Hari B. Keshava

A multi-institutional comparison of perioperative outcomes of robotic and open pancreaticoduodenectomy

Objectives: Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD). Methods: Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011–1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes. Results: Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (<3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5–133.3, P = 0.01], reduced blood loss (mean difference = −181 mL, 95% CI −355–(−7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47–0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (<12 lymph nodes harvested). Conclusions: Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.

A model for predicting prolonged length of stay in patients undergoing anatomical lung resection: a National Surgical Quality Improvement Program (NSQIP) database study

OBJECTIVES There are currently no studies that have specifically delineated the risk factors for a prolonged length of hospitalization in patients undergoing anatomical lung resection. Knowing these risk factors is important in terms of risk stratification and improving outcomes in the high-risk population. The goal of this study was to identify risk factors associated with a prolonged length of stay (≥14 days) in patients undergoing an anatomical lung resection and to further create a model for predicting the probability of a prolonged length of stay in these patients. METHODS The NSQIP database (2005-2013) was culled for data on 45 distinct preoperative, intraoperative and postoperative variables among patients undergoing anatomical pulmonary resections. Univariate and multivariate logistic regression analyses were used to determine variables that contributed to a prolonged length of stay. A scoring system was created based on these results and applied to internal and external (a single institution database) validation groups to test for the adequacy of the model through the comparison of receiver operating characteristic curves. RESULTS Fifteen factors were found to be significant for prolonged length of stay; six were preoperative (age >70 years [P < 0.0001], functional status-dependent [P = 0.0020], chronic obstructive pulmonary disease [P < 0.0001], serum sodium <135 mmol/l [P = 0.0200], ASA Class 3 [P = 0.0070] and ASA Class 4 or 5 [P = 0.0010]), one was intraoperative (open thoracotomy [P < 0.0001]) and eight were postoperative (pneumonia [P < 0.0001], unplanned reintubation [P < 0.0001], prolonged mechanical ventilation [P < 0.0001], urinary tract infection [P < 0.0001], stroke [P = 0.0020], transfusion [P = 0.0010], deep vein thrombosis/thrombophlebitis [P < 0.0001] and return to the operating room [P < 0.0001]). CONCLUSIONS A simple model for predicting the probability of a prolonged length of stay in patients undergoing anatomical lung resection has been successfully created. This model can allow for better risk stratification of patients preoperatively based on certain existing comorbidities, and can help to predict the impact the development of various postoperative complications will have on overall patient outcomes.

Timing of Heparin and Thrombus Formation in Donor Lungs after Cardiac Death

BACKGROUND Heparin is routinely administered to brain-dead donors before cardiac arrest, although it is not universally allowed for donation after cardiac death (DCD) donors due to concerns that death may be hastened. The lack of heparin may lead to thrombosis and compromised graft function. We evaluated the impact of timing of heparin administration and thrombi formation in a DCD pig model. METHODS Eight domestic adult pigs were administered systemic heparin (30,000 IU): four prior to cardiac arrest through intravenous injection (prearrest heparin) and four after cardiac arrest via injection into the right atrium followed by open cardiac massage (postarrest heparin). Pigs were euthanized with potassium chloride and a minimum of 5 minutes of cardiac silence allowed before organ procurement. Lungs were flushed with antegrade and retrograde Perfadex, and pulmonary preservation solution effluent was evaluated for gross thrombi. Organs were fixed in formalin, sagittally sectioned, and evaluated by a pulmonary pathologist blinded to treatment. RESULTS Antegrade and retrograde flushes demonstrated no significant thrombi. Gross pathologic evaluation revealed no occlusive central thrombi. Scant peripheral thrombi were detected in both treatment groups. No microscopic thrombi were noted in either treatment group. CONCLUSIONS Delayed heparin administration after cardiac death does not affect thrombus formation in an animal model of lung procurement after cardiac death. Concern about clinically significant thrombosis occurring when heparin is not given before cardiac arrest appears unfounded. These findings suggest that DCD lungs can be used regardless of antemortem heparin administration.

Cardiovascular Complications Following Thoracic Surgery

Cardiovascular events after thoracic surgery can result in increased morbidity, mortality, length of stay, and increased overall cost. The prevention of postoperative cardiovascular complications is an area of intense study, and the body of evidence guiding clinicians continues to grow. Early diagnosis and management of cardiovascular events can minimize the consequences of these complications.

Bariatric surgery may reduce the risk of Alzheimer’s diseases through GLP-1 mediated neuroprotective effects

Obesity and diabetes are associated with deficits in multiple neurocognitive domains and increased risk for dementia. Over the last two decades, there has been a significant increase in bariatric and metabolic surgery worldwide, driven by rising intertwined pandemics of obesity and diabetes, along with improvement in surgical techniques. Patients undergoing bariatric surgery achieve a significant decrease in their excess weight and a multitude of sequela associated with obesity, diabetes, and metabolic syndrome. Glucagon-like peptide 1 (GLP-1) is an intestinal peptide that has been implicated as one of the weight loss-independent mechanisms in how bariatric surgery affects type 2 diabetes. GLP-1 improves insulin secretion, inhibits apoptosis and induce pancreatic islet neogenesis, promotes satiety, and can regulate heart rate and blood pressure. Moreover, numerous studies have demonstrated potential neuroprotective and neurotrophic effects of GLP-1. Increased GLP-1 activity has been shown to increase cortical activity, promote neuronal growth, and inhibit neuronal degeneration. Specifically, in experimental studies on Alzheimers disease, GLP-1 decreases amyloid deposition and neurofibrillary tangles. Furthermore, recent studies have also suggested that GLP-1 based therapies, new class of antidiabetic drugs, have favorable effects on neurodegenerative disorders such as Alzheimers disease. We present a hypothesis that bariatric surgery can help delay or even prevent the onset of Alzheimers disease in long-term by increasing the levels of GLP-1. This hypothesis has a potential for many studies from basic science projects to large population studies to fully understand the neurological and cognitive consequences of bariatric surgery and associated rise in GLP-1.

Pediatric donor lungs for adult transplant recipients: feasibility and outcomes.

BACKGROUND There is a limited experience using pediatric organs for adult lung transplantation (LTx), with size matching the major concern. We reviewed our experience transplanting pediatric donor lungs into adult recipients with endpoints of post-LTx complications and overall patient survival. METHODS From 2/1990 to 12/2007, 609 adults underwent primary LTx at our institution. Thirty-eight (6.2%) patients underwent LTx with organs from pediatric donors (≤16 years). Of these, median donor age was 13 years (range: 7 to 16) and median recipient age 55 (range: 24 to 66). Endpoints analyzed included size matching accuracy, airway and pleural complications, time to extubation, intensive care unit (ICU) and hospital lengths of stay, as well as survival. RESULTS Gross undersizing of the donor lung was present in 2/38 (5.3%) and of the donor bronchus in 11/38 (29%). Five patients (13%) experienced a major postoperative airway complication. Thoracentesis prior to discharge was necessary in 4/38 (11%) patients and chest tube reinsertion in 10/38 (26%) for pleural effusion. Median time to extubation was 2 days. ICU and hospital lengths of stay were 6 and 16 days, respectively. Kaplan-Meier survival at 30 days, 1 year, 3 years, and 5 years post-transplant was 89%, 74%, 63%, and 55%. CONCLUSIONS Despite sizing concerns, transplantation of pediatric lungs into adult recipients is feasible. Size mismatch may predispose to higher rates of airway and pleural complications. Hospital course and overall survival appear comparable to adult-to-adult LTx, and concerns over size matching should not preclude pediatric organ use for adult candidates.

The Bigger Picture: Picking the Right Soap Box-Is it Possible to Connect with Different Audience Targets (Practitioners and Patients) from the Same Platform?

The use of Internet and social media has skyrocketed in the past decade. It did not take long until physicians realized that they could use social media as a tool for communication with patients and colleagues. Since then use of social media has exploded and the information that has become available for physicians and their patients is remarkable. In addition, because of the immediacy of the platform, messages that are incorrect or not desired can be rapidly promoted, whether deliberately or accidentally. To obtain the best use of social media, the right platform should be chosen, and this varies depending on the group one is trying to reach, and the message or visibility desired. In this article, we review the variety of options available to users.

Sigmoid volvulus in a patient with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS): a rare occurrence

Mitochondrial diseases are rare and devastating, with a wide spectrum of clinical presentations and systemic symptoms. The majority of the published literature focuses on the neuromuscular manifestations and genetic components of this mitochondrial cytopathy, however, cardiac, renal, endocrine and gastrointestinal manifestations may also be present. The authors report a case detailing a 56-year-old womans final hospitalisation from the gastrointestinal sequelae of mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) (Co Q10 deficiency variant). She presented with abdominal pain and distension associated with lactic acidosis, and was shown on imaging to have a colon perforation. This resulted in emergent surgery at which a necrotic colon secondary to a sigmoid colon was identified. Following four subsequent operations, and the development of multiorgan failure, care was eventually withdrawn. Practitioners of patients with MELAS should be cognisant of the rare but devastating gastrointestinal consequences of mitochondrial diseases.