Publications by authors named "June S Peng"

22 Publications

  • Page 1 of 1

Pathologic upstaging in resected pancreatic adenocarcinoma: Risk factors and impact on survival.

J Surg Oncol 2021 Jul 9;124(1):79-87. Epub 2021 Apr 9.

Section of Surgical Oncology, Division of Surgery, Baptist MD Anderson Cancer Center, Jacksonville, Florida, USA.

Background: Clinical and pathologic staging determine treatment of pancreatic cancer. Clinical stage has been shown to underestimate final pathologic stage in pancreatic cancer, resulting in upstaging.

Methods: National Cancer Database was used to identify clinical stage I pancreatic adenocarcinoma. Univariate, multivariable logistic regression, and Cox proportional hazard ratio were used to determine differences between upstaged and stage concordant patients.

Results: Upstaging was seen in 80.2% of patients. Factors found to be significantly associated with upstaging included pancreatic head tumors (OR 2.56), high-grade histology (OR 1.74), elevated Ca 19-9 (OR 2.09), and clinical stage T2 (OR 1.99). Upstaging was associated with a 45% increased risk of mortality compared to stage concordant disease (HR 1.44, p < .001).

Conclusion: A majority of clinical stage I pancreatic cancer is upstaged after resection. Factors including tumor location, grade, Ca 19-9, and tumor size can help identify those at high risk for upstaging.
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http://dx.doi.org/10.1002/jso.26481DOI Listing
July 2021

Gastric Cancer Treatments and Survival Trends in the United States.

Curr Oncol 2020 12 24;28(1):138-151. Epub 2020 Dec 24.

Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA 17036, USA.

Gastric cancer is the third most common cause of cancer deaths worldwide. Despite evidence-based recommendation for treatment, the current treatment patterns for all stages of gastric cancer remain largely unexplored. This study investigates trends in the treatments and survival of gastric cancer. The National Cancer Database was used to identify gastric adenocarcinoma patients from 2004-2016. Chi-square tests were used to examine subgroup differences between disease stages: Stage I, II/III and IV. Multivariate analyses identified factors associated with the receipt of guideline concordant care. The Kaplan-Meier method was used to assess three-year overall survival. The final cohort included 108,150 patients: 23,584 Stage I, 40,216 Stage II/III, and 44,350 Stage IV. Stage specific guideline concordant care was received in only 73% of patients with Stage I disease and 51% of patients with Stage II/III disease. Patients who received guideline consistent care had significantly improved survival compared to those who did not. Overall, we found only moderate improvement in guideline adherence and three-year overall survival during the 13-year study time period. This study showed underutilization of stage specific guideline concordant care for stage I and II/III disease.
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http://dx.doi.org/10.3390/curroncol28010017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816178PMC
December 2020

Adjuvant Chemotherapy After Neoadjuvant Chemotherapy for Pancreatic Cancer is Associated with Improved Survival for Patients with Low-Risk Pathology.

Ann Surg Oncol 2021 Jun 31;28(6):3111-3122. Epub 2021 Jan 31.

Section of Surgical Oncology, Baptist MD Anderson Cancer Center, 1301 Palm Avenue, Jacksonville, FL, 32207, USA.

Background: With limited evidence, the benefit of adjuvant chemotherapy (AT) after completion of neoadjuvant chemotherapy (NT) and surgical resection for patients with pancreatic adenocarcinoma is debated. Guidelines recommend 6 months of AT for patients receiving NT. However, the patient-derived benefit from additional AT remains unknown.

Methods: The National Cancer Database from 2006 to 2015 was used to identify patients undergoing NT. The chi-square test and multivariable logistic regression were used to identify differences between those receiving only NT and those receiving NT and AT. Survival analysis using the Kaplan-Meier method and the Cox proportional hazard ratio model was applied to the entire cohort and to subgroups with differing lymph node ratios (LNRs), tumor sizes, grades, and surgical margin statuses.

Results: Of the 3897 patients who received NT, 36.7 % received additional AT. Analysis of the entire cohort showed that associated survival was significantly improved with NT and AT compared with NT alone (hazard ratio [HR], 0.83; p < 0.001). In the subgroup analysis, the survival benefit of additional AT remained significant for those with negative nodal disease, an LNR lower than 0.15, low-grade histology, and negative margin status. Overall survival did not differ between those receiving NT only and those receiving NT and AT in the group with an LNR of 0.15 or higher, high-grade histology, and positive margins.

Conclusion: This study identified an increasing trend in the use of AT after NT and showed an associated survival benefit for subgroups with low-risk pathologic features. These results suggest that the addition of AT after NT likely beneficial for these subgroups.
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http://dx.doi.org/10.1245/s10434-020-09546-8DOI Listing
June 2021

Neoadjuvant chemoradiation is associated with decreased lymph node ratio in borderline resectable pancreatic cancer: A propensity score matched analysis.

Hepatobiliary Pancreat Dis Int 2021 Feb 17;20(1):74-79. Epub 2020 Aug 17.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195-0001, USA.

Background: Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy.

Methods: Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery.

Results: There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P < 0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤ 0.2, 0.2-0.4, ≥ 0.4), the BRPC group had a more favorable distribution (P < 0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096).

Conclusions: NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.
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http://dx.doi.org/10.1016/j.hbpd.2020.08.001DOI Listing
February 2021

Undertreatment of Pancreatic Cancer: Role of Surgical Pathology.

Ann Surg Oncol 2021 Mar 26;28(3):1581-1592. Epub 2020 Aug 26.

Department of Surgery, Division of Outcomes Research and Quality, College of Medicine, The Pennsylvania State University, Hershey, PA, USA.

Background: Current guidelines recommend treatment of early-stage pancreatic cancer with surgical resection and chemotherapy. Undertreatment can occur after resection when patients fail to receive adjuvant chemotherapy. Final pathologic results have the potential to bias providers to omit adjuvant chemotherapy, however, the association of surgical pathology and adjuvant chemotherapy is unknown.

Methods: Data from the National Cancer Database identified patients who underwent surgery for stage I or II pancreatic cancer. Chi-square tests and logistic regression were used to determine differences between patients receiving surgery followed by chemotherapy and those who had resection alone. Survival analysis of subgroups with favorable pathology (node-negative disease, tumor size ≤ 2 cm, well-differentiated histology) was performed by the Kaplan-Meier method and the Cox proportional hazards model.

Results: Of the 22,131 patients included in this study, 28% were considered undertreated (surgery alone). Favorable pathologic traits of negative lymph nodes, tumor 2 cm in size or smaller, and well-differentiated histology were associated with a 15-35% lower probability that adjuvant chemotherapy would be given than less favorable pathologic results (p < 0.001). Multivariable survival analysis showed significantly lower odds of mortality for patients who received resection and chemotherapy than for those who were undertreated among two subgroups: patients with node-negative disease (hazard ratio [HR] 0.774) and those with a tumor 2 cm in size or smaller (HR 0.771).

Conclusion: The patients who had early-stage pancreatic cancer with favorable pathology after pancreatectomy were less likely than those with unfavorable pathology to receive adjuvant chemotherapy. This omission had significant survival consequences for subgroups with node-negative disease and tumors 2 cm in size or smaller. Recognition of patients with favorable pathology as an undertreated group is required for efforts to be directed toward encouraging guideline-concordant care and to combat undertreatment of pancreatic cancer.
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http://dx.doi.org/10.1245/s10434-020-09043-yDOI Listing
March 2021

ASO Author Reflections: Robotic Oncologic Surgery.

Ann Surg Oncol 2020 Dec 28;27(Suppl 3):741. Epub 2020 Jul 28.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.

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http://dx.doi.org/10.1245/s10434-019-08055-7DOI Listing
December 2020

Risk-stratified analysis of pasireotide for patients undergoing pancreatectomy.

J Surg Oncol 2020 Aug 30;122(2):195-203. Epub 2020 May 30.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York.

Background And Objectives: Pasireotide was shown in a randomized trial to decrease the rate of postoperative pancreatic fistula (POPF). However, retrospective series from other centers have failed to confirm these results.

Methods: Patients who underwent pancreatoduodenectomy or distal pancreatectomy between January 2014 and February 2019 were included. Patients treated after November 2016 routinely received pasireotide and were compared to a retrospective cohort. Multivariate analysis was performed for the outcome of clinically relevant POPF (CR-POPF), with stratification by fistula risk score (FRS).

Results: Ninety-nine of 300 patients received pasireotide. The distribution of high, intermediate, low, and negligible risk patients by FRS was comparable (P = .487). There were similar rates of CR-POPF (19.2% pasireotide vs 14.9% control, P = .347) and percutaneous drainage (12.1% vs 10.0%, P = .567), with greater median number of drain days in the pasireotide group (6 vs 4 days, P < .001). Multivariate modeling for CR-POPF showed no correlation with operation or pasireotide use. Adjustment with propensity weighted models for high (OR, 1.02, 95% CI, 0.45-2.29) and intermediate (OR, 1.02, CI, 0.57-1.81) risk groups showed no correlation of pasireotide with reduction in CR-POPF.

Conclusions: Pasireotide administration after pancreatectomy was not associated with a decrease in CR-POPF, even when patients were stratified by FRS.
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http://dx.doi.org/10.1002/jso.25949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369221PMC
August 2020

ASO Author Reflections: Overcoming the Learning Curve for Minimally Invasive Esophagectomy.

Ann Surg Oncol 2020 Aug 18;27(8):3039-3040. Epub 2020 May 18.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.

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http://dx.doi.org/10.1245/s10434-020-08372-2DOI Listing
August 2020

Robotic Pelvic Exenteration for Locally Advanced Prostate Cancer.

Ann Surg Oncol 2020 Dec 4;27(13):5320-5321. Epub 2020 May 4.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Clinical Sciences Center P-645, Buffalo, NY, USA.

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http://dx.doi.org/10.1245/s10434-020-08507-5DOI Listing
December 2020

Technique for Robotic Transhiatal Esophagectomy.

Ann Surg Oncol 2020 Aug 13;27(8):3037-3038. Epub 2020 Jan 13.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.

Minimally invasive esophagectomy is increasing performed for cancers of the esophagus and gastroesophageal junction. This video demonstrates the setup and key steps for a robotic transhiatal esophagectomy with a cervical anastomosis.
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http://dx.doi.org/10.1245/s10434-019-08186-xDOI Listing
August 2020

Technique for Robotic Ivor Lewis Esophagectomy with 6-cm Linear Stapled Side-to-Side Anastomosis.

Ann Surg Oncol 2020 Mar 4;27(3):824. Epub 2019 Dec 4.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.

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http://dx.doi.org/10.1245/s10434-019-07933-4DOI Listing
March 2020

Preoperative radiation as part of a multidisciplinary strategy for a medically inoperable patient with a bleeding colon cancer.

BMJ Case Rep 2019 Aug 21;12(8). Epub 2019 Aug 21.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.

An 84-year-old man with a history of deep vein thrombosis on warfarin and coronary artery disease presented with haematochezia and was diagnosed with an ascending colon cancer. He was short of breath with lower extremity oedema at the initial surgical consultation. Evaluation revealed an acute exacerbation of congestive heart failure, and further workup and treatment were recommended by the cardiology team. After multidisciplinary discussion, he underwent radiation for the control of bleeding, followed by cardiac catheterisation and placement of a bare metal stent. The patient subsequently underwent robotic-assisted right hemicolectomy. Pathology demonstrated a complete response, and the patient recovered uneventfully. He is alive swith no evidence of disease recurrence 12 months after surgery and 18 months after initial diagnosis.
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http://dx.doi.org/10.1136/bcr-2019-229488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6720632PMC
August 2019

Minimally Invasive Ivor Lewis Esophagectomy with Linear Stapled Anastomosis Associated with Low Leak and Stricture Rates.

J Gastrointest Surg 2020 08 16;24(8):1729-1735. Epub 2019 Jul 16.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY, 14203, USA.

Background: Minimally invasive foregut surgery is increasingly performed for both benign and malignant diseases. We present a retrospective series of patients who underwent minimally invasive Ivor Lewis esophagectomy (MIE) with linear stapled anastomosis performed at two centers in the USA, with a focus on evaluating leak and stricture rates.

Methods: Patients treated from 2007 to 2018 were included, and data on demographics, oncologic treatment, pathology, and outcomes were analyzed. The surgical technique utilized laparoscopic and thoracoscopic access, with an intrathoracic esophagogastric anastomosis using a 6-cm linear stapled side-to-side technique.

Results: A total of 124 patients were included and 114 resections (91.9%) were completed in a minimally invasive fashion with a 6-cm linear stapled side-to-side anastomosis. Patients were predominantly male (90.7%) with a median age of 66.0 years and body mass index of 28.8 kg/m. Of 121 patients with malignancy, negative margins were obtained in 94.3% and median lymph node yield was 15 (IQR 12-22). In the intention to treat analysis, median operative time was 463 min (IQR 403-515), blood loss was 150 mL (IQR 100-200), and length of stay was 8 days (IQR 7-11). Postoperative complications were experienced by 64 patients (51.6%) including respiratory failure in 14 (11.3%) and pneumonia in 12 (9.7%). In patients who successfully underwent a 6-cm stapled side-to-side anastomosis, anastomotic leaks occurred in 6 patients (5.1%) without need for operative intervention, and anastomotic strictures occurred in 6 patients (5.1%) requiring endoscopic management.

Conclusions: Ivor Lewis MIE with a 6-cm linear stapled anastomosis can be completed with a high technical success rate, and low rates of anastomotic leak and stricture.
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http://dx.doi.org/10.1007/s11605-019-04320-yDOI Listing
August 2020

Minimally invasive esophagectomy-standard of care.

J Thorac Dis 2019 May;11(Suppl 9):S1387-S1388

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.

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http://dx.doi.org/10.21037/jtd.2019.03.43DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560538PMC
May 2019

Pathologic tumor response to neoadjuvant therapy in borderline resectable pancreatic cancer.

Hepatobiliary Pancreat Dis Int 2019 Aug 23;18(4):373-378. Epub 2019 May 23.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, USA. Electronic address:

Background: Previous studies have demonstrated the prognostic significance of pathologic tumor response in pancreatic adenocarcinoma following neoadjuvant therapy (NAT). The aim of this study was to determine the incidence of significant pathologic response to NAT in borderline resectable pancreatic cancer (BRPC), and association of NAT regimen and other clinico-pathologic characteristics with pathologic response.

Methods: Patients with BRPC who underwent NAT and pancreatic resection between January 2012 and June 2017 were included. Pathologic response was assessed on a qualitative scale based on the College of American Pathologists grading system. Demographics and baseline characteristics, oncologic treatment, pathology, and survival outcomes were compared.

Results: Seventy-one patients were included for analysis. Four patients had complete pathologic responses (tumor regression score 0), 12 patients had marked responses (score 1), 42 had moderate responses (score 2), and 13 had minimal responses (score 3). Patients with complete or marked responses were more likely to have received neoadjuvant gemcitabine chemoradiation (62.5%, 38.1%, and 23.1% of the complete/marked, moderate, and minimal response groups, respectively; P = 0.04). Of the complete/marked, moderate, and minimal response groups, margins were negative in 75.0%, 78.6%, and 46.2% (P = 0.16); node negative disease was observed in 87.5%, 54.8%, and 15.4% (P < 0.01); and median overall survival was 50.0 months, 31.7 months, and 23.2 months (P = 0.563). Of the four patients with pathologic complete responses, three were disease-free at 66.1, 41.7 and 31.4 months, and one was deceased with metastatic liver disease at 16.9 months.

Conclusions: A more pronounced pathologic tumor response to NAT in BRPC is correlated with node negative disease, but was not associated with a statistically significant survival benefit in this study.
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http://dx.doi.org/10.1016/j.hbpd.2019.05.007DOI Listing
August 2019

Minimally Invasive Esophageal Cancer Surgery.

Surg Oncol Clin N Am 2019 04 2;28(2):177-200. Epub 2019 Feb 2.

Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY 14203, USA. Electronic address:

Laparoscopic and thoracoscopic or robotic-assisted minimally invasive esophagectomy offers benefits in decreased postoperative complications and faster recovery. The choice of operation depends on patient and surgeon factors. McKeown or 3-field esophagectomy requires dissection in the abdomen, chest, and neck, with a cervical anastomosis. Ivor Lewis esophagectomy is performed with abdominal and right chest dissection and intrathoracic anastomosis. Transhiatal or transmediastinal esophagectomy is performed with abdominal and cervical dissections and a cervical anastomosis and is preferential in patients with significant pulmonary risk factors. Preparation and operative conduct for laparoscopic and robotic approaches for these operations, and the expected postoperative recovery are detailed.
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http://dx.doi.org/10.1016/j.soc.2018.11.009DOI Listing
April 2019

Paraduodenal inflammatory pseudotumor masquerading as malignancy.

BMJ Case Rep 2019 Feb 7;12(2). Epub 2019 Feb 7.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.

A 30-year-old woman presented with severe abdominal pain and abdominal distension. CT demonstrated two intra-abdominal masses, one involving the left lateral segment of the liver and the other adjacent to the duodenum. Initial biopsies were consistent with focal nodular hyperplasia of the liver and non-specific lymphocytic infiltrate in the paraduodenal mass. Due to persistent symptoms, the patient underwent laparoscopic resection of the paraduodenal mass. Final pathology was consistent with an inflammatory pseudotumour and the patient's symptoms subsequently resolved.
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http://dx.doi.org/10.1136/bcr-2018-226460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6381947PMC
February 2019

Multiloculated mesothelial cyst presenting as a malignant mimic.

BMJ Case Rep 2018 02 3;2018. Epub 2018 Feb 3.

Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

A 46-year-old woman was referred for a second opinion regarding an intra-abdominal mass discovered on imaging performed for abdominal pain and distension. The tumour appeared to involve the small bowel, left colon and mesentery and was initially thought to be consistent with an infiltrative tumour or loculated mucinous ascites. Due to the unusual appearance of the tumour and suspicion for an omental-based mass, a laparoscopic resection was recommended to the patient. Intraoperatively, the tumour was found to be a multiloculated, benign appearing, omental cyst without involvement of the bowel and was completely resected laparoscopically. Pathology demonstrated a multiloculated peritoneal mesothelial cyst.
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http://dx.doi.org/10.1136/bcr-2017-222280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5812408PMC
February 2018

Pancreatoduodenectomy after Roux-en-Y gastric bypass: technical considerations and outcomes.

HPB (Oxford) 2018 01 8;20(1):34-40. Epub 2017 Sep 8.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland OH, USA. Electronic address:

Background: Patients with altered anatomy due to Roux-en-Y gastric bypass (RYGB) present unique diagnostic and therapeutic challenges when they present with periampullary pathology. We describe a series of patients who underwent pancreatoduodenectomy (PD) after gastric surgery with Roux-en-Y reconstruction and review the literature to highlight technical considerations and outcomes.

Methods: Patients from two institutions were identified and data regarding preoperative workup, operative conduct, and pathologic and clinical outcomes were collected.

Results: Eleven patients were included in the institutional series. At the time of periampullary pathology, the median age was 64 years and time since RYGB was 10 years. Median operative time was 361 minutes, estimated blood loss was 500 mLs, and length of stay was 6 days. Remnant gastrectomy was performed in nine patients and reconstruction was performed using the biliopancreatic limb (BP) without revision of the jejuno-jejunostomy in ten patients. Pathology revealed pancreatic cancer (8), chronic pancreatitis (2), and duodenal cancer (1). Three patients experienced major complications and there were no 90-day mortalities.

Conclusion: Pancreatic surgeons will see an increasing number of patients with Roux-en-Y anatomy who will require evaluation and resection for periampullary diseases. For PD after RYGB, we recommend remnant gastrectomy with reconstruction using the BP limb.
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http://dx.doi.org/10.1016/j.hpb.2017.08.015DOI Listing
January 2018

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs.

J Gastrointest Surg 2017 Sep 8;21(9):1420-1427. Epub 2017 Jun 8.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, A100, Cleveland, OH, 44195, USA.

Background: There is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC.

Methods: Sequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL.

Results: Of 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62-1.37), oncologic treatment (CR 0.66, 95% CI 0.32-1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77-1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16-0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens.

Conclusions: SDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.
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http://dx.doi.org/10.1007/s11605-017-3470-6DOI Listing
September 2017

Asymmetric Hypertrophic Pyloric Stenosis with Concurrent Pancreatic Rest Presenting as Gastric Outlet Obstruction.

J Pediatr 2016 07 11;174:273-273.e1. Epub 2016 May 11.

Department of General Pediatric Surgery, Cleveland Clinic Children's Hospital, Cleveland Clinic Foundation, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.jpeds.2016.03.079DOI Listing
July 2016