Elan R. Witkowski

Outcomes following resection of pancreatic cancer

Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long‐term survival after resection. J. Surg. Oncol. 2013;107:97–103.

Use of Cholecystostomy Tubes in the Management of Patients with Primary Diagnosis of Acute Cholecystitis

BACKGROUND Management of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center. STUDY DESIGN All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes. RESULTS Mean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment. CONCLUSIONS This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.

Colectomy performance improvement within NSQIP 2005-2008

BACKGROUND All open and laparoscopic colectomies submitted to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were evaluated for trends and improvements in operative outcomes. METHODS 48,247 adults (≥18 y old) underwent colectomy in ACS NSQIP, as grouped by surgical approach (laparoscopic versus open), urgency (emergent versus elective), and operative year (2005 to 2008). Primary outcomes measured morbidity, mortality, perioperative, and postoperative complications. RESULTS The proportion of laparoscopic colectomies performed increased annually (26.3% to 34.0%), while open colectomies decreased (73.7% to 66.0%; P < 0.0001). Most emergent colectomies were open procedures (93.5%) representing 24.3% of all open cases. The overall risk-adjusted morbidity and mortality for all colectomy procedures did not show a statistically significant change over time, however, morbidity and mortality increased among open colectomies (r = 0.03) and decreased among laparoscopic colectomies (r = -0.04; P < 0.0001). Postoperative complications reduced significantly including superficial surgical site infections (9.17% to 8.20%, P < 0.004), pneumonia (4.60% to 3.97%, P < 0.0001), and sepsis (4.72%, 2005; 6.81%, 2006; 5.62%, 2007; 5.09%, 2008; P < 0.0002). Perioperative improvements included operative time (169.2 to 160.0 min), PRBC transfusions (0.27 to 0.25 units) and length of stay (10.5 to 6.61 d; P < 0.0001). CONCLUSION It appears that laparoscopic colectomies are growing in popularity over open colectomies, but the need for emergent open procedures remains unchanged. Across all colectomies, however, key postoperative and perioperative complications have improved over time. Participation in ACS NSQIP demonstrates quality improvement and may encourage greater enrollment.

Perioperative mortality after pancreatectomy: A risk score to aid decision-making

BACKGROUND Undergoing a pancreatectomy obligates the patient to risks and benefits. For complex operations such as pancreatectomy, the objective assessment of baseline risks may be useful in decision-making. We developed an integer-based risk score estimating in-hospital mortality after pancreatectomy, incorporating institution-specific mortality rates to enhance its use. METHODS Pancreatic resections were identified from the Nationwide Inpatient Sample (1998-2006), and categorized as proximal, distal, or nonspecified by the International Classification of Diseases, 9th edition. Logistic regression and bootstrap methods were used to estimate in-hospital mortality using demographics, diagnosis, comorbidities (Charlson index), procedure, and hospital volume; 80% of this cohort was selected randomly to create the score and 20% was used for validation. Score assignments were subsequently individually fitted to risk distributions around specific mortality rates. RESULTS Sixteen thousand one hundred sixteen patient discharges were identified. Nationwide in-hospital mortality was 5.3%. Integers were assigned to predictors (age group, Charlson index, sex, diagnosis, pancreatectomy type, and hospital volume) and applied to an additive score. Three score groups were defined to stratify in-hospital mortality (national mortality, 1.3%, 4.9%, and 14.3%; P < .0001), with sufficient discrimination of derivation and validation sets (C statistics, 0.72 and 0.74). Score groups were shifted algorithmically to calculate risk based on institutional data (eg, with institutional mortality of 2.0%, low-, medium-, and high-risk patient groups had 0.5%, 1.9%, and 5.4% mortality, respectively). A web-based tool was developed and is available online (http://www.umassmed.edu/surgery/panc_mortality_custom.aspx). CONCLUSION To maximize patient benefit, objective assessment of risk for major procedures is necessary. We developed a Surgical Outcomes Analysis and Research risk score predicting pancreatectomy mortality that combines national and institution-specific data to enhance decision-making. This type of risk stratification tool may identify opportunities to improve care for patients undergoing specific operative procedures.

National trends in pancreaticoduodenal trauma: interventions and outcomes

OBJECTIVES Pancreaticoduodenal trauma (PDT) is associated with substantial mortality and morbidity. In this study, contemporary trends were analysed using national data. METHODS The Nationwide Inpatient Sample for 1998-2009 was queried for patients with PDT. Interventions including any operation (Any-Op) and pancreas-specific surgery (PSURG) were identified. Trends in treatment and outcomes were determined [complications, length of stay (LoS), mortality] for the Any-Op, PSURG and non-operative (Non-Op) groups. Analyses included chi-squared tests, Cochran-Armitage trend tests and logistic regression. RESULTS A total of 27 216 patients (nationally weighted) with PDT were identified. Over time, the frequency of PDT increased by 8.3%, whereas the proportion of patients submitted to PSURG declined (from 21.7% to 19.8%; P = 0.0004) and the percentage of patients submitted to non-operative management increased (from 56.7% to 59.1%; P = 0.01). In the Non-Op group, mortality decreased from 9.7% to 8.6% (P < 0.001); morbidity and LoS remained unchanged at ∼40% and ∼12 days, respectively. In the PSURG group, mortality remained stable at ∼15%, complications increased from 50.2% to 71.8% (P < 0.0001) and LoS remained stable at ∼21 days. For all PDT patients, significant independent predictors of mortality included: the presence of combined pancreatic and duodenal injuries; penetrating trauma, and age >50 years. Having any operation (Any-Op) was associated with mortality, but PSURG was not a predictor of death. CONCLUSIONS The utilization of operations for PDT has declined without affecting mortality, but operative morbidity increased significantly over the 12 years to 2009. The development of an evidence-based approach to invasive manoeuvres and an early multidisciplinary approach involving pancreatic surgeons may improve outcomes in patients with these morbid injuries.

Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries

BACKGROUND Elderly Americans are at increased risk of head trauma, particularly fall related. The effect of warfarin on head trauma outcomes remains controversial. METHODS Medicare beneficiaries with head injuries from 2009 to 2011 were identified by International Classification of Diseases (ICD)-9 code. Preinjury warfarin use was determined using Part D claims. Multiple logistic regression models determined the association of preinjury warfarin on need for hospitalization, intensive care unit care, and occurrence of intracranial hemorrhage. Association between warfarin and in-hospital mortality was assessed using a Cox proportional hazard model. RESULTS Of 11,078 head injured patients, 5.2% were injured while on warfarin. Preinjury warfarin increased the odds of intracranial hemorrhage by 40% and doubled the risk of 30-day in-hospital mortality after adjusting for demographic and clinical factors. CONCLUSIONS Warfarin at the time of head injury increases the risk of adverse outcomes in Medicare beneficiaries with head injuries. Caution should be used when initiating anticoagulation in elderly Americans at risk for trauma.

Outcomes in operative management of pancreatic cancer.

Pancreatic cancer is a highly lethal malignancy that often presents at an advanced stage. Surgical resection can prolong survival and offers the only potential for cure. However, pancreatectomy is associated with significant morbidity and mortality. This article reviews perioperative outcomes, post‐resection long‐term survival, and innovations in the surgical management of pancreatic cancer. J. Surg. Oncol. 2014 110:592–598.

Utilization of laparoscopy for resections of stomach and esophagus cancers: Is hospital the deciding factor?

86 Background: Foregut surgery is technically complex. Outcomes for such high-stakes operations receive increasing scrutiny and the use of minimally invasive approaches has been further adopted. This study aims to determine national trends in laparoscopy utilization and patient outcomes for potentially curative cancer resections of the esophagus and stomach. Methods: Retrospective review of all esophageal and gastric cancer resections in the Nationwide Inpatient Sample during 1998 to 2011. Univariate analyses of sex, race, admission status, Elixhauser comorbidity score, year, insurance, hospital characteristics, procedure, and center volume were performed by chi-square. Cochran-Armitage test was used for trends. Logistic regressions were used to model inpatient mortality, complications and laparoscopy. Results: From 1998 to 2011, 120,527 and 25,540 patients (nationally-weighted records) underwent gastrectomies and esophagectomies for cancer. From early (1998-2002) to late (2008-2011) study years, inpatien...

528 Is Routine Intraoperative Cholangiogram Necessary in the 21st Century? a National View

The video presents technical steps for Laparoscopic Reversal of Roux-en-Y Gastric Bypass (RYGB) to normal anatomy, and results of pre and post-op metabolic testing. The patient underwent RYGB at another institution (BMI 46). Two years after RYGB (BMI 25), presented with recalcitrant hyperinsulinemic hypoglycemia episodes and hypoglycemia unawareness. A laparoscopic gastrostomy was placed in the excluded stomach. A meal test (MT) administered orally and through the gastrostomy showed altered insulin and glycemic responses through the RYGB. Laparoscopic reversal was performed. Patient symptoms subsided; and 6 months later (BMI 29), a MT showed normal insulin and glycemic profiles.

Surgery for pancreatic cancer: Unnecessary or insufficient?

e14596 Background: All potential cures for pancreatic cancer include resection. However, some patients with resectable disease do not undergo surgery, while others undergo operation but succumb quickly to recurrent disease or postoperative complications. We attempted to construct an optimal cohort of patients for resection by identifying two outlying groups who either 1) might have benefited from resection; or 2) underwent non-beneficial surgery. METHODS Patients ≥65 years old with pancreatic adenocarcinoma were identified in SEER-Medicare 1991-2007. Potential suboptimal utilization was defined as patients with locoregional disease who did not undergo resection, or patients who received resections yet died <6 months from diagnosis. Univariate and multivariate analyses were performed to identify predictors of suboptimal outcome. Survival was examined by Cox. RESULTS Among 17,450 patients, 9612 (55.1%) had metastases at diagnosis. For metastatic patients, 5,574 (58%) visited a surgeon, 828 (8.6%) were recommended for surgery, and 185 (1.9%) were resected. 7,604 (79.1%) of metastatic patients died within 6 months of diagnosis, including 100 (54.1%) of the highly-selected resection cohort. Younger metastatic patients were more likely to receive surgery (p=0.007). For patients with locoregional disease, only 6,001 (76.6%) visited a surgeon, 3,135 (40%) were recommended for resection, and 2,528 (32.3%) underwent operation. In locoregional disease, odds of surviving >6 months were independently increased by receipt of surgery (OR 3.9, 3.5-4.2) and chemotherapy (OR 4.9, 4.4-5.4). Resection also improved overall survival (HR 0.4, 0.38-0.42). However, of the total 2,713 all-stage resected patients, 654 (24.1%) died within 6 months of diagnosis. CONCLUSIONS Only one-third of patients with locoregional pancreatic cancer undergo resection, suggesting potential underutilization of surgery; however, one-quarter of resected patients die within 6 months. These results suggest that surgical therapy may be imperfectly utilized in this lethal disease. Careful consideration of resection as well as more precise stratification of perioperative risk and potential for residual/recurrent disease may help optimize the cohort on whom we operate.