Publications by authors named "Moshim Kukar"

50 Publications

Robotic Enucleation of a Large Gastroesophageal Junction Leiomyoma.

Ann Surg Oncol 2021 Jul 16. Epub 2021 Jul 16.

Division of Surgical Oncology, Department of Surgery, Penn State College of Medicine, Hershey, PA, USA.

In this multimedia article, we demonstrate transabdominal robotic enucleation of a large, multilobulated leiomyoma at the gastroesophageal junction (GEJ). The robotic platform provides stereoscopic visualization and wristed motion, which improved ease of an organ-sparing resection in a challenging anatomic location. Alternative minimally invasive approaches to tumors in this location have been reported including endoscopic, endoscopic with laparoscopic assistance, laparoscopic, and thoracoscopic approaches, with choice of approach dependent upon the location and configuration of the tumor Milito et al. in J Gastrointest Surg 24:499-504, 2020;Li et al. in Dis Esophagus. 22:185-189, 2009;Armstrong et al. in Am Surg. 79:968-972, 2013;Kent et al. in J Thorac Cardiovasc Surg. 134:176-181, 2007.
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http://dx.doi.org/10.1245/s10434-021-10409-zDOI Listing
July 2021

Robotic-assisted Ivor Lewis esophagectomy, a review of the technique.

Updates Surg 2021 Jun 20;73(3):831-838. Epub 2021 May 20.

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

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.
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http://dx.doi.org/10.1007/s13304-021-01000-yDOI Listing
June 2021

Association of same-day discharge with hospital readmission after pediatric thyroidectomy.

Pediatr Surg Int 2021 May 20. Epub 2021 May 20.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY, 14203, USA.

Background: Studies have demonstrated that same-day discharge (SDD) following thyroid resection is safe and feasible in adults but there are no similar studies in the pediatric age group. The purpose of this study is to evaluate the influence of SDD on 30-day readmission rates following thyroid surgery in pediatric patients.

Methods: This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among patients < 19 years of age who underwent thyroid resection between 2012 and 2017. Patients excluded were those discharged more than 2 days after surgery. The main exposure variable was SDD and the primary outcome was 30-day readmission. Secondary outcomes included wound complications, unplanned reoperation and death. Patient characteristics were compared using chi-squared testing and odds ratios for readmission were calculated using multivariate logistic regression.

Results: Of the 1125 patients (79% female, median age 15 years), 122 (11%) were discharged on the day of surgery. Total or near-total thyroidectomy represented the majority of operations (714, 63.5%) and patients undergoing these operations were less likely to be discharged on the same day as surgery compared to those undergoing thyroid lobectomy (4.3 vs. 22.1%, P < 0.001). Twenty-nine patients were readmitted within 30 days (3 in the same day group, 26 in the later group). There was no difference in the odds of readmission between the two groups (adjusted odds ratio in SDD compared to later discharge 1.04 [95% CI 0.29-3.75, P = 0.96; readmission rate, 2.46 vs. 2.59%). Wound complications were reported in two patients, both in the later discharge group.

Conclusion: Same-day discharge in pediatric patients undergoing thyroidectomy is not associated with an increase in 30-day readmissions or wound complications when compared to patients discharged 1 or 2 days after surgery. In selected patients, SDD may be an appropriate alternative to traditional overnight stay.
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http://dx.doi.org/10.1007/s00383-021-04927-wDOI Listing
May 2021

Gastric Cancer Disparities Among Asian American Subpopulations.

Anticancer Res 2020 Nov;40(11):6381-6385

Department of Surgery, Mayo Clinic, Jacksonville, FL, U.S.A.

Background/aim: Asian Americans (AA) are one of the largest and fastest growing minority groups in the United States consisting of 18 million people. This population is an ethnically diverse group that tends to be classified as one cohort resulting in hidden survival disparities among AA subgroups.

Patients And Methods: The National Cancer Data Base was queried for patients of Korean, Japanese or Filipino ancestry with gastric adenocarcinoma or esophageal adenocarcinoma between 2004 and 2013.

Results: A total of 28,213 patients met the inclusion criteria: 1,542 with gastric adenocarcinoma and 26,671 with esophageal adenocarcinoma. The Korean group with gastric cancer (0.42) showed improved 5-year survival over the Japanese (0.31) and Filipino (0.21; p<0.001) groups.

Conclusion: A significant difference in survival exists among AA subgroups signifying a need to acknowledge the heterogeneity of AA in future studies. Thus, individual-specific medicine with respect to race-related outcomes is extremely important.
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http://dx.doi.org/10.21873/anticanres.14659DOI Listing
November 2020

ASO Author Reflections: Does Overall Survival Benefit From Complete Pathologic Responders Vary With Treatment Approach?

Ann Surg Oncol 2020 Dec 10;27(Suppl 3):888-889. Epub 2020 Aug 10.

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

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http://dx.doi.org/10.1245/s10434-020-09012-5DOI Listing
December 2020

Prognostic Significance of Complete Pathologic Response Obtained with Chemotherapy Versus Chemoradiotherapy in Gastric Cancer.

Ann Surg Oncol 2021 Feb 31;28(2):766-773. Epub 2020 Jul 31.

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

Background: Few studies have compared the survival advantage of complete pathologic response (cPR) achieved through neoadjuvant chemotherapy (nCT) versus neoadjuvant chemoradiotherapy (nCRT) in gastric adenocarcinoma. Our study utilizes a large national cancer database to address this question.

Patients And Methods: This is a retrospective review of patients with clinical stage I to III gastric adenocarcinoma from 2004 to 2013 who received nCT or nCRT. Patients who achieved cPR were selected. Associations were evaluated using Mann-Whitney U and Fisher's exact tests. Survival information was summarized using standard Kaplan-Meier methods, where estimates of the median and 5-year survival rates were estimated with 95% confidence intervals.

Results: A total of 413 patients who had cPR were identified. Eighty-four patients received nCT and 329 patients received nCRT. Patients in the nCRT group had higher clinical stage (88.4% vs. 75.0%) and more proximal location of tumors (95.4% vs. 45.2%). The nCT group (n = 84) had a 94% 5-year survival rate, while the nCRT group's (n = 329) rate was 60% (p < 0.001). On Cox regression modeling using a propensity-weighted approach, nCT treatment was an independent predictor of improved overall survival (nCRT vs. nCT; HR 10.44, p < 0.001).

Conclusions: The use of nCT leads to a significant increase in overall survival in patients when compared with nCRT for those who achieved cPR in gastric adenocarcinoma. While this study is limited in identifying the cause for this difference in overall survival, this important finding nonetheless requires further investigation and should be considered in the development of future gastric cancer trials.
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http://dx.doi.org/10.1245/s10434-020-08921-9DOI Listing
February 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

Case reports on a gastric mass presenting with regional lymphadenopathy: A differential diagnosis is gastric schwannoma.

Int J Surg Case Rep 2020 12;72:369-372. Epub 2020 Jun 12.

Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA. Electronic address:

Background: Gastric schwannomas are uncommon among a broad range of possible diagnoses in the work up of a gastric mass. Regional lymphadenopathy associated with gastric schwannoma is an even less common occurrence and one would otherwise suspect a malignant neoplasm.

Case Presentation: We present two non-consecutive cases from a signle academic center depicting Caucasian females in their 5th and 6th decades of life with gastric schwannoma and adjacent lymphadenopathy. Multiple lymph node excisions were performed without evidence of neoplasia.

Discussion: Lymphadanopathy in the presence of a gastric mass typically represents malignant neoplasm. A less than likely presentation of gastric schwannoma with reactive regional lymph nodes poses a challenge to adequate preoperative diagnosis and increases risk for a more aggressive than necessary surgical approach with lymphadenectomy.

Conclusion: While the correlation between gastric schwannoma and lymphadenopathy is uncertain, this ought to be considered. If diagnosis can be confirmed preoperatively, omission of lymphadenectomy is appropriate.
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http://dx.doi.org/10.1016/j.ijscr.2020.05.098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306505PMC
June 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

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

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 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

Disparities in major surgery for esophagogastric cancer among hospitals by case volume.

J Gastrointest Oncol 2018 Jun;9(3):503-516

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

Background: The purpose of this study was to characterize disparities among centers performing major surgery for esophageal or gastric cancer stratified by case volume.

Methods: The National Cancer Data Base (NCDB) was queried for cases of esophagectomy or total gastrectomy. Centers were compared based on number of cases during 2004-2013: low volume [1-99], middle [100-200], and high [>200].

Results: For esophagectomy, 17,547 patients were included; 73.5% were treated in low volume centers, 14.6% in middle, and 11.9% in high. For gastrectomy, 20,059 patients were included, with 87.5%, 8.3%, and 4.3%, respectively. Patients treated at low volume centers were more likely to be of racial/ethnic minorities, uninsured, and have lower socioeconomic status. Overall survival (OS) was superior for patients treated at high volume centers. On multivariable analysis for either procedure, a higher number of disparate factors was identified in the low and middle volume centers compared to the high volume centers, which were associated with poorer OS.

Conclusions: This study identified higher numbers of disparate patient factors associated with low/middle volume centers compared to high volume centers, which were associated with worse OS, and further makes the case for performance of esophagectomy and total gastrectomy at high volume centers.
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http://dx.doi.org/10.21037/jgo.2018.01.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6006045PMC
June 2018

Laparoscopic proximal gastrectomy for gastric neoplasms.

J Surg Oncol 2018 Jul 19;118(1):95-100. Epub 2018 Jun 19.

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

Background: For cancers of the distal gastroesophageal junction or the proximal stomach, proximal gastrectomy can be performed. It is associated with several perioperative benefits compared with total gastrectomy. The use of laparoscopic proximal gastrectomy (LPG) has become an increasingly popular approach for select tumors.

Methods: We describe our method of LPG, including the preoperative work-up, illustrated depictions of the key steps of the surgery, and our postoperative pathway.

Results: A total of 6 patients underwent LPG between July, 2013 to June, 2017. Five patients had early-stage adenocarcinoma, and 1 patient had a gastrointestinal stromal tumor. The median age of the cohort was 70, and each patient had significant comorbidities. Conversion to open was required for 1 patient. All patients had negative final margins and an adequate lymph node dissection (median number of nodes examined was 15, range 12-22). The median postoperative length of stay was 7 days (range 4-7). Two patients developed anastomotic strictures requiring intervention, and 1 patient experienced significant reflux. At a median follow-up of 11 months, there was 1 recurrence. Three patients were alive without evidence of disease, and 2 patients died from other causes.

Conclusions: For carefully selected patients, LPG is a safe and reasonable alternative to total gastrectomy, which is associated with similar oncologic outcomes and low morbidity.
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http://dx.doi.org/10.1002/jso.25123DOI Listing
July 2018

Complete pathologic response is independent of the timing of esophagectomy following neoadjuvant chemoradiation for esophageal cancer.

J Gastrointest Oncol 2018 Feb;9(1):73-79

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

Background: The relationship of complete pathologic response (cPR) with the timing of esophagectomy after neoadjuvant chemoradiation (nCRT) is not well defined. We sought to determine if a delay in esophagectomy after nCRT would result in increased likelihood of cPR and improved survival.

Methods: This is a retrospective analysis of a prospectively maintained database of all patients treated with nCRT and esophagectomy between 2004 and 2014. Patients were divided into two groups based on timing of esophagectomy (≤50 . >50 days) after completion of nCRT. Survival outcomes were compared using standard Kaplan-Meier curves, and multivariable analyses were performed using Cox regression models.

Results: This study included 226 patients (males, 211 and median age, 61 years) for analysis. Fifty-two patients (23%) in the early group (≤50 days) were compared to 174 patients (77%) in the delayed group (>50 days). The two groups were similar with respect to age, gender, comorbid conditions, ECOG status, location, grade, and tumor histology. There was no statistically significant difference in cPR rate between the early and late groups (26.9% . 19.0%, respectively, P=0.24). On multivariable analysis, lower age, absence of signet cell histology, better ECOG status, shorter length of stay and cPR were independent predictors of improved survival. The median follow-up was 52 months (range, 2-110 months), and there was no difference in the median overall survival (OS) between the early and late groups (48.9 . 42.6 months, respectively, P=0.73).

Conclusions: This analysis of a large cohort of patients with esophageal cancer undergoing multi-modality therapy shows that cPR is independent of the timing of esophagectomy. Other considerations for the timing of surgery, including recovery from nCRT and patient performance, may have more relevant roles than cPR when deciding when to perform esophagectomy.
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http://dx.doi.org/10.21037/jgo.2017.09.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848031PMC
February 2018

Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery.

JAMA Surg 2018 05 16;153(5):e180214. Epub 2018 May 16.

VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas.

Importance: Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures.

Objective: To assess the association of frailty with FTR in patients undergoing inpatient surgery.

Design, Setting, And Participants: This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling.

Main Outcomes And Measures: The number of postoperative complications and inpatient FTR.

Results: A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5% for those with scores of 10 or less, 23.7% for those with scores of 11 to 20, 31.1% for those with scores of 21 to 30, 42.5% for those with scores of 31 to 40, and 54.4% for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95% CI, 3.9-7.1). Odds ratios were 8.1 (95% CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95% CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95% CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95% CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95% CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95% CI, 8.1-9.9; vs RAI score >40: 18.4; 95% CI, 15.7-21.4).

Conclusions And Relevance: Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.
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http://dx.doi.org/10.1001/jamasurg.2018.0214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875343PMC
May 2018

The first postesophagectomy chest X-ray predicts respiratory failure and the need for tracheostomy.

J Surg Res 2018 04 22;224:89-96. Epub 2017 Dec 22.

Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York. Electronic address:

Background: Esophagectomy is a major surgical procedure associated with high rates of morbidity. The purpose of this study was to determine if the immediate first postesophagectomy chest X-ray (pCXR) is associated with morbidity or mortality.

Methods: This was a single-institution analysis of patients undergoing esophagectomy, 2005-2015. A pCXR was routinely performed. A pCXR score was developed based on the number of objective abnormal findings. A statistical analysis was performed using patient/tumor variables and the pCXR score to derive adjusted odds ratios (ORs) on short-term outcomes.

Results: One hundred eighty-two patients had pCXRs. Scores ranged from 0 (normal) to 4 depending on the number of abnormalities, with a mean score of 1.6. The mean patient age was 60.7 y. Within the cohort, 92.9% had adenocarcinoma, 39.6% had T3/T4 tumors, and 48.4% were node positive. Open surgeries were performed in 51.6%, and 74.2% had chest anastomoses. The 30- and 90-d mortality rates were 2.2% and 3.9%, respectively. Increasing pCXR scores were associated with increased risk of prolonged intubation (OR: 1.67, 95% confidence interval [CI]: 1.21-2.36, P = 0.002) and tracheostomy (OR: 2.12, 95% CI: 1.08-4.16, P = 0.029). Multivariable analysis adjusting for age, comorbidities and performance status, histology, pathologic stage, surgical approach, and operative time confirmed a statistically significant association with the pCXR score and respiratory failure requiring tracheostomy (OR: 2.13, 95% CI: 1.03-4.39, P = 0.041).

Conclusions: This is the first study to show an association between the first pCXR and respiratory failure, providing new evidence that the first pCXR has important implications for pulmonary care after esophagectomy.
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http://dx.doi.org/10.1016/j.jss.2017.11.057DOI Listing
April 2018

Conditional Survival-Based "Abbreviated" Routine Cancer Surveillance for Pathologic Stage IB Melanoma.

Am Surg 2017 Nov;83(11):1256-1262

A negative sentinel lymph node biopsy (SLNB) for stage IB (T1b/T2a N0) melanoma would predict an excellent long-term prognosis. Combined with the concept of conditional survival, an "abbreviated" cancer surveillance strategy was implemented to reduce the number of visits and total length of follow-up. Retrospective review of all pathologic stage IB melanoma patients (negative SLNB) at a single institution between 2006 and 2008 after implementation of an "abbreviated" cancer surveillance; clinic visits every six months for five years followed by one annual visit (total follow-up six years). Patient demographics, tumor characteristics, and information regarding recurrences were obtained. Recurrence-free, disease-specific, and overall survival were calculated. Eighty-seven patients underwent the "abbreviated" cancer surveillance. Median age was 55.4 years and 50.6 per cent were male. Median Breslow thickness was 1.1 mm (range 0.5-2.0 mm) and 1.1 per cent were ulcerated. Primary tumor site was 49 per cent extremities, 39 per cent trunk, and 12 per cent head/neck. Median follow-up was 68.6 months. Five-year recurrence-free, disease-specific, and overall survivals were 89, 95, and 88 per cent, respectively. During surveillance, 10 patients had concerning symptoms or physical findings prompting subsequent workup, all of which were negative for recurrence/metastases. There were only three true melanoma recurrences; all were distant metastases and presented symptomatically between scheduled follow-up visits. In light of the excellent prognosis for pathologic (SLNB negative) stage IB melanoma, an "abbreviated" cancer surveillance schedule based on conditional survival would reduce both direct and indirect costs in this cohort. The few recurrences were symptomatic and unlikely to have changed with more intensive surveillance.
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November 2017

Does neoadjuvant/perioperative chemotherapy improve overall survival for T2N0 gastric adenocarcinoma?

J Surg Oncol 2018 Mar 11;117(4):659-670. Epub 2017 Nov 11.

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

Background: The purpose of this study was to determine whether neoadjuvant and/or perioperative chemotherapy (NAC) has an overall survival (OS) benefit for patients with T2N0 gastric adenocarcinoma.

Study Design: We performed retrospective analyses using the National Cancer Data Base, 2004-2013. Patients with T2N0 gastric adenocarcinoma were divided into two treatment groups: (1) NAC plus surgery (NA + S) and (2) surgery alone (S).

Results: Of 1,704 patients included, 277 (16.3%) received NAC, and 1,427 (83.7%) were treated with surgery alone. Patients in the NA + S group were more likely to be younger, have fewer comorbidities, and have larger tumors located in the proximal stomach. Although in an unadjusted analysis of OS, the NA + S group had improved survival compared to the S group (HR = 0.81, 95% CI 0.67-0.99, P < 0.0001), this was not maintained in a propensity adjusted analysis (HR = 0.89, 95% CI 0.68-1.18, P = 0.42). Similarly, propensity adjusted analyses accounting for potential bias from clinical misstaging or treatment effect from NAC did not show any OS benefit from NAC.

Conclusion: Based on the largest cohort of clinically staged T2N0 gastric adenocarcinoma, there was no OS benefit derived from NAC compared to surgery alone. For select patients with reliable preoperative staging, NAC may be omitted.
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http://dx.doi.org/10.1002/jso.24894DOI Listing
March 2018

Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications.

Surg Laparosc Endosc Percutan Tech 2017 Oct;27(5):e116-e120

*Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY †Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX.

Purpose: Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance.

Methods: We detail our technique and report a unique application of this versatile approach.

Results: Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed.

Conclusions: Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.
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http://dx.doi.org/10.1097/SLE.0000000000000446DOI Listing
October 2017

Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery.

Ann Surg 2018 Jan;267(1):57-65

Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY.

Objective: To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures.

Background: ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols.

Methods: A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs.

Results: A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis.

Conclusions: ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.
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http://dx.doi.org/10.1097/SLA.0000000000002267DOI Listing
January 2018

Novel Calculator to Estimate Overall Survival Benefit from Neoadjuvant Chemoradiation in Patients with Esophageal Adenocarcinoma.

J Am Coll Surg 2017 May 29;224(5):884-894.e1. Epub 2017 Jan 29.

Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY. Electronic address:

Background: Our group reported that patients with clinically node-negative esophageal adenocarcinoma do not derive overall survival (OS) benefit from neoadjuvant chemoradiation (nCRT) compared with clinically node-positive patients. The aim of this study was to develop a calculator that could more easily identify which patients derive OS benefit from nCRT.

Study Design: Using the National Cancer Data Base (2006 to 2012), patients with clinical status T1b to T4a, N-/+, M0 adenocarcinoma of the esophagus who underwent resection were selected. Of this cohort, 80% were randomly selected to develop and test the prediction model using Cox regression. The remaining 20% were used to internally validate the model, and performance was evaluated using receiver operating characteristic curves and area under the curves.

Results: A total of 8,974 patients met study criteria. Using the model testing cohort (7,179 patients), variables that were independently associated with OS in multivariable analysis were included in the model. These variables included Charlson-Deyo comorbidity score, tumor grade, clinical T and N status, and nCRT before surgery. Factors associated with increased risk of death were higher grade and higher T or N status. Receipt of nCRT was associated with improved OS. After validation, model performance showed an area under the curve of 0.630 and 0.682 for 1-year and 3-year OS, respectively.

Conclusions: A novel OS calculator was developed for esophageal adenocarcinoma that reasonably predicts which patients are expected to derive OS benefit from nCRT. This tool can be helpful in determining OS benefit from nCRT to assist with treatment decision making.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.01.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836490PMC
May 2017

Effectiveness of Repeat 18F-Fluorodeoxyglucose Positron Emission Tomography Computerized Tomography (PET-CT) Scan in Identifying Interval Metastases for Patients with Esophageal Cancer.

Ann Surg Oncol 2017 Jun 5;24(6):1739-1746. Epub 2017 Jan 5.

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

Introduction: An 18F-fluorodeoxyglucose positron emission tomography-computerized tomography (PET-CT) scan is performed after neoadjuvant chemoradiation (nCRT) to restage esophageal cancer. The purpose of this study was to determine the ability of PET-CT to accurately identify interval metastatic disease following nCRT.

Methods: This was a single-institution retrospective review (January 2005-February 2012) of patients with esophageal cancer treated with nCRT who underwent pre- and post-nCRT PET-CT.

Results: A total of 283 patients were treated with nCRT, of whom 258 (91.2%) had both a pre- and post-nCRT PET-CT. On the post-nCRT PET-CT, 64 patients (24.8%) had interval findings concerning for metastatic disease. Of these patients, only 10 (15.6%) had true-positive findings of metastatic disease (six biopsy proven). The sites of interval metastases included bone (4), liver (3), peritoneum (1), mediastinal lymph nodes (1), and cervical lymph nodes (1). The positive predictive value of post-nCRT PET-CT for interval metastases was 15.6% (10/64), and the yield for detecting metastases since the pre-nCRT PET-CT was 3.9% (10/258). The work-up of the 54 patients (20.9% of the initial starting group) with false-positive post-nCRT findings included biopsy (24.6%) and immediate additional imaging (45.2%). A total of 208 patients proceeded with surgery: 163 (78.4%) had no new findings on post-nCRT PET-CT, and 45 (21.6%) had new false-positive findings. False-positive sites mainly included the lung (15) and liver (14).

Conclusions: The yield of post-nCRT PET-CT for the detection of new metastatic disease was 3.9%. Post-nCRT PET-CT often leads to a high proportion of false positives and subsequent investigational work-up.
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http://dx.doi.org/10.1245/s10434-016-5754-6DOI Listing
June 2017

No Survival Difference with Neoadjuvant Chemoradiotherapy Compared with Chemotherapy in Resectable Esophageal and Gastroesophageal Junction Adenocarcinoma: Results from the National Cancer Data Base.

J Am Coll Surg 2016 12 15;223(6):784-792.e1. Epub 2016 Sep 15.

Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY. Electronic address:

Background: Neoadjuvant treatment improves survival in resectable esophageal adenocarcinoma, but the optimal regimen has not been defined. Neoadjuvant chemoradiation (nCRT) is associated with higher pathologic complete response (pCR) relative to chemotherapy (nCTX), but has not been shown to improve survival; however, previous studies have been underpowered to demonstrate a survival difference. The objective of this study was to determine if nCRT is associated with increased survival relative to nCTX in patients with resectable esophageal adenocarcinoma.

Study Design: The National Cancer Data Base (2006 to 2013) was retrospectively reviewed for patients with esophageal adenocarcinoma who underwent neoadjuvant treatment followed by resection. Data were collected regarding patient, disease, and treatment variables. Outcomes included 3- and 5-year overall survival (OS), pCR rate, and short-term postoperative outcomes. Propensity-adjusted analysis was conducted to account for baseline differences between treatment groups.

Results: Six hundred fifty patients received nCTX and 6,336 received nCRT. Patients who underwent nCTX had slightly smaller tumors, and fewer were clinical stage III at baseline. Pathologic complete response was 17.2% with nCTX and 31.6% with nCRT (p < 0.001). Receiving nCRT was associated with fewer nodes examined, fewer nodes involved, fewer T3/4 tumors, and fewer positive margins than nCTX. There was no significant difference in OS between the 2 groups (hazard ratio [HR] 1.08 nCRT vs nCTX, 95% CI 0.95, 1.21, p = 0.228). There was no significant difference in short-term postoperative outcomes by treatment modality.

Conclusions: Neoadjuvant chemoradiation is not associated with improved survival relative to nCTX for resectable esophageal adenocarcinoma. Radiation may potentially be omitted in some patients with this disease.
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http://dx.doi.org/10.1016/j.jamcollsurg.2016.09.002DOI Listing
December 2016

Pancreatic cancer metastatic to a limited number of lymph nodes has no impact on outcome.

HPB (Oxford) 2016 06;18(6):523-8

Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.

Background: The purpose of this study was to determine the association of the extent of metastatic lymph node involvement with survival in pancreatic cancer.

Methods: This is a retrospective review of a prospectively maintained database of patients who underwent resection for pancreatic adenocarcinoma, 1999-2011.

Results: 165 patients were identified and divided into 3 groups based on the number of positive lymph nodes - 0 (group A), 1-2 (B), >3 (C). Each group had 55 patients. Those in group C were more likely to have a higher T stage, poorly differentiated grade, lymphovascular invasion (LVI), higher mean intraoperative blood loss, positive margins, tumor location involving the uncinate process, and a higher likelihood of undergoing a pancreaticoduodenectomy. Median overall survival (OS) for group A, B and C was 25.5 months (mo), 21 mo and 12.3 mo, respectively (p < 0.001). No survival difference was noted for survival between groups A and B (p = 0.86). The ratio of involved lymph nodes <0.2 was predictive of improved survival (p < 0.001).

Conclusions: Resected pancreatic cancer patients with only 1-2 positive lymph nodes or less than 20% involvement have a similar prognosis to patients without nodal disease. Current staging should consider stratification based on the extent of nodal involvement.
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http://dx.doi.org/10.1016/j.hpb.2016.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4913131PMC
June 2016

Pathologic Complete Response Is an Independent Predictor of Improved Survival Following Neoadjuvant Chemoradiation for Esophageal Adenocarcinoma.

J Gastrointest Surg 2016 09 3;20(9):1541-6. Epub 2016 Jun 3.

Department of Surgical Oncology, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, 14263, USA.

Introduction: Reports of improved survival in patients with pathologic complete response (pCR) to neoadjuvant therapy for esophageal and gastroesophageal junction (GEJ) adenocarcinoma is extrapolated from heterogeneous studies that include squamous cell histology. We sought to determine if pCR is associated with a survival advantage in a homogenous group of patients with esophageal adenocarcinoma.

Methods: This is a single institution analysis of all patients with T2-T4 or node positive esophageal adenocarcinoma treated with neoadjuvant chemoradiotherapy and esophagectomy between 2004 and 2014. Patients were divided into two groups based on pathological response, pCR vs. incomplete pathological response (iPR). Survival outcomes were evaluated using standard Kaplan-Meier methods and multivariable Cox regression models.

Results: A total of 205 patients were included in the study: 38 (19 %) patients with pCR and 167 patients (81 %) with iPR. The two groups were similar with respect to clinical stage, age, gender, comorbid conditions, ECOG status, smoking, and alcohol use. Patients in the pCR group had a higher percentage of tumors located in middle third of esophagus (11 vs. 2 %, p = 0.04) while tumor grade was similar in both groups. Median follow-up was 50 months, range 2-109 months. The 3-year overall (OS) and recurrence-free survival (RFS) for iPR was 48 and 39 %, respectively, vs. 86 and 80 % for pCR group, respectively.

Conclusion: This analysis of a cohort of homogeneous patients with esophageal adenocarcinoma undergoing multimodality therapy showed that pCR is an independent predictor of improved RFS and OS. This data contributes to a growing body of evidence highlighting the benefits of neoadjuvant therapy specific to esophageal adenocarcinoma particularly when pCR is achieved.
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http://dx.doi.org/10.1007/s11605-016-3177-0DOI Listing
September 2016

Minimally Invasive Esophagectomy Utilizing a Stapled Side-to-Side Anastomosis is Safe in the Western Patient Population.

Ann Surg Oncol 2016 09 25;23(9):3056-62. Epub 2016 Apr 25.

Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY, 14263, USA.

Background: There has been an increased utilization of minimally invasive esophagectomy (MIE) in an effort to reduce morbidity, decrease length of stay, and improve quality of life. However, there are limited large series of patients undergoing MIE from the United States and no standardized approach. We reviewed our experience with MIE utilizing a stapled side-to-side anastomosis during a 7.5-year period.

Study Design: A retrospective review of prospectively maintained databases for patients undergoing planned esophagectomy were reviewed from 2007 to 2015. Esophagogastric anastomoses were performed via a 6-cm linear stapled side-to-side method. Demographics, comorbidities, surgical approach, pathology data, and postoperative morbidities were recorded and reviewed.

Results: A MIE was attempted in 303 of 315 (96 %) patients, and a total minimally invasive approach was completed in 293 of 315 (93 %) patients. Location of anastomosis was predominantly in the neck, with 244 patients (77.5 %) undergoing a total minimally invasive McKeown approach (n = 231). A total, minimally invasive Ivor-Lewis was completed in 60 patients (19.1 %). Anastomotic leak was identified in 24 patients (7.6 %). Rates of anastomotic leak were 4.4 % for Ivor-Lewis and 8.5 % for McKeown resection. Median length of stay was 8 days, and in-hospital mortality occurred in only three patients (n = 1 %). Ninety-day follow-up demonstrated a 4.1 % stricture rate requiring dilatation.

Conclusions: In the Western patient population, MIE utilizing a 6-cm stapled side-to-side anastomosis is associated with low rates of anastomotic leak, stricture, and mortality.
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http://dx.doi.org/10.1245/s10434-016-5232-1DOI Listing
September 2016
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