In this multicentre study, only post-operative complications were associated with DGE. Neither pylorus preservation nor route of enteric reconstruction (antecolic versus retrocolic) was associated with delayed gastric emptying.

Current liver allocation policy in the United States grants liver transplant candidates with stage T2 hepatocellular carcinoma (HCC) a priority Model for End-Stage Liver Disease (MELD) score of 22, regardless of age. Because advanced age may portend an increase in all-cause mortality after transplantation for any diagnosis, the aim of this study was to examine overall posttransplant survival in elderly patients with HCC versus younger cohorts. Based on Organ Procurement and Transplantation Network data, Kaplan-Meier 5-year survival rates were compared. Recipients undergoing primary liver transplantation were stratified into cohorts based on age (<70 or 70 years) and the receipt of MELD exception points for HCC. Log-rank and Wilcoxon tests were used for statistical comparisons. In 2009, 143 transplants were performed for patients who were 70 years old or older. Forty-two percent of these patients received a MELD exception for HCC. Regardless of the diagnosis, the overall survival rate was significantly attenuated for the septuagenarians versus the younger cohort. After 5 years of follow-up, this disparity exceeded 10% to 15% depending on the populations being compared. The 1-, 2-, 3-, 4-, and 5-year actuarial survival rates were 88.4%, 83.2%, 79.6%, 76.1%, and 72.7%, respectively, for the patients who were younger than 70 years and 81.1%, 73.8%, 67.1%, 61.9%, and 55.2%, respectively, for the patients who were 70 years old or older. Five-year survival was negatively affected for patients with HCC who were younger than 70 years; this disparity was not observed for patients with HCC who were 70 years old or older. In conclusion, although patients who are 70 years old or older compose a small fraction of transplant recipients in the United States, patients in this group undergoing transplantation for HCC form an even smaller subset. Overall, transplantation in this age group yields outcomes inferior to those for younger cohorts. However, unlike patients who are less than 70 years old and receive MELD exception points, overall liver transplant survival is not affected by HCC at an advanced age.

STRUCTURED ABSTRACT OBJECTIVE AND SUMMARY BACKGROUND DATA For pancreatectomy patients, mortality increases with increasing age. Our study evaluated the relative contribution of overall postoperative complications and failure to rescue rates on the observed increased mortality in older patients undergoing pancreatic resection at specialized centers. METHODS We identified 2,694 patients who underwent pancreatic resection from the ACS-NSQIP Pancreatectomy Demonstration Project at 37 high volume centers. Overall morbidity and in-hospital mortality were determined in patients <80 (N=2,496) and ≥80 (N=198) years old. Failure to rescue was the number of deaths in patients with complications divided by the total number of patients with postoperative complications. RESULTS No significant differences were observed between patients <80 and ≥80 in the rates of overall complications (41.4% vs. 39.4%, p=0.58). In-hospital mortality increased in patients ≥80 compared to patients <80 (3.0% vs. 1.1%, p=0.02). Failure to rescue rates were higher in patients ≥80 (7.7% vs. 2.7%, p=0.01). Across 37 high volume centers, unadjusted complication rates ranged from 25.0%–72.2% and failure to rescue rates ranged from 0.0%–25.0%. Among patients with postoperative complications, comorbidities associated with failure to rescue were ascites, COPD, and diabetes. Complications associated with failure to rescue included acute renal failure, septic shock, and postoperative pulmonary complications. CONCLUSION In experienced hands, the rates of complications after pancreatectomy in patients ≥80 compared to patients <80 were similar. However, when complications occurred, older patients were more likely to die. Interventions to identify and aggressively treat complications are necessary to decrease mortality in vulnerable older patients.

INTRODUCTION Multimodality therapy with chemotherapy and surgical resection is recommended for patients with locoregional pancreatic cancer, but is not received by many patients. OBJECTIVE To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer. METHODS We used Surveillance, Epidemiology, and End Results (SEER)-linked Medicare data (1992–2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment. RESULTS We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%) and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy. 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992–1995 to 13.8% of patients in 2004–2007 (p<0.0001). 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (p<0.0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs. adjuvant, 46.9% vs. 40.6%, p=0.16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy. CONCLUSION Only half of older patients with locoregional pancreatic cancer receive any treatment, and less than a quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, while half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting and survival was similar regardless of approach.

The benefits of laparoscopic surgery have not been available to the majority of Mongolians. Mongolian surgical leaders requested assistance in expanding laparoscopy. A capacity-building approach for teaching laparoscopic cholecystectomy throughout Mongolia is reviewed. A laparoscopic cholecystectomy training program was developed. The program included a didactic course and an intensive 2-week practical operating experience. Courses were taught in Ulaanbataar and at 3 of the 4 regional diagnostic referral and treatment centers from 2006 to 2010. During this training period, a total of 303 teaching laparoscopic cholecystectomies were performed. There was one common bile duct injury and one duodenal injury. The conversion rate was 2.0%. This program has been successful in creating a self-sustaining practice of training. The traditional surgical approach to gallbladder disease in Mongolia has been challenged and has, in turn, been a stimulus for improvement in the medical community.

Background Guidelines for post resection surveillance of colorectal cancer recommend a collection of the patient's history and physical examination, testing for carcinoembryonic antigen (CEA), and colonoscopy. No consistent guidelines exist for the use of abdominal computed tomography (CT) and position emission tomography (PET)/PET-CT. The goal of our study was to describe current trends, the impact of oncologic follow-up on guideline adherence, and the patterns of use of nonrecommended tests. Methods We used Texas Cancer Registry—Medicare-linked data (2000-2009) to identify physician visits, CEA testing, colonoscopy, abdominal CT, and PET/PET-CT scans in patients ≥66 years old with stage I-III colorectal cancer who underwent curative resection. Compliance with guidelines was assessed with a composite measure of physician visits, CEA tests, and colonoscopy use from start of surveillance. Results In patients who survived 3 years, the overall compliance with guidelines was 25.1%. In patients seen regularly by a medical oncologist, compliance with guidelines increased to 61.5% compared with 8.8% for those not seen by a medical oncologist regularly (P < .0001). The use of abdominal CTand PET/PET-CT increased from 57.5% and 9.5%, respectively, in 2001 to 65.8% and 24.6% (P <.0001) in 2006. Patients who saw a medical oncologist were more likely to get cross-sectionalimagingthan those whodid not (P <.0001). Conclusion Compliance with current minimum guidelines for post treatment surveillance of colorectal cancer is low and the use of nonrecommended testing has increased over time. Both compliance and use of nonrecommended tests are markedly increased in patients seen by a medical oncologist. The comparative effectiveness of CT and PET/PET-CT in the surveillance of colorectal cancer patients needs further examination.

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INTRODUCTION Trends in the use of modern chemotherapeutic regimens, primary tumor resection, and the timing of chemotherapy and resection in older patients with stage IV colorectal cancer have not been evaluated. METHODS We used cancer registry and Medicare linked data (2000-2009) to describe time trends in resection of the primary tumor and receipt of chemotherapy in patients ≥66 presenting with stage IV colorectal cancer (N=16,168). RESULTS The mean age was 77.8±7.3 years. 53.8% were women and 82.9% were white. Primary cancer sites were colon in 83.4% and rectum in 16.6%. Resection of the primary tumor decreased from 64.6% to 57.1% (P<0.0001) from 2001-2009. Systemic chemotherapy was given to 45.1% of patients. While the use of chemotherapy was stable over time (P=0.48), the use of modern regimens containing oxaliplatin or irinotecan increased from 40.9% to 75.4% (P<0.0001) of patients receiving chemotherapy. Bevacizumab use increased from 0.10% to 54.2% (P<0.0001). Survival improved by 4% per year even after controlling for treatment and tumor location (HR=0.96, 95% CI 0.95-0.97). CONCLUSIONS Survival in older patients with stage IV disease is improving over time. Surgical resection is still performed in the majority of patients. Resection rates decreased while modern chemotherapy was rapidly adopted perhaps suggesting a shift in practice patterns.