Predicting response to neoadjuvant chemotherapy for colorectal liver metastasis using deep learning on prechemotherapy cross-sectional imaging

BACKGROUND AND OBJECTIVES

Deep learning models (DLMs) are applied across domains of health sciences to generate meaningful predictions. DLMs make use of neural networks to generate predictions from discrete data inputs. This study employs DLM on prechemotherapy cross-sectional imaging to predict patients' response to neoadjuvant chemotherapy.

METHODS

Adult patients with colorectal liver metastasis who underwent surgery after neoadjuvant chemotherapy were included. A DLM was trained on computed tomography images using attention-based multiple-instance learning. A logistic regression model incorporating clinical parameters of the Fong clinical risk score was used for comparison. Both model performances were benchmarked against the Response Evaluation Criteria in Solid Tumors criteria. A receiver operating curve was created and resulting area under the curve (AUC) was determined.

RESULTS

Ninety-five patients were included, with 33,619 images available for study inclusion. Ninety-five percent of patients underwent 5-fluorouracil-based chemotherapy with oxaliplatin and/or irinotecan. Sixty percent of the patients were categorized as chemotherapy responders (30% reduction in tumor diameter). The DLM had an AUC of 0.77. The AUC for the clinical model was 0.41.

CONCLUSIONS

Image-based DLM for prediction of response to neoadjuvant chemotherapy in patients with colorectal cancer liver metastases was superior to a clinical-based model. These results demonstrate potential to identify nonresponders to chemotherapy and guide select patients toward earlier curative resection.

Outcomes after Surgical Microwave Ablation for the Treatment of Colorectal Liver Metastasis

BACKGROUND

Colorectal cancer (CRC) is the third most common cause of cancer mortality worldwide. Of these, approximately 25% will have liver metastasis. We performed 394 microwave ablations (MWA) and analyzed outcomes for survival and ablation failure.

STUDY DESIGN

Retrospective review of patients who underwent a surgical microwave ablation at a single center high-volume institution from October 2006 through September 2022 using a prospectively maintained database. Primary outcome was overall survival.

RESULTS

A total of 394 operations were performed on 328 patients with 842 tumors undergoing MWA. Median tumor size was 1.5 cm (range 0.4-7.0 cm), with the median number of tumors ablated per operation being 1 (range 1-11). A laparoscopic approach was used 77.9% of the time. Concomitant procedures were performed 63% of the time, most commonly hepatectomy (22.3%), cholecystectomy (17.5%), and colectomy (6.6%). Clavien-Dindo Grade III or IV complications occurred in 12 patients (3.6%), and all of these patients had undergone concomitant procedures. Mortality within 30 days occurred in 4 patients (1.2%). The rate of incomplete ablation (IA) was 1.5% per tumor. Local recurrence (LR) occurred at a rate of 6.3% per tumor. African Americans were found to have a higher incidence of IA and LR. One year survival probability was 91% [95% CI: 87.9 -94.3], with a mean overall survival of 57.6 months [95% CI: 49.9-65.4 months].

CONCLUSION

Surgical MWA offers a low-morbidity approach to treatment of colorectal liver metastasis (CRLM), with low rates of failure. This large series reviews the outcomes of MWA as definitive treatment for CRLM.

Surgical microwave ablation for the treatment of hepatocellular carcinoma in 791 operations

INTRODUCTION

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality and often arises in the setting of cirrhosis. The present series reviews outcomes following 791 operations.

METHODS

Retrospective review surgical MWA for HCC from March 2007 through December 2022 at a high-volume institution was performed using a prospective database. Primary outcome was overall survival.

RESULTS

A total of 791 operations in 623 patients and 1156 HCC tumors were treated with surgical MWA. Median tumor size was 2 cm (range 0.25-10 cm) with an average of 1 tumor ablated per operation (range 1-7 tumors). Nearly 90 % of patients had cirrhosis with a median MELD score of 8 (IQR = 6-11). Mortality within 30 days occurred in 13 patients (1.6 %). Per tumor, the rate of incomplete ablation was 2.25 % and local recurrence was 2.95 %. Previous ablation and tumor size were risk factors for recurrence. One-year overall survival was 82.0 % with a median overall survival of 36.5 months (95 % CI 15.7-93.7) and median disease-free survival of 15.9 months (range 5.7-37.3 months).

CONCLUSION

Surgical MWA offers a low-morbidity approach for treatment of HCC, affording low rates of incomplete ablation and local recurrence.

Robotic Revision of Hepaticojejunostomy for Benign Biliary Stricture

Surgical revision of biliary enteric anastomoses (BEA) can be a challenging undertaking and a robotic platform may provide advantages that address many of the technical obstacles. We present our technical approach and outcomes for patients undergoing robotic revision of BEA for benign strictures. A retrospective review was performed for robot-assisted benign BEA revision at our institution. Operative details, perioperative metrics, and outcomes are reported. Four patients underwent anastomotic revision following previously failed non-operative management. There were no intraoperative complications, mean length of stay was 4-days, and all patients experienced resolution of presenting clinical signs and symptoms. No patients required reoperation and there was no mortality. Postoperative outcomes were consistent with findings reported for other interventional modalities. Based on our experience we conclude robotic intervention in this context is safe and improves the technical feasibility of this complex procedure.

AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery

BACKGROUND

Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided.

METHODS

Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines.

RESULTS

Levels of evidence and strength of recommendations are presented.

DISCUSSION

While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.

Enhanced Recovery After Surgery® in Octogenarians Undergoing Hepatopancreatobiliary Surgery

Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80 years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Patients ≥80 years old in a single HPB ERAS program (September 2015-July 2018) were prospectively tracked in the ERAS Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, P=.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions.

Robotic Resection of Gallbladder Cancer: A Single-Center Retrospective Comparative Study to Open Resection

BACKGROUND

Minimally invasive surgery is gaining support for resection of gallbladder cancer (GBC). This study aims to compare operative and early outcomes of robotic resection (RR) to open resection (OR) from a single institution performing a high volume of robotic HPB surgery.

METHODS

Twenty patients with GBC underwent RR from January 2013 to August 2019. Outcomes were compared to a historical control of 23 patients with OR. Radical cholecystectomy for suspected GBC and completion operations for incidental GBC after routine cholecystectomy were both included.

RESULTS

Robotic resection had lower blood loss compared to OR (150 vs 350 mL, P = .002) and shorter postoperative length of stay (2.5 vs 6 days, P < .001), while median operative time was similar (193 vs 208 min, P = .604). There were no statistical differences in 30-day major complications or readmissions. No 30-day mortalities occurred. There was no statistical difference in survival trend (P = .438) or median lymph node harvest (5 vs 3, P = .189) for RR compared to OR.

CONCLUSION

Robotic resection of GBC is safe and efficient, with lower length of hospital stay and blood loss compared to OR. Technical benefits of robotic-assisted surgery may prove advantageous though larger studies are still needed.

Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study

BACKGROUND

Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy.

METHODS

A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019.

RESULTS

Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted.

CONCLUSION

This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.

Long-Term Clinical Outcomes of an Antibiotic-Coated Non-Cross-linked Porcine Acellular Dermal Graft for Abdominal Wall Reconstruction for High-Risk and Contaminated Wounds

BACKGROUND

Abdominal wall reconstruction in high-risk and contaminated cases remains a challenging surgical dilemma. We report long-term clinical outcomes for a rifampin-/minocycline-coated acellular dermal graft (XenMatrix™ AB) in complex abdominal wall reconstruction for patients with a prior open abdomen or contaminated wounds.

METHODS

Patients undergoing abdominal wall reconstruction at our institution at high risk for surgical site occurrence and reconstructed with XenMatrix™ AB with intent-to-treat between 2014 and 2017 were included. Demographics, operative characteristics, and outcomes were collected. The primary outcome was hernia recurrence. The secondary outcomes included length of stay, surgical site occurrence, readmission, morbidity, and mortality.

RESULTS

Twenty-two patients underwent abdominal wall reconstruction using XenMatrix™ AB during the study period. Two patients died while inpatient from progression of their comorbid diseases and were excluded. Sixty percent of patients had an open abdomen at the time of repair. All patients were from modified Ventral Hernia Working Group class 2 or 3. There were a total of four 30-day infectious complications including superficial cellulitis/fat necrosis (15%) and one intraperitoneal abscess (5%). No patients required reoperation or graft excision. Median clinical follow-up was 38.2 months with a mean of 35.2 +/- 18.5 months. Two asymptomatic recurrences and one symptomatic recurrence were noted during this period with one planning for elective repair of an eventration. Follow-up was extended by phone interview which identified no additional recurrences at a median of 45.5 and mean of 50.5 +/-12.7 months.

CONCLUSION

We present long-term outcomes for patients with high-risk and contaminated wounds who underwent abdominal wall reconstruction reinforced with XenMatrix™ AB to achieve early, permanent abdominal closure. Acceptable outcomes were noted.

Treatment of spontaneously ruptured hepatocellular carcinoma: use of laparoscopic microwave ablation and washout

BACKGROUND

Ruptured, or bleeding, hepatocellular carcinoma (rHCC) is a relatively rare disease presentation associated with high acute mortality rates. This study sought to evaluate outcomes following laparoscopic microwave ablation (MWA) and washout in rHCC.

METHODS

A retrospective single-center review was performed to identify patients with rHCC (2008-2018). The treatment algorithm consisted of transarterial embolization (TAE) or trans-arterial chemoembolization (TACE) followed by laparoscopic MWA and washout.

RESULTS

Fifteen patients with rHCC were identified (n = 5 single lesion, n = 5 multifocal disease, n = 5 extrahepatic metastatic disease). Median tumor size was 83 mm (range 5-228 mm), and 10 of 15 underwent TAE or TACE followed by laparoscopic MWA/washout. One patient required additional treatment for bleeding after MWA with repeat TAE. Thirty-day mortality was 6/15. For those patients discharged (n = 9), additional treatments included chemotherapy (n = 5), TACE (n = 3), and/or partial lobectomy (n = 2). Median follow-up was 18.2 months and median survival was 431 days (range 103-832) (one-year survival n = 7; two-year survival n = 4; three-year survival n = 3). Six patients had post-operative imaging from which one patient demonstrated recurrence.

CONCLUSION

Using laparoscopic MWA with washout may offer advantage in the treatment of ruptured HCC. It not only achieves hemostasis but also could have oncologic benefit by targeting local tumor and decreasing peritoneal carcinomatosis risk.

Pure and Hybrid Deep Learning Models can Predict Pathologic Tumor Response to Neoadjuvant Therapy in Pancreatic Adenocarcinoma: A Pilot Study

BACKGROUND

Neoadjuvant therapy may improve survival of patients with pancreatic adenocarcinoma; however, determining response to therapy is difficult. Artificial intelligence allows for novel analysis of images. We hypothesized that a deep learning model can predict tumor response to NAC.

METHODS

Patients with pancreatic cancer receiving neoadjuvant therapy prior to pancreatoduodenectomy were identified between November 2009 and January 2018. The College of American Pathologists Tumor Regression Grades 0-2 were defined as pathologic response (PR) and grade 3 as no response (NR). Axial images from preoperative computed tomography scans were used to create a 5-layer convolutional neural network and LeNet deep learning model to predict PRs. The hybrid model incorporated decrease in carbohydrate antigen 19-9 (CA19-9) of 10%. Accuracy was determined by area under the curve.

RESULTS

A total of 81 patients were included in the study. Patients were divided between PR (333 images) and NR (443 images). The pure model had an area under the curve (AUC) of .738 (P < .001), whereas the hybrid model had an AUC of .785 (P < .001). CA19-9 decrease alone was a poor predictor of response with an AUC of .564 (P = .096).

CONCLUSIONS

A deep learning model can predict pathologic tumor response to neoadjuvant therapy for patients with pancreatic adenocarcinoma and the model is improved with the incorporation of decreases in serum CA19-9. Further model development is needed before clinical application.

Effect of Margin Status on Survival After Resection of Hilar Cholangiocarcinoma in the Modern Era of Adjuvant Therapies

INTRODUCTION

Studies have shown that for patients with hilar cholangiocarcinoma (HC), survival is associated with negative resection margins (R0). This requires increasingly proximal resection, putting patients at higher risk for complications, which may delay chemotherapy. For patients with microscopically positive resection margins (R1), the use of modern adjuvant therapies may offset the effect of R1 resection.

METHODS

Patients at our institution with HC undergoing curative-intent resection between January 2008 and July 2019 were identified by retrospective record review. Demographic data, operative details, tumor characteristics, postoperative outcomes, recurrence, survival, and follow-up were recorded. Patients with R0 margin were compared to those with R1 margin. Patients with R2 resection were excluded.

RESULTS

Seventy-five patients underwent attempted resection with 34 (45.3%) cases aborted due to metastatic disease or locally advanced disease. Forty-one (54.7%) patients underwent curative-intent resection with R1 rate of 43.9%. Both groups had similar rates of adjuvant therapy (56.5% vs. 61.1%, P = .7672). Complication rates and 30 mortality were similar between groups (all P > .05). Both groups had similar median recurrence-free survival (R0 29.2 months vs. R1 27.8 months, P = .540) and median overall survival (R0 31.2 months vs. R1 38.8 months, P = .736) with similar median follow-up time (R0 29.9 months vs. R1 28.5 months, P = .8864).

CONCLUSIONS

At our institution, patients undergoing hepatic resection for HC with R1 margins have similar recurrence-free and overall survival to those with R0 margins. Complications and short-term mortality were similar. This may indicate that with use of modern adjuvant therapies obtaining an R0 resection is not an absolute mandate.

Operative Microwave Ablation for the Multimodal Treatment of Neuroendocrine Liver Metastases

Background and Purpose: Operative microwave ablation (MWA) is a safe modality for treating hepatic tumors. The aim of this study is to present our 10-year, single-center experience of operative MWA for neuroendocrine liver metastases (NLM). Methods: A single-institution retrospective review of patients who underwent operative MWA for NLM was performed (2008-2018). Demographics, primary tumor site, operative approach, combined surgical operations, and carcinoid symptoms were recorded. Clinical outcomes for major complications, readmission, and mortality were analyzed 30 days postoperatively. Postablation imaging was evaluated for incomplete ablation/missed lesions, and surveillance imaging reviewed for local, regional, and metastatic recurrence. Results: Of the 50 patients (166 targeted lesions) who received MWA for NLM, 41 (82%) were treated with a minimally invasive approach, and 22 (44%) underwent MWA concomitant with hepatectomy and/or primary tumor resection. Within the study cohort 70% of patients were treated with curative intent with a 77% (27/35) success rate. Carcinoid symptoms were reported in 40% (20/50) of patients preoperatively, and MWA treatment improved symptoms in 19/20 patients. Incomplete ablation occurred in 1/166 treated lesions. Recurrence-free survival at 1 and 5 years was 86% and 28%, respectively. Overall survival at 1 and 5 years was 94% and 70%, respectively (median follow-up 32 months, range 0-116 months). Conclusion: Operative MWA is a versatile modality, which can be safe and effectively performed alone or combined with hepatectomy for NLM, preferably using a minimally invasive approach, to achieve symptom control and possibly improve survival.

Is there a safe and effective way to wean patients off long-term glucocorticoids?

Glucocorticoids are highly effective medicines in the treatment of inflammatory disorders. However they cause severe adverse reactions, particularly where taken at high doses systemically for prolonged periods. Systemic glucocorticoids are therefore given at dosage sufficient to control the disease, then withdrawn as fast as is possible to minimise dose- and time-related adverse drug reactions without losing disease control. Adverse withdrawal reactions present a major challenge in the withdrawal of long term glucocorticoids. Suppression of the hypothalamic-pituitary-adrenal (HPA) axis causes adrenal insufficiency, which is potentially life threatening and can become symptomatic as treatment is withdrawn. Adrenal insufficiency can be extremely difficult to differentiate from 'glucocorticoid withdrawal syndrome', where patients experience symptoms despite adequate adrenal function, and from psychological dependence. Long term systemic glucocorticoids should therefore be withdrawn slowly. The rate at which the dose is tapered should initially be determined by treatment requirements of the underlying disease. Once 'physiological' doses are reached, the rate of reduction is determined by rate of HPA recovery and need for exogenous glucocorticoid cover while endogenous secretion recovers. If symptoms prevent treatment withdrawal, HPA testing should be used to look for adrenal insufficiency. Patients with adrenal insufficiency require 'physiological' doses of glucocorticoids for adrenal replacement, which may be lifelong if the HPA axis fails to recover.

Use of Artificial Intelligence Deep Learning to Determine the Malignant Potential of Pancreatic Cystic Neoplasms With Preoperative Computed Tomography Imaging

BACKGROUND

Society consensus guidelines are commonly used to guide management of pancreatic cystic neoplasms (PCNs). However, downsides of these guidelines include unnecessary surgery and missed malignancy. The aim of this study was to use computed tomography (CT)-guided deep learning techniques to predict malignancy of PCNs.

MATERIALS AND METHODS

Patients with PCNs who underwent resection were retrospectively reviewed. Axial images of the mucinous cystic neoplasms were collected and based on final pathology were assigned a binary outcome of advanced neoplasia or benign. Advanced neoplasia was defined as adenocarcinoma or intraductal papillary mucinous neoplasm with high-grade dysplasia. A convolutional neural network (CNN) deep learning model was trained on 66% of images, and this trained model was used to test 33% of images. Predictions from the deep learning model were compared to Fukuoka guidelines.

RESULTS

Twenty-seven patients met the inclusion criteria, with 18 used for training and 9 for model testing. The trained deep learning model correctly predicted 3 of 3 malignant lesions and 5 of 6 benign lesions. Fukuoka guidelines correctly classified 2 of 3 malignant lesions as high risk and 4 of 6 benign lesions as worrisome. Following deep learning model predictions would have avoided 1 missed malignancy and 1 unnecessary operation.

DISCUSSION

In this pilot study, a deep learning model correctly classified 8 of 9 PCNs and performed better than consensus guidelines. Deep learning can be used to predict malignancy of PCNs; however, further model improvements are necessary before clinical use.

The treatment sequence may matter in patients undergoing pancreatoduodenectomy for early stage pancreatic cancer in the era of modern chemotherapy

BACKGROUND

The aim of this study was to investigate outcomes associated with neoadjuvant chemotherapy in patients undergoing pancreatoduodenectomy for early stage pancreatic adenocarcinoma in the era of modern chemotherapy.

METHODS

The National Cancer Database (2010-2016) was queried for patients with clinical stage 0-2 pancreatic adenocarcinoma who underwent pancreatoduodenectomy. Patients who underwent up-front pancreatoduodenectomy were propensity matched to patients who received neoadjuvant chemotherapy. Postoperative outcomes, pathologic outcomes, and overall survival were compared.

RESULTS

A total of 2036 patients were in each group. Neoadjuvant chemotherapy was associated with shorter length of stay, lower 30-day readmission rate, and lower 30 and 90-day mortality rates (all p < 0.05). Neoadjuvant chemotherapy was associated with lower rates of positives nodes and positive resection margins (all p < 0.0001). Neoadjuvant chemotherapy was associated with longer survival (26.8 vs. 22.1months, p < 0.0001). Patients who received neoadjuvant chemotherapy followed by surgery and adjuvant therapy had the longest OS, followed by neoadjuvant + surgery, surgery + adjuvant therapy, and surgery alone (29.8 vs. 25.6 vs. 23.9 vs. 13.1 months; p < 0.0001).

CONCLUSIONS

Neoadjuvant chemotherapy is associated with improved postoperative outcomes, oncologic outcomes, and overall survival in patients with early stage pancreatic adenocarcinoma. Neoadjuvant chemotherapy should be considered in all patients with early stage pancreatic adenocarcinoma.

Factors Associated with Treatment and Survival of Early Stage Pancreatic Cancer in the Era of Modern Chemotherapy: An Analysis of the National Cancer Database

Background: Underutilization of operative management of early stage pancreatic cancer is associated with sociodemographic variables, including age, race, facility type, insurance, and education. It is currently unclear how these variables are associated with survival in patients who undergo surgery.

Methods: Patients with clinical stage I pancreatic adenocarcinoma were identified within the National Cancer Database (2010–2016). Utilization of surgery and nonoperative management was determined. Nonclinical factors associated with nonoperative management were identified by multivariable analysis. The association between nonclinical factors and survival was assessed in patients who received operative management.

Results: A total of 17,833 patients with clinical stage I pancreatic cancer were identified, and 41.2% underwent operative intervention. Approximately 46% of nonoperatively managed patients lacked a contraindication. Operatively managed patients had longer overall survival (OS) than those who were nonoperatively managed or untreated (25.1 months vs. 11.1 months vs. 5.1 months, p < 0.0001). Factors associated with nonoperative management included age, black/Hispanic race, nonacademic facilities, nonprivate health insurance, lower education level, and lower income. In operatively managed patients, nonclinical factors associated with lower OS included Medicaid (hazard ratio [HR] 1.27) and treatment at nonacademic facilities (HR 1.20–1.22). Patients on Medicaid received less adjuvant therapy and had higher 30- and 90-day mortality rates. Patients treated at nonacademic facilities received less neoadjuvant therapy, had worse pathologic outcomes, and had higher 30- and 90-day mortality rates.

Conclusions: Surgical management is underutilized in clinical stage I pancreatic cancer. Primary insurance payor and facility type appear to be associated with OS in patients who undergo operative management.

Improved oncologic outcomes for minimally invasive left pancreatectomy: Propensity-score matched analysis of the National Cancer Database

BACKGROUND AND OBJECTIVES

Minimally invasive (MIS) left pancreatectomy (LP) is increasingly used to treat pancreatic adenocarcinoma (PDAC). Despite improved short-term outcomes, no studies have demonstrated long-term benefits over open resection.

METHODS

The National Cancer Database was queried between 2010 and 2016 for patients with PDAC, grouped by surgical approach (MIS vs open). Demographics, comorbidities, clinical staging, and pathologic staging were used for propensity-score matching. Perioperative, short-term oncologic, and survival outcomes were compared.

RESULTS

After matching, both cohorts included 805 patients. There were no differences in baseline characteristics, staging, or preoperative therapy between cohorts. The MIS cohort had a shorter length of stay (6.8 ± 5.5 vs 8.5 ± 7.3 days; P < .0001) with the trend toward improved time to chemotherapy (53.9 ± 26.1 vs 57.9 ± 29.9 days; P = .0511) and margin-positive resection rate (15.3% vs 18.9%; P = .0605). Lymph node retrieval and receipt of chemotherapy were similar. The MIS cohort had higher median overall survival (28.0 vs 22.1 months; P = .0067). Subgroup analysis demonstrated the highest survival for robotic compared with laparoscopic and open LP (41.9 vs 26.6 vs 22.1 months; P < .0001).

CONCLUSIONS

This study demonstrates the safety of MIS LP and favorable long-term oncologic outcomes. The improved survival after MIS LP warrants further study with prospective, randomized trials.

Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy

BACKGROUND

Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery.

STUDY DESIGN

Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors.

RESULTS

One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created.

CONCLUSION

Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.

Pathologic response translates to improved patient survival after locoregional treatment for hepatocellular carcinoma: the importance of minimally invasive microwave ablation

BACKGROUND

Hepatectomy or transplantation can serve as curative treatment for early-stage hepatocellular carcinoma (HCC). Unfortunately, as progression remains a reality, locoregional therapies (LRT) for curative or bridging intent have become common. Efficacy on viability, outcomes, and accuracy of imaging should be defined to guide treatment.

METHODS

Patients with HCC who underwent minimally invasive (MIS) microwave ablation (MWA), transarterial chemoembolization (TACE), or both (MIS-MWA-TACE) prior to hepatectomy or transplantation were identified. Tumor response and preoperative computed tomography (CT) accuracy were assessed and compared to pathology. Clinical and oncologic outcomes were compared between MIS-MWA, TACE, and MIS-MWA-TACE.

RESULTS

Ninety-one patients, with tumors from all stages of the Barcelona Clinic Liver Cancer (BCLC) staging, were identified who underwent LRT prior to resection or transplant. Fourteen patients underwent MIS-MWA, 46 underwent TACE, and 31 underwent both neoadjuvantly. TACE population was older; otherwise, there were no differences in demographics. Fifty-seven percent of MIS-MWA patients had no viable tumor on pathology whereas only 13% of TACE patients and 29% of MIS-MWA-TACE patients had complete destruction (p = 0.004). The amount of remaining viable tumor in the explant was also significantly different between groups (MIS-MWA: 17.2%, TACE: 48.7%, MIS-MWA-TACE: 18.6%; p ≤ 0.0001). Compared with TACE, the MIS-MWA and MIS-MWA-TACE groups had significantly improved overall survival (MIS-MWA: 99.94 months, TACE: 75.35 months, MIS-MWA-TACE: 140 months; p = 0.017). This survival remained significant with stratification by tumor size. CT accuracy was found to be 50% sensitive and 86% specific for MIS-MWA. For TACE, CT had an 82% sensitivity and 33% specificity and for MIS-MWA-TACE, there was a 42% sensitivity and 78% specificity.

CONCLUSION

The impact of locoregional treatments on tumor viability is distinct and superior with MIS-MWA alone and MIS-MWA-TACE offering significant advantage over TACE alone. The extent of this effect may be implicated in the improved overall survival.

Conversion therapy for intrahepatic cholangiocarcinoma and tumor downsizing to increase resection rates: A systematic review

Intrahepatic cholangiocarcinoma (ICC) is a devastating malignant neoplasm with dismal outcomes. Several therapeutic modalities have been used with variable success to downsize these tumors for resection. Neoadjuvant therapy such as chemoembolization and radioembolization offer promising options to manage tumor burden prior to resection. A systematic review of the literature was performed with a focus on conversion therapy for ICC and tumor downsizing to increase resection rates among patients who have an initially unresectable tumor. Of 132 patients with initially unresectable ICC, we identified 27 who underwent conversion therapy with surgical resection. Adequate tumor downsizing was achieved with chemotherapy, chemoembolization, radioembolization, or combination thereof. Although negative tumor margins were possible in some patients, recurrence rates and survival outcomes were inconsistently reported. Twenty-three of 27 patients were alive at last reported follow-up. Conversion therapy for initially unresectable ICC may offer adequate tumor downsizing for resection.

Using a Mobile Application for Real-Time Collection of Patient-Reported Outcomes in Hepatopancreatobiliary Surgery within an ERAS® Pathway

Patient-reported outcomes (PROs) are essential for patient-centered health care. This pilot study implemented a mobile application customized to an hepatopancreatobiliary Enhanced Recovery After Surgery (ERAS®) program—a novel environment—for real-time collection of PROs, including ERAS® pathway compliance. Patients undergoing hepatectomy, distal pancreatectomy, or pancreaticoduodenectomy through the ERAS® program were prospectively enrolled over 10 months. The application provided education and questionnaires before surgery through 30 days postdischarge. Thresholds were set for initial adoption of the application (75%), PRO response rate (50%), and patient satisfaction (75%). Daily postdischarge health checks integrated customized responses to guide out-of-hospital care. Of 165 enrolled patients, 122 met inclusion criteria. Application adoption was 93 per cent (114/122) and in-hospital engagement remained high at 88 per cent (107/122). Patients completed 62 per cent of PRO on quality of life, postoperative pain, nausea, opioid consumption, and compliance to ERAS® pathway items, including ambulation and breathing exercises. During postcharge tracking, 12 patients reported that the application prevented a phone call to the hospital and three patients reported prevention of an emergency room visit. PRO collection through this mobile device created an integrated platform for comprehensive perioperative care, patient-initiated outcome tracking with automatic reporting, and real-time feedback for process change. Improving proactive outpatient management of complex patients through mobile technology could help restructure health-care delivery and improve resource utilization for all patients.

Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery

Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®–based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.

An objective approach to evaluate novice robotic surgeons using a combination of kinematics and stepwise cumulative sum (CUSUM) analyses

BACKGROUND

Current evaluation methods for robotic-assisted surgery (ARCS or GEARS) are limited to 5-point Likert scales which are inherently time-consuming and require a degree of subjective scoring. In this study, we demonstrate a method to break down complex robotic surgical procedures using a combination of an objective cumulative sum (CUSUM) analysis and kinematics data obtained from the da Vinci® Surgical System to evaluate the performance of novice robotic surgeons.

METHODS

Two HPB fellows performed 40 robotic-assisted hepaticojejunostomy reconstructions to model a portion of a Whipple procedure. Kinematics data from the da Vinci® system was recorded using the dV Logger® while CUSUM analyses were performed for each procedural step. Each kinematic variable was modeled using machine learning to reflect the fellows' learning curves for each task. Statistically significant kinematics variables were then combined into a single formula to create the operative robotic index (ORI).

RESULTS

The inflection points of our overall CUSUM analysis showed improvement in technical performance beginning at trial 16. The derived ORI model showed a strong fit to our observed kinematics data (R² = 0.796) with an ability to distinguish between novice and intermediate robotic performance with 89.3% overall accuracy.

CONCLUSIONS

In this study, we demonstrate a novel approach to objectively break down novice performance on the da Vinci® Surgical System. We identified kinematics variables associated with improved overall technical performance to create an objective ORI. This approach to robotic operative evaluation demonstrates a valuable method to break down complex surgical procedures in an objective, stepwise fashion. Continued research into objective methods of evaluation for robotic surgery will be invaluable for future training and clinical implementation of the robotic platform.

Prognostic impact of the Bismuth-Corlette classification: Higher rates of local unresectability in stage IIIb hilar cholangiocarcinoma

BACKGROUND

The Bismuth-Corlette (BC) classification is used to categorize hilar cholangiocarcinoma by proximal extension along the biliary tree. As the right hepatic artery crosses just behind the left bile duct, we hypothesized that BC IIIb tumors would have a higher likelihood of local unresectability due to involvement of the contralateral artery.

METHODS

A retrospective review of a prospectively maintained database identified patients with hilar cholangiocarcinoma taken to the operating room for intended curative resection between April 2008 and September 2016. Cases were assigned BC stages based on preoperative imaging.

RESULTS

Sixty-eight patients were included in the study. All underwent staging laparoscopy after which 16 cases were aborted for metastatic disease. Of the remaining 52 cases, 14 cases were explored and aborted for locally advanced disease. Thirty-eight underwent attempt at curative resection. After excluding cases aborted for metastatic disease, the chance of proceeding with resection was 55.6% for BC IIIb staged lesions compared to 80.0% of BC IIIa lesions and to 82.4% for BC I-IIIa staged lesions (P < 0.05). About 44.4% of BC IIIb lesions were aborted for locally advanced disease versus 17.6% of remaining BC stages.

CONCLUSIONS

When hilar cholangiocarcinoma is preoperatively staged as BC IIIb, surgeons should anticipate higher rates of locally unresectable disease, likely involving the right hepatic artery.

The next step in surgical quality improvement: outcome situational awareness

Summary

A similar theme unites proposed solutions for stagnant improvement in outcomes and rising health care costs: eliminate unnecessary variation in the care of surgical patients. While large quality-improvement projects like the Americal College of Surgeons National Surgical Quality Improvement Program have historically led to improved patient outcomes at the hospital level, the next step in surgical quality improvement is to eliminate unnecessary variation at the level of the individual surgeon. Critical examination of individualized clinical, financial and patient-reported outcomes — outcome situational awareness — along with peer group comparison will help surgeons to identify variation in patient care. We are piloting an interactive software platform at our institution to provide information on individualized clinical, financial and patient-reported outcomes in real time through automatic data population of a central REDCap database. These individualized data along with peer group comparison allow surgeons to objectively determine areas of potential improvement.

Experimental High-Frequency Irreversible Electroporation Using a Single-Needle Delivery Approach for Nonthermal Pancreatic Ablation In Vivo

PURPOSE

To investigate the feasibility of single-needle high-frequency irreversible electroporation (SN-HFIRE) to create reproducible tissue ablations in an in vivo pancreatic swine model.

MATERIALS AND METHODS

SN-HFIRE was performed in swine pancreas in vivo in the absence of intraoperative paralytics or cardiac synchronization using 3 different voltage waveforms (1-5-1, 2-5-2, and 5-5-5 [on-off-on times (μs)], n = 6/setting) with a total energized time of 100 μs per burst. At necropsy, ablation size/shape was determined. Immunohistochemistry was performed to quantify apoptosis using an anticleaved caspase-3 antibody. A numerical model was developed to determine lethal thresholds for each waveform in pancreas.

RESULTS

Mean tissue ablation time was 5.0 ± 0.2 minutes, and no cardiac abnormalities or muscle twitch was detected. Mean ablation area significantly increased with increasing pulse width (41.0 ± 5.1 mm² [range 32-66 mm²] vs 44 ± 2.1 mm² [range 38-56 mm²] vs 85.0 ± 7.0 mm² [range 63-155 mm²]; 1-5-1, 2-5-2, 5-5-5, respectively; p < 0.0002 5-5-5 vs 1-5-1 and 2-5-2). The majority of the ablation zone did not stain positive for cleaved caspase-3 (6.1 ± 2.8% [range 1.8-9.1%], 8.8 ± 1.3% [range 5.5-14.0%], and 11.0 ± 1.4% [range 7.1-14.2%] cleaved caspase-3 positive 1-5-1, 2-5-2, 5-5-5, respectively), with significantly more positive staining at the 5-5-5 pulse setting compared with 1-5-1 (p < 0.03). Numerical modeling determined a lethal threshold of 1114 ± 123 V/cm (1-5-1 waveform), 1039 ± 103 V/cm (2-5-2 waveform), and 693 ± 81 V/cm (5-5-5 waveform).

CONCLUSIONS

SN-HFIRE induces rapid, predictable ablations in pancreatic tissue in vivo without the need for intraoperative paralytics or cardiac synchronization.

Simplified Non-Thermal Tissue Ablation With a Single Insertion Device Enabled by Bipolar High-Frequency Pulses

OBJECTIVE

To demonstrate the feasibility of a single electrode and grounding pad approach for delivering high frequency irreversible electroporation treatments (H-FIRE) in in-vivo hepatic tissue.

METHODS

Ablations were created in porcine liver under surgical anesthesia by adminstereing high frequency bursts of 0.5-5.0 μs pulses with amplitudes between 1.1-1.7 kV in the absence of cardiac synchronization or intraoperative paralytics. Finite element simulations were used to determine the electric field strength associated with the ablation margins (E_Lethal) and predict the ablations feasible with next generation electronics.

RESULTS

All animals survived the procedures for the protocol duration without adverse events. E_Lethal of 2550, 1650, and 875 V/cm were found for treatments consisting of 100x bursts containing 0.5 μs pulses and 25, 50, and 75 μs of energized-time per burst, respectively. Treatments with 1 μs pulses consisting of 100 bursts with 100 μs energized-time per burst resulted in E_Lethal of 650 V/cm.

CONCLUSION

A single electrode and grounding pad approach was successfully used to create ablations in hepatic tissue. This technique has the potential to reduce challenges associated with placing multiple electrodes in anatomically challenging environments.

SIGNIFICANCE

H-FIRE is an in situ tumor ablation approach in which electrodes are placed within or around a targeted region to deliver high voltage electrical pulses. Electric fields generated around the electrodes induce irrecoverable cell membrane damage leading to predictable cell death in the relative absence of thermal damage. The sparing of architectural integrity means H-FIRE offers potential advantages compared to thermal ablation modalities for ablating tumors near critical structures.

Robotic-assisted versus laparoscopic left pancreatectomy at a high-volume, minimally invasive center

INTRODUCTION

While minimally invasive left pancreatectomy has become more widespread and generally accepted over the last decade, opinions on modality of minimally invasive approach (robotic or laparoscopic) remain mixed with few institutions performing a significant portion of both operative approaches simultaneously.

METHODS

247 minimally invasive left pancreatectomies were retrospectively identified in a prospectively maintained institutional REDCap™ database, 135 laparoscopic left pancreatectomy (LLP) and 108 robotic-assisted left pancreatectomy (RLP). Demographics, intraoperative variables, postoperative outcomes, and OR costs were compared between LLP and RLP with an additional subgroup analysis for procedures performed specifically for pancreatic adenocarcinoma (35 LLP and 23 RLP) focusing on pathologic outcomes and 2-year actuarial survival.

RESULTS

There were no significant differences in preoperative demographics or indications between LLP and RLP with 34% performed for chronic pancreatitis and 23% performed for pancreatic adenocarcinoma. While laparoscopic cases were faster (p < 0.001) robotic cases had a higher rate of splenic preservation (p < 0.001). Median length of stay was 5 days for RLP and LLP, and rate of clinically significant grade B/C pancreatic fistula was approximately 20% for both groups. Conversion rates to laparotomy were 4.3% and 1.8% for LLP and RLP approaches respectively. RLP had a higher rate of readmission (p = 0.035). Pathologic outcomes and 2-year actuarial survival were similar between LLP and RLP. LLP on average saved $206.67 in OR costs over RLP.

CONCLUSIONS

This study demonstrates that at a high-volume center with significant minimally invasive experience, both LLP and RLP can be equally effective when used at the discretion of the operating surgeon. We view the laparoscopic and robotic platforms as tools for the modern surgeon, and at our institution, given the technical success of both operative approaches, we will continue to encourage our surgeons to approach a difficult operation with their tool of choice.

Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence

Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for "low risk" were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as "low risk." Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the "low-risk" cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.

Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence

Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for “low risk” were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as “low risk.” Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the “low-risk” cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.

Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery

Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.

Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses

Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.

Using a Mobile Application for Real-Time Collection of Patient-Reported Outcomes in Hepatopancreatobiliary Surgery within an ERAS® Pathway

Patient-reported outcomes (PROs) are essential for patient-centered health care. This pilot study implemented a mobile application customized to an hepatopancreatobiliary Enhanced Recovery After Surgery (ERAS®) program-a novel environment-for real-time collection of PROs, including ERAS® pathway compliance. Patients undergoing hepatectomy, distal pancreatectomy, or pancreaticoduodenectomy through the ERAS® program were prospectively enrolled over 10 months. The application provided education and questionnaires before surgery through 30 days postdischarge. Thresholds were set for initial adoption of the application (75%), PRO response rate (50%), and patient satisfaction (75%). Daily postdischarge health checks integrated customized responses to guide out-of-hospital care. Of 165 enrolled patients, 122 met inclusion criteria. Application adoption was 93 per cent (114/122) and in-hospital engagement remained high at 88 per cent (107/122). Patients completed 62 per cent of PRO on quality of life, postoperative pain, nausea, opioid consumption, and compliance to ERAS® pathway items, including ambulation and breathing exercises. During postcharge tracking, 12 patients reported that the application prevented a phone call to the hospital and three patients reported prevention of an emergency room visit. PRO collection through this mobile device created an integrated platform for comprehensive perioperative care, patient-initiated outcome tracking with automatic reporting, and real-time feedback for process change. Improving proactive outpatient management of complex patients through mobile technology could help restructure health-care delivery and improve resource utilization for all patients.

Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses

Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.

Efficacy of a Laparoscopic Saline-Coupled Bipolar Sealer in Minimally Invasive Hepatobiliary Surgery

Hepatic resection presents unique surgical challenges to reduce blood loss during parenchymal division. The development of saline-coupled bipolar devices, in which hemostasis is achieved at lower temperatures than electrocautery or other bipolar sealing devices, have been employed for open hepatic resection. Saline-coupled bipolar devices have now become available for minimally invasive use. The goals of this study were to evaluate the feasibility and safety of a laparoscopic saline-coupled bipolar device for minimally invasive hepatectomy. Seventeen patients (median age 66 years, range 36-81) were consented for inclusion and enrolled. Patient demographics, intraoperative data, and surgeon feedback were collected. Seven robot-assisted partial hepatectomies, 9 laparoscopic partial hepatectomies, and 1 laparoscopic cholecystectomy with liver abscess resection were performed. Average operating time was 222 ± 33 minutes (median 188 minutes; range 61-564 minutes) with no difference between robotic versus laparoscopic time. Successful seals were achieved in all cases following application of 150 to 200 J energy (average 179 ± 3 J, average time to achieve a successful seal 9.3 ± 2.7 minutes). Estimated blood loss was 362 ± 74 mL (median 300 mL, range 5-1200 mL) and 3/17 patients received intraoperative blood transfusion. No bile leaks were detected in any of the patients. Median length of stay was 5 days (range 1-20 days), and there were no readmissions within 30 days. Postoperative morbidity occurred in 5/17 patients, all of which were Clavien Grade 1. There was no mortality within 90 days or complications requiring a return to the operating room, and there were no liver-specific morbidities. These data suggest the laparoscopic Aquamantys device represents a useful device for use in minimally invasive liver resection.

Total compared with partial pancreatectomy for pancreatic adenocarcinoma: assessment of resection margin, readmission rate, and survival from the U.S. National Cancer Database

Introduction

Total pancreatectomy for pancreatic ductal adenocarcinoma has historically been associated with substantial patient morbidity and mortality. Given advancements in perioperative and postoperative care, evaluation of the surgical treatment options for pancreatic adenocarcinoma should consider patient outcomes and long-term survival for total pancreatectomy compared with partial pancreatectomy.

Methods

The U.S. National Cancer Database was queried for patients undergoing total pancreatectomy or partial pancreatectomy for pancreatic adenocarcinoma during 1998-2006. Demographics, tumour characteristics, operative outcomes, 30-day mortality, 30-day readmission, additional treatment, and Kaplan-Meier survival curves were compared.

Results

The database query returned 807 patients who underwent total pancreatectomy and 5840 who underwent partial pancreatectomy. More patients who underwent total pancreatectomy than a partial pancreatectomy had a margin-negative resection (p < 0.0001). Mortality and readmission rates were similar in the two groups, as was long-term survival on Kaplan-Meier curves (p = 0.377). A statistically significant difference in the rate of surgery only (without additional treatment) was observed for patients in the total pancreatectomy group (p = 0.0003).

Conclusions

Although total compared with partial pancreatectomy was associated with a higher rate of margin-negative resection, median survival was not significantly different for patients undergoing either procedure. Patients who underwent total pancreatectomy were significantly less likely to receive adjuvant therapy.

Routine versus difficult cholecystectomy: using predictive analytics to assess patient outcomes

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program^® (NSQIP) Surgical Risk. Calculator (SRC) estimates postoperative outcomes. The aim of this study was to develop and validate a specific predictive outcomes model for cholecystectomy procedures.

METHODS

Patients who underwent cholecystectomy between 2008 and 2016 and were deemed too high risk for acute care general surgery (GS) and had surgery performed by the Division of Hepatopancreatobiliary Surgery (HPB) were identified. Outcomes of the HPB cholecystectomies were matched against cholecystectomies performed by GS. New predictive models for postoperative outcomes were constructed. Area under the curve was used to assess predictive accuracy for both models and internal validation was performed using bootstrap logistic regression.

RESULTS

A total of 169/934 (18%) cholecystectomies were identified as too high risk for GS. These 169 patients were matched with 126 patients who had cholecystectomy performed by GS. For GS and HPB cholecystectomies, the proposed model demonstrated better discriminative ability compared to the SRC based on ROC curves (proposed model: 0.589-0.982; SRC: 0.570-0.836) for each of the predicted outcomes.

CONCLUSION

For patients undergoing cholecystectomy, customized models are superior for predicting individual perioperative risk and allow more accurate, patient-specific delivery of care.

The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy

INTRODUCTION

Optimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying.

METHODS

Retrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVV < 12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVV ≥ 12.

RESULTS

Of 64 patients who met selection criteria, 42 (65.6%) had a SVV < 12 and 22 (34.4%) had a SVV ≥ 12. Patients with an SVV ≥ 12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVV < 12 (5.9% vs 21.3%)). Patients with an SVV ≥ 12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVV < 12 (41.2% vs 46.8%).

CONCLUSION

Goal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.

Discrepancy in Postoperative Outcomes between Auditing Databases: A NSQIP Comparison

In 2014, ACS-NSQIP® targeted pancreatectomies to improve outcome reporting and risk calculation related to pancreatectomy. At the same time, our department began prospectively collecting data for pancreatectomy in the Enhanced Recovery After Surgery® Interactive Audit System (EIAS). The purpose of this study is to compare reported outcomes between two major auditing databases for the same patients undergoing pancreatectomy. The same 171 patients were identified in both databases. Clinical outcomes were then obtained from each database and compared to determine whether reported complication rates were statistically different between auditing databases. A combination of Wilcoxon rank sum and Pearson's chi-squared tests were used to calculate statistical significance. No significant difference was appreciated in captured demographics between EIAS and NSQIP. Significant differences in reported rates for renal dysfunction, postoperative pancreatic fistula, return to the operative room, and urinary tract infection were noted between EIAS and NSQIP. Although significant differences in reported complication rates were demonstrated between EIAS and NSQIP for pancreatectomy, much of the discrepancy is attributable to subtle differences in definitions for postoperative occurrences between the two auditing databases. It is vital for surgeons to understand the exact definition that determines the complication rate for a given database.

Developing and validating a center-specific preoperative prediction calculator for risk of outcomes following major hepatectomy procedures

BACKGROUND

The American College of Surgeons NSQIP^® Surgical Risk Calculator (SRC) was developed to estimate postoperative outcomes. Our goal was to develop and validate an institution-specific risk calculator for patients undergoing major hepatectomy at Carolinas Medical Center (CMC).

METHODS

Outcomes generated by the SRC were recorded for 139 major hepatectomies performed at CMC (2008-2016). Novel predictive models for seven postoperative outcomes were constructed and probabilities calculated. Brier score and area under the curve (AUC) were employed to assess accuracy. Internal validation was performed using bootstrap logistic regression. Logistic regression models were constructed using bivariate and multivariate analyses.

RESULTS

Brier scores showed no significant difference in the predictive ability of the SRC and CMC model. Significant differences in the discriminative ability of the models were identified at the individual level. Both models closely predicted 30-day mortality (SRC AUC: 0.867; CMC AUC: 0.815). The CMC model was a stronger predictor of individual postoperative risk for six of seven outcomes (SRC AUC: 0.531-0.867; CMC AUC: 0.753-0.970).

CONCLUSION

Institution-specific models provide superior outcome predictions of perioperative risk for patients undergoing major hepatectomy. If properly developed and validated, institution-specific models can be used to deliver more accurate, patient-specific care.

Fellows' perspective of HPB training programs in North America: results of a survey

BACKGROUND

Sixteen hepatopancreatobiliary fellowship programs in North America are accredited by the Fellowship Council. This study aims to assess fellows' perceptions of their training program.

METHODS

A multiple-choice questionnaire was sent to 35 fellows to assess how they perceived their training: academics, research, operative experiences, autonomy, mentorship, program quality and weaknesses. The survey was developed using the SurveyMonkey^® tool.

RESULTS

Twenty-four of 35 fellows completed the survey. Sixteen fellows reported structured didactics; 10 reported mandatory research. As to operative experiences; 9 fellows reported exposure to minimally-invasive liver surgery; 5 reported exposure to robotics. Fourteen fellows reported using ablation; 5 reported using ablation laparoscopically; 8 reported using mostly radiofrequency ablation; 1 reported using irreversible electroporation. Eighteen fellows reported excellent training; 20 reported mentorship; 19 reported operative autonomy. Limited exposure to medical oncology/multidisciplinary care, portal hypertension surgery, and robotics surgery were perceived as program weaknesses by 7, 9, and 7 fellows, respectively.

CONCLUSION

Most fellows ranked their program quality and academic content as excellent, but they perceived a need for more exposure to medical oncology, portal hypertension surgery, and minimally-invasive surgery, with an emphasis on robotics. Fellowship training may need to integrate fellows' desires for enhanced proficiency in these clinical areas.

Discrepancy in Postoperative Outcomes between Auditing Databases: A NSQIP Comparison

In 2014, ACS-NSQIP® targeted pancreatectomies to improve outcome reporting and risk calculation related to pancreatectomy. At the same time, our department began prospectively collecting data for pancreatectomy in the Enhanced Recovery After Surgery® Interactive Audit System (EIAS). The purpose of this study is to compare reported outcomes between two major auditing databases for the same patients undergoing pancreatectomy. The same 171 patients were identified in both databases. Clinical outcomes were then obtained from each database and compared to determine whether reported complication rates were statistically different between auditing databases. A combination of Wilcoxon rank sum and Pearson's chi-squared tests were used to calculate statistical significance. No significant difference was appreciated in captured demographics between EIAS and NSQIP. Significant differences in reported rates for renal dysfunction, postoperative pancreatic fistula, return to the operative room, and urinary tract infection were noted between EIAS and NSQIP. Although significant differences in reported complication rates were demonstrated between EIAS and NSQIP for pancreatectomy, much of the discrepancy is attributable to subtle differences in definitions for postoperative occurrences between the two auditing databases. It is vital for surgeons to understand the exact definition that determines the complication rate for a given database.