Neoadjuvant chemotherapy (nCT) has an increasingly important role in the treatment of locally invasive gastric and esophageal adenocarcinoma. However, its outcomes have not been examined in cohorts of exclusively elderly patients who may not experience the same benefits as younger patients and are more vulnerable to adverse events from the treatment. The purpose of this study is to determine the impact of nCT on outcomes among elderly patients with gastric and gastroesophageal adenocarcinoma. Methods All patients who underwent curative-intent surgery for gastric and gastroesophageal adenocarcinoma between 2010 and 2018 at a high-volume multidisciplinary referral center were identified from a prospectively collected database. Early stage tumours at diagnosis (T1N0 or T2N0) and emergency resections were excluded. Patient characteristics, surgical outcomes and oncologic outcomes were verified by chart review and death dates verified using provincial registry data. Comparison was made for all variables between patients who were treated with nCT and those who were treated with surgery alone (SA). Subgroup analysis among patients aged 70+ was conducted to determine differences in outcomes among elderly patients. Results Of 766 cases in the database, 354 met inclusion criteria (SA: 99 vs nCT: 255). Of those who received nCT, 77 (30.3%) were ≥ 70 years of age. When compared to younger patients, this cohort experienced significantly more high-grade toxicity from chemotherapy (<70: 32 (18.1%); 70+: 25 (32.5%); p = 0.017), but completion rates and timely progression to surgery were similar between groups (Table 1). Multivariate analysis among elderly patients showed that patients who had nCT had similar overall survival (HR 1.04, 95% CI 0.35-1.19) and disease-free survival (HR 1.04, 95% CI 0.41-1.36) to those who were treated with SA. Conclusion Neoadjuvant chemotherapy administered to elderly patients with locally advanced gastroesophaeal adenocarcinoma results in higher rates of high-grade toxicity with no difference in long term oncologic outcomes when compared to surgery alone. Consideration should be given to upfront surgery for elderly patients with resectable gastric and gastroesophageal tumours at presentation.
Gastroesophagectomy for cancer is associated with high risk of morbidity and mortality. Careful patient selection for surgery is essential for optimizing outcomes. The purpose of this study was to develop a reliable composite risk calculator to inform pre-operative decision-making using readily available patient and tumour characteristics. Methods Patients undergoing curative-intent resection for gastroesophageal cancer from January 2010 to December 2018 were identified from a prospectively collected database. Data were verified and collected from patients’ medical records. Multiple logistic regression modeling identified pre-operative variables associated with significantly elevated risk of moderate to severe post-operative complications (Clavien-Dindo score ≥ 2) within 30 days of surgery and a nomogram was developed to form the composite risk score (CRiSCo-UGIS). Internal model validation was performed. Results Among 520 patients, independent pre-operative risk factors for complications were: female sex, age-adjusted Charlson comorbidity index ≥5, albumin <35 g/L, proximal tumour location (esophagus and gastroesophageal junction) and reduced performance status (Eastern Cooperative Oncology Group performance status 2–3) (Table 1). CRiSCo-UGIS had a good model fit (Hosmer-Lemeshow p = 0.47, area under receiver operating characteristic curve = 0.69). The overall observed-to-expected ratio was 1.0 [95% confidence interval 0.9–1.1]. Patients were divided into low (0), moderate (1–2) and high (≥3 points) risk categories. The observed risk of complications was: 42% in low-risk, 53% in moderate-risk and 80% in high-risk. Conclusion CRiSCo-UGIS can reliably predict post-operative complications for gastroesophageal cancer resection based on readily available pre-operative characteristics. This composite score can be used to guide patient selection for surgery and enhance informed consent discussions.
Abstract:Appendectomy is the mainstay of treatment for acute appendicitis. Considering the complications of surgery, antibiotic treatment has also been gaining increasing interest in cases of acute appendicitis. This study aimed to compare the efficacy of antibiotics to surgery for acute uncomplicated appendicitis. The PubMed, Medline, Medscape and Cochrane databases were searched for studies comparing antibiotics versus surgery. The six outcome measures identified were thirty-day post-therapeutic peritonitis, length of hospital stay, prevalence of total complications, prevalence of normal appendix, prevalence of mean duration of pain and duration of disability. Five prospective RCTs with a total of 1430 patients (644 in the antibiotic group and 786 in the surgical group) were included in this study. Antibiotic treatment had a success rate of 75.3%. Regarding overall mean duration of disability, the antibiotic group had a significantly shorter duration of disability than that of the surgery group (P < 0.05). The total number of complications in the antibiotic group was 3.6% while that of the surgical group was 11.6%. The overall difference for mean duration of pain, and length of hospital stay between antibiotic therapy and surgery were not found to be statistically significant (P > 0.05). Although the conservative approach has a success rate lower than appendectomy, it is a possible alternative in certain clinical scenarios. Appendectomy remains the mainstay treatment for acute appendicitis. However, additional studies clarifying the certain etiologies of appendicitis that are responsive to antibiotic treatment are needed to further support its use.
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