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Hernandez-Barco YG, Fernandez-Del Castillo C, Fradelos E, Matos Ruiz PM, Bazerbachi F, Dhandibhotla S, Lillemoe KD, Casey BW, Kambadakone A, Qadan M. The multidisciplinary pancreatic cyst clinic: A collaborative approach to streamlined management. Pancreatology 2024; 24:764-770. [PMID: 38796308 DOI: 10.1016/j.pan.2024.05.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Pancreatic cysts are often incidentally detected on routine imaging studies. Of these, mucinous cysts have a malignant potential. Several guidelines propose different management strategies, and implementation in patient care is inconsistent in the absence of dedicated infrastructure. METHODS To address the challenges of pancreatic cyst diagnosis and management, we established a multidisciplinary pancreas cyst clinic (PCC) within our health system. This clinic encompasses both tertiary care academic centers and community hospitals, with leadership from surgical oncology, gastroenterology, and radiology. Our PCC's primary goal is to provide accurate diagnosis and tailored management recommendations for all patients with pancreatic cysts. Additionally, we maintain a prospective database to study the disease's natural history and the outcomes of various treatment strategies. CLINIC INFRASTRUCTURE The clinic meets once per week for 45 min virtually via Zoom in the mornings. Patients are referred via electronic medical record (EMR) order, telephone call, or email from patient or referring provider. A dedicated advanced practice provider reviews referrals several times per day, calls patients to gather clinical data, ensures imaging is uploaded, and coordinates logistical aspects of the meeting during the dedicated time. Conferences are attended by representatives from surgery, radiology, medical pancreatology, and interventional gastroenterology. Each patient case is reviewed in detail and recommendations are submitted to referring providers and patients via an EMR message and letter. For patients requiring imaging surveillance, patients are followed longitudinally by the referring provider, gastroenterology team, or surgical team. For patients requiring endoscopic ultrasound (EUS) or surgical consultation, expedited referral to these services is made with prompt subsequent evaluation. RESULTS A total of 1052 patients from our health system were evaluated between 2020 and 2021. Of these, 196 (18.6 %) underwent EUS, 41 (3.9 %) underwent upfront surgical resection, and the remainder were referred to gastroenterology (141-13.4 %), surgery (314-29.8 %), or back to their referring provider (597-56.7 %) for ongoing surveillance in collaboration with their primary care provider (PCP). Of cysts under surveillance, 61.3 % remained stable, 13.2 % increased in size, and 2 % decreased in size. A total of 2.3 % of patients were recommended to discontinue surveillance. CONCLUSIONS The PCC provides infrastructure that has served to provide multidisciplinary review and consensus recommendations to patients with pancreatic cysts. This has served to improve the application of guidelines while providing individualized recommendations to each patient, while aiding non-expert referring providers throughout the region.
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Affiliation(s)
- Yasmin G Hernandez-Barco
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Evangelos Fradelos
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy, St. Cloud Hospital, St. Cloud, MN, USA
| | - Sarvani Dhandibhotla
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Brenna W Casey
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Motaz Qadan
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Padula D, Mauro A, Maggioni P, Kurihara H, Di Sabatino A, Anderloni A. Practical approach to acute pancreatitis: from diagnosis to the management of complications. Intern Emerg Med 2024:10.1007/s11739-024-03666-9. [PMID: 38850357 DOI: 10.1007/s11739-024-03666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.
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Affiliation(s)
- Donatella Padula
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy.
| | - Paolo Maggioni
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università Degli Studi Di Milano, Milan, Italy
| | - Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy
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Zhang C, Gudmundsdottir H, Takahashi H, Day C, Glasgow A, Wasif N, Starlinger P, Warner S, Grotz T, Smoot R, Truty M, Cleary S, Kendrick M, Nagorney D, Navin P, Halfdanarson TR, Thiels C. Accuracy of DOTATATE PET imaging in the preoperative planning of small bowel neuroendocrine tumor resection. J Surg Oncol 2023; 128:1072-1079. [PMID: 37529970 DOI: 10.1002/jso.27413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND AND OBJECTIVES We assessed the accuracy of preoperative gallium-68 DOTA-Tyr3-octreotate (DOTATATE) positron emission tomography (PET) imaging in estimating multifocality and nodal metastases of small bowel neuroendocrine tumors (sbNETs). METHODS A multicenter analysis was performed on patients with sbNETs who underwent preoperative DOTATATE PET imaging and surgical resection, with manual palpation of the entire length of the small bowel, between January 2016 and August 2022. Preoperative imaging reports and blinded secondary imaging reviews were compared to the final postoperative pathology reports. Descriptive statistics were applied. RESULTS One-hundred and four patients met inclusion criteria. Pathology showed 53 (51%) patients had multifocal sbNETs and 96 (92%) had nodal metastases. The original preoperative DOTATATE PET imaging identified multifocal sbNET in 28 (27%) patients and lymph node (LN) metastases in 80 (77%) patients. Based on original radiology reports, sensitivity for multifocal sbNET identification was 45%, specificity was 92%, positive predictive value (PPV) was 86%, and negative predictive value (NPV) was 62%. For the identification of LN metastases, sensitivity was 82%, specificity was 88%, PPV was 99%, and NPV was 29%. CONCLUSIONS Although DOTATATE PET imaging is specific and relatively accurate, sensitivity and NPV are insufficient to guide surgical planning. Preoperative use should not replace open palpation to identify additional synchronous lesions or to omit regional lymphadenectomy.
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Affiliation(s)
- Chi Zhang
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Hallbera Gudmundsdottir
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Courtney Day
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Amy Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
| | - Nabil Wasif
- Department of Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Susanne Warner
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Travis Grotz
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rory Smoot
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David Nagorney
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick Navin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Cornelius Thiels
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Seo Y, Min JH, Kim SH, Kim YK, Kim H, Cha DI, Lee JH, Heo JS, Han IW, Shin SH, Kim H, Yoon SJ, Choi SY. The role of subspecialized radiologist reviews in preoperative conference for hepato-pancreato-biliary disease. Eur J Radiol 2023; 169:111183. [PMID: 37944332 DOI: 10.1016/j.ejrad.2023.111183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/10/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE To identify the role of subspecialized radiologists in preoperative conferences of radiologists and surgeons in the management of hepato-pancreato-biliary (HPB) diseases. METHODS We retrospectively evaluated the prospective data of 247 patients (mean age, 63.8 years; 173 men) who were referred for preoperative conferences (n = 258; 11 were discussed twice) for HPB disease between September 2021 and April 2022. Before each preoperative conference, subspecialized radiologists reviewed all available imaging studies and treatment plan information. After each conference, any change to the treatment plan was documented (major, minor, or none). Additional information provided by the radiologists was collected (significant, supplementary, or none). Uni- and multivariable analyses were performed to determine factors that resulted in a major change to the treatment plan. RESULTS Of the 258 reviewed cases, a major change was made to the treatment plan in 26 cases (10.1 %) and a minor change in 41 (15.9 %). Significant information was provided in 27 cases (10.5 %) and supplementary information in 72 (27.9 %). In the multivariable analysis, additional information about local tumor extent (odds ratio [OR], 6.3; 95 % confidence interval [CI], 2.1-19.5; p = 0.001) and distant metastasis detection (OR, 33.2; 95 % CI, 5.1-216.6; p < 0.001) was significantly associated with a major change. CONCLUSION The involvement of subspecialized radiologists in preoperative conferences resulted in major treatment plan changes in 10.1 % of the cases, primarily associated with the added information about local tumor extent and distant metastasis.
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Affiliation(s)
- Yujin Seo
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Hye Min
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Seong Hyun Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Kon Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Honsoul Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Ik Cha
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hyun Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Jeong Yoon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seo-Youn Choi
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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Al-Moussally F, Fogel EL, Helft PR. An ethical analysis of endoscopic therapy decision-making in patients with refractory substance use disorder and chronic pancreatitis. Pancreatology 2022; 22:671-677. [PMID: 35691886 PMCID: PMC10118247 DOI: 10.1016/j.pan.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 05/15/2022] [Accepted: 05/30/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Feras Al-Moussally
- Indiana University School of Medicine, United States; Charles Warren Fairbanks Center of Medical Ethics, Indiana University Health, United States
| | - Evan L Fogel
- Indiana University School of Medicine, United States; Lehman, Bucksot and Sherman Section of Pancreatobiliary Endoscopy, United States
| | - Paul R Helft
- Indiana University School of Medicine, United States; Charles Warren Fairbanks Center of Medical Ethics, Indiana University Health, United States.
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Prospective Analysis of Radiology Resource Utilization and Outcomes for Participation in Oncology Multidisciplinary Conferences. Acad Radiol 2021; 28:1219-1224. [PMID: 32622744 PMCID: PMC7328639 DOI: 10.1016/j.acra.2020.05.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
RATIONALE AND OBJECTIVES Radiology participation is necessary in oncology multidisciplinary conferences (MDCs), but the resources required to do so are often unaccounted for. In this prospective study we provide an analysis of resource utilization as a function of outcomes for all MDCs covered by an entire radiology section and provide a time-based cost estimate. MATERIALS AND METHODS Following institutional review board approval, prospective data on all MDCs covered by abdominal radiologists at a single tertiary care academic center were obtained over nine weeks. A predefined questionnaire was used by a single observer who attended every imaging review and recorded the total time spent by the radiologists and several outcome measures. The total time recorded was used to provide a time-based cost estimate using a national salary survey. RESULTS Six radiologists participated in a total of 57 MDCs, with 577 cases reviewed and discussed. 181 (31%) cases were performed at outside facilities requiring full reinterpretation. Clinically significant revisions to original reports were recorded in 107 (18.5%) cases. Radiologist input directly resulted in alteration of cancer staging in 65 (11%) patients and specific recommendations for follow-up diagnostic workup in 280 (48%) of cases. The mean total time devoted by the staff radiologist per week to MDCs was 18.7 hours/week, nearly a half of full-time effort, or 8% of total effort per radiologist. The total annual projected cost of radiology coverage for each weekly MDC was $26,920. CONCLUSION Section-wide radiologist participation in MDCs directly resulted in change in clinical management in nearly half of reviewed cases. This was achieved at a notable time cost, highlighting the need for efficient integration of radiology MDC participation into radiologist workflow and compensation models.
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Chung R, Rosenkrantz AB, Shanbhogue KP. Expert radiologist review at a hepatobiliary multidisciplinary tumor board: impact on patient management. Abdom Radiol (NY) 2020; 45:3800-3808. [PMID: 32444889 DOI: 10.1007/s00261-020-02587-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To identify the frequency, source, and management impact of discrepancies between the initial radiology report and expert reinterpretation occurring in the context of a hepatobiliary multidisciplinary tumor board (MTB). METHODS This retrospective study included 974 consecutive patients discussed at a weekly MTB at a large tertiary care academic medical center over a 2-year period. A single radiologist with dedicated hepatobiliary imaging expertise attended all conferences to review and discuss the relevant liver imaging and rated the concordance between original and re-reads based on RADPEER scoring criteria. Impact on management was based on the conference discussion and reflected changes in follow-up imaging, recommendations for biopsy/surgery, or liver transplant eligibility. RESULTS Image reinterpretation was discordant with the initial report in 19.9% (194/974) of cases (59.8%, 34.5%, 5.7% RADPEER 2/3/4 discrepancies, respectively). A change in LI-RADS category occurred in 59.8% of discrepancies. Most common causes of discordance included re-classification of a lesion as benign rather than malignant (16.0%) and missed tumor recurrence (13.9%). Impact on management occurred in 99.0% of discordant cases and included loco-regional therapy instead of follow-up imaging (19.1%), follow-up imaging instead of treatment (17.5%), and avoidance of biopsy (12.4%). 11.3% received OPTN exception scores due to the revised interpretation, and 8.8% were excluded from listing for orthotopic liver transplant. CONCLUSION Even in a sub-specialized abdominal imaging academic practice, expert radiologist review in the MTB setting identified discordant interpretations and impacted management in a substantial fraction of patients, potentially impacting transplant allocation. The findings may impact how abdominal imaging sections best staff advanced MTBs.
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Affiliation(s)
- Ryan Chung
- Department of Radiology, NYU Langone Health, 660 First Ave, New York, NY, 10016, USA
| | - Andrew B Rosenkrantz
- Department of Radiology, NYU Langone Health, 660 First Ave, New York, NY, 10016, USA
| | - Krishna P Shanbhogue
- Department of Radiology, NYU Langone Health, 660 First Ave, New York, NY, 10016, USA.
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Abstract
Multidisciplinary collaboration (MDC) has been widely adopted in healthcare to optimize patient care. MDC brings several specialized healthcare providers to the table using several methods, including multidisciplinary meetings (MDMs), multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels, to reach the goal of achieving the best diagnosis and treatment plan for complex diseases. Diagnosis and management of acute/chronic pancreatitis is complex which necessitates the development and utilization of MDC. The key members of pancreatitis MDM include gastroenterologists, radiologists, pathologists, hepatobiliary surgeons, chairperson, and a coordinator. After selection of admitted or referred patients, the availability of required information is reviewed, and then each case is discussed. The final diagnosis and treatment plan is confirmed by consensus, especially for complex cases that require endoscopic intervention or pancreatectomy and patients with the possibility of pancreatic adenocarcinoma. It has been shown that MDMs have improved the clinical outcome of patients with acute/chronic pancreatitis. In addition to MDM, the feasibility of multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels for the management of pancreatic disorders has been investigated. Understanding structure, potential advantages, and limitations of MDC will help clinicians and healthcare systems in developing an optimized MDC to improve the management of acute/chronic pancreatitis. This narrative review summarized prior recommendations and explored the impact of MDC on clinical outcomes of patients with pancreatitis. Our recommendations offer a generalizable method that can be utilized by healthcare systems.
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