Amanda V. Hayman

A Multicenter Analysis of Distal Pancreatectomy for Adenocarcinoma: Is Laparoscopic Resection Appropriate?

BACKGROUND As compared with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) affords improved perioperative outcomes. The role of LDP for patients with pancreatic ductal adenocarcinoma (PDAC) is not defined. STUDY DESIGN Records from patients undergoing distal pancreatectomy (DP) for PDAC from 2000 to 2008 from 9 academic medical centers were reviewed. Short-term (node harvest and margin status) and long-term (survival) cancer outcomes were assessed. A 3:1 matched analysis was performed for ODP and LDP cases using age, American Society of Anesthesiologists (ASA) class, and tumor size. RESULTS There were 212 patients who underwent DP for PDAC; 23 (11%) of these were approached laparoscopically. For all 212 patients, 56 (26%) had positive margins. The mean number of nodes (+/- SD) examined was 12.6 +/-8.4 and 114 patients (54%) had at least 1 positive node. Median overall survival was 16 months. In the matched analysis there were no significant differences in positive margin rates, number of nodes examined, number of patients with at least 1 positive node, or overall survival. Logistic regression for all 212 patients demonstrated that advanced age, larger tumors, positive margins, and node positive disease were independently associated with worse survival; however, method of resection (ODP vs. LDP) was not. Hospital stay was 2 days shorter in the matched comparison, which approached significance (LDP, 7.4 days vs. ODP, 9.4 days, p = 0.06). CONCLUSIONS LDP provides similar short- and long-term oncologic outcomes as compared with OD, with potentially shorter hospital stay. These results suggest that LDP is an acceptable approach for resection of PDAC of the left pancreas in selected patients.

Effect of Surgeon Training, Specialization, and Experience on Outcomes for Cancer Surgery: A Systematic Review of the Literature

BackgroundOutcomes after cancer resections have been shown to be better for high-volume surgeons compared with low-volume surgeons; however, reasons for this relationship have been difficult to identify. The objective of this study was to assess studies examining the effect of surgeon training and experience on outcomes in surgical oncology.MethodsA systematic review of the literature was performed to assess articles examining the impact of surgeon training, certification, and experience on outcomes. Studies were included if they examined cancer resections and performed multivariable analyses adjusting for relevant confounding variables.ResultsAn extensive literature search identified 29 studies: 27 examined surgeon training/specialization, 1 assessed surgeon certification, and 4 evaluated surgeon experience. Of the 27 studies examining training/specialization, 25 found that specialized surgeons had better outcomes than nonspecialized surgeons. One study found that American Board of Surgery (ABS)-certified surgeons had better outcomes than noncertified surgeons. Of the two studies examining time since ABS certification, both found that increasing time was associated with better outcomes. Of the four studies that examined experience, three studies found that increasing surgeon experience was associated with improved outcomes.ConclusionsAlthough numerous studies have examined the impact of surgeon factors on outcomes, only a few cancers have been examined, and outcome measures are inconsistent. Most studies do not appear robust enough to support major policy decisions. There is a need for better data sources and consistent analyses which assess the impact of surgeon factors on a broad range of cancers and help to uncover the underlying reasons for the volume–outcome association.

Deadly partners: interdependence of alcohol and trauma in the clinical setting.

Trauma is the leading cause of death for Americans aged 1 to 45. Over a third of all fatal motor vehicle collisions and nearly eighty percent of completed suicides involve alcohol. Alcohol can be both a cause of traumatic injury as well as a confounding factor in the diagnosis and treatment of the injured patient. Fortunately, brief interventions after alcohol-related traumatic events have been shown to decrease both trauma recidivism and long-term alcohol use. This review will address the epidemiology of alcohol-related trauma, the influence of alcohol on mortality and other outcomes, and the role of prevention in alcohol-related trauma, within the confines of the clinical setting.

Using a modification of the Clavien‐Dindo system accounting for readmissions and multiple interventions: Defining quality for pancreaticoduodenectomy

The Clavien‐Dindo system (CD) does not change the grade assigned a complication when multiple readmissions or interventions are required to manage a complication. We apply a modification of CD accounting for readmissions and interventions to pancreaticoduodenectomy (PD).

Clinical characteristics and outcomes of surgically resected mucinous nonneoplastic cysts of the pancreas.

To the Editor: The American Cancer Society estimated that, in the United States, in 2011, about 44,030 people will have been diagnosed with pancreatic cancer. The relative 1-year survival rate for pancreatic cancer is only 24%, and the overall 5-year survival is 5%. Most pancreatic cancers occur within the head or neck of the organ, whereas only a small number (G10%) occurs in the tail. The lesion originating from the head are more likely to be diagnosed at an earlier stage compared to the ones from the tail. The ones occurring within the head of the pancreas cause an early onset of jaundice because of infiltration or compression on the bile duct. The most typical sign of pancreatic cancer of the head is painless obstructive jaundice with a positive Courvoisier-Terrier sign. Other signs and symptoms of pancreatic cancer are generally nonspecific: fatigue, malaise, and nausea. A more specific symptom complained is a low back pain; when present, it is suggestive of retroperitoneal invasion of the splanchnic nerve plexus by the cancer. Other symptoms commonly complained are due to pancreatic exocrine insufficiency: weight loss and malodorous and greasy stools. The destruction of the pancreatic islet can be the cause of new onset of diabetes mellitus. The usual sites of metastases in pancreatic cancer are the liver and peritoneal cavity. Other less common sites are the lung and the brain. Skeleton metastases are a rarity. Board et al, in a recent review of the literature, identified 7 cases of bone metastasis over a group of 323 patients reviewed with pancreatic adenocarcinoma (prevalence, 2.2%). The most common site of metastasis was the vertebrae (7/7 patients). The actual incidence of skeletal metastases secondary to adenocarcinoma of the exocrine pancreas remains unknown. Hereby we report a case of a male patient who presented to us with an uncommon picture of pancreatic cancer. No symptoms except a large swelling within the left shoulder region were complained by the patient. Further investigations allowed us to confirm the diagnosis a metastatic pancreatic cancer. The patient was discharged with a homedelivered palliative care setup.

Is Illinois heeding the call to regionalize pancreatic surgery

Recommendations to refer pancreatic procedures to high‐volume centers have been in place for a decade. We sought to determine whether regionalization of pancreatic procedures to high‐volume centers is occurring in Illinois.

Colonoscopy is high yield in spinal cord injury

Abstract Objectives/background Colorectal cancer (CRC) can be prevented by routine colonoscopy. CRC screening in special populations, e.g. spinal cord injury and disorders, presents unique barriers and, potentially, a higher risk of complications. We were concerned about potentially higher risks of complications and sought to determine the safety of colonoscopy. Methods Retrospective observational design using medical record review for 311 patients who underwent 368 colonoscopies from two large VA SCI centers from 1997–2008. Patient demographics and peri-procedural characteristics, including indication, bowel prep quality, and pathological findings are presented. Descriptive statistics are presented. Results The population was predominantly male and Caucasian, and 199 (64%) had high-level injuries (T6 or above). Median age at colonoscopy was 61 years (interquartile range 53–69). Just <1/2 of the colonoscopies were diagnostic, usually for evidence of rectal bleeding. Although a majority of colonoscopies were reported as poorly prepped, the proportion that were adequately prepped increased over time (from 3.7 to 61.3%, P = <0.0001). Of the 146 polyps removed, 101 (69%) were adenomas or carcinomas. Ten subjects had 11 complications, none of which required surgical intervention. Conclusions Although providing quality colonoscopic care in this population is labor intensive, the data suggests that it appears safe and therapeutically beneficial. The results indicate that the risk of screening is outweighed by the likelihood of finding polyps. Recognition of the benefit of colonoscopy in this population may have improved bowel prep and reporting over time. Spinal cord injury providers should continue to offer screening or diagnostic colonoscopy to their patients when indicated, while being aware of the special challenges that they face.

CA 19-9 nonproduction is associated with poor survival after resection of pancreatic adenocarcinoma

Background:Carbohydrate antigen (CA) 19-9 is the most common serum biomarker used in pancreatic adenocarcinoma (PC). Elevated preoperative levels have been shown to correlate with more advanced stage, greater risk of unresectability, and overall worse survival. The prognostic value of CA 19-9 nonproduction, which is present in an estimated 5% to 15% of the population, is unclear. We sought to determine whether CA 19-9 nonproduction was associated with worse survival after PC resection. Methods:We retrospectively reviewed our institution’s prospective pancreatic database for all PC patients with documented preoperative CA 19-9 values who underwent resection with curative intent from March 1992 to August 2009. After excluding 10 perioperative deaths, 200 patients remained for analysis. Results:Mean and median follow-up was 23.3 and 16.1 months, respectively. Median survival in months for patients with preoperative CA 19-9 levels in U/mL by category was as follows: normal (5.1 to 36.9): 32, nonproduction (⩽5): 21, mildly elevated (37 to 99.9): 35, highly elevated (100+): 16. Factors significantly associated with worse overall survival were: nonwhite race, nonproduction or highly elevated preoperative CA 19-9 (≥100 U/mL), estimated blood loss ≥1 L, tumor size (≥2 cm), lymph node-positivity, and advanced (3/4) histologic grade. On multivariate analysis, only CA 19-9 nonproduction or highly elevated production, estimated blood loss ≥1 L, advanced histologic grade, and node positivity remained significant in the final model. Conclusions:CA 19-9 nonproduction is not associated with improved survival after pancreatic cancer resection, as has previously been asserted, when compared with patients with normal and elevated levels.

Northwestern University Feinberg School of Medicine Uses Operations Research Tools to Improve Surgeon Training

Since the advent of work-hour limitations for surgical trainees, medical faculties have been concerned by inadequacies in two areas of resident training programs: operating room experience, which residents need to develop competence and confidence during surgery, and continuity of patient care, which engenders in residents a sense of responsibility and accountability. Previous operations research literature on resident scheduling models has discussed the development of mathematical programming models that assign residents to rotations or shifts; however, this literature has neglected the educational component. In this work, we frame the problem from an educational perspective, and we also describe the mathematical details behind several ideas and analyses in the medical literature. In addition, we present the patient assignment system, which we piloted at a large academic medical center, and discuss the relationship between the logistical and cultural challenges faced in medical training.

Mo1499 Defining Quality for Distal Pancreatectomy: Does the Laparoscopic Approach Protect Patients From Poor Quality Outcomes?

Introduction Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage a complication. Studies using these systems may misrepresent outcomes for the surgical procedures being evaluated. We define a quality outcome for distal pancreatectomy (DP) and use this metric to compare laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP).