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Background: The long-term efficacy of laparoscopic pancreaticoduodenectomy (LPD) relative to open pancreaticoduodenectomy (OPD) for pancreatic adenocarcinoma has not been well studied., Methods: The National Cancer Data Base was used to compare patients undergoing LPD and OPD for stage I-II pancreatic adenocarcinoma between 2010 and 2013., Results: 828 (10%) patients underwent LPD and 7385 (90%) OPD. There were no differences in tumor or demographic characteristics between groups. On multivariable analysis adjusted for hospital volume, LPD was associated with a lower rate of readmission (p < 0.01) and trends toward shorter initial length of stay (p = 0.14) and time to adjuvant chemotherapy (p = 0.11). There were no differences between patients undergoing LPD and those undergoing OP in rates of margin negative resection, number of lymph nodes examined, perioperative mortality and median overall survival (20.7 vs 20.9 months, p = 0.68)., Conclusions: For patients with localized pancreatic adenocarcinoma, LPD provides short-term oncologic and long-term overall survival outcomes identical to OPD and is associated with decreased rates of readmission and a trend towards accelerated recovery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Neoadjuvant protocols for early stage pancreatic adenocarcinoma (PDAC) frequently involve external beam radiation used in combination with systemic chemotherapy. The benefit of radiation in these protocols has not been determined., Methods: We examined patients with stage I and II PDAC within the National Cancer Data Base between 2006 and 2012. Propensity score matching was used to compare patients receiving neoadjuvant chemotherapy including radiation (NCRT) to those receiving neoadjuvant chemotherapy without radiation (NCT) prior to pancreaticoduodenectomy., Results: Prior to matching, NCRT patients had higher rates of T3 tumors (P = 0.046) and vascular abutment (P < 0.001). Propensity score matching (1:1) yielded 397 patients per group. Patients treated with NCRT were more likely to have node negative resections (P < 0.001) but had increased rates of 90-day mortality (P = 0.015) and demonstrated a trend towards shorter overall survival (P = 0.0502) than those receiving NCT., Conclusion: In early stage PDAC, the addition of radiation to NCT is often utilized with more advanced disease and is associated with higher perioperative mortality and no long-term overall survival benefit., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The oncologic equivalence of laparoscopic distal pancreatectomy (LDP) to open pancreatectomy (ODP) for ductal adenocarcinoma (DAC) is not established., Methods: The National Cancer Data Base was used to compare perioperative outcomes following LDP and ODP for DAC between 2010 and 2011., Results: One hundred forty-five patients underwent LDP; 625 underwent ODP. Compared with ODP, patients undergoing LDP were older (68 ± 10.1 vs 66 ± 10.5 years, P = .027), more likely treated in academic centers (70% vs 59%, P = .01), and had shorter hospital stays (6.8 ± 4.6 vs 8.9 ± 7.5 days, P < .001). Demographic data, lymph node count, 30-day unplanned readmission, and 30-day mortality were identical between groups. Multivariable regression identified a lower probability of prolonged length of stay with LDP (odds ratio .51, 95% confidence interval .327 to .785, P = .0023). There was no association between surgical approach and node count, readmission, or mortality., Conclusion: LDP for DAC provides shorter postoperative lengths of stay and rates of readmission and 30-day mortality similar to OPD without compromising perioperative oncologic outcomes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Published comparisons of laparoscopic (laparoscopic distal pancreatectomy [LDP]) to open distal pancreatectomy (ODP) identify improved lengths of stay (LOS) after LDP but do not include data on readmissions., Methods: Demographic, operative, and postoperative outcomes data for patients undergoing LDP or ODP between August 2007 and December 2009 were culled from our prospectively accruing pancreatic database. Electronic medical records were reviewed to determine cause, treatment, and LOS for readmissions., Results: Patients undergoing LDP were statistically identical to those undergoing ODP in regard to age, presentation, demographic characteristics, comorbidities, operative times, tumor sizes, morbidity, mortality, and pancreatic fistula rates. The initial LOS was statistically shorter for those undergoing LDP (4.8 ± .1 days vs 8.7 ± .1 days, P < .001). The readmission rate for LDP was statistically higher than for ODP (25% vs 8%, P < .05). Overall LOS for LDP was 7.2 ± .3 days versus 9.3 ± .1 days for ODP (P = .2)., Conclusions: Adding readmission LOS to initial LOS eliminates the perceived effect of LDP to accelerate recovery., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The US Department of Veterans Affairs (VA) Office of Quality and Performance's July 2009 report detailed the quality of VA colorectal cancer (CRC) care on the basis of 10 quality indicators (QIs). Of 21 Veterans Integrated Service Networks (VISNs), the authors' VISN ranked last or near last on more than half of the QIs. The aim of this study was to compare a national-level assessment of performance with an institutional-level clinical review., Methods: The authors reabstracted all patients seen at surgical hospitals within their VISN during the time period of the Office of Quality and Performance report and reanalyzed their performance on the 10 QIs. A number of quality improvement efforts were also implemented to further boost performance, including the creation of a computerized patient record system CRC order set and quarterly surveillance meetings., Results: After reanalysis of the VISN's QI performance for CRC patients during the time period of the OQP report, the VISN performed 18% better than reported and 2% better than the national average. Since that time, a multidisciplinary CRC committee has implemented quality improvement measures that have further improved QI performance., Conclusions: There is variability between administrative quality assessments and clinically abstracted data. Care must be taken when analyzing QIs at the national level., (Published by Elsevier Inc.)

Introduction: The pancreatic remnant remains a significant source of morbidity during laparoscopic pancreatectomy. Previous series have relied heavily on the endoscopic stapler for transection. Our study is the first to report use of a laparoscopic radiofrequency device for pancreatic transection., Methods: The laparoscopic Habib 4x delivers high-energy radio waves through a hand-held device consisting of 4 electrodes and allows for bloodless tissue transection. We retrospectively evaluated prospectively collected data. Fourteen patients were identified and used in our analysis., Results: There were no conversions, blood transfusions, reoperations, or mortalities. Average length of stay was 4.6 days. There was 1 readmission. Clinically significant fistula occurred in 2 patients (14%), only one of which required an intervention., Conclusion: Radiofrequency energy is safe and feasible for use during laparoscopic pancreatic transection. Moreover, it is technically simple to use., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: The development of upper gastrointestinal malignancies after bariatric surgery has not been well characterized. Our objective was to review the experience of patients with distal esophageal cancer that was diagnosed after bariatric surgery., Methods: A retrospective review was conducted to identify patients who had undergone bariatric surgery (1999 to 2006) and who later developed high-grade dysplasia or adenocarcinoma of the distal esophagus., Results: Three patients (of 2,875 [0.1%]) developed esophageal cancer: 2 after Roux-en-Y gastric bypass and 1 after vertical banded gastroplasty. All three patients had complaints of reflux, and two were treated with esophagectomy. The third patient presented with invasive carcinoma and died 2 years after diagnosis., Conclusions: Our findings emphasize the importance of precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease (GERD), of the necessity for continuing postsurgical surveillance in patients with known Barrett's esophagitis, and of early evaluation in patients who develop new symptoms of GERD after bariatric surgery.

Background: National efforts are underway to monitor the quality of patient care at Veterans Administration (VA) hospitals. The objective of this study was to examine treatment utilization and outcomes for localized pancreatic cancer at VA compared with non-VA hospitals., Methods: Using the National Cancer Data Base, patients with pretreatment clinical stage I/II pancreatic adenocarcinoma were identified. Treatment utilization and outcomes were assessed at VA compared with academic and community hospitals., Results: Of 35,009 patients, 2% were seen at VA, 38% at academic, and 54% at community hospitals. VA hospitals were more likely to use surgery (odds ratio 2.20, 95% confidence interval 1.73-2.79) and to administer adjuvant chemotherapy (odds ratio 1.77, confidence interval 1.28-2.46) compared with community hospitals. Adjusted perioperative mortality and 3-year survival rates after surgery were similar at VA and academic hospitals., Conclusions: For localized pancreatic cancer, patients treated at VA hospitals receive stage-specific treatments and have risk-adjusted perioperative and long-term survival rates that are comparable with those for patients treated at academic centers.

Background: The Patient Self-Determination Act requires that patients entering hospitals be asked if they have an advance directive. This has led to increased awareness of advance directives, yet surgeons have paid little attention to their use among patients undergoing even major surgery. We sought to evaluate the use of advance directives in patients undergoing pancreaticoduodenectomy and esophagectomy., Methods: Patients undergoing these operations between 1996 and 2001 at a university teaching hospital were identified and reviewed for statement of advance directive, its presence in the chart, and impact on patient care., Results: A total of 252 patients met inclusion criteria. The number of patients with an advance directive increased, but had little impact on patient care., Conclusions: More patients having major surgery have advance directives, but the number present in the medical record remains low. Further attention to advance directives would foster increased communication between surgeons and patients and extend patient autonomy.

Background: The availability of laparoscopic adrenalectomy led us to review our experience and management of adrenal and extraadrenal pheochromocytoma., Methods: Seventeen patients undergoing pheochromocytoma resection from January 1997 to August 2001 were categorized as open, laparoscopic, or laparoscopic assisted depending on the surgical approach. Hospital records were reviewed., Results: There was no significant difference between the groups in patient age, weight or preoperative blockade. Operative times for open, laparoscopic, and laparoscopic assisted adrenalectomies were 202, 218, and 260 minutes, respectively. Estimated blood loss was 562 cc, 187 cc, and 925 cc. The average hospital length of stay was 6.2, 3.0, and 5.8 days., Conclusions: Laparoscopic removal resulted in longer operative times than open, but less operative blood loss and a shorter hospital stay. The laparoscopic assisted approach did not save time nor did it lead to earlier discharge. Laparoscopic adrenalectomy was comparable to the open approach, and is preferential in tumors less than 6 cm. An open approach remains our choice for larger or extraadrenal tumors.