Heparin-binding protein as a predictor of mortality in patients with diabetes mellitus and community-acquired pneumonia in intensive care unit:a propensity score matched study

BACKGROUND:Patients with diabetes mellitus(DM)are vulnerable to community-acquired pneumonia(CAP),which have a high mortality rate.We aimed to investigate the value of heparin-binding protein(HBP)as a prognostic marker of mortality in patients with DM and CAP.METHODS:This retrospective study included CAP patients who were tested for HBP at intensive care unit(ICU)admission from January 2019 to April 2020.Patients were allocated to the DM or non-DM group and paired with propensity score matching.Baseline characteristics and clinical outcomes up to 90 days were evaluated.The primary outcome was the 10-day mortality.Receiver operating characteristic(ROC)curves,Kaplan-Meier analysis,and Cox regression were used for statistical analysis.RESULTS:Among 152 enrolled patients,60 pairs were successfully matched.There was no significant difference in 10-day mortality,while more patients in the DM group died within 28 d(P=0.024)and 90 d(P=0.008).In the DM group,HBP levels at ICU admission were higher in 10-day non-survivors than in 10-day survivors(median 182.21[IQR:55.43-300]ng/ml vs.median 66.40[IQR:34.13-107.85]ng/mL,P=0.019),and HBP levels could predict the 10-day mortality with an area under the ROC curve of 0.747.The cut-off value,sensitivity,and specificity were 160.6 ng/mL,66.7%,and 90.2%,respectively.Multivariate Cox regression analysis indicated that HBP was an independent prognostic factor for 10-day(HR 7.196,95%CI:1.596-32.455,P=0.01),28-day(HR 4.381,95%CI:1.449-13.245,P=0.009),and 90-day mortality(HR 4.581,95%CI:1.637-12.819,P=0.004)in patients with DM.CONCLUSION:Plasma HBP at ICU admission was associated with the 10-day,28-day,and 90-day mortality,and might be a prognostic factor in patients with DM and CAP.

Preoperative neutrophil-to-lymphocyte ratio predicts symptomatic anastomotic leakage in elderly colon cancer patients: Multicenter propensity score-matched analysis

BACKGROUND The neutrophil-to-lymphocyte ratio(NLR),a composite inflammatory biomarker,is associated with the prognosis in patients with colorectal tumors.However,whether the NLR can be used as a predictor of symptomatic postoperative ana-stomotic leakage(AL)in elderly patients with colon cancer is unclear.AIM To assess the role of the NLR in predicting the occurrence of symptomatic AL after surgery in elderly patients with colon cancer.METHODS Data from elderly colon cancer patients who underwent elective radical colectomy with anastomosis at three centers between 2018 and 2022 were retrospectively analyzed.Receiver operating characteristic curve analysis was performed to determine the best predictive cutoff value for the NLR.Twenty-two covariates were matched using a 1:1 propensity score matching method,and univariate and multivariate logistic regression analyses were used to determine risk factors for the development of postoperative AL.RESULTS Of the 577 patients included,36(6.2%)had symptomatic AL.The optimal cutoff value of the NLR for predicting AL was 2.66.After propensity score matching,the incidence of AL was significantly greater in the≥2.66 NLR subgroup than in the<2.66 NLR subgroup(11.5%vs 2.5%;P=0.012).Univariate logistic regression analysis revealed statistically significant correlations between blood transfusion intraoperatively and within 2 d postoper-atively,preoperative albumin concentration,preoperative prognostic nutritional index,and preoperative NLR and AL occurrence(P<0.05);multivariate logistic regression analysis revealed that an NLR≥2.66[odds ratio(OR)=5.51;95%confidence interval(CI):1.50-20.26;P=0.010]and blood transfusion intraoperatively and within 2 d postoperatively(OR=2.52;95%CI:0.88-7.25;P=0.049)were risk factors for the occurrence of symptomatic AL.CONCLUSION A preoperative NLR≥2.66 and blood transfusion intraoperatively and within 2 d postoperatively are associated with a higher incidence of postoperative symptomatic AL in elderly patients with colon cancer.The preoperative NLR has predictive value for postoperative symptomatic AL after elective surgery in elderly patients with colon cancer.

Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Background: Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy(RDP) for pancreatic ductal adenocarcinoma(PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC. Methods: Patients who underwent RDP or laparoscopic distal pancreatectomy(LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed. Results: Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time(209.7 vs. 163.2 min;P = 0.003), lower open conversion rate(0% vs. 4.8%;P < 0.001), higher cost(15 722 vs. 12 699 dollars;P = 0.003), and a higher rate of achievement of an R0 resection margin(90.5% vs. 61.9%;P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant intergroup difference(9.5% vs. 9.5%). The median disease-free survival(34.5 vs. 17.3 months;P = 0.588) and overall survival(37.7 vs. 21.9 months;P = 0.171) were comparable between the groups. Conclusions: RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Laparoscopic liver resection for hepatocellular carcinoma complicated with significant portal hypertension:A propensity score-matched survival analysis

Background: Significant portal hypertension(SPH) is a relative contraindication for patients with resectable hepatocellular carcinoma(HCC). However, increasing evidence indicates that liver resection is feasible for HCC patients with SPH. Methods: HCC patients with cirrhosis who underwent laparoscopic liver resection(LLR) in two centers from January 2013 to April 2018 were included. Surgical and survival outcomes were analyzed to explore potential prognostic factors. Propensity score matching(PSM) analysis was performed to minimize bias. Results: A total of 165 patients were divided into two groups based on the presence(SPH, n = 76) or absence(non-SPH, n = 89) of SPH. Patients in the SPH group had longer operative time, more blood loss, and more advanced TNM stage than patients in the non-SPH group( P < 0.05). However, there were no significant differences in the postoperative 90-day mortality rate( n = 0), overall postoperative complications(47.4% vs. 41.6%, P = 0.455), Clavien-Dindo classification( P = 0.347), conversion to open surgery(9.2% vs. 6.7%, P = 0.557), or length of hospitalization(16 vs. 15 days, P = 0.203) between the SPH and non-SPH groups before PSM. Similar results were obtained after PSM. The 1-, 3-, and 5-year overall survival(OS) and recurrence-free survival rates in the SPH group were not significantly different from those in the non-SPH group both before and after PSM(log-rank P > 0.05). After PSM, alpha-fetoprotein(AFP) ≥ 400 μg/L [hazard ratio(HR) = 4.71, 95% confidence interval(CI): 2.69-8.25], ascites(HR = 2.18, 95% CI: 1.30-3.66), American Society of Anesthesiologists(ASA) classification(Ⅲ vs. Ⅱ)(HR = 2.13, 95% CI: 1.11-4.07) and tumor diameter > 5 cm(HR = 3.91, 95% CI: 2.02-7.56) independently predicted worse OS. Conclusions: LLR for patients with HCC complicated with SPH appears feasible at the price of increasing operative time and blood loss. AFP, ascites, ASA classification and tumor diameter may predict the prognosis of HCC complicated with SPH after LLR.

Temporal Variations in Mortality after Liver Transplantation: Retrospective Investigation of Potential Risk Factors Using Propensity Score

Objective: We aim to detect over-time variations in mortality of liver transplant recipients stratified by the period of transplant. Since this is a retrospective investigation, bias reduction caused by possible confounding effects can be achieved by using propensity score weighting in a multivariate logistic regression model. Methods: Medical charts of all adult liver transplant recipients (n = 250) who were transplanted in three periods 2005-2009, 2010-2014 and 2015-2019 were retrospectively reviewed. The following recipient factors were analyzed: recipients and donors’ ages, sex, renal impairment, body mass index (BMI), presence of bacterial or viral infections, MELD (Model for end-stage diseases). Multivariate logistic model adjusted by Propensity Scores (PS) was used to identify the effect of the risk factors on mortality, and death within five years, in the targeted time frame. Patient outcomes are recorded as;(patient status = 1 if dead, or patient status = 0 if alive). Results: Meld score, recipient age, and renal impairments were shown to be predictors of mortality in transplanted patients. Multivariate regression model was used to identify the significance of the specified risk factors, followed by pairwise comparisons between periods. Pairwise comparisons between periods using logistic regression weighted by the inverse propensity score, correcting for the possible confounding effect of measured covariates showed that the death rate is significantly reduced in subsequent periods as compared to the initial period. Conclusions: The clinical implications of these findings are the ability to stratify patients at high risk of posttransplant death by planning more intensive and accurate management for them.

Effects of Continuous Non-Invasive Blood Pressure Monitoring on Intraoperative Hemodynamics and Postoperative Myocardial Injury in Craniotomy:Comparison Between Groups Based on Self-Control and Propensity Score Matching

Objective:To explore the effect of continuous non-invasive blood pressure monitoring on intraoperative hemodynamics and postoperative myocardial injury in craniotomy.Methods:120 cases of elective craniotomy were divided into the self-control group(continuous non-invasive blood pressure monitoring and intermittent cuff non-invasive blood pressure monitoring,CNAP group)and propensity score matching group(only intermittent cuff non-invasive blood pressure measurement in previous craniotomy,PSM group);Goal-directed hemodynamic management in CNAP group included heart rate(HR),blood pressure(BP),stroke volume(SV),stroke variability(SVV),and systemic vascular resistance index(SVRI).The main index is to compare the troponin level within 72 hours after operation between the CNAP group and the PSM group;The secondary indicators are the comparison of the hemodynamic conditions between the CNAP group and the PSM at 10 specific time points.Results:The incidence of postoperative myocardial injury in the CNAP group was significantly lower than that in the PSM group(12%vs.30%,P=0.01);in the CNAP group hypotensive episodes(6 vs.3,P=0.01),positive balance of fluid therapy(700 vs.500 mL,P<0.001),more use of vasoactive drugs(29 vs.18,P=0.04),more stable hemodynamics medical status(P=0.03)were recorded.Conclusion:The hemodynamic management strategy based on continuous non-invasive blood pressure monitoring can reduce the incidence of myocardial injury after elective craniotomy and maintain a more stable hemodynamic state.

Lenvatinib,sintilimab combined interventional treatment vs bevacizumab,sintilimab combined interventional treatment for intermediate-advanced unresectable hepatocellular carcinoma

BACKGROUND Bevacizumab and sintilimab combined interventional treatment(BeSiIT)and L envatinib and sintilimab combined interventional treatment(LeSiIT)are two commonly used therapeutic regimens for intermediate-advanced hepatocellular carcinoma(HCC)in clinical practice.AIM To compare the clinical efficacy and safety of BeSiIT and LeSiIT for the treatment of intermediate and advanced HCC.METHODS Patients diagnosed with intermediate-advanced HCC and initially treated with BeSiIT or LeSiIT in the Tianjin Medical University Cancer Institute and Hospital between February 2020 and July 2021 were included.The primary endpoint was progression-free survival(PFS),and the secondary endpoints were overall survival(OS),objective response rate(ORR),disease control rate(DCR),conversion rate,and treatmentrelated adverse events.RESULTS Total 127 patients met the inclusion criteria and were divided into BeSiIT and LeSiIT groups.Twenty-eight and fifty patients in the BeSiIT and LeSiIT groups,respectively,were assessed after 1:2 propensity score matching.PFS and OS rates were not significantly different between the two groups.No significant variations were noted in ORRs or DCRs according to the Response Evaluation Criteria in Solid Tumors(RECIST),and modified RECIST.BeSiIT group showed a better conversion rate than the LeSiIT group(P=0.043).Both groups showed manageable toxicity profiles.Multivariate analysis showed that the independent factors associated with PFS were alphafetoprotein levels and carcinoembryonic antigen score.CONCLUSION In intermediate-to-advanced HCC,the BeSiIT and LeSiIT groups exhibited acceptable toxicities and comparable PFS,OS,and ORR.

Prognostic utility of gamma-glutamyl transpeptidase to platelet ratio in patients with solitary hepatitis B virus-related hepatocellular carcinoma after hepatectomy

BACKGROUND The prognostic impact of preoperative gamma-glutamyl transpeptidase to platelet ratio(GPR)levels in patients with solitary hepatitis B virus(HBV)-related hepatocellular carcinoma(HCC)following radical resection has not been established.AIM To examine the clinical utility of GPR for prognosis prediction in solitary HBVrelated HCC patients.METHODS A total of 1167 solitary HBV-related HCC patients were retrospectively analyzed.GPR levels were compared with 908 non-HCC individuals.Overall survival(OS)and recurrence-free survival(RFS)were evaluated,and cox proportional hazard model analyses were performed to identify independent risk factors.Differences in characteristics were adjusted by propensity score matching(PSM).Subgroup and stratified survival analyses for HCC risks were performed,and a linear trend of the hazard ratio(HR)according to GPR levels was constructed.RESULTS GPR levels of patients with solitary HBV-related HCC were higher than those with hepatic hemangiomas,chronic hepatitis B and healthy control(adjusted P<0.05).Variable bias was diminished after the PSM balance test.The low GPR group had improved OS(P<0.001)and RFS(P<0.001)in the PSM analysis and when combined with other variables.Multivariate cox analyses suggested that low GPR levels were associated with a better OS(HR=0.5,95%CI:0.36-0.7,P<0.001)and RFS(HR=0.57,95%CI:0.44-0.73,P<0.001).This same trend was confirmed in subgroup analyses.Prognostic nomograms were constructed and the calibration curves showed that GPR had good survival prediction.Moreover,stratified survival analyses found that GPR>0.6 was associated with a worse OS and higher recurrence rate(P for trend<0.001).CONCLUSION Preoperative GPR can serve as a noninvasive indicator to predict the prognosis of patients with solitary HBVrelated HCC.

Clinical effect of laparoscopic radical resection of colorectal cancer based on propensity score matching

BACKGROUND The incidence of colorectal cancer(CRC)is increasing annually.Laparoscopic radical resection of CRC is a minimally invasive procedure preferred in clinical practice.AIM To investigate the clinical effect of laparoscopic radical resection of CRC on the basis of propensity score matching(PSM).METHODS The clinical data of 100 patients who received inpatient treatment for CRC at Changde Hospital,Xiangya School of Medicine,Central South University(The First People’s Hospital of Changde City)were analyzed retrospectively.The control group included patients who underwent open surgery(n=43),and those who underwent laparoscopic surgery formed the observation group(n=57).The baseline information of both groups was equipoised using 1×1 PSM.Differences in the perioperative parameters,inflammatory response,immune function,degree of pain,and physical status between the groups were analyzed.RESULTS Thirty patients from both groups were successfully matched.After PSM,baseline data showed no statistically significant differences between the groups:(1)Periop-erative parameters:The observation group had a longer surgery time,less intra-operative blood loss,earlier first ambulation and first anal exhaust times,and shorter gastric tube indwelling time than the control group;(2)Inflammatory response:24 h after surgery,the levels of interleukin-6(IL-6),C-reactive protein(CRP),and tumor necrosis factor-α(TNF-α)between groups were higher than preoperatively.IL-6,CRP,and TNF-αlevels in the observation group were lower than in the control group;(3)Immune function:At 24 h after surgery,counts of CD4-positive T-lymphocytes(CD4+)and CD4+/CD8-positive T-lymphocytes(CD8+)in both groups were lower than those before surgery,whereas CD8+was higher than that before surgery.At 24 h after surgery,both CD4+counts and CD4+/CD8+in the observation group were higher than those in the control group,whereas CD8+counts were lower;(4)Degree of pain:The visual analog scale scores in the observation group were lower than those in the control group at 24 and 72 h after surgery;and(5)Physical status:One month after surgery,the Karnofsky performance score in the observation group was higher than that in the control group.CONCLUSION Laparoscopic radical resection of CRC has significant benefits,such as reducing postoperative pain and postoperative inflammatory response,avoiding excessive immune inhibition,and contributing to postoperative recovery.

Robotic vs laparoscopic abdominoperineal resection for rectal cancer:A propensity score matching cohort study and metaanalysis

BACKGROUND Robotic surgery(RS)is gaining popularity;however,evidence for abdominoperineal resection(APR)of rectal cancer(RC)is scarce.AIM To compare the efficacy of RS and laparoscopic surgery(LS)in APR for RC.METHODS We retrospectively identified patients with RC who underwent APR by RS or LS from April 2016 to June 2022.Data regarding short-term surgical outcomes were compared between the two groups.To reduce the effect of potential confounding factors,propensity score matching was used,with a 1:1 ratio between the RS and LS groups.A meta-analysis of seven trials was performed to compare the efficacy of robotic and laparoscopic APR for RC surgery.RESULTS Of 133 patients,after propensity score matching,there were 42 patients in each group.The postoperative complication rate was significantly lower in the RS group(17/42,40.5%)than in the LS group(27/42,64.3%)(P=0.029).There wasno significant difference in operative time(P=0.564),intraoperative transfusion(P=0.314),reoperation rate(P=0.314),lymph nodes harvested(P=0.309),or circumferential resection margin(CRM)positive rate(P=0.314)between the two groups.The meta-analysis showed patients in the RS group had fewer positive CRMs(P=0.04),lesser estimated blood loss(P<0.00001),shorter postoperative hospital stays(P=0.02),and fewer postoperative complications(P=0.002)than patients in the LS group.CONCLUSION Our study shows that RS is a safe and effective approach for APR in RC and offers better short-term outcomes than LS.

Can propensity score matching replace randomized controlled trials?

Randomized controlled trials(RCTs)have long been recognized as the gold standard for establishing causal relationships in clinical research.Despite that,various limitations of RCTs prevent its widespread implementation,ranging from the ethicality of withholding potentially-lifesaving treatment from a group to relatively poor external validity due to stringent inclusion criteria,amongst others.However,with the introduction of propensity score matching(PSM)as a retrospective statistical tool,new frontiers in establishing causation in clinical research were opened up.PSM predicts treatment effects using observational data from existing sources such as registries or electronic health records,to create a matched sample of participants who received or did not receive the intervention based on their propensity scores,which takes into account characteristics such as age,gender and comorbidities.Given its retrospective nature and its use of observational data from existing sources,PSM circumvents the aforementioned ethical issues faced by RCTs.Majority of RCTs exclude elderly,pregnant women and young children;thus,evidence of therapy efficacy is rarely proven by robust clinical research for this population.On the other hand,by matching study patient characteristics to that of the population of interest,including the elderly,pregnant women and young children,PSM allows for generalization of results to the wider population and hence greatly increases the external validity.Instead of replacing RCTs with PSM,the synergistic integration of PSM into RCTs stands to provide better research outcomes with both methods complementing each other.For example,in an RCT investigating the impact of mannitol on outcomes among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial,the baseline characteristics of comorbidities and current medications between treatment and control arms were significantly different despite the randomization protocol.Therefore,PSM was incorporated in its analysis to create samples from the treatment and control arms that were matched in terms of these baseline characteristics,thus providing a fairer comparison for the impact of mannitol.This literature review reports the applications,advantages,and considerations of using PSM with RCTs,illustrating its utility in refining randomization,improving external validity,and accounting for non-compliance to protocol.Future research should consider integrating the use of PSM in RCTs to better generalize outcomes to target populations for clinical practice and thereby benefit a wider range of patients,while maintaining the robustness of randomization offered by RCTs.

Propensity score analysis demonstrated the prognostic advantage of anatomical liver resection in hepatocellular carcinoma

AIM: To compare the prognoses of hepatocellular carcinoma (HCC) patients that underwent anatomic liver resection (AR) or non-anatomic liver resection (NAR) using propensity score-matched populations.

Impact of proton pump inhibitors on clinical outcomes in patients after acute myocardial infarction: a propensity score analysis from China Acute Myocardial Infarction(CAMI) registry

Background Proton pump inhibitors(PPIs) are recommended by the latest guidelines to reduce the risk of bleeding in acute myocardial infarction(AMI) patients treated with dual antiplatelet therapy(DAPT). However, previous pharmacodynamic and clinical studies have reported controversial results on the interaction between PPI and the P2 Y12 inhibitor clopidogrel. We investigated the impact of PPIs use on in-hospital outcomes in AMI patients, aiming to provide a new insight on the value of PPIs. Methods A total of 23,380 consecutive AMI patients who received clopidogrel with or without PPIs in the China Acute Myocardial Infarction(CAMI) registry were analyzed. The primary endpoint was major adverse cardiovascular and cerebrovascular events(MACCE) defined as a composite of in-hospital cardiac death, re-infarction and stroke. Propensity score matching(PSM) was used to control potential baseline confounders. Multivariate logistic regression analysis was performed to evaluate the effect of PPIs use on MACCE and gastrointestinal bleeding(GIB). Results Among the whole AMI population, a large majority received DAPT and 67.5% were co-medicated with PPIs. PPIs use was associated with a decreased risk of MACCE(Before PSM OR: 0.857, 95% CI: 0.742-0.990, P = 0.0359;after PSM OR: 0.862, 95% CI: 0.768-0.949, P = 0.0245) after multivariate adjustment. Patients receiving PPIs also had a lower risk of cardiac death but a higher risk of complicating with stroke. When GIB occurred, an alleviating trend of GIB severity was observed in PPIs group. Conclusions Our study is the first nation-wide large-scale study to show evidence on PPIs use in AMI patients treated with DAPT. We found that PPIs in combination with clopidogrel was associated with decreased risk for MACCE in AMI patients, and it might have a trend to mitigate GIB severity. Therefore, PPIs could become an available choice for AMI patients during hospitalization.

Pancreas-sparing duodenectomy with regional lymph node dissection for early-stage ampullary carcinoma: A case control study using propensity scoring methods

AIM:To investigate the outcomes of pancreas-sparing duodenectomy(PSD)with regional lymph node dissection vs pancreaticoduodenectomy(PD).METHODS:Between August 2001 and June 2014,228 patients with early-stage ampullary carcinoma(Amp Ca)underwent surgical treatment(PD,n=159;PSD with regional lymph node dissection,n=69).The patients were divided into two groups:the PD group and the PSD group.Propensity scoring methods were used to select patients with similar disease statuses.A total of 138 matched cases,with 69 patients in each group,were included in the final analysis.RESULTS:The median operative time was shorter among the patients in the PSD group(435 min)compared with those in the PD group(481 min,P=0.048).The median blood loss in the PSD group was significantly less than that in the PD group.The median length of hospital stay was shorter for patients in the PSD group vs the PD group.The incidence of pancreatic fistula was higher among patients in the PD group vs the PSD group.The 1-,3-,and 5-year overall survival and disease-free survival rates for patients in the PSD group were 83%,70%,44%and 73%,61%,39%,respectively,and these values were not different than compared with those in the PD group(P=0.625).CONCLUSION:PSD with regional lymph node dissection presents an acceptable morbidity in addition to its advantages over PD.PSD may be a safe and feasible alternative to PD in the treatment of earlystage Amp Ca.

Down-staging depth score to predict outcomes in locally advanced rectal cancer achieving ypl stage after neoadjuvant chemo-radiotherapy versus de novo stage pl cohort:A propensity score-matched analysis

Objective：Prognosis of patients with locally advanced rectal cancer（LARC）but achieving yp T1–2N0 stage after neoadjuvant concurrent chemo-radiotherapy（CRT）has been shown to be favorable.This study aims to determine whether the long-term outcome of yp T1–2N0 cases can be comparable to that of p T1–2N0 cohort that received definitive surgery for early disease.Method：From January 2008 to December 2013,449 consecutive patients with rectal cancer were treated and their outcome maintained in a database.Patients with LARC underwent total mesorectal excision（TME）surgery at4–8 weeks after completion of CRT,and those achieving stage yp I were identified as a group.As a comparison,stage p I group pertains to patients whose initially limited disease was not upstaged after TME surgery alone.After propensity score matching（PSM）,comparisons of local regional control（LC）,distant metastasis-free survival（DMFS）,disease-free survival（DFS）and overall survival（OS）were performed using Kaplan-Meier analysis and log-rank test between yp I and p I groups.Down-staging depth score（DDS）,a novel method of evaluating CRT response,was used for subset analysis.Results：Of the 449 patients,168 matched cases were generated for analysis.Five-year LC,DMFS,DFS and OS for stage p I vs.yp I groups were 96.7%vs.96.4%（P=0.796）,92.7%vs.73.6%（P=0.025）,91.2%vs.73.6%（P=0.080）and 93.1%vs.72.3%（P=0.040）,respectively.In the DDS-favorable subset of the yp I group,LC,DMFS,DFS and OS resulted in no significant differences in comparison with the p I group（P=0.384,0.368,0.277 and0.458,respectively）.Conclusions：LC was comparable in both groups;however,distant metastasis developed more frequently in down-staged LARC than de novo early stage cases,reflecting the need to improve the efficacy of systemic treatment despite excellent pathologic response.DDS can be an indicator to identify a subset of the yp I group whose longterm oncologic outcomes are as good as those of stage p I cohort.

Cholecystectomy is associated with higher risk of recurrence after microwave ablation of hepatocellular carcinoma:a propensity score matching analysis

Objective:To explore the association between cholecystectomy and the prognostic outcomes of patients with hepatocellular carcinoma(H CC)who underwent microwave ablation(MWA).Methods:Patients with HCC(«=921)who underwent MWA were included and divided into cholecystectomy(n=114)and non-cholecystectomy groups(n=807).After propensity score matching(PSM)at a 1:2 ratio,overall survival(OS)and disease-free survival(DFS)rates were analyzed to compare prognostic outcomes between the cholecystectomy(«=114)and non-cholecystectomy groups(n=228).Univariate and multivariate Cox analyses were performed to assess potential risk factors for OS and DFS.Major complications were also compared between the groups.Results:After matching,no significant differences between groups were observed in baseline characteristics.The 1-,3-,and 5-year OS rates were 96.5%,82.1%,and 67.1%in the cholecystectomy group,and 97.4%,85.2%,and 74.4%in the non-cholecystectomy group(P=0.396);the 1-,3-,and 5-year DFS rates were 58.4%,34.5%,and 26.6%in the cholecystectomy group,and 73.6%,44.7%,and 32.2%in the non-cholecystectomy group(P=0.026),respectively.The intrahepatic distant recurrence rate in the cholecystectomy group was significantly higher than that in the non-cholecystectomy group(P=0.026),and the local tumor recurrence and extrahepatic recurrence rates did not significantly differ between the groups(P=0.609 and P=0.879).Multivariate analysis revealed that cholecystectomy(HR=1.364,95%Cl 1.023-1.819,P=0.035),number of tumors(2 vs.1:HR=2.744,95%Cl 1.925-3.912,P<0.001;3 vs.1:HR=3.411,95%Cl 2.021-5.759,P<0.001),and y-GT levels(HR=1.003,95%Cl 1.000-1.006,P<0.024)were independent risk factors for DFS.The best y-GT level cut-off value for predicting median DFS was 39.6 U/L(area under the curve=0.600,P<0.05).A positive correlation was observed between cholecystectomy and y-GT level(r=0.108,95%Cl-0.001-0.214,P=0.047).Subgroup analysis showed that the DFS rates were significantly higher in the non-cholecystectomy group than the cholecystectomy group when Y-GT>39.6 U/L(i3=0.044).The 5-,10-,15-,20-,and 25-year recurrence rates from the time of cholecystectomy were 2.63%,21.93%,42.11%,58.77%,and 65.79%,respectively.A significant positive correlation was observed between cholecystectomy and the time from cholecystectomy to recurrence(r=0.205,95%Cl 0.016-0.379,P=0.029).There were no significant differences in complications between groups(P=0.685).Conclusions:Patients with HCC who underwent cholecystectomy were more likely to develop intrahepatic distant recurrence after MWA,an outcome probably associated with increased y-GT levels.Moreover,the recurrence rates increased with time.

Short-term efficacy of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy via Huang’s three-step maneuver for advanced upper gastric cancer: Results from a propensity scorematched study

BACKGROUND Robotic surgery has been considered to be significantly better than laparoscopic surgery for complicated procedures.AIM To explore the short-term effect of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy(SPSHL)for advanced gastric cancer(GC)by Huang’s three-step maneuver.METHODS A total of 643 patients who underwent SPSHL were recruited from April 2012 to July 2017,including 35 patients who underwent robotic SPSHL(RSPSHL)and 608 who underwent laparoscopic SPSHL(LSPSHL).One-to-four propensity score matching was used to analyze the differences in clinical data between patients who underwent robotic SPSHL and those who underwent laparoscopic SPSHL.RESULTS In all,175 patients were matched,including 35 patients who underwent RSPSHL and 140 who underwent LSPSHL.After matching,there were no significant differences detected in the baseline characteristics between the two groups.Significant differences in total operative time,estimated blood loss(EBL),splenic hilar blood loss(SHBL),splenic hilar dissection time(SHDT),and splenic trunk dissection time were evident between these groups(P<0.05).Furthermore,no significant differences were observed between the two groups in the overall noncompliance rate of lymph node(LN)dissection(62.9%vs 60%,P=0.757),number of retrieved No.10 LNs(3.1±1.4 vs 3.3±2.5,P=0.650),total number of examined LNs(37.8±13.1 vs 40.6±13.6,P=0.274),and postoperative complications(14.3%vs 17.9%,P=0.616).A stratified analysis that divided the patients receiving RSPSHL into an early group(EG)and a late group(LG)revealed that the LG experienced obvious improvements in SHDT and length of stay compared with the EG(P<0.05).Logistic regression showed that robotic surgery was a significantly protective factor against both SHBL and SHDT(P<0.05).CONCLUSION RSPSHL is safe and feasible,especially after overcoming the early learning curve,as this procedure results in a radical curative effect equivalent to that of LSPSHL.

Short-term and middle-term evaluation of laparoscopic hepatectomies compared with open hepatectomies: A propensity score matching analysis

AIM To compare short-term results between laparoscopic hepatectomy and open hepatectomy using a propensity score matching. METHODS A patient in the laparoscopic liver resection(LLR) groupwas randomly matched with another patient in the open liver resection(OLR) group using a 1:1 allocated ratio with the nearest estimated propensity score. Patients of the LLR group without matches were excluded. Matching criteria included age, gender, body mass index, American Society of Anesthesiologists score, potential co-morbidities, hepatopathies, size and number of nodules, preoperative chemotherapy, minor or major liver re-sections. Intraoperative and postoperative data were compared in both groups.RESULTS From January 2012 to January 2015, a total of 241 hepa-tectomies were consecutively performed, of which 169 in the OLR group(70.1%) and 72 in the LLR group(29.9%). The conversion rate was 9.7%(n = 7). The mortality rate was 4.2% in the OLR group and 0% in the LLR group. Prior to and after propensity score matching, there was a statistically significant difference favorable to the LLR group regarding shorter operative times(185 min vs 247.5 min; P = 0.002), less blood loss(100 m L vs 300 m L; P = 0.002), a shorter hospital stay(7 d vs 9 d; P = 0.004), and a significantly lower rate of medical complications(4.3% vs 26.4%; P < 0.001). CONCLUSION Laparoscopic liver resections seem to yield better short-term and mid-term results as compared to open hepatectomies and could well be considered a privileged approach and become the gold standard in carefully selected patients.

Laparoscopic vs open total gastrectomy for advanced gastric cancer following neoadjuvant therapy:A propensity score matching analysis

BACKGROUND Laparoscopic total gastrectomy(LTG)has drawn increasing attention over the years.Although LTG has shown surgical benefits compared to open TG(OTG)in early stage gastric cancer(GC),little is known about the surgical and oncological outcomes of LTG for advanced GC following neoadjuvant therapy(NAT).AIM To compare the long-and short-term outcomes of advanced GC patients who underwent LTG vs OTG following NAT.METHODS Advanced GC patients who underwent TG following NAT between April 2011 and May 2018 at the Cancer Hospital of the Chinese Academy of Medical Sciences were enrolled and stratified into two groups:LTG and OTG.Propensity score matching analysis was performed at a 1:1 ratio to overcome possible bias.RESULTS In total,185 patients were enrolled(LTG:78;OTG:109).Of these,138 were paired after propensity score matching.After adjustment for propensity score matching,baseline parameters were similar between the two groups.Compared to OTG,LTG was associated with a significantly shorter length of hospital stay(P=0.012).The rates of R0 resection,lymph node harvest,and postoperative morbidity did not significantly differ between the two groups.Overall survival(OS)outcomes were comparable between the two groups.Pathological T and N stages were found to be independent risk factors for OS.CONCLUSION LTG can be a feasible method for advanced GC patients following NAT,as it appears to be associated with better short-and comparable long-term outcomes compared to OTG.

Real-world local recurrence rate after cold polypectomy in colorectal polyps less than 10 mm using propensity score matching

BACKGROUND Cold polypectomy(CP)is a simple and safe procedure for polyps less than 10 mm in size;however,there is concern about local recurrence following CP because of unidentified margins of excised specimens and the lack of tumor suppression effect by coagulation.Some clinical trials have evaluated local persistent recurrence;their results suggest that a higher rate of local recurrence has not been documented so far.There were few reports that observed the course over long periods of time after CP in clinical practice.AIM To evaluate the presence of local recurrence following CP and hot polypectomy(HP)using propensity score matching.METHODS We analyzed 275 patients who underwent polypectomy for non-pedunculated colorectal polyps less than 10 mm(959 Lesions)between October 2016 and 2017 and underwent follow-up endoscopy subsequently.We divided them into the CP group(706 Lesions),wherein CP was performed,and the HP group(253 Lesions),wherein HP was performed.Using propensity score matching,we extracted 215 Lesions in each group and evaluated the local recurrence and content of CP in the real clinic and adverse events using medical records.RESULTS After propensity score matching,there were no significant differences in the patients’and their endoscopic background(age,use of antithrombotics,indications,size,morphology,location of polyps,and polypectomy device)between the groups.The mean duration between colorectal polypectomy and the next follow-up colonoscopy was 17.5±7.1(range,6-39)mo in the CP group and 15.7±6.0(range,6-35)mo in the HP group,which was significantly longer in the CP group(P=0.005).The local recurrence rate was 0.93%in the CP group and 0.93%in the HP group,without a significant difference(P=0.688).Additionally,no differences were observed in the macroscopic en bloc resection rate,histopathological complete resection rate,and pathological results between the groups.Adverse events did not occur in either group.CONCLUSION Local recurrence after CP was equivalent to that following HP in clinical practice.CP is useful and safe in the treatment of non-pedunculated polyps of less than 10 mm.