Impact of Recombinant Granulocyte Colony-Stimulating Factor During Neoadjuvant Therapy on Outcomes of Resected Pancreatic Cancer

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease characterized by chronic inflammation and a tolerogenic immune response. The granulocyte colony-stimulating factor (G-CSF)-neutrophil axis promotes oncogenesis and progression of PDAC. Despite frequent use of recombinant G-CSF in the management and prevention of chemotherapy-induced neutropenia, its impact on oncologic outcomes of patients with resected PDAC is unclear.

PATIENTS AND METHODS

This cohort study assessing the impact of G-CSF administration was conducted on 351 patients with PDAC treated with neoadjuvant therapy (NAT) and pancreatic resection at a high-volume tertiary care academic center from 2014 to 2019. Participants were identified from a prospectively maintained database and had a median follow-up of 45.8 months.

RESULTS

Patients receiving G-CSF (n=138; 39.3%) were younger (64.0 vs 66.7 years; P=.008), had lower body mass index (26.5 vs 27.9; P=.021), and were more likely to receive 5-FU-based chemotherapy (42.0% vs 28.2%; P<.0001). No differences were observed in baseline or clinical tumor staging. Patients receiving G-CSF were more likely to have an elevated (>5.53) post-NAT neutrophil-to-lymphocyte ratio (45.0% vs 29.6%; P=.004). G-CSF recipients also demonstrated higher circulating levels of neutrophil extracellular traps (+709 vs -619 pg/mL; P=.006). On multivariate analysis, G-CSF treatment was associated with perineural invasion (hazard ratio [HR], 2.65; 95% CI, 1.16-6.03; P=.021) and margin-positive resection (HR, 1.67; 95% CI, 1.01-2.77; P=.046). Patients receiving G-CSF had decreased overall survival (OS) compared with nonrecipients (median OS, 29.2 vs 38.7 months; P=.001). G-CSF administration was a negative independent predictor of OS (HR, 2.02; 95% CI, 1.45-2.79; P<.0001). In the inverse probability weighted analysis of 301 matched patients, neoadjuvant G-CSF administration was associated with reduced OS.

CONCLUSIONS

In patients with localized PDAC receiving NAT prior to surgical extirpation, G-CSF administration may be associated with worse oncologic outcomes and should be further evaluated.

Epsilon aminocaproic acid is associated with acute kidney injury after life-threatening hemorrhage in children

BACKGROUND

Antifibrinolytic medications have been associated with reduced mortality in pediatric hemorrhage but may contribute to adverse events such as acute kidney injury (AKI).

STUDY DESIGN AND METHODS

We conducted a secondary analysis of the MAssive Transfusion in Children (MATIC), a prospectively collected database of children with life-threatening hemorrhage (LTH), and evaluated for risk of adverse events with either antifibrinolytic treatment, epsilon aminocaproic acid (EACA) or tranexamic acid (TXA). The primary outcome was AKI and secondary outcomes were acute respiratory distress syndrome (ARDS) and sepsis.

RESULTS

Of 448 children included, median (interquartile range) age was 7 (2-15) years, 55% were male, and LTH etiology was 46% trauma, 34% operative, and 20% medical. Three hundred and ninety-three patients did not receive an antifibrinolytic (88%); 37 (8%) received TXA and 18 (4%) received EACA. Sixty-seven (17.1%) patients in the no antifibrinolytic group developed AKI, 6 (16.2%) patients in the TXA group, and 9 (50%) patients in the EACA group (p = 0.002). After adjusting for cardiothoracic surgery, cyanotic heart disease, pre-existing renal disease, lowest hemoglobin pre-LTH, and total weight-adjusted transfusion volume during the LTH, the EACA group had increased risk of AKI (adjusted odds ratio 3.3 [95% CI 1.0 - 10.3]) compared to no antifibrinolytic. TXA was not associated with AKI. Neither antifibrinolytic treatment was associated with ARDS or sepsis.

CONCLUSION

Administration of EACA during LTH may increase the risk of AKI. Additional studies are needed to compare the risk of AKI between EACA and TXA in pediatric patients. This article is protected by copyright. All rights reserved.

Does CT scanning after pancreatoduodenectomy reduce readmission rates: an analysis of 900 resections at a high-volume center

BACKGROUND

Pancreatoduodenectomy (PD) remains associated with significant complication and readmission rates. Infection constitutes a significant proportion of morbidity. We aim to evaluate whether CT scans performed prior to discharge for suspected infection prevents readmission.

METHODS

A retrospective review of patients undergoing PD at a tertiary referral center from 2010 to 2018.

RESULTS

A total of 982 patients underwent PD: 74% had no clinical infection at the index admission. Of the non-infected patients, 59% exhibited leukocytosis, 27% underwent a CT scan, and 33.6% were readmitted. Of the non-infected patients, 148 (20.3%) experienced major complications, and this was the strongest predictor of readmission (OR: 10.5, [95% CI: 6.5-17], p = 0.0001). In the non-infected patients who had major complications, CT scanning was predictive of lower risk of readmission (OR: 0.38, [95% CI: 0.17-0.83], p = 0.015). Leukocytosis was also found to be predictive of lower risk of readmission (OR: 0.42, [95% CI: 0.18-0.98], p = 0.044). These findings did not hold true for those who had yet to experience major complications on their index admission.

CONCLUSION

CT scanning without evidence of infection was associated with reduction of readmission in the cohort with major complications and showed a trend towards preventing readmission in the overall cohort. Development of clinical algorithms to maximize the utility of this test is warranted.

Association of robotic approach with patient-reported outcomes after pancreatectomy: a prospective cohort study

BACKGROUND

Robotic-assisted pancreatectomy continues to proliferate despite limited evidence supporting its benefits from the patient's perspective. We compared patient-reported outcomes (PROs) between patients undergoing robotic and open pancreatectomies.

METHODS

PROs, measured with the FACT-Hep, FACT-G, and HCS, were assessed in the immediate postoperative (i.e., preoperative to discharge) and recovery (i.e., discharge to three months postoperative) periods. Linear mixed models estimated the association of operative approach on PROs. Minimally important differences (MIDs) were also considered.

RESULTS

Among 139 patients, 105 (75.5%) underwent robotic pancreatectomies. Compared to those who underwent open operations, those who underwent robotic operations experienced worse FACT-Hep scores that were both statistically and clinically significant (mean difference [MD] 8.6 points, 95% CI 1.0-16.3). Declines in FACT-G (MD 4.3, 95% CI -1.0 to 9.6) and HCS (MD 4.3, 95% CI 0.8-7.9) scores appeared to contribute equally in both operative approaches to the decline in total FACT-Hep score. Patients who underwent robotic versus open operations both statistically and clinically significantly improved due to improvements in HCS (MD 6.1, 95% CI 2.3-9.9) but not in FACT-G (MD 1.2, 95% CI - 5.1-7.4).

CONCLUSION

The robotic approach to pancreas surgery might offer, from the patient's perspective, greater improvement in symptoms over the open approach by three months postoperatively.

Encouraging long-term survival following autophagy inhibition using neoadjuvant hydroxychloroquine and gemcitabine for high-risk patients with resectable pancreatic carcinoma

INTRODUCTION

Preoperative autophagy inhibition with hydroxychloroquine (HCQ) in combination with gemcitabine in pancreatic adenocarcinoma (PDAC) has been shown to be safe and effective in inducing a serum biomarker response and increase resection rates in a previous phase I/II clinical trial. We aimed to analyze the long-term outcomes of preoperative HCQ with gemcitabine for this cohort.

METHODS

A review of patients enrolled between July 2010 and February 2013 in the completed phase I/II single arm (two doses of fixed-dose gemcitabine (1500 mg/m2 ) in combination with oral hydroxychloroquine administered for 31 consecutive days until the day of surgery for high-risk pancreatic cancer) was undertaken. Progression-free survival (PFS) and overall survival analysis (OS) using Kaplan-Meier estimates were performed.

RESULTS

Of 35 patients initially enrolled, 29 patients underwent surgical resection (median age at diagnosis: 62 years, 45% females). Median duration of follow-up was 7.5 years. There was a median 15% decrease in the serum CA19-9 levels following completion of neoadjuvant therapy and 83% of the cohort underwent a pancreaticoduodenectomy, 7 (24%) patients had a concomitant venous resection. On histopathology, 14 (48%) patients had at least a partial treatment response. The median PFS and OS were 11 months (95% Confidence interval [CI]: 7-28) and 31 months (95% CI: 13-47), respectively, while 9 (31%) patients survived beyond 5 years from diagnosis; a rate that compares very favorably with contemporaneous series.

CONCLUSION

Compared to historical data, neoadjuvant autophagy inhibition with HCQ plus gemcitabine is associated with encouraging long-term survival for patients with PDAC.

Impact of postoperative pancreatic fistula on long-term oncologic outcomes after pancreatic resection

BACKGROUND

The short-term morbidity associated with post-operative pancreatic fistula (POPF) is well established, however data regarding the long-term impact are lacking. We aim to characterize long-term oncologic outcomes of POPF after pancreatic resection through a single institution, retrospective study of pancreatic resections performed for adenocarcinoma from 2009 to 2016.

METHODS

Kaplan-Meier survival analysis, logistic regression, and multivariate analysis (MVA) were used to evaluate impact of POPF on overall survival (OS), disease free survival (DFS), and receipt of adjuvant chemotherapy (AC).

RESULTS

767 patients were included. 82 (10.6%) developed grade B (n = 67) or C (n = 15) POPF. Grade C POPF resulted in decreased OS when compared to no POPF (20.22 vs 26.33 months, p = 0.027) and to grade B POPF (20.22 vs. 26.87 months, p = 0.049). POPF patients were less likely to receive AC than those without POPF (59.5% vs 74.9%, p = 0.003) and grade C POPF were less likely to receive AC than all others (26.7% vs 74.2%, p = 0.0001).

CONCLUSION

POPF patients are less likely to receive AC and more likely to have delay in time to AC. These factors are exacerbated in grade C POPF and likely contribute to decreased OS. These findings validate the clinical significance of the ISGPF definition of POPF.

Impact of G-CSF during neoadjuvant therapy on outcomes of operable pancreatic cancer

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Background: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease characterized by chronic inflammation and a tolerogenic immune response. Neutropenia is a common side effect of cytotoxic chemotherapy, managed with administration of recombinant granulocyte-colony stimulating factor (G-CSF, Filgrastim). The interleukin 17 – G-CSF – neutrophil extracellular trap (NET) axis promotes oncogenesis and progression of PDAC, inhibiting adaptive immunity. We evaluated the impact of G-CSF administration during neoadjuvant therapy (NAT) on oncologic outcomes in patients with operable pancreatic cancer. Methods: A retrospective review of all patients with localized PDAC treated with NAT prior to pancreatic resection between 2014 – 2020 was completed at a single institution. G-CSF administration, type, and dose were collected from inpatient and outpatient medical records. Results: Of 351 patients treated, 138 (39%) received G-CSF during NAT with a median follow-up of 45.8 months. Patients who received G-CSF were younger (64.0 vs 66.7, p = 0.008), had lower BMI (26.5 vs 27.9, p = 0.021), and were more likely to receive 5-FU based chemotherapy (42% vs 28.2%, p < 0.0001), NAT dose reduction (40.6% vs 25.4%, p = 0.003), or experience febrile neutropenia (8.7% vs 3.3%, p = 0.029). No differences were observed in baseline or pathologic tumor staging. In patients who received G-CSF, 130 (94%) received Pegfilgrastim with a median cumulative dose of 12 mg (IQR 6-12). Patients who received G-CSF were more likely to have an elevated post-NAT neutrophil to lymphocyte ratio (45% vs 29.6%, p = 0.004) and systemic immune-inflammation index (39.5% vs 29.6%, p = 0.061). Receiving G-CSF was an independent predictor of perineural invasion (HR 2.4, 95 CI [1.08, 5.5], p = 0.031) and margin positive resection (HR 1.69, 95 CI [1.01, 2.83], p = 0.043). Patients who received G-CSF had decreased overall survival compared to patients who did not receive G-CSF (median OS: 29.2 vs 38.7 months, p = 0.0001). Receiving G-CSF during NAT was an independent negative predictor of progression free (HR 1.38, 95 CI [1.04, 1.83], p = 0.022) and overall survival (HR 2.02, 95 CI [1.45, 2.79], p < 0.0001). In a subset of patients with available pre- and post-NAT serum specimens (n = 28), G-CSF administration resulted in an increased number of citrullinated histone H3 complexes following NAT (+1378±1502 vs -300.7±1147 pg/ml, p = 0.007), indicative of enhanced peripheral NET formation. Conclusions: In patients with localized PDAC receiving NAT prior to surgical extirpation, G-CSF administration is associated with worse oncologic outcomes and should be administered with caution. Prospective randomized as well as confirmatory clinical studies are in order.

500 Minimally Invasive Robotic Pancreatoduodenectomies: One Decade of Optimizing Performance

OBJECTIVES

This study aims to present the outcomes of our decade-long experience of robotic pancreatoduodenectomy and provide insights into successful program implementation.

BACKGROUND

Despite significant improvement in mortality over the past 30 years, morbidity following open pancreatoduodenectomy remains high. We implemented a minimally invasive pancreatic surgery program based on the robotic platform as one potential method of improving outcomes for this operation.

METHODS

A retrospective review of a prospectively maintained institutional database was performed to identify patients who underwent robotic pancreatoduodenectomy (RPD) between 2008 and 2017 at the University of Pittsburgh.

RESULTS

In total, 500 consecutive RPDs were included. Operative time, conversion to open, blood loss, and clinically relevant postoperative pancreatic fistula improved early in the experience and have remained low despite increasing complexity of case selection as reflected by increasing number of patients with pancreatic cancer, vascular resections, and higher Charlson Comorbidity scores (all P<0.05). Operating room time plateaued after 240 cases at a median time of 391 minutes (interquartile rang 340-477). Major complications (Clavien >2) occurred in less than 24%, clinically relevant postoperative pancreatic fistula in 7.8%, 30- and 90-day mortality were 1.4% and 3.1% respectively, and median length of stay was 8 days. Outcomes were not impacted by integration of trainees or expansion of selection criteria.

CONCLUSIONS

Structured implementation of robotic pancreatoduodenectomy can be associated with excellent outcomes. In the largest series of RPD, we establish benchmarks for the surgical community to consider when adopting this approach.

Protective/reparative cytokines are suppressed at high injury severity in human trauma

Background

Trauma elicits a complex inflammatory response that, among multiple presenting factors, is greatly impacted by the magnitude of injury severity. Herein, we compared the changes in circulating levels of mediators with known proinflammatory roles to those with known protective/reparative actions as a function of injury severity in injured humans.

Methods

Clinical and biobank data were obtained from 472 (trauma database-1 (TD-1), University of Pittsburgh) and 89 (trauma database-2 (TD-2), Indiana University) trauma patients admitted to the intensive care unit (ICU) and who survived to discharge. Injury severity was estimated based on the Injury Severity Score (ISS), and this was used as both a continuous variable and for the purpose of grouping patients into severity-based cohorts. Samples within the first 24 hours were obtained from all patients and then daily up to day 7 postinjury in TD-1. Sixteen cytokines were assayed using Luminex and were analyzed using two-way analysis of variance (p<0.05).

Results

Patients with higher ISSs had longer ICU and hospital stays, days on mechanical ventilation and higher rates of nosocomial infection when compared with the mild and moderate groups. Time course analysis and correlations with ISS showed that 11 inflammatory mediators correlated positively with injury severity, consistent with previous reports. However, five mediators (interleukin (IL)-9, IL-21, IL-22, IL-23 and IL-17E/25) were suppressed in patients with high ISS and inversely correlated with ISS.

Discussion

These findings suggest that severe injury is associated with a suppression of a subset of cytokines known to be involved in tissue protection and regeneration (IL-9, IL-22 and IL-17E/25) and lymphocyte differentiation (IL-21 and IL-23), which in turn correlates with adverse clinical outcomes. Thus, patterns of proinflammatory versus protective/reparative mediators diverge with increasing ISS.

Laparoscopic-assisted ERCP following RYGB: a 12-year assessment of outcomes and learning curve at a high-volume pancreatobiliary center

INTRODUCTION

Treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant technical challenges. Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing access to the papilla. Our aims were to analyze our 12-year institutional outcomes and determine the learning curve for LA-ERCP.

METHODS

A retrospective review of cases between 2007 and 2019 at a high-volume pancreatobiliary unit was performed. Logistic regression was used to identify predictors of specific outcomes. To identify the learning curve, CUSUM analyses and innovative methods for standardizing the surgeon's timelines were performed.

RESULTS

131 patients underwent LA-ERCP (median age 60, 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the papilla was achieved in all cases. Indications were choledocholithiasis (78%), Sphincter of Oddi dysfunction/Papillary stenosis (18%), management of bile leak (2%) and stenting/biopsy of malignant strictures (2%). Median total, surgical and ERCP times were 180, 128 and 48 min, respectively, and 47% underwent concomitant cholecystectomy. Surgical site infection developed in 9.2% and post-ERCP pancreatitis in 3.8%. Logistic regression revealed multiple abdominal operations and magnitude of BMI decrease (between RYGB and LA-ERCP) to be predictive of conversion to open approach. CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 9 for the gastroenterology team. On binary cut analysis, 3-5 cases per surgeon were needed to optimize operative metrics.

CONCLUSION

LA-ERCP is associated with high success rates and low adverse events. We identify outcome benchmarks and a learning curve for new adopters of this increasingly performed procedure.

Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial

IMPORTANCE

In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients.

OBJECTIVE

To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage.

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019.

INTERVENTIONS

Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day all-cause mortality.

RESULTS

In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, -1.8%; 95% CI, -5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, -3.0%; 95% CI, -5.7% to -0.3%; P < .002). Patients with severe shock (systolic blood pressure ≤70 mm Hg) who received tranexamic acid demonstrated lower 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003).

CONCLUSIONS AND RELEVANCE

In injured patients at risk for hemorrhage, tranexamic acid administered before hospitalization did not result in significantly lower 30-day mortality. The prehospital administration of tranexamic acid after injury did not result in a higher incidence of thrombotic complications or adverse events. Tranexamic acid given to injured patients at risk for hemorrhage in the prehospital setting is safe and associated with survival benefit in specific subgroups of patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02086500.

CA19-9 Change During Neoadjuvant Therapy May Guide the Need for Additional Adjuvant Therapy Following Resected Pancreatic Cancer

BACKGROUND

Neoadjuvant therapy (NAT) is increasingly utilized for pancreatic cancer, however the added benefit of adjuvant therapy (AT) in this setting is unknown. We hypothesized that the magnitude of CA19-9 response to NAT can guide the need for further AT in resected pancreatic cancer.

METHODS

CA19-9 secretors who received NAT for pancreatic cancer during 2008-2016 at a single institution were analyzed and CA19-9 response (difference between pre- and post-NAT values) was measured. Kaplan-Meier estimators and Cox proportional hazard ratio models were used to determine the optimal CA19-9 response at which AT ceases to confer any additional survival benefit after NAT.

RESULTS

A total of 241 patients (mean age 65.4 years, 50% female) with complete CA19-9 data who underwent NAT followed by resection were analyzed. In a cohort of patients (n = 78) in whom CA19-9 normalized with a decrease > 50% after NAT (optimal responders), AT was not associated with additional survival benefit (40.6 vs. 39.0 months, p = 0.815). Conversely, in the cohort of patients (n = 163) in whom NAT was not associated with normalization and a decrease of ≤ 50% in CA19-9 (suboptimal responders), receipt of AT was associated with a survival benefit (34.5 vs. 19.1 months, p < 0.001) following NAT. A Cox proportional hazards model confirmed CA19-9 normalization and decrease > 50% during NAT to predict no additional survival benefit from AT.

CONCLUSIONS

The magnitude of CA19-9 response to NAT may predict the need for further AT in resected pancreatic cancer. Prospective studies are needed to elucidate the optimal interplay of NAT and AT in pancreatic cancer.

Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes

Importance

Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention.

Objective

To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin.

Design, Setting, and Participants

This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018.

Exposures

Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure.

Main Outcomes and Measures

All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score-matched cohort.

Results

Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score-matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score-matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality (adjusted HR, 0.72 [95% CI, 0.55-0.95]; ARR, 1.28% [95% CI, 0.26-2.31]) and hazard of readmission, with mortality as a competing risk at both 30 days (ARR, 2.09% [95% CI, 0.35-3.82]; sub-HR, 0.84 [95% CI, 0.72-0.98]) and 90 days (ARR, 2.78% [95% CI, 0.62-4.95]; sub-HR, 0.86 [95% CI, 0.77-0.97]). Preoperative inflammation was reduced in those with metformin prescriptions compared with those without (mean neutrophil to leukocyte ratio, 4.5 [95% CI, 4.3-4.6] vs 5.0 [95% CI, 4.8-5.3]; P < .001). E-value analysis suggested robustness to unmeasured confounding.

Conclusions and Relevance

This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.

Robotic Pancreaticoduodenectomy Is Associated with Decreased Clinically Relevant Pancreatic Fistulas: a Propensity-Matched Analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) is a major complication that adversely affects recovery. The robotic approach may decrease the incidence of this complication. This propensity-matched analysis evaluates the impact of robotic PD (RPD) on CR-POPF.

METHODS

Patients undergoing PD after the learning curve at a high-volume academic medical center were reviewed. CR-POPF outcomes after open PD (OPD) and RPD were compared. Logistic regression and propensity score matching (PSM) were used to define the independent effect of RPD on CR-POPF.

RESULTS

Of 865 PDs performed over the study period, 405 (46.8%) were OPD and 460 (53.2%) were RPD. RPD was associated with a similar overall POPF rate, but a lower incidence of CR-POPF (6.7% vs. 15.8%, p < 0.001). On multivariate analysis, RPD was an independent predictor of lower CR-POPF (OR 0.278, p < 0.001). Following propensity matching, RPD continued to be protective against the occurrence of CR-POPF (coefficient = - 0.113, p = 0.001).

CONCLUSIONS

This is the largest single-center PSM analysis to evaluate the impact of robotic approach on pancreatoduodenectomy and suggests that RPD can minimize the clinical impact of pancreatic leaks after PD.

Prognostic Value of the Systemic Immune-Inflammation Index (SII) After Neoadjuvant Therapy for Patients with Resected Pancreatic Cancer

BACKGROUND

The systemic immune-inflammation index (SII), calculated using absolute platelet, neutrophil, and lymphocyte counts, has recently emerged as a predictor of survival for patients with pancreatic ductal adenocarcinoma (PDAC) when assessed at diagnosis. Neoadjuvant therapy (NAT) is increasingly used in the treatment of PDAC. However, biomarkers of response are lacking. This study aimed to determine the prognostic significance of SII before and after NAT and its association with the pancreatic tumor biomarker carbohydrate-antigen 19-9 (CA 19-9).

METHODS

This study retrospectively analyzed all PDAC patients treated with NAT before pancreatic resection at a single institution between 2007 and 2017. Pre- and post-NAT lab values were collected to calculate SII. Absolute pre-NAT, post-NAT, and change in SII after NAT were evaluated for their association with clinical outcomes.

RESULTS

The study analyzed 419 patients and found no significant correlation between pre-NAT SII and clinical outcomes. Elevated post-NAT SII was an independent, negative predictor of overall survival (OS) when assessed as a continuous variable (hazard ratio [HR], 1.0001; 95% confidence interval [CI] 1.00003-1.00014; p = 0.006). Patients with a post-NAT SII greater than 900 had a shorter median OS (31.9 vs 26.1 months; p = 0.050), and a post-NAT SII greater than 900 also was an independent negative predictor of OS (HR, 1.369; 95% CI 1.019-1.838; p = 0.037). An 80% reduction in SII independently predicted a CA 19-9 response after NAT (HR, 4.22; 95% CI 1.209-14.750; p = 0.024).

CONCLUSION

Post-treatment SII may be a useful prognostic marker in PDAC patients receiving NAT.

Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy

Importance

Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy.

Objective

To determine if technical variables during RPD are associated with postoperative DGE.

Design, Setting, and Participants

A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016.

Exposures

Video review of gastrojejunal anastomosis during RPD.

Main Outcomes and Measures

Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined.

Results

Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04).

Conclusions and Relevance

This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.

Does robotic pancreaticoduodenectomy improve outcomes in patients with high risk morphometric features compared to the open approach

BACKGROUND

We sought to investigate whether robotic pancreatoduodenectomy (RPD) mitigates adverse outcomes in patients with high-risk morphometric features compared to the open approach (OPD).

METHODS

Morphometric parameters for RPD and OPDs were measured by two blinded radiologists. The morphometric parameter best correlating with adverse outcomes was identified and used in multivariable models to evaluate the impact of surgical approach (open vs. robotic) on outcomes of patients with high-risk morphometric features.

RESULTS

Of 282 PDs available for morphometric analysis, 134 (47.5%) underwent RPD. Average Psoas Density demonstrated the most frequent association with adverse outcomes, with correlations to prolonged LOS (ρ= -0.154, p=0.01), severe complications (ρ= -0.159, p=0.007), readmission (ρ= -0.16, p=0.007), and discharge to home (ρ= 0.2, p<0.001). On multivariable analysis of patients with high-risk morphometric features (defined as APD ≤ 50^th percentile), RPD was associated with a reduction in the likelihood of prolonged LOS (OR 0.27, p = 0.015) and a trend towards discharge home versus a rehab facility or nursing home (OR 2.26, p = 0.061).

CONCLUSION

This study confirms the association between morphometrics and outcomes following PD, and suggests that the robotic approach may be associated with improved outcomes in PD patients with high-risk morphometric features.

Can post-hoc video review of robotic pancreaticoduodenectomy predict portal/superior mesenteric vein margin status in pancreatic adenocarcinoma?

BACKGROUND

Achieving margin negative resection is a significant determinant of outcome in pancreatic adenocarcinoma (PDA). However, because of the fibrotic nature of PDA, it can be difficult to discriminate fibrosis from active disease intra-operatively. We sought to determine if post-hoc video review of robotic pancreatico-duodenectomy (RPD) could predict the portal/superior mesenteric vein (PV/SMV) margin status on final pathology.

METHODS

Experienced pancreatic surgeons, blinded to patient and operative variables, reviewed the PV/SMV margin for available RPD videos of consecutive PDA patients from 9/2012 through 6/2017.

RESULTS

107 RPD videos were reviewed. Of 76 patients (71%) predicted to have a negative vein margin on video review, 20 patients (26%) had a pathologic positive margin. 25 of 31 patients (81%) predicted to have positive margin on video review were positive on pathology. The specificity of video prediction was 90.3% with a sensitivity of 55.6% and an accuracy of 75.7%.

CONCLUSION

Post-hoc video review prediction is unable to reliably predict a positive (R1) margin at the portal vein/SMV, suggesting that intra-operative clinical assessment may be suboptimal in determining the need for more extensive resections.

Crowdsourced Assessment of Inanimate Biotissue Drills: A Valid and Cost-Effective Way to Evaluate Surgical Trainees

OBJECTIVE

Providing feedback to surgical trainees is a critical component for assessment of technical skills, yet remains costly and time consuming. We hypothesize that statistical selection can identify a homogenous group of nonexpert crowdworkers capable of accurately grading inanimate surgical video.

DESIGN

Applicants auditioned by grading 9 training videos using the Objective Structured Assessment of Technical Skills (OSATS) tool and an error-based checklist. The summed OSATS, summed errors, and OSATS summary score were tested for outliers using Cronbach's Alpha and single measure intraclass correlation. Accepted crowdworkers then submitted grades for videos in 3 different compositions: full video 1× speed, full video 2× speed, and critical section segmented video. Graders were blinded to this study and a similar statistical analysis was performed.

SETTING

The study was conducted at the University of Pittsburgh Medical Center (Pittsburgh, PA), a tertiary care academic teaching hospital.

PARTICIPANTS

Thirty-six premedical students participated as crowdworker applicants and 2 surgery experts were compared as the gold-standard.

RESULTS

The selected hire intraclass correlation was 0.717 for Total Errors and 0.794 for Total OSATS for the first hire group and 0.800 for Total OSATS and 0.654 for Total Errors for the second hire group. There was very good correlation between full videos at 1× and 2× speed with an interitem statistic of 0.817 for errors and 0.86 for OSATS. Only moderate correlation was found with critical section segments. In 1 year 275hours of inanimate video was graded costing $22.27/video or $1.03/minute.

CONCLUSIONS

Statistical selection can be used to identify a homogenous cohort of crowdworkers used for grading trainees' inanimate drills. Crowdworkers can distinguish OSATS metrics and errors in full videos at 2× speed but were less consistent with segmented videos. The program is a comparatively cost-effective way to provide feedback to surgical trainees.

Risk of Venous Thromboembolism for Patients with Pancreatic Ductal Adenocarcinoma Undergoing Preoperative Chemotherapy Followed by Surgical Resection

BACKGROUND

Pancreatic ductal adenocarcinoma (PDA) is associated with a hypercoagulable state, resulting in a high risk of venous thromboembolism (VTE). Risk of VTE is well established for patients receiving chemotherapy for advanced disease and during the perioperative period for patients undergoing surgical resection. However, data are lacking for patients undergoing neoadjuvant treatment followed by resection, who may have a unique risk of VTE because of exposure to both chemotherapy and surgery.

METHODS

The study included patients with PDA who underwent neoadjuvant therapy followed by surgery from 2007 to June 2017. Development of VTE was evaluated from the start of treatment through the 90-day postoperative period. Risk factors including demographic, treatment, and laboratory variables were evaluated.

RESULTS

The study investigated 426 patients receiving neoadjuvant therapy before surgical resection. Of these patients, 20% had a VTE within 90 days postoperatively (n = 87), and 70% of the VTE occurred during the postoperative period. The VTE included pulmonary embolism (30%), deep vein thrombosis (33%), and thrombosis of the portal vein (PV)/superior mesenteric vein (SMV) (40%). A pretreatment hemoglobin level lower than 10 g/dL and a platelet count higher than 443 were independently associated with VTE during neoadjuvant treatment. The independent predictors of postoperative VTE were a body mass index higher than 35 kg/m2, a preoperative platelet-to-lymphocyte ratio higher than 260, resection with distal pancreatectomy with celiac axis resection/total pancreatectomy, PV/SMV resection, and longer operative times. Development of VTE was associated with worse overall and disease-free survival and an independent predictor of survival and decreased likelihood of receiving adjuvant chemotherapy.

CONCLUSIONS

Venous thromboembolism during neoadjuvant therapy and the subsequent perioperative period is common and has a significant impact on outcome. Further study into novel thromboprophylaxis measures or protocols during neoadjuvant treatment and the perioperative period is warranted.

Correction to: Evolution of a Novel Robotic Training Curriculum in a Complex General Surgical Oncology Fellowship

In the XML of the original article, L. Mark Knab's first name was tagged incorrectly.

Comprehensive comparative analysis of cost-effectiveness and perioperative outcomes between open, laparoscopic, and robotic distal pancreatectomy

BACKGROUND

NSQIP data show that half of distal pancreatectomies (DP) are performed by a minimally invasive approach (MIS). Advantages have been demonstrated for MIS DP, yet comparative cost data are limited. Outcomes and cost were compared in patients undergoing open (ODP), laparoscopic (LDP), and robotic (RDP) approaches at a single institution.

METHODS

A retrospective review was performed on patients undergoing DP between 1/2010-5/2016. Analysis was intention-to-treat, and cost was available after 1/2013.

RESULTS

DP was performed in 374 patients: ODP = 85, LDP = 93, and RDP = 196. Operating time was lowest in the RDP cohort (p < 0.0001). ODP had higher estimated blood loss (p < 0.0001) and transfusions (p < 0.0001) than LDP and RDP. LDP had greater conversions to open procedures than RDP (p = 0.001). Postoperative outcomes were similar between groups. Length of stay was higher in the ODP group (p = 0.0001) than LDP and RDP. Overall cost for the ODP was higher than the RDP and LDP group (p = 0.002). On multivariate analysis, RDP reduced LOS (ODP: Odds = 6.5 [p = 0.0001] and LDP: Odds = 2.1 [p = 0.036]) and total cost (ODP: Odds = 5.7 [p = 0.002] and LDP: Odds = 2.8 [p = 0.042]) independently of all demographics and illness covariates.

CONCLUSIONS

A robotic approach is associated with reduced length of stay and cost compared to open and laparoscopic procedures.

Evolution of a Novel Robotic Training Curriculum in a Complex General Surgical Oncology Fellowship

BACKGROUND

Robotic surgery is increasingly being used for complex oncologic operations, although currently there is no standardized curriculum in place for surgical oncologists. We describe the evolution of a proficiency-based robotic training program implemented for surgical oncology fellows, and demonstrate the outcomes of the program.

METHODS

A 5-step robotic curriculum began integration in July 2013. Fellows from July 2013 to August 2017 were included. An education portfolio was created for each fellow, including pre-fellowship experience, fellowship experience with data from robotic curriculum and operative experience, and post-fellowship practice information.

RESULTS

Of 30 fellows, 20% completed a prior fellowship, 97% trained at an academic residency, 57% had prior robotic training (median 5 h), and 43% had performed robotic surgery (median 0 cases). In fellowship, on average, fellows spent 5 h on the virtual reality curriculum and performed 19 biotissue anastomoses. For total surgeries, fellows operating from the console increased over time (p = 0.005). For pancreas, the average percentage of robotic pancreaticoduodenectomy (PD) steps completed increased (p < 0.011), as did the number of PDs in which the fellow completed the entire resection (p = 0.013). Fellows were 10 times more likely to complete the entire distal than PD from the console (p < 0.01). Post-fellowship, 83% of fellows obtained an academic position, 88% utilized robotics, and 91% performed pancreatic surgery.

CONCLUSIONS

With dedicated training, fellows can safely primarily perform complex gastrointestinal robotic surgeries and, after graduation, take jobs incorporating this skill set. In this era of scrutiny on cost and outcomes, specialized training programs offer a safe integration option for complex technical skills.

Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock

BACKGROUND

After a person has been injured, prehospital administration of plasma in addition to the initiation of standard resuscitation procedures in the prehospital environment may reduce the risk of downstream complications from hemorrhage and shock. Data from large clinical trials are lacking to show either the efficacy or the risks associated with plasma transfusion in the prehospital setting.

METHODS

To determine the efficacy and safety of prehospital administration of thawed plasma in injured patients who are at risk for hemorrhagic shock, we conducted a pragmatic, multicenter, cluster-randomized, phase 3 superiority trial that compared the administration of thawed plasma with standard-care resuscitation during air medical transport. The primary outcome was mortality at 30 days.

RESULTS

A total of 501 patients were evaluated: 230 patients received plasma (plasma group) and 271 received standard-care resuscitation (standard-care group). Mortality at 30 days was significantly lower in the plasma group than in the standard-care group (23.2% vs. 33.0%; difference, -9.8 percentage points; 95% confidence interval, -18.6 to -1.0%; P=0.03). A similar treatment effect was observed across nine prespecified subgroups (heterogeneity chi-square test, 12.21; P=0.79). Kaplan-Meier curves showed an early separation of the two treatment groups that began 3 hours after randomization and persisted until 30 days after randomization (log-rank chi-square test, 5.70; P=0.02). The median prothrombin-time ratio was lower in the plasma group than in the standard-care group (1.2 [interquartile range, 1.1 to 1.4] vs. 1.3 [interquartile range, 1.1 to 1.6], P<0.001) after the patients' arrival at the trauma center. No significant differences between the two groups were noted with respect to multiorgan failure, acute lung injury-acute respiratory distress syndrome, nosocomial infections, or allergic or transfusion-related reactions.

CONCLUSIONS

In injured patients at risk for hemorrhagic shock, the prehospital administration of thawed plasma was safe and resulted in lower 30-day mortality and a lower median prothrombin-time ratio than standard-care resuscitation. (Funded by the U.S. Army Medical Research and Materiel Command; PAMPer ClinicalTrials.gov number, NCT01818427 .).

Health Disparities Impact Expected Treatment of Pancreatic Ductal Adenocarcinoma Nationally

BACKGROUND AND PURPOSE

National adherence to treatment guidelines for pancreatic ductal adenocarcinoma (PDAC) is a concern. This study aims to evaluate national expected treatment (ET) adherence for all PDAC stages. We hypothesized that both patient and hospital demographics are associated with national ET disparities for PDAC.

METHODS

Clinical stage I through IV PDAC patients were evaluated using the National Cancer Data Base from 2004 to 2013. ET was defined as surgery for stage I/II, chemotherapy or radiation for stage III, and chemotherapy for stage IV. Unexpected treatment (UT) was defined as no surgery for stage I/II, surgery for stage III, and radiation or surgery for stage IV. No treatment is denoted by NT.

RESULTS

171,351 patients were identified, of whom 56,589 (33.0%) were stage I/II, 23,459 (13.7%) were stage III, and 91,303 (53.3%) were stage IV. Of patients, 48.4% received ET, 14.7% received UT, and 36.9% received NT. ET rates were 41.1% for stage I/II, 65.4% for stage III, and 48.5% for stage IV patients. On multivariable analysis, older age, non-White race, lower socioeconomic status, being uninsured or Medicaid, increased comorbidities, nonacademic centers, and low-volume hospitals were independent negative predictors of receiving ET (P < 0.01). On subgroup analysis, high-volume academic centers had similar negative predictors of ET despite higher ET adherence overall (P < 0.01).

CONCLUSIONS

Patient and hospital factors impact ET of PDAC on a national level. These treatment disparities for PDAC are concerning, even at high-volume academic centers. Future studies need to identify the causes of treatment disparities for PDAC with intervention measures aimed to relieve treatment disparities.

Folfirinox versus gemcitabine/nab-paclitaxel for neoadjuvant treatment of resectable and borderline resectable pancreatic adenocarcinoma: A propensity matched analysis

402

Background: Comparative effectiveness of FOLFIRINOX and Gemcitabine/nab-paclitaxel (G-nP) in the neoadjuvant treatment (NAT) of pancreatic ductal adenocarcinoma (PDA), remains unknown. The aim of this study was to perform a propensity matched analysis of neoadjuvant FOLFRINOX vs G-nP for resectable(R) and borderline resectable (BR) PDA. Methods: A single institution retrospective review of all R and BR PDA patients who underwent resection after NAT with FOLFIRINOX or G-nP was performed. Comparative effectiveness analysis was conducted using inverse-probability-weighted estimators. Primary endpoint was overall survival (OS) from the time of diagnosis. Results: A total of 193 patients (FOLFIRINOX=73, G-nP=120) who underwent resection from 01/11-03/17 were included. Median OS was 28.9 months (95% CI 26.1-39.7). Patients treated with FOLFIRINOX were younger (median age 63 vs. 69 y), had less comorbidities (median CCI 4 vs. 5), more frequent BR disease (79 vs. 59%), and larger tumors (median CT size 2.9 v 2.7 cm) compared to G-nP (all p < 0.05). Duration of NAT was similar and both regimens were equally effective in achieving a 50% or 80% decline in CA19-9 (logistic regression, P 0.9). Rates of R0 resection were also similar (80%), but folfirnox was associated with a reduction in pN1 disease (56% vs. 72%, p =0.028). Receipt of adjuvant therapy was similar in both groups (74 vs. 75%, p =0.79). In a multivariable cox regression analysis utilizing only preoperative variables (FOLFIRINOX v G-nP, age, gender, CT tumor size, BR vs. R, pre NAT CA19-9 and number of NAT cycles), only the number of neoadjuvant cycles was an independent predictor of survival (HR 0.49, 95% CI 0.34-0.71, p < 0.001). In a propensity matched analysis of 166 patients using the same preoperative variables, the average treatment effect of FOLFIRINOX was to increase OS by 4.9 months above G-nP (p=0.012). Conclusions: FOLFIRINOX and Gem Abraxane are viable options for neoadjuvant treatment of PDA. In this study, FOLFIRINOX was associated with a 4.9 month improvement in OS when compared to G-nP in the neoadjuvant setting after adjusting for covariates.

Safety and feasibility of the robotic platform in the management of surgical sequelae of chronic pancreatitis

BACKGROUND/AIM

The application of minimally invasive surgery to chronic pancreatitis (CP) procedures is uncommon. Our objective was to report the safety and feasibility of the robotic approach in the treatment of surgical sequelae of CP, and provide insights into the technique, tricks, and pitfalls associated with the application of robotics to this challenging disease entity.

METHODS

A retrospective review of a prospectively maintained database of patients undergoing robotic-assisted resections and/or drainage procedures for CP at the University of Pittsburgh between May 2009 and January 2017 was performed. A video of a robotic Frey procedure is also shown.

RESULTS

Of 812 robotic pancreatic resections and reconstructions 39 were for CP indications. These included 11 total pancreatectomies [with and without auto islet transplantation], 8 Puestow procedures, 4 Frey procedures, 6 pancreaticoduodenectomies, and 10 distal pancreatectomies. Median age was 49, and 41% of the patients were female. The most common etiology for CP was idiopathic pancreatitis (n = 16, 46%). Median operative time was 324 min with a median estimated blood loss of 250 ml. None of the patients required conversion to laparotomy. A Clavien III-IV complication rate was experienced by 5 (13%) patients, including one reoperation. Excluding the eleven patients who underwent TP, rate of clinically relevant postoperative pancreatic fistula was 7% (Grade B = 2, Grade C = 0). No 30 or 90 day mortalities were recorded. The median length of hospital stay was 7 days.

CONCLUSIONS

Use of the robotic platform is safe and feasible when tackling complex pancreatic resections for sequelae of chronic pancreatitis.

A margin distance analysis of the impact of adjuvant chemoradiation on survival after pancreatoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

The role of adjuvant chemoradiotherapy (CRT) following pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDA) remains controversial. Recent data suggest that increased margin clearance (MC: distance between tumor and cut surface) is associated with improved survival after PD, but the role of adjuvant CRT in patients with known MC is undefined. We sought to delineate the impact of adjuvant CRT on survival based on MC following PD.

METHODS

Patients who underwent PD for PDA between 2002 and 2014 were retrospectively stratified into three groups based on MC: 0 mm, ≤1 mm, and >1 mm. The impact of CRT on survival in each MC group was determined by univariate and multivariate analysis.

RESULTS

Three hundred and ten patients with known MC were analyzed (0 mm =67, ≤1 mm =113, and >1 mm =130). Increasing MC was independently associated with improved OS (≤1 mm, HR 0.66, 95% CI 0.46-0.96, P=0.03; >1 mm, HR 0.51, 95% CI 0.35-0.75, P=0.001; compared to 0 mm). Adjuvant CRT was administered to 62 patients (20%). On margin-stratified multivariate analysis, adjuvant CRT was independently associated with increased OS in patients with ≤1 mm margins (HR 0.36; 95% CI 0.18-0.69, P=0.002) but not for 0 mm and >1 mm margins.

CONCLUSIONS

This analysis suggests that the benefit of adjuvant CRT may be restricted to patients with ≤1 mm MC after PD for pancreatic cancer.

Robotic approach mitigates perioperative morbidity in obese patients following pancreaticoduodenectomy

INTRODUCTION

The aim was to evaluate the impact of obesity on perioperative outcomes in patients undergoing robotic pancreaticoduodenectomy (RPD) compared to open pancreaticoduodenectomy (OPD).

METHODS

A retrospective review of all pancreaticoduodenectomies from 9/2011 to 4/2015 was performed. Obesity was defined as body mass index (BMI) > 30 kg/m².

RESULTS

Of 474 pancreaticoduodenectomies performed: RPD = 213 (45%) and OPD = 261 (55%). A total of 145 (31%) patients were obese (70 RPD, 75 OPD). Obese patients had increased EBL (p = 0.03), pancreatic fistula (B&C; p = 0.077), and wound infection (p = 0.068) compared to the non-obese. For obese patients, RPD had decreased OR time (p = 0.0003), EBL (p < 0.001), and wound infection (p = 0.001) with no difference in Clavien ≥3 complications, margins, LOS or 30-day mortality compared with OPD. In multivariate analysis, obesity was the strongest predictor of Clavien ≥3 (OR 1.6; p = 0.041) and wound infection if BMI > 35 (OR 2.6; p = 0.03). The robotic approach was protective of Clavien ≥3 (OR 0.6; p = 0.03) on univariate analysis and wound infection (OR 0.3; p < 0.001) and grade B/C pancreatic fistula (OR 0.34; p < 0.001) on multivariate analysis.

CONCLUSIONS

Obese patients are at risk for increased postoperative complications regardless of approach. However, the robotic approach mitigates some of the increased complication rate, while preserving other perioperative outcomes.

Analysis of Predictors of Resection and Survival in Locally Advanced Stage III Pancreatic Cancer: Does the Nature of Chemotherapy Regimen Influence Outcomes?

BACKGROUND

Locally advanced unresectable pancreatic cancer (LAPC) historically portends a poor prognosis. FOLFIRINOX and gemcitabine/nab-paclitaxel have proven effective in the metastatic setting. We sought to evaluate the outcomes of these regimens compared with older regimens in LAPC.

METHODS

A retrospective, single institutional review of all consecutive LAPC treated with "new" (FOLFIRINOX and/or gemcitabine/nab-paclitaxel) and "old" (gemcitabine or 5-FU) chemotherapy from 2010 to 2014 was performed. Univariate and multivariate predictors of resection and survival were determined.

RESULTS

A total of 92 patients (new chemotherapy = 61, old chemotherapy = 31) were analyzed, of which 19 (21%) underwent eventual resection (median overall survival [OS] = 32 vs. 14.3 months for unresected patients, P = 0.0002). For the overall cohort, resection (hazard ratio [HR] 0.261, P = 0.014), radiation therapy (HR 0.458, P = 0.004), number of lines of chemotherapy (HR 0.486, P = 0.012), and new chemotherapy (HR 0.593 vs. old regimens, P = 0.065) were independent predictors of OS on multivariate analyses (MVA). On MVA, predictors of eventual resection were head and neck tumors (OR 0.307, P = 0.033) or SMA involvement (OR 0.285, P = 0.023). In nonresected patients (73), MVA showed treatment with new chemotherapy (HR 0.452, P = 0.006), radiation (HR 0.459, P = 0.006), and number of lines of CT (HR 0.705, P = 0.013) to be predictors of survival.

CONCLUSIONS

In LAPC, use of FOLFIRNOX and/or gemcitabine/nab-paclitaxel is associated with improved survival compared with older chemotherapy regimens, regardless of eventual resection. Tumor location and relationship to certain vasculature are important determinants of resection in this cohort.

Primary Tumor Resection Following Favorable Response to Systemic Chemotherapy in Stage IV Pancreatic Adenocarcinoma with Synchronous Metastases: a Bi-institutional Analysis

INTRODUCTION

Patients with metastatic pancreatic adenocarcinoma have traditionally been offered palliative chemotherapy alone, and the role of surgery in these patients remains unknown.

METHODS

A bi-institutional retrospective review was performed for patients with metastatic pancreatic adenocarcinoma who underwent resection of the primary tumor from 2008 to 2013. The primary outcome measured was postoperative overall survival. Secondary outcomes included postoperative disease-free survival and overall survival from the time of diagnosis.

RESULTS

Twenty-three patients were identified who met the study criteria with a median follow-up of 30 months. Metastatic sites included the liver (n = 16), the lung (n = 6), and the peritoneum (n = 2). Chemotherapy included FOLFIRINOX (n = 14) and gemcitabine-based regimens (n = 9), with a median of 9 cycles (range 2-31) prior to surgical treatment. Median time from diagnosis to surgery was 9.7 months (IQR 5.8-12.8). Median overall survival (OS) from surgery, disease-free survival, and OS from diagnosis were 18.2 months (95 % CI 11.8-35.5), 8.6 months (95 % CI 5.2-16.8), and 34.1 months (95 % CI 22.5-46.2), respectively. The 1- and 3-year OS from surgery were 72.7 % (95 % CI 49.1-86.7) and 21.5 % (95 % CI 4.3-47.2), respectively.

CONCLUSION

Resection of the primary tumor in patients with metastatic pancreatic adenocarcinoma may be considered in highly selected patients with favorable imaging and CA 19-9 response following chemotherapy at high-volume centers providing multidisciplinary care. These patients should be enrolled in prospective clinical trials or institutional registries to better quantify the potential benefits of such a strategy.

A policy of omitting an intensive care unit stay after robotic pancreaticoduodenectomy is safe and cost-effective

BACKGROUND

Immediate postoperative admission to the intensive care unit (ICU) after pancreaticoduodenectomy (PD) is still a standard practice at many institutions. Our aim was to examine whether omission of an immediate postoperative ICU admission would be safe and result in improved outcomes and cost after robotic pancreaticoduodenectomy (RPD).

METHODS

In December 2014, a non-ICU admission policy was implemented for patients undergoing RPD. Before this date, all RPDs were routinely admitted to the ICU on post operative day = 0. Using a prospective database, outcomes of the patients in the no-ICU cohort were compared with those of the patients routinely admitted to the ICU before implementation of this policy.

RESULTS

The ICU (n = 49) and no-ICU cohorts (n = 47) were comparable in age, gender, body mass index, Charlson comorbidity index and American Society of Anesthesiologists scores, receipt of neoadjuvant therapy, operative time, estimated blood loss, tumor size, and pathologic diagnosis (all P values = NS). Clavien complications, pancreatic leak, reoperation, readmission, and mortality were similar between both the groups (all P values = NS). Hospital length of stay (LOS) was shorter for the no-ICU group (median 6.8 versus 7.7 d, P = 0.01). This reduced LOS and omission of routine postoperative ICU admission translated into a cost reduction from $23,933 (interquartile range $19,833-$28,991) in the ICU group to $19,516 (interquartile range $17,046-$23,893) in the no-ICU group, P = 0.004. The reduction in LOS and cost remained significant after adjusting for all related demographics and perioperative characteristics.

CONCLUSIONS

A standard policy of omitting a postoperative ICU admission on post operative day 0 after RPD is safe and can result in reduced LOS and overall savings in total hospital cost.

FOLFIRINOX and gemcitabine/nab-paclitaxel efficacy in the treatment of locally advanced unresectable pancreatic adenocarcinoma

399

Background: Locally advanced (LA) unresectable pancreatic adenocarcinoma (PDA) historically portends a poor prognosis with a median OS of 9-11 months. Recently, two multi-drug regimens – FOLFIRINOX and gemcitabine/nab-paclitaxel – have proven effective in the metastatic setting. We hypothesized that use of these regimens in the LA setting may improve survival. Methods: A retrospective review of a single institution’s cancer registry of all consecutive LA (unresectable) PDA patients between 2010 and 2014 was performed. LA status was verified by review of the triphasic, pancreas protocol CT scan at diagnosis using the 2015 NCCN criteria for resectability. Patients were divided into 4 groups: Group 1 = no therapy, Group 2 = “old” gemcitabine or 5-FU-based chemotherapy (CTX), Group 3 = “new” CTX (FOLFIRINOX and/or Gem/nab-paclitaxel), and Group 4 = resection after downstaging. Demographic, tumor related variables, and treatment outcomes were analyzed. Results: LA disease was verified in 107 consecutive patients. Median age was 69 years (range 36-92) and 50.5% were male. Median follow-up was 13.2 months (range 0.6-60.4). Median OS for Groups 1 (n=15), 2 (n=24), 3 (n=49), 4 (n=19) was 1.4, 11, 17.3, and 32 months respectively (p<0.001). On Cox multivariate regression (adjusted for age, sex, anatomic variables, and CA19-9 level at diagnosis), radiation (HR 0.44, p=0.003), older CTX (HR 0.16, p=0.007), newer CTX (HR 0.10, p=0.001), use of 2 or more lines of CTX (HR 0.16, p=0.022), CA19-9 decrease by >50% with any line of therapy (HR 0.31, p<0.001), and surgery (HR 0.28, p=0.002) were all significant predictors of OS in this cohort. On multivariate analysis between groups 2 and 3, newer CTX compared to older CTX (HR 0.490, p=0.02) and radiation (HR 0.510, p=0.015) provided an OS benefit. Conclusions: Compared to older CTX regimens, FOLFIRINOX and Gemcitabine/nab-paclitaxel improve survival in verified LA PDA patients. For the subset that ultimately undergoes resection, survival outcomes rival those of historically published resectable cohorts.

Effect of adjuvant (AD) radiotherapy (RT) on outcomes following pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDA): A margin-stratified analysis

311

Background: The role of RT following PD for PDA remains controversial due to ambiguity in the definition of R0/R1 margin status in existing clinical trials. Recent data suggest that increased margin clearance (MC) is associated with improved survival after PD for PDA, however the role of adjuvant radiotherapy (ADRT) in patients with known MC is undefined. We sought to analyze the influence of ADRT on outcomes of PD for PDA based on MC data. Methods: We retrospectively identified 326 patients with MC data (in mm) who underwent PD between 2002-2014. Recurrence-free (RFS) and overall survival (OS) was determined by Kaplan-Meier analysis. Hazard ratios (HR) were calculated by Cox multivariate regression analysis on significant variables. Results: Mean age was 68 yrs and 55% were male. Median follow-up was 21 mos (IQR 12-34 mos). ADRT was administered to 87 patients (27%). Median RFS and OS for the entire cohort was 14 mos and 25 mos. On univariate analysis, ADRT was not associated with improved median RFS (13 vs. 14 mos; p = NS) or OS (23 vs. 27 mos; p = NS), but increasing MC was associated with prolonged median RFS [10 (0mm) vs. 13 (0-1mm) vs. 23 mos ( > 1mm); p < 0.02 for all pairs] and OS [16 (0mm) vs. 23 (0-1mm) vs. 40 mos ( > 1mm); p < 0.01 for all pairs]. After controlling for sex, BMI, neoadjuvant therapy, LVI, PNI, lymph node ratio > 0.2, tumor size > 2.5cm, and adjuvant chemotherapy, increasing MC was independently associated with improved OS [HR 0.680; p = 0.034 (0-1mm); HR 0.451; p < 0.001 ( > 1mm), compared to 0mm]. Patients were subsequently stratified into 3 groups based on MC [0mm (n = 73); 0-1mm (n = 118); > 1mm (n = 135)]. ADRT was administered less frequently to patients with greater MC [0mm (n = 29; 41%); 0-1mm (n = 36; 31%); > 1mm (n = 22; 16%); p < 0.001]. Even when stratified by MC, ADRT was not associated with improved RFS [10 vs. 9 mos (0mm); 13 vs. 12 mos (0-1mm); 21 vs. 23 mos ( > 1mm); p = NS for all pairs] or OS [16 vs. 18 mos (0mm); 24 vs. 23 mos (0-1mm); 33 vs. 42 mos ( > 1mm); p = NS for all pairs]. Conclusions: ADRT is not associated with improved RFS or OS following PD for PDA regardless of MC. The use of RT following PD for PDA should be re-examined.

The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre

BACKGROUND

Robotic distal pancreatectomy (RDP) is performed increasingly, but knowledge of the number of cases required to attain procedural proficiency is lacking. The aim of this study was to identify the learning curve associated with RDP at a high-volume pancreatic centre.

METHODS

Metrics of perioperative safety and efficiency for all consecutive RDPs were evaluated. Outcomes were followed to 90 days. Cumulative sum (CUSUM) analysis was used to identify inflexion points corresponding to the learning curve.

RESULTS

Between 2008 and 2013, 100 patients underwent RDP. There was no 90-day mortality. In two patients (2.0%), surgery was converted to laparotomy. Thirty procedures were performed for pancreatic adenocarcinoma. Precipitous operative time reductions from an initial operative time of 331 min were observed after the first 20 and 40 cases to 266 min and 210 min, respectively (P < 0.0001). The likelihood of readmission was significantly lower after the first 40 cases (P = 0.04), and non-significant reductions were observed in incidences of major (Clavien-Dindo Grade II or higher) morbidity and Grade B and C leaks, and length of stay.

CONCLUSIONS

In this experience, RDP outcomes were optimized after 40 cases. Familiarity with the platform and dedicated training are likely to contribute to significantly shorter learning curves in future adopters.

Robotic pancreaticoduodenectomy in the presence of aberrant or anomalous hepatic arterial anatomy: safety and oncologic outcomes

BACKGROUND

Hepatic arterial anomalies (HAAs) are not infrequently encountered during pancreatic resections. In view of the current emergence of the robotic platform as a safe alternative to open surgery in experienced centres, this study sought to determine the implications of HAAs on the safety and oncologic outcomes of robotic pancreaticoduodenectomy (RPD).

METHODS

A prospectively maintained database of patients with HAAs who underwent RPD (RPD + HAA) at a single institution between 2008 and 2013 was retrospectively reviewed. Demographic information and perioperative outcomes of RPD were compared for patients with and without HAAs.

RESULTS

A total of 142 patients underwent RPD; 112 (78.9%) did not have and 30 (21.1%) did have HAAs. The majority (90.0%) of RPDs in patients with HAAs were performed for malignant indications and all aberrant vessels were preserved without conversion to laparotomy. There were no statistically significant differences between RPD patients with and without HAAs with respect to preoperative demographics, tumour characteristics, operative metrics (operative time, estimated blood loss, conversion) and postoperative outcomes, including complications, length of stay and readmissions. Negative margin (R0) rates were similar in both groups.

CONCLUSIONS

Robot-assisted pancreaticoduodenectomy is safe and feasible in patients with HAAs and has outcomes similar to those in patients with normal arterial anatomy.

Serum CA 19-9 response to neoadjuvant therapy is associated with outcome in pancreatic adenocarcinoma

BACKGROUND

Baseline carbohydrate antigen 19-9 (CA 19-9) is a useful prognostic marker in pancreatic ductal adenocarcinoma (PDA); however, data on the significance of a change in CA 19-9 following neoadjuvant therapy are lacking.

METHODS

All patients receiving neoadjuvant therapy for PDA from July 2010 to February 2013 were retrospectively reviewed. Resection rate, R0 resection rate, need for venous resection, and overall survival were correlated to CA 19-9 response. Fisher's exact test, Kaplan-Meier survival analysis, and multivariate analysis using Cox regression were used.

RESULTS

A total of 78 patients were studied (21 patients with resectable disease, 40 borderline resectable, and 17 with locally advanced disease). A variety of chemotherapies ± radiation were utilized during the study period. Overall, 56 patients (72 %) had a decrease in CA 19-9 of >50 % with neoadjuvant treatment. In borderline resectable patients, CA 19-9 response of >50 % predicted R0 resection (odds ratio 4.2; p = 0.05). In borderline resectable patients who had an increase in CA 19-9, none of five (0 %) underwent R0 resection compared with 80 % of the remaining cohort (p = 0.001). The complete pathologic response rate was 29 % in patients who had a CA 19-9 response of >90 % versus 0 % in the remaining patients (p < 0.001). A CA 19-9 response of >50 % resulted in improved overall survival (28.0 vs. 11.1 months; p < 0.0001) and was an independent predictor of survival (hazard ratio 0.26; 95 % CI 0.13-0.55; p < 0.0001).

CONCLUSIONS

CA 19-9 response to neoadjuvant therapy is associated with R0 resection rate, histopathologic response, and survival. Incorporation of this easily obtainable biomarker into future clinical trials may facilitate more rapid evaluation of novel regimens.

Malignant peritoneal mesothelioma: prognostic factors and oncologic outcome analysis

BACKGROUND

Most patients with malignant peritoneal mesothelioma (MPM) present with late-stage, unresectable disease that responds poorly to systemic chemotherapy while, at the same time, effective targeted therapies are lacking. We assessed the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) in MPM.

METHODS

We prospectively analyzed 65 patients with MPM undergoing CRS/HIPEC between 2001 and 2010. Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes.

RESULTS

Adequate CRS was achieved in 56 patients (CC-0 = 35; CC-1 = 21), and median simplified peritoneal cancer index (SPCI) was 12. Pathologic assessment revealed predominantly epithelioid histology (81 %) and biphasic histology (8 %), while lymph node involvement was uncommon (8 %). Major postoperative morbidity (grade III/IV) occurred in 23 patients (35 %), and 60-day mortality rate was 6 %. With median follow-up of 37 months, median overall survival was 46.2 months, with 1-, 2-, and 5-year overall survival probability of 77, 57, and 39 %, respectively. Median progression-free survival was 13.9 months, with 1-, 2-, and 5-year disease failure probability of 47, 68, and 83 %, respectively. In a multivariate Cox-regression model, age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), aggressive histology (epithelioid, biphasic), and postoperative sepsis were joint significant predictors of poor survival (chi square = 42.8; p = 0.00001), while age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), and aggressive histology (epithelioid, biphasic) were joint significant predictors of disease progression (Chi square = 30.6; p = 0.00001).

CONCLUSIONS

Tumor histology, disease burden, and the ability to achieve adequate surgical cytoreduction are essential prognostic factors in MPM patients undergoing CRS/HIPEC.

Robot-assisted minimally invasive distal pancreatectomy is superior to the laparoscopic technique

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) reduces postoperative morbidity, hospital stay, and recovery as compared with open distal pancreatectomy. Technical limitations of laparoscopic surgery may limit patient eligibility and require conversion to open or hand-assisted surgery to maintain patient safety. We hypothesized that robot-assisted distal pancreatectomy (RADP) was superior to LDP as a result of improved surgical manipulation and visualization, potentially expanding the indications for minimally invasive pancreatectomy.

METHODS

We performed a retrospective analysis of all minimally invasive distal pancreatectomies at University of Pittsburgh Medical Center between January 2004 and February 2011. We compared the perioperative outcomes, 90-day morbidity and mortality of our first 30 RADPs to 94 consecutive historical control LDPs.

RESULTS

Patients undergoing RADP and LDP demonstrated equivalent age, sex, race, American Society of Anesthesiologists' score, and tumor size. Postoperative length of hospital stay and rates of pancreatic fistula, blood transfusion, and readmission were not statistically different. Patients in the RADP group did not require conversion to open surgery unlike the LDP group (16%, P < 0.05) and had reduced risk of excessive blood loss. There were more pancreatic ductal adenocarcinomas approached robotically (43%) than laparoscopically (15%) (P < 0.05). Oncological outcomes in these cases were superior for the robotic-assisted group with higher rates of margin negative resection and improved lymph node yield for both benign and malignant lesions (P < 0.0001).

CONCLUSIONS

RADPs were equivalent to LDPs in nearly all measures of outcome and safety but significantly reduced the risk of conversion to open resection, despite a statistically greater probability of malignancy in the robotic cohort. We concluded that robotic assistance may broaden indications for minimally invasive pancreatectomy.

Models of lower extremity damage in mice: time course of organ damage and immune response

BACKGROUND

Post-traumatic inflammatory changes have been identified as major causes of altered organ function and failure. Both hemorrhage and soft tissue damage induce these inflammatory changes. Exposure to heterologous bone in animal models has recently been shown to mimic this inflammatory response in a stable and reproducible fashion. This follow-up study tests the hypothesis that inflammatory responses are comparable between a novel trauma model ("pseudofracture", PFx) and a bilateral femur fracture (BFF) model.

MATERIALS AND METHODS

In C57BL/6 mice, markers for remote organ dysfunction and inflammatory responses were compared in four groups (control/sham/BFF/PFx) at the time points 2, 4, and 6 h.

RESULTS

Hepatocellular damage in BFF and PFx was highly comparable in extent and evolution, as shown by similar levels of NFkappaB activation and plasma ALT. Pulmonary inflammatory responses were also comparably elevated in both trauma models as early as 2 h after trauma as measured by myeloperoxidase activity (MPO). Muscle damage was provoked in both BFF and PFx mice over the time course, although BFF induced significantly higher AST and CK levels. IL-6 levels were also similar with early and sustained increases over time in both trauma models.

CONCLUSIONS

Both BFF and PFx create similar reproducible inflammatory and remote organ responses. PFx will be a useful model to study longer term inflammatory effects that cannot be studied using BFF.