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Background: Although frailty is a known determinant of poor postoperative outcomes, it can be difficult to identify in patients before surgery. The authors sought to develop a preoperative frailty risk model to predict mortality among patients aged 65 years or more., Methods: Clinical and morphometric data including total psoas area (TPA), total psoas volume (TPV) and psoas density (Hounsfield unit average calculation, HUAC) were collected for patients undergoing hepatopancreaticobiliary (HPB) surgery between 2012 and 2014. Multivariable Cox proportional hazards regression was used to identify preoperative risk factors associated with 1-year mortality., Results: The median age of the 518 patients included in the study was 72 (i.q.r. 68-76) years; 55·6 per cent of patients were men, and half of the cohort had multiple co-morbidities (Charlson co-morbidity index (CCI) of 4 or more, 55·6 per cent). TPA cut-offs to define sarcopenia were 552·7 mm(2) /m(2) in women and 702·9 mm(2) /m(2) in men; cut-offs for TPV were 18·2 cm(3) /m(2) in women and 26·2 cm(3) /m(2) in men, whereas HUAC cut-offs were 31·1 HU in women and 33·3 HU in men. The overall 1-year mortality rate was 14·1 per cent. In multivariable analysis, risk factors associated with 1-year mortality included CCI of 4 or above (hazard ratio (HR) 2·91, 95 per cent c.i. 1·47 to 5·77; P = 0·002), malignant disease (HR 3·94, 1·17 to 13·30; P = 0·027) and sarcopenia by HUAC (HR 1·85, 1·10 to 3·10; P = 0·021). A weighted 25-point composite score was developed to stratify patients at risk of 1-year postoperative mortality. The 1-year mortality rate was noted to be 2·5 per cent among patients scoring 0-10 (low risk), 17·3 per cent among patients scoring 11-20 (intermediate risk) and 29·2 per cent among those scoring between 21 and 25 (high risk) (P < 0·001)., Conclusion: Clinical and morphometric measures of frailty accurately predict the risk of 1-year mortality following HPB surgery in elderly patients, and can be used to risk-stratify patients appropriately., (© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Objectives: The management of patients with colorectal cancer (CRC) and synchronous colorectal liver metastasis (CLM) remains controversial. The present study was conducted in order to assess the clinical and economic impacts of managing synchronous CLM with a staged versus a simultaneous surgery approach., Methods: A total of 224 patients treated for synchronous CLM during 1990-2012 were identified in the Johns Hopkins Hospital liver database. Data on clinicopathological features, perioperative outcomes and total hospital charges (inflation-adjusted) were collected and analysed., Results: Overall, 113 (50.4%) patients underwent staged surgery and 111 (49.6%) were submitted to a simultaneous CRC and liver operation. At surgery, liver-directed therapy included hepatectomy (75.0%) or combined resection and ablation (25.0%). Perioperative morbidity (30.0%) and mortality (1.3%) did not differ between groups (both P > 0.05). Median total length of hospitalization was longer in the staged (13 days) than the simultaneous (7 days) surgery group (P < 0.001). Median total hospital charges were higher among patients undergoing staged surgery (US$61,938) than among those undergoing a simultaneous operation (US$34,114) (P < 0.01). Median (simultaneous, 32.4 months versus staged, 39.6 months; P = 0.65) and 5-year (simultaneous, 27% versus staged, 29%; P = 0.60) overall survival were similar between groups., Conclusions: Patients with synchronous CLM managed with either simultaneous or staged surgery have comparable perioperative and longterm outcomes. However, patients treated with simultaneous surgery spent an average of 6 days fewer in hospital, resulting in a reduction of median hospital charges of US$27,824 (55.1%). When appropriate and technically feasible, the simultaneous surgery approach to synchronous CLM should be preferred., (© 2014 International Hepato-Pancreato-Biliary Association.)

Background: Reducing readmission is a key quality improvement target for policymakers. The purpose of the present study was to define incidence and identify factors associated with readmission after a hepatic resection., Methods: Thirty-day readmission after discharge and factors associated with a higher risk of readmission were examined among patients undergoing a hepatic resection at Johns Hopkins Hospital between 2008 and 2012., Results: Among the 338 patients, the median age was 57.9 years and 173 (51.2%) were men. Indications for surgery included colorectal cancer liver metastasis (38.2%), primary hepatic tumours (25.7%) and benign disease (3.3%). Surgical resection consisted of less than a hemi-hepatectomy in the majority of patients (n = 224, 66.3%). The median index hospitalization length-of-stay (LOS) was 5 days; 68.7% patients experienced at least one inpatient complication. Overall 30-day readmission was 14.2% (n = 48). The majority of readmitted patients (n = 46, 95.8%) had a complication prior to readmission. The median LOS for readmission was 4 [interquartile range (IQR) 2-6] days. On multivariable analysis, the strongest independent predictor of readmission was the presence of a major complication [odds ratio (OR) 5.30, 95% confidence interval (CI) 2.38-11.78, P < 0.001]., Conclusions: Readmission after a hepatic resection occurs in approximately one out of every seven patients. Patients who experience a post-operative complication are greater than five times more likely to be readmitted. Prospective studies are needed to evaluate methods to reduce unplanned readmissions., (© 2014 International Hepato-Pancreato-Biliary Association.)

Objective: This study was carried out to determine relative survival rates and trends in outcomes in patients who underwent resection of periampullary adenocarcinomas (PACs) with curative intent at a single institution over the last three decades., Methods: From 1980 to 2011, 2564 pancreaticoduodenectomies (PDs) were performed for PACs. Pathological diagnosis, therapy and survival were retrospectively analysed., Results: The primary sites included the pancreas (66%), ampulla (16%), bile duct (12%) and duodenum (6%). Operation volume increased from 11 per year in the 1980s to 135 per year in the 2000s (P < 0.001). Patients in the 1980s were younger (median age: 64 years; range: 33-90 years) than those in the 1990s (median age: 68 years; range: 31-103 years) and 2000s (median age: 68 years; range: 24-93 years) (P < 0.001). Over time, the frequency of a diagnosis of pancreatic cancer arising from intraductal papillary mucinous neoplasm increased from 2% in the 1980s to 8% in the 2000s (P < 0.001). The rate of 30-day mortality after surgery in the 1980s was 2%, which was similar to rates in the 1990s (1%) and 2000s (1%). Survival in each type of PAC did not change over time. Pancreatic cancer was associated with the worst survival (median survival: 19 months) compared with adenocarcinomas of the ampulla (median survival: 47 months), bile duct (median survival: 23 months) and duodenum (median survival: 54 months) (P < 0.001)., Conclusions: There are significant differences among PACs in longterm survival following PD. Although the numbers of patients undergoing safe resection have increased, overall longterm outcomes have not improved significantly., (© 2013 International Hepato-Pancreato-Biliary Association.)

Objectives: Right posterior sectorectomy (RPS) preserves liver volume but typically requires a longer parenchymal transection distance than does right hepatectomy (RH). This study was conducted to define the advantages of one approach over the other., Methods: Databases at two institutions were retrospectively reviewed for all patients submitted to RPS or RH between January 2000 and August 2012. Primary outcomes were perioperative complications and 90-day mortality., Results: Patients undergoing RPS (n = 100) and RH (n = 480), respectively, were similar in demographics, comorbidities, operative indications and Model for End-stage Liver Disease (MELD) mean scores (7.8 in the RPS group and 7.7 in the RH group; P = 0.49). A comparison of the RPS group with the RH group showed no significant differences in mean estimated blood loss (697 ml versus 713 ml; P = 0.900), rate of transfusions (19.2% versus 17.1%; P = 0.720), margin-positive resection (9.2% versus 11.6%; P = 0.70), complications (41.8% versus 42.0%; P = 1.000), bile leak (3.0% versus 4.0%; P = 1.000), or length of stay (7.5 days versus 8.3 days; P = 0.360). Postoperative hepatic insufficiency (defined as a postoperative bilirubin level of >7 mg/dl or significant ascites), occurred less frequently after RPS (1.0% versus 8.5%; P = 0.005). Operation type remained an independent determinant of postoperative hepatic insufficiency after controlling for preoperative risk factors (RH: hazard ratio = 9.628, 95% confidence interval 1.295-71.573; P = 0.027). A total of 28 (4.8%) patients died within 90 days; these included 25 (5.2%) patients in the RH group and three (3.0%) in the RPS group (P = 0.449)., Conclusions: Despite similar blood loss and overall morbidity, RPS is associated with less hepatic insufficiency than RH. Right posterior sectorectomy is parenchyma-sparing and should be strongly considered when it is technically feasible and oncologically sound., (© 2013 International Hepato-Pancreato-Biliary Association.)

Objectives: Management of liver metastasis (LM) from a non-colorectal, non-neuroendocrine primary carcinoma remains controversial. Few data exist on the management of hepatic metastasis from primary renal cell carcinoma (RCC). This study sought to determine the safety and efficacy of surgery for RCC LM., Methods: A total of 43 patients who underwent surgery for RCC hepatic metastasis between 1994 and 2011 were identified in a multi-institution hepatobiliary database. Clinicopathologic, operative and outcome data were collected and analysed., Results: Mean patient age was 62.4 years and most patients (67.4%) were male. The mean tumour size of the primary RCC was 6.9 cm and most tumours (72.1%) were designated as clear cell carcinoma. Nine patients (20.9%) presented with synchronous LM. Among the patients with metachronous disease, the median time from diagnosis of the primary RCC to treatment of LM was 17.2 months (range: 2.1-189.3 months). The mean size of the RCC LM was 4.0 cm and most patients (55.8%) had a solitary metastasis. Most patients (86.0%) underwent a minor resection (up to three segments). Final pathology showed margin status to be negative (R0) in 95.3% of patients. Postoperative morbidity was 23.3% and there was one perioperative death. A total of 69.8% of patients received perioperative chemotherapy. Overall 3-year survival was 62.1%. Three-year recurrence-free survival was 27.3% and the median length of recurrence-free survival was 15.5 months., Conclusions: Resection of RCC hepatic metastasis is safe and is associated with low morbidity and near-zero mortality. Although recurrence occurs in up to 50% of patients, resection can be associated with long-term survival in a well-selected subset of patients., (© 2012 International Hepato-Pancreato-Biliary Association.)

Background: Two-stage hepatectomy has been proposed for patients with bilateral colorectal liver metastases. The present study assesses the feasibility and outcome of two-stage hepatectomy for the treatment of colorectal liver metastases., Methods: From January 1994 to December 2008, 720 patients underwent liver resections at two institutions for colorectal liver metastases. The feasibility and outcomes of two-staged hepatectomies were evaluated., Results: Forty-five patients were eligible for the two-stage approach and both stages were completed in 35 patients (78%). Reasons for failure included disease progression (n= 7), poor performance status (n= 1) and death after the first stage (n= 2). Patients who completed both stages had significantly fewer lesions than patients who failed to complete the second stage (5 vs. 8; P= 0.02). No differences between the two groups were observed with regard to lesion size, receipt of radiofrequency ablation (RFA) or presence of extrahepatic disease. Post-operative morbidity (24% vs. 26%; P= 0.9) and mortality (4% vs. 5%; P= 0.8) was similar between the first and second stages. Median overall survival was 16 months. Three-year survival was significantly worse for patients failing to complete both stages (18%) compared with patients completing both stages (58%) (P < 0.001). Similar survival rates were observed between patients who completed two-stage vs. patients treated with a planned single-stage hepatectomy (58% vs. 53%; P= 0.34)., Conclusion: The two-stage strategy for colorectal liver metastases can be performed with acceptable morbidity and mortality. The second stage will not be feasible in 20-25% of patients. Patients who are able to complete the two-stage approach, however, may have long-term survival comparable to patients treated with a planned single-stage hepatectomy.

Purpose: To evaluate the impact of a multidisciplinary clinic on the clinical care recommendations of patients with pancreatic cancer compared with the recommendations the patients received prior to review by the multidisciplinary tumor board., Methods: The records of 203 consecutive patients referred to the Johns Hopkins pancreatic multidisciplinary clinic were prospectively collected from November 2006 to October 2007. Cross-sectional imaging, pathology, and medical history were evaluated by a panel of medical/radiation oncologists, surgical oncologists, pathologists, diagnostic radiologists, and geneticists. Alterations in treatment recommendations between the outside institution and the multidisciplinary clinic were recorded and compared., Results: On presentation, the outside computed tomography (CT) report described locally advanced/unresectable disease (34.9%), metastatic disease (17.7%), and locally advanced disease with metastasis (1.1%). On review of submitted imaging and imaging performed at Hopkins, 38 out of 203 (18.7%) patients had a change in the status of their clinical stage. Review of the histological slides by dedicated pancreatic pathologists resulted in changes in the interpretation for 7 of 203 patients (3.4%). Overall, 48 out of 203 (23.6%) patients had a change in their recommended management based on clinical review of their case by the multidisciplinary tumor board. Enrollment into the National Familial Pancreas Tumor Registry increased from 52 out of 106 (49.2%) patients in 2005 to 158 out of 203 (77.8%) with initiation of the multidisciplinary clinic., Conclusion: The single-day pancreatic multidisciplinary clinic provided a comprehensive and coordinated evaluation of patients that led to changes in therapeutic recommendations in close to one-quarter of patients.