion of chemoradiation.