Distribution and pathological features of pancreatic, ampullary, biliary and duodenal cancers resected with pancreaticoduodenectomy.

BACKGROUND: Pancreatic cancer (PC) has the worst survival of all periampullary cancers. This may relate to histopathological differences between pancreatic cancers and other periampullary cancers. Our aim was to examine the distribution and histopathologic features of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD) and to examine local trends of periampullary cancers resected with a PD. METHODS: A retrospective review of PD between January 2000 and December 2012 at a public metropolitan database was performed. The institutional ethics committee approved this study. RESULTS: There were 142 PDs during the study period, of which 70 cases were pre-2010 and 72 post-2010, corresponding to a recent increase in the number of cases. Of the 142 cases, 116 were for periampullary cancers. There were also proportionately more PD for PC (26/60, 43% pre-2010 vs 39/56, 70% post-2010, P = 0.005). There were 65/116 (56%) pancreatic, 29/116 (25%), ampullary, 17/116 (15%) biliary and 5/116 (4%) duodenal cancers. Nodal involvement occurred more frequently in PC (78%) compared to ampullary (59%), biliary (47%) and duodenal cancers (20%), P = 0.002. Perineural invasion was also more frequent in PC (74%) compared to ampullary (34%), biliary (59%) and duodenal cancers (20%), P = 0.002. Microvascular invasion was seen in 57% pancreatic, 38% ampullary, 41% biliary and 20% duodenal cancers, P = 0.222. Overall, clear margins (R0) were achieved in fewer PC 41/65 (63%) compared to ampullary 27/29 (93%; P = 0.003) and biliary cancers 16/17 (94%; P = 0.014). CONCLUSIONS: This study highlights that almost half of PD was performed for cancers other than PC, mainly ampullary and biliary cancers. The volume of PD has increased in recent years with an increased proportion being for PC. PC had higher rates of nodal and perineural invasion compared to ampullary, biliary and duodenal cancers.

Priority assessment of patients for elective general surgery: game on?

BACKGROUND: Clinical priority assessment criteria (CPAC) are used to generate a score by which patients are prioritized and rationed for elective surgery. It is widely believed that surgeons elevate scores to ensure their patients' acceptance for elective surgery, colloquially called gaming. The purpose of the present paper was therefore to investigate whether there was a temporal trend to an increase in the assigned priority score from the inception of CPAC to the present. METHODS: Priority and weighted inlier equivalent separations (WIES) scores between 23 April 1999 and 23 July 2002 were collected for elective general surgical cases at Auckland Hospital. A total of 5440 cases was retrospectively analysed using multiple regression techniques. Priority score was included as the dependent variable and time as an independent variable. Any change in case complexity over that period was accounted for by including the WIES score as a covariate. Multiple regression was undertaken for the combined surgeons and for individuals. RESULTS: The combined model was statistically significant but accounted for only 17% of the priority score variance. An increase of one WIES unit leads to an increase of 2.7 in priority score (P=0.0001). The relationship of priority score with time was dependent on the surgeon performing the prioritization. However, only half the surgeons had individual models that indicated gaming. CONCLUSIONS: The results show that gaming is occurring but that not all surgeons participate in this. The difference between surgeons' participation in gaming is a potential source of practice variation in the prioritization process.