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Pickens RC, Kao AM, Williams MA, Herman AC, Kneisl JS. Pediatric Surgical Reentry Strategy Following the COVID-19 Pandemic: A Tiered and Balanced Approach. Am Surg 2023; 89:267-276. [PMID: 34010059 PMCID: PMC9841456 DOI: 10.1177/00031348211011125] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND In response to the COVID-19 pandemic, children's hospitals across the country postponed elective surgery beginning in March 2020. As projective curves flattened, administrators and surgeons sought to develop strategies to safely resume non-emergent surgery. This article reviews challenges and solutions specific to a children's hospital related to the resumption of elective pediatric surgeries. We present our tiered reentry approach for pediatric surgery as well as report early data for surgical volume and tracking COVID-19 cases during reentry. METHODS The experience of shutdown, protocol development, and early reentry of elective pediatric surgery are reported from Levine's Children's Hospital (LCH), a free-leaning children's hospital in Charlotte, North Carolina. Data reported were obtained from de-identified hospital databases. RESULTS Pediatric surgery experienced a dramatic decrease in case volumes at LCH during the shutdown, variable by specialty. A tiered and balanced reentry strategy was implemented with steady resumption of elective surgery following strict pre-procedural screening and testing. Early outcomes showed a steady thorough fluctuating increase in elective case volumes without evidence of a surgery-associated positive spread through periprocedural tracking. CONCLUSION Reentry of non-emergent pediatric surgical care requires unique considerations including the impact of COVID-19 on children, each children hospital structure and resources, and preventing undue delay in intervention for age- and disease-specific pediatric conditions. A carefully balanced strategy has been critical for safe reentry following the anticipated surge. Ongoing tracking of resource utilization, operative volumes, and testing results will remain vital as community spread continues to fluctuate across the country.
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Affiliation(s)
- Ryan C. Pickens
- Department of Surgery, Atrium Health, Charlotte, NC, USA,Ryan C. Pickens, MD, General Surgery Resident, Department of Surgery, Department of Surgery Carolinas Medical Center, Atrium Health, 1000 Blythe Blvd, MEB Office 601, Charlotte, NC 28203, USA.
| | - Angela M. Kao
- Department of Surgery, Atrium Health, Charlotte, NC, USA
| | | | | | - Jeffrey S. Kneisl
- Surgical Care Division, Atrium Health, Charlotte, NC, USA,Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA,Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
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2
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Robinson JN, Davis JMK, Pickens RC, Cochran AR, King L, Salibi P, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Vrochides D. Enhanced Recovery After Surgery ® in Octogenarians Undergoing Hepatopancreatobiliary Surgery. Am Surg 2021:31348211054063. [PMID: 34866406 DOI: 10.1177/00031348211054063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80 years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Patients ≥80 years old in a single HPB ERAS program (September 2015-July 2018) were prospectively tracked in the ERAS Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, P=.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions.
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Affiliation(s)
- Jordan N Robinson
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Joshua M K Davis
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Ryan C Pickens
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Allyson R Cochran
- Carolinas Center for Surgical Outcomes Science, Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Lacey King
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Patrick Salibi
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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3
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Tschuor C, Pickens RC, Isenberg EE, Motz BM, Salibi PN, Robinson JN, Murphy KJ, Iannitti DA, Baker EH, Vrochides D, Martinie JB. Robotic Resection of Gallbladder Cancer: A Single-Center Retrospective Comparative Study to Open Resection. Am Surg 2021:31348211047491. [PMID: 34652250 DOI: 10.1177/00031348211047491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Minimally invasive surgery is gaining support for resection of gallbladder cancer (GBC). This study aims to compare operative and early outcomes of robotic resection (RR) to open resection (OR) from a single institution performing a high volume of robotic HPB surgery. METHODS Twenty patients with GBC underwent RR from January 2013 to August 2019. Outcomes were compared to a historical control of 23 patients with OR. Radical cholecystectomy for suspected GBC and completion operations for incidental GBC after routine cholecystectomy were both included. RESULTS Robotic resection had lower blood loss compared to OR (150 vs 350 mL, P = .002) and shorter postoperative length of stay (2.5 vs 6 days, P < .001), while median operative time was similar (193 vs 208 min, P = .604). There were no statistical differences in 30-day major complications or readmissions. No 30-day mortalities occurred. There was no statistical difference in survival trend (P = .438) or median lymph node harvest (5 vs 3, P = .189) for RR compared to OR. CONCLUSION Robotic resection of GBC is safe and efficient, with lower length of hospital stay and blood loss compared to OR. Technical benefits of robotic-assisted surgery may prove advantageous though larger studies are still needed.
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Affiliation(s)
- Christoph Tschuor
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.,Department of Surgical Gastroenterology and Transplantation, 53146Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, 4321University of Copenhagen, Copenhagen, Denmark
| | - Ryan C Pickens
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin E Isenberg
- School of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin M Motz
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Patrick N Salibi
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Jordan N Robinson
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Carolinas Center for Surgical Outcomes Science, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, 22442Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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K Anderson M, C Pickens R, Davis J, H Baker E, H Baker E, B Martinie J, Vrochides D. Antiplatelet therapy after pancreaticoduodenectomy with portal vein resection as the optimal preventative strategy for maintaining primary vein patency. Int J Hepatobiliary Pancreat Dis 2021. [DOI: 10.5348/100096z04ma2021ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Watson MD, Baimas-George MR, Murphy KJ, Pickens RC, Iannitti DA, Martinie JB, Baker EH, Vrochides D, Ocuin LM. Pure and Hybrid Deep Learning Models can Predict Pathologic Tumor Response to Neoadjuvant Therapy in Pancreatic Adenocarcinoma: A Pilot Study. Am Surg 2020; 87:1901-1909. [PMID: 33381979 DOI: 10.1177/0003134820982557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy may improve survival of patients with pancreatic adenocarcinoma; however, determining response to therapy is difficult. Artificial intelligence allows for novel analysis of images. We hypothesized that a deep learning model can predict tumor response to NAC. METHODS Patients with pancreatic cancer receiving neoadjuvant therapy prior to pancreatoduodenectomy were identified between November 2009 and January 2018. The College of American Pathologists Tumor Regression Grades 0-2 were defined as pathologic response (PR) and grade 3 as no response (NR). Axial images from preoperative computed tomography scans were used to create a 5-layer convolutional neural network and LeNet deep learning model to predict PRs. The hybrid model incorporated decrease in carbohydrate antigen 19-9 (CA19-9) of 10%. Accuracy was determined by area under the curve. RESULTS A total of 81 patients were included in the study. Patients were divided between PR (333 images) and NR (443 images). The pure model had an area under the curve (AUC) of .738 (P < .001), whereas the hybrid model had an AUC of .785 (P < .001). CA19-9 decrease alone was a poor predictor of response with an AUC of .564 (P = .096). CONCLUSIONS A deep learning model can predict pathologic tumor response to neoadjuvant therapy for patients with pancreatic adenocarcinoma and the model is improved with the incorporation of decreases in serum CA19-9. Further model development is needed before clinical application.
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Affiliation(s)
- Michael D Watson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Maria R Baimas-George
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Ryan C Pickens
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Lee M Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
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6
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Pickens RC, Sulzer JK, Passeri MJ, Murphy K, Vrochides D, Martinie JB, Baker EH, Ocuin LM, McKillop IH, Iannitti DA. Operative Microwave Ablation for the Multimodal Treatment of Neuroendocrine Liver Metastases. J Laparoendosc Adv Surg Tech A 2020; 31:917-925. [PMID: 33296283 DOI: 10.1089/lap.2020.0558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and Purpose: Operative microwave ablation (MWA) is a safe modality for treating hepatic tumors. The aim of this study is to present our 10-year, single-center experience of operative MWA for neuroendocrine liver metastases (NLM). Methods: A single-institution retrospective review of patients who underwent operative MWA for NLM was performed (2008-2018). Demographics, primary tumor site, operative approach, combined surgical operations, and carcinoid symptoms were recorded. Clinical outcomes for major complications, readmission, and mortality were analyzed 30 days postoperatively. Postablation imaging was evaluated for incomplete ablation/missed lesions, and surveillance imaging reviewed for local, regional, and metastatic recurrence. Results: Of the 50 patients (166 targeted lesions) who received MWA for NLM, 41 (82%) were treated with a minimally invasive approach, and 22 (44%) underwent MWA concomitant with hepatectomy and/or primary tumor resection. Within the study cohort 70% of patients were treated with curative intent with a 77% (27/35) success rate. Carcinoid symptoms were reported in 40% (20/50) of patients preoperatively, and MWA treatment improved symptoms in 19/20 patients. Incomplete ablation occurred in 1/166 treated lesions. Recurrence-free survival at 1 and 5 years was 86% and 28%, respectively. Overall survival at 1 and 5 years was 94% and 70%, respectively (median follow-up 32 months, range 0-116 months). Conclusion: Operative MWA is a versatile modality, which can be safe and effectively performed alone or combined with hepatectomy for NLM, preferably using a minimally invasive approach, to achieve symptom control and possibly improve survival.
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Affiliation(s)
- Ryan C Pickens
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Jesse K Sulzer
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Michael J Passeri
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Keith Murphy
- Carolinas Center for Surgical Outcomes Science, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - John B Martinie
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Erin H Baker
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Lee M Ocuin
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Iain H McKillop
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
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7
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Baimas-George M, Watson M, Pickens RC, Sulzer J, Murphy KJ, Ocuin L, Baker E, Martinie J, Iannitti D, Vrochides D. Faster Return to Intended Oncologic Treatment (RIOT) After Trisectionectomy Does Not Translate to Better Outcomes. Am Surg 2020; 87:309-315. [PMID: 32936007 DOI: 10.1177/0003134820950687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Resection with trisectionectomy may necessitate liver molding for adequate future liver remnant (FLR), and subsequent complications can impact return to intended oncologic therapy (RIOT). This study evaluated whether a difference in RIOT exists with the use of molding and between liver molding techniques (associating liver partition and portal vein ligation for staged hepatectomy [ALPPS] and portal vein embolization [PVE]) with trisectionectomy. METHODS A retrospective review evaluated trisectionectomies for malignancy. Outcomes were compared with and without molding, and RIOT was determined. RESULTS Fifty-one patients underwent trisectionectomy: 11 ALPPS, 14 PVE, 26 without molding. 73% of ALPPS, 64% of PVE, and 58% without molding achieved RIOT (P = .971). There were no differences found in baseline characteristics, R0 rate, length of stay, readmission, complications, or mortality. Time to RIOT was significantly different (ALPPS: 3.3 months; PVE: 5.2 months; none: 2.4 months, P = .0203). There were no differences in recurrence or survival. CONCLUSIONS Liver molding should not cause apprehension as there are no differences in achieving RIOT. Although technique alters time to RIOT, this does not translate into improved outcomes, implicating disease biology, and regeneration stimulus.
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Affiliation(s)
- Maria Baimas-George
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Ryan C Pickens
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Jesse Sulzer
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Lee Ocuin
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin Baker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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8
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Baimas-George MR, Pickens RC, Sulzer JK, Vrochides D, Martinie JB, Levi DM, Iannitti DA. A ten-year experience of inferior vena cava reconstruction for malignancy: The importance of a multidisciplinary approach with hepatobiliary surgery. Hepatobiliary Pancreat Dis Int 2020; 19:396-398. [PMID: 32307281 DOI: 10.1016/j.hbpd.2020.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/18/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Maria R Baimas-George
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA
| | - Ryan C Pickens
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA
| | - Jesse K Sulzer
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA
| | - John B Martinie
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA
| | - David M Levi
- Division of Transplant Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC 28204, USA.
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9
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Fruscione M, Pickens RC, Baker EH, Martinie JB, Iannitti DA, Hwang JJ, Vrochides D. Conversion therapy for intrahepatic cholangiocarcinoma and tumor downsizing to increase resection rates: A systematic review. Curr Probl Cancer 2020; 45:100614. [PMID: 32622478 DOI: 10.1016/j.currproblcancer.2020.100614] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/29/2020] [Accepted: 06/02/2020] [Indexed: 12/14/2022]
Abstract
Intrahepatic cholangiocarcinoma (ICC) is a devastating malignant neoplasm with dismal outcomes. Several therapeutic modalities have been used with variable success to downsize these tumors for resection. Neoadjuvant therapy such as chemoembolization and radioembolization offer promising options to manage tumor burden prior to resection. A systematic review of the literature was performed with a focus on conversion therapy for ICC and tumor downsizing to increase resection rates among patients who have an initially unresectable tumor. Of 132 patients with initially unresectable ICC, we identified 27 who underwent conversion therapy with surgical resection. Adequate tumor downsizing was achieved with chemotherapy, chemoembolization, radioembolization, or combination thereof. Although negative tumor margins were possible in some patients, recurrence rates and survival outcomes were inconsistently reported. Twenty-three of 27 patients were alive at last reported follow-up. Conversion therapy for initially unresectable ICC may offer adequate tumor downsizing for resection.
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Affiliation(s)
- Mike Fruscione
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC
| | - Ryan C Pickens
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC
| | - Erin H Baker
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC
| | - John B Martinie
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC
| | - David A Iannitti
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC
| | - Jimmy J Hwang
- Department of Medical Oncology, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC
| | - Dionisios Vrochides
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Charlotte, NC.
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10
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Pickens RC, Sulzer JK, Cochran A, Vrochides D, Martinie JB, Baker EH, Ocuin LM, Iannitti DA. Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis. Am Surg 2020. [DOI: 10.1177/000313481908500834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.
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Affiliation(s)
- Ryan C. Pickens
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Jesse K. Sulzer
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Allyson Cochran
- Carolinas Center for Surgical Outcomes Science, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - John B. Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Erin H. Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Lee M. Ocuin
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - David A. Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
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11
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Pickens RC, King L, Barrier M, Tezber K, Sulzer JK, Cochran A, Lyman WB, Mcclune G, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Hanley M, Vrochides D. Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery. Am Surg 2020. [DOI: 10.1177/000313481908500843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®–based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.
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Affiliation(s)
- Ryan C. Pickens
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lacey King
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Misty Barrier
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kendra Tezber
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jesse K. Sulzer
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Allyson Cochran
- Carolinas Center for Surgical Outcomes Science, Carolinas Medical Center, Charlotte, North Carolina; and
| | - William B. Lyman
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Garth Mcclune
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin H. Baker
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee M. Ocuin
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - Dionisios Vrochides
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
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12
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Pickens RC, Bloomer AK, Sulzer JK, Murphy K, Lyman WB, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Vrochides D, Matthews BD. Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence. Am Surg 2019; 85:1033-1039. [PMID: 31638520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for "low risk" were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as "low risk." Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the "low-risk" cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.
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13
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Pickens RC, Bloomer AK, Sulzer JK, Murphy K, Lyman WB, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Vrochides D, Matthews BD. Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence. Am Surg 2019. [DOI: 10.1177/000313481908500949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for “low risk” were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as “low risk.” Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the “low-risk” cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.
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Affiliation(s)
- Ryan C. Pickens
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ainsley K. Bloomer
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jesse K. Sulzer
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Keith Murphy
- Carolinas Center for Surgical Outcomes Science, Carolinas Medical Center, Charlotte, North Carolina; and
| | - William B. Lyman
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin H. Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee M. Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Brent D. Matthews
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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14
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Pickens RC, King L, Barrier M, Tezber K, Sulzer JK, Cochran A, Lyman WB, McClune G, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Hanley M, Vrochides D. Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery. Am Surg 2019; 85:883-894. [PMID: 31560308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.
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15
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Pickens RC, Sulzer JK, Cochran A, Vrochides D, Martinie JB, Baker EH, Ocuin LM, Iannitti DA. Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis. Am Surg 2019; 85:840-847. [PMID: 32051069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.
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Pickens RC, Jensen S, Sulzer JK, Baimas-George M, Baker EH, Vrochides D, Martinie JB, Ocuin LM, Iannitti DA. Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses. Am Surg 2019. [DOI: 10.1177/000313481908500830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.
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Affiliation(s)
- Ryan C. Pickens
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Stephanie Jensen
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jesse K. Sulzer
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Erin H. Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - John B. Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Lee M. Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - David A. Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
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17
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Pickens RC, Jensen S, Sulzer JK, Baimas-George M, Baker EH, Vrochides D, Martinie JB, Ocuin LM, Iannitti DA. Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses. Am Surg 2019; 85:813-820. [PMID: 31560300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.
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18
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Pickens RC, Sastry AV, Vrochides D, Iannitti DA. Imminent Rupture of a Hepatoma. Curr Probl Cancer 2018; 43:100451. [PMID: 30528495 DOI: 10.1016/j.currproblcancer.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Ryan C Pickens
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Amit V Sastry
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
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