Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study

"Evolving Trends in Pancreatic Cystic Tumors: A 3-Decade Single-Center Experience With 1290 Resections"

OBJECTIVE

The aim of this study was to describe our institutional experience with resected cystic tumors of the pancreas with emphasis on changes in clinical presentation and accuracy of preoperative diagnosis.

SUMMARY BACKGROUND DATA

Incidental discovery of pancreatic cystic lesions has increased and has led to a rise in pancreatic resections. It is important to analyze surgical outcomes from these procedures, and the prevalence of malignancy, pre-malignancy and resections for purely benign lesions, some of which may be unintended.

METHODS

Retrospective review of a prospective database spanning 3 decades. Presence of symptoms, incidental discovery, diagnostic studies, type of surgery, postoperative outcomes, and concordance between presumptive diagnosis and final histopathology were recorded.

RESULTS

A total of 1290 patients were identified, 62% female with mean age of 60 years. Fifty-seven percent of tumors were incidentally discovered. Ninety-day operative mortality was 0.9% and major morbidity 14.4%. There were 23 different diagnosis, but IPMN, MCN, and serous cystadenoma comprised 80% of cases. Concordance between preoperative and final histopathological diagnosis increased by decade from 45%, to 68%, and is presently 80%, rising in parallel with the use of endoscopic ultrasound, cytology, and molecular analysis. The addition of molecular analysis improved accuracy to 91%. Of misdiagnosed cases, half were purely benign and taken to surgery with the presumption of malignancy or premalignancy. The majority of these were serous cystadenomas.

CONCLUSIONS

Indications and diagnostic work-up of cystic tumors of the pancreas have changed over time. Surgical resection can be performed with very low mortality and acceptable morbidity and diagnostic accuracy is presently 80%. About 10% of patients are still undergoing surgery for purely benign lesions that were presumed to be malignant or premalignant. Further refinements in diagnostic tests are required to improve accuracy.

The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF.

METHODS

We retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients' demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF.

RESULTS

In the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group.

CONCLUSION

Of all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.

A nationwide certification system to increase the safety of highly advanced hepatobiliary-pancreatic surgery

BACKGROUND

To ensure that highly advanced hepatobiliary-pancreatic surgery (HBPS) is performed safely, the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons established a safety committee to monitor surgical safety.

METHODS

We investigated postoperative mortality rates based on summary reports of numbers and outcomes of highly advanced HBPS submitted annually by the board-certified training institutions from 2012 to 2019. We also analyzed summary reports on mortality cases submitted by institutions with high 90-day post-HBPS mortality rates and recommended site visits and surveys as necessary.

RESULTS

Highly advanced HBPS was performed in 121 518 patients during the 8-year period. Thirty-day mortality rates from 2012 to 2019 were 0.92%, 0.8%, 0.61%, 0.63%, 0.70%, 0.59%, 0.48%, and 0.52%, respectively (P < .001). Ninety-day mortality rates were 2.1%, 1.82%, 1.62%, 1.28%, 1.46%, 1.22%, 1.19%, and 0.98%, respectively (P < .001). Summary reports were submitted by 20 hospitals between 2015 and 2019. Mortality rates before and after the start of report submission and audit were 5.72% and 2.79%, respectively (odds ratio 0.690, 95% confidence interval 0.487-0.977; P = .037).

CONCLUSIONS

Development of a system for designation of board-certified expert surgeons and safety management improved the mortality rate associated with highly advanced HBPS.

Does Preoperative Estimated Glomerular Filtration Rate (eGFR) Predict Short-Term Surgical Outcomes in Patients Undergoing Pancreatic Resections?

INTRODUCTION

Preoperative eGFR has been found to be a reliable predictor of post-operative outcomes in patients with normal creatinine levels who undergo surgery. The aim of our study was to evaluate the impact of preoperative eGFR levels on short-term post-operative outcomes in patients undergoing pancreatectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreatectomy file (2014-2017) was queried for all adult patients (age ≥ 18) who underwent pancreatic resection. Patients were stratified into two groups based on their preoperative eGFR (eGFR < 60 mL/min/1.73m² and eGFR ≥ 60 mL/min/1.73m²). Outcome measures included post-operative pancreatic fistula, discharge disposition, hospital length of stay, 30-day readmission rate, and 30-day morbidity and mortality. Multivariate logistic regression analysis was performed.

RESULTS

A total of 21,148 were included in the study of which 12% (n = 2256) had preoperative eGFR < 60 mL/min/1.73m². Patients in the eGFR < 60 group had prolonged length of stay, were less likely to be discharged home, had higher minor and major complication rates, and higher rates of mortality. On logistic regression analysis, lower preoperative eGFR (< 60 mL/min/1.73m²) was associated with higher odds of prolonged length of stay [aOR: 1.294 (1.166-1.436)], adverse discharge disposition [aOR: 1.860 (1.644-2.103)], minor [aOR: 1.460 (1.321-1.613)] and major complications [aOR: 1.214 (1.086-1.358)], bleeding requiring transfusion [aOR: 1.861 (1.656-2.091)], and mortality [aOR: 2.064 (1.523-2.797)].

CONCLUSION

Preoperative decreased renal function measured by eGFR is associated with adverse outcomes in patients undergoing pancreatic resection. The results of this study may be valuable in improving preoperative risk stratification and post-operative expectations.

Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study

OBJECTIVE

To measure and compare mortality outcomes between dually eligible veterans transported by ambulance to a Veterans Affairs hospital and those transported to a non-Veterans Affairs hospital.

DESIGN

Retrospective cohort study using data from medical charts and administrative files.

SETTING

Emergency visits by ambulance to 140 Veteran Affairs and 2622 non-Veteran Affairs hospitals across 46 US states and the District of Columbia in 2001-18.

PARTICIPANTS

National cohort of 583 248 veterans (aged ≥65 years) enrolled in both the Veterans Health Administration and Medicare programs, who resided within 20 miles of at least one Veterans Affairs hospital and at least one non-Veterans Affairs hospital, in areas where ambulances regularly transported patients to both types of hospitals.

INTERVENTION

Emergency treatment at a Veterans Affairs hospital.

MAIN OUTCOME MEASURE

Deaths in the 30 day period after the ambulance ride. Linear probability models of mortality were used, with adjustment for patients' demographic characteristics, residential zip codes, comorbid conditions, and other variables.

RESULTS

Of 1 470 157 ambulance rides, 231 611 (15.8%) went to Veterans Affairs hospitals and 1 238 546 (84.2%) went to non-Veterans Affairs hospitals. The adjusted mortality rate at 30 days was 20.1% lower among patients taken to Veterans Affairs hospitals than among patients taken to non-Veterans Affairs hospitals (9.32 deaths per 100 patients (95% confidence interval 9.15 to 9.50) v 11.67 (11.58 to 11.76)). The mortality advantage associated with Veterans Affairs hospitals was particularly large for patients who were black (-25.8%), were Hispanic (-22.7%), and had received care at the same hospital in the previous year.

CONCLUSIONS

These findings indicate that within a month of being treated with emergency care at Veterans Affairs hospitals, dually eligible veterans had substantially lower risk of death than those treated at non-Veterans Affairs hospitals. The nature of this mortality advantage warrants further investigation, as does its generalizability to other types of patients and care. Nonetheless, the finding is relevant to assessments of the merit of policies that encourage private healthcare alternatives for veterans.

Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay

BACKGROUND/PURPOSE

There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy.

METHODS

Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery.

RESULTS

494 patients underwent open pancreaticoduodenectomy - 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p = 0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p < 0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p = 0.615).

CONCLUSION

ERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.

Additional MRI for initial M-staging in pancreatic cancer: a cost-effectiveness analysis

OBJECTIVE

Pancreatic cancer is portrayed to become the second leading cause of cancer-related death within the next years. Potentially complicating surgical resection emphasizes the importance of an accurate TNM classification. In particular, the failure to detect features for non-resectability has profound consequences on patient outcomes and economic costs due to incorrect indication for resection. In the detection of liver metastases, contrast-enhanced MRI showed high sensitivity and specificity; however, the cost-effectiveness compared to the standard of care imaging remains unclear. The aim of this study was to analyze whether additional MRI of the liver is a cost-effective approach compared to routinely acquired contrast-enhanced computed tomography (CE-CT) in the initial staging of pancreatic cancer.

METHODS

A decision model based on Markov simulation was developed to estimate the quality-adjusted life-years (QALYs) and lifetime costs of the diagnostic modalities. Model input parameters were assessed based on evidence from recent literature. The willingness-to-pay (WTP) was set to $100,000/QALY. To evaluate model uncertainty, deterministic and probabilistic sensitivity analyses were performed.

RESULTS

In the base-case analysis, the model yielded a total cost of $185,597 and an effectiveness of 2.347 QALYs for CE-MR/CT and $187,601 and 2.337 QALYs for CE-CT respectively. With a net monetary benefit (NMB) of $49,133, CE-MR/CT is shown to be dominant over CE-CT with a NMB of $46,117. Deterministic and probabilistic survival analysis showed model robustness for varying input parameters.

CONCLUSION

Based on our results, combined CE-MR/CT can be regarded as a cost-effective imaging strategy for the staging of pancreatic cancer.

KEY POINTS

• Additional MRI of the liver for initial staging of pancreatic cancer results in lower total costs and higher effectiveness. • The economic model showed high robustness for varying input parameters.

Obesity affects outcomes of pancreatoduodenectomy

BACKGROUND

Obesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups: <18.5 (Underweight), 18.5-24.9 (Normal Weight), 25-29.9 (Overweight), 30-34.9 (Class I obesity), 35-39.9 (Class II Obesity) and >40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups.

RESULTS

The final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25-5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54-3.22, p < 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89-3.24, p < 0.001), surgical site infections (OR 2.06, 95% CI 1.61-2.65, p < 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7-7.1, p < 0.001) in multivariable analysis.

CONCLUSIONS

In conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.

Thirty-day complication rates do not differ by race among patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND AND OBJECTIVES

Black patients with pancreatic ductal adenocarcinoma (PDAC) are less likely to receive multimodality treatment and have worse survival compared to White patients. However, little is known regarding racial differences in postoperative outcomes. The primary aim of this study was to determine if 30-day complication rates following pancreaticoduodenectomy (PD) differ by race.

METHODS

A retrospective cohort study of patients who underwent PD for PDAC from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific data set was performed. Primary outcomes were 30-day pancreas-specific and overall major complications.

RESULTS

A total of 6936 patients were identified, including 91.4% (N = 6337) White and 8.6% (N = 599) Black. Pathologic stage and rates of neoadjuvant therapy were similar among Whites and Blacks. Rates of pancreas-specific (23.9% vs. 23.1%, p = .88) and major postoperative complications (39.2% vs. 39.9%, p = .55) were similar between Whites and Blacks. By multivariable regression analysis, there was no association between race and odds of pancreas-specific complications (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.89-1.37) or overall major complications (OR 1.13, 95% CI 0.95-1.36).

CONCLUSIONS

Among patients undergoing PD for PDAC, Black race is not associated with increased pancreas-specific or overall 30-day postoperative complications. Short-term postoperative outcomes do not appear to explain the increase in pancreatic cancer mortality among Black patients.

Predictors of surgical site infection after pancreaticoduodenectomy

Background

Surgical site infection (SSI) is one of the most common complications after pancreaticoduodenectomy (PD). Thus, it is beneficial to preoperatively identify patients at high risk of developing SSI. The primary aim of the present study was to identify the factors associated with SSI after PD, and the secondary aim was to identify the adverse outcomes associated with the occurrence of SSI.

Methods

A single-centre retrospective study was conducted. All 280 patients who underwent PD at our institution from January 2008 to December 2018 were enrolled. Demographic and perioperative data were reviewed, and the potential risk factors for developing SSI and the adverse outcomes related to SSI were analysed.

Results

A total of 90 patients (32%) developed SSI. Fifty-one patients developed incisional SSI, and 39 developed organ/space SSI. Multivariate logistic analysis revealed that the significant risk factors for developing incisional SSI were preoperative biliary drainage (odds ratio, 3.04; 95% confidence interval, 1.36–6.79; p < 0.05) and postoperative pancreatic fistula (odds ratio, 2.78; 95% confidence interval, 1.43–5.38; p < 0.05), and the risk factors for developing organ/space SSI were preoperative cholangitis (odds ratio, 10.07; 95% confidence interval, 2.31–49.75; p < 0.05) and pancreatic fistula (odds ratio, 6.531; 95% confidence interval, 2.30–18.51; p < 0.05). Enterococcus spp., Escherichia coli and Klebsiella pneumoniae were the common bacterial pathogens that caused preoperative cholangitis as well as SSI after PD. The patients in the SSI group had a longer hospital stay and a higher rate of delayed gastric emptying than patients in the non-SSI group.

Conclusions

The presence of postoperative pancreatic fistula was a significant risk factor for both incisional and organ/space SSI. Any efforts to reduce postoperative pancreatic fistula would decrease the incidence of incisional SSI as well as organ/space SSI after pancreaticoduodenectomy. Preoperative biliary drainage should be performed in selected patients to reduce the incidence of incisional SSI. Minimizing the occurrence of preoperative cholangitis would decrease the incidence of developing organ/space SSI.

Incidence and risk factors for post-operative mortality, hospitalization, and readmission rates following pancreatic cancer resection

Background

The only potentially curative approach for pancreatic cancer is surgical resection, but this technically challenging procedure carries risks for postoperative morbidities and mortality. This study of a large, contemporary national database illustrates incidences of, and risk factors for, post-procedural mortality, prolonged hospital stay, and 30-day readmission.

Methods

From the National Cancer Database (NCDB), stage I-III pancreatic adenocarcinomas were identified [2004-2015]. Surgical techniques included pancreaticoduodenectomy, partial pancreatectomy (selective removal of the pancreatic body/tail), total pancreatectomy (removal of the entire pancreas) with or without subtotal resection of the duodenum and/or stomach, and extended pancreatectomy. Predictors of 30/90-day post-operative mortality, 30-day readmission rates, and prolonged hospital stay (>17 days per receiver operating curve analysis) were identified via multivariable logistic regression.

Results

Overall, 24,798 patients were analyzed (median age of 66). The majority of cases were T3 (47%), N0 (65%), pancreatic head lesions (83%), and treated with pancreaticoduodenectomy (57%). Only 16% received neoadjuvant therapy. Overall unadjusted risk of 30- and 90-day mortality ranged from 1.3-2.5% and 4.1-7.1%, respectively, depending on extent of surgery. Independent predictors of 30-/90-day mortality included preoperative therapy, increasing age, higher comorbidity score, lower income, case volume, and more extensive surgery. Similar findings were demonstrated regarding prolonged hospital stay and 30-day readmission. Age ≥70 was most associated with 30-day mortality, whereas age ≥60 was most associated with 90-day mortality and prolonged hospital stay.

Conclusions

Quantitation of incidences and risk factors for postoperative outcomes following resection for pancreatic cancer is essential for judicious patient selection and shared decision-making between providers and patients.

Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy-Does It Affect the Surgical Outcomes? A Propensity Score-Matched Study

BACKGROUND

There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD.

PATIENTS AND METHOD

This is a propensity score-matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay.

RESULTS

The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas.

CONCLUSION

Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.

Blood Transfusion is an Independent Risk Factor for Postoperative Serious Infectious Complications After Pancreaticoduodenectomy

BACKGROUND/PURPOSE

Blood transfusionhas been considered as a risk factor for postoperative infection after major surgery. However, the relationship between perioperative blood transfusion and the development of serious infections after pancreaticoduodenectomy remains controversial. The purpose of this study was to analyze risk factors associated with postoperative serious infections following pancreaticoduodenectomy.

METHODS

We conducted a retrospective study of 212 patients who underwent pancreaticoduodenectomy during past 2 years and assessed the risk factors for serious infectious complications.

RESULTS

Serious infections developed in 61 patients (29 %) including 47 cases of surgical site infection (SSI), 19 cases of bacteremia, and 13 cases of pneumonia. One patient died of severe septic shock. A multivariate logistic regression analysis of perioperative factors identified that pancreatic fistula (P < 0.01, OR = 9.763) and blood transfusion (P < 0.01, OR = 3.216) were significant risk factors for serious infections. After excluding 46 patients with pancreatic fistula, blood transfusion continued to be an independent risk factor for serious infections (P < 0.01, OR = 5.831).

CONCLUSION

Blood transfusion was the strongest independent factor for serious infections after pancreaticoduodenectomy, which should be considered a quality indicator for the performance of pancreaticoduodenectomy.

Mortality following pancreatectomy for elderly rural veterans with pancreatic cancer

PURPOSE

The objective of this study was to examine rural/urban differences in post-operative mortality for elderly dually eligible Veteran patients with pancreatic cancer treated by surgery with or without adjuvant therapy.

MATERIALS AND METHODS

In this retrospective observational study, Medicare claims data were used to identify elderly dually eligible Veteran patients with pancreatic cancer who underwent pancreatectomy with or without adjuvant therapy. Hierarchical logistic regression models adjusted for age, rurality of residence, post-operative complication rate, length of stay, blood transfusion during admission, and co-morbidity were examined to assess differences in mortality between rural and urban Veteran patients.

RESULTS

Among 4,686 dually eligible Veteran patients with pancreatic cancer who underwent pancreatectomy between 1997 and 2011, those who lived in a small rural town focused area had significantly higher odds of one-year mortality (Odds Ratio [OR]= 1.50; p<0.01; Confidence Interval [CI]: 1.15-1.95), compared to those who lived in an urban focused area. Surgical or 90-day mortality was not significantly associated with the rurality of the Veterans' residence. Patients who were younger, had fewer comorbidities, and shorter length of stay had lower odds of dying at 90days and one year.

CONCLUSIONS

Using a nationally representative database we found that rural and older patients had worse long-term post-operative outcomes than their urban and younger counterparts, while there were no rural/urban differences in early post-operative outcomes. The study adds to evidence pointing to disparities in the quality of care of Veterans based on place of residence.

Comparing VA and Non-VA Quality of Care: A Systematic Review

BACKGROUND

The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems.

METHODS

Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions.

RESULTS

Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions.

DISCUSSION

The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.

Postoperative complications and overall survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

INTRODUCTION

Pancreaticoduodenectomy (PD) performed for pancreatic ductal adenocarcinoma (PDA) has a postoperative morbidity of 40-50%. In this study, we analyzed the impact of high grade complications after PD for PDA on overall survival.

METHODS

A total of 596 patients that underwent PD for PDA between 2001 and 2009 were identified from a prospective database. Complications were defined and graded (1-5) as per our Institutional Surgical Secondary Events Program. High grade complications were defined as ≥grade 3. Postoperative mortality (≤90 days) was excluded. Univariate and multivariate analyses were performed to identify factors associated with overall survival.

RESULTS

Median survival was 24 months. Overall complication rate was 51% (301/596). Low grade complications were recorded in 266 patients (45%) and high grade complications in 22% (n = 129). Our 90 day mortality was 3.7% (n = 22). Anastomotic fistula/leak/abscess rate was 14% (n = 82). Multivariate Cox-Regression analysis identified node positivity, estimated blood loss (EBL) >600 ml, length of stay (LOS) >10 days, margin positivity, and vascular procedures as predictors of decreased overall survival (P < 0.05). High grade complications were not associated with overall survival (P = 0.948).

CONCLUSION

In this study, the occurrence of high grade postoperative complications was not associated with overall survival.

Excess Weight Adversely Influences Treatment Length of Postoperative Pancreatic Fistula: A Retrospective Study of 900 Patients

OBJECTIVES

Pancreatectomy is still associated with a high morbidity rate, even in high-volume centers, and a leading cause of morbidity is represented by postoperative pancreatic fistula (POPF). Many previous studies have evaluated the risk factors for the occurrence of POPF, but protracted courses of POPF have not been fully discussed.

METHODS

This study included 900 patients who underwent pancreatectomy between January 1991 and June 2013 after exclusion of patients who underwent total pancreatectomy. Subgroup analysis of the duration of drain placement was conducted among patients with POPF to identify predictive factors for a protracted course of POPF.

RESULTS

Overall, 292 patients (32.4%) had clinically relevant POPF (grade B/C). The length of drain placement in patients with a body mass index (BMI) of 25 kg/m(2) or greater was significantly longer than that in patients with a BMI of less than 25 kg/m(2) (44.8 ± 25.2 vs 33.8 ± 21.2 days, respectively; P = 0.001). The operative procedure, duct diameter, and pancreatic texture, which were independent risk factors for clinically relevant POPF, did not delay removal of the drainage tubes.

CONCLUSIONS

A BMI of 25 kg/m(2) or greater was the only factor associated with delayed POPF healing. Vigilant postoperative management after pancreatectomy should be considered in obese patients.

Efficacy of Neoadjuvant Versus Adjuvant Therapy for Resectable Pancreatic Adenocarcinoma: A Decision Analysis

BACKGROUND

Neoadjuvant therapy-based protocols for potentially resectable pancreatic adenocarcinoma (PAC) have not been directly compared with adjuvant protocols in large prospective randomized trials. This study aimed to compare the efficacy of neoadjuvant versus adjuvant therapy-based management by using a formal decision analytic model.

METHODS

A decision analytic model was created with a Markov process to compare neoadjuvant and adjuvant chemo- and/or chemoradiation therapy-based strategies for simulated cohorts of patients with potentially resectable PAC. Base-case probabilities were derived from the published data of 21 prospective phases 2 and 3 trials (3708 patients) between 1997 and 2014. The primary outcome measures determined in an intent-to-treat fashion were overall and quality-adjusted survival rates. One- and two-way sensitivity analyses were performed to assess the effects of model uncertainty on outcomes.

RESULTS

The median overall survival and 2-year survival rates for the patients in the standard adjuvant therapy arm of the study were 20 months and 42.2 % versus 22 months and 46.8 % for those in the neoadjuvant strategy arm. Quality-adjusted survival was 18.4 and 19.8 months, respectively. Sensitivity analysis demonstrated that when recurrence-free survival after completion of neoadjuvant therapy and resection is less than 13.9 months or when the rate for progression of disease precluding resection during neoadjuvant therapy is greater than 44 %, the neoadjuvant strategy is no longer the favored option.

CONCLUSIONS

The decision analytic model suggests that neoadjuvant therapy-based management improves the outcomes for patients with potentially resectable pancreatic cancer. However, the benefits in terms of overall and quality-adjusted survival are modest.

Modified One-layer Duct-to-mucosa Pancreaticojejunostomy Reduces Pancreatic Fistula After Pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a major source of morbidity after pancreaticoduodenectomy (PD). The purpose of this retrospective study comparing one-layer pancreaticojejunostomy (PJ) with two-layer PJ after PD was to evaluate whether the one-layer duct-to-mucosa PJ after PD can reduce the incidence of POPF.A total of 194 consecutive patients who underwent PD by one surgeon (Y. Miao) from January 2011 to February 2014 were included in this study. Among those patients, 104 underwent one-layer PJ (one-layer group) and 90 patients underwent two-layer PJ (two-layer group), respectively. Preoperative clinicopathologic features, intraoperative parameters, postoperative morbidity with focus on POPF, were compared between the two groups.The overall incidence of POPF was 19.6% (38/194), and clinically relevant grade B/C POPF rates were 8.6% (16/194) and 3.1% (6/194), respectively. There were no differences in patients' demographics and operation related factors between the two groups. However, the incidence of POPF in the one-layer group was significantly lower than in two-layer group (13.5% [14/104 patients] and 26.7% [24/90 patients] respectively; p=0.021). The median postoperative hospital stay was also significantly lower in the one-layer group compared to the two-layer group (13 days vs. 15 days, p=0.035). One patient in two-layer group died due to postoperative hemorrhage.One-layer duct-to-mucosa pancreaticojejunostomy is a simple and easy technique for pancreaticojejunal anastomosis after PD, and can reduce the POPF rate in comparison to the two-layer technique.

Nosocomial Infections and Microbiologic Spectrum after Major Elective Surgery of the Pancreas, Liver, Stomach, and Esophagus

BACKGROUND

The majority of infections treated by surgeons are nosocomial infections (NI). The frequency of these infections in relation to the organ operated on as well as the organisms involved are not well defined. Detailed knowledge of these issues is essential for optimal care of surgical patients. This study aimed to determine infection rates and the responsible pathogens after major elective surgery of the pancreas, liver, stomach, and esophagus.

METHODS

Between January 1, 2005 and August 31, 2007, the records of all patients of the Department of General, Abdominal and Vascular Surgery, University Hospital Magdeburg (Germany) with elective resection of the pancreas, liver, stomach, and esophagus were evaluated retrospectively. Study parameters were: Patient number, age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, indication for resection, operation duration, length of stay (LOS) in the intensive care unit (ICU) and in hospital, mortality, organ-related rate and kind of NI, and microbiologic spectrum. Nosocomial infections were defined as: Surgical site infection (U.S. Centers for Disease Control and Prevention [CDC] 1 or 2) and intra-abdominal infection (CDC 3), urinary tract infection, clinical sepsis, blood stream and catheter-related infection, respiratory tract infection, and pneumonia.

RESULTS

A total of 358 patients were included: 150 (42%) with pancreas resection, 91 (25%) with liver resection, 105 (29%) with gastric resection, and 12 (3%) with esophagus resection. Median LOS in the ICU for all groups was 48.8 h (interquartile range [IQR] 24.9-91.8 h), median LOS in hospital was 16 d (IQR 13-23 d), and in-hospital mortality was 4.5%. Patients with NI had significantly greater in-hospital death and prolonged stay in hospital and ICU (p<0.001). In 120 (33.5%) patients, one or more NI occurred (range, 83% in esophagus patients to 21% in liver patients). Intra-abdominal (16.5%) and surgical site infections (12.3%) were most frequent; 80.8% of the NI were culture-positive. The most frequent clinically relevant isolates were Escherichia coli (12.4%), coagulase-negative staphylococci (CoNS) (12.2%), and Enterococcus faecium (9.7%). The highest resistance rates were found for Staphylococcus aureus (methicillin-resistant S. aureus [MRSA] 29.4%) and Pseudomonas aeruginosa (23.5%).

CONCLUSIONS

For patients undergoing elective surgery of the pancreas, liver, stomach, and esophagus, considerable differences in demographic factors, frequency, and kind of NI exist. The consequences of NI force surgeons to analyze pre-operative risk factors carefully, assess indications for operation thoroughly, and optimize all controllable parameters.

Body Surface Area: A new predictive factor of mortality and pancreatic fistula after pancreaticoduodenectomy: A cohort-study

INTRODUCTION

To assess the role of Body Surface Area (BSA) in predicting pancreatic fistula and mortality after pancreaticoduodenectomy.

METHODS

The data of patients who underwent pancreaticoduodenectomy between January 1992 to December 2012 at the University Hospital of Caen were collected prospectively and analyzed retrospectively. Pancreatic fistula was determined according to the ISPGF (International Study Group for Pancreatic Fistula) criteria. The Clavien and Dindo classification was used for grading post-operative complications and BSA was calculated according to the Boyd formula. Patients were classified as "large" and "non-large" using a BSA value ≥1.82 to define the large group and the non-large group. The primary end points were post-operative mortality rate, and the rate and grade of post-operative pancreatic fistula.

RESULTS

411 patients underwent pancreaticoduodenectomy with a mean age of 61.2 (±12.1) year. Six patients (1.45%) died post-operatively. Patients with a BSA ≥1.82 had a significantly higher risk of post-operative death: OR 3.55 [1.43-8.80] (p < 0.0005). Eighty-five patients (20.7%) developed a post-operative pancreatic fistulas. The grade A pancreatic fistula rate was 87.1%. Patients with a BSA ≥1.82 had a significantly higher risk of developing overall post-operative pancreatic fistula (p < 0.038). Multivariate analysis showed that "large" patients (1.86, 95%CI[1.09-3.92], p = 0.0229), soft pancreas (6.5, 95%CI[2.39-9.31], p = 0.0155) and a BMI ≥ 25 (1.09, 95%CI[1.031-1.163], p = 0.0407) were independent risk factors of pancreatic fistula.

CONCLUSION

Body Surface Area is a useful factor after pancreaticoduodenectomy to predict mortality and post-operative fistula.

Screening for pancreatic cancer

Even with improved cancer care generally, the incidence and death rate is increasing for pancreatic cancer. Concern exists that a further increase in deaths caused by pancreatic cancer will be seen as other causes of death, such as heart disease and other cancers, decline. Critical exploration of screening high-risk patients as a tool to reduce deaths from pancreatic cancer should be considered. Technological advances and improved understanding of pancreatic cancer biology provides an opportunity to identify and test a panel of early detection biomarkers easily, accurately, and inexpensively measured in blood, urine, stool, or saliva samples. These biomarkers may have additional usefulness in staging, stratification for treatment, establishing prognosis, and assessing response to therapy in this disease. Screening may prove to be one of several strategies to improve outcomes in a disease that has otherwise been difficult to defeat.

Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study

BACKGROUND

Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas.

METHODS

Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa).

RESULTS

The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p < 0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01-0.08; p < 0.001).

CONCLUSION

The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.

Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures

BACKGROUND

Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS).

METHODS

Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement.

RESULTS

Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million [95% confidence interval (CI), 19.4-34.6] procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9-12.3).

CONCLUSIONS

This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes.

Screening for pancreatic cancer: why, how, and who?

Pancreatic cancer is the fourth most common cause of cancer mortality in the United States, with 5-year survival rates for patients with resectable tumors ranging from 15% to 20%. However, most patients presenting with distant metastases, are not resectable, and have a 5-year survival rate of close to 0%. This demonstrates a need for improved screening to identify pancreatic cancer while the tumor is still localized and amenable to surgical resection. Studies of patients with pancreatic tumors incidentally diagnosed demonstrate longer median survival than tumors discovered only when the patient is symptomatic, suggesting that early detection may improve outcome. Recent evidence from genomic sequencing indicates a 15-year interval for genetic progression of pancreatic cancer from initiation to the metastatic stage, suggesting a sufficient window for early detection. Still, many challenges remain in implementing effective screening. Early diagnosis of pancreatic cancer relies on developing screening methodologies with highly sensitive and specific biomarkers and imaging modalities. It also depends on a better understanding of the risk factors and natural history of the disease to accurately identify high-risk groups that would be best served by screening. This review summarizes our current understanding of the biology of pancreatic cancer relevant to methods available for screening. At this time, given the lack of proven benefit in this disease, screening efforts should probably be undertaken in the context of prospective trials.

The effect of visceral fat mass on pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Obesity is associated with perioperative complications and has been considered a risk factor for surgical outcomes of patients undergoing abdominal surgery. The aim of this study is to evaluate the impact of the amount of visceral fat on postoperative morbidity of patients who underwent pancreaticoduodenectomy (PD).

METHODS

We reviewed 181 patients who underwent surgery for periampullary lesions at the Department of Surgery, Gangnam Severance Hospital, Yonsei University Health System between January 2003 and June 2010. The visceral fat area (VFA) and subcutaneous fat area were calculated by computed tomography software.

RESULTS

The mean body mass index (BMI) was 23.4 kg/m(2) (±3.1 kg/m(2)), and the mean VFA was 94.4 cm(2) (±49.5 cm(2)). The mean intraoperative blood loss, and the incidence of clinically relevant pancreatic fistula (grade B/C) and clinically relevant delayed gastric emptying (grade B/C) were significantly higher in the high-VFA group (≥100 cm(2)). In univariate analysis, the incidence of clinically relevant pancreatic fistula (grade B/C) was significantly higher in the high-BMI group (≥25 kg/m(2)), the high-VFA group(≥100 cm(2)), the large intraoperative blood loss and transfusion group, and in patients with pathology of nonpancreatic origin (ampulla, bile duct, or duodenum). In multivariate analysis, the high-VFA group (≥100 cm(2)) and patients with pathology of nonpancreatic origin were identified as independent factors for clinically relevant pancreatic fistula.

CONCLUSION

VFA is a better indicator for the development of pancreatic fistula after PD than BMI. High VFA (≥100 cm(2)) is a risk factor for developing a pancreatic fistula after PD.

Feasibility of video-assisted thoracoscopic surgery lobectomy in Veterans Administration patients

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) pulmonary lobectomy has been associated with decreased complication rates and length of stay compared with lobectomy by thoracotomy. No studies have addressed VATS lobectomy in Veterans Administration (VA) patients.

METHODS

A retrospective review was undertaken of 50 VATS lobectomies performed between August 2007 and June 2009 by one surgeon in a VA hospital, a university-affiliated county hospital, and a private community hospital.

RESULTS

VA patients had more medical comorbidities, poorer lung function, greater current smoker status, and fewer preoperative biopsies. Pleural adhesions or hilar lymphadenopathy were encountered more commonly in VA than nonfederal patients. Surgical times and number of procedures performed were greater in VA patients. There was no statistically significant difference in the risk of postoperative complications or chest tube duration although length of stay was longer for VA patients.

CONCLUSIONS

VATS lobectomy is feasible in a VA setting. The evidence strongly suggests that veterans can benefit from VATS lobectomy in terms of improved outcomes and diminished length of stay compared with thoracotomy.

Compliance with and effects of preoperative immunonutrition in patients undergoing pancreaticoduodenectomy

BACKGROUND/PURPOSE

This study was conducted to ascertain the feasibility and effectiveness of preoperative enteral immunonutrition using an immune-enhanced formula (Impact) in patients undergoing pancreaticoduodenectomy.

METHODS

Twenty-five patients undergoing an elective pancreaticoduodenectomy were asked to ingest Impact for 5 days (750 mL/day) prior to surgery in addition to their normal diets. We retrospectively compared the early postoperative outcomes of the Impact group (n = 18), which consisted of patients who fully complied with the study protocol, and a control group (n = 13), which consisted of patients who had not ingested Impact prior to surgery.

RESULTS

Overall, 82.6% of the patients complied with the preoperative oral ingestion of Impact; all but four patients tolerated a daily intake of 750 mL. While the clinical backgrounds of the Impact and control groups were not significantly different, the frequency of incisional wound infection was lower (0 vs. 30.8%, p = 0.012) and the change in systemic severity as evaluated using the acute physiology and chronic health evaluation (APACHE)-II scoring system was milder (p = 0.033) in the Impact group than in the control group.

CONCLUSION

The preoperative oral ingestion of Impact was well tolerated and appeared to be effective for preventing incisional wound infection and reducing the response to surgical stress in patients undergoing a pancreaticoduodenectomy.

Limitations of patient-associated co-morbidity model in predicting postoperative morbidity and mortality in pancreatic operations

BACKGROUND

Patient-associated co-morbidities are a potential cause of postoperative complications. The National Surgical Quality Improvement Project (NSQIP) collects data on patient outcomes to provide risk-adjusted outcomes data to participating hospitals. However, operations which may have a high distribution of technically-related complications, such as pancreatic operations, may not be adequately assessed using such predictive models.

METHODS

A combined data set of NSQIP Public Use files (PUF) from 2005 to 2008 was created. Using this database, multiple logistic regression analyses were used to generate a predictive model of 30-day postoperative morbidity and mortality for pancreatic operations and all other operations recorded in NSQIP. Receiver-operator characteristic curves were generated and the area under those curves (AUROC) used to generate a c-statistic to assess the model's discriminatory ability. Observed-to-expected (O/E) ratios of for mortality and morbidity using not only patient-associated co-morbidities, but operation-associated information, such as work relative-value units and Current Procedural Terminology codes, were generated. Data were analyzed in SPSS.

RESULTS

In the 4-year period analyzed, there were 7,097 complex pancreatic procedures done which were compared to 568,371 procedures that were not. For postoperative mortality, the AUROC was less for pancreatic operations (0.741) compared to all other operation (0.947) and all other inpatient operations (0.927). Similarly for postoperative morbidity, the AUROC was less for pancreatic operations (0.598) compared to all other operations (0.764) and all other inpatient operations (0.817). However, the O/E ratios were similar in both groups for mortality (all other operations, 0.94 vs. pancreatic operations, 0.92) and morbidity (0.98 for both).

CONCLUSIONS

These data imply that the factors used to assess postoperative mortality and morbidity may not completely explain postoperative outcomes in pancreatic operations. These procedures are technically demanding and can have morbidities not related to pre-existing co-morbid conditions; therefore, preoperative prediction based on pre-existing co-morbidities may have limitations in these types of operations.

Unplanned reoperation and reintervention after pancreatic resections: an analysis of risk factors

BACKGROUND

The purpose of the study was to determine the incidence of any unplanned reoperation or reintervention procedure after pancreatic resection and to identify the underlying risk factors.

METHODS

A total of 189 consecutive pancreatic resections performed from 2001-2008 were searched for any unplanned reoperation, percutaneous drainage, or angiographic reintervention. A retrospective analysis of a prospectively maintained database, including patient characteristics, comorbidities, details of surgery, specific complications, incidence of reoperation/reintervention, and mortality was performed.

RESULTS

Overall rates of reoperation, reintervention, and mortality were 6.3% (12/189), 7.9% (15/189), and 1.6% (3/189), respectively. Four patients underwent reintervention and reoperation, so the combined reoperation/reintervention rate was 12.2% (23/189). Reoperation (P < 0.001) and reintervention (P = 0.002) correlated with mortality. Hemorrhage (relative risk [RR], 58; P = 0.0017) and the combination of hemorrhage and pancreatic fistula (RR, 117; P < 0.0001) were identified as risk factors for unplanned reoperation, hemorrhage (RR, 82; P = 0.005), pancreatic fistula (RR, 42; P < 0.001), and the combination of both complications (RR, 246; P < 0.001) for reoperation and/or reintervention. Other patient- or procedure-related factors did not influence the reoperation and/or reintervention rates significantly.

CONCLUSIONS

Pancreatic fistula and hemorrhage are the predominant factors that afford unplanned reoperation/reintervention. Although reporting the incidence of unplanned reoperation will include the most severe postoperative complications, a considerable number of reinterventions are missed. Therefore, in outcome analyses of pancreatic surgery, not only reoperations but also any interventional therapies should be included.

Postoperative mortality and complications

Recent publications not only underline the risks of age and disease during surgery but also help us quantify the risks with greater precision. Importantly, patient factors often have a stronger association with postoperative mortality than surgical factors. Important factors preoperatively are: age, American Society of Anaesthesiologist (ASA) physical status, emergency surgery, and plasma albumin concentration. There is emerging work on quantifying frailty as a further risk factor for perioperative complication and mortality as well as need for higher level of care after discharge from hospital. Important postoperative complications include sepsis and kidney injury. Preventing, detecting and managing complications and mortality is the greatest challenge facing those caring for surgical patients, including anaesthetists. Evidence for the long term effects of perioperative complications adds further importance to minimizing perioperative complications. Newer approaches in patient care, particularly co-management during the postoperative phase by different specialities are emerging. Managing high-risk patients should also be enhanced with greater surveillance and more rapid and appropriate response; ensuring we do not fail to rescue our patients.

Risk factors for mortality in major digestive surgery in the elderly: a multicenter prospective study

OBJECTIVE

To identify the mortality risk factors of elderly patients (≥65 years old) during major digestive surgery, as defined according to the complexity of the operation.

BACKGROUND

In the aging populations of developed countries, the incidence rate of major digestive surgery is currently on the rise and is associated with a high mortality rate. Consequently, validated indicators must be developed to improve elderly patients' surgical care and outcomes.

METHODS

We acquired data from a multicenter prospective cohort that included 3322 consecutive patients undergoing major digestive surgery across 47 different facilities. We assessed 27 pre-, intra-, and postoperative demographic and clinical variables. A multivariate analysis was used to identify the independent risk factors of mortality in elderly patients (n = 1796). Young patients were used as a control group, and the end-point was defined as 30-day postoperative mortality.

RESULTS

In the entire cohort, postoperative mortality increased significantly among patients aged 65-74 years, and an age ≥65 years was by itself an independent risk factor for mortality (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.36-3.59; P = 0.001). The mortality rate among elderly patients was 10.6%. Six independent risk factors of mortality were characteristic of the elderly patients: age ≥85 years (OR, 2.62; 95% CI, 1.08-6.31; P = 0.032), emergency (OR, 3.42; 95% CI, 1.67-6.99; P = 0.001), anemia (OR, 1.80; 95% CI, 1.02-3.17; P = 0.041), white cell count > 10,000/mm³ (OR, 1.90; 95% CI, 1.08-3.35; P = 0.024), ASA class IV (OR, 9.86; 95% CI, 1.77-54.7; P = 0.009) and a palliative cancer operation (OR, 4.03; 95% CI, 1.99-8.19; P < 0.001).

CONCLUSION

Characterization of independent validated risk indicators for mortality in elderly patients undergoing major digestive surgery is essential and may lead to an efficient specific workup, which constitutes a necessary step to developing a dedicated score for elderly patients.

Sociodemographics and comorbidities influence decisions to undergo pancreatic resection for neoplastic lesions

INTRODUCTION

Pancreatic resection is being performed with increasing frequency and safety. Technical outcomes and long-term survival for neoplastic lesions are well reported; however, reasons why patients do not undergo surgery for potentially resectable lesions are not well understood. The aim of this study was to determine the factors contributing to the decision not to operate for resectable pancreatic neoplasms.

METHODS

From 2004 to 2008, all patients with resectable pancreatic neoplasms at a single high-volume hepatopancreaticobiliary center were evaluated. The impact of patient factors, sociodemographics, medical comorbidities (Charlson combined comorbidity index (CCI) and ACCI), disease factors (tumor characteristics), and surgical factors (type of resection required) on the decision to undergo pancreatectomy were analyzed using univariate and multivariate binary logistic regression analysis.

RESULTS

Three hundred seventy-five patients with resectable pancreatic lesions were identified. The median age was 62 years (21-93); 203 out of 375 (54.1%) were males. Fifty-five (14.7%) did not undergo resection. On univariate analysis, age (odds ratio (OR) 1.116, p < 0.001), non-English speaking background (NESB; OR 4.276, p = 0.001), tumor type (p = 0.001 increased for cystic neoplasms including intraductal papillary mucinous neoplasm), CCI score (OR 1.239, p = 0.001), and ACCI score (OR 1.433, p < 0.001) were associated with an increased risk of not undergoing resection. Gender, age, marital status, and urban residence were not predictive. On multivariate analysis, NESB (p = 0.018) and the ACCI (p = 0.002) remained predictive of not undergoing resection. The majority of patients did not undergo surgery because the patient declined in 25 out of 55 (45.5%), and resection was not offered in 15 out of 55 (27.3%). In the remainder, medical contraindications precluded surgery. Advanced age, tumor type, comorbidities (27.3%), age (21.8%), surgical risk (29.1%), frailty (18.2%), and uncertain diagnosis (5.5%) were cited as reasons for not proceeding with surgery.

CONCLUSION

Patients with a higher ACCI and those from a NESB are less likely to undergo surgery for resectable neoplastic lesions of the pancreas. These factors must be taken into consideration in the decision-making process when considering surgery for patients with pancreatic neoplasms. Novel strategies should be employed to optimize access to surgery for patients with resectable pancreatic neoplasms.

Pancreatectomy risk calculator: an ACS-NSQIP resource

BACKGROUND

The morbidity of pancreatoduodenectomy remains high and the mortality may be significantly increased in high-risk patients. However, a method to predict post-operative adverse outcomes based on readily available clinical data has not been available. Therefore, the objective was to create a 'Pancreatectomy Risk Calculator' using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

The 2005-2008 ACS-NSQIP data on 7571 patients undergoing proximal (n = 4621), distal (n = 2552) or total pancreatectomy (n = 177) as well as enucleation (n = 221) were analysed. Pre-operative variables (n = 31) were assessed for prediction of post-operative mortality, serious morbidity and overall morbidity using a logistic regression model. Statistically significant variables were ranked and weighted to create a common set of predictors for risk models for all three outcomes.

RESULTS

Twenty pre-operative variables were statistically significant predictors of post-operative mortality (2.5%), serious morbidity (21%) or overall morbidity (32%). Ten out of 20 significant pre-operative variables were employed to produce the three mortality and morbidity risk models. The risk factors included age, gender, obesity, sepsis, functional status, American Society of Anesthesiologists (ASA) class, coronary heart disease, dyspnoea, bleeding disorder and extent of surgery.

CONCLUSION

The ACS-NSQIP 'Pancreatectomy Risk Calculator' employs 10 easily assessable clinical parameters to assist patients and surgeons in making an informed decision regarding the risks and benefits of undergoing pancreatic resection. A risk calculator based on this prototype will become available in the future as on online ACS-NSQIP resource.

The cost of resident education

BACKGROUND

Patients cared for by surgeons with resident coverage have an increase in cost versus those patients cared for by surgeons without resident coverage, despite no significant difference in complications. We evaluated the reasons for the disparate cost.

METHODS

In a single institutional analysis, patients received their care from a group of eight surgeons, four with and four without resident coverage. We analyzed ancillary costs, including pharmacy, radiology, laboratory, and central supply costs, and length of stay, total cost, and hospital margin for these patients. In a separate analysis, we compared data that contributes to cost from the National Surgical Quality Improvement Program (NSQIP) database, including age in years, ASA class I-IV, total operating room time in minutes (min), length of hospital stay in days (d), number of patients with a return to OR in 30 d, and complications.

RESULTS

There were no significant differences in ancillary costs in patients cared for by residents. The length of stay was longer in patients cared for by residents (3.3 versus 4.6 d, no resident versus resident, respectively, P = 0.0001). When adjusted for the length of stay, the difference between total costs was $1949/d versus $2103/d (P = NS) for the no resident versus resident groups, respectively. There were 32,685 patients evaluated in the NSQIP database. In all comparisons, operating room time was significantly longer in patients with procedures involving residents.

CONCLUSION

The increase in cost in patients cared for by surgeons with residents is not from significant differences in ancillary costs, and may be from length of stay. Surgical procedures are significantly longer with resident involvement.

ACS-NSQIP has the potential to create an HPB-NSQIP option

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was started in 2004. Presently, 58% of the 198 hospitals participating in ACS-NSQIP are academic or teaching hospitals. In 2008, ACS-NSQIP initiated a number of changes and made risk-adjusted data available for use by participating hospitals. This analysis explores the ACS-NSQIP database for utility in developing hepato-pancreato-biliary (HPB) surgery-specific outcomes (HPB-NSQIP).

METHODS

The ACS-NSQIP Participant Use File was queried for patient demographics and outcomes for 49 HPB operations from 1 January 2005 through 31 December 2007. The procedures included six hepatic, 16 pancreatic and 23 complex biliary operations. Four laparoscopic or open cholecystectomy operations were also studied. Risk-adjusted probabilities for morbidity and mortality were compared with observed rates for each operation.

RESULTS

During this 36-month period, data were accumulated on 9723 patients who underwent major HPB surgery, as well as on 44,189 who received cholecystectomies. The major HPB operations included 2847 hepatic (29%), 5074 pancreatic (52%) and 1802 complex biliary (19%) procedures. Patients undergoing hepatic resections were more likely to have metastatic disease (42%) and recent chemotherapy (7%), whereas those undergoing complex biliary procedures were more likely to have significant weight loss (20%), diabetes (13%) and ascites (5%). Morbidity was high for hepatic, pancreatic and complex biliary operations (20.1%, 32.4% and 21.2%, respectively), whereas mortality was low (2.3%, 2.7% and 2.7%, respectively). Compared with laparoscopic cholecystectomy, the open operation was associated with higher rates of morbidity (19.2% vs. 6.0%) and mortality (2.5% vs. 0.3%). The ratios between observed and expected morbidity and mortality rates were <1.0 for hepatic, pancreatic and biliary operations.

CONCLUSIONS

These data suggest that HPB operations performed at ACS-NSQIP hospitals have acceptable outcomes. However, the creation of an HPB-NSQIP has the potential to improve quality, provide risk-adjusted registries with HPB-specific data and facilitate multi-institutional clinical trials.

Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection

BACKGROUND

The relationship between hospital volume and perioperative mortality in pancreaticoduodenectomy has been well established. We studied whether associations exist between hospital volume and hospital clinical resources and between both of these factors to mortality to help explain this relationship.

STUDY DESIGN

This two-part study reviewed publicly available hospital information from the Leapfrog Group, HealthGrades, and hospital Web sites. Hospitals were evaluated for Leapfrog ICU staffing criteria and Safe Practice Score; HealthGrades five-star rating for complex gastrointestinal procedures and operations; and presence of a general surgery residency, gastroenterology fellowship, and interventional radiology. Evaluation used trend analysis and multiple logistic regression analysis. The second part determined the mortality rate for pancreaticoduodenectomy using inpatient mortality data from the National Inpatient Sample and Leapfrog. Hospitals were categorized by low volume (< or = 10/year), high volume (> or = 11/year), strong clinical support (presence of all support factors), and weak clinical support (absence of any factor). Data were correlated by number of pancreatic resections per hospital, hospital system clinical resources, and operative mortality.

RESULTS

As hospital volume increased, statistically significant increases occurred in the frequency of hospitals meeting Leapfrog ICU staffing criteria (p < 0.0001), Leapfrog Safe Practice Score (p = 0.0004), HealthGrades 5-star rating (p < 0.00001), general surgery residency (p < 0.00001), gastroenterology fellowship (p < 0.00001), and interventional radiology services (p < 0.00001). No significant relationships were found between resection volume and any one of the clinical support factors and perioperative death. Presence of strong clinical support was associated with lower mortality (odds ratio = 0.32; p = 0.001).

CONCLUSIONS

System clinical resources were more influential in operative mortality for pancreatic resection. This might help explain why high-volume hospitals, low-volume surgeons in high-volume institutions, and some lower-volume hospitals with excellent clinical resources have lower perioperative mortality rates for pancreatic resection.

Perioperative Mortality Risk Score using Pre- and Post-operative Risk Factors in Older Patients

We developed a risk score for 30-day postoperative mortality: the Perioperative Mortality risk score. We used a derivation cohort from a previous study of surgical patients aged 70 years or more at three large metropolitan teaching hospitals, using the significant risk factors for 30-day mortality from multivariate analysis. We summed the risk score for each of six factors creating an overall Perioperative Mortality score. We included 1012 patients and the 30-day mortality was 6%.

The three preoperative factors and risk scores were (“three A's”): 1) age, years: 70 to 79=1, 80 to 89=3, 90+=6; 2) ASA physical status: ASA I or II=0, ASA III=3, ASA IV=6, ASA V=15; and 3) preoperative albumin <30 g/l=2.5.

The three postoperative factors and risk scores were (“three I's”) 1) unplanned intensive care unit admission =4.0; 2) systemic inflammation =3; and 3) acute renal impairment=2.5. Scores and mortality were: <5=1%, 5 to 9.5=7% and ≥10=26%.

We also used a preliminary validation cohort of 256 patients from a regional hospital. The area under the receiver operating characteristic curve (C-statistic) for the derivation cohort was 0.80 (95% CI 0.74 to 0.86) similar to the validation C-statistic: 0.79 (95% CI 0.70 to 0.88), P=0.88. The Hosmer-Lemeshow test (P=0.35) indicated good calibration in the validation cohort. The Perioperative Mortality score is straightforward and may assist progressive risk assessment and management during the perioperative period. Risk associated with surgical complexity and urgency could be added to this baseline patient factor Perioperative Mortality score.

Feeding patients following pancreaticoduodenectomy: a UK national survey

INTRODUCTION

Providing nutrition for patients following pancreaticoduodenectomy (PD) is vital but can be challenging. Due to the lack of UK national guidelines for the provision of nutrition and nutritional pre-operative assessment regarding PD, a national survey was conducted.

PATIENTS AND METHODS

A questionnaire was sent to the Department of Nutrition and Dietetics at each of the 31 specialist pancreatic centres listed with the Pancreatic Society of Great Britain and Ireland. Questions were asked regarding the nutritional assessment and treatment of patients undergoing classical PD and pylorus-preserving PD (PPPD) resections.

RESULTS

Twenty-two centres responded to the questionnaire. With regard to PD and PPPD, 82% routinely feed patients following resection, 32% have a regimen for staring feeds, 18% carry out pre-operative nutritional assessment, five centres have funding for an hepatobiliary dietition, and only four centres have a specialist hepatobiliary dietition employed. There was no consensus regarding the type or route of feeding, and at least one centre reported using parenteral nutrition exclusively.

CONCLUSIONS

Very few centres in the UK have funding for a hepatobiliary dietition. Hence pre-operative nutritional assessment in patients undergoing PD and PPPD does not receive much input. Although the importance of postoperative feeding in these patients is appreciated in all major units, there is no consensus with regards to feeding regimens. The authors hope this observational study will address these issues with this important message and stimulate further study in this area.

Screening of high-risk families for pancreatic cancer

PURPOSE OF REVIEW

To discuss how to recognise and manage high-risk individuals.

RECENT FINDINGS

Publication of initial results of screening for pancreatic cancer from US centres. Several masses and premalignant lesions have been detected, but the detection of the first pancreatic cancer through an organised study of screening has yet to be published. There has been progress in risk stratification; the role of diabetes in predisposing for cancer has been characterised and molecular modalities have been published which could be used in conjunction with imaging in a screening programme. A mutation in the palladin gene was found to segregate with the disease in a family with a clear predisposition for pancreatic cancer, though this has yet to be found in other such kindreds.

SUMMARY

Significant challenges remain to be solved in screening for early pancreatic cancer. Risk stratification needs to be improved and high-risk patients included in research-based screening programmes. It will be impossible to confirm that screening can detect cancers early enough for curative treatment until the results of these prospective studies become available.

Resident versus no resident: a single institutional study on operative complications, mortality, and cost

BACKGROUND

Previous studies have demonstrated an increase in surgical morbidity, mortality, duration of stay, and costs in teaching hospitals. These studies are confounded by many variables. Controlling for these variables, we studied the effect of surgical residents on these outcomes during rotations with non-academic-based teaching faculty at a teaching hospital.

METHODS

Patients received care at a single teaching hospital from a group of 8 surgeons. Four surgeons did not have resident coverage (group 1) and the other 4 had coverage (group 2). Continuous severity adjusted complications, mortality, length of stay, cost, and hospital margin data were collected and compared.

RESULTS

Five common procedures were examined: bowel resection, laparoscopic cholecystectomy, hernia, mastectomy, and appendectomy. Comparing all procedures together, there were no differences in complications between the groups, although there was greater mortality, a greater duration of stay, and higher costs in group 2. When comparing the 5 most common procedures individually, there was no difference in complications or mortality, although a greater length of stay and higher costs in group 2.

CONCLUSIONS

Comparing the most common procedures performed individually, patients cared for by surgeons with surgical residents at a teaching hospital have an increase in duration of stay and cost, although no difference in complications or mortality compared to surgeons without residents.

Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm

AIM

To evaluate the effect of polypropylene mesh-reinforced pancreatojejunostomy on pancreatic leakage.

METHODS

Seventeen consecutive patients with paraampullar malignancy received polyprolene mesh-reinforced pancreatodudeonectomy and the Child's method was used to rebuild the alimentary tract.

RESULTS

The mean time of polyprolene mesh-reinforced pancreatojejunostomy was 22 min. Anastomosis could endure 30-500 cm H(2)O pressure during operation. All patients recovered without pancreatic leakage.

CONCLUSION

Polyprolene mesh-reinforced pancreato-jejunostomy is a feasible and reliable procedure to prevent pancreatic leakage.

Preoperative predictors for complications after pancreaticoduodenectomy: impact of BMI and body fat distribution

BACKGROUND

The purpose of this study was to examine the preoperative patient and radiographic factors that are associated with operative morbidity after pancreaticoduodenectomy.

MATERIAL AND METHODS

Patient characteristics and preoperative radiographic findings and their association with postoperative complications after pancreaticoduodenectomy were analyzed for 356 patients with pancreatic adenocarcinoma who underwent resection between 2000 and 2005.

RESULTS

Postoperative complications developed in 135 patients (38%). The most common complications were pancreatic fistula/abscess (15%), wound infection (14%), and delayed gastric emptying (4%). On multivariate analysis, the only preoperative radiographic factors associated with having any postoperative complication were the absence of pancreatic atrophy and the extent of central obesity determined by the thickness of retrorenal visceral fat (VF). Complications occurred in 51% of patients with VF > or = 2 cm, compared to 31% of patients with VF < 2 cm, p < 0.001. Postoperatively, pancreatic fistula developed in 24% of patients with VF > or = 2 cm and in only 10% of patients with VF < 2 cm, p = 0.01. Wound infections occurred in 21% of the patients with body mass index greater than or equal to 30 kg/m(2) compared to 12% of the nonobese patients, p = 0.03.

CONCLUSIONS

Generalized obesity is associated with postoperative wound infections after pancreaticoduodenectomy. The degree of visceral fat on preoperative cross-sectional imaging is associated with significantly higher rates of overall complications and pancreatic fistula.