Bennett Sean, Coburn Natalie, Law Calvin, Mahar Alyson, Zhao Haoyu, Singh Simron, Zuk Victoria, Myrehaug Sten, Gupta Vaibhav, Levy Jordan, Hallet Julie
Department of Surgery, University of Toronto, Toronto, ON, Canada.
Cancer Program, Sunnybrook Research Institute, Toronto, ON, Canada.
Ann Surg. 2022 Nov 1;276(5):e450-e458. doi: 10.1097/SLA.0000000000004647. Epub 2020 Nov 18.
We examined the impact of upfront small bowel resection (USBR) for metastatic small bowel neuroendocrine (SB-NET) compared to nonoperative management (NOM) on long-term healthcare utilization and survival outcomes.
The role of early resection of the primary tumor in metastatic SB-NET remains controversial. Conflicting data exist regarding its clinical and survival benefits.
This is a population-based retrospective matched comparative cohort study of adults diagnosed with synchronous metastatic SB-NET between 2001 and 2017 in Ontario. USBR was defined as resection within 6 months of diagnosis. Primary outcomes were subsequent unplanned acute care admissions and small bowel-related surgery. Secondary outcome was overall survival. USBR and NOM patients were matched 2:1 using a propensity-score. We used time-to-event analyses with cumulative incidencefunctions and univariate Andersen-Gill regression for primary outcomes. E value methods assessed the potential for residual confounding.
Of 1000 patients identified, 785 had USBR. The matched cohort included 348 patients with USBR and 174 with NOM. Patients with USBR had lower 3-year risk of subsequent admissions (72.6% vs 86.4%, P < 0.001) than those with NOM, with hazard ratio 0.72 (95% confidence interval 0.570.91). USBR was associated with lower risk of subsequent small bowel-related surgery (15.4% vs 40.3%, P < 0.001), with hazard ratio 0.44 (95% confidence interval 0.29-0.67). E -values indicated it was unlikely that the observed risk estimates could be explained by an unmeasured confounder. Sensitivity analysis excluding emergent resections to define USBR did not alter the results.
USBR for SB-NETs in the presence of metastatic disease was associated with better patient-oriented outcomes of decreased subsequent admissions and interventions, compared to NOM. USBR should be considered for metastatic SB-NETs.
我们研究了与非手术治疗（NOM）相比， upfront小肠切除术（USBR）对转移性小肠神经内分泌肿瘤（SB-NET）患者长期医疗利用和生存结局的影响。
原发性肿瘤早期切除在转移性SB-NET中的作用仍存在争议。关于其临床和生存获益的数据相互矛盾。
这是一项基于人群的回顾性匹配比较队列研究，研究对象为2001年至2017年在安大略省被诊断为同步转移性SB-NET的成年人。USBR定义为诊断后6个月内进行的切除术。主要结局是随后的非计划性急性护理入院和小肠相关手术。次要结局是总生存期。USBR组和NOM组患者采用倾向评分进行2:1匹配。我们使用事件发生时间分析和累积发病率函数以及单变量Andersen-Gill回归分析主要结局。E值法评估了潜在的残余混杂因素。
在1000例确诊患者中，785例行USBR。匹配队列包括348例USBR患者和174例NOM患者。与NOM患者相比，USBR患者随后入院的3年风险更低（72.6%对86.4%，P<0.001），风险比为0.72（95%置信区间0.57-0.91）。USBR与随后小肠相关手术的风险较低相关（15.4%对40.3%，P<0.001），风险比为0.44（95%置信区间0.29-0.67）。E值表明观察到的风险估计不太可能由未测量的混杂因素解释。排除紧急切除以定义USBR的敏感性分析未改变结果。
与NOM相比，存在转移性疾病时对SB-NET进行USBR与更好的以患者为导向的结局相关，即随后的入院和干预减少。对于转移性SB-NET应考虑行USBR。
