After Pancreatectomy, the “90 Days from Surgery” Definition Is Superior to the “30 Days from Discharge” Definition for Capture of Clinically Relevant Readmissions

The Role of Preoperative Inflammatory Markers in Pancreatectomy: a Norwegian Nationwide Cohort Study

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.

Laparoscopic Distal Pancreatectomy Following Prior Upper Abdominal Surgery (Pancreatectomy and Prior Surgery)

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.

Laparoscopic distal pancreatectomy in patients with poor physical status

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.

Impact of BRAF mutations on clinical outcomes following liver surgery for colorectal liver metastases: An updated meta-analysis

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.

Implementation and training with laparoscopic distal pancreatectomy: 23-year experience from a high-volume center

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.

Quality of Care Among Medicare Patients Undergoing Pancreatic Surgery: Safety Grade, Magnet Recognition, and Leapfrog Minimum Volume Standards-Which Quality Benchmark Matters?

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.

Does Fungal Biliary Contamination after Preoperative Biliary Drainage Increase Postoperative Complications after Pancreaticoduodenectomy?

(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.

National Trends in Centralization of Surgical Care and Multimodality Therapy for Pancreatic Adenocarcinoma

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.

Validation of MTL30 as a quality indicator for colorectal surgery

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.

Clinical Factors Associated With Practice Variation in Discharge Opioid Prescriptions After Pancreatectomy

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.

Textbook Outcomes Among Medicare Patients Undergoing Hepatopancreatic Surgery

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.

Outcome after pancreatectomy for neuroendocrine neoplams according to the WHO 2017 grading system: A retrospective multicentric analysis of 138 consecutive patients

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.

Incidence of and Risk Factors for Multiple Readmissions after Kidney Transplantation

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.

Impact of concomitant ablation on the perioperative outcomes of patients with colorectal liver metastases undergoing hepatectomy: a propensity score matched nationwide analysis

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.

Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients

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.

Impact of Neoadjuvant Chemotherapy on the Postoperative Outcomes of Patients Undergoing Liver Resection for Colorectal Liver Metastases: A Population-Based Propensity-Matched Analysis

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.

Evaluation of preoperative nutritional variables to predict postoperative complications after pancreaticoduodenectomy

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.

Predictive Power of the NSQIP Risk Calculator for Early Post-Operative Outcomes After Whipple: Experience from a Regional Center in Northern Ontario

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.

Hospital readmission after pancreaticoduodenectomy: A systematic review and meta-analysis

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.

Robotic versus laparoscopic distal pancreatectomy: a French prospective single-center experience and cost-effectiveness analysis

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.

Surgery for pancreatic cancer: critical radiologic findings for clinical decision making

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.

The Comprehensive Complication Index (CCI®): Added Value and Clinical Perspectives 3 Years "Down the Line"

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.

Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis

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.

Impact of obesity on surgical outcomes of laparoscopic distal pancreatectomy: A Norwegian single-center study

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.

Timed Stair Climbing Is the Single Strongest Predictor of Perioperative Complications in Patients Undergoing Abdominal Surgery

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.