Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience

Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association

BACKGROUNDS

A pancreatic fistula (PF) is the most relevant complication after a pancreaticoduodenectomy (PD). This retrospective multicentric study attempts to elucidate the risk factors and complications of a PF in a large cohort of patients undergoing a PD for ductal adenocarcinoma.

METHODS

Using a survey tool, clinical data of 1325 patients undergoing a PD for ductal adenocarcinoma at 37 institutions, between January 2004 and December 2009, were collected. Peri-operative risk factors associated with PF and its association with morbidity and mortality were assessed. Morbidity and PF were graded according to the ISGPF (International Study group for pancreatic fistula) definition and the Dindo-Clavien classification.

RESULTS

Overall PF, mortality, morbidity and relaparotomy rates were 14.3%, 3.8%, 54.4% and 11.7%, respectively. PF occurred more frequently after a pancreaticojejunostomy (PJ) compared with a pancreaticogastrostomy (PG) (16.8% vs. 10.4%; P = 0.0012). Independent risk factors for PF by multivariate analysis were absence of pre-operative diabetes (P = 0.0014), PJ reconstruction (P = 0.0035), soft pancreatic parenchyma (P < 0.0001) and low-volume centre (P = 0.0286). Clinically relevant PF (grade B and C) and severe complications (Dindo-Clavien grade IIIB, IV, V) were significantly more frequent after PJ than PG (71.6% vs. 28.3%; P = 0.030 and 24.8% vs. 19.1%; P = 0.015, respectively). Overall mortality and relaparotomy rates were similar after PG and PJ.

CONCLUSIONS

A soft pancreatic parenchyma, the absence of pre-operative diabetes, PJ and low-volume centre are independent risk factors for PF after PD for ductal adenocarcinoma. A significantly higher incidence and clinical severity of PF are associated with PJ.

Time trends in the treatment and prognosis of resectable pancreatic cancer in a large tertiary referral centre

OBJECTIVES

Mortality in pancreatic cancer has remained unchanged over the last 20-30 years. The aim of the present study was to analyse survival trends in a selected population of patients submitted to resection for pancreatic cancer at a single institution.

METHODS

Included were 544 patients who underwent pancreatectomy for pancreatic cancer between 1990 and 2009. Patients were categorized into two subgroups according to the decade in which resection was performed (1990-1999 and 2000-2009). Predictors of survival were analysed using univariate and multivariate analyses.

RESULTS

Totals of 114 (21%) and 430 (79%) resections were carried out during the periods 1990-1999 and 2000-2009, respectively (P < 0.0001). Hospital length of stay (16 days versus 10 days; P < 0.001) and postoperative mortality (3% versus 1%; P = 0.160) decreased over time. Median disease-specific survival significantly increased from 16 months in the first period to 29 months in the second period (P < 0.001). Following multivariate analysis, poorly differentiated tumour [hazard ratio (HR) 3.1, P < 0.001], lymph node metastases (HR = 1.9, P < 0.001), macroscopically positive margin (R2) resection (HR = 3.2, P < 0.0001), no adjuvant therapy (HR = 1.6, P < 0.001) and resection performed in the period 1990-1999 (HR = 2.18, P < 0.001) were significant independent predictors of a poor outcome.

CONCLUSIONS

Longterm survival after surgery for pancreatic cancer significantly improved over the period under study. Better patient selection and the routine use of adjuvant therapy may account for this improvement.

Quality of narrative operative reports in pancreatic surgery

BACKGROUND

Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy.

METHODS

We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness.

RESULTS

We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration.

CONCLUSION

The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care.

Clinical and economic consequences of pancreatic fistula after elective pancreatic resection

BACKGROUND

Postoperative pancreatic fistula is the main cause of morbidity after pancreatic resection. This study aimed to quantify the clinical and economic consequences of pancreatic fistula in a medium-volume pancreatic surgery center.

METHODS

Hospital records from patients who had undergone elective pancreatic resection in our department were identified. Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula (ISGPF). The consequences of pancreatic fistula were determined by treatment cost, hospital stay, and out-patient follow-up until the pancreatic fistula was completely healed. All costs of the treatment are calculated in Euros. The cost increase index was calculated for pancreatic fistula of grades A, B, and C as multiples of the total cost for the no fistula group.

RESULTS

In 54 months, 102 patients underwent elective pancreatic resections. Forty patients (39.2%) developed pancreatic fistula, and 54 patients (52.9%) had one or more complications. The median length of hospital stay for the no fistula, grades A, B, and C fistula groups was 12.5, 14, 20, and 59 days, respectively. The hospital stay of patients with fistula of grades B and C was significantly longer than that of patients with no fistula (P<0.001). The median total cost of the treatment was 4952, 4679, 8239, and 30 820 Euros in the no fistula, grades A, B, and C fistula groups, respectively.

CONCLUSIONS

The grading recommended by the ISGPF is useful for comparing the clinical severity of fistula and for analyzing the clinical and economic consequences of pancreatic fistula. Pancreatic fistula prolongs the hospital stay and increases the cost of treatment in proportion to the severity of the fistula.

Schematic pancreatic configuration: a risk assessment for postoperative pancreatic fistula after pancreaticoduodenectomy

INTRODUCTION

Postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). Preoperative risk assessment of POPF is desirable in careful preparation for operation. The aim of this study was to assess simple and accurate risk factors for clinically relevant POPF based on a schematic understanding of the pancreatic configuration using preoperative multidetector computed tomography.

METHODS

Three hundred and eighteen consecutive patients who underwent PD in the National Cancer Center Hospital East between November 2006 and March 2013 were investigated. Pre-, intra-, and postoperative clinicopathological findings as well as pancreatic configuration data were analyzed for the risk of clinically relevant POPF. POPF was defined according to the International Study Group of Pancreatic Fistula classification. POPF grade A occurred in 52 patients (16.4%), grade B in 84 (26.4%), and grade C in 6 (1.9%).

CONCLUSIONS

Independent risk factors for POPF grade B/C included main pancreatic duct diameter (MPDd) < 2 mm (P = 0.001), parenchymal thickness ≥ 8 mm (P = 0.018), not performing portal vein/superior mesenteric vein resection (P = 0.004), and amylase level of drainage fluid on postoperative day 3 ≥ 375 IU/L (P < 0.001). Pancreatic configuration data including MPDd and parenchymal thickness were good indicators of clinically relevant POPF.

The clinical impact of early complete pancreatic head devascularisation during pancreatoduodenectomy

BACKGROUND

Early inferior pancreaticoduodenal artery (IPDA) ligation reduces intraoperative blood loss during pancreatoduodenectomy, but the impact on oncologic and long-term outcomes remains unknown. The aim of this study was to review the impact of complete pancreatic head devascularization during pancreatoduodenectomy on blood loss, transfusion rates, and clinicopathologic outcomes.

METHODS

Clinicopathologic and outcome data were retrieved from a prospective database for all pancreatoduodenectomies performed from April 2004 to November 2010 and compared between early (IPDA+; n = 62) and late (IPDA-; n = 65) IPDA ligation groups.

RESULTS

Early IPDA ligation was associated with reduced blood loss (394 ± 21 vs 679 ± 24 ml, P < .001) and perioperative transfusion (P = .031). A trend toward improved R0 resection was seen in patients with pancreatic adenocarcinoma (IPDA+ vs IPDA-, 100% vs 82%; P = .059), but this did not translate to improved 2-year (IPDA+ vs IPDA-, 76% vs 65%; P = .426) or overall (P = .82) survival.

CONCLUSIONS

Early IPDA ligation reduces blood loss and transfusion requirements. Despite overall survival being unchanged, a trend toward improved R0 resection is encouraging and justifies further studies to ascertain the true oncologic significance of this technique.

Pre-operative prediction of pancreatic fistula: is it possible?

BACKGROUND/OBJECTIVES

Understanding a patient's risk of pancreatic fistula (PF) prior to pancreatoduodenectomy (PD) would permit an individualised approach to patient selection, consent and, potentially, treatment. Various intra and post operative factors including pancreatic duct width and steatosis are associated with PF. We sought to identify whether information available in the pre-operative phase can predict PF.

METHODS

Associations between patient characteristics, pre-operative blood test results, data from pre-operative CT imaging and PF were explored. Pancreatic density (Hounsfield units, Hu), pancreatic duct size and gland thickness were measured using CT imaging.

RESULTS

PF occurred in 42 of 155 cases (types A, B and C: 32, 8, 2 respectively). An inverse relationship between duct width and PF was observed. The odds ratio of PF, for each 1 mm increase in duct width, was 0.639 (95% CI = 0.531-0.769, p < 0.001). The gland thickness and density at the pancreatic resection margin were positively associated with PF (both p = 0.03). No patient variable was associated with PF.

CONCLUSIONS

Pancreatic duct width has previously been assessed at the time of operation and simply regarded as normal or wide. Consideration of duct width as a continuous variable using pre-operative CT imaging can be used to simply predict risk of PF. The association between pancreatic density and PF is a novel finding. Whether pancreatic density in Hu relates to steatosis, as it does for hepatic steatosis, merits further review given the association between pancreatic steatosis and PF.

Robotic versus open pancreatectomy: a systematic review and meta-analysis

BACKGROUND

Robotic surgery is gaining momentum with advantages for minimally invasive management of pancreatic diseases. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of robotic versus open pancreatectomy.

METHODS

A systematic review of the literature was performed to identify studies comparing robotic pancreatectomy and open pancreatectomy. Postoperative outcomes, intraoperative outcomes, and oncologic safety were evaluated. Meta-analysis was performed using a random-effect model.

RESULTS

Seven studies matched the selection criteria, including 137 (40 %) cases of robotic pancreatectomy and 203 (60 %) cases of open pancreatectomy. None of the included studies were randomized. Overall complication rate was significantly lower in robotic group [risk difference (RD) = -0.12, 95 % confidence interval (CI) -0.22 to -0.01, P = 0.03], as well as reoperation rate (RD = -0.12; CI -0.2 to -0.03, P = 0.006) and margin positivity (RD = -0.18; 95 % CI -0.3 to -0.06, P = 0.003). There was no significant difference in postoperative pancreatic fistula (POPF) incidence and mortality. The median (range) conversion rate was 10 % (0-12 %).

CONCLUSIONS

The results of this meta-analysis suggest that robotic pancreatectomy is as safe and efficient as, if not superior to, open surgery for patients with benign or malignant pancreatic diseases. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.

Malnutrition and pancreatic surgery: prevalence and outcomes

BACKGROUND

Pancreatic surgery is associated with severe postoperative morbidity. Identification of patients at high risk may provide a way to allocate resources objectively and focus care on those patients in greater need. The Authors evaluate the prevalence of malnutrition and its effect on the postoperative morbidity of patients undergoing pancreatic surgery for malignant tumors.

METHODS

Data were collected from 143 patients who had undergone pancreatic resection for cancer. Prevalence of malnutrition was evaluated by several validated screening tools and correlated to the incidence of surgical site infection, overall morbidity, mortality, and hospital stay.

RESULTS

Overall, 88% of patients were at medium-high risk of malnutrition. Patients at high risk of malnutrition presented a fourfold longer postoperative hospitalization period and a higher morbidity rate (53.2%) than those patients at low risk of malnutrition. Malnutrition, evaluated by MUST and NRI, was an independent predictor of overall morbidity using multivariate analysis (P = 0.00145, HR = 2.6581, 95% CI = 1.3589-8.5698, and P = 0.07129, HR = 1.9953, 95% CI = 0.9723-13.548, respectively).

CONCLUSION

Malnutrition is a relevant predictor of post-operative morbidity and mortality after pancreatic surgery. Patients underwent pancreatic resection for malignant tumors are usually malnourished. Preoperative malnutrition screening is mandatory in order to assess the risk and to treat the malnutrition.

Can pancreaticoduodenectomy performed at a comprehensive community cancer center have comparable results as major tertiary center?

BACKGROUND

Pancreatic resection is a definitive treatment modality for pancreatic neoplasm. Pancreaticoduodenectomy (PD) is the primary procedure for tumor arising from head of pancreas. Prognosis is overwhelmingly poor despite adequate resection. We maintained a prospective database covering years 2001 to 2010. Outcome data is analyzed and compared with those from tertiary centers.

METHODS

Sixty-two patients with various histology were included. Pylorus preserving pancreatico-duodenectomy (PPPD), classic pancreaticoduodenectomy, and subtotal pancreatectomy were procedures performed. Three patients had portal venorrhaphy performed to obtain clinically negative margin. Forty six patients had malignancy on final pathologic analysis.

RESULTS

The average age of patients was 63. Mean preoperative CA19-9 for exocrine pancreatic malignancies was higher than for more benign lesions. There was a decrease in operative time during this period. Blood transfusion was uncommon. There was very few pancreatic leak among the patients. Two bile leaks were identified, one controlled with the drainage tube and the other one required repeat surgery. The primary reason for the prolonged hospitalization was gastric ileus. For patients without a gastrostomy tube, nasogastric tube was kept in until gastric ileus resolved. 30 days mortality rate was calculated at 4.8. Mean survival time during our follow up was 30.6 months. Comparing to published literature, present series' mortality, morbidity, and survival are similar. Five year survival was 39%.

CONCLUSION

Despite overall poor outcome for patients with pancreatic and biliary malignancies, we conclude that surgery can be performed in community hospitals with special interest in treating pancreatic disorder, offering patients equivalent survival and quality of life as those operated in tertiary centers.

Impact of surgical volume on nationwide hospital mortality after pancreaticoduodenectomy

AIM: To evaluate the impact of surgical volume on nationwide hospital mortality after pancreaticoduodenectomy (PD) for periampullary tumors in South Korea.

METHODS: Periampullary cancer patients who underwent PD between 2005 and 2008 were analyzed from the database of the Health Insurance Review and Assessment Service of South Korea. A total of 126 hospitals were divided into 5 categories, each similar in terms of surgical volume for each category. We used hospital mortality as a quality indicator, which was defined as death during the hospital stay for PD, and calculated adjusted mortality through multivariate logistic models using several confounder variables.

RESULTS: A total of eligible 4975 patients were enrolled in this study. Average annual surgical volume of hospitals was markedly varied, ranging from 215 PDs in the very-high-volume hospital to < 10 PDs in the very-low-volume hospitals. Admission route, type of medical security, and type of operation were significantly different by surgical volume. The overall hospital mortality was 2.1% and the observed hospital mortality by surgical volume showed statistical difference. Surgical volume, age, and type of operation were independent risk factors for hospital death, and adjusted hospital mortality showed a similar difference between hospitals with observed mortality. The result of the Hosmer-Lemeshow test was 5.76 (P = 0.674), indicating an acceptable appropriateness of our regression model.

CONCLUSION: The higher-volume hospitals showed lower hospital mortality than the lower-volume hospitals after PD in South Korea, which were clarified through the nationwide database.

A modern approach to teaching pancreatic surgery: stepwise pancreatoduodenectomy for trainees

INTRODUCTION

Pancreatoduodenectomy (PD) has always been regarded as one of the most technically demanding abdominal procedures, even when carried out in high-volume centers by experienced surgeons. The reduction in higher surgical trainees working hours has led to reduced exposure, and consequently less experience in operative procedures. Furthermore, trainees have also become victims as health care systems striving for operating room efficiency, have attempted to reduce procedure duration by encouraging consultant led procedures at the expense of training. A strategy therefore needs to be developed to match the ability of the trainee with the complexity of the surgical procedure. As a PD can be deconstructed into a number of different steps, it may indeed be an ideal training operation for varying levels of ability.

METHODS

We describe our technique for PD and break it down to nine steps of varying technical ability making it suitable for many different stages of surgical training.

RESULTS

The complexity and variety of steps required to perform a PD makes it an ideal training operation from the junior surgical trainee to the most senior fellow, allowing the development of a wide range of skill sets.

DISCUSSION

Since the introduction of reduced working hours (48 h per week in Europe and 80 h per week in the USA) the "apprenticeship" model of surgical training has shifted towards a time-limited program with greater emphasis on supervision. Due to the complexity of surgery, and the perception of diminished levels of trainees' competency, a PD is often viewed as a consultant level operation. We believe that PD is an excellent model as it provides opportunities for trainees with varying levels of operative experience so that a PD could be considered the ideal "teaching case". Breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients' safety and allowing the surgery to be expedited in a timely manner.

Pancreatic enucleation: improved outcomes compared to resection

INTRODUCTION

Pancreatic enucleation is associated with a low operative mortality and preserved pancreatic parenchyma. However, enucleation is an uncommon operation, and good comparative data with resection are lacking. Therefore, the aim of this analysis was to compare the outcomes of pancreatic enucleation and resection.

MATERIAL AND METHODS

From 1998 through 2010, 45 consecutive patients with small (mean, 2.3 cm) pancreatic lesions underwent enucleation. These patients were matched with 90 patients undergoing pancreatoduodenectomy (n = 38) or distal pancreatectomy (n = 52). Serious morbidity was defined in accordance with the American College of Surgeons-National Surgical Quality Improvement Program. Outcomes were compared with standard statistical analyses.

RESULTS

Operative time was shorter (183 vs. 271 min, p < 0.01), and operative blood loss was significantly lower (160 vs. 691 ml, p < 0.01) with enucleation. Fewer patients undergoing enucleation required monitoring in an intensive care unit (20% vs. 41%, p < 0.02). Serious morbidity was less common among patients who underwent enucleation compared to those who had a resection (13% vs. 29%, p = 0.05). Pancreatic endocrine (4% vs. 17%, p = 0.05) and exocrine (2% vs. 17%, p < 0.05) insufficiency were less common with enucleation. Ten-year survival was no different between enucleation and resection.

CONCLUSION

Compared to resection, pancreatic enucleation is associated with improved operative as well as short- and long-term postoperative outcomes. For small benign and premalignant pancreatic lesions, enucleation should be considered the procedure of choice when technically appropriate.

A learning curve for living donor liver transplantation

BACKGROUND

The number of living donor liver transplantations performed has increased rapidly in many Eastern transplant centres. However, the impact of the transplant centres' experience and learning on the transplant outcomes are not well established. Aim of the study was to evaluate the learning curve for living donor liver transplantation in our centre.

METHODS

Data from 156 recipients and 156 donors who underwent surgery were reviewed. Intraoperative data and postoperative outcomes of both donors and recipients were retrospectively analysed. Recipients and donors were divided into three groups that consisted of 52 consecutive cases each.

RESULTS

Surgical duration and intraoperative blood loss during donor surgery were decreased significantly between the earlier and the more recent cases (423±39 vs. 400±44 min and 959±523 vs. 731±278 mL, respectively; P<0.01). Rates of postoperative complications and functional changes were not statistically different amongst the three donor groups. Immediate complication rate of the first 52 recipients was higher than those of the second and third cohorts. Long-term survival rates of the three recipient groups were similar.

CONCLUSIONS

The learning curve greatly influenced immediate outcomes of recipients during the early transplant period. However, it had little influence on donor outcome; long-term outcome improvement of recipients did not depend on the accumulation of experience alone.

The burden of infection for elective pancreatic resections

BACKGROUND

Infection control is potentially a critical quality indicator but remains incompletely understood, especially in high-acuity gastrointestinal surgery. Our objective was to evaluate the incidence and impact of infections after elective pancreatectomy at the practice level.

METHODS

All pancreatectomies performed by three pancreatic surgical specialists over an 8-year period (2001-2009) followed standardized perioperative care, including timely antibiotic administration. Infections were defined according to National Surgery Quality Improvement Program criteria, while complication severity was based on Clavien grade. Clinical and economic outcomes were evaluated and predictors of infection identified by regression analysis.

RESULTS

Of 550 major pancreatic resections, 288 (53%) had some complication, of which 167 (31%) were infectious. Rates of infection differed by type of resection (proximal pancreatectomy > others; P = .029) but not by presence of malignancy. Major infections (Clavien 3-5; n = 62), occurred in 11% of cases. Infection was not the primary cause of death in any patient. Infection was associated with increases in hospital stay, operative times, transfusions, blood loss, intensive care unit use, and readmission (34% vs 12%). Types of infection were as follows: wound infection (14%), infected pancreatic fistula (9%), urinary tract infection (7%), pneumonia (6%), and sepsis (2%). The use of total parenteral nutrition (odds ratio [OR], 7.3), coronary artery disease (OR, 2.1), and perioperative hypotension (OR, 1.6) predicted any infection. Total costs for cases with infection increased grade-for-grade across the Clavien scale, with infection accounting for 38% of the overall cost differential.

CONCLUSION

Infectious complications occurred frequently, compromising numerous outcomes and increasing costs markedly. These data provide a foundation for understanding the baseline consequences of infection in high-acuity gastrointestinal surgery and offer opportunities for process evaluation and initiatives in infection control at the practice level.

Robotic versus open pancreaticoduodenectomy: a comparative study at a single institution

BACKGROUND

Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures, and its application is poorly reported in the literature so far. To date, few data are available comparing a minimally invasive approach to open PD. The aim of the present study is to compare the robotic and open approaches for PD at a single institution.

METHODS

Data from 83 consecutive PD procedures performed between January 2002 and May 2010 at a single institution were retrospectively reviewed. Patients were stratified into two groups: the open group (n = 39; 47%) and the robotic group (n = 44; 53%).

RESULTS

Patients in the robotic group were statistically older (63 years of age versus 56 years; p = 0.04) and heavier (body mass index: 27.7 vs. 24.8; p = 0.01); and had a higher American Society of Anesthesiologists (ASA) score (2.5 vs. 2.15; p = 0.01) when compared to the open group. Indications for surgery were the same in both groups. The robotic group had a significantly shorter operative time (444 vs. 559 min; p = 0.0001), reduced blood loss (387 vs. 827 ml; p = 0.0001), and a higher number of lymph nodes harvested (16.8 vs. 11; p = 0.02) compared to the open group. There was no significant difference between the two groups in terms of complication rates, mortality rates, and hospital stay.

CONCLUSIONS

The authors present one of the first studies comparing open and robotic PD. While it is too early to draw definitive conclusions concerning the long-term outcomes, short-term results show a positive trend in favor of the robotic approach without compromising the oncological principles associated with the open approach.

Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital

BACKGROUND

Despite the close relationship between hospital volume and mortality after pancreaticoduodenectomy (PD), the role of surgeon volume still remains an open issue. Retrospective multi-institutional reviews considered only in-hospital mortality, whereas no data about major complications are available so far. The aim of this study is to assess the independent impact of surgeon volume on outcome after PD in a single high-volume institution.

METHODS

Demographics and clinical and surgical variables were prospectively collected on 610 patients who underwent PD from August 2001 to August 2009. The cutoff value to categorize high- and low-volume surgeons (HVS and LVS, respectively) was 12 PD/year. The primary endpoint was operative mortality (death within 30-day post-discharge). Secondary endpoints were morbidity, pancreatic fistula (PF), and length of hospital stay (LOS).

RESULTS

In the whole series, mortality was 4.1%, overall morbidity was 61.3%, and PF rate was 27.5%. Two HVS performed 358 PD (58.6%), while six LVS performed 252 PD (41.4%). Mortality was 3.9% for HVS and 4.3% for LVS (p=0.84). The major complication rate was similar for HVS and LVS (14.5% vs. 16.2%). The PF rate was higher for LVS (32.4% vs. 24.1%, p=0.03). The mean LOS was 15.5 days for HVS vs. 16.9 days for LVS (p=0.11). At multivariate analysis, risk factors for PF occurrence were LVS, soft pancreatic stump, small duct diameter, and longer operative time.

CONCLUSION

Low-volume surgeons had a higher PF rate. However, this did not increase mortality and major morbidity rates probably because of the protective effect of high-volume hospital in improving patient rescue from life-threatening complications.

Surgical Apgar score predicts perioperative morbidity in patients undergoing pancreaticoduodenectomy at a high-volume center

OBJECTIVES

Pancreaticoduodenectomy (PD) remains a procedure that carries considerable morbidity. Numerous studies have evaluated factors to predict patients at risk. The aim of this study was to determine whether the surgical Apgar score (SAS) predicts perioperative morbidity and mortality.

METHODS

We examined 553 patients undergoing successful PD between January 2000 and December 2010. Postoperative complications were graded using the Clavien scale, and the SAS (range, 0-10) was determined. The Cochran-Armitage test for trend was used to determine the association between grouped SAS scores (0-2, 3-4, 5-6, 7-8, and 9-10) and each of the outcomes.

RESULTS

The average patient age was 64 years, and there was an even distribution of males and females. There were 11 perioperative deaths (2%), 186 grade 2 or higher complications (34%), and 86 major complications (grades 3-5, 16%). Additionally, 61 patients developed pancreatic fistulae (11%). Statistical analysis determined that SAS was a significant predictor of grade 2 or higher complications (p < 0.0001), major morbidity (p = 0.01), and pancreatic fistula (p = 0.04) but not mortality (p = 0.20).

CONCLUSIONS

We demonstrate that the SAS is a significant predictor of perioperative morbidity for patients undergoing PD. This score should be used to identify patients at higher risk in order to prioritize use of postoperative critical care beds and hospital resources.

Hospital Volume, Margin Status, and Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers ( P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively ( P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.

Factors influencing blood loss and allogeneic blood transfusion practice in craniosynostosis surgery

OBJECTIVE/AIMS

To identify factors influencing perioperative blood loss and transfusion practice in craniosynostotic corrections.

BACKGROUND

Craniosynostotic corrections are associated with large amounts of blood loss and high transfusion rates.

METHODS

A retrospective analysis was performed of all pediatric craniosynostotic corrections during the period from January 2003 to October 2009. The primary endpoint was the receipt of an allogeneic blood transfusion (ABT) during or after surgery. Pre-, intra-, and postoperative data were acquired using the electronic hospital registration systems and patients' charts.

RESULTS

Forty-four patients were operated using open surgical techniques. The mean estimated blood loss during surgery was 55 ml·kg(-1). In 42 patients, red blood cells were administered during or after surgery with a mean of 38 ml·kg(-1). In 23 patients, fresh frozen plasma was administered with a mean of 28 ml·kg(-1). A median of two different donors per recipient was found. Longer duration of surgery and lower bodyweight were associated with significantly more blood loss and red blood cell transfusions. Higher perioperative blood loss and surgery at an early age were correlated with a longer duration of admission.

CONCLUSIONS

In this study, craniosynostotic corrections were associated with large amounts of blood loss and high ABT rates. The amount of ABT could possibly be reduced by appointing a dedicated team of physicians, by using new less-invasive surgical techniques, and by adjusting anesthetic techniques.

Therapeutic management of hemorrhage from visceral artery pseudoaneurysms after pancreatic surgery

INTRODUCTION

Hemorrhage from pseudoaneurysms after pancreatic surgery is a rare but life-threatening and complicated complication. The study presents our experience to provide therapeutic management for this rare condition.

METHODS

Between February 1994 and January 2011, 35 patients experienced hemorrhage from pseudoaneurysms in our hospital. Medical data of this rare complication were analyzed retrospectively.

RESULTS

The prevalence of hemorrhage from pseudoaneurysms was 3.2% (35/1,102). Sixteen patients (45.7%) experienced sentinel bleeding. Pancreatic fistula (74.3%) and intra-abdominal abscess (57.1%) were two common complications prior to hemorrhage. Of 35 patients, 20 underwent endovascular intervention, 14 received surgical re-laparotomy, and bleeding stopped spontaneously in one. The overall mortality rate was 22.9%. Technical success rate of endovascular treatment was 87%. There were significant differences in the mortality rate (10.0% vs 42.9%), operation time (72.8 vs 123.9 min), estimated blood loss (1,835 vs 3,000 ml), and intensive care unit stay (3.6 vs 8.6 days) between endovascular and surgical treatment. Mean follow-up was 19.2 ± 17.0 (range, 5-63 months).

CONCLUSION

Endovascular intervention represents the first-line treatment for hemorrhage from pseudoaneurysms after pancreatic surgery. Endovascular embolization or stent-graft placement should be selected individually depending on the involved artery and its vascular anatomy.

Complications after pancreaticoduodenectomy for pancreatic cancer: a retrospective study

Postoperative complications, such as pancreatic fistulae, after pancreaticoduodenectomy for pancreatic cancers are associated with surgical outcomes of patients with pancreatic cancers. A total of 160 patients with pancreatic cancers undergoing pancreaticoduodenectomy were retrospectively analyzed. Patients were grouped into a fistulae group (n = 34) and a nonfistulae group (n = 126). The fistulae group had a significantly higher morbidity rate than the nonfistulae group (P < 0.0001), but hospital mortality was not different in both groups (P = 0.481). There was a higher incidence of intra-abdominal hemorrhage in patients with pancreatic fistulae than in those without fistulae. Two patients in fistulae group underwent reoperation. Patients with pancreatic fistulae had significantly longer hospital stay than those without fistulae. Pancreatic duct diameter, smoking, years of tobaccos consumption, preoperative jaundice, and surgical hours were associated with risk of fistulae on univariate analysis. In a multivariate analysis, diameter of pancreatic duct, surgical hours, and preoperative jaundice were independent risk factors of pancreatic fistulae. Incidence of pancreatic fistulae after pancreaticoduodenectomy is significantly influenced by the size of pancreatic duct diameter, surgical time, and preoperative jaundice. Early postoperative hemorrhage could be cautiously prevented. The survival is not significantly impacted by pancreatic fistulae.

Robotic technologies in surgical oncology training and practice

The modern-day surgeon is frequently exposed to new technologies and instrumentation. Robotic surgery (RS) has evolved as a minimally invasive technique aimed to improve clinical outcomes. RS has the potential to alleviate the inherent limitations of laparoscopic surgery such as two dimensional imaging, limited instrument movement and intrinsic human tremor. Since the first reported robot-assisted surgical procedure performed in 1985, the technology has dramatically evolved and currently multiple surgical specialties have incorporated RS into their daily clinical armamentarium. With this exponential growth, it should not come as a surprise the ever growing requirement for surgeons trained in RS as well as the interest from residents to receive robotic exposure during their training. For this reason, the establishment of set criteria for adequate and standardized training and credentialing of surgical residents, fellows and those trained surgeons wishing to perform RS has become a priority. In this rapidly evolving field, we herein review the past, present and future of robotic technologies and its penetration into different surgical specialties.

Current surgical aspects of palliative treatment for unresectable pancreatic cancer

Despite all improvements in both surgical and other conservative therapies, pancreatic cancer is steadily associated with a poor overall prognosis and remains a major cause of cancer mortality. Radical surgical resection has been established as the best chance these patients have for long-term survival. However, in most cases the disease has reached an incurable state at the time of diagnosis, mainly due to the silent clinical course at its early stages. The role of palliative surgery in locally advanced pancreatic cancer mainly involves patients who are found unresectable during open surgical exploration and consists of combined biliary and duodenal bypass procedures. Chemical splanchnicectomy is another modality that should also be applied intraoperatively with good results. There are no randomized controlled trials evaluating the outcomes of palliative pancreatic resection. Nevertheless, data from retrospective reports suggest that this practice, compared with bypass procedures, may lead to improved survival without increasing perioperative morbidity and mortality. All efforts at developing a more effective treatment for unresectable pancreatic cancer have been directed towards neoadjuvant and targeted therapies. The scenario of downstaging tumors in anticipation of a future oncological surgical resection has been advocated by trials combining gemcitabine with radiation therapy or with the tyrosine kinase inhibitor erlotinib, with promising early results.

Side-branch intraductal papillary mucinous neoplasms of the pancreatic head/uncinate: resection or enucleation?

INTRODUCTION

Side-branch intraductal papillary mucinous neoplasms (IPMN) of the pancreatic head/uncinate are an increasingly common indication for pancreaticoduodenectomy (PD). However, enucleation (EN) may be an alternative to PD in selected patients to improve outcomes and preserve pancreatic parenchyma.

AIM

To determine peri-operative outcomes in patients with side-branch IPMN of the pancreatic head/uncinate undergoing EN or PD compared with a cohort of patients with pancreatic adenocarcinoma (PA) undergoing PD.

METHODS

Retrospective review of a prospectively collected, combined, academic institutional series from 2005 to 2008. Of 107 pancreatic head/uncinate IPMN, enucleation was performed in 7 (IPMN EN) and PD was performed in 100 (IPMN PD) with 17 of these radiographically amenable to EN (IPMN PD(en) ). During the same time period, 281 patients underwent PD for PA (Control PD).

RESULTS

Operative time was shorter (p<0.05) and blood loss (p<0.05) was less in the IPMN EN group compared with all other groups. Peri-operative mortality and morbidity of all IPMN groups (IPMN EN, IPMN PD(en) ) were similar to the Control PD group. Overall pancreatic fistulae rate in the IPMN EN group was higher than in the IPMN PD(en) and Control PD groups; however, the rate of grade C pancreatic fistulae was the same in all groups.

CONCLUSIONS

Pancreaticoduodenectomy for side-branch IPMNs can be performed safely. Compared with PD, enucleation for IPMN has less blood loss, shorter operative time and similar morbidity, mortality, hospital length of stay (LOS) and readmission rate. Enucleation should be considered more frequently as an option for patients with unifocal side-branch IPMN.

Nationwide survey and establishment of a clinical database for gastrointestinal surgery in Japan: Targeting integration of a cancer registration system and improving the outcome of cancer treatment

As there was no nationwide database for gastrointestinal surgery in Japan at the time, in 2006, a Clinical Database Committee was established in the Japanese Society of Gastrointestinal Surgery (JSGS) to create a clinical database in Japan. The Committee first organized preliminary nationwide Japanese surveys in gastrointestinal surgery in 2006 and 2007. Data from more than 770,000 patients were accumulated from these web-based surveys, including 333,627 patients in 1039 institutions in 2006 and 440,230 patients in 1464 institutions in 2007. The mortality rate was stratified by organ, surgical procedure and hospital volume without using risk-adjustment techniques. The overall mortality rate was 0.95% in the 2006 survey and 0.92% in the 2007 survey. The organ-based analysis found that the mortality rates were almost similar in 2006 and 2007. Hospital volume influenced the mortality rate in six major surgical procedures, namely esophagectomy, gastrectomy, total gastrectomy, low anterior rectal resection, hepatic resection and pancreaticoduodenectomy. A risk reduction of 30-80% was noted in each surgical procedure, at least in our non-risk-adjusted analysis, in hospitals with a high volume of operations. These preliminary surveys indicate that hospital volume might influence the mortality rate after major abdominal surgery. Further analysis using risk-adjustment techniques should be conducted to understand the specific contribution of hospital volume to surgical mortality. A nationwide database of patients who have undergone gastrointestinal surgery and risk-adjustment analysis of the data are currently planned in Japan.