Timing of mastectomy and the effect on the likelihood of outpatient surgery and cost savings in breast cancer patients.

BACKGROUND: Same-day discharge after mastectomy has potential patient- and hospital-level benefits; however, few data are available regarding factors affecting the likelihood of same-day discharge in order to address barriers. We sought to evaluate factors contributing to same-day discharge, focusing on the timing of mastectomy during the operative day. METHODS: We conducted a single-institution retrospective review of patients who underwent mastectomies for malignancy over a 3-y time frame. Clinicopathologic variables were collected along with a binary variable for mastectomy start time (morning versus afternoon). Our primary endpoint was rate of same-day discharge. A multivariable logistic regression model was constructed from significant univariate variables to determine independent predictors of same-day discharge. A secondary endpoint was a cost-utility analysis for morning versus afternoon start time, using hospital cost data. RESULTS: There were 451 patients included in the analysis. Factors associated with same-day discharge rate included the American Society of Anesthesiologists score, use of a preoperative regional anesthesia block, type of mastectomy performed, individual surgeon variation, and a morning start for the mastectomy. On multivariable analysis, morning start was a strong independent predictor of same-day discharge (odd ratio = 2.83; 95% CI, 1.75-4.60). The cost-utility analysis favored a morning start, with average cost savings of $550 per patient. CONCLUSION: Despite patient- and surgeon-specific variations, simple scheduling policies can improve same-day discharge rates after mastectomy, leading to improved hospital bed use and cost reduction.

Kirsten rat sarcoma (KRAS) oncogene mutation predicts magnitude of response and outcomes in hepatic arterial infusion pump therapy of unresectable colorectal liver metastases.

Background: The Kirsten rat sarcoma (KRAS) mutation predicts negative outcomes following resection of colorectal liver metastases (CRLM) and adjuvant hepatic arterial infusion (HAI) pump chemotherapy. Less is known on the effects of KRAS mutation on tumor response in patients with unresectable CRLM undergoing HAI chemotherapy with floxuridine. Methods: This is a retrospective cohort study investigating the effects of KRAS mutation on tumor response in patients with unresectable CRLM treated with HAI chemotherapy. Primary endpoint was objective response rate (ORR), secondary endpoints included overall tumor response and conversion to resectability. Results: Twenty-five patients with unresectable liver metastases from colorectal cancer were treated with HAI chemotherapy between 2017-2019. Median number of liver lesions was 12 (range, 1-59) and almost all (n=24) had prior chemotherapy before starting HAI therapy. Median number of cycles administered via HAI pump was 6 (range, 3-12). Overall decrease in liver tumor burden was 63.5% (median; range, -257-100%) with an ORR of 20/25 (80%) and 10 (40%) patients converting to resectable status. Eleven (44%) patients had KRAS positive tumors. When compared to wild-type, KRAS positive tumors had less overall percent decrease (58% vs. 70%; P=0.04) and ORR (7/11 vs. 13/13; P=0.03). Fewer patients with KRAS positive tumors converted to resectable status during HAI therapy (2/11 vs. 8/13; P=0.05). At a median follow-up of 14.6 months (range, 4.0-36.6 months), overall survival is 45% among KRAS-positive and 77% for wild type patients. Conclusions: KRAS mutational status in patients with unresectable liver metastases from colorectal cancer predicts worse response to HAI chemotherapy compared to wild type.

Preoperative tranexamic acid does not reduce transfusion rates in major oncologic surgery: Results of a randomized, double-blind, and placebo-controlled trial.

BACKGROUND AND OBJECTIVES: Allogeneic blood transfusions are associated with worse postoperative outcomes in oncologic surgery. The aim of this study was to introduce a preoperative intervention to reduce transfusion rates in this population. METHODS: Adult patients undergoing major oncologic surgery in five categories with similar transfusion rates were recruited. Enrollees received a single preoperative intravenous dose of placebo or tranexamic acid (1000 mg). The primary outcome measure was perioperative transfusion rate. Secondary outcome measures included: estimated blood loss, thromboembolic events, morbidity, hospital length of stay, and readmission rate. RESULTS: Seventy-six patients were enrolled, 39 in the tranexamic acid group and 37 in the placebo group, respectively. Demographics and surgery type were equivalent between groups. The transfusion rates were 8 out of 39 (20.5%) in the tranexamic acid group and 5 out of 37 (13.5%) in the placebo group, respectively (P = .418). Median estimated blood loss was 400 mL (interquartile range [IQR] = 150-600) in the tranexamic acid group compared with 300 mL (IQR = 150-800) in the placebo group (P = .983). There was one pulmonary embolism in each arm and no deep venous thrombosis (P > .999). CONCLUSION: Preoperative administration of tranexamic acid at a 1000 mg intravenous dose does not decrease transfusion rates or estimated blood loss in patients undergoing major oncologic surgery.

Impact of Neoadjuvant Versus Adjuvant Chemotherapy on the Extent of Axillary Surgery for Clinically Node-Negative Breast Cancers of Triple-Negative and HER2-Overexpressing Phenotypes.

BACKGROUND: Breast cancer patients with triple-negative or human epidermal growth factor receptor 2 (HER2)-overexpressing phenotypes are recommended to receive chemotherapy for primary tumors greater than 1 cm regardless of nodal status. Neoadjuvant chemotherapy may eradicate subclinical nodal metastases and reduce the extent of axillary surgery performed. PATIENTS AND METHODS: A query of the National Cancer Database Participant User File was performed for new cases of female breast cancer from 2012 to 2015. Inclusion criteria were clinical N0 status, receipt of chemotherapy, and receipt of axillary surgery. Exclusions included hormone-positive/HER2-negative tumors and/or distant metastatic disease. Subjects were divided into groups by receipt of neoadjuvant or adjuvant chemotherapy. The primary end point was the extent of axillary surgery, defined as sentinel lymph node biopsy alone or axillary lymph node dissection (ALND). Subgroup analyses were performed on the basis of tumor phenotype and surgery of the primary site. RESULTS: A total of 66,771 female patients were included, 15,967 of whom underwent neoadjuvant chemotherapy. ALND rates were higher in patients who received adjuvant chemotherapy (30.6% vs. 28.8%, P < .001). Among tumor phenotypes, the extent of axillary surgery was reduced most significantly for hormone-negative, HER2-positive disease (30.0% vs. 25.8%, P < .001). ALND rates were more substantially reduced for patients who underwent mastectomy (41.3% vs. 36.1%, P < .001) compared to partial mastectomy (21.8% vs. 20.1%, P = .002). Adjuvant chemotherapy was an independent predictor of ALND (odds ratio, 1.26; 95% confidence interval, 1.19-1.33). CONCLUSION: Neoadjuvant chemotherapy reduces the extent of axillary surgery in clinically node-negative, nonluminal breast cancers.

Implementation of a Weekly Administrative Hour and the Impact on Case Logging and Duty Hour Reporting in Surgical Residents.

OBJECTIVE: To investigate the impact of a dedicated weekly administrative hour on case logging, duty hour reporting, and duty hour violations. DESIGN: Retrospective analyses of 2 timeframes pre-implementation and post-implementation of a dedicated weekly administrative hour in a surgical residency were assessed for changes in duty hour reporting, case logging, and duty hour violations. The preimplementation period spanned from July 2011 to June 2014 and the postimplementation period from July 2014 to June 2017. SETTING: Community-based, university-affiliated hospital. PARTICIPANTS: A total of 79 surgical residents were included over a 6-year period. The subjects worked before and after the implementation of a weekly dedicated administrative time. RESULTS: Seven and 30-day procedure logging rates improved from 28.7% to 37.2% and 52.7% to 69.9%, respectively (p < 0.001). PGY 1 residents showed a significant increase in procedures logged within 7 days during the postimplementation period. PGY 1, PGY 2 and PGY 3 all showed a significant increase in procedures logged within 30 days during the postimplementation period. Seven and 30-day duty hour completion rates increased postimplementation from 7.8% to 9.2% (p < 0.001) and 64.7% to 67.3% (p < 0.001), respectively. Duty hour violations decreased in the postimplementation time frame (40.6% vs 29.2%, p < 0.001). Duty hour violations were more common in earlier years of training. PGY 1 were 15.6 times more likely to have an 80 hours. per week violation than a PGY5 (OR: 15.1; 95% CI: 2.1-118.0). CONCLUSIONS: Procedural logging and duty hour compliance improved after implementation of a dedicated weekly time for administrative duties. The year of a resident in training is related to compliance with logging and may impact the incidence of duty hour violations. Residents reported significantly fewer duty hour violations, however this may be multifactorial.

The impact of obesity on treatment choices and outcomes in operable breast cancer.

INTRODUCTION: Obesity has been associated with negative oncologic outcomes in breast cancer. METHODS: Retrospective review of patients with operable breast cancer at a single institution from 2009 to 2012. Patients with carcinoma in situ or metastatic disease were excluded. Variables included utilization of MRI, surgical treatment, perioperative, and long-term oncologic outcomes. Primary outcome was rate of breast conserving surgery. Secondary outcomes included MRI utilization, contralateral prophylactic mastectomy, and perioperative outcomes. RESULTS: There were 1566 patients included for the study, 596 (38%) of whom were obese. MRI was utilized less in obese patients (62.4% vs 51.2%, p < 0.001). Breast conserving surgery was more common in obese patients (53.1% vs 59.7%, p 0.010). There was no difference in performance of contralateral prophylactic mastectomy or post-mastectomy reconstruction. Perioperative outcomes were inferior in obese patients including increased surgical site infections (5.7% vs 11.7%, p < 0.001), return to the emergency department (2.5% vs 5.2%, p 0.004), and hospital readmissions (1.8% vs 3.7%, p 0.017). No difference in survival was observed. CONCLUSION: Obese patients with operable breast cancer receive different treatment than non-obese patients, however survival and recurrence outcomes were similar among the two groups.

Is there a role for Ytrrium-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma?

BACKGROUND: Selective internal radiation therapy (SIRT) with Ytrrium-90 (Y-90) has been used to treat hepatic malignancies with success. This study focuses on the efficacy and safety of Y-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma (ICC). METHODS: A single-institution retrospective case review was performed for patients with unresectable and metastatic ICC treated with Y-90 between 2006 and 2016. RESULTS: Seventeen patients with ICC underwent 21 Y-90 treatments. Four patients had undergone prior liver resection, and six patients had extrahepatic disease at the time of treatment. Five year overall survival was 26.8%, with a median survival of 33.6 months. One patient underwent margin negative liver resection after a single treatment. Complications were appreciated in two cases. Ninety-day mortality was 0%. CONCLUSION: Treatment of ICC using Y-90 is a safe and promising procedure. Further research is needed to clarify its role in the treatment of unresectable and metastatic ICC.

Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial.

BACKGROUND: The purpose of this study was to compare patient outcomes for thoracic epidural anesthesia (TEA) with transversus abdominis plane (TAP) blocks. METHODS: A prospective, randomized trial was performed for patients undergoing abdominal oncologic surgeries. RESULTS: There were 32 TAP and 35 TEA subjects. The TEA group demonstrated increased episodes of hypotension in the first 24 h (3 v 0.6, p = 0.02). There was no difference in 24-48 h fluid balance between the groups. Overall parenteral morphine equivalents of opioids administered for the TEA group were higher for each postoperative day (p < 0.05). The post-operative survey did not demonstrate any difference in subjective pain between the TAP and TEA groups (6 v 6 p = 0.35). There was no attributable morbidity associated with either technique. CONCLUSIONS: TAP block use was associated with lower parenteral morphine equivalent usage and decreased incidence of hypotension in the early post-operative period compared to TEA.

Liver Resection After Selective Internal Radiation Therapy with Yttrium-90 is Safe and Feasible: A Bi-institutional Analysis.

BACKGROUND: Treatment with yttrium-90 (Y90) microspheres has emerged as a viable liver-directed therapy for patients with unresectable tumors and those outside transplantation criteria. A select number of patients demonstrate a favorable response and become candidates for surgical resection. METHODS: Patients who underwent selective internal radiation therapy (SIRT) with Y90 microspheres at two institutions were reviewed. Patients who underwent liver resection were included in the study. The data gathered included demographics, tumor characteristics, response to Y90, surgical details, perioperative outcomes, and survival. RESULTS: The inclusion criteria were met by 12 patients. The diagnoses included metastatic disease from colorectal adenocarcinoma (n = 6), neuroendocrine tumor (n = 1), and ocular melanoma (n = 1) in addition to hepatocellular carcinoma (n = 4). The median time from liver disease diagnosis to Y90 treatment was 5.5 months (range 2-92 months). The median time from Y90 treatment to surgery was 9.5 months (range 3-20 months). The surgical approach included right hepatectomy (n = 3), extended right hepatectomy (n = 5), extended left hepatectomy (n = 1), segmentectomy with ablation (n = 2), and segmentectomy with isolated liver perfusion (n = 1). The hospital stay was 7 days (range 4-31 days), and 67% of the patients were discharged home. The readmission rate was 42%. The 90-day morbidity and mortality rates were respectively 42 and 8%. At this writing, the median overall survival has not been reached at 25 months. CONCLUSION: Liver resection after Y90 SIRT is a challenging surgical procedure with high rates of perioperative morbidity and hospital readmission. However, for properly selected patients, potential exists for extending disease-free and overall survival in the current era of multimodal therapy for malignant liver disease.

Sarcopenia and survival in patients undergoing pancreatic resection.

BACKGROUND: Recent studies have suggested that lean core muscle area may predict outcomes from major abdominal surgeries. Pancreatic resections have been independently analyzed less frequently. METHODS: Pancreatic resections from 2005 to 2012 were reviewed. Sarcopenia was defined as the lowest tertile for lean psoas muscle area (LPMA). Preoperative risk factors, including comorbidities, albumin, weight loss, age and gender, were analyzed with a primary endpoint of overall survival. Secondary endpoints included complications, discharge destination and readmission. RESULTS: The study sample of 270 patients had complications in 42% of patients, with 26% developing serious complication. The majority (80%) were discharged home, and 1.9% died in the peri-operative period. The mean length of follow up was 31.2 months (range 0-94), and 37% required at least one readmission. LPMA was predictive of discharge destination for females (p = 0.038). Sarcopenia was predictive of readmission in males, compared to subjects in the second LPMA tertile (HR 0.3; 95% CI: 0.1-0.9). In all male subjects, including a subset with adenocarcinoma, patients with sarcopenia were more likely to die than males in the highest LPMA tertile (HR: 2.6; 95% CI: 1.4-4.8 and HR: 2.4; 95% CI: 1.2-4.9, respectively). In all patients with pancreatic ductal adenocarcinoma, transfusion (HR: 1.9; 95% CI: 1.1-3.4) and positive margins (HR: 2.0; 95% CI: 1.2-3.3) were the only factors predictive of overall survival. CONCLUSIONS: Sarcopenia appears to be a predictor of overall survival in male patients undergoing pancreatic resections, but not specifically for patients with pancreatic ductal adenocarcinoma. As prospective data in future studies are identified, sarcopenia may become a useful tool in predicting outcomes.

Using next-generation sequencing to determine potential molecularly guided therapy options for patients with resectable pancreatic adenocarcinoma.

BACKGROUND: Genomic sequencing technology may identify personalized treatment options for patients with pancreatic adenocarcinoma. METHODS: The study was conducted using tissue specimens obtained from 2012 to 2014. Patients with resected pancreatic adenocarcinoma were identified. Next-generation sequencing was performed from paraffin-tumor blocks. Mutational profiles were reviewed to determine available targeted therapies and clinical trial eligibility. RESULTS: Thirty patients were identified. The incidence of mutations was: Kirsten rat sarcoma viral oncogene homolong (KRAS) = 87%, tumor protein 53 (TP53) = 63%, cyclin-dependent kinase inhibitor 2A (CDKN2A) = 20%, Mothers Against Decapentaplegic Homolog 4 (SMAD4) = 20%, epidermal growth factor receptor (EGFR) = 7%. Multiple mutations were found in 73%. All CDKN2A mutations occurred in male patients (P = .06), and there was a trend toward younger patient age in this group (P = .13). Potential for Federal Drug Administration (FDA)-approved targeted therapies was identified in 8 of 30 (27%). In addition, 29 of 30 (97%) had mutations applicable for ongoing phase I or II clinical trials. CONCLUSIONS: Next-generation sequencing of resected pancreatic adenocarcinoma specimens can determine common genetic mutations and identify patients who may be eligible for off-label use of targeted therapies or clinical trial enrollment.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis.

BACKGROUND: The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention. METHODS: A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS). RESULTS: One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis. CONCLUSIONS: Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.

Left-Sided Breast Irradiation does not Result in Increased Long-Term Cardiac-Related Mortality Among Women Treated with Breast-Conserving Surgery.

BACKGROUND: Standard therapy following lumpectomy for breast cancer has included adjuvant whole-breast radiotherapy. Recent, long-term studies have suggested a possible association between left-sided whole breast radiotherapy and long-term cardiac-related mortality. We sought to determine whether left-sided breast cancers treated with breast-conserving treatment have worse cardiac-related outcomes. METHODS: The surveillance, epidemiology, and end results database was queried for female breast cancer cases diagnosed from 1990 to 1999. Subjects who underwent lumpectomy and adjuvant radiotherapy were included for study and grouped according to laterality. The primary outcome measure was the rate of cardiac-related mortality. Secondary outcome measures were overall and cancer-specific survival. A Cox proportional hazards model was constructed to analyze the primary outcome measure and included age, race, grade, stage, hormone receptor status, and histologic subtype. RESULTS: A total of 66,687 subjects were identified. These were divided equally by laterality groups: 33,866 left (50.8 %) and 32,801 right (49.2 %). Median follow-up was 15.5 years, and the groups were otherwise well-matched. Left-sided cancer was not associated with poorer survival for any of the metrics. Fifteen-year overall survival and disease-specific survival were 62.8 and 87.0 % for left-sided and 63.0 and 87.1 % for right-sided breast cancers, respectively (p = 0.260, p = 0.702). Rate of cardiac-related mortality at 5-, 10-, and 15-year follow-up were 1.5, 4.3, and 7.7 % for left-sided cancers and 1.6, 4.4, and 8.0 % for right-sided cancers, respectively (p = 0.435). CONCLUSIONS: In this large population-based study, women receiving left-sided external beam radiation for breast cancer did not have an increase in cardiac-related mortality.

Predicting length of stay and conversion to open cholecystectomy for acute cholecystitis using the 2013 Tokyo Guidelines in a US population.

BACKGROUND: The 2013 Tokyo Guidelines (TG13) for acute cholecystitis have not been studied extensively in US populations. METHODS: A retrospective review of patients with acute cholecystitis within a single system from 2009 to 2013 was performed. The diagnosis and severity of acute cholecystitis were assigned by the TG13. The primary outcome measures were length of stay and conversion to open cholecystectomy. RESULTS: Four hundred and forty-five patients with acute cholecystitis were studied. For all patients, length of stay (P < 0.001), disposition to home (P < 0.001), and morbidity (P = 0.003) were related to increasing TG13 grade. For surgical patients (n = 256), worsened outcomes with increasing TG13 grade were seen for conversion to open (P = 0.001), operative duration (P < 0.001), length of stay (P < 0.001), disposition to home (P < 0.001), and readmission (P = 0.037). On multivariate analysis, TG13 grade was an independent predictor of increasing length of stay (P = 0.009) and conversion to open surgery (grade 2: OR 7.63 (2.25-25.90), grade 3: OR 24.2 (5.0-116.37)). CONCLUSIONS: Wide adoption of the TG13 in the US can better inform patients, hospital systems, and payers of the expected outcomes of acute cholecystitis.

A multidisciplinary approach for abdominal venous involvement in oncologic resections.

BACKGROUND: An aggressive surgical approach to locally advanced malignancy is being increasingly used in the absence of distant metastatic disease. This includes resection and reconstruction of major venous structures. We investigated the results of using a multidisciplinary surgical approach in these instances. METHODS: The study data were obtained from a university-affiliated hospital from January 1, 2006, to December 31, 2012. All patients who underwent an oncologic resection using a multidisciplinary approach with vascular surgery consultation were included in the analysis. Primary outcomes analyzed included rate of margin positivity, postoperative venous patency, and survival. Secondary outcome measures included operative time, estimated blood loss, and length of hospital stay. RESULTS: A total of 23 patients met criteria for study. Venous involvement included the portal and/or superior mesenteric vein and inferior vena cava in 14 and 9 patients, respectively. Nine patients had clear vascular involvement before surgery and received preoperative consultation. Overall margins were positive in 56.5%, whereas the rate of vascular margin positivity was 30.4%. The postoperative venous patency rate was 65.0%. There were no perioperative mortalities, and median survival was 10 months (range, 4-80). CONCLUSIONS: Major venous resections and reconstructions in oncologic surgery are safe but associated with a high rate of positive margins. Future efforts should focus on identifying patients in the preoperative phase to provide opportunity for optimal multidisciplinary planning.

Is there truly an oncologic indication for interval appendectomy?

BACKGROUND: The rate of recurrent appendicitis is low following nonoperative management of complicated appendicitis. However, recent data suggest an increased rate of neoplasms in these cases. METHODS: The study was a retrospective review of patients with acute appendicitis at 2 university-affiliated community hospitals over a 12-year period. The primary outcome measure was the incidence of appendiceal neoplasm following interval appendectomy. RESULTS: Six thousand thirty-eight patients presented with acute appendicitis. Appendectomy was performed in 5,851 (97%) patients at the index admission. Of the 188 patients treated with initial nonoperative management, 89 (47%) underwent interval appendectomy. Appendiceal neoplasms were identified in 11 of the 89 (12%) patients. These included mucinous neoplasms (n = 6), carcinoid tumors (n = 4), and adenocarcinoma (n = 1). The rate of neoplasm in patients over age 40 was 16%. CONCLUSIONS: There is a significant rate of neoplasms identified in patient over age 40 undergoing interval appendectomy. This should be considered following nonoperative management of complicated appendicitis.

Comparison of stapling techniques and management of the mesoappendix in laparoscopic appendectomy.

Many techniques for laparoscopic appendectomy have been proposed with few comparative studies. We performed a retrospective review of all patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from 2006 to 2011. Techniques were: (1) transection of the mesoappendix and appendix with a single staple line (SSL); (2) transection of the mesoappendix and appendix with multiple staple lines (MSL); and (3) transection of the mesoappendix with ultrasonic shears and the appendix with a single staple line (USSL). A total of 565 cases were reviewed (149 SSL, 259 MSL, and 157 USSL). Patients treated with the SSL technique had decreased operative duration (P<0.001) and length of stay (P=0.003) despite equivalent disease presentations. Multivariate analysis demonstrated decreased operative duration with the SSL technique (P=0.001). Use of a SSL for transection of the mesoappendix and appendix is both a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes.

Measuring the impact of the American College of Surgeons Oncology Group Z0011 trial on breast cancer surgery in a community health system.

BACKGROUND: The American College of Surgeons Oncology Group Z0011 trial has been lauded as practice changing. We sought to identify its impact on breast cancer surgery in the community hospital setting. METHODS: A retrospective review was performed from 8 community hospitals identifying patients with invasive breast cancer meeting the Z0011 criteria. The primary outcome measures were the rate of completion axillary lymph node dissection (ALND) and performance of intraoperative sentinel lymph node (SLN) analysis over time. RESULTS: A total of 1,125 lumpectomies with SLN biopsies were performed with 180 subjects meeting inclusion criteria. Performance of ALND (P < .0001) and intraoperative SLN analysis (P < .0001) declined during each time period. Patients more likely to undergo ALND included those with extracapsular extension (odds ratio [OR] 12.8, 95% confidence interval [CI] 2.5 to 67.1) and those who underwent reoperative surgery (OR 10.8, 95% CI 2.6 to 44.4) or intraoperative SLN analysis (OR 5.1, 95% CI 1.2 to 21.9). CONCLUSION: American College of Surgeons Oncology Group Z0011 trial has been rapidly practice changing in the community hospital setting.

The drowning whipple: perioperative fluid balance and outcomes following pancreaticoduodenectomy.

BACKGROUND AND OBJECTIVES: Given the high incidence of postoperative morbidity following pancreaticoduodenectomy (PD), efforts at improving patient outcomes are vital. We sought to determine the impact of perioperative fluid balance on outcomes following PD in order to identify a targeted strategy for reducing morbidity. METHODS: A retrospective review of consecutive PDs from 2008 to 2012 was completed. Cumulative fluid balances were recorded at 0, 24, 48, and 72 hr postoperatively and patients were divided into quartiles. Multivariate analyses were performed accounting for age, gender, diagnosis, ASA class, estimated blood loss, colloid and blood product use, and hemoglobin nadir. The predefined primary outcome measures were 90-day morbidity (Clavien grade ≥ III), mortality, and hospital readmission. RESULTS: One hundred sixty-nine PDs were performed during the study period. The 90-day morbidity and mortality rates for the cohort were 40.2% and 3.0%, respectively, while hospital length of stay was 13.6 ± 6.7 days (mean ± SD). Higher fluid balance at 48 and 72 hr postoperatively was an independent predictor of morbidity and length of stay on multivariate analysis. CONCLUSIONS: Higher postoperative fluid balance is associated with increased postoperative morbidity and longer hospital stay following PD. Efforts at maintaining a fluid-restrictive strategy should be emphasized in this population.