Ammara A. Watkins

Incorporation of Procedure-specific Risk Into the ACS-NSQIP Surgical Risk Calculator Improves the Prediction of Morbidity and Mortality After Pancreatoduodenectomy.

Objective: This multicenter study sought to evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP) surgical risk calculator for predicting outcomes after pancreatoduodenectomy (PD) and to determine whether incorporating other factors improves its predictive capacity. Background: The ACS-NSQIP surgical risk calculator has been proposed as a decision-support tool to predict complication risk after various operations. Although it considers 21 preoperative factors, it does not include procedure-specific variables, which have demonstrated a strong predictive capacity for the most common and morbid complication after PD – clinically relevant pancreatic fistula (CR-POPF). The validated Fistula Risk Score (FRS) intraoperatively predicts the occurrence of CR-POPF and serious complications after PD. Methods: This study of 1480 PDs involved 47 surgeons at 17 high-volume institutions. Patient complication risk was calculated using both the universal calculator and a procedure-specific model that incorporated the FRS and surgeon/institutional factors. The performance of each model was compared using the c-statistic and Brier score. Results: The FRS was significantly associated with 30-day mortality, 90-day mortality, serious complications, and reoperation (all P < 0.0001). The procedure-specific model outperformed the universal calculator for 30-day mortality (c-statistic: 0.79 vs 0.68; Brier score: 0.020 vs 0.021), 90-day mortality, serious complications, and reoperation. Neither surgeon experience nor institutional volume significantly predicted mortality; however, surgeons with a career PD volume >450 were less likely to have serious complications (P < 0.001) or perform reoperations (P < 0.001). Conclusions: Procedure-specific complication risk influences outcomes after pancreatoduodenectomy; therefore, risk adjustment for performance assessment and comparative research should consider these preoperative and intraoperative factors along with conventional ACS-NSQIP preoperative variables.

Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy

BACKGROUND Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. METHODS From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C). ACB values were derived from fistula severity scores based on the Modified Accordion Severity Grading. The ACB of POPFs was compared between PD and DP. RESULTS POPFs were more common after DP compared with PD (34.5 vs 27.2%; P < .001); however, the incidence of any complication was greater after PD (64.9 vs 53.2%; P < .001). When POPFs occurred, they were more likely to be the highest-graded complication after DP compared with PD (65.1 vs 51.6%; P < .001). ACB significantly varied between PDs and DPs for grade C POPFs (0.804 vs 0.611; P < .001). POPFs accounted for 31.2% of the overall complication burden after DP compared with 17.5% of the burden after PD. ACB differed significantly across both institutions and surgeons in terms of POPFs, nonfistulous complications, and overall complications (all P < .05). CONCLUSION Although POPFs occur less frequently after PD, they are associated with a greater complication burden compared with DP. ACB varies significantly between health care providers, suggesting the need for risk-adjusted comparisons of complication severity. Using ACB to evaluate a distinct morbidity has the potential to aid in assessing the impact of procedure-specific complications.

Assessing the Accuracy and Readability of Online Health Information for Patients With Pancreatic Cancer

IMPORTANCE The degree to which patients are empowered by written educational materials depends on the texts readability level and the accuracy of the information provided. The association of a websites affiliation or focus on treatment modality with its readability and accuracy has yet to be thoroughly elucidated. OBJECTIVE To compare the readability and accuracy of patient-oriented online resources for pancreatic cancer by treatment modality and website affiliation. DESIGN An online search of 50 websites discussing 5 pancreatic cancer treatment modalities (alternative therapy, chemotherapy, clinical trials, radiation therapy, and surgery) was conducted. The websites affiliation was identified. Readability was measured by 9 standardized tests, and accuracy was assessed by an expert panel. MAIN OUTCOMES AND MEASURES Nine standardized tests were used to compute the median readability level of each website. The median readability scores were compared among treatment modality and affiliation categories. Accuracy was determined by an expert panel consisting of 2 medical specialists and 2 surgical specialists. The 4 raters independently evaluated all websites belonging to the 5 treatment modalities (a score of 1 indicates that <25% of the information is accurate, a score of 2 indicates that 26%-50% of the information is accurate, a score of 3 indicates that 51%-75% of the information is accurate, a score of 4 indicates that 76%-99% of the information is accurate, and a score of 5 indicates that 100% of the information is accurate). RESULTS The 50 evaluated websites differed in readability and accuracy based on the focus of the treatment modality and the websites affiliation. Websites discussing surgery (with a median readability level of 13.7 and an interquartile range [IQR] of 11.9-15.6) were easier to read than those discussing radiotherapy (median readability level, 15.2 [IQR, 13.0-17.0]) (P = .003) and clinical trials (median readability level, 15.2 [IQR, 12.8-17.0]) (P = .002). Websites of nonprofit organizations (median readability level, 12.9 [IQR, 11.2-15.0]) were easier to read than media (median readability level, 16.0 [IQR, 13.4-17.0]) (P < .001) and academic (median readability level, 14.8 [IQR, 12.9-17.0]) (P < .001) websites. Privately owned websites (median readability level, 14.0 [IQR, 12.1-16.1]) were easier to read than media websites (P = .001). Among treatment modalities, alternative therapy websites exhibited the lowest accuracy scores (median accuracy score, 2 [IQR, 1-4]) (P < .001). Nonprofit (median accuracy score, 4 [IQR, 4-5]), government (median accuracy score, 5 [IQR, 4-5]), and academic (median accuracy score, 4 [IQR, 3.5-5]) websites were more accurate than privately owned (median accuracy score, 3.5 [IQR, 1.5-4]) and media (median accuracy score, 4 [IQR, 2-4]) websites (P < .004). Websites with higher accuracy were more difficult to read than websites with lower accuracy. CONCLUSIONS AND RELEVANCE Online information on pancreatic cancer overestimates the reading ability of the overall population and lacks accurate information about alternative therapy. In the absence of quality control on the Internet, physicians should provide guidance to patients in the selection of online resources with readable and accurate information.

Nationwide Evaluation of Patient Selection for Minimally Invasive Distal Pancreatectomy Using American College of Surgeons' National Quality Improvement Program.

Objective: To assess current nationwide case selection factors for minimally invasive distal pancreatectomy (MIDP) and identify actual risk factors for adverse outcomes compared with open distal pancreatectomy (ODP). Background: Patient selection criteria that predict outcomes after MIDP remain unknown. As a result, widespread adoption of this surgical technique may have been delayed and its potential benefits possibly under-exploited. Methods: Retrospective cohort study of elective ODP and MIDP performed at 106 centers in 2014, using the pancreas-targeted American College of Surgeons’ National Quality Improvement Program (ACS-NSQIP) database. Exclusion criteria were neoadjuvant treatment or pancreatitis as only diagnosis. Primary outcome includes a composite major morbidity metric, reflecting adverse events including mortality and reoperation. Multivariable modeling was used to detect current selection factors and to identify actual risk factors of composite major morbidity. Results: A total of 928 patients underwent ODP (n = 472) or MIDP (n = 456) using a laparoscopic or robot-assisted approach, 24% for pancreatic ductal adenocarcinoma (PDAC). Current selection factors for MIDP were benign disease (odds ratio: OR: 1.56, CI: 1.10–2.21) and body mass index (BMI) 30–40 (OR: 1.41, CI: 1.04–1.91). Current selection factors for ODP were PDAC (OR: 0.45, CI: 0.31–0.64), benign tumor size >5 centimeters (OR: 0.40, CI: 0.23–0.67), and multivisceral procedures (OR: 0.39, CI: 0.26–0.59). Risk factors for composite major morbidity did not differ between ODP and MIDP. A trend was observed between MIDP and a lower risk of composite major morbidity compared with ODP (OR: 0.43, CI: 0.17–1.07). Conclusions: Current selection factors for ODP or MIDP (benign disease, tumor size, and BMI) do not mitigate the risk of major morbidity. We found no evidence that MIDP should be avoided based on tumor etiology or size, BMI, or patient physical status.

Weight loss after bariatric surgery in obese adolescents: a systematic review and meta-analysis

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m2) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m2) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m2) at 6 months, was -5.4 (-3.0, -7.8) after gastric band, -11.5 (-8.8, -14.2) after gastric sleeve, and -18.8 (-10.9, -26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m2) was -10.3 (-7.0, -13.7) after gastric band, -13.0 (-11.0, -15.0) after gastric sleeve, and -15.0 (-13.5, -16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.

Pancreatogastrostomy Vs. Pancreatojejunostomy: a Risk-Stratified Analysis of 5316 Pancreatoduodenectomies

Brett L. Ecker & Matthew T. McMillan & Laura Maggino & Valentina Allegrini & Horacio J. Asbun & Chad G. Ball & Claudio Bassi & Joal D. Beane & Stephen W. Behrman & Adam C. Berger & Mark Bloomston & Mark P. Callery & John D. Christein & Euan Dickson & Elijah Dixon & Jeffrey A. Drebin & Carlos Fernandez-Del Castillo & William E. Fisher & Zhi Ven Fong & Ericka Haverick & Robert H. Hollis & Michael G. House & Steven J. Hughes & Nigel B. Jamieson & Tara S. Kent & Stacy J. Kowalsky & John W. Kunstman & Giuseppe Malleo & Ronald R. Salem & Kevin C. Soares & Vicente Valero III & Ammara A. Watkins & Christopher L. Wolfgang & Amer H. Zureikat & Charles M. Vollmer Jr

Using Individual Clinical Evaluations to Assess Residents’ Clinical Judgment; Feasibility and Residents’ Perception

OBJECTIVE In surgical training, most assessment tools focus on advanced clinical decision-making or operative skill. Available tools often require significant investment of resources and time. A high stakes oral examination is also required to become board-certified in surgery. We developed Individual Clinical Evaluation (ICE) to evaluate intern-level clinical decision-making in a time- and cost-efficient manner, and to introduce the face-to-face evaluation setting. DESIGN Intern-level ICE consists of 3 clinical scenarios commonly encountered by surgical trainees. Each scenario was developed to be presented in a step-by-step manner to an intern by an attending physician or chief resident. The interns had 17 minutes to complete the face-to-face evaluation and 3 minutes to receive feedback on their performance. The feedback was transcribed and sent to the interns along with incorrect answers. Eighty percent correct was set as a minimum to pass each scenario and continue with the next one. Interns who failed were retested until they passed. Frequency of incorrect response was tracked by question/content area. After passing the 3 scenarios, interns completed a survey about their experience with ICE. SETTING Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS All first-year surgery residents in our institution (n = 17) were invited to complete a survey. RESULTS All 2016-2017 surgical interns (17) completed the ICEs. A total of

Outcomes Data in Pain Studies: In Reply to Barbul and colleagues

171 (US) was spent conducting the ICEs, and an average of 17 minutes was used to complete each evaluation. In total, 5 different residents failed 1 scenario, with the most common mistake being: failing to stabilize respiration before starting management. After completing the 3 clinical scenarios, more than 90% of respondents agreed or strongly agreed that the evaluations were appropriately challenging for training level, and that the evaluations helped to identify personal strengths and weaknesses in skill and knowledge. The majority believed their knowledge improved as a result of the ICE and felt better prepared to manage these scenarios (88% and 76%, respectively). CONCLUSIONS The ICE is an inexpensive and time efficient way to introduce interns to board type examinations and assess their preparedness for perioperative patient care issues. Common errors were identified which were able to inform educational efforts. ICEs were well accepted by residents. Next steps include extension of the ICE to PGY2 and PGY3 residents.

The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy

It is gratifying to see that these results were interesting to an authority like Dr Barbul and colleagues. We certainly agree that there are theoretical risks and concerns for increased surgical site infections with local cryotherapy application. We hope our study spurs future studies that are powered to sufficiently detect adverse events after cryotherapy as well as efficacy between different regimens of cryotherapy. Notably, of the 3 surgical site infections in our cryotherapy group, 1 occurred in a patient who underwent an abdominoperineal resection and had an infection only at the perineal wound. This portion of the wound did not have particular exposure to the ice packs. All wound infections were of Clavien-Dindo classification grade II and did not significantly alter the patient’s postoperative recovery. Additionally, although not formally studied, we have used cryotherapy routinely on virtually all surgical oncology and urologic oncology abdominal wounds at Emory University since accumulation of these data in 2011.Wehave not identified an increase in surgical site infections using ourNSQIP database. In a recent series of 67 cases abstracted byNSQIP, no wound infections were noted. Although not equal in wound-classification category, within the orthopaedic and obstetric literature there are multiple meta-analyses and systemic reviews providing evidence that cryotherapy does not increase rates of surgical site infections. Knee arthroplasty, which carries risk for hardware infection, a devastating complication, routinely is treated with postoperative cryotherapy at many facilities in the United States. Meta-analyses and systemic reviews of trials have not found an increased incidence of surgical site infections among the cryotherapy arms. Cryotherapy is also routinely used postoperatively in the field of orthopaedic sports medicine. A previous systematic review and a meta-analysis of randomized control trials on anterior cruciate ligament repair also do not demonstrate an increased incidence of surgical site infections among cryotherapy groups. A meta-analysis of cryotherapy use for perineal wounds after childbirth additionally did not find an increase in postoperative wound infections, although one of the trials analyzed noted increased edema and ecchymosis. Our patients were all normothermic, and this is another excellent point made by the reviewers. Perhaps patients who cannot maintain normothermia will be at increased risk for surgical site infections, and this issue needs to be further investigated. Our study group did not include any patients requiring postoperative ICU care. Patients in the ICU have more fluctuations in body temperature, hemodynamics, and blood glucose that can affect wound healing and tissue perfusion. This study certainly prompts numerous questions that need to be further examined in larger series with sufficient power to detect postoperative complications as well as patient quality of life. We look forward to additional feedback on our work and subsequent studies on the topic. We do believe that the decreased pain scores and patient satisfaction noted in our study combined with low risk profile of cryotherapy warrants our continued use of cryotherapy in our patients undergoing abdominal operations.