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Walana W, Gyilbagr F, Buunaaim ADB. Preoperative Hemoglobin Level Predicts Surgical Site Infections in Trauma Orthopedic Surgery: A Cohort Study. J Trop Med 2025; 2025:7737328. [PMID: 39949898 PMCID: PMC11824301 DOI: 10.1155/jotm/7737328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 01/10/2025] [Indexed: 02/16/2025] Open
Abstract
Background: Surgical site infections resulting from trauma orthopedic surgery increase morbidity and mortality rates and generate additional costs for the healthcare system. Preoperative and postoperative blood parameters have been described as risk predictors for surgical site infection in other surgical areas. The purpose of this study was to assess the role of preoperative and postoperative hematological parameters in predicting the risk of surgical site infections in trauma orthopedic surgery. Methods: Data on patients' demographics were collected from their medical records and the operation reports. Preoperative and postoperative blood samples were collected for a complete blood count assay. The blood cell parameters as predictors of surgical site infection after trauma orthopedic surgery were determined by the Mann-Whitney U test to assess the differences in the median between the dependent and independent variables. p value < 0.05 was considered statistically significant. Results: Out of the 210 patients who were followed postsurgery, 14 (6.7%) developed surgical site infection following trauma orthopedic surgery. The mean age of the study participants was 33.08 ± 19.23 (Mean ± SD), with a range of 86 to 0.67 years old. Low preoperative hemoglobin level was identified as a predictor of surgical site infection following trauma orthopedic surgery (p=0.019). None of the postoperative blood parameters measured was significantly associated with surgical site infections after trauma orthopedic surgery in Northern Ghana. Conclusion: In conclusion, our study demonstrates that preoperative hemoglobin level is a useful hematological parameter for predicting surgical site infection following trauma orthopedic surgery. These inexpensive and common hematological parameters could assist in guiding preventive efforts to reduce surgical site infections and improve outcomes for vulnerable patients undergoing trauma orthopedic surgery. Assessing preoperative hemoglobin levels is crucial in identifying patients at increased risk of developing surgical site infections. Preoperative optimization, including incorporating hemoglobin levels into predictive risk models can help to assess these at-risk persons better. Educate patients on the need to optimize their hemoglobin levels before surgery and discuss potential interventions, including iron supplementation or transfusion.
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Affiliation(s)
- Williams Walana
- Department of Clinical Microbiology, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Fredrick Gyilbagr
- Department of Clinical Microbiology, School of Medicine, University for Development Studies, Tamale, Ghana
- Department of Laboratory Service, Tamale Teaching Hospital, Tamale, Ghana
| | - Alexis D. B. Buunaaim
- Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
- Department of Trauma Orthopedics, Tamale Teaching Hospital, Tamale, Ghana
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Gratsianskiy D, Patel D, Sucandy I, Pattilachan TM, Christodoulou M, Rosemurgy A, Ross SB. An institutional analysis of hospital readmission following a robotic pancreaticoduodenectomy. J Robot Surg 2024; 19:20. [PMID: 39661231 DOI: 10.1007/s11701-024-02186-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Accepted: 12/05/2024] [Indexed: 12/12/2024]
Abstract
This study sought to identify the primary reasons for hospital readmissions and examine patient outcomes and associated costs following readmission after robotic pancreaticoduodenectomy. We conducted a retrospective analysis of 435 patients who underwent robotic pancreaticoduodenectomy between 2012 and 2024. Readmitted patients within 30 days post-surgery were compared to non-readmitted patients using Student's t-test and Fisher's exact test. Data are presented as median (mean ± SD). In the study cohort, 86 patients (20%) were readmitted within 30 days after surgery. No significant differences were found in patient demographics or outcomes. The most common causes for readmission included insufficient patient education (n = 18), infection (n = 16), and gastrointestinal bleeding (n = 13). The readmitted cohort had significantly higher costs at $40,452 (± 30,724) compared to $31,438 (± 31,546.2) for non-readmitted patients (p < 0.001). Median survival was similar between the two groups (36 vs. 34 months, p = 0.88). Although some readmissions are inevitable, this study provides compelling evidence that inadequate patient education is a primary contributor to increased healthcare costs. The lack of sufficient education appears to have no mitigating effect on patient outcomes. Implementing a proactive, thorough patient education approach, combined with improved emergency department awareness, presents a promising strategy for reducing costly readmissions.
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Affiliation(s)
- Denis Gratsianskiy
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Dharti Patel
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Iswanto Sucandy
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Tara M Pattilachan
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Sharona B Ross
- Foregut and HPB Division, Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA.
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Ukegjini K, Müller PC, Warschkow R, Tarantino I, Jonas JP, Oberkofler CE, Petrowsky H, Schmied BM, Steffen T. Discharge C-reactive protein predicts 90-day readmission after pancreatoduodenectomy: a conditional inference tree analysis. HPB (Oxford) 2024; 26:1387-1398. [PMID: 39164121 DOI: 10.1016/j.hpb.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 07/14/2024] [Accepted: 08/02/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND The aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD). METHODS A two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission. RESULTS Of 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55-0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%-95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60-0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003). CONCLUSION CRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort. TRIAL REGISTRATION Our retrospective analysis did not require registration with a publicly accessible registry.
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Affiliation(s)
- Kristjan Ukegjini
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland.
| | - Philip C Müller
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland; Department of Surgery, Clarunis - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, CH-4002 Basel, Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
| | - Ignazio Tarantino
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
| | - Jan P Jonas
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Christian E Oberkofler
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland; Vivévis AG - Visceral, Tumour and Robotic Surgery, Clinic Hirslanden Zurich, Witellikerstrasse 40, CH-8032 Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, CH-8091 Zürich, Switzerland
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
| | - Thomas Steffen
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland
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Lv TR, Wang JK, Li FY, Hu HJ. The effectiveness of combined extrahepatic bile duct resection in radically resected cases with intrahepatic cholangiocarcinoma: a SEER-based retrospective cohort study and an external validation. Int J Surg 2024; 110:5342-5354. [PMID: 38788199 PMCID: PMC11392128 DOI: 10.1097/js9.0000000000001661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of the combined extrahepatic bile duct resection (EHBDR) in cases with intrahepatic cholangiocarcinoma (IHCC) in terms of clinicopathological features and long-term survival. METHODS Radically resected cases with IHCC from 2000 to 2020 were identified from Surveillance, Epidemiology, and End Results (SEER) database. Comparative analyses were performed between resected IHCC patients who received EHBDR and those without EHBDR. Moreover, an external validation was further performed based on a single-center cohort. RESULTS A total of 1521 radically resected cases with IHCC (EHBDR: 189) were identified from the SEER database. Comparable age, sex, race, marital status, liver cirrhosis, differentiation status, and adjuvant chemotherapy were acquired between the two groups. EHBDR was associated with a higher incidence of adequate lymphadenectomy ( P <0.001). The incidence of cases with T3-4 or N+ disease was significantly higher in EHBDR group ( P <0.001). Adjuvant radiotherapy was more frequently performed in cases with EHBDR ( P <0.001). EHBDR failed to bring any survival benefit and was associated with a worse prognosis even after matching. Similar findings have also been revealed in the external validation cohort ( n =522, EHBDR: 117). EHBDR was associated with more extended resections, more aggressive tumor biological features, and worse prognosis. In the matched validation cohort, EHBDR was still associated with a higher incidence of early recurrence. CONCLUSION EHBDR was an indicator of the advanced stage and failed to bring any survival benefit. It is the tumor stage that really determines the prognosis. More in-depth analyses focusing on different situations of EHBDR with more detailed clinical data are required.
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Affiliation(s)
- Tian-Run Lv
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun-Ke Wang
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fu-Yu Li
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hai-Jie Hu
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University
- Research Center for Biliary Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Quatromoni JG, Roses R, Lee MK, Jackson OA, Jackson BM, Gaffey AC. Temporary mesenteric venous shunting for portal vein reconstruction: A novel technical adjunct. J Vasc Surg Cases Innov Tech 2024; 10:101540. [PMID: 38989262 PMCID: PMC11234095 DOI: 10.1016/j.jvscit.2024.101540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/01/2024] [Indexed: 07/12/2024] Open
Abstract
Pancreatic resection not infrequently requires portal vein (PV) repair or replacement. PV reconstruction often requires bypass grafting or patch venoplasty, and these grafts and patches require time to thaw or harvest. Mesenteric ischemia and congestion with associated bowel edema may result from prolonged venous occlusion during thawing, harvesting, and reconstructing. Temporary shunting of the mesenteric venous circulation may mitigate these adverse effects. Twenty-one patients were shunted using Argyle shunts during PV reconstruction from 2010 to 2020. Reconstructions in this series consisted of aortic homograft interposition grafts (52%), bovine pericardial patches (38%), internal jugular vein interposition grafts (5%), and internal jugular patches (5%). No intraoperative complications resulted from shunt placement; technical success of PV reconstruction was 100%. Temporary venous shunting during PV reconstruction is safe, technically straightforward, and may serve to decrease the duration of venous mesenteric occlusion.
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Affiliation(s)
- Jon G. Quatromoni
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH
| | - Robert Roses
- Division of Endocrine and Oncologic Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Major K. Lee
- Division of Gastrointestinal Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Oksana A. Jackson
- Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Benjamin M. Jackson
- Division of Vascular and Endovascular Therapy, Lehigh Valley Heart and Vascular Institute, Allentown, PA
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California-San Diego, La Jolla, CA
| | - Ann C. Gaffey
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California-San Diego, La Jolla, CA
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Singh RK, Gurana KR. Readmissions Following Pancreaticoduodenectomy: Experience From a Tertiary Care Center in India. Cureus 2024; 16:e65140. [PMID: 39176340 PMCID: PMC11338694 DOI: 10.7759/cureus.65140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/24/2024] Open
Abstract
Background An enhanced recovery approach in surgery helps early postoperative discharge. With the decreasing trend of morbidity and mortality in recent times in patients undergoing complex procedures such as pancreaticoduodenectomy, readmissions are the next major concern. The causes and outcomes of these readmissions should be investigated for their impact on patient care and prevention. Methodology A total of 997 patients discharged after pancreaticoduodenectomy from a tertiary care center in northern India, between 1989 and 2021, were studied retrospectively to assess the readmission rate for sequelae after pancreaticoduodenectomy. The causes, interventions, outcomes, and predictive factors were studied. Results A total of 103 (10.3%) patients required readmission for sequelae after pancreaticoduodenectomy, and 52 (50.4%) patients required interventions. The most common cause for readmission in our study was intra-abdominal collection (n = 23, 22.3%). Of these 103 patients, 63 (61.2%) had good outcomes, 36 (34.9%) had fair outcomes, and four (3.9%) had bad outcomes. Overall, 53 (51.5%) of 103 patients were readmitted within 30 days of discharge, most commonly with intra-abdominal collection (16 of 53, 30.1%). Of these 53 patients, 22 (41.5%) required interventions, 34 (64.1%) had good outcomes, and 27 (50.9%) were readmitted within seven days of discharge. Of these 27 patients, 12 (44.4%) required interventions, with 24 (88.8%) experiencing good outcomes. Of the 103 patients, 12 (11.6%) were readmitted between 31 and 90 days, mostly due to external stent, T-tube, or percutaneous transhepatic biliary drainage-related problems. Overall, 38 (36.9%) of 103 patients were readmitted after 90 days, mostly with incisional hernia and strictured hepaticojejunostomy. Of these 38 patients, 26 (68.4%) required intervention, and 23 (60.5%) had good outcomes. A previous history of cholangitis (odds ratio (OR) = 1.771, 95% confidence interval (CI) = 1.17-2.67, p = 0.007), postoperative fever (OR = 1.628, 95% CI = 1.081-2.452, p = 0.02), wound infection (OR = 2.011, 95% CI = 1.332-3.035, p = 0.001), and wound dehiscence (OR = 2.136, 95% CI = 1.333-3.423, p = 0.002) predicted readmission on univariate analysis. Multivariate analysis showed a previous history of cholangitis (OR = 1.755, CI = 1.158-2.659, p = 0.008) and wound infection (OR = 1.995, 95% CI = 1.320-2.690, p = 0.001) as factors independently predicting readmission. Conclusions Readmitted patients have high intervention rates and good recovery rates. Readmissions should not be considered a scale for poor healthcare. Patient education, proper management of postoperative complications, and a properly designed discharge care system can help tackle this problem.
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Affiliation(s)
- Rajneesh Kumar Singh
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, IND
| | - Krishna Rao Gurana
- Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, IND
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Boyev A, Azimuddin A, Prakash LR, Newhook TE, Maxwell JE, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Lee JE, Snyder RA, Katz MHG, Tzeng CWD. Classification of Post-pancreatectomy Readmissions and Opportunities for Targeted Mitigation Strategies. Ann Surg 2024; 279:1046-1053. [PMID: 37791481 DOI: 10.1097/sla.0000000000006112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
OBJECTIVE Within a learning health system paradigm, this study sought to evaluate reasons for readmission to identify opportunities for improvement. BACKGROUND Post-pancreatectomy readmission rates have remained constant despite improved index hospitalization metrics. METHODS We performed a single-institution case-control study of consecutive patients with pancreatectomy (October 2016 to April 2022). Complications were prospectively graded in biweekly faculty and advanced practice provider meetings. We analyzed risk factors during index hospitalization and categorized indications for 90-day readmissions. RESULTS A total of 835 patients, median age 65 years and 51% (427/835) males, underwent 64% (534/835) pancreatoduodenectomies, 34% (280/835) distal pancreatectomies, and 3% (21/835) other resections. Twenty-four percent (204/835) of patients were readmitted. The primary indication for readmission was technical in 51% (105/204), infectious in 17% (35/204), and medical/metabolic in 31% (64/204) of patients. Procedures were required in 77% (81/105) and 60% (21/35) of technical and infectious readmissions, respectively, while 66% (42/64) of medical/metabolic readmissions were managed noninvasively. During the index hospitalization, benign pathology [odds ratio (OR): 1.8, P =0.049], biochemical pancreatic leak (OR: 2.3, P =0.001), bile/gastric/chyle leak (OR: 6.4, P =0.001), organ-space infection (OR: 3.4, P =0.007), undrained fluid on imaging (OR: 2.4, P =0.045), and increasing white blood cell count (OR: 1.7, P =0.045) were independently associated with odds of readmission. CONCLUSIONS Most readmissions following pancreatectomy were technical in origin. Patients with complications during the index hospitalization, increasing white blood cell count, or undrained fluid before discharge were at the highest risk for readmission. Predischarge risk stratification of readmission risk factors and augmentation of in-clinic resources may be strategies to reduce readmission rates.
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Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Marchese U, Desbiens JF, Lenne X, Naveendran G, Tzedakis S, Gaillard M, Bruandet A, Theis D, Boyer L, Truant S, Fuks D, El Amrani M. Study of Risk Factors for Readmission After Pancreatectomy for Cancer: Analysis of Nationwide Cohort. Ann Surg 2024; 279:486-492. [PMID: 37254769 DOI: 10.1097/sla.0000000000005929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To identify the factors associated with readmission after pancreatectomy for cancer and to assess their impact on the 1-year mortality in a French multicentric population. BACKGROUND Pancreatectomy is a complex procedure with high morbidity that increases the length of hospital stay and jeopardizes survival. Hospital readmissions lead to increased health system costs, making this a topic of great interest. METHODS Data collected from patients who underwent pancreatectomy for cancer between 2011 and 2019 were extracted from a French national medico-administrative database. A descriptive analysis was conducted to evaluate the association of baseline variables, including age, sex, liver-related comorbidities, Charlson Comorbidity Index, tumor localization, and use of neoadjuvant therapy, along with hospital type and volume, with readmission status. Centers were divided into low and high volumes according to the cutoff of 26 cases/year. Logistic regression models were developed to determine whether the identified bivariate associations persisted after adjusting for the patient characteristics. The mortality rates during readmission and at 1 year postoperatively were also determined. RESULTS Of 22,935 patients who underwent pancreatectomy, 9129 (39.3%) were readmitted within 6 months. Readmission rates by year did not vary over the study period, and mean readmissions occurred within 20 days after discharge. Multivariate analysis showed that male sex [odds ratio (OR) = 1.12], age >70 years (OR = 1.16), comorbidities (OR = 1.21), distal pancreatectomy (OR = 1.11), and major postoperative complications (OR = 1.37) were predictors of readmission. Interestingly, readmission and surgery in low-volume centers increased the risk of death at 1 year by a factor of 2.15 [(2.01-2.31), P < 0.001] and 1.31 [(1.17-1.47), P < 0.001], respectively. CONCLUSIONS Readmission after pancreatectomy for cancer is high with an increased rate of 1-year mortality.
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Affiliation(s)
- Ugo Marchese
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Jean-François Desbiens
- Department of digestive surgery and Transplantation, CHRU de Lille, Lille
- Lille university, Lille
| | - Xavier Lenne
- Lille university, Lille
- Department of Medical Information, CHRU de Lille, Lille
| | - Gaanan Naveendran
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Stylianos Tzedakis
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Martin Gaillard
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Amelie Bruandet
- Lille university, Lille
- Department of Medical Information, CHRU de Lille, Lille
| | - Didier Theis
- Lille university, Lille
- Department of Medical Information, CHRU de Lille, Lille
| | - Laurent Boyer
- Department of Medical Information La Timone Hospital, Marseille
- Aix-Marseille University, Jardin du Pharo, Marseille
| | - Stephanie Truant
- Department of digestive surgery and Transplantation, CHRU de Lille, Lille
- Lille university, Lille
| | - David Fuks
- Department of Digestive, HPB and Endocrine Surgery, Cochin Hospital, AP-HP Centre, Paris
- Paris University - 15 rue de l'école de médecine, Paris
| | - Mehdi El Amrani
- Department of digestive surgery and Transplantation, CHRU de Lille, Lille
- Lille university, Lille
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Irfan A, Gleason F, Reddy S, Heslin MJ, Rose JB. Resection Versus Observation for Small (≤2 cm) Pancreatic Neuroendocrine Tumors. Am Surg 2023; 89:4675-4680. [PMID: 36134675 DOI: 10.1177/00031348221129501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We hypothesized that those patients with pancreatic neuroendocrine tumors (pNETs) ≤2 cm managed nonoperatively would have comparable disease progression to individuals undergoing an operation. METHODS Patients diagnosed with nonfunctional pNETs ≤ 2 cm who were evaluated at a single comprehensive cancer center from 2010 to 2017 were selected from a cancer registry database. Clinicopathologic variables were obtained via retrospective chart review. Primary outcomes were overall and disease specific survival. Variables were compared between the 2 groups using chi-square and independent t-test. RESULTS Fifty-two individuals had tumors ≤2 cm, of whom 75% had an operation, while 25% were observed. Each treatment arm had similar distributions of gender, race, and tumor location. The most common operation was distal pancreatectomy (n = 29) followed by pancreatoduodenectomy (n = 6). Nine patients had grade III postoperative complications and 4 had grade IV under Clavien-Dindo classification. The observation group was noted to have a mean disease progression interval of 80.9 months, while those who underwent an operation had a mean disease progression interval of 94.6 months (P = .246). CONCLUSIONS Overall disease progression in patients with pNETs ≤ 2 cm without evidence of metastasis at the time of presentation is not different between those who underwent operation compared to those observed.
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Affiliation(s)
- Ahmer Irfan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Frank Gleason
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sushanth Reddy
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Martin J Heslin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J Bart Rose
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Fong ZV, Teinor J, Yeo TP, Rinaldi D, Greer JB, Lavu H, Qadan M, Johnston FM, Ferrone CR, Chang DC, Yeo CJ, Wolfgang CL, Warshaw AL, Lillemoe KD, Fernandez-del Castillo C, Wolff JL, Wu AW, Weiss MJ. Profile of the Postoperative Care Provided for Patients With Pancreatic and Periampullary Cancers by Family and Unpaid Caregivers. JCO Oncol Pract 2023; 19:551-559. [PMID: 37192429 PMCID: PMC10424914 DOI: 10.1200/op.22.00736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/10/2023] [Accepted: 03/22/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE Patients with pancreatic and periampullary cancers may experience significant reduction in their quality of life and often rely on family and unpaid caregivers for assistance after surgery. However, as caregivers are not systematically identified, little is known about the nature, difficulty, and personal demands of assistance they provide. We aim to assess the frequency and difficulty of specific assistance caregivers provide and identify potential interventions that could alleviate the caregiving demands. METHODS This was a prospective, multi-institutional study of caregivers accompanying patients with periampullary and pancreatic cancer at their 1-month postpancreatectomy office visit. An instrument that drew heavily on the National Study of Caregiving was administered to caregivers. RESULTS Of 240 caregivers, more than half (58.3%) of caregivers were the patients' spouse, a quarter (25.8%) were daughters or sons, 12.9% other relatives, and 2.9% nonrelatives. Caregivers least frequently provided assistance with transportation (14.6% every day) and most frequently provided assistance with housework (65.0% every day, P = .003) and diet (56.5% every day, P = .004). Caregivers reported the least difficulty helping patients with exercise (1.5% somewhat difficult). Caregivers reported significantly more difficulty with assisting with housework (14.5% somewhat difficult, P < .001) and diet (14.9% somewhat difficult, P < .001). Caregivers identified the immediate postpancreatectomy and early discharge periods as the most stressful phases. They also reported having received very little information about available services that could have supported their efforts. CONCLUSION Caregivers of patients with periampullary or pancreatic cancer provide considerable assistance in the postoperative period and many reported difficulty in assisting with housework and diet. Work is needed to better prepare and support caregivers to better enable them to adequately care for patients with pancreas and periampullary cancer.
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Affiliation(s)
| | - Jonathan Teinor
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Dee Rinaldi
- Thomas Jefferson University, Philadelphia, PA
| | | | - Harish Lavu
- Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | - Jennifer L. Wolff
- Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Albert W. Wu
- Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Matthew J. Weiss
- Northwell Health Cancer Institute, Zucker School of Medicine, Manhasset, NY
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11
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Fong ZV, Lwin TM, Aliaj A, Wang J, Clancy TE. Four-Day Robotic Whipple: Early Discharge after Robotic Pancreatoduodenectomy. J Am Coll Surg 2023; 236:1172-1179. [PMID: 36728297 DOI: 10.1097/xcs.0000000000000560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The authors aimed to assess the safety of an enhanced recovery after surgery (ERAS) and early discharge pathway in a robotic pancreatoduodenectomy (PD) program and compared outcomes with an open PD control cohort to identify the synergistic effects of robotic surgery and an ERAS pathway on lengths of stay (LOS). STUDY DESIGN Consecutive patients undergoing open or robotic PD from a single surgeon between March 2020 and July 2022 were identified. Logistic regression models were used for adjusted analyses of postoperative outcomes. RESULTS There were 134 consecutive PD patients, of which 40 (30%) were performed robotically. Pancreatic adenocarcinoma was the most common indication in both open (56%) and robotic (55%, p = 0.51) groups, with a similar proportion of them being borderline resectable or locally advanced tumors (78% vs 82% in robotic group, p = 0.82). The LOS was significantly shorter in the robotic PD group (median, 5 [IQR 4 to 7] days) when compared with the open PD group (median, 6 [IQR 5 to 8] days, p < 0.001). LOS of 4 days or fewer were observed in 40% of the robotic PD group compared with only 3% of patients in the open PD group (p < 0.001). There was no difference in the overall readmission rate (10% vs 12% in the robotic PD group, p = 0.61). On multivariable logistic regression, robotic PD was independently associated with higher odds of LOS of 4 days or fewer (odds ratio 22.4, p = 0.001) when compared with open PD. CONCLUSIONS An ERAS and early discharge pathway could be safely implemented in a robotic PD program. Patients undergoing robotic PD have significantly shorter length of stay without increased complication or readmission rate compared with open PD, with 40% of patients undergoing robotic PD achieving a LOS of 4 days or fewer.
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Affiliation(s)
- Zhi Ven Fong
- From the Division of Surgical Oncology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, MA
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12
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Mazzola M, Giani A, Veronesi V, Bernasconi DP, Benedetti A, Magistro C, Bertoglio CL, De Martini P, Ferrari G. Multidimensional evaluation of the learning curve for totally laparoscopic pancreaticoduodenectomy: a risk-adjusted cumulative summation analysis. HPB (Oxford) 2023; 25:507-517. [PMID: 36872109 DOI: 10.1016/j.hpb.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/03/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Laparoscopic pancreaticoduodenectomy (LPD) is a challenging procedure. We investigated the learning curve (LC) for LPD with a multidimensional analysis. METHODS Data of patients undergoing LPD between 2017 and 2021, operated by a single surgeon, were considered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis. RESULTS 113 patients were selected. Rates of conversion, overall postoperative complication, severe complication and mortality were 4%, 53%, 29% and 4%, respectively. RA-CUSUM analysis showed a LC with three phases: competency (procedures 1-51), proficiency (procedures 52-94), and mastery (after procedure 94). Operative time was lower in both phase two (588.17 vs 541.13 min, p = 0.001) and three (534.72 vs 541.13 min, p = 0.004) with respect to phase one. Severe complication rate was lower in mastery as compared to competency phase (42% vs 6%, p = 0.005). During mastery phase a greater number of lymph nodes was harvested in comparison to proficiency phase. CONCLUSIONS According to our LC analysis, 52 procedures were required to achieve technical competency in LPD. Mastery, which corresponded to a reduction in operative time and surgical failures, was acquired after 94 procedures.
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Affiliation(s)
- Michele Mazzola
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy.
| | - Alessandro Giani
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Valentina Veronesi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy
| | - Davide P Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy; ASST Grande Ospedale Metropolitano Niguarda, Department of Advanced Training Research and Development, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Antonio Benedetti
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Carmelo Magistro
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Camillo L Bertoglio
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Paolo De Martini
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Giovanni Ferrari
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
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13
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Palen A, Garnier J, Ewald J, Delpero JR, Turrini O. Readmission after pancreaticoduodenectomy: Birmingham score validation. HPB (Oxford) 2023; 25:172-178. [PMID: 36437219 DOI: 10.1016/j.hpb.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/14/2022] [Accepted: 08/15/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Birmingham score predicts the risk of hospital readmission after pancreaticoduodenectomy (PD). This study aimed to validate the risk score in a different healthcare cohort. METHODS From 2017 to 2021, 301 patients underwent PD. The Birmingham score was applied to 276 patients. Postoperative deceased patients (n = 7) or those requiring a completion of pancreatectomy (n = 18) were excluded. RESULTS Forty-seven (17%) patients were readmitted after a median delay of 9 (range 1-49) days and stayed for 5 (range 1-27) days; 4 (8.5%) died during the hospital stay. The leading cause of readmission was a septic condition (53%), mostly resolved by medical treatment (77%). A multivariate analysis identified the occurrence of a clinically relevant postoperative pancreatic fistula, the score criteria, and the score itself as independent factors favouring readmission. Readmission rates in patients with low [n = 97 (35%)], intermediate [n = 98 (36%)], and high [n = 81 (29%)] scores were 5%, 17%, and 31%, respectively (P < 0.01). CONCLUSION This study confirmed the relevance and robustness of the Birmingham risk score. Patients with a high risk of readmission after PD, identified based on the score, were discharged to a partnership medical centre close to the pancreatic centre to plan readmission and avoid futile unplanned hospitalisation.
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Affiliation(s)
- Anaïs Palen
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, Aix-Marseille University, Institut Paoli-Calmettes, CRCM, Marseille, France
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14
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Malgras B, Dokmak S, Aussilhou B, Pocard M, Sauvanet A. Management of postoperative pancreatic fistula after pancreaticoduodenectomy. J Visc Surg 2023; 160:39-51. [PMID: 36702720 DOI: 10.1016/j.jviscsurg.2023.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.
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Affiliation(s)
- B Malgras
- Digestive and endocrine surgery department, Bégin Army Training Hospital, 69, avenue de Paris, 94160 Saint-Mandé, France; Val de Grâce School, 1, place Alphonse-Lavéran, 75005 Paris, France
| | - S Dokmak
- Hepatobiliary and pancreatic surgery department, Paris-Cité University, Beaujon Hospital, AP-HP, 92110 Clichy, France
| | - B Aussilhou
- Hepatobiliary and pancreatic surgery department, Paris-Cité University, Beaujon Hospital, AP-HP, 92110 Clichy, France
| | - M Pocard
- Department of pancreatic and hepatobiliary digestive surgery and liver transplantation, Pitié Salpêtrière Hospital, 41-83, boulevard de l'Hôpital, 75013 Paris, France; UMR 1275 CAP Paris-Tech, Paris-Cité University, Lariboisière Hospital, 2, rue Ambroise-Paré, 75010 Paris, France
| | - A Sauvanet
- Hepatobiliary and pancreatic surgery department, Paris-Cité University, Beaujon Hospital, AP-HP, 92110 Clichy, France.
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15
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Kokkinakis S, Kritsotakis EI, Maliotis N, Karageorgiou I, Chrysos E, Lasithiotakis K. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 21:527-537. [PMID: 35513962 DOI: 10.1016/j.hbpd.2022.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 04/13/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.
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Affiliation(s)
- Stamatios Kokkinakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, Division of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete 71110, Greece
| | - Neofytos Maliotis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Ioannis Karageorgiou
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece.
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16
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Fong ZV, Teinor J, Yeo TP, Rinaldi D, Greer JB, Lavu H, Qadan M, Johnston FM, Ferrone CR, Chang DC, Yeo CJ, Wolfgang CL, Warshaw AL, Lillemoe KD, Fernandez-del Castillo C, Weiss MJ, Wolff JL, Wu AW. Assessment of Caregivers' Burden When Caring for Patients With Pancreatic and Periampullary Cancer. J Natl Cancer Inst 2022; 114:1468-1475. [PMID: 35984312 PMCID: PMC9664174 DOI: 10.1093/jnci/djac153] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/14/2022] [Accepted: 08/01/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Family and other unpaid caregivers play an active role in the recovery of individuals with pancreatic and periampullary cancer after pancreatectomy. However, little is known about caregivers' experiences and how to better support them. METHODS Caregivers accompanying patients to 1-month postpancreatectomy visits at 3 hospitals completed an electronic survey between November 2018 and February 2020. We examine measures of absenteeism and work productivity loss among the subset of caregivers who reported working for pay and comparatively assess caregiver experiences by employment status. All analyses were performed as 2-sided tests. RESULTS Of 265 caregivers approached for study participation, 240 (90.6%) enrolled. Caregivers were primarily female (70.8% female, 29.2% male) and spouses (58.3%) or adult children (25.8%) of patients, with a median age of 60 years. Of the 240 caregivers included in the study, 107 (44.6%) worked for pay. Nearly half (44.4%) of working caregivers reported being absent from work because of caregiving amounting to a 14% loss in work hours. While at work, 58.9% of working caregivers reported increased work difficulty as a result of caregiving. Taken together, an estimated 59.7% loss in work productivity was experienced because of caregiving in the month following pancreatectomy. After adjustment for sociodemographic factors, working (vs nonworking) caregivers reported increased financial (odds ratio [OR] = 2.32; P = .04) and emotional (OR = 1.93; P = .04) difficulties and daily activity restrictions (OR = 1.85; P = .048). CONCLUSIONS Working caregivers of patients with pancreatic and periampullary cancer experience negative impacts on work and productivity, and caregiving-related financial and emotional difficulties may be amplified. This study highlights the need for workplace policies to support unpaid cancer caregiving.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Teinor
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Theresa P Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dee Rinaldi
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Matthew J Weiss
- Department of Surgery, Northwell Health University Hospital, Manhasset, NY, USA
| | - Jennifer L Wolff
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Albert W Wu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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17
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Tfaily MA, Ghanem P, Farran SH, Dabdoub F, Kanafani ZA. The role of preoperative albumin and white blood cell count in surgical site infections following whipple surgery. Sci Rep 2022; 12:19184. [PMID: 36357432 PMCID: PMC9649662 DOI: 10.1038/s41598-022-21849-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022] Open
Abstract
Whipple surgery is associated with a high risk of surgical sites infections (SSIs). Nutritional deficiency has been associated with an increased risk of wound infections. This study aims at exploring the role of preoperative albumin levels in predicting the risk of SSIs following Whipple surgery. A total of 23,808 individuals were identified from the ACS-NSQIP database from years 2011 to 2017. The primary exposure was pre-operative albumin while the secondary exposure was white blood cell (WBC) count. The primary outcome was divided into superficial and deep surgical site infections (S/D SSI) and organ-space SSI. All statistical analyses were conducted using IBM Statistical Package for Social Sciences version 26. Levels of pre-operative serum albumin less than 3.73 g/L, dirty and contaminated wounds and longer operative time were associated with increased odds for developing S/D SSIs (OR = 1.14, OR = 1.17, OR = 1.06, respectively, p-value < 0.05). Pre-operative WBC level (/L) was associated with a risk of developing an organ-space SSI but not S/D SSI (OR = 1.02, p-value 0.003). This study demonstrates the predictive role of pre-operative albumin in developing S/D SSIs and highlights the need to develop therapeutic strategies to optimize the pre-operative nutritional health status of patients undergoing Whipple surgery.
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Affiliation(s)
- Mohamad Ali Tfaily
- grid.189967.80000 0001 0941 6502Department of Internal Medicine, Emory University, Atlanta, GA USA ,grid.411654.30000 0004 0581 3406Department of Internal Medicine, American University of Beirut Medical Center, Faculty of Medicine, Beirut, Lebanon
| | - Paola Ghanem
- grid.21107.350000 0001 2171 9311Department of Medical Oncology, Johns Hopkins University, Baltimore, MD USA
| | - Sarah H. Farran
- grid.22903.3a0000 0004 1936 9801Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - Fatema Dabdoub
- grid.411654.30000 0004 0581 3406Department of Internal Medicine, American University of Beirut Medical Center, Faculty of Medicine, Beirut, Lebanon
| | - Zeina A. Kanafani
- grid.411654.30000 0004 0581 3406Department of Internal Medicine, American University of Beirut Medical Center, Faculty of Medicine, Beirut, Lebanon
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18
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Dumortier J, Guillaud O, Valette PJ, Partensky C, Paliard P, Boillot O, Erard D. Prophylactic sequential antibiotic therapy for recurrent liver/biliary sepsis. Clin Res Hepatol Gastroenterol 2022; 46:101979. [PMID: 35710040 DOI: 10.1016/j.clinre.2022.101979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Recurrent liver/biliary sepsis are rare and can occur in different situations. Curative treatment of acute septic episodes is based on antibiotics. Nevertheless, recurrent sepsis can be life-threatening, and the treatment of the underlying disease could be complex, and eventually not possible. The aim of the present study was to report our experience on prophylactic sequential antibiotic therapy for recurrent liver/biliary sepsis in a large cohort of patients with long follow-up. METHODS All patients who received a prophylactic sequential antibiotic therapy for recurrent liver/biliary sepsis in our institution from 2005 to 2020 were included. Prophylactic sequential antibiotic therapy was based on per os antibiotics with expected antibacterial activity on digestive bacteria, mainly Gram-negative bacilli. The primary end-point was the reduction of the number of septic episodes to 1 or less episode per year, and not severe (not requiring hospitalization). RESULTS Were included 33 adult patients and the main initial disease/condition leading to prophylaxis was history of hepaticojejunostomy (78.8%). The majority of septic episodes required hospitalization (57.6%). First line prophylactic sequential antibiotic therapy was weekly ciprofloxacin in all cases. First line therapy was successful in the long-term in 19 patients (57.6%), with a median follow-up of 92 months (range: 25-206). Global efficacy (first-second-third lines) was 28/33 (84.8%). CONCLUSIONS The results of the present study with very long follow-up suggest that prophylactic sequential antibiotic therapy can successfully prevent recurrent liver/biliary sepsis with good tolerance.
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Affiliation(s)
- Jérôme Dumortier
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France.
| | - Olivier Guillaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France
| | - Pierre-Jean Valette
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Radiologie digestive, Lyon, France
| | - Christian Partensky
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Chirurgie digestive, Lyon, France
| | - Pierre Paliard
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-gastroentérologie, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Olivier Boillot
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Chirurgie digestive, Lyon, France
| | - Domitille Erard
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service d'Hépato-gastroentérologie, Lyon, France
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19
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Al Abbas AI, Hamad AB, Zenati MS, Zureikat AH, Zeh HJ, Hogg ME. Does CT scanning after pancreatoduodenectomy reduce readmission rates: an analysis of 900 resections at a high-volume center. HPB (Oxford) 2022; 24:1770-1779. [PMID: 35871133 DOI: 10.1016/j.hpb.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/18/2022] [Accepted: 06/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) remains associated with significant complication and readmission rates. Infection constitutes a significant proportion of morbidity. We aim to evaluate whether CT scans performed prior to discharge for suspected infection prevents readmission. METHODS A retrospective review of patients undergoing PD at a tertiary referral center from 2010 to 2018. RESULTS A total of 982 patients underwent PD: 74% had no clinical infection at the index admission. Of the non-infected patients, 59% exhibited leukocytosis, 27% underwent a CT scan, and 33.6% were readmitted. Of the non-infected patients, 148 (20.3%) experienced major complications, and this was the strongest predictor of readmission (OR: 10.5, [95% CI: 6.5-17], p = 0.0001). In the non-infected patients who had major complications, CT scanning was predictive of lower risk of readmission (OR: 0.38, [95% CI: 0.17-0.83], p = 0.015). Leukocytosis was also found to be predictive of lower risk of readmission (OR: 0.42, [95% CI: 0.18-0.98], p = 0.044). These findings did not hold true for those who had yet to experience major complications on their index admission. CONCLUSION CT scanning without evidence of infection was associated with reduction of readmission in the cohort with major complications and showed a trend towards preventing readmission in the overall cohort. Development of clinical algorithms to maximize the utility of this test is warranted.
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Affiliation(s)
- Amr I Al Abbas
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Mazen S Zenati
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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20
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Abstract
OBJECTIVES Delayed gastric emptying (DGE) is a complication that affects the length of hospitalization and associated cost after pancreaticoduodenectomy (PD). The reported risk factors for DGE were controversial. This study aimed to identify risk factors for the development of DGE after PD. METHODS The patients who underwent PD between October 2010 and October 2020 were retrospectively examined. Multivariate analysis was performed to predict the variables causing DGE. RESULTS In total, 225 patients underwent PD. The pylorus preserving PD was applied to 151 patients (67%), whereas standard PD to 74 (33%). The DGE was detected in 26 patients (11.5%). The majority of cases were classified as grade A (57.7%), whereas 38.4% as grade B and 3.9% as grade C. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 3.48; 95% confidence interval [CI], 1.45-8.34; P = 0.05), the preoperative biliary stent (OR, 2.5; 95% CI, 1.04-5.99; P = 0.039), and the pylorus resection (OR, 3.05; 95% CI, 1.28-7.25; P = 0.012) were independently associated with DGE. CONCLUSIONS We demonstrated that implementation of the preoperative stent, pylorus resection, and diabetes mellitus are independent risk factors for DGE. Pylorus preservation should remain the standard of care in PD.
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21
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Lv TR, Liu F, Hu HJ, Regmi P, Ma WJ, Yang Q, Jin YW, Li FY. The role of extra-hepatic bile duct resection in the surgical management of gallbladder carcinoma. A first meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:482-491. [PMID: 34955314 DOI: 10.1016/j.ejso.2021.11.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 10/06/2021] [Accepted: 11/26/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To systematically evaluate the clinicopathological and prognostic value of extra-hepatic bile duct resection (EHBDR) in the surgical management of patients with gallbladder carcinoma (GBC), especially in non-jaundiced patients. METHODS PubMed, EMBASE and the Cochrane Library were searched up to March 1st 2021 for comparative studies between bile duct resected and non-resected groups. RevMan5.3 and Stata 13.0 software were used for the statistical analyses. RESULTS EHBDR did not correlate with a better overall survival (OS) (P = 0.17) or disease-free survival (P = 0.27). No survival benefit was also observed in patients with T2N1 (P = 0.4), T3N0 (P = 0.14) disease and node-positive patients (P = 0.75), rather, EHBDR was even harmful for patients with T2N0 (P = 0.01) and node-negative disease (P = 0.02). Significantly higher incidences of recurrent disease (P = 0.0007), postoperative complications (P < 0.00001) and positive margins (P = 0.02) were detected in the bile duct-resected group. The duration of postoperative hospital stay between the two groups was comparable (P = 0.58). Selection bias was also detected in our analysis that a significantly higher proportion of advanced lesions with T3-4 or III-IV disease was observed in the bile duct-resected group (P < 0.00001). EHBDR only contributed to a greater lymph yield (P = 0.01). CONCLUSION EHBDR has no survival advantage for patients with GBC, especially for those with non-jaundiced disease. Considering the unfairness of comparing OS between jaundiced patients receiving EHBDR with non-jaundiced patients without EHBDR, we could only conclude that routine EHBDR in non-jaundiced patients is not recommended and future well-designed studies with more specific subgroup analyses are required for further validation.
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Affiliation(s)
- Tian-Run Lv
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Fei Liu
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Hai-Jie Hu
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
| | - Parbatraj Regmi
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Wen-Jie Ma
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Qing Yang
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Yan-Wen Jin
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Fu-Yu Li
- Department of Biliary Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
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22
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Kou HW, Hsu CP, Chen YF, Huang JF, Chang SC, Lee CW, Wang SY, Yeh CN, Yeh TS, Hwang TL, Hsu JT. The Severity of Postoperative Pancreatic Fistula Predicts 30-Day Unplanned Hospital Visit and Readmission after Pancreaticoduodenectomy: A Single-Center Retrospective Cohort Study. Healthcare (Basel) 2022; 10:126. [PMID: 35052290 PMCID: PMC8775671 DOI: 10.3390/healthcare10010126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/21/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Unplanned hospital visits (UHV) and readmissions after pancreaticoduodenectomy (PD) impact patients' postoperative recovery and are associated with increased financial burden and morbidity. The aim of this study is to identify predictive factors related to these events and target the potentially preventable UHV and readmissions. METHODS We enrolled 518 patients in this study. Characteristics were compared between patients with or without UHV and readmissions. RESULTS The unplanned visit and readmission rate was 23.4% and 15.8%, respectively. Postoperative pancreatic fistula (POPF) grade B or C, the presence of postoperative biliary drainage, and reoperation were found to be predictive factors for UHV, whereas POPF grade B or C and the presence of postoperative biliary drainage were independently associated with hospital readmission. The most common reason for readmission was an infection, followed by failure to thrive. The overall mortality rate in the readmission group was 4.9%. CONCLUSIONS UHV and readmissions remain common among patients undergoing PD. Patients with grade B or C POPF assessed during index hospitalization harbor an approximately two-fold increased risk of subsequent unplanned visits or readmissions compared to those with no POPF or biochemical leak. Proper preventive strategies should be adopted for high-risk patients in this population to maintain the continuum of healthcare and improve quality.
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Affiliation(s)
- Hao-Wei Kou
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Chih-Po Hsu
- Department of Surgery, Division of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (C.-P.H.); (J.-F.H.)
| | - Yi-Fu Chen
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Jen-Fu Huang
- Department of Surgery, Division of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (C.-P.H.); (J.-F.H.)
| | - Shih-Chun Chang
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Chao-Wei Lee
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Shang-Yu Wang
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Chun-Nan Yeh
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Ta-Sen Yeh
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Tsann-Long Hwang
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
| | - Jun-Te Hsu
- Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City 333, Taiwan; (H.-W.K.); (Y.-F.C.); (S.-C.C.); (C.-W.L.); (S.-Y.W.); (C.-N.Y.); (T.-S.Y.); (T.-L.H.)
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NARI GA, LOPEZ A, LAYUN JL, MARIOT D, LOPEZ F, DE-ELIAS ME. IS THE ANATOMICAL SEQUENCE OF GASTRIC AND BILIARY ANASTOMOSIS IN THE PANCREATODUODENECTOMY RECONSTRUCTION THE CAUSE OF AN INCREASE IN THE INCIDENCE OF CHOLANGITIS? A TECHNICAL VARIANT PRESENTATION AND INITIAL RESULTS. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1688. [PMID: 36134820 PMCID: PMC9484826 DOI: 10.1590/0102-672020220002e1688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Several methods have been proposed for the reconstruction of digestive transit
after pancreatoduodenectomy. Biliary anastomosis positioned before gastric
anastomosis helps reduce postoperative reflux and cholangitis.
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Affiliation(s)
- Gustavo Adrian NARI
- Transito Caceres de Allende Hospital, Argentina; La Canada Sanatorium, Argentina
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24
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Fong ZV, Hashimoto DA, Jin G, Haynes AB, Perez N, Qadan M, Ferrone CR, Castillo CFD, Warshaw AL, Lillemoe KD, Traeger LN, Chang DC. Simulated Volume-Based Regionalization of Complex Procedures: Impact on Spatial Access to Care. Ann Surg 2021; 274:312-318. [PMID: 31449139 PMCID: PMC7032992 DOI: 10.1097/sla.0000000000003574] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study simulates the regionalization of pancreatectomies to assess its impact on spatial access in terms of patient driving times. BACKGROUND Although policies to regionalize complex procedures to high-volume centers may improve outcomes, the impact on patient access is unknown. METHODS Patients who underwent pancreatectomies from 2005 to 2014 were identified from California's statewide database. Round-trip driving times between patients' home ZIP code and hospital addresses were calculated via Google Maps. Regionalization was simulated by eliminating hospitals performing <20 pancreatectomies/yr, and reassigning patients to the next closest hospital that satisfied the volume threshold. Sensitivity analyses were performed for New York and Medicare patients to assess for influence of geography and insurance coverage, respectively. RESULTS Of 13,317 pancreatectomies, 6335 (47.6%) were performed by hospitals with <20 cases/yr. Patients traveled a median of 49.8 minutes [interquartile range (IQR) 30.8-96.2] per round-trip. A volume-restriction policy would increase median round-trip driving time by 24.1 minutes (IQR 4.5-53.5). Population in-hospital mortality rates were estimated to decrease from 6.7% to 2.8% (P < 0.001). Affected patients were more likely to be racial minorities (44.6% vs 36.5% of unaffected group, P < 0.001) and covered by Medicaid or uninsured (16.3% vs 9.8% of unaffected group, P < 0.001). Sensitivity analyses revealed a 17.8 minutes increment for patients in NY (IQR 0.8-47.4), and 27.0 minutes increment for Medicare patients (IQR 6.2-57.1). CONCLUSIONS A policy that limits access to low-volume pancreatectomy hospitals will increase round-trip driving time by 24 minutes, but up to 54 minutes for 25% of patients. Population mortality rates may improve by 1.5%.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Ginger Jin
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Alex B Haynes
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Numa Perez
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Lara N Traeger
- Behavioral Medicine Service, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Zheng X, Sun QJ, Zhou B, Jin M, Yan S. Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature. World J Clin Cases 2021; 9:4844-4851. [PMID: 34222457 PMCID: PMC8223850 DOI: 10.12998/wjcc.v9.i18.4844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.
CASE SUMMARY A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.
CONCLUSION Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.
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Affiliation(s)
- Xiang Zheng
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Qing-Jing Sun
- The Affiliated Hospital of Stomatology, School of Stomatology, Zhejiang University School of Medicine, and Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
| | - Bo Zhou
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Ming Jin
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Sheng Yan
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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Morrison ZD, van Steenburgh H, Gabel SA, Gabor R, Sharma R, Wernberg JA. Pancreaticoduodenectomy is safe in appropriately resourced rural hospitals. Surgery 2021; 170:1474-1480. [PMID: 34092374 DOI: 10.1016/j.surg.2021.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/25/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Research shows improved safety and treatment outcomes for patients undergoing pancreaticoduodenectomy at high-volume centers. Regionalization of pancreaticoduodenectomy to high-volume urban centers can result in unintended negative consequences for rural patients and communities. This report examines outcomes after pancreaticoduodenectomy performed at a rural hospital and compares them with national standards. METHODS A prospectively maintained database of pancreatic operations performed at a rural tertiary hospital was queried. Demographic and clinical information for patients undergoing pancreaticoduodenectomy (2007-2019) was analyzed. Primary outcomes were the rates of patient mortality and morbidity. Secondary outcomes were readmission rates, indications, and associations with clinical variables. RESULTS We included 118 patients in our study. There were 41 postoperative complications (34.7%), including 1 death (0.9%). The 90-day readmission rate was 24.6%. The most common indication for readmission was deep space infection (n = 7, 24.1%). Patients requiring an intraoperative transfusion were more likely to need hospital readmission (41.4% vs 9.0% of patients without transfusion, P = .016). Patients with postoperative complications required readmission more frequently (51.7% vs 29.2%, P = .093). These findings are similar to data from urban hospitals. CONCLUSION Patient safety and surgical outcomes after pancreaticoduodenectomy performed in appropriately resourced rural hospitals can be comparable with national standards. Safely treating rural patients near their home benefits patients and their communities.
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Affiliation(s)
- Zachary D Morrison
- Marshfield Clinic Health System-Marshfield Medical Center, Marshfield, WI.
| | | | | | - Rachel Gabor
- Marshfield Clinic Health System-Marshfield Clinic Research Institute, Marshfield, WI
| | - Rohit Sharma
- Marshfield Clinic Health System-Marshfield Medical Center, Marshfield, WI
| | - Jessica A Wernberg
- Marshfield Clinic Health System-Marshfield Medical Center, Marshfield, WI
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Finch LM, Baltatzis M, Byott S, Ganapathy AK, Kakani N, Lake E, Cadwallader R, Hazar C, Seriki D, Butterfield S, Jegatheeswaran S, Jamdar S, de Liguori Carino N, Siriwardena AK. Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage. ANNALS OF SURGERY OPEN 2021; 2:e038. [PMID: 37638254 PMCID: PMC10455063 DOI: 10.1097/as9.0000000000000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage. Methods This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage. Results Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days). Conclusions This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.
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Affiliation(s)
- Louise M. Finch
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Minas Baltatzis
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Sam Byott
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Nirmal Kakani
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Edward Lake
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Rosemary Cadwallader
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Can Hazar
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Dare Seriki
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Stephen Butterfield
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Santhalingam Jegatheeswaran
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Saurabh Jamdar
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Nicola de Liguori Carino
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ajith K. Siriwardena
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Kim DH, Yoon YS, Han HS, Cho JY, Lee JS, Lee B. Effect of Enhanced Recovery After Surgery program on hospital stay and 90-day readmission after pancreaticoduodenectomy: a single, tertiary center experience in Korea. Ann Surg Treat Res 2021; 100:76-85. [PMID: 33585352 PMCID: PMC7870429 DOI: 10.4174/astr.2021.100.2.76] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/15/2020] [Accepted: 11/08/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose Despite increasing number of reports on Enhanced Recovery After Surgery program (ERAS) and readmission after pancreaticoduodenectomy (PD) from Western countries, there are very few reports on this topic from Asian countries. This study aimed to evaluate the effects of ERAS on hospital stay and readmission and to identify reasons and risk factors for readmission after PD. Methods This retrospective cohort study included 670 patients who underwent open PD from January 2003 to December 2017. The patients were classified into ERAS (n = 352) and non-ERAS (n = 318) groups. Patients' characteristics, perioperative outcomes, and readmission rates were compared. Results There were no significant differences in the postoperative complication rates between the groups. The mean postoperative hospital stay was significantly shorter in the ERAS group (24.5 vs. 18.0 days, P < 0.001), but the 90-day readmission rate was similar in the 2 groups (9.1% vs. 8.5%, P = 0.785). Complications associated with pancreatic fistula (42.4%) were the most common cause for readmission. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05–3.24; P = 0.034), preoperative non-jaundice (OR, 0.45; 95% CI, 0.25–0.82; P = 0.009) and severe postoperative complications (OR, 4.12; 95% CI, 2.34–7.26; P < 0.001) were identified as risk factors for readmission. Conclusion The results confirmed that the ERAS program for PD was beneficial in reducing postoperative stay without increasing readmission risks. To decrease readmission rates, prudent discharge planning and medical support should be considered in patients who experience severe complications.
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Affiliation(s)
- Doo-Hun Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jai-Young Cho
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun-Seo Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Boram Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Bonds M, Garwe T, Rozich N, Oluborode B, Sarwar Z, Postier RG, Morris KT. Risk Factors Associated With Readmission After Pancreatectomy: A Single-Institution Retrospective Cohort Study. Am Surg 2021; 88:1104-1110. [PMID: 33517699 DOI: 10.1177/0003134820988824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pancreatectomy has a significant rate of procedure-specific morbidity which can result in readmission. Readmission has been proposed as a measure of quality. The goal of this study is to determine what factors are associated with readmission after pancreatectomy and whether readmission can be prevented. METHODS A retrospective review of a single institution's pancreatectomies between January 2011 and April 2015 was performed. Demographic, perioperative, and outpatient data were collected from the medical record. Primary outcome was 90-day readmission. Univariate and multivariable analyses were performed to determine which factors were associated with increased risk for readmission. RESULTS A total of 257 patients met inclusion criteria; the 90-day readmission rate was 32.7%. The median time to readmission was 13 days. Readmitted patients were more likely to have a postoperative pancreatic fistula (POPF) on univariate analysis. Surgical site infections were more common in readmitted patients (18% vs 6.4%, P = .0138). Upon multivariable adjustment, only POPF (P = .0005) remained significant. A positive dose-response relationship was noted between POPF grade and the odds of readmission with odds ratios (ORs) ranging from 1.6 (95% Confidence Interval (CI): .6-4.1) for grade A to 16.7 (95% CI: 1.8-156.8) for grade C, albeit with limited precision. CONCLUSIONS Readmission after pancreatectomy is a common occurrence despite the many advancements in perioperative care. Our data suggest that POPF is a risk factor for readmission after pancreatectomy. Presently, this factor is not clearly preventable. This suggests that readmission may not be the best measure of quality to utilize in the evaluation of pancreatic surgery.
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Affiliation(s)
- Morgan Bonds
- Department of General Surgery, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
| | - Tabitha Garwe
- Department of General Surgery, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA.,Department of Biostatistics and Epidemiology, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
| | - Noah Rozich
- Department of General Surgery, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
| | - Babawale Oluborode
- Department of Biostatistics and Epidemiology, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
| | - Zoona Sarwar
- Department of Biostatistics and Epidemiology, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
| | - Russell G Postier
- Department of General Surgery, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
| | - Katherine T Morris
- Department of General Surgery, 6186University of Oklahoma Health Science Center, Oklahoma, OK, USA
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Takeda Y, Saiura A, Inoue Y, Mise Y, Ishizawa T, Takahashi Y, Ito H. Early Fistulography Can Predict Whether Biochemical Leakage Develops to Clinically Relevant Postoperative Pancreatic Fistula. World J Surg 2020; 44:1252-1259. [PMID: 31820055 DOI: 10.1007/s00268-019-05315-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND As complete prevention of postoperative pancreatic fistula (POPF) after pancreatic surgery remains difficult, many risk factors for clinically relevant POPF (CR-POPF) have been reported. However, their clinical impact could be limited because all previous reports included patients without biochemical leakage (BL) that rarely developed to CR-POPF. Therefore, a new strategy for identifying high-risk patients who develop delayed complications from patients with confirmed BL and for implementing interventions for such patients in the early postoperative period is required. This study aimed to examine the role of fistulography in predicting CR-POPF from confirmed BL. METHODS Consecutive patients diagnosed with BL on postoperative day 3 after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from January 2013 to June 2015 in our institution were included. Fistulography was performed 1 week after the operation, and the associations between findings on fistulography and delayed complications associated with POPF were evaluated. RESULTS Eighty-four (37%) of 227 patients who underwent PD and 45 (48%) of 94 patients who underwent DP were included and divided to two groups according to fistulographic findings (simple type, n = 107, 83%; cavity type, n = 22, 17%). The latter finding was associated with a greater morbidity rate (Clavien-Dindo grade ≥ 2: 36% vs 59%, p = 0.018) and a worse final POPF grade (B/C 64% vs 95%, p = 0.003). In the multivariate analysis, cavity type on fistulography was a significant predictive factor for grade B/C POPF. CONCLUSIONS Fistulography is a useful examination for identifying patients with a high risk of developing delayed complications associated with POPF.
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Affiliation(s)
- Yoshinori Takeda
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akio Saiura
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan. .,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Yosuke Inoue
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Takeaki Ishizawa
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Hiromichi Ito
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
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Aguayo E, Antonios J, Sanaiha Y, Dobaria V, Kwon OJ, Sareh S, Benharash P, King JC. Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017. J Surg Res 2020; 255:517-524. [PMID: 32629334 DOI: 10.1016/j.jss.2020.05.084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/27/2020] [Accepted: 05/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD). MATERIALS AND METHODS We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality. RESULTS Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission. CONCLUSIONS Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.
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Affiliation(s)
- Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - James Antonios
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California; Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Oh Jin Kwon
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California; Department of Surgery, Harbor UCLA, Torrance, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, California
| | - Jonathan C King
- Department of Surgery, University of California Los Angeles, Los Angeles, California.
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Utsumi M, Aoki H, Nagahisa S, Nishimura S, Une Y, Kimura Y, Taniguchi F, Arata T, Katsuda K, Tanakaya K. Preoperative Nutritional Assessment Using the Controlling Nutritional Status Score to Predict Pancreatic Fistula After Pancreaticoduodenectomy. In Vivo 2020; 34:1931-1939. [PMID: 32606165 PMCID: PMC7439862 DOI: 10.21873/invivo.11990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023]
Abstract
UNLABELLED Backgound: This study aimed to determine the usefulness of the Controlling Nutritional Status (CONUT) scorescore for predicting postoperative pancreatic fistula (POPF). PATIENTS AND METHODS Data from 108 consecutive pancreaticoduodenectomy cases performed at the Surgery Department of Iwakuni Clinical Center, from April 2008 to May 2018, were included. Preoperative patient data and postoperative complication data were collected. RESULTS Of the 108 patients (male=65; female=43; mean age=70 years), 41 (37.9%) had indication for pancreaticoduodenectomy due to pancreatic carcinoma. Grade B or higher POPF was diagnosed in 32 patients (29.6%). In the multivariate analysis, body mass index ≥22 kg/m2 [odds ratio (OR)=5.24; p=0.005], CONUT score ≥4 (OR=3.28; p=0.042), non-pancreatic carcinoma (OR=47.17; p=0.001), and a low computed tomographic contrast attenuation value (late/early ratio) (OR=4.39; p=0.029) were independent risk factors for POPF. CONCLUSION Patients with high CONUT score are at high risk for POPF. Preoperative nutritional intervention such as immunonutrition might help reduce the POPF risk in these patients.
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Affiliation(s)
- Masashi Utsumi
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Seichi Nagahisa
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Seitaro Nishimura
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuta Une
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuji Kimura
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Takashi Arata
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Koh Katsuda
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
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Birgin E, Téoule P, Galata C, Rahbari NN, Reissfelder C. Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis. Pancreatology 2020; 20:736-745. [PMID: 32386969 DOI: 10.1016/j.pan.2020.04.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/10/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cholangitis is a serious biliary complication following biliary-enteric anastomosis (BEA). However, the rate of cholangitis in the postoperative period and its associated risk factors are inconclusive. The objective of this systematic review and meta-analysis was to assess the onset and risk factors of cholangitis after biliary-enteric reconstruction in literature. METHODS MEDLINE, EMBASE, and Cochrane databases were searched systematically to identify studies reporting about cholangitis following biliary-enteric anastomosis. Meta-analyses were performed for risk factors using random effects model with odds ratio (OR) and 95% confidence interval (95 %CI) as effect measures. Study quality was assessed by the MINORS (methodological index for non-randomized studies) criteria. RESULTS 28 studies involving 6904 patients were included in the study. The pooled rate for postoperative cholangitis (POC) was 10% (95 %CI: 8 %-13%) with studies reporting about an early- and late-onset of cholangitis. Male sex (OR 2.08; 95 %CI: 1.33-3.24; P = 0.001), postoperative hepatolithiasis (OR 137.19; 95 %CI: 29.00-648.97; P < 0.001) and postoperative anastomotic stricture (OR 178.29; 95 %CI: 68.64-463.11; P < 0.001) were associated with a higher risk of a late-onset of POC with a pooled rate of 8% (95 %CI: 6 %-11%) after a median time interval of 12 months. The quality of the included studies was low to moderate. CONCLUSION Cholangitis is a frequent complication after BEA. Consensus definition and prospective trials are required to assess optimal therapeutic strategies. We proposed a standardized definition and grading of POC to enable comparisons between future studies.
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Affiliation(s)
- Emrullah Birgin
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Patrick Téoule
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christian Galata
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Hue JJ, Navale S, Schiltz N, Koroukian SM, Ammori JB. Factors affecting readmission rates after pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:182-190. [PMID: 31957977 DOI: 10.1002/jhbp.706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pancreatectomy is a complex operation with a historic readmission rate of approximately 20%. Hospital readmissions lead to increased patient and health system costs, morbidity, and mortality making them a topic of great interest. The objective of this study was to identify factors associated with readmission after pancreatectomy in order to target areas for improvement. METHODS Pancreatectomy procedures for malignancy in adults from 2005 to 2011 were identified in the California State Inpatient Database. Descriptive analysis was conducted to evaluate the association between baseline variables and readmission status. Logistic regression models were developed to determine whether the bivariate associations identified persisted after adjusting for patient characteristics. RESULTS Of the 4262 patients who underwent a pancreatectomy, 843 (19.8%) were readmitted within 30 days. Readmission rates by year did not vary over the study period. Results from multivariable analysis showed that males, Hispanics, Medicare recipients, patients with an initial length of stay >11 days, patients who were discharged to a skilled nursing facility, and those with chronic anemia were more likely to be readmitted compared to those without these characteristics. The majority of readmissions occurred within 15 days after discharge. CONCLUSIONS Readmissions after pancreatectomy are multifactorial. Preoperative optimization, minimizing postoperative complications, and assuring patients have been evaluated by a multidisciplinary team may reduce the readmission rate.
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Affiliation(s)
- Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Suparna Navale
- Department of Population and Quantitative Health Sciences, School of Medicine, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Nicholas Schiltz
- Department of Population and Quantitative Health Sciences, School of Medicine, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, OH, USA
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Simpson RE, Wang CY, House MG, Zyromski NJ, Schmidt CM, Nakeeb A, Ceppa EP. Travel distance affects rates and reasons for inpatient visits after pancreatectomy. HPB (Oxford) 2019; 21:818-826. [PMID: 30595461 DOI: 10.1016/j.hpb.2018.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/10/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Centralization of complex surgical care leads to increased travel distances for patients. We sought to determine if increased travel distance to the index hospital altered inpatient Visit rates following pancreatectomy. METHODS Pancreatectomies from 2013-2016 were reviewed retrospectively from a single high-volume institution. Travel distance for 936 patients was determined, and patients were grouped by 50-mile increments. Visits (Observations or Readmissions) and corresponding reasons were gathered. RESULTS 222 patients (23.7%) had a Visit to any hospital (AH) within 90 days postoperative; 195 (87.8%) were to the index hospital (IH). The <50 miles group had the highest Visit rate to AH (28.6% vs. 17.8% vs. 24.6%; P = 0.008) and the IH (26.9% vs. 15.2% vs. 20.6%; P = 0.002) compared to 50-100 and > 100 miles. This trend was statistically significant for Observations, but not Readmissions. Gastrointestinal (GI) complaints alone led to 20.7% patients requiring Visits to AH at 90-days, mostly in <50miles group for Visits and Observations at AH and IH. CONCLUSIONS Patients closest to the IH had the highest Visit and Observation rate following pancreatectomy without affecting Readmission rate, with GI complaints as a driving factor. Inpatient education and outpatient symptom management may reduce repeat hospitalization.
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Affiliation(s)
- Rachel E Simpson
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Christine Y Wang
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Michael G House
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN, 46202, USA.
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Sham JG, Gage MM, He J. Contemporary issues in the surgical management of pancreatic neuroendocrine tumours. SURGICAL PRACTICE 2019. [DOI: 10.1111/1744-1633.12349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jonathan G. Sham
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| | - Michele M. Gage
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
| | - Jin He
- Department of SurgeryJohns Hopkins Hospital Baltimore Maryland USA
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Mackay TM, Wellner UF, van Rijssen LB, Stoop TF, Busch OR, Groot Koerkamp B, Bausch D, Petrova E, Besselink MG, Keck T, van Santvoort HC, Molenaar IQ, Kok N, Festen S, van Eijck CHJ, Bonsing BA, Erdmann J, de Hingh I, Buhr HJ, Klinger C. Variation in pancreatoduodenectomy as delivered in two national audits. Br J Surg 2019; 106:747-755. [DOI: 10.1002/bjs.11085] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
AbstractBackgroundNationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.MethodsAnonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.ResultsOverall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P < 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.ConclusionThis comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.
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Affiliation(s)
- T M Mackay
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - U F Wellner
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - L B van Rijssen
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - T F Stoop
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - D Bausch
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - E Petrova
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - T Keck
- German Society for General and Visceral Surgery StuDoQ|Pancreas and Clinic of Surgery, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - H C van Santvoort
- Sint Antonius Hospital, Nieuwegein
- University Medical Centre Utrecht, Utrecht
| | - I Q Molenaar
- Sint Antonius Hospital, Nieuwegein
- University Medical Centre Utrecht, Utrecht
| | - N Kok
- Antoni van Leeuwenhoek Hospital, Amsterdam
| | | | | | | | - J Erdmann
- Leiden University Medical Centre, Leiden
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Idrees JJ, Rosinski BF, Merath K, Chen Q, Bagante F, Pawlik TM. Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database. HPB (Oxford) 2019; 21:291-300. [PMID: 30201297 DOI: 10.1016/j.hpb.2018.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/22/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Objectives were to determine the causes of readmission and assess the cost-effectiveness of high (HQ) and low quality (LQ) hospitals in performing pancreatic resection, by using readmission rates as the measure of quality. METHODS We identified 53,572 pancreatic resection cases from National Readmission Database from 2010 through 2014. Hospitals were risk adjusted and ranked based on readmission. Top 20% HQ hospitals having the lowest readmission rates were compared to the bottom 20% LQ hospitals with the highest readmission rates. RESULTS The 90-day readmission rate was 27.2% (HQ: 25.7%, LQ: 30.9%, p < 0.001). Compared to LQ, HQ hospitals had lower mortality (2.1% vs 10.2%, p < 0.001) and major complication (10.5% vs 53%, p < 0.001). Major complication during index operation was a major predictor of readmission (RR: 1.6, 95% CI: 1.6-1.7, p < 0.001). The optimal cut point of hospital volume associated with low mortality was 70 or more cases/year. Per year of survival benefit at HQ hospitals, the costs were lower by $9,293 with cost-savings of $6.98 million/year. CONCLUSION HQ hospitals were cost-effective at performing pancreatic resection and achieved substantial cost-savings by avoiding major complications during index operation and having lower rates of readmissions. Hospital readmission rate is a strong marker of quality of care.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Brad F Rosinski
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Fernández Del Castillo C. Safe surgery for cystic tumors of the pancreas. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:85-86. [PMID: 30746958 DOI: 10.17235/reed.2019.6042/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cystic tumors of the pancreas are a common indication for pancreatic surgery, and many of them are incidentally-discovered. Some of these tumors are malignant, and many others are pre-malignant. Less than two generations ago, pancreatic surgery was risky business. Surgical mortality, even in some of the best institutions in the world, was about 25%. Complications were very common and not infrequently patients required reoperations and had to remain in the hospital for weeks or even months. They emerged from this highly debilitated, and often went on to have a very poor quality of life. Not surprisingly, for these reasons, pancreatic resection was used only as a "last resort", and mostly for cancer.
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Boteon APCS, Boteon YL, Hodson J, Osborne H, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts JK, Sutcliffe RP. Multivariable analysis of predictors of unplanned hospital readmission after pancreaticoduodenectomy: development of a validated risk score. HPB (Oxford) 2019; 21:26-33. [PMID: 30049642 DOI: 10.1016/j.hpb.2018.06.1802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/20/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unplanned hospital readmission after pancreaticoduodenectomy (PD) is usually due to surgical complications and has significant clinical and economic impact. This study developed a risk score to predict 30-day readmission after PD. METHODS Patients undergoing PD between 2009 and 2016 were reviewed from a prospective database. Predictors of readmission were identified using a multivariable logistic regression model, from which a points-based risk scoring system was derived. RESULTS 81 of 518 patients (15.6%) were readmitted within 30 days. History of cardiac disease ([odds ratio] OR = 2.12; 95% CI: 1.12-4.56), CRP>140 mg/L on post-operative day 3 (OR = 2.34; 95% CI: 1.37-4.35) and comprehensive complication index >14 (OR = 1.74; 95% CI: 1.03-2.85) were independent predictors of readmission. The regression coefficients were used to generate a risk score with excellent calibration (p = 0.917) and good discrimination (c-index = 0.65; 95% CI: 0.58-0.71; p < 0.001). Patients were categorised as low, moderate and high risk, with readmission rates of 6.4%, 13.4% and 23.0% respectively (p < 0.001). CONCLUSION The risk score identifies patients at high risk of readmission after pancreaticoduodenectomy. Such patients may benefit from pre-discharge imaging and/or enhanced follow-up, which may potentially reduce the impact of readmissions.
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Affiliation(s)
- Amanda P C S Boteon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Yuri L Boteon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - James Hodson
- Medical Statistics, Institute of Translational Medicine, University Hospitals Birmingham, UK
| | - Helen Osborne
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - John Isaac
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Ravi Marudanayagam
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Darius F Mirza
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - John K Roberts
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK
| | - Robert P Sutcliffe
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK.
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Mahvi DA, Pak LM, Urman RD, Gold JS, Whang EE. Discharge destination following pancreaticoduodenectomy: A NSQIP analysis of predictive factors and post-discharge outcomes. Am J Surg 2018; 218:342-348. [PMID: 30553461 DOI: 10.1016/j.amjsurg.2018.11.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Pancreaticoduodenectomy is a complex surgical procedure. The purpose of this study was to identify factors associated non-home discharge destination and to characterize outcomes after non-home discharge. METHODS 10,719 pancreaticoduodenectomy cases contained in the National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset (years 2014-2016) were examined with univariate and multivariate logistic regression. RESULTS 1336 patients (12.5%) were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors significantly associated with non-home discharge on multivariate analysis were female gender, older age, elevated BMI, poor functional status or dyspnea, smoking, low albumin, COPD, and ascites. Intraoperative factors significantly associated with non-home discharge destination on multivariate analysis were longer operative time, open surgery, softer pancreatic texture, drain placement, and jejunostomy tube placement. A nomogram was generated for estimating probability of non-home discharge immediately after surgery. CONCLUSION Preoperative and intraoperative factors can be used to predict probability of non-home discharge immediately after completion of pancreaticoduodenectomy.
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Affiliation(s)
- David A Mahvi
- Department of Surgery, Brigham and Women's Hospital/ Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Linda M Pak
- Department of Surgery, Brigham and Women's Hospital/ Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
| | - Jason S Gold
- Department of Surgery, Brigham and Women's Hospital/ Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA; Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA.
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital/ Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA; Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA.
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Winer LK, Dhar VK, Wima K, Lee TC, Morris MC, Shah SA, Ahmad SA, Patel SH. Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:1743-1751. [PMID: 29869090 DOI: 10.1007/s11605-018-3813-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Our goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHODS Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance. RESULTS POPF was identified in 17.3% of patients (n = 18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p = 0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03-1.55, p = 0.03). CONCLUSION High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.
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Affiliation(s)
- Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA.
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Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. PLoS One 2018; 13:e0203841. [PMID: 30212577 PMCID: PMC6136772 DOI: 10.1371/journal.pone.0203841] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. METHODS All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. RESULTS A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001). CONCLUSIONS Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.
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Affiliation(s)
- Allison N. Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
| | - Todd W. Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Reid B. Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
- * E-mail:
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Marchegiani G, Andrianello S, Pieretti-Vanmarcke R, Malleo G, Marchese T, Panzeri F, Fernandez-Del Castillo C, Lillemoe KD, Bassi C, Salvia R, Ferrone CR. Hospital readmission after distal pancreatectomy is predicted by specific intra- and post-operative factors. Am J Surg 2018; 216:511-517. [DOI: 10.1016/j.amjsurg.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/30/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022]
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Howard JD, Ising MS, Delisle ME, Martin RCG. Hospital readmission after pancreaticoduodenectomy: A systematic review and meta-analysis. Am J Surg 2018; 217:156-162. [PMID: 30017309 DOI: 10.1016/j.amjsurg.2018.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Appropriate postoperative readmission rates and modifiable risk factors for readmission have yet to be defined for many operations. This systematic review and meta-analysis attempt to define these parameters for pancreaticoduodenectomy. MATERIALS AND METHODS The main outcomes were readmission rate, risk factors, and reasons for readmission. Meta-analyses were performed when data was homogeneous, otherwise, a qualitative review was performed. RESULTS The 30-day, 90-day, and overall readmission rates were 17.63%, 26.14%, and 27.18%, respectively. In the meta-analysis, chronic pancreatitis (OR, 1.44, p = 0.04), operative length (MD, 26.1; p < 0.01), wound infection (OR, 1.9, p < 0.01), intra-abdominal abscess (OR, 3.79, p < 0.01), VTE (OR, 2.27, p = 0.01), and LOS (MD, 1.66, p < 0.01) where associated with readmission. CONCLUSION Hospital readmission will continue to be a quality metric and will influence reimbursement models. Thirty and 60-day readmission data underestimate the true readmission rate. Chronic pancreatitis, operative length, and several post-operative complications were associated with greater readmission. More uniform reporting is necessary to identify modifiable risk factors associated with readmission.
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Affiliation(s)
- Jeffrey D Howard
- University of Louisville, Hiram C. Polk Dept. of Surgery, Louisville, KY, 40202, United States.
| | - Mickey S Ising
- University of Louisville, Hiram C. Polk Dept. of Surgery, Louisville, KY, 40202, United States.
| | - Megan E Delisle
- University of Manitoba, Dept. of Surgery, 2009-311 Hargrave St, Winnipeg, MB, R3B 0V8, Canada.
| | - Robert C G Martin
- University of Louisville, Hiram C. Polk Dept. of Surgery, Louisville, KY, 40202, United States.
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Mazmudar A, Castle J, Yang AD, Bentrem DJ. The association of length of hospital stay with readmission after elective pancreatic resection. J Surg Oncol 2018; 118:7-14. [DOI: 10.1002/jso.25093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/16/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Aditya Mazmudar
- Department of Surgery; Feinberg School of Medicine; Northwestern University; Chicago Illinois
| | - Joshua Castle
- Department of Surgery; Feinberg School of Medicine; Northwestern University; Chicago Illinois
| | - Anthony D. Yang
- Department of Surgery; Feinberg School of Medicine; Northwestern University; Chicago Illinois
| | - David J. Bentrem
- Department of Surgery; Feinberg School of Medicine; Northwestern University; Chicago Illinois
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Ramanathan R, Mason T, Wolfe LG, Kaplan BJ. Predictors of Short-Term Readmission After Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:998-1006. [PMID: 29404986 DOI: 10.1007/s11605-018-3700-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Readmissions are a common complication after pancreaticoduodenectomy and are increasingly being used as a performance metric affecting quality assessment, public reporting, and reimbursement. This study aims to identify general and pancreatectomy-specific factors contributing to 30-day readmission after pancreaticoduodenectomy, and determine the additive value of incorporating pancreatectomy-specific factors into a large national dataset. METHODS Prospective American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) data were retrospectively analyzed for patients who underwent pancreaticoduodenectomy (PD) between 2011 and 2015. Additionally, a subset of patients with pancreatectomy-targeted data between 2014 and 2015 were analyzed. RESULTS Outcomes of 18,440 pancreaticoduodenectomies were analyzed, and found to have an 18.7% overall readmission rate. Multivariable modeling with pancreatectomy-specific variables increased the predictive value of the model (area under receiver operator characteristic 0.66 to 0.73). Statistically significant independent contributors to readmission included renal insufficiency, sepsis, septic shock, organ space infection, dehiscence, venous thromboembolism, pancreatic fistula, delayed gastric emptying, need for percutaneous drainage, and reoperation. CONCLUSIONS Large registry analyses of pancreatectomy outcomes are markedly improved by the incorporation of granular procedure-specific data. These data emphasize the need for prevention and careful management of perioperative infectious complications, fluid management, thromboprophylaxis, and pancreatic fistulae.
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Affiliation(s)
- Rajesh Ramanathan
- Department of Surgery, Virginia Commonwealth University, 1200 E. Broad St, PO Box 980011, Richmond, VA, 23298, USA.,Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Travis Mason
- Department of Surgery, Virginia Commonwealth University, 1200 E. Broad St, PO Box 980011, Richmond, VA, 23298, USA
| | - Luke G Wolfe
- Department of Surgery, Virginia Commonwealth University, 1200 E. Broad St, PO Box 980011, Richmond, VA, 23298, USA
| | - Brian J Kaplan
- Department of Surgery, Virginia Commonwealth University, 1200 E. Broad St, PO Box 980011, Richmond, VA, 23298, USA.
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C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:818-830. [PMID: 29327310 DOI: 10.1007/s11605-017-3658-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 12/11/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications. METHODS Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis. RESULTS Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter < 3 mm and serum C-reactive protein ≥ 100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p < 0.01) and pancreatic fistula (p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62-0.82, p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01). CONCLUSIONS C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.
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Sallinen VJ, Le Large TYS, Tieftrunk E, Galeev S, Kovalenko Z, Haugvik SP, Antila A, Franklin O, Martinez-Moneo E, Robinson SM, Panzuto F, Regenet N, Muffatti F, Partelli S, Wiese D, Ruszniewski P, Dousset B, Edwin B, Bartsch DK, Sauvanet A, Falconi M, Ceyhan GO, Gaujoux S. Prognosis of sporadic resected small (≤2 cm) nonfunctional pancreatic neuroendocrine tumors - a multi-institutional study. HPB (Oxford) 2018; 20:251-259. [PMID: 28988702 DOI: 10.1016/j.hpb.2017.08.034] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 07/30/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malignant potential of small (≤20 mm) nonfunctional pancreatic neuroendocrine tumors (sNF-PNET) is difficult to predict and management remain controversial. The aim of this study was to assess the prognosis of sporadic nonmetastatic sNF-PNETs. METHODS Patients were identified from databases of 16 centers. Outcomes and risk factors for recurrence were identified by uni- and multivariate analyses. RESULTS sNF-PNET was resected in 210 patients, and 66% (n = 138) were asymptomatic. Median age was 60 years, median tumor size was 15 mm, parenchyma-sparing surgery was performed in 42%. Postoperative mortality was 0.5% (n = 1), severe morbidity rate was 14.3% (n = 30), and 14 of 132 patients (10.6%) with harvested lymph nodes had metastatic lymph nodes. Tumor size, presence of biliary or pancreatic duct dilatation, and WHO grade 2-3 were independently associated with recurrence. Patients with tumors sized ≤10 mm were disease free at last follow-up. The 1-, 3- and 5-year disease-free survival rates for patients with tumors sized 11-20 mm on preoperative imaging were 95.1%, 91.0%, and 87.3%, respectively. CONCLUSIONS In sNF-PNETs, the presence of biliary or pancreatic duct dilatation or WHO grade 2-3 advocate for surgical treatment. In the remaining patients, a wait-and-see policy might be considered.
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Affiliation(s)
- Ville J Sallinen
- Department of Abdominal Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Tessa Y S Le Large
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Elke Tieftrunk
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Shamil Galeev
- General Surgery Department, Saint Luke's Clinical Hospital, Saint Petersburg, Russia
| | - Zahar Kovalenko
- Federal Medical and Rehabilitation Center, Department of Surgical Oncology, Moscow, Russia
| | - Sven-Petter Haugvik
- The Intervention Center, Oslo University Hospital, Oslo, Norway; Department of Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Oskar Franklin
- Department of Surgical and Perioperative Sciences, Umea University, Umea, Sweden
| | - Emma Martinez-Moneo
- Gastroenterology Department, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
| | - Stuart M Robinson
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Francesco Panzuto
- Digestive and Liver Disease Unit, Sant'Andrea Hospital - Sapienza University of Rome, Italy
| | - Nicolas Regenet
- Department of Digestive and Endocrine Surgery, Institut des Maladies Digestives (IMAD), Nantes 44093, France
| | - Francesca Muffatti
- Chirurgia Del Pancreas, Chirurgia Del Pancreas, Pancreas Translational & Clinical Research Center, Università Vita e Salute, Ospedale San Raffaele IRCC, Milano, Italy
| | - Stefano Partelli
- Chirurgia Del Pancreas, Chirurgia Del Pancreas, Pancreas Translational & Clinical Research Center, Università Vita e Salute, Ospedale San Raffaele IRCC, Milano, Italy
| | - Dominik Wiese
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Philippe Ruszniewski
- Department of Gastroenterology, Pôle des Maladies de L'Appareil Digestif (PMAD), DHU Unity, Clichy 92110, France; Université Paris Diderot, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Pancreatic and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Oslo, Norway; Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Alain Sauvanet
- Université Paris Diderot, Paris, France; AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de L'Appareil Digestif (PMAD), DHU Unity, University Paris VII, AP-HP, Hôpital Beaujon, Clichy 92110, France
| | - Massimo Falconi
- Chirurgia Del Pancreas, Chirurgia Del Pancreas, Pancreas Translational & Clinical Research Center, Università Vita e Salute, Ospedale San Raffaele IRCC, Milano, Italy
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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