G. Paul Wright

Predicting length of stay and conversion to open cholecystectomy for acute cholecystitis using the 2013 Tokyo Guidelines in a US population

The 2013 Tokyo Guidelines (TG13) for acute cholecystitis have not been studied extensively in US populations.

The drowning whipple: Perioperative fluid balance and outcomes following pancreaticoduodenectomy

Given the high incidence of postoperative morbidity following pancreaticoduodenectomy (PD), efforts at improving patient outcomes are vital. We sought to determine the impact of perioperative fluid balance on outcomes following PD in order to identify a targeted strategy for reducing morbidity.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis

BACKGROUND The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention. METHODS A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS). RESULTS One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmanns procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis. CONCLUSIONS Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.

Outcomes of cytoreduction with hyperthermic intraperitoneal chemotherapy: our experience at a midwest community hospital

BACKGROUND Most cytoreduction with hyperthermic intraperitoneal chemotherapy procedures are performed at academic tertiary referral centers with numerous surgical oncology faculty. The objective of this study was to review the postoperative morbidity and mortality data of our institution, a large community hospital. METHODS This was a retrospective cohort study of patients who underwent cytoreduction with hyperthermic intraperitoneal chemotherapy at a single institution. Two surgical oncologists performed all the procedures between May 2005 and June 2011. RESULTS We retrospectively analyzed 57 patients. The most common pathology being treated was pseudomyxoma peritonei (34 of 57; 59.6%), followed by colorectal cancer (9 of 57; 15.8%). Other types of cancer included peritoneal mesothelioma and gastric adenocarcinoma. The average surgery time was 6.9 hours. Approximately 51% of patients suffered grade 3 or 4 morbidity and there were no perioperative mortalities. CONCLUSIONS Cytoreduction with hyperthermic intraperitoneal chemotherapy can be performed at our institution with comparable outcomes as academic referral centers.

Patient perspectives on postoperative visits after common general operative procedures

BACKGROUND Many postoperative concerns after common general operative procedures may be addressed over the phone, thereby saving time and resources for both the patient and surgeon. METHODS Over a 6-month time period, patients who underwent laparoscopic cholecystectomy, appendectomy for uncomplicated appendicitis, and inguinal or umbilical hernia repair were mailed an anonymous survey. The primary outcome measure was whether or not patients felt their concerns could have been addressed adequately over the phone in place of an office visit. RESULTS A total of 1,406 surveys were mailed with 339 responses (24%: 174 laparoscopic cholecystectomy, 83 inguinal hernia, 41 appendectomy, and 41 umbilical hernia). One hundred twelve (33%) felt their concerns could have been addressed adequately over the phone without an office visit. Patients who spent less time with their doctor at the appointment favored telephone follow-up (P < .001). Patients undergoing inguinal hernia were less interested in telephone follow-up compared with laparoscopic cholecystectomy (15% vs 41%; P < .001), appendectomy (15% vs 34%; P = .018), and umbilical hernia (15% vs 37%; P = .010). Of 66 patients (20%) with self-reported complications, 44% sought care from a healthcare provider other than their primary surgeon. CONCLUSION These observations are important for healthcare organizations seeking to maximize surgeon efficiency while improving patient satisfaction.

Comparison of stapling techniques and management of the mesoappendix in laparoscopic appendectomy.

Many techniques for laparoscopic appendectomy have been proposed with few comparative studies. We performed a retrospective review of all patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from 2006 to 2011. Techniques were: (1) transection of the mesoappendix and appendix with a single staple line (SSL); (2) transection of the mesoappendix and appendix with multiple staple lines (MSL); and (3) transection of the mesoappendix with ultrasonic shears and the appendix with a single staple line (USSL). A total of 565 cases were reviewed (149 SSL, 259 MSL, and 157 USSL). Patients treated with the SSL technique had decreased operative duration (P<0.001) and length of stay (P=0.003) despite equivalent disease presentations. Multivariate analysis demonstrated decreased operative duration with the SSL technique (P=0.001). Use of a SSL for transection of the mesoappendix and appendix is both a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes.

Regional therapies for the treatment of primary and metastatic hepatic tumors: A disease-based review of techniques and critical appraisal of current evidence

The practice of hepatic surgery has become increasingly complex as additional therapeutic options emerge to treat both primary and metastatic tumors of the liver. Liver-directed therapy options include selective internal radiation therapy (SIRT), stereotactic body radiation therapy, chemoembolization, bland embolization, hepatic artery infusion chemotherapy (HAIC), and ablative techniques such as microwave or radiofrequency ablation. Hepatocellular carcinoma has been treated with many of these therapies for palliation of symptoms, definitive treatment, and as a bridge to transplantation. Intrahepatic cholangiocarcinoma, particularly patients with unresectable disease, have demonstrated clinical responses to both SIRT as well as HAIC. Colorectal liver metastases have been treated with all of these techniques with varying degrees of success depending on the clinical scenario. A detailed understanding of these technologies and the evidence supporting their use is essential for the modern hepatic surgeon to properly sequence therapies and provide salvage options when first-line treatment has failed. This review describes these techniques and their appropriate usage based on the disease of interest and the respective evidence currently available.

Mo1633 Sarcopenia Does Not Impact Morbidity or Survival in Patients With Resectable Esophageal Adenocarcinoma

Introduction: Sarcopenia has been identified as a potential predictive variable for outcomes in selective surgical procedures and disease processes. The benefit of using sarcopenia for such purposes in oncologic surgery remains unclear. Methods: A retrospective review was conducted for all patients undergoing resection of esophageal adenocarcinoma with intention for cure at a single institution from 2006-2012. Lean psoas muscle area (LPMA) and LMPA/ BMI were calculated at the level of the L4 vertebral body using preoperative computed tomography correcting for muscle density. Patients were analyzed in tertiles based on these measurements. The primary outcome measures were anastomotic leak, 90-day morbidity (Clavien grade ≥ 3), and long-term overall survival. Multivariate analyses were performed for the primary outcome measures. A p value < 0.05 was considered significant. Results: One hundred six consecutive patients were identified and 100 patients had preoperative CT scans available for review. The mean patient age was 63±11 and 62% underwent neoadjuvant therapy. All surgical procedures were performed open and approaches included transhiatal (76%), Ivor-Lewis (11%), and three-field (13%) esophagectomy. The anastomotic leak rate was 10% and 90-day morbidity rate was 38%. Neither LPMA nor LPMA/BMI were significant predictors of anastomotic leak (LMPA p=0.503; LPMA/BMI p=0.268) or morbidity (LPMA p=0.787; LPMA/BMI p=0.528). Median overall survival was 2.8 years. Tertiles for LPMA (p=0.210) and LPMA/BMI (p=0.409) were not predictive of long-term survival (Fig. 1,2). Conclusion: Sarcopenia is not predictive of short term outcomes or longterm overall survival following esophagectomy for esophageal adenocarcinoma.

A Multidisciplinary Approach for Abdominal Venous Involvement in Oncologic Resections

BACKGROUND An aggressive surgical approach to locally advanced malignancy is being increasingly used in the absence of distant metastatic disease. This includes resection and reconstruction of major venous structures. We investigated the results of using a multidisciplinary surgical approach in these instances. METHODS The study data were obtained from a university-affiliated hospital from January 1, 2006, to December 31, 2012. All patients who underwent an oncologic resection using a multidisciplinary approach with vascular surgery consultation were included in the analysis. Primary outcomes analyzed included rate of margin positivity, postoperative venous patency, and survival. Secondary outcome measures included operative time, estimated blood loss, and length of hospital stay. RESULTS A total of 23 patients met criteria for study. Venous involvement included the portal and/or superior mesenteric vein and inferior vena cava in 14 and 9 patients, respectively. Nine patients had clear vascular involvement before surgery and received preoperative consultation. Overall margins were positive in 56.5%, whereas the rate of vascular margin positivity was 30.4%. The postoperative venous patency rate was 65.0%. There were no perioperative mortalities, and median survival was 10 months (range, 4-80). CONCLUSIONS Major venous resections and reconstructions in oncologic surgery are safe but associated with a high rate of positive margins. Future efforts should focus on identifying patients in the preoperative phase to provide opportunity for optimal multidisciplinary planning.

Impact of Chronic Pancreatitis on Pancreatic Resections for Malignancy

Background: Chronic pancreatitis has been shown to have potential benefit in pancreatic resections by reducing postoperative pancreatic fistula. We sought to investigate the impact of chronic pancreatitis on oncologic surgical outcomes. Materials and Methods: Consecutive partial pancreatectomies performed for malignant disease from 2005-2011 were reviewed. Patients were divided for analysis based on the presence of chronic pancreatitis. The primary outcome measures were need for intraoperative re-excision of margins and final margin status. Secondary outcome measures included pancreatic fistula rate and overall morbidity which were graded in standardized fashion. Significance was assessed for p<0.05. Results: One hundred fifty-four patients met criteria for study, 48 of which had chronic pancreatitis. Demographics, co-morbidities, diagnoses, and surgical technique were equivalent between groups. Though there was a trend towards increased re-excision of margins in the chronic pancreatitis group (p<0.08), there were no significant differences in any surgical outcome measures between groups including final margin status, pancreatic fistula rate, and overall morbidity. Multivariate analysis failed to identify chronic pancreatitis as a predictive factor for any of the chosen outcome variables. Conclusion: Despite potential for difficult dissection due to inflammatory changes in chronic pancreatitis, we found no differences in oncologic outcomes in patients undergoing pancreatectomy.