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Sawchuk T, Verhoeff K, Jogiat U, Mocanu V, Shapiro AMJ, Anderson B, Dajani K, Bigam DL. Impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy: a NSQIP retrospective cohort analysis of 25,848 patients. Surg Endosc 2024; 38:5030-5040. [PMID: 39009724 DOI: 10.1007/s00464-024-11018-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 06/30/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Efforts to preoperatively risk stratify and optimize patients before pancreaticoduodenectomy continue to improve outcomes. This study aims to determine the impact of hypoalbuminemia on outcomes following pancreaticoduodenectomy and outline optimal hypoalbuminemia cut-off values in this population. METHODS The ACS-NSQIP (2016-2021) database was used to extract patients who underwent pancreaticoduodenectomy, comparing those with hypoalbuminemia (< 3.0 g/L) to those with normal albumin. Demographics and 30-day outcomes were compared. Multivariable modeling evaluated factors including hypoalbuminemia to characterize their independent effect on serious complications, and mortality. Optimal albumin cut-offs for serious complications and mortality were evaluated using receiver-operating characteristic curves. RESULTS We evaluated 25,848 pancreaticoduodenectomy patients with 2712 (10.5%) having preoperative hypoalbuminemia. Patients with hypoalbuminemia were older (68.2 vs. 65.1; p < 0.0001), and were significantly more likely to be ASA class 4 or higher (13.9% vs. 6.7%; p < 0.0001). Patients with hypoalbuminemia had significantly more 30-day complications and after controlling for comorbidities hypoalbuminemia remained a significant independent factor associated with 30-day serious complications (OR 1.80, p < 0.0001) but not mortality (OR 1.37, p = 0.152). CONCLUSIONS Hypoalbuminemia plays a significant role in 30-day morbidity following pancreaticoduodenectomy. Preoperative albumin may serve as a useful marker for risk stratification and optimization.
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Affiliation(s)
- Taylor Sawchuk
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, AB, Canada.
| | - Uzair Jogiat
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | | | - Blaire Anderson
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Khaled Dajani
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - David L Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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McKay B, Brough D, Kilburn D, Cavallucci D. Safety and feasibility of instituting a robotic pancreas program in the Australian setting: a case series and narrative review. ANZ J Surg 2024; 94:1247-1253. [PMID: 38529778 DOI: 10.1111/ans.18998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Minimally invasive pancreatic resection has been gathering interest over the last decade due to the technical demands and high morbidity associated with these typically open procedures. We report our experience with robotic pancreatectomy within an Australian context. METHODS All patients undergoing robotic distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) at two Australian tertiary academic hospitals between May 2014 and December 2020 were included. RESULTS Sixty-two patients underwent robotic pancreatectomy during the study period. Thirty-four patients with a median age of 68 years (range 42-84) were in the PD group whilst the DP group included 28 patients with a median age of 60 years (range 18-78). Thirteen patients (46.4%) in the DP group had spleen-preserving procedures. There were 13 conversions (38.2%) in the PD group whilst 0 conversions occurred in the DP group. The Clavien-Dindo grade ≥III complication rate was 26.4% and 17.9% in the PD and DP groups, respectively. Two deaths (5.9%) occurred within 90-days in the PD group whilst none were observed in the DP group. The median length of hospital stay was 11.5 days (range 4-56) in the PD group and 6 days (range 2-22) in the DP group. CONCLUSION Robotic pancreatectomy outcomes at our institution are comparable with international literature demonstrating it is both safe and feasible to perform. With improved access to this platform, robotic pancreas surgery may prove to be the turning point for patients with regards to post-operative complications as more experience is obtained.
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Affiliation(s)
- Bartholomew McKay
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David Brough
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Daniel Kilburn
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - David Cavallucci
- Department of Hepatopancreaticobiliary Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- School of Medicine, Royal Brisbane Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
- Department of Surgery, The Wesley Hospital, Brisbane, Queensland, Australia
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Morita Y, Sakaguchi T, Matsumoto A, Ida S, Muraki R, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Takeuchi H. The cholinesterase and C-reactive protein score is a potential predictor of pseudoaneurysm formation after pancreaticoduodenectomy in patients with soft pancreas. BMC Surg 2023; 23:344. [PMID: 37964345 PMCID: PMC10647161 DOI: 10.1186/s12893-023-02211-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/29/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Pseudoaneurysm (PA) rupture after pancreaticoduodenectomy (PD) is a life-threatening complication. Most PA cases originate from postoperative pancreatic fistulas (POPFs). Although several risk factors for POPF have been identified, specific risk factors for PA formation remain unclear. Therefore, we retrospectively analyzed PD cases with soft pancreas and proposed a novel strategy for early detection of PA formation. METHODS Overall, 120 patients underwent PD between 2010 and 2020 at our institution; of these, 65 patients with soft pancreas were enrolled. We evaluated the clinicopathological factors influencing PA formation and developed a risk score to predict PA formation. RESULTS In total, 11 of the 65 patients developed PAs (PA formation group: PAG), and 8 of these 11 PAs ruptured. The median time to PA formation was 15 days, with a minimum of 5 days. The PAG was significantly older than the non-PA formation group, were predominantly men, and had comorbid diabetes mellitus. Pre- and intra-operative findings were similar between the two groups. Importantly, no significant differences were found in postoperative drain amylase levels and total drain amylase content. Cholinesterase and C-reactive protein (CRP) levels on postoperative day (POD) 3 were significantly different between the two groups. Multivariate analysis showed that cholinesterase ≤ 112 U/L and CRP ≥ 16.0 mg/dl on POD 3 were independent predictors of PA formation. CONCLUSIONS Decreased cholinesterase and elevated CRP on POD 3 (Cho-C score) are useful predictors of PA formation in cases with soft pancreas. In such cases, periodic computed tomography evaluations and strict drain management are necessary to prevent life-threatening hemorrhage.
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Affiliation(s)
- Yoshifumi Morita
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
- Division of Surgical care, Morimachi, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | | | - Akio Matsumoto
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Shinya Ida
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ryuta Muraki
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ryo Kitajima
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Satoru Furuhashi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Makoto Takeda
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yoshihiro Hiramatsu
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
- Department of Perioperative Functioning Care & Support, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Dahal S, Gyawali S, Neupane P, Neupane P, Hamal A, Verma R, Pachhai P, Khadka R, Karki B, Khatiwada RD, Kansakar PBS. Comparison of abdominal depth with subcutaneous fat thickness in predicting surgical site infection among patients undergoing hepatopancreatobiliary surgery: a prospective observational study. Ann Med Surg (Lond) 2023; 85:4720-4724. [PMID: 37811037 PMCID: PMC10552989 DOI: 10.1097/ms9.0000000000001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/27/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Surgical site infection (SSI) is a significant cause of postoperative morbidity resulting in an increased hospital stay and cost. Various measures have been used to predict SSI such as subcutaneous fat thickness (SCFT) and abdominal depth (AD) in case of abdominal surgeries. The objective of the study was to compare SCFT with AD to predict SSI in HPB surgeries. Methods A prospective observational study was conducted from February 2020 to February 2021, which included 76 patients who underwent elective open hepatopancreatobiliary surgeries. SCFT and AD at the level of the umbilicus were measured preoperatively using the computed tomography abdomen. The occurrence of SSI was evaluated in correlation with SCFT and AD. SCFT and AD were compared using the receiver operating characteristic curve for prediction of SSI. Results Twenty-five (32.3%) patients who underwent elective HPB surgeries developed SSI. 72% of the SSI were superficial. In multivariate analysis, only SCFT was associated with SSI, which was statistically significant. It was compared with AD using the receiver operating characteristic curve where SCFT proved to be better at predicting SSI (AUC=0.884) with cut-off =2.13 cm, sensitivity 84%, and specificity 86%), compared to AD with an AUC of 0.449. Conclusion SSI is the common cause of increased morbidity following hepato-pancreato-biliary surgeries with risk factors including SCFT and AD. Approximately one-third of patient developed SSI, with most the common being superficial SSI. SCFT at the incision site was associated with an increased rate of SSI and the better predictor for SSI as compared with the AD.
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Affiliation(s)
- Suman Dahal
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Sushil Gyawali
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | | | | | - Aliza Hamal
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Rupesh Verma
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Prarthana Pachhai
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Rabi Khadka
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Badal Karki
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Raj D. Khatiwada
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Prasan B. S. Kansakar
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
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Axentiev A, Shmelev A, Cunningham SC. Predictors of In-Hospital Mortality Following Pancreatectomy. Cureus 2023; 15:e45830. [PMID: 37881394 PMCID: PMC10593593 DOI: 10.7759/cureus.45830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND In-hospital mortality rates following all types of pancreatic resections (PRs) have decreased over recent decades. Our aim was to identify predictors of in-hospital mortality following pancreatic resection. METHODS All patients undergoing pancreatic resection were sampled from the National Inpatient Sample (NIS) in the years 2007-2012. Predictors of in-hospital mortality were identified and incorporated into a binary logistic regression model. RESULTS A total of 111,568 patients underwent pancreatectomy. Annual mortality rates decreased from 4.3% in 2007 to 3.5% in 2012. Independent predictors of in-hospital mortality included age ≥75 years (vs. <65 years, OR = 2.04; 95% CI: 1.61-2.58), nonelective procedure status (OR = 1.46; 95% CI: 1.19-1.80), resection other than distal pancreatic resection (vs. Whipple, OR = 2.14; 95% CI: 1.71-2.69; other partial, OR = 2.48; 95% CI: 1.76-3.48), lower hospital volume (OR = 1.28; 95% CI: 1.09-1.49), indication for pancreatic resection other than benign diseases (vs. malignant, OR = 1.63; 95% CI: 1.25-2.15; other, OR = 2.48; 95% CI: 1.76-3.48), pulmonary complications (OR = 12.36; 95% CI: 10.11-15.17), infectious complications (OR = 2.17; 95% CI: 1.78-2.64), noninfectious wound complications and pancreatic leak (OR = 1.94; 95% CI: 1.53-2.46), and acute myocardial infarction (OR = 2.03; 95% CI: 1.32-3.06). DISCUSSION Our findings identify predictors of inpatient mortality following pancreatectomy, with pulmonary complications representing the single most significant factor for increased mortality. These findings complement and expand on previously published data and, if applied to perioperative care, may enhance survival following pancreatectomy.
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Affiliation(s)
- Anna Axentiev
- Surgery, Ascension Saint Agnes Hospital, Baltimore, USA
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Louise Lalisang AN, Nugroho A, Putranto AS, Mazni Y, Lalisang TJM. Keep It or Leave It? Comparison of Preoperative Scoring as Mortality Predictor Post-Pancreaticoduodenectomy. Asian Pac J Cancer Prev 2023; 24:2885-2893. [PMID: 37642078 PMCID: PMC10685213 DOI: 10.31557/apjcp.2023.24.8.2885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is the common procedure in resectable periampullary malignancies. However, the postoperative mortality rate for PD is relatively high. Mortality scoring system helps surgeons to decide patients' eligibility for surgery to minimize mortality risk. This study aimed to compare four scoring systems for mortality prediction after PD in the Indonesian population. METHODS In this cross-sectional study, data were retrospectively collected from medical records for patients who underwent PD due to periampullary malignancy between January 2010 and January 2022. We assessed scoring accuracy, cut-off, sensitivity, specificity, negative predictive value, positive predictive value, and area under the curve (AUC) of Naples prognostic score (NPS), Whipple-ABACUS (WA), modified Pitt score (MPS), and Pitt score. RESULT Of the 116 patients who met the criteria, the mortality rate was 12.1%. Mean age was 51.64 ± 10.22 years consist of 75.9% group <60 years and 24.1% ≥60 years, with 46.6% male and 53.4% female. The AUC from highest to lowest were Pitt Score 0.890 (p<0.001), MPS 0.775 (p 0.001), WA 0.627 (p 0.123), and NPS 0.505 (p 0.949) with the level of accuracy of each score were Pitt Score and MPS 67.2%, WA 50.0%, and NPS 59.5%. CONCLUSION Pitt and MPS scores have the highest accuracy of all the scoring systems in this study. MPS has the advantage of having fewer components, making it easy to implement. MPS can replace the role of the Pitt Score in predicting post-procedure PD mortality in Indonesia. Further studies that include the intraoperative factors are needed to increase the scoring accuracy.
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Affiliation(s)
- Arnetta Naomi Louise Lalisang
- Division of Digestive Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia, dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Adianto Nugroho
- Hepatobiliary unit, Digestive Division, Department of Surgery, Fatmawati Hospital, Jakarta, Indonesia.
| | - Agi Satria Putranto
- Division of Digestive Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia, dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Yarman Mazni
- Division of Digestive Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia, dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Toar Jean Maurice Lalisang
- Division of Digestive Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia, dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
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Bellotti R, Cardini B, Strolz CJ, Stättner S, Oberhuber R, Braunwarth E, Resch T, Scheidl S, Margreiter C, Schneeberger S, Öfner D, Maglione M. Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy. J Clin Med 2023; 12:3318. [PMID: 37176758 PMCID: PMC10179219 DOI: 10.3390/jcm12093318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques. METHODS This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used. RESULTS Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015). CONCLUSION Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.
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Affiliation(s)
- Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Carola J. Strolz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergut Hospital, 4840 Vöcklabruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
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Khachfe HH, Hammad AY, AlMasri S, deSilva A, Kraftician J, Lee KK, Zureikat AH, Paniccia A. Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma. J Surg Res 2023; 284:164-172. [PMID: 36577229 PMCID: PMC11200326 DOI: 10.1016/j.jss.2022.11.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Conflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). METHODS All patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan-Meier survival analysis. RESULTS Of the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. CONCLUSIONS Obesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.
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Affiliation(s)
- Hussein H Khachfe
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Abdulrahman Y Hammad
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Samer AlMasri
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Annissa deSilva
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Jasmine Kraftician
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, Pennsylvania.
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Kapoor D, Perwaiz A, Singh A, Kumar AN, Chaudhary A. Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase. Langenbecks Arch Surg 2023; 408:130. [PMID: 36991246 DOI: 10.1007/s00423-023-02865-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/19/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases. METHODS This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model. RESULTS The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM. CONCLUSION Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Arun N Kumar
- Department of Data Science, Alke Research Private Limited, Bengaluru, Karnataka, India
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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Alhulaili ZM, Pleijhuis RG, Nijkamp MW, Klaase JM. External Validation of a Risk Model for Severe Complications following Pancreatoduodenectomy Based on Three Preoperative Variables. Cancers (Basel) 2022; 14:cancers14225551. [PMID: 36428643 PMCID: PMC9688739 DOI: 10.3390/cancers14225551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is the only cure for periampullary and pancreatic cancer. It has morbidity rates of 40-60%, with severe complications in 30%. Prediction models to predict complications are crucial. A risk model for severe complications was developed by Schroder et al. based on BMI, ASA classification and Hounsfield Units of the pancreatic body on the preoperative CT scan. These variables were independent predictors for severe complications upon internal validation. Our aim was to externally validate this model using an independent cohort of patients. METHODS A retrospective analysis was performed on 318 patients who underwent PD at our institution from 2013 to 2021. The outcome of interest was severe complications Clavien-Dindo ≥ IIIa. Model calibration, discrimination and performance were assessed. RESULTS A total of 308 patients were included. Patients with incomplete data were excluded. A total of 89 (28.9%) patients had severe complications. The externally validated model achieved: C-index = 0.67 (95% CI: 0.60-0.73), regression coefficient = 0.37, intercept = 0.13, Brier score = 0.25. CONCLUSIONS The performance ability, discriminative power, and calibration of this model were acceptable. Our risk calculator can help surgeons identify high-risk patients for post-operative complications to improve shared decision-making and tailor perioperative management.
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Affiliation(s)
- Zahraa M. Alhulaili
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
| | - Rick G. Pleijhuis
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
| | - Maarten W. Nijkamp
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
| | - Joost M. Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
- Correspondence:
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Amini N, D'Adamo CR, Khashchuk D, Dodson R, Katlic M, Wolf J, Mavanur A. Accuracy of National Surgical Quality Improvement Program Risk Calculator Among Elderly Patients Undergoing Pancreas Resection. J Surg Res 2022; 279:567-574. [DOI: 10.1016/j.jss.2022.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/12/2022] [Accepted: 06/28/2022] [Indexed: 10/31/2022]
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Moore TM, Calkins ME, Rosen AFG, Butler ER, Ruparel K, Fusar-Poli P, Koutsouleris N, McGuire P, Cannon TD, Gur RC, Gur RE. Development of a probability calculator for psychosis risk in children, adolescents, and young adults. Psychol Med 2022; 52:3159-3167. [PMID: 33431073 PMCID: PMC8273212 DOI: 10.1017/s0033291720005231] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Assessment of risks of illnesses has been an important part of medicine for decades. We now have hundreds of 'risk calculators' for illnesses, including brain disorders, and these calculators are continually improving as more diverse measures are collected on larger samples. METHODS We first replicated an existing psychosis risk calculator and then used our own sample to develop a similar calculator for use in recruiting 'psychosis risk' enriched community samples. We assessed 632 participants age 8-21 (52% female; 48% Black) from a community sample with longitudinal data on neurocognitive, clinical, medical, and environmental variables. We used this information to predict psychosis spectrum (PS) status in the future. We selected variables based on lasso, random forest, and statistical inference relief; and predicted future PS using ridge regression, random forest, and support vector machines. RESULTS Cross-validated prediction diagnostics were obtained by building and testing models in randomly selected sub-samples of the data, resulting in a distribution of the diagnostics; we report the mean. The strongest predictors of later PS status were the Children's Global Assessment Scale; delusions of predicting the future or having one's thoughts/actions controlled; and the percent married in one's neighborhood. Random forest followed by ridge regression was most accurate, with a cross-validated area under the curve (AUC) of 0.67. Adjustment of the model including only six variables reached an AUC of 0.70. CONCLUSIONS Results support the potential application of risk calculators for screening and identification of at-risk community youth in prospective investigations of developmental trajectories of the PS.
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Affiliation(s)
- Tyler M. Moore
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Lifespan Brain Institute, Penn Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Monica E. Calkins
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Lifespan Brain Institute, Penn Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Adon F. G. Rosen
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ellyn R. Butler
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kosha Ruparel
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Lifespan Brain Institute, Penn Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Paolo Fusar-Poli
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- OASIS service, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Nikolaos Koutsouleris
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University Munich, Germany
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Tyrone D. Cannon
- Departments of Psychology and Psychiatry, Yale University, New Haven, CT 06520, USA
| | - Ruben C. Gur
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Lifespan Brain Institute, Penn Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Raquel E. Gur
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Lifespan Brain Institute, Penn Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Narcotic sparing postoperative analgesic strategies after pancreatoduodenectomy: analysis of practice patterns for 1004 patients. HPB (Oxford) 2022; 24:1145-1152. [PMID: 35151580 DOI: 10.1016/j.hpb.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Improved post-operative outcomes have been demonstrated in gastrointestinal procedures where a narcotic sparing strategy has been utilized. Data for pancreaticoduodenectomy (PD) patients is limited. This study reviews an institutional database for outcomes based on initial analgesic strategy. METHODS 1004 consecutive patients who underwent PD at Emory University between 2010 and 2017, were included in the analysis. Patients were divided into groups based on primary analgesic strategy employed: epidural alone (EPI), patient controlled opiate analgesia (PCA), dual (dual-PCA/EPI) and other (non-PCA/EPI). Postoperative outcomes for each group were analyzed utilizing univariate and multivariate linear regression. RESULTS 448 (44.6%) patients were treated with EPI, 300 (29.9%) were given a PCA, 78 (7.8%) had dual-PCA/EPI and 178 (17.7%) had non-PCA/EPI analgesia. On univariate analysis, increased BMI (p = 0.030), PCA use (p < 0.001), venous thromboembolism (VTE) (p < 0.001), post-operative pancreatic fistula (POPF) (p < 0.001) and Ileus/delayed gastric emptying (DGE) (p < 0.001) were all correlated with increased LOS. On multivariate linear regression, VTE (b-coefficient 9.07, p = 0.004) POPF (8.846, p = 0.001), Ileus/DGE (4.464, p = 0.004) and PCA use (1.75, p = 0.003) were associated with significantly increased LOS. CONCLUSION A primary narcotic sparing strategy is associated with a significantly reduced LOS and lower rates of Ileus/DGE. Mean opiate usage was significantly lower in the EPI and non-EPI/PCA groups.
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Kisana H, Hui CH, Deeyor S, Martin JR, Stecher C, Hustedt JW. Development of a Risk Stratification Scoring System to Predict General Surgical Complications for Patients Undergoing Foot and Ankle Surgery. Orthopedics 2022; 45:139-144. [PMID: 35201937 DOI: 10.3928/01477447-20220217-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hyponatremia (<135 mEq/L), and anemia (hematocrit value, men <42%; women <38%). Point scores for each factor were: anemia, +10; hypoalbuminemia, +9; elevated creatinine level, +6; CHF, +4; diabetes mellitus, +3; hyponatremia, +3; COPD, +2; hypertension, +2; age, +1; and tobacco abuse, +1. For the validation cohort, we stratified patients according to risk as low (0-20 points), medium (21-30 points), and high (≥31 points) risk. In terms of having a postoperative complication, compared with low-risk patients, patients who were at medium risk had an odds ratio of 4.7 (95% CI, 2.8-7.9) and those at high risk had an odds ratio of 8.3 (95% CI, 4.8-14.5). [Orthopedics. 2022;45(3):139-144.].
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Perioperative risk of pancreatic head resection-nomogram-based prediction of severe postoperative complications as a decisional aid for clinical practice. Langenbecks Arch Surg 2022; 407:1935-1947. [PMID: 35320379 PMCID: PMC9399026 DOI: 10.1007/s00423-021-02426-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/29/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE To develop nomograms for pre- and early-postoperative risk assessment of patients undergoing pancreatic head resection. METHODS Clinical data from 956 patients were collected in a prospectively maintained database. A test (n = 772) and a validation cohort (n = 184) were randomly generated. Uni- and multi-variate analysis and nomogram construction were performed to predict severe postoperative complications (Clavien-Dindo Grades III-V) in the test cohort. External validation was performed with the validation cohort. RESULTS We identified ASA score, indication for surgery, body mass index (BMI), preoperative white blood cell (WBC) count, and preoperative alkaline phosphatase as preoperative factors associated with an increased perioperative risk for complications. Additionally to ASA score, BMI, indication for surgery, and the preoperative alkaline phosphatase, the following postoperative parameters were identified as risk factors in the early postoperative setting: the need for intraoperative blood transfusion, operation time, maximum WBC on postoperative day (POD) 1-3, and maximum serum amylase on POD 1-3. Two nomograms were developed on the basis of these risk factors and showed accurate risk estimation for severe postoperative complications (ROC-AUC-values for Grades III-V-preoperative nomogram: 0.673 (95%, CI: 0.626-0.721); postoperative nomogram: 0.734 (95%, CI: 0.691-0.778); each p ≤ 0.001). Validation yielded ROC-AUC-values for Grades III-V-preoperative nomogram of 0.676 (95%, CI: 0.586-0.766) and postoperative nomogram of 0.677 (95%, CI: 0.591-0.762); each p = 0.001. CONCLUSION Easy-to-use nomograms for risk estimation in the pre- and early-postoperative setting were developed. Accurate risk estimation can support the decisional process, especially for IPMN-patients with an increased perioperative risk.
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Filho JELP, Tustumi F, Coelho FF, Júnior SS, Honório FCC, Henriques AC, Dias AR, Waisberg J. The impact of venous resection in pancreatoduodectomy: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27438. [PMID: 34622858 PMCID: PMC8500612 DOI: 10.1097/md.0000000000027438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/02/2021] [Accepted: 09/17/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Vein resection pancreatoduodenectomy (VRPD) may be performed in selected pancreatic cancer patients. However, the main risks and benefits related to VRPD remain controversial. OBJECTIVE This review aimed to evaluate the risks and survival benefits that the VRPD may add when compared with standard pancreatoduodenectomy (PD). METHODS A systematic review and meta-analysis of studies comparing VRPD and PD were performed. RESULTS VRPD was associated with a higher risk for postoperative mortality (risk difference: -0.01; 95% confidence interval [CI] -0.02 to -0.00) and complications (risk difference: -0.05; 95% CI -0.09 to -0.01) than PD. The length of hospital stay was not different between the groups (mean difference [MD]: -0.65; 95% CI -2.11 to 0.81). In the VRPD, the operating time was 69 minutes higher on average (MD: -69.09; 95% CI -88.4 to -49.78), with a higher blood loss rate (MD: -314.04; 95% CI -423.86 to -195.22). In the overall survival evaluation, the hazard ratio for mortality during follow-up on the group of VRPD was higher compared to the PD group (hazard ratio: 1.13; 95% CI 1.03-1.23). CONCLUSION VRPD is associated with a higher risk of short-term complications and mortality and a lower probability of survival than PD. Knowing the risks and potential benefits of surgery can help clinicians to properly manage pancreatic cancer patients with venous invasion. The decision for surgery with major venous resection should be shared with the patients after they are informed of the risks and prognosis.
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Affiliation(s)
| | - Francisco Tustumi
- Hospital Estadual Mario Covas, Santo Andre, SP, Brazil
- Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Fabricio Ferreira Coelho
- Hospital Estadual Mario Covas, Santo Andre, SP, Brazil
- Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Sérgio Silveira Júnior
- Hospital Estadual Mario Covas, Santo Andre, SP, Brazil
- Universidade de São Paulo, Sao Paulo, SP, Brazil
| | | | | | - André Roncon Dias
- Hospital Estadual Mario Covas, Santo Andre, SP, Brazil
- Universidade de São Paulo, Sao Paulo, SP, Brazil
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Lapshyn H, Petruch N, Thomaschewski M, Sondermann S, May K, Frohneberg L, Petrova E, Zemskov S, Honselmann KC, Braun R, Keck T, Wellner UF, Bolm L. A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy. Pancreatology 2021; 21:957-964. [PMID: 33775565 DOI: 10.1016/j.pan.2021.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/28/2021] [Accepted: 03/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) can be associated with severe postoperative morbidity. This study aims to develop a preoperative POPF risk calculator that can be easily implemented in clinical routine. METHODS Patients undergoing PD were identified from a prospectively-maintained database. A total of 11 preoperative baseline and CT-based radiological parameters were used in a binominal logistic regression model. Parameters remaining predictive for grade B/C POPF were entered into the risk calculator and diagnostic accuracy measures and ROC curves were calculated for a training and a test patient cohort. The risk calculator was transformed into a simple nomogram. RESULTS A total of 242 patients undergoing PD in the period from 2012 to 2018 were included. CT-imaging-based maximum main pancreatic duct (MPD) diameter (p = 0.047), CT-imaging-based pancreatic gland diameter at the anticipated resection margin (p = 0.002) and gender (p = 0.058) were the parameters most predictive for grade B/C POPF. Based on these parameters, a risk calculator was developed to identify patients at high risk of developing grade B/C POPF. In a training cohort of PD patients this risk calculator was associated with an AUC of 0.808 (95%CI 0.726-0.874) and an AUC of 0.756 (95%CI 0.669-0-830) in the independent test cohort. A nomogram applicable as a visual risk scale for quick assessment of POPF grade B/C risk was developed. CONCLUSION The preoperative POPF risk calculator provides a simple tool to stratify patients planned for PD according to the risk of developing postoperative grade B/C POPF. The nomogram visual risk scale can be easily integrated into clinical routine and may be a valuable model to select patients for POPF-preventive therapy or as a stratification tool for clinical trials.
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Affiliation(s)
- Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Natalie Petruch
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Michael Thomaschewski
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Stefan Sondermann
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Katharina May
- Department of Radiology, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Laura Frohneberg
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Sergii Zemskov
- Department of General Surgery, Bogomolets National Medical Unoversity, Kiev, Ukraine
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Rüdiger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany.
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562 Luebeck, Germany
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Root-Cause Analysis of Mortality Following Pancreatic Resection (CARE Study): A Multicenter Cohort Study. Ann Surg 2021; 274:789-796. [PMID: 34334643 DOI: 10.1097/sla.0000000000005118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate. BACKGROUND Despite undeniable progress in pancreatic surgery for over a century, postoperative outcome remain particularly worse and could be further improved. METHODS All patients undergoing pancreatectomy between January 2015 and December 2018 and died post-operatively within 90 days after were included. RCA was performed in two stages: the first being the exhaustive collection of data concerning each patient from preoperative to death and the second being blind analysis of files by an independent expert committee. A typical root cause of death was defined with the identification of avoidable death. RESULTS Among the 3195 patients operated on in nine participating centers, 140 (4.4%) died within 90 days after surgery. After the exclusion of 39 patients, 101 patients were analyzed. The cause of death was identified in 90% of cases. After RCA, mortality was preventable in 30% of cases, mostly consequently to a preoperative assessment (disease evaluation) or a deficient postoperative management (notably pancreatic fistula and hemorrhage). An inappropriate intraoperative decision was incriminated in 10% of cases. The comparative analysis showed that young age and arterial resection, especially unplanned, were often associated with avoidable mortality. CONCLUSION One third of postoperative mortality after pancreatectomy seems to be avoidable, even if the surgery is performed in high volume centers. These data suggest that improving postoperative pancreatectomy outcome requires a multidisciplinary, rigorous and personalized management.
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Beane JD, Borrebach JD, Billderback A, Onuma AE, Adam MA, Zureikat AH, Pitt HA. Small pancreatic neuroendocrine tumors: Resect or enucleate? Am J Surg 2021; 222:29-34. [DOI: 10.1016/j.amjsurg.2020.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 12/18/2022]
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Al Abbas AI, Borrebach JD, Pitt HA, Bellon J, Hogg ME, Zeh HJ, Zureikat AH. Development of a Novel Pancreatoduodenectomy-Specific Risk Calculator: an Analysis of 10,000 Patients. J Gastrointest Surg 2021; 25:1503-1511. [PMID: 32671801 DOI: 10.1007/s11605-020-04725-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 06/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is often performed in frail patients and is associated with significant morbidity. The five-factor modified frailty index (mFI-5) has been utilized to predict adverse postoperative outcomes, but has not been tested in PD. We aimed to develop risk tools to generate and predict 30-day outcomes after PD and compare their performance with the mFI-5. Risk tools were then used to generate a PD-specific calculator. METHODS Elective PDs from the 2014-2016 ACS NSQIP® Procedure Targeted Pancreatectomy PUFs were identified. Multivariable logistic regression models were constructed to predict postoperative mortality, any complication, serious complication, clinically relevant postoperative pancreatic fistula (CR-POPF), and discharge not-to-home. Predictive accuracy was evaluated through repeated stratified tenfold cross-validation and compared to the mFI-5. RESULTS Nine thousand eight hundred sixty-seven PDs were captured. Nine risk factors were retained: sex, age, BMI, DM, HTN, ASA classification, pancreatic duct size, gland texture, and adenocarcinoma. Cross-validated C-indices ranged from 0.49 to 0.61 for the mFI-5 and 0.63 to 0.75 for our risk models. The best-performing model was for discharge not-to-home (C = 0.75), and the model delivering the largest increase in predictive accuracy was for CR-POPF (CmFI-5/Model = 0.49/0.70). A user-friendly risk calculator was created predicting the five outcomes of interest. CONCLUSION We have created a PD-specific risk calculator that outperforms the mFI-5. This calculator may serve as a useful adjunct in shared decision-making for patients and surgeons.
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Affiliation(s)
- Amr I Al Abbas
- Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Henry A Pitt
- Temple University Health System, Philadelphia, PA, USA
| | | | | | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA.
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Traub B, Link KH, Kornmann M. Curing pancreatic cancer. Semin Cancer Biol 2021; 76:232-246. [PMID: 34062264 DOI: 10.1016/j.semcancer.2021.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/14/2022]
Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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Complications After Immediate 2-Stage Tissue Expander/Implant Breast Reconstruction: A Deeper Look at the Second Stage. Ann Plast Surg 2021; 84:638-643. [PMID: 31800563 DOI: 10.1097/sap.0000000000002126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Complications after 2-stage tissue expander/implant breast reconstruction have been studied as outcomes of a single procedure. We separately evaluated complications after the second stage and assessed factors associated with the outcomes of the second stage of breast reconstruction. METHODS Patients who underwent immediate 2-stage breast reconstruction between February 2010 and April 2017 were retrospectively reviewed. Patient demographics, surgical factors of the first stage of breast reconstruction, and complications and number of revision surgeries after the second stage were recorded. Factors associated with postoperative complications were analyzed, and a risk-scoring system was devised. RESULTS We analyzed 619 patients who underwent 653 immediate 2-stage breast reconstructions. Multivariate analysis showed that complications were associated independently with smoking history, radiotherapy, and a final inflation volume of 450 mL or greater. Each factor contributed 1 point in the creation of a risk-scoring system. The overall complication rate was increased as the risk score increased (1.2%, 4.7%, and 16.0% for 0, 1, and 2 risk scores, respectively, P < 0.001). Revision operation rate was also significantly different across the 3 groups (0.2%, 1.6%, and 12.0% for 0, 1, and 2 risk scores, respectively, P < 0.001). The area under the receiver operating characteristic curve was 0.732 and 0.731 for the logistic regression model and risk-scoring system, respectively (P = 0.975). CONCLUSIONS In the second stage of immediate 2-stage tissue expander/implant breast reconstruction, the rate of complication and revision surgery can be predicted by a novel risk-scoring system. Greater attention and preventive measures for complications are needed for high-risk patients.
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Schlick CJR, Ellis RJ, Merkow RP, Yang AD, Bentrem DJ. Development and validation of a risk calculator for post-discharge venous thromboembolism following hepatectomy for malignancy. HPB (Oxford) 2021; 23:723-732. [PMID: 32988755 PMCID: PMC7990740 DOI: 10.1016/j.hpb.2020.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/16/2020] [Accepted: 09/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-discharge venous thromboembolism (VTE) chemoprophylaxis decreases VTEs following cancer surgery, however identifying high-risk patients remains difficult. Our objectives were to (1) identify factors available at hospital discharge associated with post-discharge VTE following hepatectomy for malignancy and (2) develop and validate a post-discharge VTE risk calculator to evaluate patient-specific risk. METHODS Patients who underwent hepatectomy for malignancy from 2014 to 2017 were identified from the ACS NSQIP hepatectomy procedure targeted module. Multivariable logistic regression identified factors associated with post-discharge VTE. A post-discharge VTE risk calculator was constructed, and predicted probabilities of post-discharge VTE were calculated. RESULTS Among 11 172 patients, 95 (0.9%) developed post-discharge VTE. Post-discharge VTE was associated with obese BMI (OR 2.29 vs. normal BMI [95%CI 1.31-3.99]), right hepatectomy/trisegmentectomy (OR 1.63 vs. partial/wedge [95%CI 1.04-2.57]), and several inpatient postoperative complications: renal insufficiency (OR 5.29 [95%CI 1.99-14.07]), transfusion (OR 1.77 [95%CI 1.12-2.80]), non-operative procedural intervention (OR 2.97 [95%CI 1.81-4.86]), and post-hepatectomy liver failure (OR 2.22 [95%CI 1.21-4.08]). Post-discharge VTE risk ranged from 0.3% to 30.2%. Twenty iterations of 10-fold cross validation identified internal validity. CONCLUSIONS Risk factors from all phases of care, including inpatient complications, are associated with post-discharge VTE following hepatectomy. Identifying high-risk patients may allow for personalized risk-based post-discharge chemoprophylaxis prescribing.
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Affiliation(s)
- Cary Jo R. Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan J. Ellis
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David J. Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA
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Qu G, Wang D, Xu W, Wu K, Guo W. The Systemic Inflammation-Based Prognostic Score Predicts Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy. Int J Gen Med 2021; 14:787-795. [PMID: 33727855 PMCID: PMC7955733 DOI: 10.2147/ijgm.s299167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/22/2021] [Indexed: 01/07/2023] Open
Abstract
Background Although many studies have confirmed the correlation between inflammation-based or nutritional markers and postoperative complications in patients undergoing colorectal cancer surgery, their correlation after undergoing pancreaticoduodenectomy (PD) remains unclear. Methods We retrospectively reviewed the clinical data of patients who underwent PD in Beijing Friendship hospital between 2018 and 2020. Univariate analysis, multivariate analysis, and receiver operating characteristic curve (ROC) were performed. We assessed the preoperative modified Glasgow Prognostic Score (mGPS), C-reactive protein/albumin ratio (CAR), C-reactive protein (CRP), postoperative Glasgow Prognostic Score (poGPS), CRP on postoperative day 3 (POD3) and CAR on POD3. The optimal cut-off values were determined by performing logistic regression analysis. Results Of the 172 patients who underwent PD, 74 (43.0%) developed complications, of whom 27 (15.7%) had clinically relevant postoperative pancreatic fistulas (CR-POPF) and 36 (20.9%) had positive drainage fluid cultures. Elevated levels of preoperative mGPS (P<0.001), poGPS (P<0.001), CRP (P<0.001) and CAR on POD3 were associated with postoperative complications. CRP on POD3 (OR=1.028, 95% CI=1.017-1.039, P<0.001) was an independent risk factor associated with postoperative complications in both univariate and multivariate analyses. CAR on POD 3 showed the largest area under the curve (AUC=0.883, P<0.001). Compared with CAR<4.86, CAR ≥4.86 on POD3 was associated with a higher probability of complications (85.5% vs 14.6%, P<0.001), especially CR-POPF (33.3% vs 4.9%, P<0.001), intra-abdominal infection (36.2% vs 10.7%, P<0.001) with a positive drainage fluid culture. Conclusion CAR, an inflammatory response-based marker, can effectively predict early postoperative complications in patients undergone PD.
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Affiliation(s)
- Guangzhen Qu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Dong Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Weiyu Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Kai Wu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Wei Guo
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
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Nevarez NM, Brajcich BC, Liu J, Ellis R, Ko CY, Pitt HA, D'Angelica MI, Yopp AC. Cefoxitin versus piperacillin-tazobactam as surgical antibiotic prophylaxis in patients undergoing pancreatoduodenectomy: protocol for a randomised controlled trial. BMJ Open 2021; 11:e048398. [PMID: 33664081 PMCID: PMC7934720 DOI: 10.1136/bmjopen-2020-048398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Although antibiotic prophylaxis is established in reducing postoperative surgical site infections (SSIs), the optimal antibiotic for prophylaxis in pancreatoduodenectomy (PD) remains unclear. The study objective is to evaluate if administration of piperacillin-tazobactam as antibiotic prophylaxis results in decreased 30-day SSI rate compared with cefoxitin in patients undergoing elective PD. METHODS AND ANALYSIS This study will be a multi-institution, double-arm, non-blinded randomised controlled superiority trial. Adults ≥18 years consented to undergo PD for all indications who present to institutions participating in the National Surgical Quality Improvement Program Hepato-Pancreato-Biliary (NSQIP HPB) Collaborative will be included. Data collection will use the NSQIP HPB Collaborative Surgical Clinical Reviewers. Patients will be randomised to either 1-2 g intravenous cefoxitin or 3.375-4.5 g intravenous piperacillin-tazobactam within 60 min of surgical incision. The primary outcome will be 30-day postoperative SSI rate following PD. Secondary outcomes will include 30-day postoperative mortality; specific postoperative complication rate; and unplanned reoperation, length of stay, and hospital readmission. A subset of patients will have bacterial isolates and sensitivities of intraoperative bile cultures and SSIs. Postoperative SSIs and secondary outcomes will be analysed using logistic regression models with the primary predictor as the randomised treatment group. Additional adjustment will be made for preoperative biliary stent presence. Additionally, bacterial cultures and isolates will be summarised by presence of bacterial species and antibiotic sensitivities. ETHICS AND DISSEMINATION This study is approved by the Institutional Review Board at Memorial Sloan Kettering Cancer Center. This trial will evaluate the effect of piperacillin-tazobactam compared with cefoxitin as antibiotic prophylaxis on the hazard of postoperative SSIs. The results will be disseminated regardless of the effect of the intervention on study outcomes. The manuscript describing the effect of the intervention will be submitted to a peer-reviewed journal when data collection and analyses are complete. TRIAL REGISTRATION NUMBER NCT03269994.
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Affiliation(s)
- Nicole M Nevarez
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jason Liu
- American College of Surgeons, Chicago, Illinois, USA
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Ryan Ellis
- American College of Surgeons, Chicago, Illinois, USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, Illinois, USA
| | - Henry A Pitt
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adam C Yopp
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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AlSowaiegh R, Naar L, Mokhtari A, Parks JJ, Fawley J, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA. Does the Emergency Surgery Score predict failure to discharge the patient home? A nationwide analysis. J Trauma Acute Care Surg 2021; 90:471-476. [PMID: 33055577 DOI: 10.1097/ta.0000000000002980] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Emergency Surgery Score (ESS) is a point-based scoring system validated to predict mortality and morbidity in emergency general surgery (EGS). In addition to demographics and comorbidities, ESS accounts for the acuity of disease at presentation. We sought to examine whether ESS can predict the destination of discharge of EGS patients, as a proxy for quality of life at discharge. METHODS Using the 2007 to 2017 American College of Surgeons National Surgical Quality Improvement Program database, we identified all EGS patients. EGS cases were defined as per American College of Surgeons National Surgical Quality Improvement Program as those performed by a general surgeon within a short interval from diagnosis or the onset of related symptomatology, when the patient's well-being and outcome may be threatened by unnecessary delay and patient's status could deteriorate unpredictably or rapidly. Emergency Surgery Score patients were then categorized by their discharge disposition to home versus rehabilitation or nursing facilities. All patients with missing ESS or discharge disposition and those discharged to hospice, senior communities, or separate acute care facilities were excluded. Emergency Surgery Score was calculated for each patient. C statistics were used to study the correlation between ESS and the destination of discharge. RESULTS Of 6,485,915 patients, 84,694 were included. The mean age was 57 years, 51% were female, and 79.6% were discharged home. The mean ESS was 5. Emergency Surgery Score accurately and reliably predicted the discharge destination with a C statistic of 0.83. For example, ESS of 1, 10, and 20 were associated with 0.9%, 56.5%, and 100% rates of discharge to a rehabilitation or nursing facility instead of home. CONCLUSION Emergency Surgery Score accurately predicts which EGS patients require discharge to rehabilitation or nursing facilities and can thus be used for preoperatively counseling patients and families and for improving early discharge preparations, when appropriate. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Reem AlSowaiegh
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Naar L, El Hechi M, Kokoroskos N, Parks J, Fawley J, Mendoza AE, Saillant N, Velmahos GC, Kaafarani HMA. Can the Emergency Surgery Score (ESS) predict outcomes in emergency general surgery patients with missing data elements? A nationwide analysis. Am J Surg 2020; 220:1613-1622. [PMID: 32102760 DOI: 10.1016/j.amjsurg.2020.02.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Emergency Surgery Score (ESS) is an accurate mortality risk calculator for emergency general surgery (EGS). We sought to assess whether ESS can accurately predict 30-day morbidity, mortality, and requirement for postoperative Intensive Care Unit (ICU) care in patients with missing data variables. METHODS All EGS patients with one or more missing ESS variables in the 2007-2015 ACS-NSQIP database were included. ESS was calculated assuming that a missing variable is normal (i.e. no additional ESS points). The correlation between ESS and morbidity, mortality, and postoperative ICU level of care was assessed using the c-statistics methodology. RESULTS Out of a total of 4,456,809 patients, 359,849 were EGS, and of those 256,278 (71.2%) patients had at least one ESS variable missing. ESS correlated extremely well with mortality (c-statistic = 0.94) and postoperative requirement of ICU care (c-statistic = 0.91) and well with morbidity (c-statistic = 0.77). CONCLUSION ESS performs well in predicting outcomes in EGS patients even when one or more data elements are missing and remains a useful bedside tool for counseling EGS patients and for benchmarking the quality of EGS care.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Schlick CJR, Yuce TK, Yang AD, McGee MF, Bentrem DJ, Bilimoria KY, Merkow RP. A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery. Surgery 2020; 169:240-247. [PMID: 33077197 DOI: 10.1016/j.surg.2020.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis. METHODS Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed. RESULTS Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors. CONCLUSION Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.
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Affiliation(s)
- Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL.
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Ginalis EE, Danish SF. Magnetic resonance–guided laser interstitial thermal therapy for brain tumors in geriatric patients. Neurosurg Focus 2020; 49:E12. [DOI: 10.3171/2020.7.focus20462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThere is a paucity of studies assessing the use of MR-guided laser interstitial thermal therapy (LITT), specifically in the elderly population. The aim of this study was to evaluate the safety of LITT for brain tumors in geriatric patients.METHODSGeriatric patients (≥ 65 years of age) treated with LITT for intracranial tumors at a single institution between January 2011 and November 2019 were retrospectively identified. The authors grouped patients into two distinct age cohorts: 65–74 years (group 1) and 75 years or older (group 2). Baseline characteristics, operative parameters, postoperative course, and morbidity were recorded for each patient.RESULTSFifty-five geriatric patients underwent 64 distinct LITT procedures for brain tumors. The majority of lesions (40 [62.5%]) treated were recurrent brain metastases or radiation necrosis. The median modified frailty index was 0.1 (low frailty; range 0–0.4) for patients in group 1 and 0.2 (intermediate frailty; range 0–0.4) for patients in group 2 (p > 0.05). The median hospital length of stay (LOS) was 1 day (IQR 1–2 days); there was no significant difference in LOS between the age groups. The hospital stay was significantly longer in patients who presented with a neurological symptom and in those who experienced a postoperative complication. The majority of patients (43 [68.3%] of 63 cases) were fit for discharge to their preoperative accommodation following LITT. The rate of discharge to home was not significantly different between the age groups. Those discharged to rehabilitation facilities were more likely to have presented with a neurological symptom. Nine patients (14.1% of cases) were found to have acute neurological complications following LITT, with nearly all patients showing complete or partial recovery at follow-up. The 30-day postoperative mortality rate was 1.6% (1 case). The complication and 30-day postoperative mortality rates were not significantly different between the two age groups.CONCLUSIONSLITT can be considered a minimally invasive and safe neurosurgical procedure for the treatment of intracranial tumors in geriatric patients. Careful preoperative preparation and postoperative care is essential as LITT is not without risk. Appropriate patient selection for cranial surgery is essential, because neurosurgeons are treating an increasing number of elderly patients, but advanced age alone should not exclude patients from LITT without considering frailty and comorbidities.
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Sharib J, Esserman L, Koay EJ, Maitra A, Shen Y, Kirkwood KS, Ozanne EM. Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective. Surgery 2020; 168:601-609. [PMID: 32739138 PMCID: PMC8754171 DOI: 10.1016/j.surg.2020.04.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu Shen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
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Schwartz PB, Stahl CC, Ethun C, Marka N, Poultsides GA, Roggin KK, Fields RC, Howard JH, Clarke CN, Votanopoulos KI, Cardona K, Abbott DE. Retroperitoneal sarcoma perioperative risk stratification: A United States Sarcoma Collaborative evaluation of the ACS-NSQIP risk calculator. J Surg Oncol 2020; 122:795-802. [PMID: 32557654 PMCID: PMC7744355 DOI: 10.1002/jso.26071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The ACS-NSQIP risk calculator predicts perioperative risk. This study tested the calculator's ability to predict risk for outcomes following retroperitoneal sarcoma (RPS) resection. METHODS The United States Sarcoma Collaborative database was queried for adults who underwent RPS resection. Estimated risk for outcomes was calculated twice in the risk calculator, once using sarcoma-specific CPT codes and once using codes indicative of most comorbid organ resection (eg nephrectomy). ROC curves were generated, with area under the curve (AUC) and Brier scores reported to assess discrimination and calibration. An AUC < 0.6 was considered ineffective discrimination. A negative ▲ Brier indicated improved performance relative to baseline outcome rates. RESULTS In total, 482 patients were identified with a 42.3% 90-day complication rate. Discrimination was poor for all outcomes except "all complications" and "renal failure." Baseline outcome rates were better predictors than calculator estimates except for "discharge to nursing or rehab facility" and "renal failure." Replacing sarcoma-specific CPT codes with resection-specific codes did not improve performance. CONCLUSION The ACS-NSQIP risk calculator poorly predicted outcomes following RPS resection. Changing sarcoma-specific CPT to resection-specific codes did not improve performance. Comorbidities in the calculator may not effectively capture perioperative risk. Future work should evaluate a sarcoma-specific calculator.
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Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - Cecilia Ethun
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Nicholas Marka
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - George A Poultsides
- Department of Surgery, Division of Surgical Oncology, Stanford University, Palo Alto, California
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Ryan C Fields
- Department of Surgery, Siteman Cancer Center, Washington University, St. Louis, Missouri
| | - John H Howard
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Callisia N Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
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Schlick CJR, Merkow RP, Yang AD, Bentrem DJ. Post-discharge venous thromboembolism after pancreatectomy for malignancy: Predicting risk based on preoperative, intraoperative, and postoperative factors. J Surg Oncol 2020; 122:675-683. [PMID: 32531819 PMCID: PMC7755307 DOI: 10.1002/jso.26046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Extended chemoprophylaxis is recommended for high-risk patients following pancreatectomy for malignancy. However, quantifying risk remains difficult. We sought to (a) identify factors associated with post-discharge venous thromboembolism (VTE) following pancreatectomy for malignancy and (b) develop a post-discharge VTE risk calculator to identify high-risk patients. METHODS Patients who underwent pancreatectomy for malignant histology from 2014 to 2018 were identified from the ACS NSQIP pancreatectomy procedure targeted dataset. Preoperative, intraoperative, and postoperative factors known at hospital discharge were evaluated for association with post-discharge VTE via multivariable logistic regression. A post-discharge VTE risk calculator was developed and validated. RESULTS Of 19 340 analyzed patients, 280 (1.5%) developed post-discharge VTE. Post-discharge VTE was associated with increasing body mass index (BMI; eg, morbidly obese BMI odds ratio [OR]: 1.99 [95% confidence interval {CI}: 1.30-3.02] vs normal BMI), procedure type (distal pancreatectomy OR: 1.47 [95% CI: 1.02-2.12] vs pancreaticoduodenectomy), pancreatic fistula (OR: 1.59 [95% CI: 1.19-2.13]) and delayed gastric emptying (OR: 1.81 [95% CI: 1.29-2.52]). Patients' predicted probability of post-discharge VTE ranged from 0.7% to 9.0%. Twenty iterations of 10-fold cross-validation demonstrated internal validity. CONCLUSIONS Preoperative, intraoperative, and postoperative factors were associated with post-discharge VTE following pancreatectomy for malignancy. This post-discharge VTE risk calculator allows for quantification of individual post-discharge VTE risk, which ranged from 0.7% to 9.0%.
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Affiliation(s)
- Cary Jo R. Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J. Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
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Driedger MR, Puig CA, Thiels CA, Bergquist JR, Ubl DS, Habermann EB, Grotz TE, Smoot RL, Nagorney DM, Cleary SP, Kendrick ML, Truty MJ. Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients. BMC Surg 2020; 20:169. [PMID: 32718311 PMCID: PMC7385869 DOI: 10.1186/s12893-020-00822-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/10/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. METHODS ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. RESULTS Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). CONCLUSION Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.
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Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Carlos A Puig
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - John R Bergquist
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Research and Policy, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Roberts KJ, Boteon APCS, Marcon F, Abradelo M, Dasari B, Muiesan P, Marudanayagam R, Sutcliffe RP, Isaac J, Mirza DF. Risk adjusted assessment of individual surgeon's pancreatic fistula outcomes. HPB (Oxford) 2020; 22:452-460. [PMID: 31445781 DOI: 10.1016/j.hpb.2019.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/19/2019] [Accepted: 07/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a major cause of morbidity following pancreatoduodenectomy. The risk of POPF varies between individuals and thus assessment without risk adjustment is crude. However, despite the availability of numerous scores to determine risk, no study has provided a risk adjusted assessment of POPF outcomes. METHODS The observed and risk adjusted occurrence of POPF from consecutive patients operated upon by eight surgeons were recorded. Surgeons varied in experience from newly appointed (n = 5) to established (n = 3). CUSUM (cumulative sum) analysis was used to assess performance. RESULTS 104 POPF occurred among 519 patients (20.0%). The occurrence of POPF was significantly lower among experienced surgeons (20/186, 10.7% vs 84/333, 25.2%; p < 0.001). Following risk adjustment surgeons observed 16.6 fewer to 6.5 excess POPF per 100 patients than predicted. Analysis of the CUSUM plots demonstrated the experienced surgeons performed steadily with a gradual reduction in observed POPF compared to what was predicted. The new surgeon's performance was less consistent and evidence of a learning curve was observed with steady improvement occurring after 50-70 patients. CONCLUSIONS Risk adjusted assessment of POPF demonstrates differences between experienced and less experienced surgeons. This method could be used to audit practice and observe effects of changes to technique.
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Affiliation(s)
- Keith J Roberts
- University of Birmingham, Birmingham, United Kingdom; Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom.
| | - Amanda P C S Boteon
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Francesca Marcon
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Manuel Abradelo
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Bobby Dasari
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Paolo Muiesan
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Ravi Marudanayagam
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Robert P Sutcliffe
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - John Isaac
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
| | - Darius F Mirza
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Queen Elizabeth University Hospitals Birmingham, NHS Foundation Trust, B15 2TH, United Kingdom
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Hashimoto D, Mizuma M, Kumamaru H, Miyata H, Chikamoto A, Igarashi H, Itoi T, Egawa S, Kodama Y, Satoi S, Hamada S, Mizumoto K, Yamaue H, Yamamoto M, Kakeji Y, Seto Y, Baba H, Unno M, Shimosegawa T, Okazaki K. Risk model for severe postoperative complications after total pancreatectomy based on a nationwide clinical database. Br J Surg 2020; 107:734-742. [PMID: 32003458 DOI: 10.1002/bjs.11437] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/18/2019] [Accepted: 10/28/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Total pancreatectomy is required to completely clear tumours that are locally advanced or located in the centre of the pancreas. However, reports describing clinical outcomes after total pancreatectomy are rare. The aim of this retrospective observational study was to assess clinical outcomes following total pancreatectomy using a nationwide registry and to create a risk model for severe postoperative complications. METHODS Patients who underwent total pancreatectomy from 2013 to 2017, and who were recorded in the Japan Society of Gastroenterological Surgery and Japanese Society of Hepato-Biliary-Pancreatic Surgery database, were included. Severe complications at 30 days were defined as those with a Clavien-Dindo grade III needing reoperation, or grade IV-V. Occurrence of severe complications was modelled using data from patients treated from 2013 to 2016, and the accuracy of the model tested among patients from 2017 using c-statistics and a calibration plot. RESULTS A total of 2167 patients undergoing total pancreatectomy were included. Postoperative 30-day and in-hospital mortality rates were 1·0 per cent (22 of 2167 patients) and 2·7 per cent (58 of 167) respectively, and severe complications developed in 6·0 per cent (131 of 2167). Factors showing a strong positive association with outcome in this risk model were the ASA performance status grade and combined arterial resection. In the test cohort, the c-statistic of the model was 0·70 (95 per cent c.i. 0·59 to 0·81). CONCLUSION The risk model may be used to predict severe complications after total pancreatectomy.
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Affiliation(s)
- D Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University, Kumamoto, Japan.,Department of Gastroenterological Surgery, Omuta Tenryo Hospital, Fukuoka, Japan
| | - M Mizuma
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - H Kumamaru
- Department of Healthcare Quality Assessment, University of Tokyo, Tokyo, Japan
| | - H Miyata
- Department of Healthcare Quality Assessment, University of Tokyo, Tokyo, Japan.,Department of Health Policy and Management, Keio University, Tokyo, Japan
| | - A Chikamoto
- Department of Gastroenterological Surgery, Kumamoto University, Kumamoto, Japan
| | - H Igarashi
- Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan
| | - T Itoi
- Department of Gastroenterology, Tokyo Medical University, Tokyo, Japan
| | - S Egawa
- Division of International Cooperation for Disaster Medicine, Tohoku University, Miyagi, Japan
| | - Y Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Japan
| | - S Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - S Hamada
- Division of Gastroenterology, Tohoku University, Miyagi, Japan
| | - K Mizumoto
- Cancer Centre, Kyushu University Hospital, Fukuoka, Japan
| | - H Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - M Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Y Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University, Kobe, Japan
| | - Y Seto
- Department of Gastrointestinal Surgery, University of Tokyo, Tokyo, Japan
| | - H Baba
- Department of Gastroenterological Surgery, Kumamoto University, Kumamoto, Japan
| | - M Unno
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - T Shimosegawa
- Department of Gastroenterology, South Miyagi Medical Centre, Miyagi, Japan
| | - K Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
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36
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Pre-Operative, Intra-Operative, and Post-Operative Factors Associated with Post-Discharge Venous Thromboembolism Following Colorectal Cancer Resection. J Gastrointest Surg 2020; 24:144-154. [PMID: 31420856 PMCID: PMC6992485 DOI: 10.1007/s11605-019-04354-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/30/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is the most common preventable cause of 30-day post-operative mortality, with many events occurring after hospital discharge. High-level evidence supports post-discharge VTE chemoprophylaxis following abdominal/pelvic cancer resection; however, some studies support a more tailored approach. Our objectives were to (1) identify risk factors associated with post-discharge VTE in a large cohort of patients undergoing colorectal cancer resection and (2) develop a post-discharge VTE risk calculator. METHODS Patients who underwent colorectal cancer resection from 2012 to 2016 were identified from ACS NSQIP colectomy and proctectomy procedure-targeted modules. Multivariable logistic regression was used to identify factors associated with post-discharge VTE. Incorporating pre-operative, intra-operative, and post-operative variables, a post-discharge VTE risk calculator was constructed and validated. RESULTS Of 51,139 patients, 387 (0.76%) developed post-discharge VTE. Pre-operative factors associated with post-discharge VTE included BMI (e.g., morbidly obese OR 2.27, 95% CI 1.65-3.12 vs. normal BMI), and thrombocytosis (OR 1.41, 95% CI 1.03-1.92). Intra-operative factors included operative time (4-6 h OR 1.56, 95% CI 1.12-2.17; > 6 h, OR 1.85, 95% CI 1.21-2.84, vs. < 2 h), and type of operation (e.g., open partial colectomy OR 1.67, 95% CI 1.30-2.16 vs. laparoscopic partial colectomy). Post-operative factors included anastomotic leak (OR 2.05, 95% CI 1.31-3.21) and post-operative ileus (OR 1.39, 95% CI 1.07-1.79). Using the risk calculator, the predicted probability of post-discharge VTE ranged from 0.04 to 10.29%. On a 10-fold cross validation, the calculator's mean C-Statistic was 0.65. CONCLUSIONS Patient-specific factors are associated with varying rates of post-discharge VTE. We present the first post-discharge VTE risk calculator designed for use at the time of discharge following colorectal cancer resection.
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Jung GH, Hwang HK, Lee WJ, Kang CM. Extremely high white blood cell counts on postoperative day 1 do not predict severe complications following distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:377-384. [PMID: 31825005 PMCID: PMC6893049 DOI: 10.14701/ahbps.2019.23.4.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/14/2019] [Accepted: 07/25/2019] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Distal pancreatectomy(DP) is associated with high morbidity. In clinical practice, postoperative white blood cell(WBC) counts are useful indicators of infection complications. The aim of this study was to determine the relevance of extremely high postoperative day (POD)1 WBC counts after DP and their relationship to perioperative outcomes. Methods From December 2005 to December 2016, data from patients who had open or minimally invasive DP surgery (robot or laparoscopy, MIS) for benign or borderline malignant tumors were retrospectively reviewed. Patients were divided into groups based on POD1 WBC count (>20K, High and <20K, Low) for comparisons. Results Twelve patients (4.6%) were categorized into the High group. There were significant differences in age (p=0.019), BMI (p=0.010), and spleen-preserving rate (p=0.002) between the High and Low groups. In binary logistic regression analysis, the risk factors for severe complication was age (p=0.032) and open DP (p=0.005), not POD1 WBC count. Conclusions Extremely high WBC count after POD1 after DP was not associated with severe complications, but was associated with splenectomy. Surgical methods and age were associated with severe complications.
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Affiliation(s)
- Gun Hee Jung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Clinic, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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Tan E, Song J, Lam S, D'Souza M, Crawford M, Sandroussi C. Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis. Int J Surg 2019; 72:59-68. [PMID: 31580919 DOI: 10.1016/j.ijsu.2019.09.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/11/2019] [Accepted: 09/26/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pancreatic cancer is a disease of the elderly. Surgical resection is usually offered to patients in early stage disease; however, pancreatic resection in the elderly is controversial. METHODS MEDLINE, EMBASE and Cochrane Library, were searched for studies comparing short- and long-term outcomes of elderly (above the age of 70) with non-elderly patients (below the age of 70) following pancreatic resection for pancreatic adenocarcinoma over the period from the inception of electronic database to 2017. Twelve articles documenting 4860 patients were included. A meta-analysis of data on patient characteristics, operative techniques, and perioperative outcomes were analysed. Our primary endpoint was postoperative mortality, defined as 30-day mortality or in-hospitalisation mortality. RESULTS There were 919 patients in the elderly group and 3941 patients in the non-elderly group. Elderly patients had worse ASA scores (p < 0.001) and more cardiovascular comorbidities (p = 0.002). Tumour size, T-stage, N-stage and tumour grade were similar between the elderly and non-elderly group (p > 0.05). Fewer elderly patients received a concomitant venous resection with their pancreatectomy (RR0.80, p = 0.003, I2 = 0%), achieved a negative margin status (RR0.76, p = 0.02, I2 = 28%) and underwent adjuvant chemotherapy treatment (RR0.69, p < 0.001, I2 = 42%). Overall complication (RR1.15, p < 0.001, I2 = 47%), in particular, respiratory complications (RR2.33, p = 0.004, I2 = 39%), was higher in the elderly group. There was no difference in postoperative pancreatic fistula formation, postoperative haemorrhage, intraabdominal abscess and length of hospital stay between both groups (p > 0.05). Postoperative mortality was similar between both groups (p = 0.17). Subgroup analysis according to the time of enrolment (<2000, ≥2000) showed a significant subgroup effect (Chi2 = 3.44, p = 0.06, I2 = 70.9%) and revealed that postoperative mortality in the elderly group improved over time (Before 2000: n = 1654, subtotal RR2.27, p = 0.02, I2 = 0%; From 2000 onwards: n = 3206, subtotal RR1.00, p = 0.99, I2 = 0%). CONCLUSION Fewer elderly patients received chemotherapy and portal vein resection to achieve a clear margin. Pancreatic resection of pancreatic adenocarcinoma can be performed safely on elderly patients with acceptable risks in experienced centres by specialist hepatobiliary surgeons. Age alone should not be the only determinant for the selection of patients for surgical treatment of pancreatic adenocarcinoma.
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Affiliation(s)
- Elinor Tan
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia.
| | - Jialu Song
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia
| | - Susanna Lam
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia
| | - Mario D'Souza
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; Sydney Local Health District Clinical Research Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Michael Crawford
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Charbel Sandroussi
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, 145-147 Missenden Road, Camperdown, NSW, 2050, Australia
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Two open whipples a day: Excessive or efficient. Am J Surg 2019; 219:390-393. [PMID: 31761301 DOI: 10.1016/j.amjsurg.2019.10.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Demand for pancreatic surgery is rising, occasionally necessitating consecutive PDs to be performed by a single surgeon in the same workday. The safety of this practice is unknown. METHODS Institutional prospective ACS-NSQIP data were reviewed for PDs (2013-2017). Instances where a single surgeon performed two PDs in the same day were a PD pair (PD1, PD2) and compared with univariable analysis. Paired vs. unpaired-PD matched analyses were performed. RESULTS 661 PDs (25-PD pairs) were performed. PD1 and PD2 revealed similar infectious (12% vs16%), pulmonary (8% vs8%), cardiovascular (12% vs4%), and aggregate (24% vs24%) morbidity (P>0.05). Pancreatic fistula (B + C 0%), delayed gastric emptying (4% vs12%), hospital stay (9.3 vs8.8 days), and 30-day mortality (4% vs4%) were similar (P > 0.05). Matched outcomes were similar except higher cardiovascular morbidity for paired vs. unpaired PD (7% vs0%; P = 0.015). CONCLUSION With proper patient selection, and in experienced hands at high-volume centers, two consecutive open PDs may be safely performed.
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40
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Dave A, Beal EW, Lopez-Aguiar AG, Poultsides G, Makris E, Rocha FG, Kanji Z, Ronnekleiv-Kelly S, Rendell VR, Fields RC, Krasnick BA, Idrees K, Smith PM, Nathan H, Beems M, Maithel SK, Pawlik TM, Schmidt CR, Dillhoff ME. Evaluating the ACS NSQIP Risk Calculator in Primary Pancreatic Neuroendocrine Tumor: Results from the US Neuroendocrine Tumor Study Group. J Gastrointest Surg 2019; 23:2225-2231. [PMID: 30941685 PMCID: PMC10178764 DOI: 10.1007/s11605-019-04120-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In a changing health care environment where patient outcomes will be more closely scrutinized, the ability to predict surgical complications is becoming increasingly important. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) online risk calculator is a popular tool to predict surgical risk. This paper aims to assess the applicability of the ACS NSQIP calculator to patients undergoing surgery for pancreatic neuroendocrine tumors (PNETs). METHODS Using the US Neuroendocrine Tumor Study Group (USNET-SG), 890 patients who underwent pancreatic procedures between 1/1/2000-12/31/2016 were evaluated. Predicted and actual outcomes were compared using C-statistics and Brier scores. RESULTS The most commonly performed procedure was distal pancreatectomy, followed by standard and pylorus-preserving pancreaticoduodenectomy. For the entire group of patients studied, C-statistics were highest for discharge destination (0.79) and cardiac complications (0.71), and less than 0.7 for all other complications. The Brier scores for surgical site infection (0.1441) and discharge to nursing/rehabilitation facility (0.0279) were below the Brier score cut-off, while the rest were equal to or above and therefore not useful for interpretation. CONCLUSION This work indicates that the ACS NSQIP risk calculator is a valuable tool that should be used with caution and in coordination with clinical assessment for PNET clinical decision-making.
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Affiliation(s)
- Apeksha Dave
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Alexandra G Lopez-Aguiar
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | | | - Flavio G Rocha
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Zaheer Kanji
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Sean Ronnekleiv-Kelly
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Victoria R Rendell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MI, USA
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, St. Louis, MI, USA
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University, Nashville, TN, USA
| | - Hari Nathan
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Megan Beems
- Division of Hepatopancreatobiliary and Advanced Gastrointestinal Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary E Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 320 W. 10th Ave, M256 Starling Loving Hall, Columbus, OH, 43210-1267, USA.
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Wong C, Augustine H, Saleh A, Naji F, Hu J, Rapanos T. Use of the National Surgical Quality Initiative Program in Vascular Surgery Research. Ann Vasc Surg 2019; 61:434-444.e12. [DOI: 10.1016/j.avsg.2019.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 04/06/2019] [Accepted: 04/14/2019] [Indexed: 12/21/2022]
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Stevens CL, Reid JL, Babidge WJ, Maddern GJ. Peer review of mortality after pancreaticoduodenectomy in Australia. HPB (Oxford) 2019; 21:1470-1477. [PMID: 30956163 DOI: 10.1016/j.hpb.2019.03.356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/21/2019] [Accepted: 03/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. METHODS ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. Assessor's determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. RESULTS The study included 87 deaths reported to ANZASM after PD. Forty-two major complications were considered significant clinical events in 29/84 (35%) of patients. The assessor determined that there was a delay in recognising a significant complication in 18/84 (21%) of patients. In 14/84 (17%) of patients, ANZASM assessment questioned the decision to operate. CONCLUSION Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. Late recognition, and therefore delayed action to treat complications, in almost a quarter of deaths is a significant finding that warrants consideration for clinicians involved in the postoperative care of PD patients.
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Affiliation(s)
- Claire L Stevens
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia.
| | - Jessica L Reid
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
| | - Wendy J Babidge
- Discipline of Surgery, University of Adelaide, Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Australia
| | - Guy J Maddern
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
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Polonski A, Izbicki JR, Uzunoglu FG. Centralization of Pancreatic Surgery in Europe. J Gastrointest Surg 2019; 23:2081-2092. [PMID: 31037503 DOI: 10.1007/s11605-019-04215-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems. METHODS A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases. RESULTS Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort. CONCLUSION As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.
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Affiliation(s)
- Adam Polonski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany. .,Department of General Visceral and Thoracic Surgery, University of Hamburg Medical Institutions, Martinistr 52, 20252, Hamburg, Germany.
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
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Mehtsun WT, Hashimoto DA, Ferrone CR. Status of 5-Year Survivors of the Whipple Procedure for Pancreatic Adenocarcinoma. Adv Surg 2019; 53:253-269. [PMID: 31327451 DOI: 10.1016/j.yasu.2019.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Winta T Mehtsun
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA.
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Pancreatic Fluid Interleukin-1β Complements Prostaglandin E2 and Serum Carbohydrate Antigen 19-9 in Prediction of Intraductal Papillary Mucinous Neoplasm Dysplasia. Pancreas 2019; 48:1026-1031. [PMID: 31404023 PMCID: PMC6699881 DOI: 10.1097/mpa.0000000000001377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES We sought to determine if interleukin (IL)-1β and prostaglandin E2 (PGE2) (inflammatory mediators in pancreatic fluid) together with serum carbohydrate antigen (CA) 19-9 could better predict intraductal papillary mucinous neoplasm (IPMN) dysplasia than individual biomarkers alone. METHODS Pancreatic cyst fluid (n = 92) collected via endoscopy or surgery (2003-2016) was analyzed for PGE2 and IL-1β (enzyme-linked immunosorbent assay). Patients had surgical pathology-proven IPMN. Threshold values (PGE2 [>1100 pg/mL], IL-1β [>20 pg/mL], and serum CA 19-9 [>36 U/mL]) were determined. RESULTS Levels of IL-1β were higher in high-grade dysplasia (HGD)/invasive-IPMN (n = 42) compared with low/moderate IPMN (n = 37) (median [range], 54.6 [0-2671] vs 5.9 [0-797] pg/mL; P < 0.001; area under curve [AUC], 0.766). Similarly, PGE2 was higher in HGD/invasive IPMN (n = 45) compared with low/moderate IPMN (n = 47) (median [range], 1790 [20-15,180] vs. 140 [10-14,630] pg/mL; P < 0.001; AUC, 0.748). Presence of elevated PGE2 and IL-1β (AUC, 0.789) provided 89% specificity and 82% positive predictive value (PPV) for HGD/invasive IPMN. Elevated levels of all 3 provided 100% specificity and PPV for HGD/invasive IPMN. CONCLUSIONS Cyst fluid PGE2, IL-1β, and serum CA 19-9 in combination optimize specificity and PPV for HGD/invasive IPMN and may help build a panel of markers to predict IPMN dysplasia.
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Alfieri S, Boggi U, Butturini G, Pietrabissa A, Morelli L, Di Sebastiano P, Vistoli F, Damoli I, Peri A, Lapergola A, Fiorillo C, Panaccio P, Pugliese L, Ramera M, De Lio N, Di Franco G, Rosa F, Menghi R, Doglietto GB, Quero G. Full Robotic Distal Pancreatectomy: Safety and Feasibility Analysis of a Multicenter Cohort of 236 Patients. Surg Innov 2019; 27:11-18. [PMID: 31394981 DOI: 10.1177/1553350619868112] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.
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Affiliation(s)
- Sergio Alfieri
- Università Cattolica del Sacro Cuore of Rome, Fondazione Policlinico "A Gemelli" IRCCS of Rome, Rome, Italy
| | - Ugo Boggi
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Pisa, Italy
| | | | | | - Luca Morelli
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Pisa, Italy
| | | | - Fabio Vistoli
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Pisa, Italy
| | | | - Andrea Peri
- Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Claudio Fiorillo
- Università Cattolica del Sacro Cuore of Rome, Fondazione Policlinico "A Gemelli" IRCCS of Rome, Rome, Italy
| | | | | | | | - Nelide De Lio
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Pisa, Italy
| | - Gregorio Di Franco
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Pisa, Italy
| | - Fausto Rosa
- Università Cattolica del Sacro Cuore of Rome, Fondazione Policlinico "A Gemelli" IRCCS of Rome, Rome, Italy
| | - Roberta Menghi
- Università Cattolica del Sacro Cuore of Rome, Fondazione Policlinico "A Gemelli" IRCCS of Rome, Rome, Italy
| | | | - Giuseppe Quero
- Università Cattolica del Sacro Cuore of Rome, Fondazione Policlinico "A Gemelli" IRCCS of Rome, Rome, Italy
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The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN. J Gastrointest Surg 2019; 23:1593-1603. [PMID: 30603862 DOI: 10.1007/s11605-018-4026-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/18/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE(S) A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance. METHODS Three hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991-2016). Main-duct dilation included those ≥ 5 mm or "dilated" on radiographic reports. Statistics compared groups using Student's T/Mann-Whitney U tests for continuous variables or chi-square/Fisher's exact test for categorical variables with P < 0.05 considered significant. RESULTS High-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN. CONCLUSIONS Remnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant.
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Marubashi S, Liu JY, Miyata H, Cohen ME, Ko CY, Seto Y, Gotoh M. Surgical quality improvement programs in Japan and USA: Report from the collaborative projects between Japanese Society of Gastroenterological Surgery and American College of Surgeons National Surgical Quality Improvement Program. Ann Gastroenterol Surg 2019; 3:343-351. [PMID: 31346572 PMCID: PMC6635687 DOI: 10.1002/ags3.12250] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/10/2019] [Accepted: 03/21/2019] [Indexed: 01/15/2023] Open
Abstract
The Japanese Society of Gastroenterological Surgery (JSGS) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have collaboratively developed several clinical projects since 2011 using two nationwide clinical registries with the goal of achieving further improvement of surgical quality in both countries. In this review, the historical viewpoints and the collaboration between JSGS and ACS and their use of nationwide registries [National Clinical Database (NCD) and NSQIP] for research are reviewed. We have carried out a joint project, the 30-day Mortality Risk Model Study and, currently, we are working on several joint projects such as the Morbidity-Mortality Study, Japan-USA Calibration Study, Geriatric Study, and Safety Culture Study as well as Auditing in JSGS/NCD with reference to the NSQIP method. These joint projects will continue to provide us with important information and data to drive improvements in surgical care in both countries. This will also help us to identify any unknown weaknesses in the health-care systems of the USA and Japan.
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Affiliation(s)
| | - Jessica Y. Liu
- Division of Research and Optimal Patient CareAmerican College of SurgeonsChicagoUSA
| | | | - Mark E. Cohen
- Division of Research and Optimal Patient CareAmerican College of SurgeonsChicagoUSA
| | - Clifford Y. Ko
- Division of Research and Optimal Patient CareAmerican College of SurgeonsChicagoUSA
| | - Yasuyuki Seto
- Japanese Society of Gastroenterological SurgeryTokyoJapan
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Rates of Serious Complications Estimated by the ACS-NSQIP Surgical Risk Calculator in Predicting Oncologic Outcomes of Patients Treated with Pancreaticoduodenectomy for Pancreatic Head Cancer. J Gastrointest Surg 2019; 23:1180-1187. [PMID: 30465189 DOI: 10.1007/s11605-018-4041-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The purpose of this study was to validate the predictive value of the oncologic outcome in addition to the validation of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator in patients treated with pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) for pancreatic head cancer. METHODS From June 2005 to December 2014, 199 patients underwent PD or PPPD for pancreatic head cancer. Medical records were retrospectively reviewed for investigating general patient characteristics and any comorbid diseases. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. In a propensity score matching analysis, disease-free survival (DFS) and overall survival (OS) were estimated according to calculated severe complication rate (CSCR). RESULTS The CSCR > 17.9% (n = 69) and CSCR < 17.9% (n = 130) groups were significantly different considering number of the retrieved lymph nodes (22.95 ± 14.0 vs 18.80 ± 10.1, p = 0.029), histologic grade (p = 0.0235), and incidence of lymphovascular invasion (p = 0.026). The CSCR < 17.9% group had longer DFS (17.0 vs. 11.0 months, p = 0.015), but the OS was similar between the groups (39.0 vs. 23.0 months, p = 0.48). In the 1:2 propensity score analysis, the CSCR < 17.9% group had longer DFS and OS (DFS 26.0 vs. 11.0 months, p = 0.009; OS 44.0 vs. 26.0 months, p = 0.023). CONCLUSION The ACS NSQIP surgical risk calculator predicts surgical risk in patients with pancreatic head cancer who undergo PD or PPPD. Furthermore, this tool can help predict the prognosis of surgically treated pancreatic head cancer.
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