Meghan A. Arnold

1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience

Pancreaticoduodenectomy (PD) with the possible addition of neoadjuvant or adjuvant therapy is the standard of care in the United States for adenocarcinoma originating in the pancreatic head, neck, and uncinate process. We reviewed 1423 patients who underwent a PD for a malignancy originating in the pancreas at our institution between 1970 and 2006. We examined 1175 PDs for ductal adenocarcinomas in greater detail. Eighteen different histological types of pancreatic cancer were identified; the most common diagnoses included ductal adenocarcinoma, neuroendocrine carcinoma, and IPMN with invasive cancer. Patients with ductal adenocarcinoma were analyzed in detail. The median age was 66 years, with patients in the present decade significantly older (68 years), on average, than patients in the three prior decades (e.g., 60 years in 1970, P=0.02). The median tumor diameter was 3 cm; 42% of the resections had positive margins and 78% had positive lymph nodes. The perioperative morbidity was 38%. The median postoperative stay declined over time, from 16 days in the 1980s to 8 days in the 2000s (P<0.001). The perioperative mortality declined from 30% in the 1970s to 1% in the 2000s (P<0.001). The median survival for all patients with ductal adenocarcinoma was 18 months (1-year survival =65 %, 2-year survival =37%, 5-year survival =18%). In a Cox proportional hazards model, pathological factors having a significant impact on survival included tumor diameter, resection margin status, lymph node status, and histologic grade. This is the largest single-institution experience with PD for pancreatic cancer. Patients who have cancers with favorable pathological features have a statistically significant improved long-term survival.

Nutrition and Wound Healing

Summary: The relationship between nutrition and wound healing–-after injury or surgical intervention–-has been recognized for centuries. There is no doubt that adequate carbohydrate, fat, and protein intake is required for healing to take place, but research in the laboratory has suggested that other specific nutritional interventions can have significant beneficial effects on wound healing. Successful translation into the clinical arena, however, has been rare. A review of normal metabolism as it relates to wound healing in normoglycemic and diabetic individuals is presented. This is followed by an assessment of the current literature and the data that support and refute the use of specialized nutritional support in postoperative and wounded patients. The experimental evidence for the use of arginine, glutamine, vitamins, and micronutrient supplementation is described. Most of the experimental evidence in the field supporting the use of specialized nutritional support has not been borne out by clinical investigation. A summary of the clinical implications of the data is presented, with the acknowledgment that each patients plan of care must be individualized to optimize the relationship between nutrition and wound healing.

Lorenz Bar Repair of Pectus Excavatum in the Adult Population: Should it be Done?

BACKGROUND Although extensive literature exists on the Lorenz bar repair of pectus excavatum (PE) in pediatric patients, few data examine this repair in adults or compare long-term outcomes in adults with the pediatric population. We identified the preoperative characteristics, postoperative complications, and outcomes of adult patients undergoing Lorenz bar repair of PE who had bar removal and compared these outcomes with a pediatric population undergoing the same procedure. METHODS A retrospective review (1997 to 2006) of patients undergoing primary repair of PE with a Lorenz bar identified 107 individuals aged older than 18 and 137 patients aged 6 to 14, of whom 52 and 80 had their bar(s) removed, respectively. These latter patients were the focus of analysis. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. RESULTS The median (interquartile range, IQR) age and pectus index of adult patients (81% men) at the time of repair was 23 (18 to 30) years and 3.8 (3.5 to 4.3), respectively. In 2 adults (3.9%), PE recurred after bar removal, and 6 (11.6%) required surgical revision for bar displacement or upper sternal depression. These rates of complications were similar to those found in children undergoing Lorenz bar repair of PE at our institution. CONCLUSIONS Lorenz bar placement to correct PE in adults can be performed safely and effectively, with rates of bar displacement, sternal depression, recurrence, and reoperation that are not statistically different than those found in a younger pediatric population.

Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

BACKGROUND/PURPOSE Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux. METHODS A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patients profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ(2) tests and t tests. RESULTS Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open. CONCLUSION Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.

Benchmarking the quality of care of infants with low-risk gastroschisis using a novel risk stratification index

BACKGROUND The nationwide mortality of neonates with gastroschisis was compared to determine whether significant variations in outcome occurred at the hospital level. METHODS Utilizing a previously developed risk-stratification index, low-risk neonates with gastroschisis were identified by a score of < or = 2. Only hospitals that had a record of treating >25 low-risk neonates were included in the analysis. Hospital performance in treating infants with gastroschisis was categorized into moderate and extreme outliers. RESULTS A total of 4,344 neonates with gastroschisis were identified at 506 individual hospitals. Low-risk neonates had an overall mortality of 2.9% compared with high-risk neonates whose overall mortality was 24.4%. Forty hospitals treated >25 low-risk neonates in the years studied for a total of 1,775 low-risk patients. The mean, in-hospital mortality of this cohort was 3.1% (range, 0-14.3). Eight hospitals were moderate outliers with mortality rates between 3.8% and 8.0%. Two hospitals were extreme outliers with mortality rates of 8.6% and 14.3%. CONCLUSION A substantial variation exists in the mortality of neonates with low-risk gastroschisis across hospitals. Further improvements in survival may, thus, depend on targeting quality improvement initiatives to standardization of operative approaches as well improvements in nonoperative factors such as neonatal intensive care unit practices, nurse-to-patient ratios, and levels of intensivist staffing.

Pectus bar repair of pectus excavatum in patients with connective tissue disease

PURPOSE Few studies address the surgical correction of pectus excavatum (PE) in patients with connective tissue disease (CTD). We have identified the preoperative characteristics, postoperative complications, and outcomes of patients with CTD undergoing bar repair of PE and compared these outcomes to a control group without CTD. METHODS A retrospective review of patients undergoing primary repair of PE with a bar procedure from 1997 to 2006 identified 22 patients with CTD. Of those, 20 (90.9%) had their bars removed. We identified 223 patients of similar age without CTD whose bars were removed. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. RESULTS Among those with CTD, the median age at repair was 15.5 years, with a mean pectus index of 4.0 +/- 1.4. Three patients (13.6%) experienced bar displacement or upper sternal depression requiring surgical revision. Only 1 patient recurred after bar removal. Rates of bar displacement, upper sternal depression, and recurrence were not statistically different than those in the comparison group. CONCLUSIONS Patients with CTD benefit from primary bar repair of PE and experience excellent operative outcomes after repair, with complication rates being no different than those found in similarly aged control patients.

Concurrent Infantile Pneumomediastinum and Pneumoperitoneum

Pneumomediastinum in an infant is uncommon, and most literature on the subject is anecdotal or retrospective. Concurrent pneumomediastinum and pneumoperitoneum in an infant is even more unusual. We report the case of a 7-month-old infant with long-chain acyl-coenzyme A dehydrogenase deficiency who was admitted to the hospital because of respiratory failure and in whom radiographs revealed simultaneous pneumomediastinum and pneumoperitoneum. Benign findings at the abdominal examination and the presence of pneumomediastinum in the setting of assisted mechanical ventilation led to the diagnosis of air dissection syndrome. We review the radiographic findings associated with air dissection syndrome and discuss the management of concurrent nonsurgical pneumomediastinum and pneumoperitoneum in an infant.