Timing of Surgery and Social Determinants of Health Related to Pathologic Complete Response after Total Neoadjuvant Therapy for Rectal Adenocarcinoma: Retrospective Study of National Cancer Database.

Total neoadjuvant therapy (TNT) for rectal adenocarcinoma (RAC) involves multi-agent chemotherapy and radiation before definitive surgery. Previous studies of the rest period (time between radiation and surgery) and pathologic complete response (pCR) have produced mixed results. The objective of this study was to evaluate the relationship between the rest period and pCR. This study utilized the National Cancer Database (NCDB) to retrospectively analyze 5997 stage-appropriate RAC cases treated with TNT from 2016 to 2020. The overall pCR rate was 18.6%, with most patients undergoing induction chemotherapy followed by long-course chemoradiation (81.5%). Multivariable logistic regression models revealed a significant non-linear relationship between the rest period and pCR (p = 0.033), with optimal odds at 14.7-15.9 weeks post radiation (odds ratio: 1.49, 95% confidence interval: 1.13-1.98) when compared to 4.0 weeks. Medicaid, distance to the treatment facility, and community education were associated with decreased odds of pCR. Findings highlight the importance of a 15-16-week post-radiation surgery window for achieving pCR in RAC treated with TNT and socioeconomic factors influencing pCR rates. Findings also emphasize the need for clinical trials to incorporate detailed analyses of the rest period and social determinant of health to better guide clinical practice.

Feasibility and Outcomes of Same-Day Surgery in Primary and Reoperative Laparoscopic Hiatal Hernia Repair.

OBJECTIVE: To assess the feasibility and outcomes of same-day surgery in primary and reoperative laparoscopic hiatal hernia repairs. METHODS: Same-day surgery was planned in elective procedures with ASA II-IV. An Enhanced Recovery After Surgery (ERAS) protocol was implemented to achieve same-day surgery, and opioid-based anesthesia was replaced by opioid-free anesthesia. Outcomes were assessed by length of stay, transition from same-day surgery to observation or inpatient, and postoperative emergency department visits/readmissions. The predictors of same-day surgery were assessed. Values are presented as median (interquartile range). RESULTS: From 04/13/2017 to 09/29/2022, there were 518 laparoscopic hiatal hernia repairs in 491 patients, 428/518 (82.6%) were primary, and 90/518 (17.4%) were reoperative. In the primary group, 314/428 (73.4%) were planned as same-day surgery and 246/314 (78.3%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 77/314 (24.5%) vs. same-day surgery with opioid-free anesthesia protocol in 169/314 (53.8%), p < 0.001, 41/246 (16.7%) same-day surgery primary procedures had emergency department visit post-discharge, and 26/246 (10.6%) were readmitted. In the reoperative group, 51/90 (56.7%) were planned as same-day surgery, and 27/51 (52.9%) were performed as same-day surgery. Same-day surgery with opioid-based anesthesia protocol was performed in 2/51 (3.9%) vs. same-day surgery with opioid-free anesthesia protocol in 25/51 (49.0%), p < 0.001, 3/27 (11.1%) same-day surgery reoperative procedures had emergency department visit post-discharge, and 3/27 (11.1%) were readmitted. Opioid-free anesthesia protocol was the positive predictor of same-day surgery compared to opioid-based anesthesia protocol (OR 7.44 [95% CI: 2.94, 18.83]), p < 0.001. Negative predictors were ASA III compared to II (OR 0.52 [95% CI: 0.28, 0.94]), p = 0.031, and duration of operation (OR 0.98 [0.97, 0.99]) p < 0.001. CONCLUSION: Laparoscopic hiatal hernia repair can be performed as same-day surgery in the majority of primary and reoperative procedures with good outcomes and low postoperative emergency department visits and readmissions. The odds of same-day surgery are higher with opioid-free anesthesia, lower ASA, and shorter operative time.

Opioid-Free Anesthesia and Same-Day Surgery Laparoscopic Hiatal Hernia Repair.

BACKGROUND: Laparoscopic hiatal hernia repair is commonly performed with a 1 to 2 night hospitalization. Our aim was to compare the feasibility and short-term outcomes of same-day surgery (SDS) laparoscopic hiatal hernia repair with an opioid-based anesthesia protocol (OBAP) vs an opioid-free anesthesia protocol (OFAP). STUDY DESIGN: Outcomes and pharmacy costs of repairs with OBAP were compared with OFAP. Values were expressed as median (interquartile range) and costs as means. RESULTS: There were 244 primary laparoscopic repairs. OBAP was used in 191 of 244 (78.3%) vs OFAP in 53 of 244 (21.7%). The length of stay was 1 day (0 to 2) vs 0 days (0 to 1), p = 0.006. There was no difference between the percentage of patients requiring analgesics and dosage between the 2 groups. SDS was planned in 157 and performed in 74 of 122 (60.7%) vs 33 of 35 (94.3%), p < 0.001. The age was 56 years (45 to 63) vs 60 years (56 to 68), p = 0.025. There were more type I hiatal hernia in SDS-OBAP and more type III and IV in SDS-OFAP, p = 0.031. American Society of Anesthesiologists Physical Status was II (II-III) vs III (II-III), p = 0.045. SDS was not performed in 50 of 157 (31.8%), 48 of 122 (39.3%) vs 2 of 35 (5.7%), p < 0.001. Out of 157 planned SDS, nausea/retching were causes of transition in 19 of 122 (15.6%) vs 0 of 35 (0%), p = 0.020. Multivariable logistic regression showed the odds of SDS were 8.21 times (95% CI 3.10 to 21.71; p < 0.001) greater in OFAP compared with OBAP, adjusting for sex, age, body mass index, American Society of Anesthesiologists Physical Status, type of hiatal hernia, type of procedure, and duration of the operation. Patients with opioid medication after SDS discharge were 74 of 74 (100%) vs 22 of 33 (66.7%), p < 0.001. CONCLUSIONS: Opioid-free anesthesia increases the feasibility of SDS hiatal hernia repair with less perioperative nausea and comparable pain control and pharmacy cost.

A Prospective Population-Based Study of Cardiovascular Disease Mortality following Treatment for Breast Cancer among Men in the United States, 2000-2019.

Male breast cancer is rare but its incidence and mortality are increasing in the United States, with racial/ethnic disparities in survival reported. There is limited evidence for cardiotoxicity of cancer treatment among men with breast cancer. We evaluated the relation between breast cancer treatment and cardiovascular disease (CVD) mortality among men and investigated the salient roles that race/ethnicity play on this relation. Data were from 5216 men with breast cancer aged ≥ 40 years from the Surveillance, Epidemiology, and End Results program who were diagnosed from 2000 to 2019 and underwent surgery. Competing risk models were used to estimate hazards ratios (HR) and 95% confidence intervals (CI). During a median follow-up of 5.6 years, 1914 deaths occurred with 25% attributable to CVD. In multivariable-adjusted models, men who received chemotherapy had elevated risk for CVD (HR: 1.55, 95%CI: 1.18-2.04). This risk was higher among Hispanic men (HR: 3.96, 95%CI: 1.31-12.02) than non-Hispanic Black and non-Hispanic White men. There was no significant association between radiotherapy and CVD deaths. In this population-based study, treatment with chemotherapy was associated with elevated risk of CVD mortality in men with breast cancer. Racial/ethnic disparities in the association of chemotherapy and CVD mortality were observed.