High performing whipple patients: factors associated with short length of stay after open pancreaticoduodenectomy

The Role of a Community Surgeon in the Care of Hepatopancreatobiliary Patients: Short-Term Outcomes and Learning Curve

Background Owing to the well-established volume-outcome relationship, hepatopancreatobiliary (HPB) surgery is commonly regionalized to academic, teaching hospitals. However, regionalization is associated with decreased access for some populations in need, as well as geographic and financial barriers for patients. If high surgeon and institutional volumes can be achieved, the community, non-teaching HPB surgical practice could help alleviate some issues associated with regionalization. The HPB experience of a community surgeon immediately after surgical oncology training was reviewed, hypothesizing that high volumes with acceptable short-term outcomes could be achieved, although a learning curve may be observed. Materials and methods Electronic medical records from 2013 to 2023 were reviewed. Data included patient demographics, perioperative details, pathology, complications, and deaths over 90 postoperative days. Perioperative quality metrics were assessed for trends over time in pancreaticoduodenectomy (PD) and liver resection subgroups. Results A total of 295 patients underwent 176 (59.7%) pancreatic and 119 (40.3%) hepatobiliary operations. The most common operations were PD (n=87; 49.4%) and partial hepatic lobectomy (n=56; 41.1%). In the pancreas group, morbidity was 25% (n=44), and mortality was 4.5% (n=8). In the hepatobiliary group, morbidity and mortality were 19.3% (n=23) and 5.0% (n=6), respectively. Within the PD and liver resection subgroups, operative time, estimated blood loss, and hospital length of stay (LOS) trended downward over time, with LOS decreasing significantly. Conclusion High HPB volumes with acceptable short-term outcomes can be achieved by a solo practitioner in the community, non-teaching setting. For PDs and liver resections, perioperative metrics trended downward over time, illustrating the learning curve encountered after training.

Are Antibiotics of Value for a Whipple Procedure?

Pancreatoduodenectomy is a complex surgical procedure with a high rate of morbidity, of which surgical-site infections (SSIs) make a large portion. Reduction of SSI rates is critical to decrease hospital lengths of stay, readmissions, delays in adjuvant therapies, and financial health care burden. Current clinical guidelines recommend the administration of cefoxitin as surgical prophylaxis prior to pancreatoduodenectomy. In April 2023, a randomized controlled trial was published in JAMA which showed that piperacillin-tazobactam as perioperative surgical prophylaxis prior to pancreatoduodenectomy decreased 30 day SSI rates (primary outcome), clinically relevant postoperative pancreatic fistula, postoperative sepsis, and Clostridium difficile infection rates.

Four-Day Robotic Whipple: Early Discharge after Robotic Pancreatoduodenectomy

BACKGROUND

The authors aimed to assess the safety of an enhanced recovery after surgery (ERAS) and early discharge pathway in a robotic pancreatoduodenectomy (PD) program and compared outcomes with an open PD control cohort to identify the synergistic effects of robotic surgery and an ERAS pathway on lengths of stay (LOS).

STUDY DESIGN

Consecutive patients undergoing open or robotic PD from a single surgeon between March 2020 and July 2022 were identified. Logistic regression models were used for adjusted analyses of postoperative outcomes.

RESULTS

There were 134 consecutive PD patients, of which 40 (30%) were performed robotically. Pancreatic adenocarcinoma was the most common indication in both open (56%) and robotic (55%, p = 0.51) groups, with a similar proportion of them being borderline resectable or locally advanced tumors (78% vs 82% in robotic group, p = 0.82). The LOS was significantly shorter in the robotic PD group (median, 5 [IQR 4 to 7] days) when compared with the open PD group (median, 6 [IQR 5 to 8] days, p < 0.001). LOS of 4 days or fewer were observed in 40% of the robotic PD group compared with only 3% of patients in the open PD group (p < 0.001). There was no difference in the overall readmission rate (10% vs 12% in the robotic PD group, p = 0.61). On multivariable logistic regression, robotic PD was independently associated with higher odds of LOS of 4 days or fewer (odds ratio 22.4, p = 0.001) when compared with open PD.

CONCLUSIONS

An ERAS and early discharge pathway could be safely implemented in a robotic PD program. Patients undergoing robotic PD have significantly shorter length of stay without increased complication or readmission rate compared with open PD, with 40% of patients undergoing robotic PD achieving a LOS of 4 days or fewer.

Hepatopancreaticobiliary Surgical Outcomes at a Community Hospital

There is a national trend towards regionalizing complex hepatopancreaticobiliary (HPB) surgeries to high-volume institutions. Due to geographic and socioeconomic constraints, however, many patients in the United States continue to undergo HPB surgery at local community hospitals. This study evaluated complex HPB surgeries performed by a single surgeon at a low-volume community hospital from May 2007 to June 2021. A retrospective review of medical records (n=163) was done to collect data on patient demographics and outcomes. Surgical outcomes of HPB procedures were compared to published data from high-volume centers. Overall mortality within 30 days of the procedure was 1% (n=1). Using Clavien-Dindo classification, the major complication rate was 10%, including 8% grade III and 2% grade IV complications. Reoperation (2%) and readmission (3%) were rare in this population. Median length of stay was 7 days and median estimated blood loss was 500 milliliters. Surgical outcomes from the community hospital were comparable to high-volume centers. For pancreatic cancer patients treated at the community hospital, Kaplan-Meier curves revealed comparable 5-year survival time to national data. Complex HPB procedures can be safely performed at a low-volume hospital in Hawai'i with outcomes comparable to large tertiary centers.

Prophylactic Perioperative Antibiotics in Open Pancreaticoduodenectomy: When Less Is More and When It Is Not. A National Surgical Quality Improvement Program Propensity-Matched Analysis

INTRODUCTION

We hypothesized that first-generation cephalosporins (G1CEP) provide adequate antimicrobial coverage for pancreaticoduodenectomy (PD) when no biliary stent is present but might be inferior to second-generation cephalosporins or broad-spectrum antibiotics (G2CEP/BS) in decreasing surgical-site infection (SSI) rates when a biliary stent is present.

METHODS

The National Surgical Quality Improvement Program 2014-2019 was used to select patients who underwent elective open PD. We divided the population into no-stent versus stent groups based on the status of biliary drainage and then divided each group into G1CEP versus G2CEP/BS subgroups based on the choice of perioperative antibiotics. We matched the subgroups per a propensity score match and analyzed postoperative outcomes.

RESULTS

Six thousand two hundred forty five cases of 39,779 were selected; 2821 in the no-stent (45.2%) versus 3424 (54.8%) in the stent group. G1CEP were the antibiotics of choice in 2653 (42.5%) versus G2CEP/BS in 3592 (57.5%) cases. In the no-stent group, we matched 1129 patients between G1CEP and G2CEP/BS. There was no difference in SSI-specific complications (20.3% versus 21.0%; P = 0.677), general infectious complications (25.7% versus 26.9%; P = 0.503), PD-specific complications, overall morbidity, length of stay, or mortality. In the stent group, we matched 1244 pairs. G2CEP/BS had fewer SSI-specific complications (19.9% versus 26.6%; P < 0.001), collections requiring drainage (9.6% versus 12.9%; P = 0.011), and general infectious complications (28.5% versus 34.1%; P = 0.002) but no difference in overall morbidity, mortality, length of stay, and readmission rates.

CONCLUSIONS

G2CEP/BS are associated with reduced rates of SSI-specific and infectious complications in stented patients undergoing open elective PD. In patients without prior biliary drainage, G1CEP seems to provide adequate antimicrobial coverage.

Quality of life after pancreatic surgery - A systematic review

BACKGROUND

Surgery for patients with pancreatic cancer carries a high risk of major post-operative complications and only marginally improves overall survival. This review aims to assess the impact of surgical resection on health-related quality of life (HRQOL) of pancreatic cancer patients.

METHODS

A systematic review of the literature was performed according to the PRISMA guidelines. All studies assessing QOL using validated questionnaires in pancreatic cancer patients undergoing surgical resection were included.

RESULTS

Twenty-two studies were assessed. Patients reported a decrease in physical, social and global scales within the first 3 months after surgery. These values showed improvement and were comparable to baseline values by 6 months. Recovery in emotional functioning towards baseline figures was demonstrated in the first 3 months post-operatively. Symptom scales including pain, fatigue and diarrhoea deteriorated after surgery, but reverted to baseline after 3-6 months.

CONCLUSIONS

Surgical resection for pancreatic cancer has short-term negative impact on QOL. In the longer term, this will improve and eventually recover to baseline values after 6 months. Knowledge on the impact of surgery on QOL of pancreatic cancer patients is necessary to facilitate decision-making and tailoring of surgical techniques to the individual patient.

Obesity Does Not Influence Delayed Gastric Emptying Following Pancreatoduodenectomy

Background: The data about obesity on postoperative outcome after pancreatoduodenectomy (PD) are inconsistent, specifically in relation to gastric motility and delayed gastric emptying (DGE). Methods: Two hundred and eleven patients were included in the study and patients were retrospectively analyzed in respect to pre-existing obesity (obese patients having a body mass index (BMI) ≥ 30 kg/m2 vs. non-obese patients having a BMI < 30 kg/m2, n = 34, 16% vs. n = 177, 84%) in relation to demographic factors, comorbidities, intraoperative characteristics, mortality and postoperative complications with special emphasis on DGE. Results: Obese patients were more likely to develop clinically relevant pancreatic fistula grade B/C (p = 0.008) and intraabdominal abscess formations (p = 0.017). However, clinically relevant DGE grade B/C did not differ (p = 0.231) and, specifically, first day of solid food intake (p = 0.195), duration of intraoperative administered nasogastric tube (NGT) (p = 0.708), rate of re-insertion of NGT (0.123), total length of NGT (p = 0.471) or the need for parenteral nutrition (p = 0.815) were equally distributed. Moreover, mortality (p = 1.000) did not differ between the two groups. Conclusions: Obese patients do not show a higher mortality rate and are not at higher risk to develop DGE. We thus show that in our study, PD is feasible in the obese patient in regard to postoperative outcome with special emphasis on DGE.

Simulated Volume-Based Regionalization of Complex Procedures: Impact on Spatial Access to Care

OBJECTIVE

This study simulates the regionalization of pancreatectomies to assess its impact on spatial access in terms of patient driving times.

BACKGROUND

Although policies to regionalize complex procedures to high-volume centers may improve outcomes, the impact on patient access is unknown.

METHODS

Patients who underwent pancreatectomies from 2005 to 2014 were identified from California's statewide database. Round-trip driving times between patients' home ZIP code and hospital addresses were calculated via Google Maps. Regionalization was simulated by eliminating hospitals performing <20 pancreatectomies/yr, and reassigning patients to the next closest hospital that satisfied the volume threshold. Sensitivity analyses were performed for New York and Medicare patients to assess for influence of geography and insurance coverage, respectively.

RESULTS

Of 13,317 pancreatectomies, 6335 (47.6%) were performed by hospitals with <20 cases/yr. Patients traveled a median of 49.8 minutes [interquartile range (IQR) 30.8-96.2] per round-trip. A volume-restriction policy would increase median round-trip driving time by 24.1 minutes (IQR 4.5-53.5). Population in-hospital mortality rates were estimated to decrease from 6.7% to 2.8% (P < 0.001). Affected patients were more likely to be racial minorities (44.6% vs 36.5% of unaffected group, P < 0.001) and covered by Medicaid or uninsured (16.3% vs 9.8% of unaffected group, P < 0.001). Sensitivity analyses revealed a 17.8 minutes increment for patients in NY (IQR 0.8-47.4), and 27.0 minutes increment for Medicare patients (IQR 6.2-57.1).

CONCLUSIONS

A policy that limits access to low-volume pancreatectomy hospitals will increase round-trip driving time by 24 minutes, but up to 54 minutes for 25% of patients. Population mortality rates may improve by 1.5%.

Active smokers show ameliorated delayed gastric emptying after pancreatoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is the most common complication following pancreatoduodenectomy (PD). The data about active smoking in relation to gastric motility have been inconsistent and specifically the effect of smoking on gastric emptying after PD has not yet been investigated in detail.

METHODS

295 patients at our department underwent PD between January 2009 and December 2019. Patients were analyzed in relation to demographic factors, diagnosis, pre-existing conditions, intraoperative characteristics, hospital stay, mortality and postoperative complications with special emphasis on DGE. All complications were classified according to the definitions of the International Study Group on Pancreatic Surgery.

RESULTS

274 patients were included in the study and analyzed regarding their smoking habits (non or former smokers, n = 88, 32.1% vs. active smokers, n = 186, 68.6%). Excluded were patients for whom no information about their smoking habits was available (n = 3), patients who had had gastric resection before (n = 4) and patients with prolonged postoperative resumption to normal diet independently from DGE (long-term ventilation > 7 days, fasting due to pancreatic fistula) (n = 14). Smokers were younger than non-smokers (61 vs. 69 years, p ≤ 0.001) and mainly male (73% male vs. 27% female). Smoking patients showed significantly more pre-existing pulmonary conditions (19% vs. 8%, p = 0.002) and alcohol abuse (48% vs. 23%, p ≤ 0.001). We observe more blood loss in smokers (800 [500-1237.5] vs. 600 [400-1000], p = 0.039), however administration of erythrocyte concentrates did not differ between both groups (0 [0-2] vs. 0 [0-2], p = 0.501). 58 out of 88 smokers (66%) and 147 out of 186 of non-smokers (79%) showed malign tumors (p = 0.019). 35 out of 88 active smokers (40%) and 98 out of 188 non- or former smokers (53%) developed DGE after surgery (p = 0.046) and smokers tolerated solid food intake more quickly than non-smokers (postoperative day (POD7 vs. POD10, p = 0.004). Active smokers were less at risk to develop DGE (p = 0.051) whereas patients with pulmonary preexisting conditions were at higher risk for developing DGE (p = 0.011).

CONCLUSIONS

Our data show that DGE occurs less common in active smokers and they tolerate solid food intake more quickly than non-smokers. Further observation studies and randomized, controlled multicentre studies without the deleterious effect of smoking, for instance by administration of a nicotine patch, are needed to examine if this effect is due to nicotine administration.

Patient-Specific Factors Drive Intensive Care Unit and Total Hospital Length of Stay in Operative Patients with Brain Tumor

BACKGROUND

Hospital length of stay (LOS) is an important cost driver in neurosurgery. Broader surgical literature has shown that patient-related factors, including comorbidities, and procedure-related factors, such surgeon experience, may be associated with LOS. Because value optimization strategies may be targeted toward either domain, this study investigated the contributions of patient-related and procedure-related factors in predicting prolonged intensive care unit LOS (iLOS) and total hospital LOS (tLOS).

METHODS

Data for adult patients undergoing brain tumor surgery (2017-2019) were collected. Bivariate analyses for iLOS and tLOS were performed using the Mann-Whitney U test and Fisher exact test. Variables associated with either outcome with P < 0.10 were included in patient-only, procedure-only, and patient+procedure factor multivariate linear regression models. Model discrimination was quantified using C-statistics.

RESULTS

Our 654 patients had a mean age of 57.54 years (standard deviation, ± 14.34 years). For iLOS, the patient-only model significantly outperformed the procedure-only model (P < 0.0001) and performed similarly to the patient+procedure model (P = 0.50). Other than tumor diagnosis, 5-Factor Modified Frailty Index score was the only factor associated with iLOS (P < 0.001) and tLOS (P < 0.001) on multivariate analysis. When predicting prolonged tLOS, the patient-only model significantly outperformed the procedure-only model (P < 0.0001), and performed similarly to patient+procedure models (P = 0.49).

CONCLUSIONS

Patient-specific factors are the main drivers of prolonged iLOS and tLOS among patients with brain tumor. Frailty was significantly associated with both iLOS and tLOS on multivariate analysis. Efforts to improve care value should focus on strategies to optimize patient status, such as prehabilitation and enhanced recovery after surgery.

HOXB5 promotes proliferation, migration, and invasion of pancreatic cancer cell through the activation of the GSK3β/β-catenin pathway

Many homeobox (HOX) genes have been shown to be related to cancer progression. HOXB5, a member of the HOX genes, is overexpressed in retinoblastoma cancer and positively regulates the breast cancer cell proliferation as well as invasion. However, the role and underlying mechanism of HOXB5 in pancreatic cancer cells are still unclear. HOXB5 expression was measured in four pancreatic cancer cell lines, including PANC-1, ASPC-1, MIA-PaCa-2, and CFPAC-1. PANC-1 and ASPC-1 cells were selected for cell transfection experiments. Cell proliferation, migration, and invasion were measured by Cell Counting Kit-8 (CCK-8) assay, wound healing assay, and transwell assay. Expressions of epithelial-to-mesenchymal transition (EMT) markers were determined by western blotting. Immunofluorescence staining and cellular morphology were used to confirm the effect of HOXB5 dysregulation on pancreatic cancer cells. We found that HOXB5 was markedly expressed in pancreatic cancer cell lines. HOXB5 overexpression contributed to proliferation, migration, and invasion in ASPC-1 cells, whereas HOXB5 knockdown decreased proliferation, migration, and invasion of PANC-1 cells. Western blotting confirmed that overexpression of HOXB5 promoted the EMT process. Conversely, knockdown of HOXB5 alleviated EMT. Furthermore, knockdown of HOXB5 suppressed proliferation, migration, and invasion of pancreatic cancer cells via the Glycogen synthase kinase 3β (GSK3β)/β-catenin pathway. Our study demonstrates that HOXB5 is a tumor promoter in pancreatic cancer, and the GSK3β/β-catenin pathway is important in HOXB5-induced proliferation, migration, and invasion in pancreatic cancer cells.

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

(1) Background: preoperative biliary drainage before pancreaticoduodenectomy (PD) is associated with bacterial biliary contamination (>85%) and a significant increase in global and infectious complications. In view of the lack of published data, the aim of our study was to investigate the impact of fungal biliary contamination after biliary drainage on the complication rate after PD. (2) Methods: a multicentric retrospective study that included 224 patients who underwent PD after biliary drainage with intraoperative biliary culture. (3) Results: the global rate of positive intraoperative biliary sample was 92%. Respectively, the global rate of biliary bacterial contamination and the rate of fungal contamination were 75% and 25%, making it possible to identify two subgroups: bacterial contamination only (B+, n = 154), and bacterial and fungal contamination (BF+, n = 52). An extended duration of preoperative drainage (62 vs. 49 days; p = 0.08) increased the risk of fungal contamination. The overall and infectious complication rates were not different between the two groups. In the event of postoperative infectious or surgical complications, the infectious samples taken did not reveal more fungal infections in the BF+ group. (4) Conclusions: fungal biliary contamination, although frequent, does not seem to increase the rate of global and infectious complications after PD, preceded by preoperative biliary drainage.

Optimizing the outcomes of pancreatic cancer surgery

Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.

Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

The need for nutritional support following pancreaticoduodenectomy is well recognised due to the high prevalence of malnutrition, but the optimal delivery route is still debated. This meta-analysis evaluated postoperative outcomes in patients receiving enteral or parenteral nutrition.

METHODS

EMBASE, MEDLINE and Cochrane databases were searched to identify randomised controlled trials comparing enteral and parenteral nutrition in patients undergoing pancreaticoduodenectomy. The primary outcome measure was delayed gastric emptying (DGE). Secondary outcome measures included length of hospital stay (LOS); postoperative pancreatic fistula (POPF); post-pancreaticoduodenectomy haemorrhage (PPH); and infective complications (IC).

RESULTS

Five randomised controlled trials met inclusion criteria and reported on 690 patients (enteral nutrition n = 383; and parenteral nutrition n = 307). Median age was 61.5 years (interquartile range 60.1-63.6). The pooled relative risk (RR) of the primary outcome, DGE, was 0.97 (95% confidence interval (CI) 0.52-1.81, p = 0.93). There were no statistically significant difference in the secondary outcome measures of POPF (RR 1.07, 95% CI 0.42-2.76, p = 0.88); PPH (RR 0.67, 95% CI 0.31-1.48, p = 0.33) and infectious complications (RR 0.76, 95% CI 0.50-1.17, p = 0.22). However, LOS favoured enteral nutrition, weighted mean difference -1.63 days (95% CI -2.80, -0.46, p = 0.006).

CONCLUSIONS

EN is associated with a significantly shorter LOS compared to PN in patients undergoing pancreaticoduodenectomy.

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.

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

BACKGROUND

This study was designed to determine whether a standardized recovery pathway could reduce post-pancreaticoduodenectomy hospital length of stay to 5 days without increasing complication or readmission rates.

STUDY DESIGN

Pancreaticoduodenectomy patients (high-risk patients excluded) were enrolled in an IRB-approved, prospective, randomized controlled trial (NCT02517268) comparing a 5-day Whipple accelerated recovery pathway (WARP) with our traditional 7-day pathway (control). Whipple accelerated recovery pathway interventions included early discharge planning, shortened ICU stay, modified postoperative dietary and drain management algorithm, rigorous physical therapy with in-hospital gym visit, standardized rectal suppository administration, and close telehealth follow-up post discharge. The trial was powered to detect an increase in postoperative day 5 discharge from 10% to 30% (80% power, α = 0.05, 2-sided Fisher's exact test, target accrual: 142 patients).

RESULTS

Seventy-six patients (37 WARP, 39 control) were randomized from June 2015 to September 2017. A planned interim analysis was conducted at 50% trial accrual resulting in mandatory early stoppage, as the predefined efficacy end point was met. Demographic variables between groups were similar. The WARP significantly increased the number of patients discharged to home by postoperative day 5 compared with controls (75.7% vs 12.8%; p < 0.001) without increasing readmission rates (8.1% vs 10.3%; p = 1.0). Overall complication rates did not differ between groups (29.7% vs 43.6%; p = 0.24), but the WARP significantly reduced the time from operation to adjuvant therapy initiation (51 days vs 66 days; p = 0.005) and hospital cost ($26,563 vs $31,845; p = 0.011).

CONCLUSIONS

The WARP can safely reduce hospital length of stay, time to adjuvant therapy, and cost in selected pancreaticoduodenectomy patients without increasing readmission risk.

Epidural Analgesia Improves Postoperative Pain Control but Impedes Early Discharge in Patients Undergoing Pancreatic Surgery

OBJECTIVES

The aim of this study was to evaluate the impact of epidural analgesia (EA) on postoperative length of stay (LOS), expeditious discharge, and pain relief after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).

METHODS

Retrospective reviews of 2014-2015 American College of Surgeons National Surgical Quality Improvement Program databases and our institutional pancreatic surgery database were conducted.

RESULTS

On univariate analysis, EA was associated with statistically significant longer lengths of stay for both PD and DP. On comparative analysis at mode LOS, discharged before versus after 7 days for PD and 6 days for DP, EA was a significant predictor for the longer groups for both procedures on multivariable analysis (PD, odds ratio of 1.465, P < 0.001; DP, odds ratio of 1.471, P = 0.004). On review of our institution's pancreatic surgery database, patient-reported pain scores were significantly lower in the EA groups than intravenous narcotics groups on the day of surgery only for both PD and DP.

CONCLUSIONS

Epidural analgesia was associated with longer LOS with a most pronounced effect on early discharge after surgery for patients undergoing open PD and DP. It only resulted in superior pain control on the day of surgery.

Multivariable analysis of predictors of unplanned hospital readmission after pancreaticoduodenectomy: development of a validated risk score

BACKGROUND

Unplanned hospital readmission after pancreaticoduodenectomy (PD) is usually due to surgical complications and has significant clinical and economic impact. This study developed a risk score to predict 30-day readmission after PD.

METHODS

Patients undergoing PD between 2009 and 2016 were reviewed from a prospective database. Predictors of readmission were identified using a multivariable logistic regression model, from which a points-based risk scoring system was derived.

RESULTS

81 of 518 patients (15.6%) were readmitted within 30 days. History of cardiac disease ([odds ratio] OR = 2.12; 95% CI: 1.12-4.56), CRP>140 mg/L on post-operative day 3 (OR = 2.34; 95% CI: 1.37-4.35) and comprehensive complication index >14 (OR = 1.74; 95% CI: 1.03-2.85) were independent predictors of readmission. The regression coefficients were used to generate a risk score with excellent calibration (p = 0.917) and good discrimination (c-index = 0.65; 95% CI: 0.58-0.71; p < 0.001). Patients were categorised as low, moderate and high risk, with readmission rates of 6.4%, 13.4% and 23.0% respectively (p < 0.001).

CONCLUSION

The risk score identifies patients at high risk of readmission after pancreaticoduodenectomy. Such patients may benefit from pre-discharge imaging and/or enhanced follow-up, which may potentially reduce the impact of readmissions.

Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy

INTRODUCTION

Pancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations. We hypothesized that implementation of a standardized perioperative care pathway would facilitate safe discharge by five days after pancreaticoduodenectomy.

METHODS

We performed a retrospective cohort study of patients undergoing pancreaticoduodenectomy 18 months prior to and 18 months following implementation of a perioperative care pathway at a quaternary center performing high volume pancreatic surgery.

RESULTS

A total of 145 patients underwent pancreaticoduodenectomy (mean age 63 ± 10 years, 52% female), 81 before and 64 following pathway implementation, and the groups were similar in terms of preoperative comorbidities. The percentage of patients discharged within 5 days of surgery increased from 36% to 64% following pathway implementation (p = 0.001), with no observed differences in post-operative serious adverse events (p = 0.34), pancreatic fistula grade B or C (p = 0.28 and p = 0.27 respectively), or delayed gastric emptying (p = 0.46). Multivariate regression analysis showed length of stay ≤5 days three times more likely after pathway implementation. Rates of readmission within 30 days (20% pre- vs. 22% post-pathway (p = 0.75)) and 90 days (27% pre- vs. 36% post-pathway (p = 0.27)) were unchanged after pathway implementation, and were no different between patients discharged before or after day 5 at both 30 days (19% ≤5 days vs. 23% ≥ 6 days (p = 0.68)) and 90 days (32% ≤5 days vs. 30% ≥ 6 days (p = 0.81)).

CONCLUSIONS

Standardizing perioperative care via enhanced recovery protocols for patients undergoing pancreaticoduodenectomy facilitates safe discharge by post-operative day five.

Sarcopenia is associated with a greater incidence of delayed gastric emptying following pancreaticoduodenectomy

BACKGROUND AND AIMS

Sarcopenia is the degenerative loss of skeletal muscle and has been associated with a variety of post-operative complications. We propose sarcopenia is associated with delayed gastric emptying (DGE) following elective pancreaticoduodenectomy (PD).

METHODS

A retrospective analysis of a computerised database maintained in real time of all patients undergoing PD within our hepatobiliary unit was performed. The cross-sectional area of the psoas muscle at the upper border of L3 was calculated and corrected for patient height. The lowest quartile of gender specific groups was considered to be sarcopenic.

RESULTS

61 patients were included, 32 male and 29 female of whom 8 from each group were sarcopenic (26.2%). Although the sarcopenic and non-sarcopenia groups were found to be comparable, significantly more sarcopenic patients were older (75 vs 64 years, p = 0.003), had a lower body mass index (21.9 vs 25.0 kg/m², p = 0.003) and suffered from DGE (7/16 vs 8/45, p = 0.045). On multivariate analysis, these variables maintained their significance with DGE having an OR of 6.042 (p = 0.036).

CONCLUSION

Sarcopenia is significantly associated with DGE, older age and lower BMI in this specific cohort of patients. Further research into the reversibility of this phenomenon is warranted.

Mortality after pancreaticoduodenectomy: assessing early and late causes of patient death

BACKGROUND

Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored.

METHODS

All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods.

RESULTS

A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76).

CONCLUSIONS

Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.

Thoracic paravertebral block versus thoracic epidural analgesia for post-operative pain control in open pancreatic surgery: A randomized controlled trial

STUDY OBJECTIVE

The purpose of this study was to compare the efficacy of bilateral ultrasound guided thoracic paravertebral catheters to a thoracic epidural after open pancreatic surgery.

DESIGN

This was a prospective non-blinded randomized controlled trial.

SETTING

Academic hospital operating room, postoperative recovery area, and ward.

PATIENTS

53 patients aged 18 and above who had open pancreatic surgery.

INTERVENTIONS

Patients received either bilateral thoracic paravertebral block at T8 with an infusion of 0.2% ropivacaine or thoracic epidural analgesia at T7/8 with an infusion of 0.125% bupivacaine with hydromorphone 6 μg/mL.

MEASUREMENTS

Pain scores, opioid use, length of recovery room and hospital stay, adverse events, and incidence of nausea and vomiting.

MAIN RESULTS

There was no difference in baseline demographics between the two groups. There were no significant differences in pain scores between the two groups in each of the first five days after surgery. There was no difference in length of stay nor nausea and vomiting. There was significantly less modality related adverse events in the paravertebral group compared to the epidural group (p = 0.02).

CONCLUSIONS

The use of thoracic paravertebral catheters provided comparable analgesia and less modality related adverse events when compared to a thoracic epidural in patients undergoing open pancreaticoduodenectomy.

Pancreaticoduodenectomy: minimizing the learning curve

Background

Pancreaticoduodenectomy outcomes improve as surgeon experience increases. We analyzed the outcomes of pancreaticoduodenectomy for any improvements over time to assess the learning curve.

Methods

A retrospective study of patients undergoing consecutive pancreaticoduodenectomy by a single surgeon at the beginning of practice was performed. Operative factors and 90-day outcomes were examined and trends over the course of the 4-year time period were analyzed.

Results

Between July 2011 and June 2015, 124 patients underwent pancreaticoduodenectomy (including total pancreatectomy, n=17) by open (n=93) or a laparoscopic (n=31) approach. The median operative time was 305 minutes which significantly improved over time. The median blood loss and length of stay were 250 mL and 6 days respectively which did not change over time. The pancreatic fistula rate, total morbidity, major morbidity, and mortality, and readmission rate was 7.5%, 41.1%, 14.5%, 1.6%, and 15.3% respectively and did not change over time. Pancreaticoduodenectomy was performed most commonly for pancreatic adenocarcinoma (51.6%) with a negative margin rate of 91.1% which significantly improved over time.

Conclusions

The performance of pancreaticoduodenectomy improves as surgical experience is gained. However, a learning curve that impacts patient outcomes can be considerably diminished by appropriate training, high-volume practice/institution, proficient mentorship and experienced multidisciplinary team.

Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer

BACKGROUND

Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer.

METHODS

A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included.

RESULTS

After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months.

CONCLUSION

Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.

Postoperative infections represent a major determinant of outcome after pancreaticoduodenectomy: Results from a high-volume center

BACKGROUND

Despite improvements in perioperative care, mortality and morbidity rates associated with pancreatic operation still reach 2% and >50%, respectively. Infectious complications after pancreaticoduodenectomy occur in about one-third of the cases. The aim of the study is to define the real burden of infectious complications after pancreaticoduodenectomy and to analyze the risk factors associated with their onset.

METHODS

Data of consecutive pancreaticoduodenectomies performed at the authors' institution from January 2011 to June 2016 were retrieved from a prospectively maintained database. Based on the presence of infectious complications, the population was separated into 2 groups (infection group positive [IG+] and infection group negative [IG-]) and then compared.

RESULTS

During the study period 893 pancreaticoduodenectomies were performed. Overall, infectious complications were detected in 409 out of 893 patients (45.8%). Preoperative biliary drain was the only independent preoperative risk factor for the development of infectious complications (P < .001, odds ratio 3.8). Each complication was found to be statistically more frequent in IG+. In addition, IG+ also had a prolonged hospital stay (P < .020, odds ratio 1.1) and all deaths occurred in this group. The overall multisite infection rate was 41.6%. Multidrug-resistant bacteria were detected in 78.5% of patients. The development of multisite infection was the best predictor of outcome after pancreaticoduodenectomy.

CONCLUSION

The development of postoperative infectious complications is a major determinant of outcome after pancreaticoduodenectomy. In this setting, the reliable negative predictors of the outcome include preoperative biliary drain, site of infection, multidrug-resistant bacteria infections and type of bacteria. Multisite infection was found to be the best predictor of a worse postoperative course after pancreaticoduodenectomy.

Factors associated with prolonged hospitalization in patients undergoing pancreatoduodenectomy

BACKGROUND

Complex surgeries such as a pancreatoduodenectomy (PD) traditionally have long hospital stays (LOS).

METHODS

Patients who underwent elective PD at our institution from 8/2011-6/2015 were retrospectively examined. Interquartile ranges were calculated from LOS. Patient were compared between the highest quartile and the remainder of the cohort.

RESULTS

492 patients had a median LOS of 9 days, with 106 (22%) admitted for >14 days. Characteristics associated with prolong hospitalization include age (p = 0.004) and preoperative albumin <3.5 (p = 0.007). Significant intra-operative measures associated with prolonged LOS were blood loss (EBL, p = 0.004) and increased operative time (p = 0.008). Any complication extended hospitalizations (p < 0.001). Patients in the top quartile were less likely to be discharged home (p < 0.0001) and more likely to be readmitted (p < 0.0001).

CONCLUSION

Older patients with hypoalbuminemia are at higher risk of prolonged LOS following PD as well as high EBL, operative time, and surgical complications. Focused efforts to counsel and optimize patients pre-operatively and minimize intra-operative complications may shorten hospital stays.

Does neoadjuvant chemotherapy affect morbidity, mortality, reoperations, or readmissions in patients undergoing lumpectomy or mastectomy for breast cancer?

BACKGROUND

The influence of neoadjuvant chemotherapy (NAC) prior to breast cancer surgery on postoperative complications is unclear. Our objective was to determine whether NAC was associated with postoperative outcomes in patients undergoing lumpectomy or mastectomy without reconstruction.

METHODS

Patients meeting inclusion criteria were identified from the National Surgical Quality Improvement Program (NSQIP) database participant user files from 2005 through 2012, after which NSQIP discontinued the NAC variable. Primary outcome measures included a composite measure of morbidity and mortality (M&M) and reoperations and readmissions within 30 days of the index procedure. Rates of postoperative complications stratified by receipt of NAC were compared by χ2. A logistic regression model was then built that included confounding factors for M&M.

RESULTS

There were 30,309 patients meeting inclusion criteria. NAC was not associated with any postoperative outcomes from 2005 through 2012, but it was associated with higher M&M in lumpectomy patients during 2011 to 2012 [P=0.011, odds ratio (OR) 2.579; 95% confidence interval (CI), 1.239-5.368].

CONCLUSIONS

The finding that NAC was associated with higher M&M in lumpectomy patients during 2011 to 2012 warrants further investigation. Therefore, we recommend that the NSQIP database reinstitute the NAC variable to allow monitoring during anticipated changes in chemotherapy agents and protocols.

Current status and progress of pancreatic cancer in China

Cancer is currently one of the most important public health problems in the world. Pancreatic cancer is a fatal disease with poor prognosis. As in most other countries, the health burden of pancreatic cancer in China is increasing, with annual mortality rates almost equal to incidence rates. The increasing trend of pancreatic cancer incidence is more significant in the rural areas than in the urban areas. Annual diagnoses and deaths of pancreatic cancer in China are now beyond the number of cases in the United States. GLOBOCAN 2012 estimates that cases in China account for 19.45% (65727/337872) of all newly diagnosed pancreatic cancer and 19.27% (63662/330391) of all deaths from pancreatic cancer worldwide. The population's growing socioeconomic status contributes to the rapid increase of China's proportional contribution to global rates. Here, we present an overview of control programs for pancreatic cancer in China focusing on prevention, early diagnosis and treatment. In addition, we describe key epidemiological, demographic, and socioeconomic differences between China and developed countries. Facts including no nationwide screening program for pancreatic cancer, delay in early detection resulting in a late stage at presentation, lack of awareness of pancreatic cancer in the Chinese population, and low investment compared with other cancer types by government have led to backwardness in China's pancreatic cancer diagnosis and treatment. Finally, we suggest measures to improve health outcomes of pancreatic cancer patients in China.

Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results.

METHODS

A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management.

RESULTS

A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved.

CONCLUSIONS

ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs.

Minimally invasive pancreatectomy for cancer: a critical review of the current literature

Minimally invasive surgery (MIS) has transformed operative practices by offering patients procedures with reduced hospital stay and recovery compared to that of open operations. In spite of the advantages of a MIS approach, the application to pancreatectomy has only recently emerged. This review aims to analyze and discuss available comparative studies as they relate to resection techniques for treatment of malignant disease. A PubMed search was used to obtain original studies and meta-analyses relating to MIS pancreatectomy from 2008 to 2013. Several studies were identified that reported on the application of MIS specifically to the treatment of cancer, many of which were retrospective, single-institution studies. Notwithstanding an inherent selection bias, several studies suggest that MIS can provide equivalent R0 resection rates, number of lymph nodes harvested, and survival to that of open resection. Furthermore, parameters such as blood loss and length of stay are significantly reduced in patients treated with MIS. The current literature supports the conclusion that MIS is safe and effective as a treatment for cancer in well-selected patients in the hands of experienced surgeons. However, the published studies to date are observational in nature and therefore higher quality studies will be needed to support the application and generalizability of MIS in the treatment of pancreatic malignancies.

Sarcopenia is an independent predictor of complications following pancreatectomy for adenocarcinoma

BACKGROUND AND OBJECTIVES

Sarcopenia, which is subclinical loss of skeletal muscle mass, is commonly observed in patients with malignancy. The objective of this study is to determine the correlation between sarcopenia and operative complications following pancreatectomy for cancer.

METHODS

A retrospective review of a pancreatectomy database was performed. The Hounsfield Unit Average Calculation (HUAC) of the psoas muscle, a marker of muscle density and fatty infiltration, was measured from preoperative CT scans. Complications were graded and multivariate logistic regression analysis was performed.

RESULTS

One hundred eighteen patients met criteria for analysis; the overall morbidity rate was 78.8% (n = 93). There were 31 (26.3%) patients who met criteria for sarcopenia using the HUAC. When analyzed as a continuous variable, sarcopenia was an independent predictor of major grade III complications, length of stay, intensive care unit admission, delayed gastric emptying, and infectious, gastrointestinal, pulmonary, and cardiac complications.

CONCLUSIONS

These data suggest that sarcopenia as measured with the HUAC, a value that can be obtained from a preoperative CT scan, is a significant independent predictor of surgical outcome and can be used to improve patient selection and informed consent prior to pancreatectomy in patients with cancer.