Nick C. Levinsky

Management of acute appendicitis: the impact of CT scanning on the bottom line.

BACKGROUND Acute appendicitis continues to be a common general surgical problem. Little is known about whether the contribution to margin has been affected by changes in technology. STUDY DESIGN Patients undergoing appendectomy for acute appendicitis from June 2005 to May 2007 were evaluated for demographics, diagnostic and treatment alternatives, and outcomes. Financial outcomes were assessed. Efficiency, including admission to emergency department bed to incision (bed to knife time [BTK]), operative length, and hospital length of stay (LOS) were assessed. RESULTS During the 2 years of the study, there were no differences in demographics, insurance status, case length, diagnostic accuracy, pathology, LOS, or outcomes. Both laparoscopy and CT use increased between the 2 study years (odds ratio [OR]: 1.68, p = 0.06; 95% CI, 0.98-2.89 and OR: 1.83, p = 0.06, CI, 0.98-3.45, respectively). Mean BTK time increased by about 1 hour: 465 minutes versus 521 minutes (p = 0.032; 95% CI, 0.08-1.78) in univariate analysis. However, multivariate analysis demonstrated no difference in BTK time between years (p = 0.136). After controlling for gender, year of operation, and insurance status, obtaining a CT study added 3.5 hours to BTK time (p < 0.001; 95% CI, 2.41-4.45). Women had BTK times 55 minutes longer than men when controlling for similar covariates (p = 0.027; 95% CI, 0.11-1.74). Laparoscopy contributed to shorter mean LOS (-0.78 days, p = 0.04), and gangrenous appendicitis (1.80 days, p < 0.001) and complications (4.23 days, p < 0.001) increased LOS. Mean contribution to margin decreased from

Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis.

6,347 to

Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy

4,295 (p = 0.068). CONCLUSIONS Increasing use of CT scanning in acute appendicitis increases cost of care, decreases contribution to margin, prolongs patients stay in the emergency department, and delays time to operation.

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach

PURPOSE Traditional decompressive and/or pancreatic resection procedures have been the cornerstone of operative therapy for refractory abdominal pain secondary to chronic pancreatitis. Management of patients that fail these traditional interventions represents a clinical dilemma. Salvage therapy with completion pancreatectomy and islet cell autotransplantation (CPIAT) is an emerging treatment option for this patient population; however, outcomes after this procedure have not been well-studied. METHODS All patients undergoing CPIAT after previous decompressive and/or pancreatic resection for the treatment of chronic pancreatitis at our institution were identified for inclusion in this single-center observational study. Study end points included islet yield, narcotic requirements, glycemic control, and quality of life (QOL). QOL was assessed using the Short Form (SF)-36 health questionnaire. RESULTS Sixty-four patients underwent CPIAT as salvage therapy. The median age at time of CPIAT was 38 years (interquartile range [IQR], 14.7-65.4). The most common etiology of chronic pancreatitis was idiopathic pancreatitis (66%; n = 42) followed by genetically linked pancreatitis (9%; n = 6) and alcoholic pancreatitis (8%; n = 5). All of these patients had previously undergone prior limited pancreatic resection or decompressive procedure. The majority of patients (50%; n = 32) underwent prior pancreaticoduodenectomy, whereas the remainder had undergone distal pancreatectomy (17%; n = 11), Frey (13%; n = 8), Puestow (13%; n = 8), or Berne (8%; n = 5) procedures. Median time from initial surgical intervention to CPIAT was 28.1 months (IQR, 13.6-43.0). All of these patients underwent a successful CPIAT. Mean operative time was 502.2 minutes with average hospital duration of stay of 13 days. Islet cell isolation was feasible despite previous procedures with a mean islet yield of 331,304 islet cell equivalents, which totaled an islet cell autotransplantation of 4,737 ± 492 IEQ/kg body weight. Median patient follow-up was 21.2 months (IQR, 7.9-36.8). Before CPIAT, all patients required a mean of 120.8 morphine equivalent milligrams per day (MEQ/d), which improved to 48.5 MEQ (P < .001 compared with preoperative requirements) at most recent follow-up. Of these patients, 44% (n = 28) achieved narcotic independence. All patients were able to achieve stable glycemic control with a mean insulin requirement of 16 units per day. Of these patients, 20% (n = 13) were insulin independent after CPIAT. Mean postoperative glycosylated hemoglobin was 7.8% (range, 4.6-12.5). Islet cell viability was confirmed with endocrine testing and mean C-peptide levels 6 months after CPIAT were 0.91 ng/mL (range, 0.1-3.0). The SF-36 QOL survey administered postoperatively demonstrated improvement in all tested modules. CONCLUSION This study is the first to examine the results of salvage therapy with CPIAT for patients with refractory chronic pancreatitis. Patients undergoing CPIAT achieved improved postoperative narcotic requirements, stable glycemic control, and improved QOL.

The natural history of chronic pancreatitis after operative intervention: The need for revisional operation

In patients with borderline resectable pancreas cancers, clinicians frequently consider radiographic response as the primary driver of whether patients should be offered surgical intervention following neoadjuvant therapy (NT). We sought to determine any correlation between radiographic and pathologic response rates following NT.