Prognostic Factors in Patients With Borderline Resectable Pancreatic Ductal Adenocarcinoma Undergoing Resection.

BACKGROUND: Neoadjuvant treatment (NT) has become standard in the management of borderline resectable pancreatic cancer (BR-PDAC), improving prognosis. The primary mechanism for this improvement remains unclear. METHODS: Clinicopathological data of patients with BR-PDAC who underwent resection between January 2008 and December 2018 at a single institution were retrospectively reviewed. Univariable and multivariate analyses were used to compare survival between patients who received NT vs. those who underwent upfront resection (UR). RESULTS: A total of 138 patients were included, 64 underwent UR and 74 NT. Neoadjuvant treatment resulted in higher margin-negative (R0) resection rate (68.9%) than UR (43.8%, P = .005). Neoadjuvant treatment was associated with improved overall survival (OS, P = .009) and progression-free survival (PFS, P = .027). R0 resection was also associated with improved OS (P < .001) and PFS (P < .001). On multivariable analysis, when adjusting for clinically relevant variables without considering R status, NT was an independent predictor for improved OS (P = .046) and PFS (P = .040). When additionally accounting for margin status, R0 was an independent predictor for improved OS (P < .001) and PFS (P < .001), while NT was not. Subgroup analysis, stratified by margin status, revealed that NT was not an independent predictor for OS or PFS for either subgroup. DISCUSSION: Neoadjuvant treatment is associated with improved OS and PFS in patients with BR-PDAC; however, this effect is outweighed by margin status. These results suggest that the primary benefit of NT was dependent on facilitating R0 resection. Upfront resection might remain a valid treatment option if R0 resection could be accurately predicted.

Predicting Surgical Margins in Patients With Borderline Resectable and Locally Advanced Pancreatic Cancer Undergoing Resection.

BACKGROUND: Many patients with borderline resectable/locally advanced pancreatic ductal adenocarcinoma (borderline resectable [BR]/locally advanced [LA] pancreatic ductal adenocarcinoma [PDAC]) undergoing resection will have positive resection margins (R1), which is associated with poor prognosis. It might be useful to preoperatively predict the margin (R) status. METHODS: Data from patients with BR/LA PDAC who underwent a pancreatectomy between 2008 and 2018 at Brigham and Women's Hospital were retrospectively reviewed. Logistic regression analysis was used to evaluate the association between R status and relevant preoperative factors. Significant predictors of R1 resection on univariate analysis (P < .1) were entered into a stepwise selection using the Akaike information criterion to define the final model. RESULTS: A total of 142 patients with BR/LA PDAC were included in the analysis, 60(42.3%) had R1 resections. In stepwise selection, the following factors were identified as positive predictors of an R1 resection: evidence of lymphadenopathy at diagnosis (OR = 2.06, 95% CI: 0.99-4.36, P = .056), the need for pancreaticoduodenectomy (OR = 3.81, 96% CI: 1.15-15.70, P = .040), extent of portal vein/superior mesenteric vein involvement at restaging (<180°, OR = 3.57, 95% CI: 1.00-17.00, P = .069, ≥180°, OR = 7,32, 95% CI: 1.75-39.87, P = .010), stable CA 19-9 serum levels (less than 50% decrease from diagnosis to restaging, OR = 2.27, 95% CI: 0.84-6.36 P = .107), and no preoperative FOLFIRINOX (OR = 2.17, 95% CI: 0.86-5.64, P = .103). The prognostic nomogram based on this model yielded a probability of achieving an R1 resection ranging from <5% (0 factors) to >70% (all 5 factors). CONCLUSIONS: Relevant preoperative clinicopathological characteristics accurately predict positive resection margins in patients with BR/LA PDAC before resection. With further development, this model might be used to preoperatively guide surgical decision-making in patients with BR/LA PDAC.

Temporal Assessment of Prognostic Factors in Patients With Pancreatic Ductal Adenocarcinoma Undergoing Neoadjuvant Treatment and Resection.

BACKGROUND: The clinicopathologic factors associated with the survival of patients with pancreatic ductal adenocarcinoma (PDAC) during the different phases of neoadjuvant treatment (NT)-at diagnosis, restaging, or postoperatively-remain unclear. METHODS: Data of patients with PDAC who underwent pancreatic resection after NT between 2008 and 2018 were retrospectively collected. Clinicopathologic characteristics and outcomes were compared stratified by resection margin status. Three multivariable regression models (at diagnosis, restaging, and postoperatively) were constructed to assess the temporal impact of different prognostic factors on all-cause survival (ACS) and disease-free survival (DFS). RESULTS: All patients were diagnosed with a nonmetastatic PDAC and were appropriate candidates for NT according to the current National Comprehensive Cancer Network guidelines. From a total of 83 patients, 57 (68.7%) had a negative resection margin >1 mm (R0), whereas 26 patients (31.3%) had a positive resection margin (R1). At diagnosis, planned procedure (P = 0.017) and CA19-9 >100 U/mL (P = 0.047) were independent prognostic factors of decreased ACS. At restaging, planned procedure (P = 0.017), FOLFIRINOX (P = 0.026), and tumor size >30 mm (P = 0.030) were independent prognostic factors for increased and decreased ACS, respectively. Postoperatively, R0 was an independent prognostic factor for improved ACS (P = 0.005) and DFS (P = 0.002), whereas adjuvant therapy (P = 0.006) was associated with increased ACS. Lymph node involvement (P = 0.019) was associated with decreased DFS. CONCLUSIONS: At diagnosis, restaging, and postoperatively, different, relevant clinicopathologic factors significantly impact the survival of patients with nonmetastatic PDAC undergoing NT. An R0 resection remains the most important prognostic factor and therefore should be the primary goal of surgical treatment in the neoadjuvant setting.

Contemporary indications for and outcomes of hepatic resection for neuroendocrine liver metastases.

BACKGROUND: Although surgical resection is associated with the best long-term outcomes for neuroendocrine liver metastases (NELM), the current indications for and outcomes of surgery for NELM from a population perspective are not well understood. AIM: To determine the current indications for and outcomes of liver resection (LR) for NELM using a population-based cohort. METHODS: A retrospective review of the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program and targeted hepatectomy databases was performed to identify patients who underwent LR for NELM. Perioperative characteristics and 30-d morbidity and mortality were analyzed. RESULTS: Among 669 patients who underwent LR for NELM, the median age was 60 (interquartile range: 51-67) and 51% were male. While the number of metastases resected ranged from 1 to 9, the most common (45%) number of tumors resected was one. The majority (68%) of patients had a largest tumor size of < 5 cm. Most patients underwent partial hepatectomy (71%) while fewer underwent a right or left hepatectomy or trisectionectomy. The majority of operations were open (82%) versus laparoscopic (17%) or robotic (1%). In addition, 30% of patients underwent intraoperative ablation while 45% had another concomitant operation including cholecystectomy (28.8%), bowel resection (20.2%), or partial pancreatectomy (3.4%). Overall 30-d morbidity and mortality was 29% and 1.3%, respectively. On multivariate analysis, American Society of Anesthesiologists class ≥ 3 [odds ratios (OR), OR = 2.089, 95% confidence intervals (CI): 1.197-3.645], open approach (OR = 1.867, 95%CI: 1.148-3.036), right hepatectomy (OR = 1.618, 95%CI: 1.014-2.582), and prolonged operative time of > 230 min (OR = 1.731, 95%CI: 1.168-2.565) were associated with higher 30-d morbidity while intraoperative ablation and concomitant procedures were not. CONCLUSION: LR for NELM was performed with relatively low postoperative morbidity and mortality. Concomitant procedures performed at the time of LR did not increase morbidity.

The impact of somatic SMAD4 mutations in colorectal liver metastases.

Recent advances in cancer genomics have led to the identification of many molecular pathways involved in colorectal cancer (CRC) carcinogenesis. Pre-clinical and clinical data have shown that gene mutations involved in several of these pathways have an important prognostic impact, particularly on the outcomes of patients with metastatic CRC. Therefore, specific information on such gene mutational status can be potentially used as biomarkers to guide genome-oriented personalized treatment and ultimately improve patient outcomes. Drosophila protein, mothers against decapentaplegic homolog 4 (SMAD4) has a critical intermediate role in the TGFß signaling pathway. Loss of SMAD4 expression is associated with both metastatic development and worse response to chemotherapy for patients with CRC. Additionally, it has been reported that the loss of SMAD4 function is independently associated with decreased recurrencefree (RFS) and overall survival (OS) for patients with CRC, especially for patients with advanced stages of disease. Furthermore, among patients who undergo hepatectomy for colorectal liver metastases (CRLM), SMAD4 mutations are associated with a high likelihood of simultaneously carrying RAS mutations, which independently predict worse OS. Although recent evidence highlights the prognostic importance of somatic SMAD4 mutations in CRLM, ongoing research is necessary to untangle the specific molecular mechanisms involved in the complex SMAD4 regulatory network as well as the synergism with other mutations implicated in the pathogenesis of CRC. The detailed elucidation of such mechanisms may potentially aid the development of future trials in establishing novel, targeted therapeutic advances to further guide clinical decision-making for patients with CRC.

Validation of early drain removal after pancreatoduodenectomy based on modified fistula risk score stratification: a population-based assessment.

BACKGROUND: Recent studies on postoperative pancreatic fistula (POPF) prevention following pancreatoduodenectomy (PD) have proposed omission of perioperative drains for negligible/low-risk patients and early drain removal (≤POD3) for intermediate/high-risk patients with POD1 drain amylase levels of ≤5000 U/L, though this has not been validated using a nationwide cohort. METHODS: The ACS-NSQIP targeted pancreatectomy database from 2014 to 2016 was queried to identify patients who underwent PD. Patients with POD1 drain amylase levels of ≤5000 U/L were initially stratified as negligible/low- or intermediate/high-risk based on a previously validated modified fistula risk score (mFRS). Differences in relevant postoperative outcomes were then compared among patients who underwent early (≤POD3) vs. late (≥POD4) drain removal. RESULTS: Among 1825 patients who underwent PD, 1540 (84%) had POD1 drain amylase of ≤5000 U/L: 719 (47%) high-risk and 821 (53%) low-risk. Among high-risk patients, early drain removal (n = 205, 29%) was associated with lower rates of POPF (3% vs. 18%, p < 0.001), clinically relevant (CR)-POPF (2% vs. 15%, p < 0.001), overall morbidity (27% vs. 47%, p < 0.001), serious morbidity (15% vs. 24%, p = 0.007) and hospital length of stay (LOS, 7 vs. 8 days, p < 0.001). Similarly, early drain removal in low-risk patients (n = 273, 33%) was associated with decreased rates of POPF (1% vs. 6%, p = 0.003), CR-POPF (1% vs. 5%, p = 0.014), overall morbidity (28% vs. 41%, p = 0.0003), serious morbidity (8% vs. 14%, p = 0.015) and LOS (6 vs. 8 days, p < 0.001). On multivariate logistic regression analysis, early drain removal remained associated with significantly decreased odds of POPF, CR-POPF, overall and serious morbidity as well as LOS among both high- and low-risk patients (all p < 0.05). CONCLUSIONS: Among patients with POD1 drain amylase ≤5000 U/L following PD, early drain removal (≤POD3) is associated with improved postoperative outcomes among both high- and low-risk patients. Early drain removal based on POD1 drain amylase is indicated regardless of mFRS.

Impact of Neoadjuvant Chemotherapy on the Postoperative Outcomes of Patients Undergoing Liver Resection for Colorectal Liver Metastases: A Population-Based Propensity-Matched Analysis.

BACKGROUND: The role of neoadjuvant chemotherapy in the management of colorectal liver metastases remains controversial. We sought to investigate whether neoadjuvant systemic chemotherapy contributes to clinically significant increases in postoperative morbidity and mortality using a population-based cohort. STUDY DESIGN: The American College of Surgeons NSQIP Targeted Hepatectomy Participant Use Files were queried from 2014 to 2016 to identify patients with colorectal liver metastases who underwent liver resection. Patients were stratified by receipt of neoadjuvant chemotherapy using propensity score matching. Univariate and multivariable analyses were used to characterize the effect of neoadjuvant chemotherapy on perioperative morbidity and mortality. RESULTS: After propensity score matching, 1,416 (50%) patients received neoadjuvant chemotherapy before hepatectomy and 1,416 (50%) underwent liver resection without neoadjuvant chemotherapy. There were no differences in age (60 vs 61 years), maximum tumor size (≤5 cm: 79% vs 80%, >5 cm: 21% vs 20%), resection type (partial hepatectomy: 69% vs 70%), simultaneous colectomy (9% vs 9%), or use of preoperative portal vein embolization (5% vs 5%) in those undergoing neoadjuvant chemotherapy compared with those who did not (all, p > 0.05). Overall 30-day postoperative morbidity (34% vs 33%), including rates of biliary fistula (6% vs 5%), post-hepatectomy liver failure (5% vs 5%), and mortality rates (0.8% vs 0.7%), were similar among patients who received neoadjuvant chemotherapy vs those who did not (all, p > 0.05). On multivariable analysis, receipt of neoadjuvant chemotherapy was not associated with increased morbidity (odds ratio 1.07; 95% CI 0.90 to 1.27; p = 0.43) or mortality (odds ratio 1.09; 95% CI 0.44 to 2.72; p = 0.85). CONCLUSIONS: In this propensity-matched population-based cohort study, the use of neoadjuvant systemic chemotherapy was not associated with higher rates of complications, biliary fistula, post-hepatectomy liver failure, or mortality among patients with colorectal liver metastases undergoing liver resection.

Impact of concomitant ablation on the perioperative outcomes of patients with colorectal liver metastases undergoing hepatectomy: a propensity score matched nationwide analysis.

BACKGROUND: Intraoperative ablation (IA) is often performed at the time of liver resection (LR) for colorectal liver metastases (CRLMs) but its impact on postoperative outcomes remains poorly understood. METHODS: The ACS-NSQIP targeted hepatectomy database was used to identify patients who underwent LR vs LR + IA for CRLMs during 2014-2016. Perioperative outcomes were compared following propensity score match based on age, receipt of neoadjuvant therapy, operative approach, liver resection type, tumor diameter and number of metastases. RESULTS: Among 1,384 patients, 692 (50%) underwent LR alone and 692 (50%) underwent LR + IA. After propensity score matching, overall morbidity (22% vs 13%, P < 0.0001) was increased among patients undergoing LR alone compared to LR + IA, whereas mortality did not differ (1.1% vs 0.8%, P=0.5911). On multivariable analysis, ASA class ≥3 (OR: 1.5, 95% CI: 1.06-2.3), preoperative biliary stent (OR: 3.5, 95% CI: 0.9-13.01), biliary reconstruction (OR: 5.02, 95% CI: 1.3-18.6), operative time > 245 minutes (OR: 1.8, 95% CI:1.3-2.4) and IA (OR:0.5, 95% CI:0.3-0.7) were associated with overall morbidity. CONCLUSIONS: In this propensity matched nationwide analysis of patients undergoing LR for CRLM, the use of concomitant IA was associated with decreased postoperative morbidity compared to LR alone. These findings suggest that IA combined with LR is a safe approach that may expand the number of patients who are candidates for curative-intent surgical strategies.

Early Morbidity and Mortality after Minimally Invasive Liver Resection for Hepatocellular Carcinoma: a Propensity-Score Matched Comparison with Open Resection.

BACKGROUND: The impact of minimally invasive surgery on the short-term outcomes of patients with hepatocellular carcinoma (HCC) undergoing liver resection remains poorly defined. METHODS: The ACS-NSQIP-targeted hepatectomy database was used to identify patients who underwent liver resection for HCC during 2014-2016. A 1:1 propensity score matching was created between patients who underwent open (OLR) vs. minimally invasive liver resection (MILR) based on age, ASA score, liver resection type, liver texture, and stage of disease. The short-term outcomes of patients undergoing OLR vs. MILR were compared. RESULTS: Among a total cohort of 1816 patients, propensity score matching resulted in 728 liver resections: 364 (50%) OLR and 364 (50%) MILR. Overall morbidity (29% vs. 23%, P = 0.04) was greater among patients undergoing OLR compared with MILR, whereas mortality did not differ between the two approaches (2% vs 1%, P = 0.57). MILR was associated with significant reductions in hospital LOS (6 vs. 4 days, P < 0.0001) but no difference in operative time (188 vs. 171 min, P = 0.13). On multivariate logistic regression analysis, age ≥ 65 (OR:1.6, 95%CI: 1.1-2.3, P = 0.0065), ASA class ≥ 3 (OR:2.7, 95%CI: 1.5-4.7, P = 0.0003), preoperative blood transfusion (OR:9.7, 95%CI: 1.06-90.3, P = 0.04), T ≥ 3 (OR:1.9, 95%CI: 1.09-3.4, P = 0.02), operative time > 200 min (OR:1.8, 95%CI: 1.2-2.5, P = 0.0011), and OLR (OR:1.4, 95%CI: 1.002-2.03, P = 0.04) were associated with increased odds of overall morbidity. CONCLUSIONS: MILR for HCC is associated with a shorter hospital LOS and reduced postoperative complication rates, even after controlling for important patient and clinicopathologic confounders, compared to OLR. Efforts to expand the use of MILR for hepatobiliary surgery are warranted.

Identifying Hospital Cost Savings Opportunities by Optimizing Surgical Approach for Distal Pancreatectomy.

BACKGROUND: The economic implications of relevant clinicopathologic factors on the surgical approach to distal pancreatectomy (DP) should be clearly defined and understood to potentially allow the implementation of cost reduction strategies. METHODS: Administrative and clinical datasets of patients undergoing a DP between 2012 and 2016 were merged and queried. Univariate and multivariate analyses were used to identify clinicopathologic predictors of cost differentials for minimally invasive DP (MIDP) relative to open DP (ODP). Time trends in cost were also assessed to identify opportunities for cost containment. RESULTS: Among two hundred and twenty five patients, 128 underwent an ODP (57%) and 97 a MIDP (43%). The DP groups were comparable with regard to relevant perioperative and disease characteristics. Total hospitalization and total OR costs for MIDP were significantly lower (- 12%, P = 0.0048) and higher (+ 16%, P < 0.0001) respectively, compared to ODP. On univariate analysis, age > 60 (- 12%, P = 0.0262), BMI > 25 (- 10%, P = 0.0222), ASA class ≥ 3 (- 11%, P = 0.0045), OpTime > 230 min (- 16%, P = 0.0004), and T stage ≥ 3 (- 8%, P = 0.0452) were associated with decreased total costs after MIDP compared to ODP. Linear regression analysis revealed that BMI > 25 (Estimate - 0.31, SE 0.15, P = 0.0482), ASA class ≥ 3 (Estimate - 0.36, SE 0.17, P = 0.0344), and T stage ≥ 3 (Estimate - 0.57, SE 0.26, P = 0.0320) were associated with decreased hospitalization costs after MIDP compared to ODP. Overtime, total hospitalization cost for MIDP increased from - 21 to 1% (P = 0.0197), while OR costs for MIDP decreased from + 41% to - 2% (P = 0.0049), nearly equalizing the cost differences between ODP and MIDP. CONCLUSIONS: Relevant clinicopathologic factors predicted decreased hospitalization costs after MIDP relative to ODP. In equivalent stages of disease, optimizing the surgical approach to DP based on specific clinicopathologic characteristics may afford significant cost-saving opportunities.

Hepatocellular Carcinoma in Transplantable Child-Pugh A Cirrhotics: Should Cost Affect Resection vs Transplantation?

BACKGROUND: There is no consensus regarding the optimal surgical treatment for transplantable hepatocellular carcinoma (HCC) patients with well-compensated cirrhosis. Our aim was to compare outcomes between Child-Pugh A (CPA) cirrhotics who underwent liver resection or transplantation for HCC. METHODS: Clinicopathologic data were retrospectively collected for all surgically treated HCC patients between 7/1992 and 12/2015. Disease-free survival (DFS) and overall survival (OS) were calculated from the time of operation or diagnosis (intention-to-treat analysis including patients removed from the transplant list). The average overall cost including pre-operative and post-operative procedures was calculated for each group. RESULTS: Of the 513 surgically treated HCC patients, 184 had CPA cirrhosis and fulfilled the Milan criteria (MC). Of those, 95 (52%) were resected and 89 (48%) were transplanted. Twenty-two patients were removed from the transplant list. Transplanted patients were younger (p < 0.001), had a higher MELD score (p < 0.001) and a higher frequency of hepatitis C (p < 0.001). Length of stay and postoperative complication rates were similar between groups. DFS was longer for transplanted patients (3-, 5-, and 10-year DFS rates 48, 44, 31% vs 96, 94, 94%, respectively, p < 0.001). OS was similar between groups (3-, 5-, and 10-year OS rates 76, 62, 41% vs 82, 77, 53%, respectively, p = 0.07). Only size of greatest lesion and T stage were independent predictors of OS. The cost was much higher for the transplant group, even when accounting for the treatment of recurrences ($37,391 vs $137,996). CONCLUSIONS: Since OS is similar between CPA cirrhotics within the MC undergoing resection or transplantation for HCC, but cost is significantly higher for transplantation. Resection should be considered for first-line treatment.

Population-Based Assessment of Selective Drain Placement During Pancreatoduodenectomy Using the Modified Fistula Risk Score.

BACKGROUND: Recent studies on postoperative pancreatic fistula (POPF) prevention suggest that omission of perioperative drains is safe for negligible- or low-risk patients undergoing pancreatoduodenectomy (PD). However, this proposed pathway has not been validated in a nationwide cohort. STUDY DESIGN: The ACS-NSQIP-targeted pancreatectomy database from 2014 to 2016 was queried to identify patients who underwent PD. Using a previously validated modified Fistula Risk Score (mFRS), patients were stratified as negligible/low- or intermediate/high-risk. Multivariate regression models were used to analyze the effect of intraoperative drain placement on relevant perioperative outcomes in both high- and low-risk patients. RESULTS: Among 6,730 patients undergoing PD, 3,375 (50%) were high-risk; 3,355 (50%) were low-risk. Among high-risk patients, drain placement (n = 3,093, 92%) was associated with a higher rate of POPF (26% vs 16%, p = 0.0003), clinically relevant (CR) POPF (20% vs 12%, p = 0.0015), and extended hospital length of stay (LOS, 9 vs 7 days, p < 0.0001), but decreased serious morbidity (29% vs 35%, p = 0.0330). Similarly, drain placement in low-risk patients (n = 2,785, 83%) was associated with a higher rate of POPF (11% vs 6%, p = 0.0006) and extended LOS (8 vs 7 days, p < 0.0001), yet lower serious morbidity (18% vs 23%, p = 0.0037). On multivariate logistic regression, drain placement was associated with significantly increased odds of CR-POPF and a significantly reduced incidence of serious morbidity among both high-risk (odds ratio [OR] 0.72, 95% CI 0.55 to 0.94, p = 0.0155) and low-risk patients (OR 0.71, 95% CI 0.57 to 0.89, p = 0.0027). CONCLUSIONS: In this population-based cohort, the mFRS was unable to stratify patients relative to the need for selective drain placement during PD. For both high- and low-risk patients, perioperative drain placement was associated with increased rates of POPF, CR-POPF, and extended LOS, but decreased incidence of serious morbidity.

Specific Medicare Severity-Diagnosis Related Group Codes Increase the Predictability of 30-Day Unplanned Hospital Readmission After Pancreaticoduodenectomy.

BACKGROUND: The Medicare Severity-Diagnosis Related Group coding system (MS-DRG) is routinely used by hospitals for reimbursement purposes following pancreatic surgery. We aimed to determine whether specific pancreatectomy MS-DRG codes, when combined with distinct clinicopathologic and perioperative characteristics, increased the accuracy of predicting 30-day readmission after pancreaticoduodenectomy (PD). METHODS: Demographic, clinicopathologic, and perioperative factors were compared between readmitted and non-readmitted patients at Brigham and Women's Hospital following PD. Different pancreatectomy DRG codes, currently used for reimbursement purposes [407: without complication/co-morbidity (CC), 406: with CC, and 405: with major CC] were combined with clinical factors to assess their predictability of readmission. Univariate and multivariable analyses were performed to evaluate outcomes. RESULTS: Among 354 patients who underwent PD between 2010 and 2017, 69 (19%) were readmitted. The incidence of readmission was 13, 32, and 55% for patients with assigned DRG codes 407, 406, and 405, respectively (P = 0.0395). Readmitted patients were more likely to have had T4 disease (P = 0.0007), a vascular resection (P = 0.0078), and longer operative times (P = 0.012). On multivariable analysis, combining DRG 407 with relevant clinicopathologic factors was unable to predict readmission. In contrast, DRG 406 code among patients with N positive disease (P = 0.0263) and LOS > 10 days (P = 0.0505) was associated with readmission. DRG 405, preoperative obstructive jaundice (OR: 7.5, CI: 1.5-36, P = 0.0130), vascular resection (OR: 7.7, CI: 1.1-51, P = 0.0336), N positive stage of disease (OR: 0.2, CI: 0-0.9, P = 0.0447), and operative time > 410 min (OR: 5.9, CI: 1-32, P = 0.0399) were each strongly associated with 30-day readmission after PD [likelihood ratio (LR) < 0.0001]. CONCLUSIONS: Distinct pancreatectomy MS-DRG classification codes (405), combined with relevant clinicopathologic and perioperative characteristics, strongly predicted 30-day readmission after PD. DRG classification algorithms can be implemented to more accurately identify patients at a higher risk of readmission.

Independent Predictors of Increased Operative Time and Hospital Length of Stay Are Consistent Across Different Surgical Approaches to Pancreatoduodenectomy.

BACKGROUND: While minimally invasive approaches are increasingly being utilized for pancreatoduodenectomy (PD), factors associated with prolonged operative time (OpTime) and hospital length of stay (LOS) remain poorly defined, and it is unclear whether these factors are consistent across surgical approaches. METHODS: The ACS-NSQIP targeted pancreatectomy database from 2014 to 2016 was used to identify all patients who underwent open (OPD), laparoscopic (LPD), or robotic (RPD) pancreatoduodenectomy. Multivariable linear regression analyses were used to evaluate predictors of OpTime and LOS, as well as quantify the changes observed relative to each surgical approach. RESULTS: Among 10,970 patients, PD procedure types varied: 9963 (92%) open, 418 (4%) laparoscopic, and 409 (4%) robotic. LOS was longer for the open and laparoscopic approaches (11 vs. 11 vs. 10 days, P = 0.0068), whereas OpTime was shortest for OPD (366 vs. 426 vs. 435 min, P < 0.0001). Independent predictors of a prolonged OpTime were ASA class ≥ 3 (P = 0.0002), preoperative XRT (P < 0.0001), pancreatic duct < 3 mm (P = 0.0001), T stage ≥ 3 (P = 0.0108), and vascular resection (P < 0.0001) for OPD; T stage ≥ 3 (P = 0.0510) and vascular resection (P = 0.0062) for LPD; and malignancy (P = 0.0460) and conversion to laparotomy (P = 0.0001) for RPD. Independent predictors of increased LOS were age ≥ 65 years (P = 0.0002), ASA class ≥ 3 (P = 0.0012), hypoalbuminemia (P < 0.0001), and preoperative blood transfusion (P < 0.0001) for OPD as well as an OpTime > 370 min (all p < 0.05) and specific postoperative complications (all p < 0.05) for all surgical approaches. CONCLUSIONS: Perioperative risk factors for prolonged OpTime and hospital LOS are relatively consistent across open, laparoscopic, and robotic approaches to PD. Particular attention to these factors may help identify opportunities to improve perioperative quality, enhance patient satisfaction, and ensure an efficient allocation of hospital resources.

Comparison of Perioperative Outcomes between Open, Laparoscopic, and Robotic Distal Pancreatectomy: an Analysis of 1815 Patients from the ACS-NSQIP Procedure-Targeted Pancreatectomy Database.

BACKGROUND: Robotic surgery is gaining acceptance for distal pancreatectomy (DP). Nevertheless, no multi-institutional data exist to demonstrate the ideal clinical circumstances for use and the efficacy of the robot compared to the open or laparoscopic techniques, in terms of perioperative outcomes. METHODS: The 2014 ACS-NSQIP procedure-targeted pancreatectomy data for patients undergoing DP were analyzed. Demographics and clinicopathological and perioperative variables were compared between the three approaches. Univariate and multivariable analyses were used to evaluate outcomes. RESULTS: One thousand eight hundred fifteen DPs comprised 921 open distal pancreatectomies (ODPs), 694 laparoscopic distal pancreatectomies (LDPs), and 200 robotic distal pancreatectomies (RDPs). The three groups were comparable with respect to demographics, ASA score, relevant comorbidities, and malignant histology subtype. Compared to the ODP group, patients undergoing RDP had lower T-stages of disease (P = 0.0192), longer operations (P = 0.0030), shorter hospital stays (P < 0.0001), and lower postoperative 30-day morbidity (P = 0.0476). Compared to the LDP group, RDPs were longer operations (P < 0.0001) but required fewer concomitant vascular resections (P = 0.0487) and conversions to open surgery (P = 0.0068). On multivariable analysis, neoadjuvant therapy (P = 0.0236), malignant histology (P = 0.0124), pancreatic reconstruction (P = 0.0006), and vascular resection (P = 0.0008) were the strongest predictors of performing an ODP. CONCLUSIONS: The open, laparoscopic, and robotic approaches to distal pancreatectomy offer particular advantages for well-selected patients and specific clinicopathological contexts; therefore, clearly demonstrating the most suitable use and superiority of one technique over another remains challenging.

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive.

BACKGROUND: Current literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied. METHODS: Thirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes. RESULTS: On multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient's lower educational level (P = 0.0233), the absence of family during the delivery of discharge instructions (P = 0.0098), episodic intermittent nausea at discharge (P = 0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P = 0.0137), and the inability or failure to adhere to the clinician's instructions in the outpatient setting (P = 0.0048). CONCLUSION: Transitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.

Distal pancreatic resection for neuroendocrine tumors: is laparoscopic really better than open?

BACKGROUND: The latest studies on surgical and cost-analysis outcomes after laparoscopic distal pancreatectomy (LDP) highlight mixed and insufficient results. Whereas several investigators have compared surgical outcomes of LDP vs. open distal pancreatectomy (ODP) for adenocarcinomas, few similar studies have focused on pancreatic neuroendocrine tumors (PNETs). METHODS: We reviewed the medical records of PNET patients undergoing distal pancreatectomy between 2004 and 2014. Patients were divided into LDP vs. ODP groups. Demographics, relevant comorbidities, oncologic variables, and cost-analysis data were assessed. Survival and Cox proportional hazards analyses were used to evaluate outcomes. RESULTS: Of the 171 distal pancreatectomies for PNETs, 73 were laparoscopic, whereas 98 were open. Patients undergoing LDP demonstrated significantly lower rates of postoperative complications (P=0.028) and had significantly shorter hospital stays (P=0.008). On multivariable analysis, positive resection margins (P=0.046), G3 grade (P=0.036), advanced WHO classification (P=0.016), TNM stage (P=0.018), and readmission (P=0.019) were significantly associated with poor survival; however, method of resection (LDP vs. ODP) was not (P=0.254). The median total direct costs of LDP vs. ODP did not differ significantly. CONCLUSIONS: In response to the recent considerable controversy surrounding the costs and surgical outcomes of LDP vs. ODP, our results show that LDP for PNETs is cost-neutral and significantly reduces postoperative morbidity without compromising oncologic outcomes and survival.

Noninvasive intraductal papillary mucinous neoplasms and mucinous cystic neoplasms: recurrence rates and postoperative imaging follow-up.

BACKGROUND: Although surveillance guidelines for resected invasive mucinous neoplastic cysts are well-established, those for noninvasive cysts are not defined. We used our experience with resected noninvasive mucinous neoplastic cysts to define recurrence rates and the optimal frequency of postoperative imaging follow-up. METHODS: We reviewed the medical records of 134 patients with resected, pathologically confirmed noninvasive mucinous neoplasms between 2002 and 2012. Demographics, comorbidities, cyst characteristics, and recurrence were evaluated. Survival analysis was used to estimate the distribution of time to recurrence and regression models were used to investigate factors associated with recurrence. RESULTS: Eighty-seven patients with intraductal papillary mucinous neoplasms (IPMNs) were compared with 47 patients with mucinous cystic neoplasms (MCNs). Those with MCNs were more often females (P = .001), significantly younger (P = .001), more symptomatic (P = .009), and had cysts more often located in the tail (P < .001). Median follow-up was 42 months. Recurrence rates for IPMNs were 0%, 5%, and 10% versus 0% for MCNs respectively at postoperative years 1, 2, and 3 (P = .014). On multivariable analysis, size >3 cm (P = .027), higher grade dysplasia (P = .043), and positive resection margins (P < .001) were significantly associated with recurrence. CONCLUSION: Resected noninvasive IPMNs with moderate- or high-grade dysplasia and negative resection margins require imaging follow-up every 2 years, given the 16% overall recurrence rate. Although the follow-up interval for noninvasive, low-grade, dysplastic IPMNs with negative margins could be lengthened, all noninvasive IPMNs having positive margins require yearly follow-up at the minimum. Resected noninvasive MCNs--irrespective of grade and margin status--do not require surveillance, although the development of branch duct-IPMNs in the remnant pancreas can be investigated in the long term at the discretion of the provider.

Impact of weight-loss surgery and diabetes status on serum ALT levels.

BACKGROUND: Alanine aminotransferase (ALT) is used to detect non-alcoholic fatty liver disease and has been associated with increased risk of metabolic syndrome and type II diabetes mellitus (T2DM). Bariatric procedures result in significant weight loss and a rapid resolution of T2DM. We aimed to study the impact of bariatric interventions on ALT levels in patients with or without T2DM and compare this effect between different types of weight-loss procedures. METHODS: We reviewed 756 patients undergoing bariatric surgery. Demographics, co-morbidities, baseline and post-operative ALT and HbA1C levels, weight-loss data, and diabetes status were recorded. ALT levels were compared between different procedures and between diabetic and non-diabetic patients. Chi-square test, ANOVA, and t test were used to evaluate outcomes. RESULTS: Males and diabetics had significantly higher ALT at baseline. Both Roux-en-Y gastric bypass surgery (RYGB) and laparoscopic adjustable gastric banding (LAGB) resulted in significant reduction in ALT levels beginning at the third post-operative month (20 and 17 %, respectively, compared to baseline, p < 0.001). ALT remained at the new low level up to year 3 after surgery. The degree of reduction was similar for both procedures and was independent of the degree of weight loss. In diabetics, ALT reduction was associated with improvement in disease; but in T2DM patients who remained on insulin, ALT remained elevated. CONCLUSIONS: RYGB and LAGB decrease ALT levels to the same degree and independent of weight loss. Our data confirm higher ALT in diabetics and demonstrate a rapid normalization after bariatric surgery with a simultaneous decrease in HbA1C. These results suggest that ALT may be used as a marker of metabolic improvement after bariatric surgery.