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Because of the biologic aggressiveness and late presentation of pancreatic ductal adenocarcinoma (PDAC), up to 80% of patients have locally advanced or metastatic disease at presentation. The success of multiagent chemotherapy regimens in the management of metastatic disease has been translated to patients with locally advanced PDAC. Both FOLFIRINOX (fluorouracil/folinic acid/irinotecan/oxaliplatin) and gemcitabine/nab-paclitaxel are used to downstage locally advanced PDAC to render it eligible for resection with curative intent. This paradigm shift has significantly expanded the pool of patients who are eligible for resection with curative intent. However, the generalizability of present studies and the patient selection process are unclear. This article provides an evidence-based review of patient selection considerations and management algorithms, and details our institution’s approach to patients with locally advanced PDAC after preoperative chemotherapy.

Long-term pancreatoduodenectomy (PD) survivors have previously reported favorable quality of life (QoL). However, there has been a paucity of studies utilizing pancreas-specific modules for QoL assessment, which may uncover disability that general modules cannot detect.The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-PAN26 questionnaires were administered to PD survivors who were at least 5 years out of their operations for neoplasms (1998-2011, study cohort) and compared their scores with published preoperative scores of patients with pancreatic cancer (control cohort). The clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large ( 20) based on validated interpretation of clinically important differences.Of 1266 patients who underwent PD, there were 305 survivors with valid contact information, of whom 248 responded to the questionnaire (response rate 81.3%) and made up the study cohort. The median follow-up was 9.1 years (range 5.1-21.2 years). When compared with the control cohort, patients in the study cohort reported higher pancreatic pain (41.7 ± 17.6 vs. 18.1 ± 20.5, p 0.001, CR large), sexuality dissatisfaction (63.0 ± 37.5 vs. 35.1 ± 34.3, p 0.001, CR large), altered bowel habits (37.6 ± 30.6 vs. 20.0 ± 24.5, p 0.001, CR moderate), and digestive symptoms (26.3 ± 29.5 vs. 18.7 ± 27.8, p = 0.002, CR small) scores. There was a higher prevalence of bloating, indigestion, and flatulence, but lower prevalence of future health worry (71.7% vs. 89.6%, p 0.001) and limitation in planning activities (30.1% vs. 48.3%, p 0.001) at 5 years.While post-PD patients had better long-term global QoL than healthy controls, a more granular, pancreas-specific questionnaire uncovered digestive abnormalities and sexuality dissatisfaction. These data can better inform clinical decision making and provide potential areas for improvement and patient support.

The incidence of cholangiocarcinoma has doubled over the last 15 years with a similar rise in mortality, which provides the impetus for standardization of evidence-based care through the establishment of guidelines. We compared available guidelines on the clinical management of cholangiocarcinoma in the United States and Europe, which included the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), British Society of Gastroenterology (BSG) and the International Liver Cancer Association (ILCA) guidelines. There is discordance in the recommendation for biopsy in patients with potentially resectable cholangiocarcinoma and in the recommendation for use of fluorodeoxyglucose positron emission tomography scans. Similarly, the recommendation for preoperative biliary drainage for extrahepatic and perihilar cholangiocarcinoma in the setting of jaundice is inconsistent across all four guidelines. The BILCAP (capecitabine) and ABC-02 trials (gemcitabine with cisplatin) have provided the strongest evidence for systemic therapy in the adjuvant and palliative settings, respectively, but all guidelines have refrained from setting them as standard of care, given heterogeneity in the study cohorts and ABC-02’s negative intention-to-treat results. Future progress in enhancing survivorship of patients with cholangiocarcinoma would likely entail improvements in diagnostic biomarkers and novel systemic therapies. Based on recent results from studies of targeted therapy, future iterations of the guidelines will likely incorporate molecular profiling.

Prior literature suggests that cancer patients with hyperglycemia and type 2 diabetes mellitus (DM) exhibit worse oncologic and overall outcomes. Tumor metabolism and anabolism pathophysiology may explain this association, although this has not been adequately studied in adrenocortical carcinoma (ACC). We hypothesized that DM would be associated with worse oncological outcomes in ACC, and we utilized data from a national database and institutional sources for multimodal analysis.Both a multi-institutional database (the Collaborative Endocrine Surgery Quality Improvement Program or CESQIP) and a single-center longitudinal cohort (Dana Farber Cancer Institute or DFCI) were queried as unique retrospective cohorts to identify patients with ACC. Patient demographics, tumor characteristics, DM-specific variables, and oncologic outcome data were assessed. Results were analyzed via univariate analysis and multivariable linear regression analysis. Statistical significance was defined as p 0.05.Forty-eight CESQIP patients met inclusion criteria; 16 (33.0%) had DM. DM patients had a higher frequency of recurrence on longitudinal follow-up (12.5% v 0.0%, p = 0.04). Persistent disease was observed in 68.8% of DM patients and 40.6% of non-DM patients (p = 0.06). Patients in the DFCI cohort with lower average glucose values ( 110 mg/dL) had a significant survival benefit (p .0001). A mean serum glucose 110 mg/dL had increased risk (HR 36.3, 95% confidence interval 1.6, 831.3) for all-cause mortality.This multi-institutional, multimodal analysis suggests that patients with DM have worse oncologic and overall outcomes for ACC. While further study is warranted, consideration should be given among clinicians to optimize glycemic control as part of their ACC management.

Cancer center accreditation is designed to identify centers that provide high-quality cancer care. This also guides patients and referring physicians towards centers of excellence for specialized care. We sought to examine if cancer center accreditation was associated with improved long-term oncologic outcomes in patients with pancreatic adenocarcinoma.Using the SEER-Medicare database, we identified patients who underwent pancreatectomy for pancreatic adenocarcinoma from 1996 to 2013. Hospitals were categorized into three groups: National Cancer Institute-designated (NCI-designated) centers, Commission on Cancer (CoC)-accredited centers, and "non-accredited" (NA) centers. Multilevel mixed-effects models were used to calculate adjusted examined lymph nodes, disease-specific survival (DSS), and overall survival (OS).We identified 5,118 patients who underwent pancreatectomy at 632 hospitals (41.0% NA, 49.6% CoC, 9.4% NCI). NCI-designated centers had a greater median number of lymph nodes examined compared with CoC-accredited or NA centers (14 vs. 10 vs. 11.0 nodes, respectively; p 0.001). Patients treated at NCI centers had a higher 5-year DSS compared to those treated at CoC or NA centers (31.2% vs. 23.6% vs. 23.0%, respectively; p 0.001). Finally, patients treated at NCI centers had a higher 5-year OS compared to those treated at CoC or NA centers (23.5% vs. 18.9% vs. 17.9%, respectively; p 0.001). The associations held true when adjusted analyses were performed.Patients with resected pancreatic cancer treated at NCI-designated centers were associated with improved long-term oncologic outcomes. There was no difference between CoC-accredited centers compared with NA centers. Meticulous validation of accreditation is warranted globally prior to implementation.

Outpatient adrenalectomy has the potential to decrease costs, improve inpatient capacity, and decrease patient exposure to hospital-acquired conditions. Still, the practice has yet to be widely adopted and current studies demonstrating the safety of outpatient adrenalectomy are limited by sample size, extensive exclusion criteria, and no comparison to inpatient cases. We aimed to study the characteristics and safety of outpatient adrenalectomy using the largest such sample to date across 2 academic medical centers and 3 minimally invasive approaches.All minimally invasive adrenalectomies were identified, starting from the time outpatient adrenalectomy was initiated at each institution. Cases involving removal of other organs, bilateral adrenalectomies, and cases in which a patient was admitted to the hospital before the day of surgery were excluded. Patient, tumor, and case characteristics were compared between outpatient and inpatient cases, and multivariable regression analysis was used to assess odds of 30-day readmission and/or complication.Of 203 patients undergoing minimally invasive adrenalectomy, 49% (n = 99) were performed on an outpatient basis. Outpatient disposition was more likely in the setting of lower estimated blood loss, case completion before 3 pm, and for surgery performed in the setting of nodule/mass and primary hyperaldosteronism versus Cushing's syndrome, pheochromocytoma, and metastasis (P.05). There were no significant differences in patient age, body mass index, American Society of Anesthesiologists class, procedure performed, or total time under anesthesia between inpatient and outpatient cases. On adjusted analysis, outpatient adrenalectomy was not associated with increased 30-day readmission rate (odds ratio 0.23 [confidence interval 0.04-1.26] P = .09) or 30-day complication rate (odds ratio 0.21 [confidence interval 0.06-0.81] P = .02).Outpatient adrenalectomy can be performed safely without increased risk of 30-day complications or readmission in appropriately selected candidates.

Background Readmission after abdominal aortic aneurysm (AAA) repair to a different (nonindex) hospital has been shown to be associated with high mortality rates. Factors influencing this association remain unknown. The objective of this study was to determine the impact of hospital teaching status on nonindex hospital readmission and mortality. Methods An observational analysis of the longitudinally linked California Office of Statewide Health Planning and Development database was conducted from 1995 to 2009. Patients who were readmitted within 30 days after open AAA repair were included. The primary outcome measured was mortality on readmission. Results Over the 15-year study period, 3,475 readmissions after AAA were analyzed, of which 1,020 (29.4%) were to a nonindex hospital. After adjusting for age, race, gender, insurance, comorbidities, perioperative factors, and reason for readmission, nonindex readmission for patients undergoing their initial operation at a teaching hospital did not impact mortality (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.28–2.17, P = 0.63). Nonindex readmission for patients undergoing their initial operation at a nonteaching hospital, however, significantly increased mortality (OR 1.63, 95% CI 1.04–2.54, P = 0.03). Conclusions Readmission to a different hospital is associated with a higher mortality rate for patients undergoing AAA repair at nonteaching hospitals. This effect is not seen in patients having their initial operation performed at teaching hospitals, possibly due to infrastructure at these hospitals allowing for decreased impact from fragmentation of care. In cases where triage to an index hospital for readmission is not possible, communication at a high level between the index hospital and readmission hospital is paramount.

Background and Objectives Despite routine inclusion of lymphovascular invasion (LVI) status in pathologic reports of resected pancreatic ductal adenocarcinomas (PDA), the clinical implications of LVI have not been well characterized. Methods This study is a retrospective review of 2640 patients who underwent a pancreatectomy for PDA at Thomas Jefferson University Hospital, Massachusetts General Hospital, or Johns Hopkins Hospital (2003-2014). Clinical and pathologic records were extracted from institutional databases. Results The median post-resection survival for the total cohort was 19.2 months with a 5-year survival rate of 15.2%. In a multivariate Cox proportional hazards model including conventional pathologic features, LVI was an independent predictor of survival (HR = 1.14, P = 0.017). In a stratified Kaplan-Meier survival analysis, patients with N0, LVI- PDA had a significantly improved overall survival compared to those with N0, LVI+ PDA (median 31 vs 24 mo, P = 0.020). Similarly, patients with N1, LVI- PDA had superior survival to patients with N1, LVI+ disease (18.6 vs 16.5 mo, P = 0.001). Conclusions As the first large scale study focused on the clinical impact of LVI status in PDA, these data indicate that this routinely reported pathologic feature is a bona fide and independent adverse prognostic factor.

Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms with the potential for progression to pancreatic cancer. Recognized by the global medical community just over two decades ago, IPMN have gained great epidemiological and clinical relevance thanks to the widespread use of cross-sectional abdominal imaging, which has led to a surge in the number of incidental pancreatic cysts being diagnosed. As our understanding of this disease has improved, we now know that some IPMN have a very elevated risk of cancer and require surgical resection, while others are low-risk lesions and can be followed. The approach to IPMN must therefore strike a balance between preventing the over-utilization of surgery and the timely recognition and treatment of patients with high-risk lesions. Several clinical, radiographic, and laboratory parameters have been proposed to risk-stratify IPMN, leading to the publication of management guidelines that do not always converge in their recommendations. The goal of this clinical therapeutic review is to describe the strategic approach to IPMN at the Massachusetts General Hospital, and how our current understanding, management algorithm, and future directions have been informed by research efforts at our institution and other centers.

Objective General surgery training has evolved to align with changes in work hour restrictions, supervision regulations, and reimbursement practices. This has culminated in a lack of operative autonomy, leaving residents feeling inadequately prepared to perform surgery independently when beginning fellowship or practice. A resident-run minor surgery clinic increases junior resident autonomy, but its effects on patient outcomes have not been formally established. This pilot study evaluated the safety of implementing a resident-run minor surgery clinic within a university-based general surgery training program. Design Single institution case-control pilot study of a resident-run minor surgery clinic from 9/2014 to 6/2015. Rotating third-year residents staffed the clinic once weekly. Residents performed operations independently in their own procedure room. A supervising attending surgeon staffed each case prior to residents performing the procedure and viewed the surgical site before wound closure. Postprocedure patient complications and admissions to the hospital because of a complication were analyzed and compared with an attending control cohort. Setting Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. Participants Ten third-year general surgery residents. Results Overall, 341 patients underwent a total of 399 procedures (110 in the resident clinic vs. 289 in the attending clinic). Minor surgeries included soft tissue mass excision (n = 275), abscess incision and drainage (n = 66), skin lesion excision (n = 37), skin tag removal (n = 15), and lymph node excision (n = 6). There was no significant difference in the overall rate of patients developing a postprocedure complication within 30 days (3.6% resident vs. 2.8% attending; p = 0.65); which persisted on multivariate analysis. Similar findings were observed for the rate of hospital admission resulting from a complication. Resident evaluations overwhelmingly supported the rotation, citing increased operative autonomy as the greatest strength. Conclusions Implementation of a resident-run minor surgery clinic is a safe and effective method to increase trainee operative autonomy. The rotation is well suited for mid-level residents, as it provides an opportunity for realistic self-evaluation and focused learning that may enhance their operative experience during senior level rotations.

Background Whether the risk of venous thromboembolism (VTE) may be reduced by preoperative administration of prophylactic heparin is unknown. We hypothesized that timing of heparin administration does not significantly alter the incidence of VTE in pancreatic surgery. Methods An analysis was conducted using data from Massachusetts General Hospital's National Surgical Quality Improvement Program from 2012 to 2017. All patients admitted for elective pancreatic resection were included. The primary outcome was development of VTE. Multivariable regression was performed, adjusting for patient demographics and various clinical factors. Results In total, 1448 patients were analyzed, of whom 1062 received preoperative heparin (73.3%). Overall, 36 (2.5%) patients developed VTE. On unadjusted analysis, there was no statistically significant difference between patients who received preoperative heparin compared with those who did not (2.6% vs. 1.3%, respectively; p = 0.079). On adjusted analysis, there was an association with increased VTE rates among patients who received preoperative heparin (OR 2.93, 95% CI 1.10–7.81; p = 0.031). Conclusion There was an association between preoperative heparin administration and increased incidence of VTE on adjusted analysis, possibly reflecting appropriate surgical judgment in patient selection for prophylaxis. These data question the inclusion of preoperative VTE pharmacologic prophylaxis as a reliable quality indicator.

159 Background: Older adults with GI cancer often experience poor surgical outcomes, yet little is known about their PROs, such as physical function, quality of life (QOL), and physical and psychological symptom burden. Methods: As part of a randomized trial of perioperative geriatric care, we prospectively enrolled adults age ≥65 with GI cancer planning to undergo surgical resection. We asked patients preoperatively to self-report their physical function (activities of daily living [ADLs] and instrumental ADLs [IADLs]), QOL (EORTC QLQ-C30), symptom burden (Edmonton Symptom Assessment System [ESAS], scores > 3 considered moderate/severe [mod/sev]), depression symptoms (Geriatric Depression Scale [GDS], scores > 4 represent a positive screen for depression), and comorbidities. We used regression models to explore relationships among PROs and clinical outcomes (receiving planned surgery, postoperative complications [Clavien-Dindo], hospital readmissions within 90 days, and survival). Results: From 9/2016 - 4/2019, we enrolled 160 of 221 (72.4%) patients approached (median age: 72, range: 65-92). At baseline, most (53.1%) reported at least one comorbidity and required assistance with ADLs (94.8%) and IADLs (52.3%). Patients reported an average of 2.56 mod/sev ESAS symptoms, and 27.7% screened positive for depression. For surgical outcomes, 137 patients (85.6%) underwent planned surgery, and 99 (72.2%) of these had at least one postoperative complication. Greater independence with ADLs was associated with undergoing planned surgery (OR = 1.21, P = .02), lower risk of complications (OR = 0.81, P < .01), and improved survival (HR = 0.87, P = .02), but not readmissions. Greater independence with IADLs was associated with undergoing planned surgery (OR = 1.30, P = .03) and improved survival (HR = 0.73, P < .01), but not other outcomes. Higher baseline QOL was only associated with lower risk of postoperative complications (OR = 0.97, P = .04). Higher depression scores were only associated with worse survival (HR = 1.13, P = .02). Higher baseline symptom burden predicted for shorter time to readmission (HR = 1.13, p = .03). Patient-reported number of comorbidities was associated with shorter time to readmission (HR = 1.49, p = .03) and higher risk of complications (OR = 1.70, P = .03). Conclusions: Older adults with GI cancer often have baseline functional limitations and a high symptom burden, all of which are associated with worse clinical outcomes. Future work should study whether addressing preoperative PROs could improve older patients’ surgical outcomes. Clinical trial information: NCT02810652 .

147 Background: Preoperative therapy for localized pancreatic cancer represents an emerging treatment paradigm with the potential to provide significant benefits, yet with complex risks. Research is lacking about whether clinicians effectively communicate key components of informed decision-making for patients considering this treatment. Methods: From 2017-2019, we conducted a two-part, mixed methods study. In part 1, we conducted interviews with clinicians (medical/radiation/surgical oncology, n = 13) and patients with pancreatic cancer who had received preoperative therapy (n = 18) to explore perceptions of information needed to make informed decisions about preoperative therapy, from which we generated a list of key elements. In part 2, we audio recorded the initial multidisciplinary visits of patients with pancreatic cancer eligible for preoperative therapy (n = 20). Two coders (94% concordance) independently identified whether clinicians discussed key elements from part 1. Patients also completed a post-visit survey reporting whether clinicians discussed the key elements. We explored discordance between audio recordings and patient reports using qualitative, explanatory themes. Results: In part 1, we identified 13 key elements of informed treatment decision-making, including treatment logistics, alternatives, and potential risks/benefits. In part 2, recordings showed that most visits included discussions about logistics, such as the chemotherapy schedule (n = 20) and use of a port-a-cath (n = 20), whereas few included discussions about risks, such as the potential for hospitalizations (n = 7), urgent visits (n = 6), or needing help with daily tasks (n = 6). Patients reported hearing about potential benefits, such as likelihood of achieving surgery (n = 10) and cure (n = 7), even when these were not discussed. Qualitative themes across these discordant cases included clinician optimism regarding present day results versus historical findings and mentions of positive outcomes from prior patients without citing specific data or potential adverse outcomes. Conclusions: We identified key elements of information patients with pancreatic cancer need to make informed decisions about preoperative therapy. Although clinicians frequently disclosed much of this information, we found multiple cases of patient-clinician discordance for certain key elements, which underscores the need for interventions to enhance patient-clinician communication regarding pancreatic cancer treatment decisions.

BACKGROUND Early invasive carcinoma may be encountered in association with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. The natural history of these early invasive lesions is unknown. METHODS Pancreatic surgical databases from 4 high-volume centers were queried for IPMNs, with invasive components measuring 20 mm or less. All cases were reviewed by GI gastrointestinal pathologists, and pathologic features were analyzed to identify predictors of recurrence and survival. RESULTS A total of 70 small IPMN-associated invasive carcinomas (≤20-mm invasion) were identified, comprising 25% of resected IPMN-associated carcinomas (n = 280). Most of these small invasive cancers were multifocal (66%), less than 10 mm in size (73%), and arose in the setting of a main duct IPMN (96%). The most common adenocarcinoma subtypes were tubular (57%) and colloid (29%). Lymph node metastases were present in 19% of cases and 23% were T3 lesions. The overall recurrence rate was 24% (n = 17), and the median time to recurrence was 16 months (range: 4-132 months). Median and 5-year survival rates were 99 months and 59%. Recurrence patterns of invasive disease were local in 35%, distant in 47%, and both in 18%. Lymphatic spread and T3 stage were predictive of recurrence (univariate, P = 0.006), whereas tubular carcinoma type was the most predictive of poor overall survival (multivariate hazard ratio = 3.7, P = 0.04). CONCLUSIONS This study represents the largest multi-institutional experience of resected small IPMN-associated carcinoma. Although these malignancies may frequently be cured with resection, recurrence risk is significant. Lymphatic spread, increased T stage, and tubular type carcinoma were associated with the poorest outcome.

Randomized controlled trials have historically been regarded as the gold standard of modern clinical research tools, allowing us to elucidate the efficacy of novel therapeutics in an unparalleled manner. However, when attempting to generalize trial results to broader populations, it becomes apparent that the unexplained outcome variability exists among treatment recipients, suggesting that randomized controlled trials harbor inherent limitations. Herein, we explore the benefits of health services (outcomes) research utilization in addressing variation in patient outcomes following surgical intervention in the non-randomized setting, with a specific focus on hepatopancreaticobiliary surgery outcomes. To achieve this, we have constructed a framework that outlines the complex interactions existing between therapeutic, patient, and provider factors that subsequently lead to variation in outcomes. By exploring examples in the current literature, we have highlighted the areas where the knowledge is currently lacking and can be further strengthened through the application of outcomes research. Furthermore, we have attempted to demonstrate the utility of alternative study designs in the investigation of novel clinical questions currently unanswered in the field of hepatopancreaticobiliary surgery.

BackgroundMost studies on learning curves for pancreaticoduodenectomy have been based on single-surgeon series at tertiary academic centers or are inferred indirectly from volume-outcome relationships. Our aim is to describe mortality rates associated with cumulative surgical experience among non-teaching hospitals.Study designObservational study of a statewide inpatient database. Analysis included hospitals that began performing pancreaticoduodenectomy between 1996 and 2010, as captured by the California Office of Statewide Health Planning and Development database. Cases were numbered sequentially within each hospital. The same sequential series (e.g., first 10 cases, 11th through 20th cases) were identified across hospitals. The outcome measure was in-hospital mortality.ResultsA total of 1210 cases from 143 non-teaching hospitals were analyzed. The average age was 63 years old, and the majority of patients were non-Hispanic white. The median overall mortality rate was 9.75 %. The mortality rate for the first 10 aggregated cases was 11.3 %. This improved for subsequent cases, reaching 7.1 % for the 21st-30th cases. However, the mortality rate then increased, reaching 16.7 % by the 41st-50th cases before falling to 0.0 % by the 61st-70th cases.ConclusionsInitial improvement in surgical outcomes relative to cumulative surgical experience is not sustained. It is likely that factors other than surgical experience affect outcomes, such as less rigorous assessment of comorbidities or changes in support services. Vigilance regarding outcomes should be maintained even after initial improvements.

Objective Trials for endovascular aneurysm repair (EVAR) report lower perioperative mortality and morbidity, but also higher costs compared with open repair. However, few studies have examined the subsequent cost of follow-up evaluations and interventions. Therefore, we present the index and 5-year follow-up costs of EVAR from the Endurant Stent Graft System Post Approval Study. Methods From August 2011 to June 2012, 178 patients were enrolled in the Endurant Stent Graft System Post Approval Study de novo cohort and treated with the Medtronic Endurant stent graft system (Medtronic Vascular, Santa Rosa, Calif), of whom 171 (96%) consented for inclusion in the economic analysis and 177 participated in the quality-of-life (QOL) assessment over a 5-year follow-up period. Cost data for the index and follow-up hospitalizations were tabulated directly from hospital bills and categorized by Uniform Billing codes. Surgeon costs were calculated by Current Procedural Terminology codes for each intervention. Current Procedural Terminology codes were also used to calculate imaging and clinic follow-up reimbursement as surrogate to cost based on year-specific Medicare payment rates. Additionally, we compared aneurysm-related versus nonaneurysm-related subsequent hospitalization costs and report EuroQol 5D QOL dimensions. Results The mean hospital cost per person for the index EVAR was $45,304 (interquartile range [IQR], $25,932-$44,784). The largest contributor to the overall cost was operating room supplies, which accounted for 50% of the total cost at a mean of $22,849 per person. One hundred patients had 233 additional post index admission inpatient admissions; however, only 32 readmissions (14%) were aneurysm related, with a median cost of $13,119 (IQR, $4570-$24,153) compared with a nonaneurysm-related median cost of $6609 (IQR, $1244-$26,466). Additionally, 32 patients were admitted a total of 37 times for additional procedures after index admission, of which 14 (38%) were aneurysm-related. The median cost of hospitalization for aneurysm-related subsequent intervention was $22,023 (IQR, $13,177-$47,752), compared with a median nonaneurysm-related subsequent intervention cost of $19,007 (IQR, $8708-$33,301). After the initial 30-day visit, outpatient follow-up imaging reimbursement averaged $550 per person per year ($475 for computed tomography scans, $75 for the abdomen), whereas annual office visits averaged $107 per person per year, for a total follow-up reimbursement of $657 per person per year. There were no significant differences in the five EuroQol 5D QOL dimensions at each follow-up compared with baseline. Conclusions Costs associated with index EVAR are driven primarily by cost of operating room supplies, including graft components. Subsequent admissions are largely not aneurysm related; however, cost of aneurysm-related hospitalizations is higher than for nonaneurysm admissions. These data will serve as a baseline for comparison with open repair and other devices.

There is no consensus on the use of chest imaging in pancreatic ductal adenocarcinoma (PDAC) patients. Among PDAC patients, we examined the use of chest computed tomography (CT) over time and determined whether the use of chest CT led to a survival difference or change in management via identification of indeterminate lung nodules (ILNs). Retrospective clinical data was collected for patients diagnosed with PDAC from 1998 to 2014. We examined the proportion of patients undergoing staging chest CT scan and those who had ILN, defined as ≥ 1 well-defined, noncalcified lung nodule(s) ≤ 1 cm in diameter. We determined time to overall survival (OS) using multivariate Cox regression. We also assessed changes in management of PDAC patients who later developed lung metastasis only. Of the 2710 patients diagnosed with PDAC, 632 (23%) had greater than one chest CT. Of those patients, 451 (71%) patients had ILNs, whereas 181 (29%) had no ILNs. There was no difference in median overall survival in patients without ILNs (16.4 [13.6, 19.0] months) versus those with ILN (14.8 [13.6, 15.8] months, P = 0.18). Examining patients who developed isolated lung metastases (3.3%), we found that staging chest CTs did not lead to changes in management of the primary abdominal tumor. Survival did not differ for PDAC patients with ILNs identified on staging chest CTs compared with those without ILNs. Furthermore, ILN identification did not lead to changes in management of the primary abdominal tumor, questioning the utility of staging chest CTs for PDAC patients.

Objective: The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD). Background: The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons’ control. Methods: From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization. Results: The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was “potentially modifiable” by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence. Conclusion: Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

Perioperative mortality rate (POMR) is a suggested indicator for surgical quality worldwide. Currently, POMR is often sampled by convenience; a data-driven approach for calculating sample size has not previously been attempted. We proposed a novel application of a bootstrapping sampling technique to estimate how much data are needed to be collected to reasonably estimate POMR in low-resource countries where 100% data capture is not possible. Six common procedures in low- and middle-income countries were analysed by using population database in New York and California. Relative margin of error by dividing the absolute margin of error by the true population rate was calculated. Target margin of error was ±50%, because this level of precision would allow us to detect a moderate-to-large effect size. Target margin of error was achieved at 0.3% sampling size for abdominal surgery, 7% for fracture, 10% for craniotomy, 16% for pneumonectomy, 26% for hysterectomy and 60% for C-section. POMR may be estimated with fairly good reliability with small data sampling. This method demonstrates that it is possible to use a data-driven approach to determine the necessary sampling size to accurately collect POMR worldwide.

Necrotizing pancreatitis has historically been treated with open necrosectomy, which carries a high morbidity and mortality rate. More recently, there has been a shift towards endoscopic and percutaneous approaches employed as part of a minimally invasive step-up approach. Herein, we describe the technical approaches to video-assisted retroperitoneal debridement and sinus tract endoscopic debridement of pancreatic necrosis. Additionally, we review important patient selection considerations and the strengths and weaknesses of each of the approaches.

Electronic supplementary material The online version of this article ( https://doi.org/10.1007/s11605-017-3547-2 ) contains supplementary material, which is available to authorized users.

Objective:The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.Background:The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circ

Liver resection for colorectal and neuroendocrine hepatic metastases has traditionally been associated with favorable results in well-selected patients. However, the role of hepatic resection and other liver-directed therapies for non-colorectal, non-neuroendocrine liver metastases has been less adequately described. In this chapter, we review the current literature on surgical and other locoregional treatment strategies for non-colorectal, non-neuroendocrine liver metastases, focusing on prognostic factors, survival outcomes, and selection criteria based on the specific histology of the primary tumor, including breast cancer, genitourinary tract cancer, non-colorectal gastrointestinal tract cancer, and melanoma.

Differences in amputation rates for limb ischemia between white and black patients have been extensively studied. Our goal was to determine whether biases in provider decision-making contribute to the disparity. We hypothesized that the magnitude of the disparity is affected by surgeon and hospital factors.Analysis of the New York Statewide Planning and Research Cooperative System database was performed for 1999 to 2014. Black and white patients with ICD9 codes for peripheral vascular disease, who received either an amputation or salvage procedure, were included. The primary endpoint was treatment choice.We analyzed 215,480 inpatient admissions. The overall amputation rate was 38.0%, and blacks were significantly more likely to receive amputations than whites on unadjusted (42.6% vs 28.6%, p0.001), and multivariable analyses (odds ratio [OR] 1.45, 95% CI 1.31 to 1.60, p0.001). This difference was more pronounced among high total vascular volume surgeons (OR 1.74, 95% CI 1.50 to 2.00, p0.001), but not among those with low total vascular volume (OR 1.06, 95% CI 0.90 to 1.24, p = 0.49); high volume hospitals (OR 1.57, 95% CI 1.39 to 1.78, p0.001), but not among those with low amputation volume (OR 0.96, 95% CI 0.73 to 1.27, p0.80); and surgeons who treat fewer black patients (OR 1.58, 95% CI 1.44 to 1.73, p0.001) vs surgeons who see more black patients (OR 1.43, 95% CI 1.30 to 1.57, p0.0.001).Black patients are significantly more likely to receive an amputation than a salvage procedure when presenting with significant peripheral vascular diseases. High procedural volume does not seem to reduce unequal treatment; diversity of surgeon practice does.

The increased incidence of bile duct injuries (BDIs) after the adoption of laparoscopic cholecystectomy has been well documented. However, the longitudinal impact of bile leaks and BDIs on survival and healthcare use have not been studied adequately. The aims of this analysis were to determine the incidence, long-term outcomes, and costs of bile leaks and ductal injuries in a large population.The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Bile leaks, BDIs, and their management strategy were defined. Survival was calculated by Kaplan-Meier failure estimates with multivariable regression and propensity analyses. Cost analyses used inflation adjustments and institution-specific cost-to-charge ratios.Of 711,454 cholecystecomies, bile leaks occurred in 3,551 patients (0.50%) and were managed almost exclusively by endoscopists. Bile duct injuries occurred in 1,584 patients (0.22%) with 84% managed surgically. Patients with a bile leak were more likely to die at 1 year (2.4% vs 1.4%; odds ratio 1.85; p0.001). Similarly, BDI patients had an increased 1-year mortality (7.2% vs 1.3%; odds ratio 2.04; p0.0001). Survival of BDI patients was better with an operative approach (odds ratio 0.19; p0.001) when compared with endoscopic management. Operatively managed BDIs were also associated with fewer emergency department visits and readmissions, as well as lower cumulative costs at 1 year ($60,539 vs $118,245; p0.001).The 0.22% incidence of BDIs observed in California is lower than reported in the first decade after the introduction of laparoscopic cholecystectomy. Bile leaks are 2.3 times more common than BDIs. Patients with a bile leak or BDI have diminished survival. Surgical repair of a BDI leads to enhanced survival and reduced cumulative cost compared with endoscopic management.

OBJECTIVE To perform an unbiased assessment of first postoperative day (POD 1) drain amylase level and pancreatic fistula (PF) after pancreaticoduodenectomy (PD). BACKGROUND Recent evidence demonstrated that drain abandonment in PD is unsafe. Early drain amylase levels have been proposed as predictors of PF after PD, allowing for selection of patients for early drain removal. METHODS Daily drain amylase levels were correlated with the development of PF in 2 independent cohorts of patients undergoing PD: training cohort (n = 126; year 2008) and validation cohort (n = 369; years 2009-2012). RESULTS POD 1 drain amylase level had the highest predictive ability (concordance index: 0.911) for PF in the training cohort. An amylase level of 612 U/L or higher showed the best accuracy (86%), sensitivity (93%), and specificity (79%). Thus, a cutoff value of 600 U/L was utilized. In the validation cohort, 229 (62.1%) patients had a POD 1 drain amylase level of lower than 600 U/L, and PF developed in only 2 (0.9%) cases; whereas in patients with POD 1 drain amylase level of 600 U/L or higher (n = 140) the PF rate was 31.4% (odds ratio [OR] = 52, P < 0.0001). On multivariate analysis, POD 1 drain amylase level of lower than 600 U/L (OR = 0.0192, P < 0.0001) was a stronger predictor of the absence of PF than pancreatic gland texture (OR = 0.193, P = 0.002) and duct diameter (OR = 0.861, P = 0.835). CONCLUSIONS After PD, the risk of PF is less than 1% if POD 1 drain amylase level is lower than 600 U/L. We propose that in this group, which comprise more than 60% of patients, drains should be removed on POD 1.

Background: Intraductal papillary mucinous adenocarcinoma (IPMCs) occur more frequently in main-duct intraductal papillary mucinous neoplasms. Methods: Review of the literature. Results: The prognosis of IPMCs depends on its histopathological subtype: colloid IPMCs have superior survival rates mainly secondary to more favorable pathological features, whereas tubular IPMCs have survival outcomes similar to that of conventional pancreatic adenocarcinomas. The epithelial background plays an equally important role in defining the biology of IPMCs: gastric IPMC subtypes demonstrate an overall worse survival outcome when compared to intestinal, pancreatobiliary, and oncocytic subtypes. Lymph node involvement is one of the strongest predictors of survival in IPMC, with a decreasing overall survival as the lymph node ratio increases. There is little evidence to support adjuvant chemoradiation in patients with IPMC. Conclusion: Our current understanding of IPMC biology based on histopathological and epithelial background subtypes as well as clinicopathological predictors should influence patient counseling and selection for adjuvant therapy.

Current guidelines recommend cholecystectomy (CCY) during the index admission for mild to moderate biliary pancreatitis as delayed CCY is associated with a substantial risk of recurrent biliary events. Delayed CCY is recommended in severe pancreatitis. The optimal timing of CCY in necrotizing pancreatitis, however, has not been well studied. We sought to determine the safety of single-stage CCY performed at the time of necrosectomy and its effectiveness in preventing subsequent biliary complications. We retrospectively queried our institutional database of patients who underwent pancreatic necrosectomy for necrotizing pancreatitis from 1992 to 2012. We identified 217 consecutive patients who underwent pancreatic necrosectomy during the study period. The most common etiologies of pancreatitis were biliary (41 %) and alcoholic (24 %), with a median computed tomography (CT) severity index score of 6 ± 1.6 and a 63.6 % incidence of infected necrosis. Ninety-eight patients had undergone CCY prior to necrosectomy. Seventy patients (59 % of those with gallbladders in situ) underwent CCY at the time of pancreatic necrosectomy. CCY was not performed in the remaining 49 due to a clear non-biliary etiology (35 %), technical difficulty (29 %), intraoperative hemodynamic instability (18 %), or surgeon preference (18 %). Postoperative morbidity and mortality was no different between the CCY and no CCY groups, with no bile duct injury or bile leaks in patients undergoing CCY at the time of necrosectomy. Of the patients undergoing CCY, 43 % of patients without cholelithiasis or biliary sludge on preoperative imaging had gallstones or sludge identified pathologically after single-stage CCY. Of those who did not receive a single-stage CCY, biliary complications developed in 17 (35 %) of patients (21 % cholecystitis, 14 % recurrent gallstone pancreatitis) at a median time to incidence of 10 months. Seventeen (35 %) patients eventually received a postnecrosectomy cholecystectomy, of which 75 % required an open procedure. Single-stage CCY at the time of pancreatic necrosectomy is safe in selected patients and should be performed if technically feasible to prevent future biliary complications and reduce the need for a subsequent separate, often open, CCY.

Approximately 20–40% of patients with “resectable” pancreatic adenocarcinoma (PDAC) by imaging criteria have metastatic disease on exploration. Our aim was to assess the potential impact of staging laparoscopy versus upfront laparotomy in “resectable” patients found to have metastatic PDAC. Clinicopathologic data was retrospectively collected for all patients with PDAC undergoing an operation with curative intent between 2001–2015 at a single institution. Of the 1001 patients undergoing surgical evaluation, 151 had unsuspected metastatic PDAC. Staging laparoscopy was performed in 59% (89/151) of patients, while 41% (62/151) underwent an exploratory laparotomy with or without prophylactic bypass. There were no differences in patient demographics and preoperative CA 19-9 levels between the staging laparoscopy and exploratory laparotomy groups. However, staging laparoscopy was more often performed for pancreatic body/tail lesions (85% vs 60% for pancreatic head lesions, p

OBJECTIVES The aims of this study were to compare the safety, efficacy, and patients' quality of life with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDIs) in type 3c diabetes mellitus (T3cDM) following total pancreatectomy (TP) and pancreatic enzyme usage. METHODS Thirty-nine patients with T3cDM (18 CSII patients vs 21 MDI patients) who underwent TP between 2000 and 2016 at 3 Harvard-affiliated hospitals and the University of Minnesota returned prospectively obtained questionnaires examining quality of life and both endocrine and exocrine pancreatic functions. RESULTS Main indications for TP were as follows: chronic pancreatitis (n = 19), intraductal papillary mucinous neoplasm (n = 12), and adenocarcinoma (n = 4). Median hemoglobin A1c using MDIs was 8.1% versus 7.3% in CSII. Severe hypoglycemic events using MDIs were increased compared with CSII (P = 0.02). There were no significant differences in quality-of-life measures with CSII versus MDIs. Pancreatic enzyme dose per meal (P < 0.05) differed between the hospitals. Gastrointestinal symptoms and unintended weight loss (P < 0.01) were more common with low doses of pancreatic enzymes. CONCLUSIONS After TP, CSII therapy is safe compared with MDIs in T3cDM and not associated with an increase in severe hypoglycemic events. Pancreatic enzyme replacement therapy is highly variable with low doses associated with unintentional weight loss and gastrointestinal symptoms.

Background Although barriers to granting surgical residents autonomy in the operating room are well described, few have proposed practical strategies to overcome these barriers. Our department adopted a multidisciplinary approach to develop a rotation that aimed to grant chief residents structured operative autonomy. In this study, we assess the feasibility of implementation, impact on patient safety, and educational benefit to residents after the program's pilot year. Study Design During a 1-month rotation, chief residents began cases alone using their own operative block time. The attending surgeon was notified when the critical portion of the operation was reached and supervised its completion. Postoperative complications, intraoperative adverse events, readmissions, operation duration, and length of stay in a subset of patients that underwent a cholecystectomy or appendectomy were compared with patients operated on by standard resident services. Follow-up surveys were administered to residents 1 year after graduation. Results One hundred and twenty-four operations, which ranged in complexity, were performed by chief residents. Unadjusted subset analysis comparing the structured operative autonomy (n = 54) and standard resident (n = 718) services outcomes for appendectomies and cholecystectomies revealed no significant differences in 30-day postoperative complications (5.6% vs 4.0%; p = 0.59), major intraoperative adverse events, or readmissions (3.7% vs 3.8%; p = 1.00), respectively. Multivariate analysis performed for 30-day complications (odds ratio 0.8; 95% CI 0.2 to 3.2; p = 0.76) and readmissions (odds ratio 0.4; 95% CI 0.1 to 2.1; p = 0.3) corroborated unadjusted findings. All participants (n = 8) strongly agreed that the rotation eased their transition to fellowship or independent practice. Conclusions Structured operative autonomy overcomes known barriers to granting chief residents autonomy in the operating room. When used for select general surgery cases, resident education is enhanced without impacting patient outcomes. This training model has the potential to improve the surgical independence of graduating residents.

OBJECTIVE Our aim was to assess quality of life (QOL) and functionality in a large cohort of patients ≥5-years after pancreaticoduodenectomy (PD). BACKGROUND Long-term QOL outcomes after PD for benign or malignant disease are largely undocumented. METHODS We administered the EORTC QLQ-C30 questionnaire to patients who underwent PD for neoplasms from 1998 to 2011 and compared their scores with an age- and sex-matched normal population. Clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (>20) based on validated interpretation of clinically important differences. RESULTS Of 305 PD survivors, 245 (80.3%) responded, of whom 157 (64.1%) underwent PD for nonmalignant lesions. Median follow-up was 9.1 years (range 5.1 -21.2 yrs). New-onset diabetes developed in 10.6%; 50.4% reported taking pancreatic enzymes; 54.6% reported needing antacids. Compared with the age- and sex-adjusted controls, PD survivors demonstrated higher global QOL (78.7 vs 69.7, CR small, P < 0.001), physical (86.7 vs 77.9, CR small, P < 0.001) and role-functioning scores (86.3 vs 74.1, CR medium, P < 0.001). Using linear regression and adjusting for socioeconomic variables, there were no differences in QOL or functional scores in the benign versus malignant subgroups. Older age at operation was associated with worse physical-functioning (-0.4/yr, P = 0.008). Taking pancrelipase (-6.8, P = 0.035) or antacids (-6.3, P = 0.044) were both associated with lower social-functioning scores. CONCLUSIONS Patients who had a PD demonstrated better global QOL, physical- and role-functioning scores at 5-years when compared with age- and sex-matched controls. Approximately half of the patients required pancreatic enzyme replacement, while only 11% developed new-onset diabetes.

Recent advances in imaging and the increasing use of neoadjuvant therapy puts the contemporary utility of staging laparoscopy for patients with pancreatic adenocarcinoma (PDAC) into question. This study aimed to develop a prognostic score to optimize prevention of an unnecessary laparotomy and minimize the rate for unnecessary laparoscopy. Clinicopathologic data were evaluated for all patients undergoing surgical intervention for PDAC between 2001 and 2015, who were stratified into group 1 (2001–2008) and group 2 (2009–2014). The study identified 1001 patients eligible for analysis, 331 (33%) of whom underwent a staging laparoscopy before exploration. An unnecessary laparotomy was prevented for 44.4% of the patients in period 1 and for 24% of the patients in period 2 (p