Andrew J. Page

Management of borderline and locally advanced pancreatic cancer: Where do we stand?

Many patients with pancreas cancer present with locally advanced pancreatic cancer (LAPC). The principle tools used for diagnosis and staging of LAPC include endoscopic ultrasound, axial imaging with computed tomography and magnetic resonance imaging, and diagnostic laparoscopy. The definition of resectability has historically been vague, as there is considerable debate and controversy as to the definition of LAPC. For the patient with LAPC, there is some level of involvement of the surrounding vascular structures, which include the superior mesenteric artery, celiac axis, hepatic artery, superior mesenteric vein, or portal vein. When feasible, most surgeons would recommend possible surgical resection for patients with borderline LAPC, with the goal of an R0 resection. For initially unresectable LAPC, neoadjuvant should be strongly considered. Specifically, these patients should be offered neoadjuvant therapy, and the tumor should be assessed for possible response and eventual resection. The efficacy of neoadjuvant therapy with this approach as a bridge to potential curative resection is broad, ranging from 3%-79%. The different modalities of neoadjuvant therapy include single or multi-agent chemotherapy combined with radiation, chemotherapy alone, and chemotherapy followed by chemotherapy with radiation. This review focuses on patients with LAPC and addresses recent advances and controversies in the field.

Surgical management of noncolorectal cancer liver metastases.

The number of hepatectomies performed for metastatic cancer has dramatically increased over the past 2 decades. Hepatectomy for stage IV colorectal cancer is now considered the standard of care for resectable patients with isolated hepatic disease and acceptable performance status. However, the indications for resection of noncolorectal origin liver metastases are not as clearly defined. This review focuses on emerging data for the resection of noncolorectal metastatic disease to the liver, with a focus on indications for surgical resection. Specifically, we review the current data on the surgical management of nonneuroendocrine and neuroendocrine tumors metastatic to the liver. Cancer 2014;120:3111–3121.

Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection

Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery.

Hepatocellular Carcinoma: Diagnosis, Management, and Prognosis

The successful management of hepatocellular carcinoma (HCC) requires a multidisciplinary approach, incorporating hepatologists, oncologists, surgical oncologists, transplant surgeons, and radiologists. With improvements in technology and better long-term outcomes data, management strategies for HCC have become more methodical and more successful. This article focuses on some of the most critical advances relating to carcinogenesis, surveillance, and management.

Laparoscopic Versus Open Appendectomy: An Analysis of Outcomes in 17,199 Patients Using ACS/NSQIP

BackgroundThe current study was undertaken to evaluate the outcomes for open and laparoscopic appendectomy using the 2008 American College of Surgeons: National Surgical Quality Improvement Program (ACS/NSQIP) Participant Use File (PUF). We hypothesized that laparoscopic appendectomy would have fewer infectious complications, superior perioperative outcomes, and decreased morbidity and mortality when compared to open appendectomy.Study DesignUsing the Current Procedural Technology (CPT) codes for open (44950) and laparoscopic (44970) appendectomy, 17, 199 patients were identified from the ACS/NSQIP PUF file that underwent appendectomy in 2008. Univariate analysis with chi-squared tests for categorical data and t tests or ANOVA tests for continuous data was used. Binary logistic regression models were used to evaluate outcomes for independent association by multivariable analysis.ResultsOf the patients, 3,025 underwent open appendectomy and 14,174 underwent laparoscopic appendectomy. Patients undergoing laparoscopic appendectomy had significantly shorter operative times and hospital length of stay. They also had a significantly lower incidence of superficial and deep surgical site infections, wound disruptions, fewer complications, and lower perioperative mortality when compared to patients undergoing open appendectomy.ConclusionsUsing the ACS/NSQIP PUF file, we demonstrate that laparoscopic appendectomy has better outcomes than open appendectomy for the treatment of appendicitis. While the operative treatment of appendicitis is surgeon specific, this study lends support to the laparoscopic approach for patients requiring appendectomy.

Enhanced Recovery After Surgery Protocols for Open Hepatectomy—Physiology, Immunomodulation, and Implementation

There has been recent interest in enhanced-recovery after surgery (ERAS®) or “fast-track” perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.

Patient perceptions regarding the likelihood of cure after surgical resection of lung and colorectal cancer: Perception of Cure After Surgery

The objective of the current study was to characterize the prevalence of the expectation that surgical resection of lung or colorectal cancer might be curative. The authors sought to assess patient‐level, tumor‐level, and communication‐level factors associated with the perception of cure.

A nationwide analysis of the use and outcomes of perioperative epidural analgesia in patients undergoing hepatic and pancreatic surgery

BACKGROUND We sought to define trends in the use of epidural analgesia (EA) for hepatopancreatic procedures, as well as to characterize inpatient outcomes relative to the use of EA. METHODS The Nationwide Inpatient Sample database was queried to identify all elective hepatopancreatic surgeries between 2000 and 2012. In-hospital outcomes were compared among patients receiving EA vs conventional analgesia using propensity matching. RESULTS EA utilization was 7.4% (n = 3,961). The use of EA among minimally invasive procedures increased from 3.8% in 2000 to 9.1% in 2012. The odds of sepsis (odds ratio [OR] .72, 95% confidence interval [CI] .56 to .93), respiratory failure (OR .79, 95% CI .69 to .91), and postoperative pneumonia (OR .77, 95% CI .61 to .98), as well as overall in-hospital mortality (OR .72, 95% CI .56 to .93) were lower in the EA cohort (all P < .05). In contrast, no association was noted between EA and postoperative hemorrhage (OR .81, 95% CI .65 to 1.01, P = .06). CONCLUSIONS EA use among patients undergoing hepatopancreatic procedures remains low. After controlling for confounding factors, EA remained associated with a reduction in specific pulmonary-related complications, as well as in-hospital mortality.

Initiating an Enhanced Recovery Pathway Program: An Anesthesiology Department’s Perspective

BACKGROUND Enhanced recovery pathways (ERPs) for surgical patients may reduce variation in care and improve perioperative outcomes. Mainstays of ERPs are standardized perioperative pathways. At The Johns Hopkins Hospital (Baltimore), an integrated ERP was proposed to further reduce the surgical site infection rate and the longer-than-expected hospital length of stay in colorectal surgery patients. METHODS To develop the technical components of the anesthesia pathway, evidence on enhanced recovery was reviewed and the limitations of the hospital infrastructure and policies were considered. The goals of the perioperative anesthesiology pathway were achieving superior analgesia, minimizing postoperative nausea and vomiting, facilitating patient recovery, and preserving perioperative immune function. ERP was implemented in phases during a 30-day period, starting with the anesthesiology elements and followed by the pre- and postoperative surgical team processes. The perioperative anesthetic regimen was tailored to meet the goal of preservation of perioperative immune function (in an attempt to decrease surgical site infection and cancer recurrence), in part by minimizing perioperative opioid use. RESULTS After six months of exposure to all ERP elements, a 45% reduction in length of stay was observed among colorectal surgery patients. In addition, patient satisfaction scores for this cohort of patients improved from the 37th percentile preimplementation to >97th percentile postimplementation. CONCLUSIONS Development of an ERP requires collaboration among surgeons, anesthesiologists, and nurses. Thoughtful, collaborative pathway development and implementation, with recognition of the strengths and weakness of the existing surgical health care delivery system, should lead to realization of early improvement in outcomes.

The Effect of Intravenous Midazolam on Postoperative Nausea and Vomiting: A Meta-Analysis.

BACKGROUND:Research has shown that high-risk surgical patients benefit from a multimodal therapeutic approach to prevent postoperative nausea and vomiting (PONV). Our group sought to investigate the effect of administering IV midazolam on PONV. METHODS:This meta-analysis included 12 randomized controlled trials (n = 841) of adults undergoing a variety of surgical procedures that investigated the effect of both preoperative and intraoperative IV midazolam on PONV in patients undergoing general anesthesia. RESULTS:Administration of IV midazolam was associated with significantly reduced PONV (risk ratio [RR] = 0.55; 95% confidence interval [CI], 0.43–0.70), nausea (RR = 0.62; 95% CI, 0.40–0.94), vomiting (RR = 0.61; 95% CI, 0.45–0.82), and rescue antiemetic administration (RR = 0.49; 95% CI, 0.37–0.65) within 24 hours. Individual subgroup analyses of trials excluding the use of thiopental for induction, trials of either female sex or high-risk surgery, trials involving nitrous oxide maintenance, and trials using midazolam in combination with known antiemetics all yielded similar reductions in PONV end points within 24 hours of surgery. CONCLUSIONS:Administration of preoperative or intraoperative IV midazolam is associated with a significant decrease in overall PONV, nausea, vomiting, and rescue antiemetic use. Providers may consider the administration of IV midazolam as part of a multimodal approach in preventing PONV.