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Ukegjini K, Müller PC, Warschkow R, Tarantino I, Jonas JP, Oberkofler CE, Petrowsky H, Schmied BM, Steffen T. Discharge C-reactive protein predicts 90-day readmission after pancreatoduodenectomy: a conditional inference tree analysis. HPB (Oxford) 2024:S1365-182X(24)02229-9. [PMID: 39164121 DOI: 10.1016/j.hpb.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/14/2024] [Accepted: 08/02/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND The aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD). METHODS A two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission. RESULTS Of 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55-0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%-95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60-0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003). CONCLUSION CRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort. TRIAL REGISTRATION Our retrospective analysis did not require registration with a publicly accessible registry.
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Affiliation(s)
- Kristjan Ukegjini
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland.
| | - Philip C Müller
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland; Department of Surgery, Clarunis - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, CH-4002 Basel, Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
| | - Ignazio Tarantino
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
| | - Jan P Jonas
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Christian E Oberkofler
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland; Vivévis AG - Visceral, Tumour and Robotic Surgery, Clinic Hirslanden Zurich, Witellikerstrasse 40, CH-8032 Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
| | - Thomas Steffen
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
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Sahakyan MA, Kleive D, Dille-Amdam RG, Kjeseth T, Waardal K, Edwin B, Nymo LS, Lassen K. The Role of Preoperative Inflammatory Markers in Pancreatectomy: a Norwegian Nationwide Cohort Study. J Gastrointest Surg 2023; 27:1650-1659. [PMID: 37322265 PMCID: PMC10412490 DOI: 10.1007/s11605-023-05726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/27/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND PURPOSE Preoperative inflammatory markers, such as Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio, were shown to be associated with prognosis in patients undergoing pancreatectomy for cancer. However, little is known about their predictive role in a Western population. METHODS The Norwegian National Registry for Gastrointestinal Surgery (NORGAST) was used to capture all pancreatectomies performed within the study period (November 2015-April 2021). The association between the preoperative inflammatory markers and postoperative outcomes was studied. Their impact on survival was examined in patients operated for pancreatic ductal adenocarcinoma. RESULTS A total of 1554 patients underwent pancreatectomy in this period. Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio were associated with severe complications (Accordion grade ≥ III) in the univariable but not in the multivariable analysis. C-reactive protein to albumin ratio, but not Glasgow prognostic score and modified Glasgow prognostic score, was linked to survival following pancreatectomy for ductal adenocarcinoma. In the multivariable model, age, neoadjuvant chemotherapy, ECOG score, C-reactive protein to albumin ratio and total pancreatectomy correlated with survival. Also, preoperative C-reactive protein to albumin ratio was significantly associated with survival after pancreatoduodenectomy. CONCLUSIONS Preoperative Glasgow prognostic score, modified Glasgow prognostic score and C-reactive protein to albumin ratio have no role in predicting the complications after pancreatectomy. C-reactive protein to albumin ratio is a significant predictor for survival in ductal adenocarcinoma, yet its clinical relevance should be explored in conjunction with the pathology parameters and adjuvant therapy.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Dyre Kleive
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Rachel G Dille-Amdam
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Trond Kjeseth
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kim Waardal
- Department of Acute and Digestive Surgery, Haukeland University Hospital, Bergen, Norway
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT, the Arctic University of Norway, Tromsø, Norway
| | - Kristoffer Lassen
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, UiT, the Arctic University of Norway, Tromsø, Norway
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Sahakyan MA, Tholfsen T, Kleive D, Yaqub S, Kazaryan AM, Buanes T, Røsok BI, Labori KJ, Edwin B. Laparoscopic Distal Pancreatectomy Following Prior Upper Abdominal Surgery (Pancreatectomy and Prior Surgery). J Gastrointest Surg 2021; 25:1787-1794. [PMID: 33170476 PMCID: PMC8275495 DOI: 10.1007/s11605-020-04858-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/31/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Previous abdominal surgery can be a risk factor for perioperative complications in patients undergoing laparoscopic procedures. Today, distal pancreatectomy is increasingly performed laparoscopically. This study investigates the consequences of prior upper abdominal surgery (PUAS) for laparoscopic distal pancreatectomy (LDP). METHODS Patients who had undergone LDP from April 1997 to January 2020 were included. Based on the history and type of PUAS, these were categorized into three groups: minimally invasive (I), open (II), and no PUAS (III). To reduce possible confounding factors, the groups were matched in 1:2:4 fashion based on age, sex, body mass index (BMI) and American Society of Anesthesiology grade. RESULTS After matching, 30, 60, and 120 patients were included in the minimally invasive, open and no PUAS groups, respectively. No statistically significant differences were found in terms of intraoperative outcomes. Postoperative morbidity, mortality and length of hospital stay were similar. Open PUAS was associated with higher Comprehensive Complication Index (33.7 vs 20.9 vs 26.2, p = 0.03) and greater proportion of patients with ≥ 2 complications (16.7 vs 0 vs 6.7%, p = 0.02) compared with minimally invasive and no PUAS. Male sex, overweight (BMI 25-29.9 kg/m2), diagnosis of neuroendocrine neoplasia, and open PUAS were risk factors for severe morbidity in the univariable analysis. Only open PUAS was statistically significant in the multivariable model. CONCLUSIONS PUAS does not impair the feasibility and safety of LDP as its perioperative outcomes are largely comparable to those in patients without PUAS. However, open PUAS increases the burden and severity of postoperative complications.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Center, Oslo University Hospital, Pikshospitalet, 0027, Oslo, Norway.
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
- Department of Research & Development, Division of Emergencies and Critical Care , Oslo University Hospital , Oslo, Norway.
| | - Tore Tholfsen
- Department of HPB Surgery, Oslo University Hospital, Pikshospitalet, Oslo, Norway
| | - Dyre Kleive
- Department of HPB Surgery, Oslo University Hospital, Pikshospitalet, Oslo, Norway
| | - Sheraz Yaqub
- Department of HPB Surgery, Oslo University Hospital, Pikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Center, Oslo University Hospital, Pikshospitalet, 0027, Oslo, Norway
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway
- Department of Faculty Surgery N2, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Trond Buanes
- Department of Research & Development, Division of Emergencies and Critical Care , Oslo University Hospital , Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Bård Ingvald Røsok
- Department of HPB Surgery, Oslo University Hospital, Pikshospitalet, Oslo, Norway
| | - Knut Jørgen Labori
- Department of HPB Surgery, Oslo University Hospital, Pikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Pikshospitalet, 0027, Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care , Oslo University Hospital , Oslo, Norway
- Department of HPB Surgery, Oslo University Hospital, Pikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
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Sahakyan MA, Tholfsen T, Kleive D, Waage A, Buanes T, Labori KJ, Røsok BI, Edwin B. Laparoscopic distal pancreatectomy in patients with poor physical status. HPB (Oxford) 2021; 23:877-881. [PMID: 33092964 DOI: 10.1016/j.hpb.2020.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/15/2020] [Accepted: 10/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is advantageous over open surgery in the treatment of benign pancreatic lesions and low-grade malignancies. Yet the evidence on the relationship between comorbidities and the outcomes of LDP remains scarce. METHODS Patients who had undergone LDP for all indications between April 1997 and December 2019 were included. Preoperative physical status was defined according to the American Society of Anesthesiology (ASA) criteria. Perioperative outcomes were compared between the patients with high (ASA III-IV) and low/moderate anesthetic risk (ASA I-II). RESULTS A total of 605 patients were eligible for analysis including 190 with ASA III-IV and 415 with ASA I-II. The former was associated with older age, male gender, preexisting medical conditions, greater total number of comorbidities and red blood cell transfusion. The rate of medical complications was significantly higher in high-risk patients. Multivariable analysis identified ASA III-IV and operative time as independent predictors for medical complications. Overall/severe morbidity, surgical complications and mortality rates were similar. CONCLUSIONS Poor physical status defined as ASA grades III-IV predicts medical complications, but has a limited impact on surgical complications and severe morbidity of LDP. Thus, it should not be considered as a contraindication for LDP.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia.
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anne Waage
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Trond Buanes
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Norway
| | - Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Norway
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Impact of BRAF mutations on clinical outcomes following liver surgery for colorectal liver metastases: An updated meta-analysis. Eur J Surg Oncol 2021; 47:2722-2733. [PMID: 34099355 DOI: 10.1016/j.ejso.2021.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/25/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Data regarding clinical outcomes of patients undergoing hepatic resection for BRAF-mutated colorectal liver metastases (CRLM) are scarce. Most of the studies report an impaired median overall survival (OS) in BRAF-mutated patients, but controversial Results regarding both recurrence-free survival (RFS) and recurrence patterns. The purpose of this updated meta-analysis was to better precise the impact of BRAF mutations on clinical outcomes following liver surgery for CRLM study, especially on recurrence. METHODS A systematic literature review was performed to identify articles reporting clinical outcomes including both OS and RFS, recurrence patterns, and clinicopathological details of patients who underwent complete liver resection for CRLM, stratified according to BRAF mutational status. RESULTS Thirteen retrospective studies, including 5192 patients, met the inclusion criteria. The analysis revealed that both OS (OR = 1.981; 95% CI = [1.613-2.432]) and RFS (OR = 1.49; 95% CI [1.01-2.21]) were impaired following liver surgery for CRLM in BRAF-mutated patients. Risks of both hepatic (OR = 0.42; 95% CI [0.18-0.98]) and extrahepatic recurrences (OR = 0.53; 95% CI [0.33-0.83] were significantly higher in BRAF-mutated patients. These patients tended to have higher rates of right-sided colon primary tumors, primary positive lymph nodes, and multiple CRLM. CONCLUSIONS This meta-analysis confirms that BRAF mutations impair both OS and RFS following liver surgery. Therefore, BRAF mutational status should probably be included in further prognostic scores for the assessment of the expected clinical outcomes following surgery for CRLM.
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Sahakyan MA, Røsok BI, Tholfsen T, Kleive D, Waage A, Ignjatovic D, Buanes T, Labori KJ, Edwin B. Implementation and training with laparoscopic distal pancreatectomy: 23-year experience from a high-volume center. Surg Endosc 2021; 36:468-479. [PMID: 33534075 PMCID: PMC8741682 DOI: 10.1007/s00464-021-08306-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/09/2021] [Indexed: 02/05/2023]
Abstract
Background Distal pancreatectomy is the most common procedure in minimally-invasive pancreatic surgery. Data in the literature suggest that the learning curve flattens after performing up to 30 procedures. However, the exact number remains unclear. Methods The implementation and training with laparoscopic distal pancreatectomy (LDP) in a high-volume center were studied between 1997 and 2020. Perioperative outcomes and factors related to conversion were assessed. The individual experiences of four different surgeons (pioneer and adopters) performing LDP on a regular basis were examined. Results Six hundred forty LDPs were done accounting for 95% of all distal pancreatectomies performed throughout the study period. Conversion was needed in 14 (2.2%) patients due to intraoperative bleeding or tumor adherence to the major vasculature. Overall morbidity and mortality rates were 35 and 0.6%, respectively. Intra- and postoperative outcomes did not change for any of the surgeons within their first 40 cases. Operative time significantly decreased after the first 80 cases for the pioneer surgeon and did not change afterwards although the proportion of ductal adenocarcinoma increased. Tumor size increased after the first 80 cases for the first adopter without affecting the operative time. Conclusions In this nearly unselected cohort, no significant changes in surgical outcomes were observed throughout the first 40 LDPs for different surgeons. The exact number of procedures required to overcome the learning curve is difficult to determine as it seems to depend on patient selection policy and specifics of surgical training at the corresponding center. Supplementary Information The online version of this article (10.1007/s00464-021-08306-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway. .,Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. .,Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Anne Waage
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Trond Buanes
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Sugery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Moro A, Ejaz A, Dillhoff M, Cloyd J, Tsung A, Pawlik TM. Quality of Care Among Medicare Patients Undergoing Pancreatic Surgery: Safety Grade, Magnet Recognition, and Leapfrog Minimum Volume Standards-Which Quality Benchmark Matters? J Gastrointest Surg 2021; 25:269-277. [PMID: 32040811 DOI: 10.1007/s11605-019-04504-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The association of national quality benchmarking metrics with postoperative outcomes following complex surgery remains unknown. We assessed the relationship between the "quality trifactor" of Leapfrog minimum volume standards, Hospital Safety Grade A, and Magnet Recognition with outcomes of Medicare patients undergoing pancreatectomy. METHODS The Standard Analytic Files (SAF) merged with Leapfrog Hospital Survey and Leapfrog Safety Scores Denominator Files were reviewed to identify Medicare patients who underwent pancreatic procedures between 2013 and 2015. Primary outcomes were overall and serious complications, as well as 30- and 90-day mortality. Multivariable logistic regression analyses were conducted to evaluate possible associations among hospitals meeting the quality trifactor and short-term outcomes. RESULTS Among 4853 Medicare patients, 909 (18.7%) underwent pancreatectomy at hospitals meeting the quality trifactor. Among 260 hospitals, 7.3% (n = 19) met the quality trifactor. Safety Grade A (48.8%, n = 127) was the most commonly met criterion followed by Magnet Recognition (36.2%, n = 94); the Leapfrog minimum volume standards were achieved by 25% (n = 65) of hospitals. Patients undergoing surgery at hospitals that were only Safety Grade A and Magnet designated, but did not meet Leapfrog criteria, had higher odds of serious complications (OR 1.59, 95% CI 1.00-2.51). In contrast, patients undergoing treatment at hospitals having all three designations (i.e., the quality trifactor) had 40% and 39% lower odds of both serious complications (OR 0.60, 95% CI 0.37-0.97) and 90-day mortality (OR 0.61, 95% CI 0.42-0.89), respectively. In turn, patients undergoing pancreatectomy at quality trifactor hospitals had higher odds of experiencing the composite quality measure textbook outcome (OR 1.28, 95% CI 1.03-1.59) versus patients undergoing pancreatectomy at non-trifactor hospitals. CONCLUSION While Safety Grade A and Magnet designation alone were not associated with higher odds of an optimal composite outcome following pancreatectomy, compliance with Leapfrog criteria to achieve the "quality trifactor" metric was associated with lower odds of serious complications and mortality.
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Affiliation(s)
- Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Ayesha Farooq
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lu Wu
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amika Moro
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Tortajada P, Sauvanet A, Truant S, Regenet N, Souche R, Benoist S, Muscari F, Regimbeau JM, Gaujoux S, Cunha AS, Schwarz L. Does Fungal Biliary Contamination after Preoperative Biliary Drainage Increase Postoperative Complications after Pancreaticoduodenectomy? Cancers (Basel) 2020; 12:E2814. [PMID: 33007843 PMCID: PMC7599947 DOI: 10.3390/cancers12102814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
(1) Background: preoperative biliary drainage before pancreaticoduodenectomy (PD) is associated with bacterial biliary contamination (>85%) and a significant increase in global and infectious complications. In view of the lack of published data, the aim of our study was to investigate the impact of fungal biliary contamination after biliary drainage on the complication rate after PD. (2) Methods: a multicentric retrospective study that included 224 patients who underwent PD after biliary drainage with intraoperative biliary culture. (3) Results: the global rate of positive intraoperative biliary sample was 92%. Respectively, the global rate of biliary bacterial contamination and the rate of fungal contamination were 75% and 25%, making it possible to identify two subgroups: bacterial contamination only (B+, n = 154), and bacterial and fungal contamination (BF+, n = 52). An extended duration of preoperative drainage (62 vs. 49 days; p = 0.08) increased the risk of fungal contamination. The overall and infectious complication rates were not different between the two groups. In the event of postoperative infectious or surgical complications, the infectious samples taken did not reveal more fungal infections in the BF+ group. (4) Conclusions: fungal biliary contamination, although frequent, does not seem to increase the rate of global and infectious complications after PD, preceded by preoperative biliary drainage.
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Affiliation(s)
- Pauline Tortajada
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, CEDEX, France;
| | - Alain Sauvanet
- Department of Hepatobiliary and Liver Transplantation, Hôpital Beaujon, 100 Boulevard Général Leclerc, 92118 Clichy, France;
| | - Stephanie Truant
- Department of Digestive Surgery and Transplantation, Hôpital Huriez, Rue Michel Polonowski, 59037 Lille, France;
| | - Nicolas Regenet
- Department of Digestive Surgery, CHU Nantes, 1 Place Alexis Ricordeau, 44000 Nantes, France;
| | - Régis Souche
- Department of Hepatobiliary and Transplantation, CHU Montpelliers, 191 Avenue du Doyen Gaston Giraud, 34295 Montpellier, CEDEX 5, France;
| | - Stéphane Benoist
- Department of Digestive Surgery, CHU du Kremlin Bicêtre, 78 Rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France;
| | - Fabrice Muscari
- Department of Digestive Surgery and Transplantation, CHU Toulouse Rangueil, 1, Avenue du Pr Jean Poulhès, 31059 Toulouse, CEDEX, France;
| | - Jean Marc Regimbeau
- Department of Digestive Surgery, CHU Amiens-Picardie Site Sud, 1 Rond-Point du Professeur Christian Cabrol, 80054 Amiens, CEDEX 1, France;
| | - Sebastien Gaujoux
- Department of Digestive Surgery, Hepatobiliary and Metabolic Surgery, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France;
| | - Antonio Sa Cunha
- Department of Hepatobiliary and Liver Transplantation, Centre Hépato-Biliaire de Paul Brousse, 38 rue de la Chapelle, 94800 Villejuif, France;
| | - Lillian Schwarz
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, F-76031 Rouen, CEDEX, France;
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National Trends in Centralization of Surgical Care and Multimodality Therapy for Pancreatic Adenocarcinoma. J Gastrointest Surg 2020; 24:2021-2029. [PMID: 31420860 DOI: 10.1007/s11605-019-04361-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/05/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Studies have demonstrated that multimodality therapy and surgery at high volume centers are associated with a longer survival. However, it is unknown if these data have translated into national changes in care delivery. METHODS Patients with stages I-III pancreatic adenocarcinomas who underwent resections between 2004 and 2010 were identified from the National Cancer Data Base. The primary outcome was a 3-year overall survival. Temporal trends in survival outcomes and treatment variables were measured. A mediation analysis using the Lin method was used to discern the relative contribution of changes in treatment variables towards improvements in survival over time. RESULTS A total of 22,196 patients were identified. Between 2004 and 2010, a 90-day peri-operative mortality remained unchanged (8.5 % to 8.4 %, p = 0.488), 3-year overall survival improved from 26 to 30% (p < 0.001), use of adjuvant/neoadjuvant chemotherapy increased (51 % to 61 %, p < 0.001), and more cases shifted to high volume centers (46 % at institutions performing > 10 cases/year in 2004 vs. 65 % in 2010, p < 0.001). On multivariable analysis, 32 % of the improvement in survival over time was attributable to receipt of chemotherapy, while 12 % was due to the shift of patients towards high volume centers (p < 0.001). CONCLUSIONS Over the period from 2004 to 2010, a 3-year survival increased for patients undergoing resection for pancreatic cancer. This survival improvement can be partially attributed to the increasing utilization of chemotherapy and centralization of surgical care at high volume centers. A continued emphasis on these factors will likely result in further prolongation of a survival following resection.
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Matthes N, Diers J, Schlegel N, Hankir M, Haubitz I, Germer CT, Wiegering A. Validation of MTL30 as a quality indicator for colorectal surgery. PLoS One 2020; 15:e0238473. [PMID: 32857807 PMCID: PMC7454590 DOI: 10.1371/journal.pone.0238473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/16/2020] [Indexed: 01/01/2023] Open
Abstract
Background Valid indicators are required to measure surgical quality. These ideally should be sensitive and selective while being easy to understand and adjust. We propose here the MTL30 quality indicator which takes into account 30-day mortality, transfer within 30 days, and a length of stay of 30 days as composite markers of an uneventful operative/postoperative course. Methods Patients documented in the StuDoQ|Colon and StuDoQ|Rectal carcinoma register of the German Society for General and Visceral Surgery (DGAV) were analyzed with regard to the effects of patient and tumor-related risk factors as well as postoperative complications on the MTL30. Results In univariate analysis, the MTL30 correlated significantly with patient and tumor-related risk factors such as ASA score (p<0.001), age (p<0.001), or UICC stage (p<0.001). There was a high sensitivity for the postoperative occurrence of complications such as re-operations (p<0.001) or subsequent bleeding (p<0.001), as well as a significant correlation with the CDC classification (p<0.001). In multivariate analysis, patient-related risk factors and postoperative complications significantly increased the odds ratio for a positive MTL30. A negative MTL30 showed a high specify for an uneventful operative and postoperative course. Conclusion The MTL30 is a valid indicator of colorectal surgical quality.
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Affiliation(s)
- Niels Matthes
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johannes Diers
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Imme Haubitz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Biochemistry and Molecular Biology, Theodor Boveri Institute, University of Wuerzburg, Wuerzburg, Germany
- * E-mail:
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Clinical Factors Associated With Practice Variation in Discharge Opioid Prescriptions After Pancreatectomy. Ann Surg 2020; 272:163-169. [PMID: 30499795 DOI: 10.1097/sla.0000000000003112] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To characterize opioid discharge prescriptions for pancreatectomy patients. BACKGROUND Wide variation in and over-prescription of opioids after surgery contribute to the United States opioid epidemic through persistent use past the postoperative period. Objective strategies guiding discharge opioid prescriptions for oncologic surgery are lacking, and factors driving prescription amount are not fully delineated. METHODS Characteristics of pancreatectomy patients (March 2016-August 2017) were retrospectively abstracted from a prospective database. Discharge opioids prescriptions were converted to oral morphine equivalents (OME). Regression models identified variables associated with discharge OME. RESULTS In 158 consecutive patients, median discharge OME was 250 mg (range 0-3950). Discharge OME was labeled "low" (<200 mg) for 33 patients (21%) and "high" (>400 mg) for 38 (24%). Only shorter operative time (odds ratio [OR]-0.14, P = 0.004) and inpatient team (OR-15.39, P < 0.001) were independently associated with low discharge OME. Older age was the only variable associated with high discharge OME. Fifty-seven patients (36%) used zero opioids in the last 24-hours predischarge, yet 52 of 57 (91%) still received discharge opioids. Older age (OR-1.07), grade B/C pancreatic fistula (OR-3.84), and epidural use (OR-3.12) were independently associated with zero last-24-hours OME (all P ≤ 0.040). CONCLUSIONS The wide variation in discharge opioid prescriptions is heavily influenced by provider routine/bias and not by objective criteria such as last-24-hours OME. Quality improvement strategies could include aggressive weaning protocols to increase the proportion of patients with zero/near-zero last-24-hour OME and limiting prescriptions to a conservative multiplier of the last-24-hour OME.
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Abstract
OBJECTIVE To define and test "Textbook Outcome" (TO)-a composite measure for healthcare quality-among Medicare patients undergoing hepatopancreatic resections. Hospital variation in TO and Medicare payments were analyzed. BACKGROUND Composite measures of quality may be superior to individual measures for the analysis of hospital performance. METHODS The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. TO was defined as: no postoperative surgical complications, no prolonged length of hospital stay, no readmission ≤ 90 days after discharge, and no postoperative mortality ≤ 90 days after surgery. Medicare payments were compared among patients who achieved TO versus patients who did not. Multivariable logistic regression was used to investigate patient factors associated with TO. A nomogram to predict probability of TO was developed and validated. RESULTS TO was achieved in 44% (n = 5919) of 13,467 patients undergoing hepatopancreatic surgery. Adjusted TO rates at the hospital level varied from 11.1% to 69.6% for pancreatic procedures and from 16.6% to 78.7% for liver procedures. Prolonged length of hospital stay represented the major obstacle to achieve TO. Average Medicare payments were substantially higher among patients who did not have a TO. Factors associated with TO on multivariable analysis were age, sex, Charlson comorbidity score, previous hospital admissions, procedure type, and surgical approach (all P > 0.05). CONCLUSIONS Less than one-half of Medicare patients achieved a TO following hepatopancreatic procedures with a wide variation in the rates of TO among hospitals. There was a discrepancy in Medicare payments for patients who achieved a TO versus patients who did not. TO could be useful for the public reporting of patient level hospital performance and hospital variation.
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Souche R, Coignac A, Dupuy M, Bertrand M, Raingeart I, Guiu B, Herrero A, Panaro F, Obled S, Portales F, Riviere B, Ramos J, Borie F, Quenet F, Colombo PE, Prudhomme M, Assenat E, Fabre JM. Outcome after pancreatectomy for neuroendocrine neoplams according to the WHO 2017 grading system: A retrospective multicentric analysis of 138 consecutive patients. Clin Res Hepatol Gastroenterol 2020; 44:286-294. [PMID: 31543336 DOI: 10.1016/j.clinre.2019.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/23/2019] [Accepted: 08/16/2019] [Indexed: 02/04/2023]
Abstract
AIM The aim of this study was to evaluate the new World Health Organization (WHO) 2017 grading system and the others clinicopathological factors in pancreatic neuroendocrine tumor (panNET) operated patients. METHODS Histological staging was based on the WHO 2017 grading system. Outcome after surgery and predictors of overall survival (OS) and disease free survival (DFS) were evaluated. RESULTS A total of 138 patients underwent surgical resection with a severe morbidity and mortality rates of 14.5% and 0.7% respectively. Five years OS differed according to WHO 2017: 95% among 58 patients with NETG1, 82% in 68 patients with NETG2, 35% in 7 patients with NETG3 and 0% in 5 patients with NECG3 (P<0.0001). Independent predictors of worse OS were age>60 y.o (P=0.014), synchronous metastasis (P=0.005) and WHO 2017 with significant differences between NETG1 versus NETG2 (P=0.005), NETG3 (P<0.001) and NECG3 (P<0.001). Independent predictors of worse DFS were symptomatic NET (P=0.038), pN+ status (P=0.027) and WHO 2017 with significant differences between NETG1 versus NETG3 (P=0.014) and NECG3 (P=0.009). CONCLUSION The WHO 2017 grading system is a useful tool for patient prognosis after panNET resection and the tailoring of therapeutic strategy. Surgery could provide good results in NETG3 patients.
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Affiliation(s)
- Regis Souche
- Digestive and Mini-invasive Surgery unit, Department of Digestive Surgery and Transplantation, St Eloi Hospital, centre hospitalier universitaire, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Université de Montpellier-Nîmes, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France.
| | - Antoine Coignac
- Digestive and Mini-invasive Surgery unit, Department of Digestive Surgery and Transplantation, St Eloi Hospital, centre hospitalier universitaire, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Université de Montpellier-Nîmes, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Marie Dupuy
- Department of Medical Oncology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Martin Bertrand
- Department of Digestive Surgery, University of Montpellier-Nîmes, Carémeau Hospital, place du professeur Debré, 30900 Nîmes, France
| | - Isabelle Raingeart
- Department of Endocrinology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Boris Guiu
- Department of Radiology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Astrid Herrero
- Digestive and Mini-invasive Surgery unit, Department of Digestive Surgery and Transplantation, St Eloi Hospital, centre hospitalier universitaire, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Université de Montpellier-Nîmes, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Fabrizio Panaro
- Digestive and Mini-invasive Surgery unit, Department of Digestive Surgery and Transplantation, St Eloi Hospital, centre hospitalier universitaire, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Université de Montpellier-Nîmes, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Stephane Obled
- Department of Gastroenterology, University of Montpellier-Nîmes, Carémeau Hospital, place du professeur Debré, 30900 Nîmes, France
| | - Fabienne Portales
- Oncology, université de Montpellier-Nîmes, institut du cancer de Montpellier (ICM), parc Euromédecine, 208, rue des Apothicaires, 34298 Montpellier, France
| | - Benjamin Riviere
- Department of Pathology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Jeanne Ramos
- Department of Pathology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Frederic Borie
- Department of Digestive Surgery, University of Montpellier-Nîmes, Carémeau Hospital, place du professeur Debré, 30900 Nîmes, France
| | - Francois Quenet
- Digestive & Oncologic Surgery, université de Montpellier-Nîmes, institut du cancer de Montpellier (ICM), parc Euromédecine, 208, rue des Apothicaires, 34298 Montpellier, France
| | - Pierre-Emmanuel Colombo
- Digestive & Oncologic Surgery, université de Montpellier-Nîmes, institut du cancer de Montpellier (ICM), parc Euromédecine, 208, rue des Apothicaires, 34298 Montpellier, France
| | - Michel Prudhomme
- Department of Digestive Surgery, University of Montpellier-Nîmes, Carémeau Hospital, place du professeur Debré, 30900 Nîmes, France
| | - Eric Assenat
- Department of Medical Oncology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
| | - Jean-Michel Fabre
- Digestive and Mini-invasive Surgery unit, Department of Digestive Surgery and Transplantation, St Eloi Hospital, centre hospitalier universitaire, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Université de Montpellier-Nîmes, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France
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- Digestive and Mini-invasive Surgery unit, Department of Digestive Surgery and Transplantation, St Eloi Hospital, centre hospitalier universitaire, 80, avenue Augustin-Fliche, 34295 Montpellier, France; Université de Montpellier-Nîmes, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France; Department of Medical Oncology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France; Department of Digestive Surgery, University of Montpellier-Nîmes, Carémeau Hospital, place du professeur Debré, 30900 Nîmes, France; Department of Endocrinology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France; Department of Radiology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France; Department of Gastroenterology, University of Montpellier-Nîmes, Carémeau Hospital, place du professeur Debré, 30900 Nîmes, France; Oncology, université de Montpellier-Nîmes, institut du cancer de Montpellier (ICM), parc Euromédecine, 208, rue des Apothicaires, 34298 Montpellier, France; Department of Pathology, université de Montpellier-Nîmes, centre hospitalier universitaire, 641, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France; Digestive & Oncologic Surgery, université de Montpellier-Nîmes, institut du cancer de Montpellier (ICM), parc Euromédecine, 208, rue des Apothicaires, 34298 Montpellier, France
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Schucht J, Davis EG, Jones CM, Cannon RM. Incidence of and Risk Factors for Multiple Readmissions after Kidney Transplantation. Am Surg 2020. [DOI: 10.1177/000313482008600230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Unplanned readmission is often used as a surgical quality metric. A subset of kidney transplant recipients undergos multiple readmissions (MRs), although the incidence and risk factors are not well described. The aim of this study was to evaluate risk factors for MR after deceased donor kidney transplantation. All patients undergoing deceased donor kidney transplantation at a single center over a three-year period were analyzed via retrospective chart review for factors associated with MR. P values <0.05 were considered significant. Of 141 patients, the 30-day readmission rate was 26.2 per cent. MR occurred in 43 (30.5%) patients. Age, race, gender, initial organ function, and dialysis vintage were not associated with MR. Diabetic recipients, those who received basiliximab induction, those with acute rejection, and those with unplanned reoperations were at increased risk for MR. Infection was the most common reason for initial readmission in patients with MR (23.3%). One-year patient survival and death-censored graft survival were reduced for patients with MR. MRs are required for 30 per cent of kidney transplant recipients, primarily because of infection and immunologic causes. Recipients with diabetes and those who have acute rejection are at greatest risk.
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Affiliation(s)
- Jessica Schucht
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Eric G. Davis
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Christopher M. Jones
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Robert M. Cannon
- From the Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky
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Xourafas D, Pawlik TM, Ejaz A, Dillhoff M, Abdel-Misih S, Tsung A, Cloyd JM. Impact of concomitant ablation on the perioperative outcomes of patients with colorectal liver metastases undergoing hepatectomy: a propensity score matched nationwide analysis. HPB (Oxford) 2019; 21:1079-1086. [PMID: 30718184 DOI: 10.1016/j.hpb.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/20/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intraoperative ablation (IA) is often performed at the time of liver resection (LR) for colorectal liver metastases (CRLMs) but its impact on postoperative outcomes remains poorly understood. METHODS The ACS-NSQIP targeted hepatectomy database was used to identify patients who underwent LR vs LR + IA for CRLMs during 2014-2016. Perioperative outcomes were compared following propensity score match based on age, receipt of neoadjuvant therapy, operative approach, liver resection type, tumor diameter and number of metastases. RESULTS Among 1,384 patients, 692 (50%) underwent LR alone and 692 (50%) underwent LR + IA. After propensity score matching, overall morbidity (22% vs 13%, P < 0.0001) was increased among patients undergoing LR alone compared to LR + IA, whereas mortality did not differ (1.1% vs 0.8%, P=0.5911). On multivariable analysis, ASA class ≥3 (OR: 1.5, 95% CI: 1.06-2.3), preoperative biliary stent (OR: 3.5, 95% CI: 0.9-13.01), biliary reconstruction (OR: 5.02, 95% CI: 1.3-18.6), operative time > 245 minutes (OR: 1.8, 95% CI:1.3-2.4) and IA (OR:0.5, 95% CI:0.3-0.7) were associated with overall morbidity. CONCLUSIONS In this propensity matched nationwide analysis of patients undergoing LR for CRLM, the use of concomitant IA was associated with decreased postoperative morbidity compared to LR alone. These findings suggest that IA combined with LR is a safe approach that may expand the number of patients who are candidates for curative-intent surgical strategies.
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Affiliation(s)
- Dimitrios Xourafas
- Department of surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sherif Abdel-Misih
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients. J Gastrointest Surg 2019; 23:1157-1165. [PMID: 30820798 DOI: 10.1007/s11605-019-04139-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear. METHODS Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model. RESULTS A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522). CONCLUSION While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.
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Silvestri M, Coignac A, Delicque J, Herrero A, Borie F, Guiu B, Fabre JM, Souche R. Level of pancreatic division and postoperative pancreatic fistula after distal pancreatectomy: A retrospective case-control study of 157 patients with non-pancreatic ductal adenocarcinoma lesions. Int J Surg 2019; 65:128-133. [DOI: 10.1016/j.ijsu.2019.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 01/08/2023]
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Impact of Neoadjuvant Chemotherapy on the Postoperative Outcomes of Patients Undergoing Liver Resection for Colorectal Liver Metastases: A Population-Based Propensity-Matched Analysis. J Am Coll Surg 2019; 229:69-77.e2. [PMID: 30905856 DOI: 10.1016/j.jamcollsurg.2019.03.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/26/2019] [Accepted: 03/11/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of neoadjuvant chemotherapy in the management of colorectal liver metastases remains controversial. We sought to investigate whether neoadjuvant systemic chemotherapy contributes to clinically significant increases in postoperative morbidity and mortality using a population-based cohort. STUDY DESIGN The American College of Surgeons NSQIP Targeted Hepatectomy Participant Use Files were queried from 2014 to 2016 to identify patients with colorectal liver metastases who underwent liver resection. Patients were stratified by receipt of neoadjuvant chemotherapy using propensity score matching. Univariate and multivariable analyses were used to characterize the effect of neoadjuvant chemotherapy on perioperative morbidity and mortality. RESULTS After propensity score matching, 1,416 (50%) patients received neoadjuvant chemotherapy before hepatectomy and 1,416 (50%) underwent liver resection without neoadjuvant chemotherapy. There were no differences in age (60 vs 61 years), maximum tumor size (≤5 cm: 79% vs 80%, >5 cm: 21% vs 20%), resection type (partial hepatectomy: 69% vs 70%), simultaneous colectomy (9% vs 9%), or use of preoperative portal vein embolization (5% vs 5%) in those undergoing neoadjuvant chemotherapy compared with those who did not (all, p > 0.05). Overall 30-day postoperative morbidity (34% vs 33%), including rates of biliary fistula (6% vs 5%), post-hepatectomy liver failure (5% vs 5%), and mortality rates (0.8% vs 0.7%), were similar among patients who received neoadjuvant chemotherapy vs those who did not (all, p > 0.05). On multivariable analysis, receipt of neoadjuvant chemotherapy was not associated with increased morbidity (odds ratio 1.07; 95% CI 0.90 to 1.27; p = 0.43) or mortality (odds ratio 1.09; 95% CI 0.44 to 2.72; p = 0.85). CONCLUSIONS In this propensity-matched population-based cohort study, the use of neoadjuvant systemic chemotherapy was not associated with higher rates of complications, biliary fistula, post-hepatectomy liver failure, or mortality among patients with colorectal liver metastases undergoing liver resection.
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Yamamoto M, Kawaguchi Y, Ichida A, Matsumura M, Sakamoto Y, Arita J, Akamatsu N, Kaneko J, Kokudo N, Hasegawa K. Evaluation of preoperative nutritional variables to predict postoperative complications after pancreaticoduodenectomy. Nutrition 2019; 67-68S:100006. [PMID: 34332712 DOI: 10.1016/j.nutx.2020.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/30/2019] [Accepted: 12/20/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Perioperative malnutrition reportedly increases postoperative morbidity and mortality rates after abdominal surgery, including pancreaticoduodenectomy (PD). However, few studies have focused on the association between preoperative nutritional variables and the incidence of postoperative complications. The present study aimed to evaluate preoperative nutritional parameters to predict the incidence of postoperative complications after PD. METHODS A total of 140 consecutive patients underwent PD between May 2012 and April 2015. Preoperative nutritional variables included body mass index, total lymphocyte count, albumin, total cholesterol, cholinesterase, and transthyretin. The rates of Clavien-Dindo (C-D) grade ≥II complications were evaluated for each nutritional variable. Predictive factors for the incidence of C-D grade ≥II complications were evaluated by assessing pre- and intraoperative factors. RESULTS Of the 140 patients, 108 were included in the study after excluding 32 patients with missing data on preoperative nutritional variables. A cholinesterase concentration of <250 IU/L (odds ratio: 2.82; 95% confidence interval, 1.12-7.80; P = 0.028) was the only independent predictive factor for the incidence of C-D grade ≥II postoperative complications. CONCLUSIONS Low cholinesterase concentrations were significantly associated with a higher incidence of postoperative morbidity in patients undergoing PD. Preoperative nutritional variables can be used as predictors of postoperative complications after PD.
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Affiliation(s)
- Masaki Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masaru Matsumura
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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Jiang HY, Kohtakangas EL, Asai K, Shum JB. Predictive Power of the NSQIP Risk Calculator for Early Post-Operative Outcomes After Whipple: Experience from a Regional Center in Northern Ontario. J Gastrointest Cancer 2018; 49:288-294. [PMID: 28462447 DOI: 10.1007/s12029-017-9949-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND NSQIP Risk Calculator was developed to allow surgeons to inform their patients about their individual risks for surgery. Its ability to predict complication rates and length of stay (LOS) has made it an appealing tool for both patients and surgeons. However, the NSQIP Risk Calculator has been criticized for its generality and lack of detail towards surgical subspecialties, including the hepatopancreaticobiliary (HPB) surgery. We wish to determine whether the NSQIP Risk Calculator is predictive of post-operative complications and LOS with respect to Whipple's resections for our patient population. As well, we wish to identify strategies to optimize early surgical outcomes in patients with pancreatic cancer. METHODS We conducted a retrospective review of patients who underwent elective Whipple's procedure for benign or malignant pancreatic head lesions at Health Sciences North (Sudbury, Ontario), a tertiary care center, from February 2014 to August 2016. Comparisons of LOS and post-operative complications between NSQIP-predicted and actual ones were carried out. NSQIP-predicted complications rates were obtained using the NSQIP Risk Calculator through pre-defined preoperative risk factors. Clinical outcomes examined, at 30 days post-operation, included pneumonia, cardiac events, surgical site infection (SSI), urinary tract infection (UTI), venous thromboembolism (VTE), renal failure, readmission, and reoperation for procedural complications. As well, mortality, disposition to nursing or rehabilitation facilities, and LOS were assessed. RESULTS A total of 40 patients underwent Whipple's procedure at our center from February 2014 to August 2016. The average age was 68 (50-85), and there were 22 males and 18 females. The majority of patients had independent baseline functional status (39/40) with minimal pre-operative comorbidities. The overall post-operative morbidity was 47.5% (19/40). The rate of serious complication was 17.5% with four Clavien grade II, two grade III, and one grade V complications. One mortality occurred within 30 days after surgery. NSQIP Risk Calculator was predictive for the majority of post-surgical complication types, including pneumonia, SSI, VTE, reoperation, readmission, and disposition to rehabilitation or nursing home. Our center appears to have a higher rate of UTI than NSQIP predicted (O/E = 3.9), as well, the rate of cardiac complication (O/E = 3.1) also appears to be higher at our center. With respect to readmission rates (O/E = 0.6) and renal failure (O/E = 0), NSQIP provided overestimated rates. The average LOS was 11.9 ± 0.9 days, which was not significantly different from the average LOS of 11.5 ± 0.3 days predicted by NSQIP (p = 0.3). Overall, 80% of discharges occurred less than or within 3 days of that predicted by NSQIP. CONCLUSION NSQIP Risk Calculator is predictive of post-operative complications and LOS for patients who have undergone Whipple's at our center. A more HPB-focused NSQIP calculator may accurately project post-operative complication in the pre-operative period. Nevertheless, the generic NSQIP has allowed us to examine our existing practice of post-operative care and has paved way to reduce cardiac and urinary complications in the future.
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Affiliation(s)
- Henry Y Jiang
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada.,Faculty of Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Erica L Kohtakangas
- Faculty of Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Kengo Asai
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada.,Faculty of Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Jeffrey B Shum
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada. .,Faculty of Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada. .,, 41 Ramsey Lake Road, Sudbury, ON, P3E 5J1, Canada.
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Sahakyan MA, Kleive D, Kazaryan AM, Aghayan DL, Ignjatovic D, Labori KJ, Røsok BI, Edwin B. Extended laparoscopic distal pancreatectomy for adenocarcinoma in the body and tail of the pancreas: a single-center experience. Langenbecks Arch Surg 2018; 403:941-948. [DOI: 10.1007/s00423-018-1730-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/06/2018] [Indexed: 12/11/2022]
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Howard JD, Ising MS, Delisle ME, Martin RCG. Hospital readmission after pancreaticoduodenectomy: A systematic review and meta-analysis. Am J Surg 2018; 217:156-162. [PMID: 30017309 DOI: 10.1016/j.amjsurg.2018.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Appropriate postoperative readmission rates and modifiable risk factors for readmission have yet to be defined for many operations. This systematic review and meta-analysis attempt to define these parameters for pancreaticoduodenectomy. MATERIALS AND METHODS The main outcomes were readmission rate, risk factors, and reasons for readmission. Meta-analyses were performed when data was homogeneous, otherwise, a qualitative review was performed. RESULTS The 30-day, 90-day, and overall readmission rates were 17.63%, 26.14%, and 27.18%, respectively. In the meta-analysis, chronic pancreatitis (OR, 1.44, p = 0.04), operative length (MD, 26.1; p < 0.01), wound infection (OR, 1.9, p < 0.01), intra-abdominal abscess (OR, 3.79, p < 0.01), VTE (OR, 2.27, p = 0.01), and LOS (MD, 1.66, p < 0.01) where associated with readmission. CONCLUSION Hospital readmission will continue to be a quality metric and will influence reimbursement models. Thirty and 60-day readmission data underestimate the true readmission rate. Chronic pancreatitis, operative length, and several post-operative complications were associated with greater readmission. More uniform reporting is necessary to identify modifiable risk factors associated with readmission.
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Affiliation(s)
- Jeffrey D Howard
- University of Louisville, Hiram C. Polk Dept. of Surgery, Louisville, KY, 40202, United States.
| | - Mickey S Ising
- University of Louisville, Hiram C. Polk Dept. of Surgery, Louisville, KY, 40202, United States.
| | - Megan E Delisle
- University of Manitoba, Dept. of Surgery, 2009-311 Hargrave St, Winnipeg, MB, R3B 0V8, Canada.
| | - Robert C G Martin
- University of Louisville, Hiram C. Polk Dept. of Surgery, Louisville, KY, 40202, United States.
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Souche R, Herrero A, Bourel G, Chauvat J, Pirlet I, Guillon F, Nocca D, Borie F, Mercier G, Fabre JM. Robotic versus laparoscopic distal pancreatectomy: a French prospective single-center experience and cost-effectiveness analysis. Surg Endosc 2018; 32:3562-3569. [PMID: 29396754 DOI: 10.1007/s00464-018-6080-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/28/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Benefits and cost-effectiveness of robotic approach for distal pancreatectomy (DP) remain debated. In this prospective study, we aim to compare the short-term results and real costs of robotic (RDP) and laparoscopic distal pancreatectomy (LDP). METHODS From 2011 until 2016, all consecutive patients underwent minimally invasive DP were included and data were prospectively collected. Patients were assigned in two groups, RDP and LDP, according to the availability of the Da Vinci® Surgical System for our Surgical Unit. RESULTS A minimally invasive DP was performed in 38 patients with a median age of 61 years old (44-83 years old) and a BMI of 26 kg/m2 (20-31 kg/m2). RDP group (n = 15) and LDP group (n = 23) were comparable concerning demographic data, BMI, ASA score, comorbidities, malignant lesions, lesion size, and indication of spleen preservation. Median operative time was longer in RDP (207 min) compared to LDP (187 min) (p = 0.047). Conversion rate, spleen preservation failure, and perioperative transfusion rates were nil in both groups. Pancreatic fistula was diagnosed in 40 and 43% (p = 0.832) of patients and was grade A in 83 and 80% (p = 1.000) in RDP and LDP groups, respectively. Median postoperative hospital stay was similar in both groups (RDP: 8 days vs. LDP: 9 days, p = 0.310). Major complication occurred in 7% in RDP group and 13% in LDP group (p = 1.000). Ninety-days mortality was nil in both groups. No difference was found concerning R0 resection rate and median number of retrieved lymph nodes. Total cost of RDP was higher than LDP (13611 vs. 12509 €, p < 0.001). The difference between mean hospital incomes and costs was negative in RDP group contrary to LDP group (- 1269 vs. 1395 €, p = 0.040). CONCLUSION Short-term results of RDP seem to be similar to LDP but the high cost of RDP makes this approach not cost-effective actually.
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Affiliation(s)
- Regis Souche
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France.
| | - Astrid Herrero
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Guillaume Bourel
- Medical Information Department, La Colombière Hospital, University of Montpellier, 39 Avenue Charles Flahault, 34295, Montpellier, France
| | - John Chauvat
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Isabelle Pirlet
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Françoise Guillon
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - David Nocca
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Frederic Borie
- Digestive Surgery Department, Carémeau Hospital, University of Montpellier, Place du Professeur Debré, 30900, Nîmes, France
| | - Gregoire Mercier
- Medical Information Department, La Colombière Hospital, University of Montpellier, 39 Avenue Charles Flahault, 34295, Montpellier, France
| | - Jean-Michel Fabre
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier, 80 Avenue Augustin Fliche, 34295, Montpellier, France
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Surgery for pancreatic cancer: critical radiologic findings for clinical decision making. Abdom Radiol (NY) 2018; 43:374-382. [PMID: 28948329 DOI: 10.1007/s00261-017-1332-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States, with an estimated 53,670 new cases diagnosed and an estimated 43,090 deaths in 2017. This high mortality rate is in part due to the small percentage of patients diagnosed with local disease, as well as the biologically aggressive nature of the disease. While only 10-20% of patients will present with surgically resectable disease, this is the only possible curative therapy. Five-year survival of resected pancreatic cancer ranges from 12 to 27%. The National Comprehensive Cancer Network (NCCN) guidelines recommend specific guidelines for imaging modalities used in the diagnosis and staging of pancreatic adenocarcinoma. Indeed, high-quality imaging is not only necessary to accurately stage the disease, but is critical for the determination of key clinical decision branch points such as the determination of surgical resectability. Identification of the lesion within the pancreas, the degree of extra-pancreatic extension, and potential involvement of surrounding vascular structures with the tumor are all findings necessary to classify patients as having resectable, borderline resectable, or with unresectable primary tumors. This article reviews imaging modalities used to evaluate the pancreatic cancer patient from the surgeon's perspective, with particular emphasis on determination of resectability and preoperative planning, as well as imaging in the postoperative period.
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Souche R, Fuks D, Perinel J, Herrero A, Guillon F, Pirlet I, Perniceni T, Borie F, Cunha AS, Gayet B, Fabre JM. Impact of laparoscopy in patients aged over 70 years requiring distal pancreatectomy: a French multicentric comparative study. Surg Endosc 2018; 32:3164-3173. [DOI: 10.1007/s00464-018-6033-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/03/2018] [Indexed: 12/19/2022]
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Alyami M, Kim BJ, Villeneuve L, Vaudoyer D, Képénékian V, Bakrin N, Gilly FN, Cotte E, Glehen O, Passot G. Ninety-day post-operative morbidity and mortality using the National Cancer Institute’s common terminology criteria for adverse events better describe post-operative outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Int J Hyperthermia 2017; 34:532-537. [DOI: 10.1080/02656736.2017.1367846] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Mohammad Alyami
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
- King Salman Scholarship Program, Saudi Arabian Cultural Bureau, Paris, France
| | - Bradford J. Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Laurent Villeneuve
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
- Pole IMER, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
| | - Delphine Vaudoyer
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
| | - Vahan Képénékian
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Naoual Bakrin
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Francois-Noel Gilly
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Eddy Cotte
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Olivier Glehen
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
| | - Guillaume Passot
- The Department of Surgical Oncology, CHU Lyon Sud, Hospices civils de Lyon, University of Lyon, France
- EMR 37-38, Lyon 1 University, Lyon, France
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The Comprehensive Complication Index (CCI®): Added Value and Clinical Perspectives 3 Years "Down the Line". Ann Surg 2017; 265:1045-1050. [PMID: 28486288 DOI: 10.1097/sla.0000000000002132] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To explore the added value of the comprehensive complication index (CCI) to standard assessment of postoperative morbidity, and to clarify potential controversies for its application. BACKGROUND The CCI was introduced about 3 years ago as a novel metric of postoperative morbidity, integrating in a single formula all complications by severity, ranging from 0 (uneventful course) to 100 (death). It remains unclear, how often the CCI adds to standard reporting of complications and how to apply it in complex postoperative courses. METHODS CCI data were prospectively collected over a 1-year period at our institution. The proportion of patients with more than 1 complication and the severity of those complications were assessed to determine the additional value of the CCI compared to the Clavien-Dindo classification. Complex and controversial cases were presented to 90 surgeons worldwide to achieve consensus in weighing each postoperative event. Descriptive statistics were used to evaluate agreement among surgeons and to suggest solutions for consistent use of the CCI. RESULTS Complications were identified in 24% (290/1212) of the general surgical population. Of those, 44% (127/290) developed more than 1 complication by the time of discharge, and thereby CCI added information to the standard grading system of complications. Information gained by the CCI increased with the complexity of surgery and observation time. CONCLUSIONS The CCI adds information on postoperative morbidity in almost half of the patients developing complications, with particular value following extensive surgery and longer postoperative observation up to 3 months. Each single complication, independently of their inter-connection, should be included in the CCI calculation to best mirror the patients' postoperative morbidity.
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Sahakyan MA, Edwin B, Kazaryan AM, Barkhatov L, Buanes T, Ignjatovic D, Labori KJ, Røsok BI. Perioperative outcomes and survival in elderly patients undergoing laparoscopic distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:42-48. [PMID: 27794204 DOI: 10.1002/jhbp.409] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mushegh A. Sahakyan
- The Interventional Centre; Oslo University Hospital; 0027 Oslo Norway
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
- Department of Surgery; Yerevan State Medical University; Yerevan Armenia
| | - Bjørn Edwin
- The Interventional Centre; Oslo University Hospital; 0027 Oslo Norway
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
- Department of HPB Surgery; Oslo University Hospital; Oslo Norway
| | - Airazat M. Kazaryan
- The Interventional Centre; Oslo University Hospital; 0027 Oslo Norway
- Department of Digestive Surgery; Akershus University Hospital; University of Oslo; Lørenskog Norway
| | - Leonid Barkhatov
- The Interventional Centre; Oslo University Hospital; 0027 Oslo Norway
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
| | - Trond Buanes
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
- Department of HPB Surgery; Oslo University Hospital; Oslo Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery; Akershus University Hospital; University of Oslo; Lørenskog Norway
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Labori KJ, Brudvik KW. Follow-up After Surgery for Pancreatic Ductal Adenocarcinoma: Steps Toward an International Consensus. Pancreas 2017; 46:e2-e3. [PMID: 27977631 DOI: 10.1097/mpa.0000000000000689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Oslo, Norway
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Sahakyan MA, Røsok BI, Kazaryan AM, Barkhatov L, Haugvik SP, Fretland ÅA, Ignjatovic D, Labori KJ, Edwin B. Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis. Surg Endosc 2016; 31:2310-2316. [PMID: 27620912 DOI: 10.1007/s00464-016-5233-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/30/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution. METHODS Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital-Rikshospitalet. Twenty-four (53.3 %) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7 %) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP). RESULTS Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53-320) vs 102 (50-373) min, P = 0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3 %; P = 0.19 and 20.8 vs 33.3 %, P = 0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2-80) vs 7 (2-52), P = 0.49]. A case-matched analysis demonstrated shorter operating time [145 (90-350) vs 103 (50-233) min, P = 0.02], but higher readmission rate following LLPE (25 vs 3.1 %, P = 0.037). CONCLUSION LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.
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Affiliation(s)
- Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway.
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.
- Department of Surgery No 1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Bård Ingvald Røsok
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Leonid Barkhatov
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Sven-Petter Haugvik
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Knut Jørgen Labori
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of HPB Sugery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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Sahakyan MA, Røsok BI, Kazaryan AM, Barkhatov L, Lai X, Kleive D, Ignjatovic D, Labori KJ, Edwin B. Impact of obesity on surgical outcomes of laparoscopic distal pancreatectomy: A Norwegian single-center study. Surgery 2016; 160:1271-1278. [PMID: 27498300 DOI: 10.1016/j.surg.2016.05.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/10/2016] [Accepted: 05/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity is known as a risk factor for intra- and postoperative complications in pancreatic operation. However, the operative outcomes in obese patients undergoing laparoscopic distal pancreatectomy remain unclear. METHODS A total number of 423 patients underwent laparoscopic distal pancreatectomy at Oslo University Hospital-Rikshospitalet from April 1997 to December 2015. Patients were categorized into 3 groups based on the body mass index: normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2). After excluding underweight patients, 402 patients were enrolled in this study. RESULTS Obese patients had significantly longer operative time and increased blood loss compared with overweight and normal weight patients (190 [61-480] minutes vs 158 [56-520] minutes vs 153 [29-374] minutes, P = .009 and 200 [0-2,800] mL vs 50 [0-6250] mL vs 90 [0-2,000] mL, P = .01, respectively). A multiple linear regression analysis identified obesity as predictive of prolonged operative time and increased blood loss during laparoscopic distal pancreatectomy. The rates of clinically relevant pancreatic fistula and severe complications (≥grade III by Accordion classification) were comparable in the 3 groups (P = .23 and P = .37, respectively). A multivariate logistic regression model did not demonstrate an association between obesity and postoperative morbidity (P = .09). The duration of hospital stay was comparable in the 3 groups (P = .13). CONCLUSION In spite of longer operative time and greater blood loss, laparoscopic distal pancreatectomy in obese patients is associated with satisfactory postoperative outcomes, similar to those in normal weight and overweight patients. Hence, laparoscopic distal pancreatectomy should be equally considered both in obese and nonobese patients.
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Affiliation(s)
- Mushegh A Sahakyan
- Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of Surgery No1, Yerevan State Medical University after M.Heratsi, Yerevan, Armenia.
| | - Bård Ingvald Røsok
- Department of HPB Sugery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Airazat M Kazaryan
- Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Leonid Barkhatov
- Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Xiaoran Lai
- Department of Biostatistics, Oslo Center for Biostatistics and Epidemiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Dyre Kleive
- Department of HPB Sugery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dejan Ignjatovic
- Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Lørenskog, Norway
| | - Knut Jørgen Labori
- Department of HPB Sugery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway; Department of HPB Sugery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Timed Stair Climbing Is the Single Strongest Predictor of Perioperative Complications in Patients Undergoing Abdominal Surgery. J Am Coll Surg 2016; 222:559-66. [PMID: 26920993 DOI: 10.1016/j.jamcollsurg.2016.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/13/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current methods to predict patients' perioperative morbidity use complex algorithms with multiple clinical variables focusing primarily on organ-specific compromise. The aim of the current study was to determine the value of a timed stair climb in predicting perioperative complications for patients undergoing abdominal surgery. STUDY DESIGN From March 2014 to July 2015, three hundred and sixty-two patients attempted stair climbing while being timed before undergoing elective abdominal surgery. Vital signs were measured before and after stair climb. Ninety-day postoperative complications were assessed by the Accordion Severity Grading System. The prognostic value of stair climb was compared with the American College of Surgeons NSQIP risk calculator. RESULTS A total of 264 (97.4%) patients were able to complete the stair climb. Stair climb time directly correlated to changes in both mean arterial pressure and heart rate as an indicator of stress. An Accordion grade 2 or higher complication occurred in 84 (25%) patients. There were 8 mortalities (2.4%). Patients with slower stair climb times had increased complication rates (p < 0.0001). In multivariable analysis, stair climb time was the single strongest predictor of complications (odds ratio = 1.029; p < 0.0001), and no other clinical comorbidity reached statistical significance. Receiver operative characteristic curves predicting postoperative morbidity by stair climb time was superior to that of the American College of Surgeons risk calculator (area under the curve = 0.81 vs 0.62; p < 0.0001). Additionally, slower patients had greater deviations from predicted length of hospital stay (p = 0.034). CONCLUSIONS Stair climb provides measurable stress, accurately predicts postoperative complications, and is easy to administer in patients undergoing abdominal surgery. Larger patient populations with a diverse group of operations will be needed to validate the use of stair climbing in risk-prediction models.
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