Search

Our objective was to examine the associations between early discharge and readmission after major abdominal operations.Advances in patient care resulted in earlier patient discharge after complex abdominal operations. Whether early discharge is associated with patient readmissions remains controversial.Patients who had colorectal, liver, and pancreas operations abstracted in 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were included. Patient readmission was stratified by 6 operative groups. Patients who were discharged before median discharge date within each operative group were categorized as an early discharge. Analyses tested associations between early discharge and likelihood of 30-day postoperative unplanned readmission.A total of 364,609 patients with major abdominal operations were included. Individual patient groups and corresponding median day of discharge were: laparoscopic colectomy (n = 152,575; median = 4), open colectomy (n =137,462; median = 7), laparoscopic proctectomy (n = 12,238; median = 5), open proctectomy (n = 24,925; median = 6), major hepatectomy (n = 9,805; median = 6), pancreatoduodenectomy (n = 27,604; median = 8). Early discharge was not associated with an increase in proportion of readmissions in any operative group. Early discharge was associated with a decrease in average proportion of patient readmissions compared to patients discharged on median date in each of the operative groups: laparoscopic colectomy 6% versus 8%, open colectomy 11% versus 14%, laparoscopic proctectomy 13% versus 16%, open proctectomy 13% vs 17%, major hepatectomy 8% versus 12%, pancreatoduodenectomy 16% versus 20% (all P ≤ 0.02). Serious morbidity composite was significantly lower in patients who were discharged early than those who were not in each operative group (all P0.001).Early discharge in selected patients after major abdominal operations is associated with lower, and not higher, rate of 30-day unplanned readmission.

Efficacy of single-shot opioid spinal analgesia after pancreatoduodenectomy remains understudied and lacks comparison to standard continuous thoracic epidural analgesia (TEA).Pancreatoduodenectomy patients who underwent TEA or opioid spinal for postoperative pain management from 2015 to 2020 were included in this observational cohort study. Primary outcome was patient-reported mean daily pain scores. Secondary outcomes included postoperative morphine milligram equivalents (MMEs) and length of stay (LOS). Multivariable linear regression models were constructed to compare risk-adjusted outcomes.180 patients were included: 56 TEA and 124 opioid spinal. Compared to epidural patients, opioid spinal patients were more likely to be older (67.0 vs. 64.6, p=0.045), have greater BMI (26.5 vs. 24.4, p=0.02), and less likely to be smokers (19.4% vs. 41.1%, p=0.002). Opioid spinal, compared to TEA, was associated with lower intraoperative MMEs (0.25 vs. 22.7, p0.001) and postoperative daily MMEs (7.9 vs. 10.3, p=0.03) on univariate analysis. However, after multivariable adjustment, there was no difference in average pain scores across the postoperative period (spinal vs. epidural: 4.18 vs. 4.14, p=0.93), daily MMEs (p=0.50), or LOS (p=0.23).There was no significant difference in postoperative pain scores, opioid use, or LOS between patients managed with TEA or opioid spinal after pancreatoduodenectomy.

Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (69.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23% vs 27% vs 36%, respectively, P = 0.445) and similar 5-year OS (21% vs 24% vs 33%, respectively, P = 0.287). Thirty-five (24%) patients were bridged to transplantation with TACE and/or RFA. The 5-year OS was significantly improved in patients bridged to transplantation (P < 0.001). Survival does not differ between patients with solitary HCC ≤ 3 cm treated with TACE or RFA. Patients who were bridged to transplantation had significantly greater OS compared with patients who were not transplanted.

Curative intent treatment strategies for patients with hepatocellular carcinoma (HCC) include liver resection, liver transplantation, and arguably tumor ablation. Locoregional therapies including transarterial chemoembolization (TACE) as well as transarterial radioembolization (TARE) remain viable treatment options for patients who are not candidates for therapy with curative intent or patients awaiting liver transplantation receiving downstaging treatment as part of intention to proceed with transplantation.

BACKGROUND: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy and to better understand the impact of bile leak on morbidity and mortality. METHODS: Adult patients in the 2014–2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak. RESULTS: Of 6,859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly higher in patients after major compared to minor hepatectomy (12.6% vs 5.1%, p

BACKGROUND: Independent associations between chronic liver disease, MELD, and postoperative outcomes among patients selected for liver resection have not been completely established. We hypothesized independent associations between MELD, cirrhosis, and postoperative mortality. METHODS: Patient-level data from the targeted hepatectomy module and ACS NSQIP PUF during 2014–2015 were merged. Multivariable regression models with interaction effect between MELD and liver texture (normal vs congested/fatty vs cirrhotic) tested the independent effects of covariates on mortality and morbidity. RESULTS: 3,530 patients were included, of whom 668 patients (19%) had cirrhosis. ACS NSQIP defined mortality (3.9%vs1.1%) and morbidity (23.5%vs15.8%) were higher in patients with cirrhosis (both p

Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (±9.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23%

Background: Americas Hepato-Pancreato-Biliary (HPB) Association established the HPB ultrasound (US) course in 2012. This aim of this work is to describe the motivations and experiences of North American surgeons in US following course work. Methods: An anonymous on-line survey of open-ended questions was sent to previous course participants. Analysis was conducted using qualitative methods. Results: Between 2012 and 2018, 69 surgeons from the United States (63) and Canada(6) took the HPB US course, 15 of which (21.7%) returned the survey. The desire for US training/experience and certification were dominant reasons to take coursework.The most common challenges to incorporate US into practice were related to US system, where cost issues were dominant. Conclusion: Cost of the US system is an important challenge to incorporate US into practice. Although HPB surgeons are motivated to seek US training to enhance knowledge and skills, they are also interested in obtaining US certification.

OBJECTIVE The purpose of this study was to determine whether bacterial contamination of islets affects graft success after total pancreatectomy with islet autotransplantation (TPIAT). BACKGROUND Factors associated with insulin independence after TPIAT are inconclusive. Although bacterial contamination does not preclude transplantation, the impact of bacterial contamination on graft success is unknown. METHODS Patients who received TPIAT at the University of Virginia between January 2007 and January 2016 were reviewed. Patient charts were reviewed for bacterial contamination and patients were prospectively contacted to assess rates of insulin independence. RESULTS There was no significant difference in demographic or perioperative data between patients who achieved insulin independence and those who did not. However, six of 27 patients analyzed (22.2%) grew bacterial contaminants from culture of the final islet preparations. These patients had significantly lower islet yield and C-peptide at most recent follow-up (P

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p 0.001).Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

This study compared the morbidity and mortality following hepatectomy for benign liver tumors and hepatic metastases.This retrospective cohort study compared patients who underwent hepatectomy for benign liver tumors and metastases reported to National Surgical Quality Improvement Program between 2005 and 2011.A total of 5,542 patients underwent hepatectomy: 1,164 (21%) for benign and 4,378 (79%) for metastatic diseases. Patients with benign tumors were younger, predominantly female, and were less likely to have preoperative comorbidities (all P.037). Rates of major complications including infections, embolism, renal failure, stroke, coma, cardiac arrest, reoperation, and ventilator dependence were similar between the 2 groups (all P ≥ .05). Thirty-day mortality was .9% among patients with benign tumors and 1.4% among patients with metastases (P = .128). After adjusting for significant effects of age and major complications (both P ≤ .007), benign vs malignant diagnosis and extent of hepatectomy was not associated with 30-day survival (both P ≥ .083).Despite patients with benign disease being younger and healthier, risks of major complications are similar after hepatectomy for benign and metastatic disease. Hepatectomy should be offered selectively for patients with benign liver tumors.

Background Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored. Methods All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods. Results A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76). Conclusions Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.

Background and Objectives: DNA molecular analysis has been suggested as a tool to evaluate pancreatic cysts. This study assesses whether the addition of DNA molecular analysis alters clinical management. Methods: This is a retrospective review of 46 consecutive patients who underwent EUS-FNA of pancreatic cysts with DNA molecular analysis at two major academic institutions. Cases were presented to two pancreaticobiliary surgeons first without and then with DNA molecular analysis data. The primary outcome was the frequency with which clinical management was altered with the addition of DNA molecular analysis. Results: Forty-six patients with a mean age of 62.0 (±13.4) years and mean cyst size of 3.2 (±2.3) cm were included in the study. Cyst carcinoembryonic antigen (CEA) was available in 30 patients and ranged from 0.4 to 15,927 ng/mL. DNA molecular analysis was described as benign in 23 (50%), statistically indolent in 13 (28%), statistically higher risk in 9 (20%), and indeterminate in 1 (2%). Surgeon #1 changed the management in 13/46 cases (28%) and surgeon #2 changed the management in 12/46 cases (26%) with the addition of DNA molecular analysis. When organized by CEA concentration, those with an intermediate CEA (45–800 ng/mL) or without a CEA concentration had a management changed more frequently (40%) compared to all others (P < 0.05). Conclusions: The addition of DNA molecular analysis alters the clinical management of pancreatic cystic lesions most often when CEA levels are intermediate (45–800 ng/mL) or when no CEA concentration is available. Use of DNA molecular analysis can be considered in this cohort. Further study of molecular markers in pancreatic cystic lesions is recommended.

The impact of venous thromboembolism (VTE) after hepatectomy on patient morbidity, mortality, and resource usage remains poorly defined. Better understanding of thromboembolic complications is needed to improve perioperative management and overall outcomes. About 3973 patients underwent hepatectomy within NSQIP between 2005 and 2008. Patient characteristics, operative features, and postoperative correlates of VTE were compared with identify risk factors for VTE and to assess its overall impact on postoperative outcomes. Overall incidence of postoperative VTE was 2.4 per cent. Risk factors for postoperative VTE included older age, male gender, compromised functional status, degree of intraoperative blood transfusion, preoperative albumin level (all P < 0.05), and extent of hepatectomy ( P = 0.004). Importantly, major postoperative complications, including acute renal failure, pneumonia, sepsis, septic shock, reintubation, prolonged ventilation, cardiac arrest, and reoperation were all associated with higher rates of VTE (all P < 0.05). Operative mortality was increased among patients with VTE (6.5% vs 2.4%, P = 0.03), and patients with VTE had a 2-fold increase in hospital length of stay (12.0 vs 6.0 days, P < 0.001). Postoperative VTE remains a significant source of morbidity, mortality, and increased resource usage after hepatectomy in the United States. Routine aggressive VTE prophylaxis measures are imperative to avoid development of VTE among patients requiring hepatectomy.

OBJECTIVES Delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) is associated with increased hospital length of stay (LOS) and health care costs. We hypothesized that a long gastrojejunostomy for PD (LGPD) is associated with decreased incidence of DGE. METHODS Data were reviewed from patients who underwent standard PD (SPD), pylorus-preserving PD (PPPD), or LGPD with a 9-cm-long anastomosis between August 2000 and July 2010. Primary outcomes included presence and grade of DGE and LOS. The International Study Group of Pancreatic Surgery definition was used to define DGE. RESULTS A total of 194 PDs (28 SPDs, 82 PPPDs, and 84 LGPDs) were performed. The rates of DGE were 46.4%, 37.8%, and 16.7%, respectively (P = 0.001). The LGPD was associated with fewer grades B/C DGE (2.4%) compared to SPD (10.7%) and PPPD (17.5%). Rates of postoperative abdominal fluid collection and abscess were similar among the groups. Patients with DGE had significantly longer LOS (14.0 vs 7.0 days, P < 0.001). CONCLUSIONS This is the first study evaluating the effect of a long gastrojejunostomy on the incidence of DGE after PD. The LGPD is associated with significantly decreased DGE compared to SPD and PPPD and warrants further exploration as a means to improve outcome for patients who undergo PD.

BackgroundPopulation‐based studies historically report underutilization of a resection in patients with colorectal metastases to the liver. Recent data suggest limitations of the methods in the historical analysis. The present study examines trends in a hepatic resection and survival among Medicare recipients with hepatic metastases.MethodsMedicare recipients with incident colorectal cancer diagnosed between 1991 and 2009 were identified in the SEER(Surveillance, Epidemiology and End Results)‐Medicare dataset. Patients were stratified into historical (1991–2001) and current (2002–2009) cohorts. Analyses compared treatment, peri‐operative outcomes and survival.ResultsOf 31 574 patients with metastatic colorectal cancer to the liver, 14 859 were in the current cohort treated after 2002 and 16 715 comprised the historical control group. The overall proportion treated with a hepatic resection increased significantly during the study period (P

To characterize clinical and radiological features associated with biliary cystic tumors (BCTs) of the liver, and to define recurrence-free and overall survival.Biliary cystadenoma (BCA) and biliary cystadenocarcinoma (BCAC) are rare tumors that arise in the liver.Between 1984 and 2013, 248 patients who underwent surgical resection of BCA or BCAC were identified. Clinical and outcome data were analyzed.Median total bilirubin, CA19-9, and carcinoembryonic antigen (CEA) levels were 0.6 mg/dL, 15.0 U/mL, and 2.7 ng/mL, respectively. Preoperative imaging included computed tomography only (62.5%), magnetic resonance imaging only (6.9%), or CT + MRI (18.5%). Features on cross-sectional imaging included multiloculation (56.9%), mural nodularity (16.5%), and biliary ductal dilatation (17.7%). The presence of these factors did not reliably predict BCAC versus BCA (sensitivity, 81%; specificity, 21%). Median biliary cyst size was 10.0 cm (interquartile range, 7-13 cm). Operative interventions included unroofing/partial excision of the lesion (14.1%), less than hemihepatectomy (48.8%), or hemi-/extended hepatectomy (36.3%). On pathology most lesions were BCA (89.1%), whereas 27 (10.9%) were BCAC. At last follow-up, there were 46 (18.3%) recurrences; 2 patients who initially had BCA recurred with BCAC. Median overall survival was 18.1 years; 1-year, 3-year, and 5-year survival was 95.0%, 86.8%, and 84.2%, respectively. Long-term outcomes were associated with BCAC versus BCA, as well as the presence of spindle cell/ovarian stroma (both P0.05).Among patients undergoing surgery for BCT, associated malignancy was uncommon (10%) and no preoperative findings reliably predicted underlying BCAC. After excision of BCA, long-term outcomes were good; however, patients with BCAC had a worse long-term prognosis.

Background Cholangiocarcinoma (CCA) is a malignancy with a poor 5-year survival rate (5%-10%). ERCP-directed radiofrequency ablation (RFA) or photodynamic therapy (PDT) can be performed as palliative therapy for unresectable CCA. ERCP with PDT is associated with improved survival compared with stent placement alone. However, ERCP-directed RFA has not been directly compared with PDT in patients with CCA. Objective To compare overall survival in patients with unresectable CCA who underwent palliative ERCP-directed RFA versus PDT. Design Retrospective cohort study. Setting Tertiary-care academic medical center. Patients Forty-eight patients with unresectable CCA who underwent ERCP-directed ablative therapy for palliation of unresectable CCA. Interventions ERCP-directed RFA or PDT. Main Outcome Measurements Overall survival by Kaplan-Meier analysis after initial treatment with either RFA or PDT. Results Patients who underwent RFA (n = 16) demonstrated an overall survival similar to that of those who underwent PDT (n = 32), with a median survival of 9.6 versus 7.5 months, respectively ( P = .799). Patient age ( P = .45), sex ( P = .52), and lead time ( P = .59) from presentation to initial RFA or PDT had no significant association with survival. The presence of distant metastasis was inversely associated with survival (hazard ratio 3.55; 95% confidence interval, 1.29-9.77; P = .014). Patients who underwent RFA (compared with PDT) had a lower mean number of plastic stents placed per month (0.45 vs 1.10, P = .001) but also had more episodes of stent occlusion (0.06 vs 0.02, P = .008) and cholangitis (0.13 vs 0.05, P = .008) per month. Limitations Retrospective, single-center design. Conclusions Survival after ERCP-directed RFA and PDT was not statistically different in patients with unresectable CCA. A randomized, controlled trial is warranted to validate these preliminary results.

Cystic diseases of the liver occur in about 5-10% of the population.(1) While simple cysts are most common, biliary cystic tumors (BCT), namely biliary cystadenoma (BCA) and cystadenocarcinoma (BCAC) can arise in a subset of patients. Hueter first reported BCA in 1887 and Keen reported the first BCA resection five years later.(2, 3) Since that time, there has been a relative paucity of data published on the surgical management of BCT. Due to the rarity of BCT, many clinicians may be unfamiliar with the diagnostic features, therapeutic management, and natural history of these liver neoplasms. We herein provide an evidence-based review of BCT with particular emphasis on early recognition and approach to management. A search of available electronic databases including MEDLINE/Pubmed using the terms “biliary cystadenoma”, “biliary cystadenocarcinoma”, and “non parasitic hepatic cysts” was conducted. Additionally, we searched the MeSH database under the heading “Liver Neoplasm” in combination with the above referenced terms and Boolean operator AND or OR. Criteria for inclusion included English language articles using human subjects (Figure 1). Open in a separate window Figure 1 A PRISMA diagram defining the method of inclusion and exclusion for studies utilized in the review.

Background The utilization of post‐operative clinical pathways leads to shorter hospital stays and decreased healthcare costs. This study evaluated patient outcomes after implementation of a 6‐day discharge pathway after a pancreaticoduodenectomy. Methods A post‐operative clinical pathway was developed and implemented for patients undergoing a pancreaticoduodenectomy at the present institution aimed at discharge by post‐operative day six. Patient charts were retrospectively reviewed to determine the rates of adherence to the pathway at each step, readmission and post‐operative complications. Results In total, 113 consecutive patients underwent a pancreaticoduodenectomy, receiving post‐operative care under the clinical pathway guidelines. The median length of stay was 7 days (mode 6 days); 41% of patients were discharged by post‐operative day six, 62% by day seven and 79% by day eight. In univariate analysis, delayed gastric emptying was associated with a delayed discharge after post‐operative day six (P = 0.002). There were no post‐operative deaths and 16% of patients required readmission within 30 days of discharge. In univariate analysis, obesity was the only variable associated with an increased rate of readmission (P Discussion Clinical pathway utilization after a pancreaticoduodenectomy allows a high percentage of patients to be discharged within a week and is associated with a low rate of readmission. Clinical pathway implementation allows for safe and efficient patient care.

Background Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach. Results There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients. Discussion Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.

Background Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. Materials and methods Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. Results Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm ( n = 229, 44%), primary hepatic neoplasm ( n = 108, 21%), primary extra-hepatic biliary neoplasm ( n = 23, 4%), and nonmalignant indications ( n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). Conclusions Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.

The impact of venous thromboembolism (VTE) after hepatectomy on patient morbidity, mortality, and resource usage remains poorly defined. Better understanding of thromboembolic complications is needed to improve perioperative management and overall outcomes. About 3973 patients underwent hepatectomy within NSQIP between 2005 and 2008. Patient characteristics, operative features, and postoperative correlates of VTE were compared with identify risk factors for VTE and to assess its overall impact on postoperative outcomes. Overall incidence of postoperative VTE was 2.4 per cent. Risk factors for postoperative VTE included older age, male gender, compromised functional status, degree of intraoperative blood transfusion, preoperative albumin level (all P0.05), and extent of hepatectomy (P = 0.004). Importantly, major postoperative complications, including acute renal failure, pneumonia, sepsis, septic shock, reintubation, prolonged ventilation, cardiac arrest, and reoperation were all associated with higher rates of VTE (all P0.05). Operative mortality was increased among patients with VTE (6.5% vs 2.4%, P = 0.03), and patients with VTE had a 2-fold increase in hospital length of stay (12.0 vs 6.0 days, P0.001). Postoperative VTE remains a significant source of morbidity, mortality, and increased resource usage after hepatectomy in the United States. Routine aggressive VTE prophylaxis measures are imperative to avoid development of VTE among patients requiring hepatectomy.

Background Chronic pancreatitis and its resultant pain, glandular dysfunction, and detriment to quality of life is a challenging and resource-intensive problem for health care systems despite the plethora of modalities developed to treat it. Removal of the gland and source of pain via total pancreatectomy is an effective, albeit drastic solution, with the potential for morbidity due to the complete loss of endocrine and exocrine function. The consequent “brittle diabetes” due to loss of endocrine function and glucagon-dependent counter-regulation may be ameliorated by autologous islet transplantation. Unfortunately, factors leading to optimal outcomes are poorly defined. Results Data is mixed and limited to case series from institutions currently performing the procedure, but factors predictive of islet cell yields and overall insulin-independence include: disease etiology, metabolic status, and duration and severity of the disease. Imaging studies may prove an appropriate method for determination of pancreatic volume and disease complications prior to operative intervention. Although potentially overlooked, the resultant malabsorptive diarrhea, traditionally treated with pancreatic enzyme replacement therapy, is a significant barrier to postoperative quality of life and still requires further research and investigation. Discussion T otal pancreatectomy with autologous islet transplantation is a proven and effective method for treating those with intractable pain from chronic pancreatitis, but remains barred from widespread use due to cost, limited availability, and potential morbidity. Though great advances have been made, additional efforts at perioperative optimization, appropriate candidate selection and time to intervention must still be sought to further improve post-operative outcomes.

Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases performed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants.

Heparin-induced thrombocytopenia is a common adverse effect of treatment with heparin resulting in paradoxical thromboses. An immunoglobulin G class "heparin-induced thrombocytopenia antibody" attaches to a heparin-platelet factor 4 protein complex. The antibody then binds to the FcγIIa receptor on the surface of a platelet, resulting in activation, consumption, and thrombocytopenia in the clinical syndrome of heparin-induced thrombocytopenia. In contradistinction to other drug-induced thrombocytopenias that lead to a risk of hemorrhage, the state of thrombocytopenia in heparin-induced thrombocytopenia leads to an acquired hypercoagulability syndrome. Bilateral adrenal hemorrhage associated with heparin-induced thrombocytopenia has become an increasingly documented association. The adrenal gland has a vascular construction that lends itself to venous thrombus in the setting of heparin-induced thrombocytopenia and subsequent arterial hemorrhage. A literature search revealed 17 reported cases of bilateral adrenal hemorrhage in the setting of heparin-induced thrombocytopenia uniformly presenting with complete hemodynamic collapse.An Ovid MEDLINE search of the English-language medical literature was conducted, identifying articles describing cases of bilateral adrenal hemorrhage in the setting of heparin-induced thrombocytopenia.All cases with this association were included in the review.A total of 14 articles were identified, describing 17 individual case reports of bilateral adrenal hemorrhage associated with heparin-induced thrombocytopenia. All cases confirmed known characteristics of heparin-induced thrombocytopenia and uniformly revealed hypotension due to adrenal insufficiency. There were five deaths, resulting in an overall mortality rate of 27.8%, and 100% mortality in the three cases where adrenal insufficiency went unrecognized.The secondary complication of adrenal vein thrombosis leading to bilateral adrenal hemorrhage remains insufficiently recognized and undertreated. The nonspecific presentation of adrenal hemorrhage and insufficiency as a complication of heparin-induced thrombocytopenia, coupled with the catastrophic clinical course of untreated adrenal collapse, requires a high index of suspicion to achieve rapid diagnosis and provide life-saving therapy.

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 (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

BACKGROUND: Management of neuroendocrine tumor liver metastasis (NELM) remains controversial, with some advocating an aggressive surgical approach while others have adopted a more conservative strategy. We sought to define the efficacy of the surgical management of NELM in a large multicenter international cohort of patients. METHODS: We identified 339 patients who underwent surgical management for NELM from 1985 to 2009 from an international database of eight major hepatobiliary centers. Relevant clinicopathologic data were assessed using Kaplan-Meier and Cox regression models. RESULTS: Most patients had a pancreatic (40%) or small bowel (25%) neuroendocrine tumor (NET) primary. The majority of patients (60%) had bilateral liver disease. At surgery, 78% of patients underwent hepatic resection, 3% ablation alone, and 19% resection + ablation. Major hepatectomy was performed in 45% of patients, and 14% underwent a second liver operation. Carcinoid was the most common NET histological subtype (53%). Median survival was 125 months, with overall 5- and 10-year survival of 74%, and 51%, respectively. Disease recurred in 94% of patients at 5 years. Patients with hormonally functional NET who had R0/R1 resection benefited the most from surgery (P = 0.01). On multivariate analyses, synchronous disease [hazard ratio (HR) = 1.9], nonfunctional NET hormonal status (HR = 2.0), and extrahepatic disease (HR = 3.0) remained predictive of worse survival (all P < 0.05). CONCLUSIONS: Liver-directed surgery for NELM is associated with prolonged survival; however, the majority of patients will develop recurrent disease. Patients with hormonally functional hepatic metastasis without prior extrahepatic or synchronous disease derive the greatest survival benefit from surgical management.

This review focuses on the common general surgical referral problem of an undefined liver lesion. Understanding the clinical context in which the patient presents allows one to narrow the differential diagnosis and develop a focused evaluation plan. Most often, MRI is the most helpful initial study to define the likely diagnosis. If the appropriate radiologic expertise exists locally, most of the diagnostic evaluation, if not all, is feasible by a practicing general surgeon. Likewise, understanding the fundamentals of liver anatomy and physiology will facilitate the general surgeons' ability to evaluate the patient's imaging and liver reserve to decide whether local surgical care can be done safely. If local care is not available or safe, referral to a hepatobiliary specialist is appropriate. Ultimately, it is most important for the general surgeon contemplating surgery on the liver to understand his or her own limitations and the limits of their institutions' capabilities in providing pre- and postoperative care. It is particularly important to understand the pitfalls associated with decision-making for complex hepatobiliary problems and when considering an operation on anybody with significant intrinsic liver disease. When faced with these scenarios, the practicing general surgeon should always raise the question: "Is this patient better served at a hepatobiliary center or one that offers liver transplant?" If yes, a phone call, if not a referral, to a tertiary center to discuss the case is reasonable before embarking on a potentially hazardous operation.

Background Benign biliary strictures (BBS) are usually managed with plastic stents, whereas placement of uncovered metallic stents has been associated with failure related to mucosal hyperplasia. Objective We analyzed the efficacy and safety of temporary placement of a covered self-expanding metal stent (CSEMS) in BBS. Design Patients with BBS received temporary placement of CSEMSs until adequate drainage was achieved; confirmed by resolution of symptoms, normalization of liver function tests, and imaging. Setting Tertiary-care center with long-standing experience with CSEMSs. Patients Seventy-nine patients with BBS secondary to chronic pancreatitis (32), calculi (24), liver transplant (16), postoperative biliary repair (3), autoimmune pancreatitis (3), and primary sclerosing cholangitis (1). Intervention ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or a rat-tooth forceps. Main Outcome Measurements End points were efficacy, morbidity, and clinical response. Results CSEMSs were removed from 65 patients. Resolution of the BBS was confirmed in 59 of 65 patients (90%) after a median follow-up of 12 months after removal (range 3-26 months). If patients who were lost to follow-up, developed cancer, or expired were considered failures, then an intent-to-treat global success rate of 59 of 79 (75%) was obtained. Complications associated with placement included 3 post-ERCP pancreatitis (4%), 1 postsphincterotomy bleed (1%), and 2 pain that required CSEMS removal (2%). In 11 patients (14%), the CSEMS migrated. In 1 patient, CSEMS removal was complicated by a bile leak that was successfully managed with plastic stents. Limitation Pilot study from a single center. Conclusions Temporary CSEMS placement in patients with BBS offers a potential alternative to surgery.

Recent international consensus guidelines propose that cystic pancreatic tumors less than 3 cm in size in asymptomatic patients with no radiographic features concerning for malignancy are safe to observe; however, there is little published data to support this recommendation. The purpose of this study was to determine the prevalence of malignancy in this group of patients using pancreatic resection databases from five high-volume pancreatic centers to assess the appropriateness of these guidelines. All pancreatic resections performed for cystic neoplasms ≤3 cm in size were evaluated over the time period of 1998–2006. One hundred sixty-six cases were identified, and the clinical, radiographic, and pathological data were reviewed. The correlation with age, gender, and symptoms (abdominal pain, nausea and vomiting, jaundice, presence of pancreatitis, unexplained weight loss, and anorexia), radiographic features suggestive of malignancy by either computed tomography, magnetic resonance imaging, or endoscopic ultrasound (presence of solid component, lymphadenopathy, or dilated main pancreatic duct or common bile duct), and the presence of malignancy was assessed using univariate and multivariate analysis. Among the 166 pancreatic resections for cystic pancreatic tumors ≤3 cm, 135 cases were benign [38 serous cystadenomas, 35 mucinous cystic neoplasms, 60 intraductal papillary mucinous neoplasms (IPMN), 1 cystic papillary tumor, and 1 cystic islet cell tumor], whereas 31 cases were malignant (14 mucinous cystic adenocarcinomas and 13 invasive carcinomas and 4 in situ carcinomas arising in the setting of IPMN). A greater incidence of cystic neoplasms was seen in female patients (99/166, 60%). Gender was a predictor of malignant pathology, with male patients having a higher incidence of malignancy (19/67, 28%) compared to female patients (12/99, 12%; p < 0.02). Older age was associated with malignancy (mean age 67 years in patients with malignant disease vs 62 years in patients with benign lesions (p < 0.05). A majority of the patients with malignancy were symptomatic (28/31, 90%). Symptoms that correlated with malignancy included jaundice (p < 0.001), weight loss (p < 0.003), and anorexia (p < 0.05). Radiographic features that correlated with malignancy were presence of a solid component (p < 0.0001), main pancreatic duct dilation (p = 0.002), common bile duct dilation (p < 0.001), and lymphadenopathy (p < 0.002). Twenty-seven of 31(87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy. Forty-five patients (27%) were identified as having asymptomatic cystic neoplasms. All but three (6.6%) of the patients in this group had benign disease. Of the patients that had no symptoms and no radiographic features, 1 out of 30 (3.3%) had malignancy (carcinoma in situ arising in a side branch IPMN). Malignancy in cystic neoplasms ≤3 cm in size was associated with older age, male gender, presence of symptoms (jaundice, weight loss, and anorexia), and presence of concerning radiographic features (solid component, main pancreatic duct dilation, common bile duct dilation, and lymphadenopathy). Among asymptomatic patients that displayed no discernable radiographic features suggestive of malignancy who underwent resection, the incidence of occult malignancy was 3.3%. This study suggests that a group of patients with small cystic pancreatic neoplasms who have low risk of malignancy can be identified, and selective resection of these lesions may be appropriate.

The task of breaking bad news, whether news of need for biopsy or a new breast cancer diagnosis, is increasingly performed by breast imaging radiologists. Most radiologists have little exposure to didactic teaching or modeling for learning methods of breaking bad news. Understanding barriers for communicating bad news and general improvements in communication, such as avoiding jargon and active listening, are initial steps in learning this important task. Bad news should be communicated to a patient in a supportive environment and directly in simple, but not blunt, terms. The amount of news delivered at any one time must be judged by a patient's response. It may be preferable to deliver bad news in smaller portions to allow time for a patient to cope. The use of a "warning shot," particularly at the time of diagnostic imaging, can be helpful to alert patients to forthcoming bad news. Common patient responses to bad news include shock, disbelief, denial, fear, anger, and guilt. An empathetic response from a physician demonstrates support. In breast imaging, providing a patient with perspective about her risk for breast cancer or the characteristics of the cancer if early may instill hope without giving false reassurance. Establishing a plan, typically an appointment with a breast surgeon in the setting of breast cancer, allows a patient to have a sense of control over her disease. Offering additional support also demonstrates empathy. The task of delivering bad news is an important task that, if done well, improves patients' ability to cope with their disease.

Re-resection for gallbladder carcinoma incidentally discovered after cholecystectomy is routinely advocated. However, the incidence of finding additional disease at the time of re-resection remains poorly defined. Between 1984 and 2006, 115 patients underwent re-resection at six major hepatobiliary centers for gallbladder carcinoma incidentally discovered during cholecystectomy. Data on clinicopathologic factors, operative details, TNM tumor stage, and outcome were collected and analyzed. Data on the incidence and location of residual/additional carcinoma discovered at the time of re-resection were also recorded. On pathologic analysis, T stage was T1 7.8%, T2 67.0%, and T3 25.2%. The median time from cholecystectomy to re-resection was 52 days. At the time of re-resection, hepatic surgery most often consisted of formal segmentectomy (64.9%). Patients underwent lymphadenectomy (LND) (50.5%) or LND + common bile duct resection (43.3%). The median number of lymph nodes harvested was 3 and did not differ between LND alone (n = 3) vs LND + common duct resection (n = 3) (P = 0.35). Pathology from the re-resection specimen noted residual/additional disease in 46.4% of patients. Of those patients staged as T1, T2, or T3, 0, 10.4, and 36.4%, respectively, had residual disease within the liver (P = 0.01). T stage was also associated with the risk of metastasis to locoregional lymph nodes (lymph node metastasis: T1 12.5%; T2 31.3%, T3 45.5%; P = 0.04). Cystic duct margin status predicted residual disease in the common bile duct (negative cystic duct, 4.3% vs positive cystic duct, 42.1%) (P = 0.01). Aggressive re-resection for incidental gallbladder carcinoma is warranted as the majority of patients have residual disease. Although common duct resection does not yield a greater lymph node count, it should be performed at the time of re-resection for patients with positive cystic duct margins because over one-third will have residual disease in the common bile duct.

Background Management of biliary leaks includes ERCP and stent placement. The ability to temporarily place a partially covered self-expandable metallic stent (CSEMS) might offer an advantage in the treatment of biliary leaks. Objective We analyzed our 2 years' experience when using this innovative technique. Design Patients in whom a previous ERCP had failed to resolve a bile leak or patients with severe comorbidities were offered CSEMS and were followed prospectively for clinical and radiologic responses. Setting Tertiary-care center with long-standing experience of using CSEMS. Patients A total of 16 patients were included. Of these, 7 had previously undergone unsuccessful plastic stent placement, 3 had previously failed ERCP, and 7 had severe comorbidities that prevented multiple interventions. Intervention ERCP with placement of a CSEMS covering the cystic duct take-off in the case of a cystic-stump leak. CSEMS were removed after resolution of the leak. Main Outcome Measurements Efficacy and safety of the CSEMS in bile leaks; complications were also evaluated. Results Of the patients studied, 15 responded to CSEMS placement with complete resolution of the leak on imaging. One patient with partial cholecystectomy relapsed and underwent drainage; another patient responded to the treatment but required revision because of migration. CSEMS were left in place for a median time of 3 months (range, 1-17 months). Complications included 1 proximal and 1 distal migration. Limitations Pilot study from a single center. Conclusions CSEMS is an excellent option in this subgroup of patients not responding to plastic stent placement or with severe comorbidities.

OBJECTIVES Characterization of pancreatic cysts using endoscopic ultrasound-guided fine-needle aspiration includes cytological interpretation and chemical analysis. We prospectively analyzed the contribution of carcinoembryonic antigen (CEA) and cytological identification of extracellular mucin as predictors of mucinous neoplasia and malignancy. METHODS From January 2003 to October 2005, all patients referred to the University of Virginia with cystic lesions of the pancreas underwent endoscopic ultrasound-guided fine-needle aspiration with cytological evaluation and CEA level analysis. Data were collected prospectively and confirmed by resection or tissue biopsy. Univariate and multivariate analyses were performed on the following variables with regard to their ability to predict mucinous neoplasia: age ( 55 years), sex, CEA level ( 300 ng/mL), and cytological appreciation of extracellular mucin (positive or negative). P values less than 0.05 were considered significant. RESULTS A total of 43 patients were included in this study. There were 19 men and 24 women with a mean age of 63 +/- 14 years. The only complication was pancreatitis secondary to cyst leak in one patient. Multivariate analysis confirmed CEA level greater than 300 ng/mL (P= 0.007) and the identification of mucin (P < 0.001) as significant predictors. CONCLUSIONS With pancreatic cyst fluid analysis, the strongest predictor of mucinous neoplasia is the presence of identifiable mucin, followed by a CEA level greater than 300 ng/mL. The workup of cystic lesions of the pancreas should include chemical analysis for the CEA level and cytological examination with particular attention to extracellular mucin.

Background EUS–guided pancreaticogastrostomy (EPG) has been reported as an alternative to surgery in cases of pancreatic stricture where ERCP is unsuccessful. Objective We analyzed our 3-year experience with this innovative technique. Design Patients with failed ERCP for pancreatic drainage were offered EPG over a 3-year period and were followed up prospectively in terms of clinical and radiologic response. Setting Tertiary care center offering ERCP and interventional EUS. Patients Thirteen patients were included in this study. Seven had surgical diversion Six patients had unaltered enteral anatomy and stricture related to chronic pancreatitis (3), gallstone pancreatitis (2), and intraductal pancreatic mucinous neoplasm (1). Intervention EUS-guided puncture and opacification of the pancreatic duct was performed, creating a transgastric fistula with placement of a guidewire into the main pancreatic duct and subsequent ductal decompression with a plastic endoprosthesis. Main Outcome Measurements Mean main pancreatic duct size, pain score, and weight before and after intervention. Results Ten patients had successful endoprosthesis placement across the pancreaticogastric fistula. One patient underwent brush cytologic study, which diagnosed pancreatic malignancy, and underwent surgical resection. After a mean follow-up of 14 months, the mean pancreatic duct size in treated patients decreased from 4.6 to 3.0 mm ( P = .01); the pain score decreased from 7.3 to 3.6 ( P = .01). Complications included one case of bleeding requiring hemoclip placement and 1 case of contained perforation. Limitations Pilot study from a single center. Conclusions EPG is a safe and feasible alternative to surgical intervention in this subgroup of patients where conventional ERCP is not possible.

Background The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk-adjustment model for patients who require hepatic resection does not include metrics of underlying chronic liver disease. The applicability of the current risk adjustment model is under debate. This study aims to assess the impact of chronic liver disease on the ACS NSQIP estimates of postoperative morbidity and mortality. Study design This retrospective cohort study included all cases of hepatic resection at our quaternary referral institution between 2006 and 2013. Metrics of chronic liver disease were abstracted and linked with the ACS NSQIP risk-adjustment model estimated probabilities of morbidity and mortality for each case. Sequential general linear models were used to estimate differences in ACS NSQIP probabilities of morbidity and mortality associated with measures of underlying chronic liver disease. Results A total of 522 hepatic resections were performed during the study period. The patient cohort included 91 patients with fibrosis (17%) and 38 patients with cirrhosis (7%). The mean ACS NSQIP estimated probability of morbidity was 0.24 ± 0.11 and probability of mortality was 0.02 ± 0.02. Fibrosis was associated with increased probability of morbidity (0.26 ± 0.11; P = .019); cirrhosis was also associated with increased probability of morbidity (0.27 ± 0.10; P = .059). Parenchymal liver disease was not associated with increased probability of mortality (all P ≥ .62). Increased probabilities of mortality were associated with diagnosis and extent of resection (both P Conclusions In patients selected for hepatectomy, metrics of chronic liver disease were associated with differences in ACS NSQIP estimated probability of morbidity. Incorporation of metrics of chronic liver disease into the ACS NSQIP targeted hepatectomy modules should improve estimates of risk after hepatic resection.

IgG4-associated cholangitis can mimic hilar cholangiocarcinoma. Previously reported patients with IgG4-associated cholangitis mimicking cholangiocarcinoma had elevated serum IgG4 levels and long-segment biliary strictures. However, in the absence of other diagnostic criteria for malignancy, IgG4-associated cholangitis should remain a consideration among patients with normal serum IgG4 and a hilar mass suspicious for cholangiocarcinoma. The presence of a hilar mass and a malignant-appearing biliary stricture in two patients with normal serum IgG4 prompted further evaluation and subsequent concomitant liver and bile duct resection and reconstruction. The diagnosis of IgG4-associated cholangitis was established during the pathologic evaluation of the resected specimens. IgG4-associated cholangitis is a known imitator of hilar cholangiocarcinoma and should be considered in the differential diagnosis even among serologically IgG4-negative patients with a hilar mass prior to operative resection.

An isolated intrahepatic or sectorial bile duct stricture or injury is uncommon. When it occurs, it can be a vexing problem. Following hepatic trauma or operation, an intrahepatic or isolated sectorial duct may be injured directly or from ischemia. Strictures in sectorial and segmental bile ducts also can occur from inflammatory conditions. A structured approach to diagnosis and treatment is required to insure optimal treatment outcomes in this patient population. In general, treatment is to restore bilioenteric continuity or to remove the affected hepatic segment/sector.

Purpose After adopting a night float system, the residency program at the University of Virginia Health System Department of Surgery initiated a daily morning report (MR). The conference was originated to sign out new admissions and consults from the previous day to the services that would assume care. Although initially oriented toward transfer of patient information, MR is also hypothesized to serve as a competency-based resident education tool. Methods An anonymous survey was distributed to on-service residents (n = 25). Questions were asked on a 5-point Likert scale. Respondents also ranked the weekly conferences, including MR, in terms of educational benefit derived. Results Most residents agreed that MR is an efficient method to sign-out patient care [84% stongly agree (SA) or agree (A)] and that it provides an excellent educational experience (88% SA or A). They agreed that it is presented in an evidence-based format (88% SA or A). Regarding the core competencies, residents all asserted that MR addresses "patient care" (100% SA or A) and "medical knowledge" (100% SA or A). Most agreed that it addresses "professionalism" (60% SA or A), "interpersonal skills and communication" (76% SA or A), and "practice-based learning and improvement" (92% SA or A). The 4 most important components identified with respect to continuing to improve both patient care and resident education were the presence of the on-call attending, a review of relevant radiology, provision of follow-up on select cases, and critical review of the literature. On average, MR was seen as the most educational conference, with 52% of residents ranking it first. Conclusions Although MR is ubiquitous in most primary care residency programs, such a conference has not typically been held on surgical services. The MR was developed at the University of Virginia Health System Department of Surgery as a necessity for patient sign-out. As this conference has continued to evolve, it has become an excellent tool for resident education. It now serves the purpose of enhancing patient care and medical education and of providing evidence of learning and assessment of the general competencies. The MR provides an example for program directors of how to tailor existing resident work sessions or conferences to meet Accreditation Council for Graduate Medical Education (ACGME) competency requirements.

Pancreatic ductal adenocarcinoma is thought to develop through a series of genetic events through its purported precursor lesion, pancreatic intraepithelial neoplasia (PanIN). Little, however, is known regarding the role of possible precursor lesions in the development of other primary neoplasms of the pancreas. This study investigated the prevalence of PanIN, as defined by recent consensus statements, in pancreata with uncommon types of primary neoplasms. All pancreata resected at the University of Virginia from June 1, 1991 to March 1, 2005 for neoplasia not diagnosed as conventional ductal adenocarcinoma were reviewed and classified according to the World Health Organization's classification schema for tumors of the exocrine and endocrine pancreas. All slides from these cases were then assessed for PanIN, which was classified according to the criteria of the most recent consensus statement. Three acinar cell carcinomas (ACCs), 18 mucinous cystic neoplasms (MCNs), 24 pancreatic endocrine tumors (PETs), 12 serous cystadenomas (SCs), and 3 solid-pseudopapillary tumors (SPTs) were identified. PanIN was identified in the pancreata of 3 of 3 ACCs, 17 of 18 MCNs, 16 of 24 PETs, 10 of 12 SCs, and 2 of 3 SPTs. The degree of PanIN was noted to trend with patient age. Although the high prevalence of PanIN in pancreata concomitantly harboring certain uncommon neoplasms of the pancreas could signify its role as a precursor lesion for those neoplasms, its high prevalence throughout our series may simply be the result of a coincidental, prevalent finding seen in all pancreata, especially with aging. Because of the ubiquitous nature of PanIN, it should not be used histologically to assist in the diagnosis and subclassification of pancreatic neoplasia.

The purpose of this study was to assess the characteristics of surgical infections after hepatic resection (HR) to identify factors accounting for increased postoperative mortality. Advances in operative technique and care have decreased morbidity and mortality after HR. However, infections after HR continue to be a major contributor to postoperative morbidity and mortality. All HR done during a 7-year period were analyzed and compared to our prospective surgical infection database. Factors contributing to infectious complications and mortality were identified. HR (n = 207) were performed with an overall mortality of 5.8 per cent. Nine patients (3.3%) had 18 infections; 6 (60%) had multiple infection sites, most commonly the peritoneum, blood, or wound. Three infected patients died. Lung and line infections occurred in 2 (67%) infection-related deaths. No single comorbidity increased postoperative infection risk, but an average of 6.7 co-morbid conditions were present. All infection-related deaths were associated with ventilator-dependence. All infection-related deaths occurred after resection of a mean of four segments. Additional procedures at the time of HR, operative drains, or transfusion requirements did not impact infectious complications or mortality. Methicillin-resistant Staphylococcus sp. was isolated in all infection-related deaths. The mean time from HR to initiation of treatment was 8 days for infection survivors and 13.3 days for infection-related deaths. Infectious mortality after HR remains significant. Contributing risk factors are advanced age, multiple comorbid conditions, and extent of HR. Ventilator-dependence and delays in antibiotic therapy were associated with infectious mortality. Although gram-negative enteric infections were more common, abdominal, lung, and line infections with gram-positive cocci had higher associated mortality; especially when antibiotic resistant strains were present.