Pancreatic resections: 30 and 90-day outcomes in octogenarians.

BACKGROUND: Pancreatic tumors are frequently found in a geriatric population. Given that the median age of patients with pancreatic cancer is 70 years at diagnosis and the ubiquity of CT and MRI imaging has increased the detection of pancreas masses, pancreatic surgeons often find themselves operating on patients of advanced age. This study sought to evaluate the outcomes of pancreatic resection in an octogenarian population at a single institution with a dedicated surgical oncology team. STUDY DESIGN: A retrospective chart review was performed for all patients undergoing pancreatic resection over a 13-year period at an academic community cancer center. Patient characteristics and operative outcomes were compared between patients aged 80 and older, and those younger than 80. Student t-tests, Fisher's exact test, and Kruskal-Wallis tests were used for univariate analyses. RESULTS: Over the 13-year period, a total of 48 patients of 403 undergoing pancreatic resections were aged 80 or older. Of these 48 patients, 35 underwent pancreaticoduodenectomy (Whipple) and 13 underwent distal pancreatectomy. Patient characteristics including ASA classification were similar among the two age groups. The procedures themselves were equally complicated with similar operative times, transfusion requirements, estimated blood losses, and portal vein resections. The number and severity of complications such as delayed gastric emptying and pancreatic leak were not statistically different between the two groups. Additionally, the 30-day reoperation, readmission, and mortality rates were not statistically different. Outcomes at 90-days revealed an increased rate of readmission amongst octogenarians who underwent Whipple without an increase in rates of major complications. The total number of deaths in the octogenarian group was 3 (6.2%) vs. 6 (1.7%) in the non-octogenarian group (p = 0.080). The median length of stay was similar amongst the two age groups. CONCLUSIONS: At a large-volume academic community cancer center with a dedicated surgical oncology team, highly selected octogenarians can undergo pancreatic resection safely with outcomes that do not differ significantly from their younger counterparts.

A Comparison of Colectomy Outcomes Utilizing Open, Laparoscopic, and Robotic Techniques.

INTRODUCTION: Robotic colectomy could reduce morbidity and postoperative recovery over laparoscopic and open procedures. This comparative review evaluates colectomy outcomes based on surgical approach at a single community institution. METHODS: A retrospective review of all patients who underwent colectomy by a fellowship-trained colon and rectal surgeon at a single institution from 2015 through 2019 was performed, and a cohort developed for each approach (open, laparoscopic, and robotic). 30-day outcomes were evaluated. For dichotomous outcomes, univariate logistic regression models were used to quantify the individual effect of each predictor of interest on the odds of each outcome. Continuous outcomes received a similar approach; however, linear and Poisson regression modeling were used, as appropriate. RESULTS: 115 patients were evaluated: 14% (n = 16) open, 44% (n = 51) laparoscopic, and 42% (n = 48) robotic. Among the cohorts, there was no statistically significant difference in operative time, rate of reoperation, readmission, or major complications. Robotic colectomies resulted in the shortest length of stay (LOS) (Kruskal-Wallis P < .0001) and decreased estimated blood loss (EBL) (Kruskal-Wallis P = .0012). Median age was 63 years (interquartile range [IQR] 53-72). 54% (n = 62) were female. Median American Society of Anesthesiologists physical status classification was 3 (IQR 2-3). Median body mass index was 28.67 (IQR 25.03-33.47). A malignant diagnosis was noted on final pathology in 44% (n = 51). CONCLUSION: Among the 3 approaches, there was no statistically significant difference in 30-day morbidity or mortality. There was a statistically significant decreased LOS and EBL for robotic colectomies.

Spaced Education With ABSITE Quest Resulting in Improved American Board of Surgery In-Training Examination Performance.

OBJECTIVE: The American Board of Surgery In-Training Examination (ABSITE) is an annual exam taken by general surgery residents as a cognitive assessment of the knowledge gained throughout each year of training. Several question banks are available for ABSITE preparation. However, ABSITE Quest (AQ) utilizes a method called spaced education which has been demonstrated to help with retaining information longer and improve exam performance. This study hypothesizes that using this method will help residents improve their ABSITE performance. DESIGN: Retrospective survey data was collected from residents who participated in AQ, including postgraduate year (PGY) level, as well as 2019 and 2020 ABSITE percentiles. AQ user data was used to match respondent's total number of questions completed and daily engagement level to the survey data. Paired, single-tailed student's t test was used to evaluate the significance of ABSITE percentile change between 2019 and 2020 among AQ users. SETTING: ChristianaCare, Newark, DE, United States. Nonclinical. PARTICIPANTS: All ABSITE Quest users were surveyed (n = 390), of which 104 responded. 21 responses were from PGY1 residents and were excluded, resulting in a total of 83 responses. RESULTS: The mean percentile difference of AQ users from 2019 to 2020 was +15.8 (p < 0.00001). When categorizing by the total number of questions completed, high users demonstrated a mean percentile difference of +15.3 (p = 0.00002), average users had a difference of +19.1 (p = 0.00029), and low users showed a percentile difference of +1.2 (p = 0.45244). When categorizing by daily engagement level, high users demonstrated a mean percentile difference of +17.9 (p < 0.00001), low users had a mean percentile difference of +15.3 (p = 0.00124), and minimal users showed a mean percentile change of -5.7. CONCLUSIONS: The use of the spaced education method with ABSITE Quest, especially in users with a greater number of questions completed and high levels of daily engagement, correlated with a significant improvement on ABSITE performance.

Right Patient, Right Place, Right Time : Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the Level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

Right Patient, Right Place, Right Time: Field Triage and Transfer to Level I Trauma Centers.

INTRODUCTION: This study sought to compare the outcomes of trauma patients taken directly from the field to a level I trauma center (direct) versus patients that were first brought to a level III trauma center prior to being transferred to a level I (transfer) within our inclusive Delaware trauma system. METHODS: A retrospective review of the level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single level I trauma center from two surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts. RESULTS: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared to direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (OR 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001). DISCUSSION: Delays in presentation to our level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care.

High volume pancreaticoduodenectomy performed at an academic community cancer center.

BACKGROUND: We sought to evaluate the post-operative outcomes of patients undergoing pancreaticoduodenectomy at a high volume academic community cancer center. METHODS: A retrospective review was performed of patients undergoing pancreaticoduodenectomy over a 10-year period. RESULTS: Over 10 years, 213 patients underwent pancreaticoduodenectomy. Median age was 66y. Most patients had significant comorbidities (median ASA = 3) and were overweight (median BMI = 27). Median operative time and blood loss were 253 min and 500 ml, respectively. 160 (75%) out of 213 patients had a malignant lesion on final pathology. 121 (76%) out of 160 had R0 resection. Median lymph nodes harvested was 13. Overall incidence of DGE was 31% (67/213), with clinically significant DGE in 15% (32/213). Pancreatic leak rate was 18% (37/213), with clinically significant leaks in 10% (21/213). Median length of stay was 8 days. Grade 3/4 morbidity rate was 21% (44/206), and 30-day mortality was 2% (5/213). CONCLUSIONS: At a high volume academic community cancer center, pancreaticoduodenectomy can be performed with excellent outcomes on par with any academic center or university hospital.

Complex distal pancreatectomy outcomes performed at a single institution.

OBJECTIVE: Discuss the outcomes of distal pancreatectomy in a high volume academic community cancer center. INTRODUCTION: Distal pancreatectomy can be done with minimal morbidity and mortality in high volume centers. However, there are limited reports of distal pancreatectomy being performed in the community. This study sought to define the experience with distal pancreatectomy at a high volume community cancer center with a dedicated surgical oncology team. METHODS: A retrospective chart review was performed for patients undergoing distal pancreatectomy performed over a twelve year period (2005-2017) at an academic community cancer center. RESULTS: 157 patients underwent distal pancreatectomy. The distribution of open, laparoscopic and robotic resections were 96 (61%), 42 (27%) and 19 (12%) respectively. Concomitant organ resection other than splenectomy was performed in 54 (34%) patients. Spleen sparing resections were performed in 6 (4%) patients. 84 (54%) out of the 157 resections had a malignant lesion on final pathology. Median length of stay was 6 days with 25 (16%) patients readmitted within 30 days. Grade 3 or 4 morbidity rate was 18% (28/157). The incidence of clinically significant pancreatic fistula (Grade B/C) was 8% (13/157). The reoperative rate was 3% (5/157). Overall 30 day mortality in all patients was 0.6% (1/157). CONCLUSION: This is the largest series of distal pancreatic resections reported in a community cancer hospital. In a high volume academic community cancer center with a dedicated surgical oncology team, distal pancreatic resections can be performed with short hospital stays, minimal morbidity, and a mortality rate of less than 1%.