Purvi Parikh

Effect of Hospital Volume, Surgeon Experience, and Surgeon Volume on Patient Outcomes After Pancreaticoduodenectomy: A Single-Institution Experience

OBJECTIVE To determine the importance of hospital volume, surgeon experience, and surgeon volume in performing pancreaticoduodenectomy (PD). DESIGN, SETTING, AND PATIENTS From 1980 through 2007, 1003 patients underwent PD by 19 surgeons at a university hospital. MAIN OUTCOME MEASURES Patient morbidity and mortality, quality of resection, and learning curve were examined according to hospital volume (period 1: 1980-2003 vs period 2: 2004-2007), surgeon experience (total number of PDs), and surgeon volume (number of PDs per year). RESULTS Perioperative morbidity and mortality for all 1003 PDs were 41% and 3%, respectively. Differences existed between period 1 and period 2 in percentage of PDs performed in elderly patients (7% vs 17%), mortality (4% vs 2%), estimated blood loss (1817 mL vs 780 mL), length of stay (18 days vs 12 days), and proportion of International Study Group on Pancreatic Fistula grade C pancreatic fistulae (29% vs 12%). Surgeons with less experience (<50 PDs) performed PD with higher morbidity (53% vs 39%), pancreatic fistula rate (20% vs 10%), estimated blood loss (1918 mL vs 1101 mL), and operative time (458 minutes vs 335 minutes) compared with surgeons with more experience (> or =50 PDs). Experienced surgeons had comparable outcomes irrespective of annual volume. Mortality, margins, and number of lymph nodes resected were not affected by surgeon experience or surgeon volume. Learning curves projected that less experienced surgeons would achieve morbidity and mortality rates equivalent to those of experienced surgeons when they reached 20 and 60 PDs, respectively. CONCLUSIONS Improvement in PD outcomes, including mortality, occurred with increased PD volume at a pancreatic center. Surgeon experience remained an important determinant of overall morbidity. Experienced surgeons, however, had comparable outcomes irrespective of annual volume.

Pancreatic Necrosectomy: North American Mortality Is Much Lower than Expected

BACKGROUND The aim of this analysis was to explore the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine outcomes of patients undergoing debridement for pancreatic and peripancreatic necrosis. Single-institution series suggest that the mortality of patients undergoing pancreatic necrosectomy has improved but remains at 15% to 20%. But no national data have been available for patients with necrotizing pancreatitis. In 2007, a CPT code specific for debridement of pancreatic necrosis became available. STUDY DESIGN The ACS-NSQIP Participant Use File was queried for all patients who had debridement of pancreatic and peripancreatic necrosis (CPT code 48105) from January 1, 2007, through December 31, 2007. Patient demographics, observed (O) and expected (E) morbidity and mortality, and indices (O/E) were evaluated. A multivariate stepwise logistic regression was performed to determine predictors of mortality. RESULTS During this 12-month period, data were accumulated on 161 patients. The mean age was 54 years; 71% were male; and 75% were Caucasian. The mean body mass index was 30.3 kg/m(2); 29% had diabetes; and 11% abused alcohol. Forty-two percent were transferred to NSQIP hospitals from other facilities. Overall morbidity was 62%, and 30-day mortality was 6.8%, but morbidity and mortality indices were 0.86 and 0.33, respectively. Increased age and blood urea nitrogen were independent predictors of mortality. CONCLUSIONS These data suggest that patients undergoing debridement for pancreatic and peripancreatic necrosis at ACS-NSQIP hospitals provide a new North American sample and have better than predicted outcomes. We concluded that ACS-NSQIP is a powerful tool to assess contemporary outcomes of uncommon, high-risk procedures.

Management of the primary tumor in patients with metastatic pancreatic neuroendocrine tumor: a contemporary single-institution review.

BACKGROUND Pancreatic nonfunctioning neuroendocrine tumors (PNFNETs) are an uncommon malignancy and often present with metastatic disease. There is a lack of information on the management of the primary tumor in patients who present with unresectable synchronous hepatic metastases. METHODS A retrospective review (2001-2008) of PNFNETs was conducted. Patients were divided into 3 groups: PNFNET without evidence of hepatic metastasis (group A), PNFNET with metastatic disease involving less than 50% of the liver (group B), and PNFNET with metastatic disease involving more than 50% of the liver (group C). Clinical data and outcomes were analyzed. RESULTS Thirty-five patients with PNFNET were identified (group A = 15, group B = 11, group C = 9). Resection of the pancreatic tumor was performed in 26 patients. With a mean follow-up period of 30 months, death from disease progression occurred in 1 patient in group A, none in group B, and in 7 in group C. CONCLUSIONS In selected patients, resection of the primary pancreatic tumor even in the setting of unresectable but limited hepatic metastases may be indicated.

Surgical management of pancreatic cancer--distal pancreatectomy.

Distal pancreatectomy is the standard procedure for tumors located in the body and tail of the pancreas. In the last three decades, significant progress has been made with regard to technical aspects as well as perioperative care so that excellent mortality and morbidity rates can be achieved. Recently, there is growing evidence that distal pancreatectomy may be performed laparoscopically in selected patients, offering the advantages of minimally invasive surgery. Unfortunately, the oncologic outcomes for pancreatic adenocarcinoma remain poor, in part due to the late stage of presentation in most patients. We review the history of distal pancreatectomy, discuss current indications for performing this procedure, compare operative techniques in performing distal pancreatectomy, and review both the early complications seen in patients who have undergone a distal pancreatectomy and the long-term metabolic and oncologic outcomes of these patients.

Ethics in Global Surgery

Interest in making contributions to medical practice and research in low and middle income countries (LMIC) has become increasingly prevalent. The greatest strides have been made in preventive and primary care health measures applied toward vaccination strategies for infectious diseases, maternal and child health, and the HIV/AIDS pandemic. However, for many reasons, addressing surgical disease in LMIC’s has been a challenge. Although individual groups continue to deliver surgical care throughout the world, an organized agenda for surgical care has been lacking. Concentrated efforts by organizations such as the World Health Organization Global Initiative for Essential and Emergency Surgical Care (WHO-GIEESC) and more recently, the Lancet Commission on Global Surgery and the advocacy-based Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care (G4 Alliance) are finally yielding benefits by building political priority for surgical care as part of the global development agenda. In May 2015, the World Health Assembly (WHA) passed a landmark resolution on the importance of surgical care in the universal health care plan. The WHA mandate was a significant step towards mobilizing vital surgical initiatives, individuals, institutions, and health care teams. Given the significance of these initiatives, it is imperative and timely, that the ethical issues surrounding global surgery are delineated and better understood. Surgeons who function in this realm carry a significant burden of responsibility to provide safe, cost-effective, culturally-appropriate and good quality care in the most ethical manner possible

Abstract C17: Unequal Financial Burdens Highlight Racial Disparities of Colon Cancer Patients in New York

Background: We have previously investigated racial disparities in colorectal cancer outcomes and discovered outcomes differences according to racial group. In our ongoing studies we sought to determine whether these disparities in survival resulted in unequal financial burdens between black and white patients. The purpose of this study was to identify whether financial disparities exist between the black and Caucasian colorectal cancer patients within New York State, with the ultimate goal of eliminating any differences. Research Design: The Statewide Planning and Research Cooperative System (SPARCS) database of New York State (NYS) was used to compare costs of colon cancer surgery hospitalizations of the black and Caucasian patient populations between 2009-2013. Student t-tests were performed for comparison of inpatient hospital discharge, ambulatory surgery, and emergency department admission within the SPARCS database. Facility costs were calculated using hospital discharge data and Institutional Cost Reports. Logistic regression analysis examined race as the dependent variable to identify the etiology of cost disparity. Results: Overall, 26,477 patients (white, n= 21,606; and black, n=4,871) underwent colon cancer treatment. Treatment costs in the black population were higher compared to the white population (mean,

Management of Unusual Sources of Upper GI Bleeding

64,747 vs

Persistent Pancreatic Fistula

58,127; median,

Pancreatectomy risk calculator: an ACS-NSQIP resource

44,951 vs

Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era.

41, 285) (p Conclusion: This study revealed that the black colon cancer population had higher costs than the Caucasian colon cancer population. We identified emergent operations and longer hospitalization as the primary etiologies for this disparity. Sufficient colon cancer screening for the black population might reduce the number of emergent operations and reduce length of hospitalization if the cancer is detected at an earlier stage. Note: This abstract was not presented at the conference. Citation Format: Brian C. Oveson, Purvi Parikh, Dana Telem, Jennifer Williams, Roberto Bergamaschi, Aaron Sasson, Mark Talamini, Joseph Kim. Unequal Financial Burdens Highlight Racial Disparities of Colon Cancer Patients in New York. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C17.