Swee H. Teh

Patient and Hospital Characteristics on the Variance of Perioperative Outcomes for Pancreatic Resection in the United States: A Plea for Outcome-Based and Not Volume-Based Referral Guidelines

HYPOTHESIS There is an effect of patient and hospital characteristics on perioperative outcomes for pancreatic resection in the United States. DESIGN Retrospective cohort study. SETTING Academic research. PATIENTS Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003. MAIN OUTCOME MEASURES In-hospital mortality, perioperative complications, and mortality following a major complication. RESULTS A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The in-hospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P < .001). After adjusting for other confounders, the odds of in-hospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals. CONCLUSIONS Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.

Model for End-stage Liver Disease score fails to predict perioperative outcome after hepatic resection for hepatocellular carcinoma in patients without cirrhosis

BACKGROUND The Model for End-stage Liver Disease (MELD) score was developed to reflect the hepatocellular reserve in patients with cirrhosis. We hypothesized that the MELD score would not be predictive of perioperative outcome after hepatic resection in patients without cirrhosis. METHODS We performed a case-control study of all consecutive patients from 1995 through 2005 undergoing hepatic resection for HCC. RESULTS Group A (21 patients without cirrhosis) had a mean age of 57 years, which was similar to control group B (25 patients with cirrhosis), with a mean age of 60 years. The mean tumor size in group A was 9.8 cm compared with that of group B, which was 4.8 cm (P = .03). The American Joint Committee on Cancer stage in group A was I in 14%, II in 5%, and III in 81% versus I in 48%, II in 16%, and 111 in 36% in group B (P = .002). Eighty-six percent of group A patients had a major hepatic resection (>2 segments) compared with 40% in group B (P = .001). The perioperative morbidity and mortality were 24% and 4.8%, respectively, in group A compared with 64% (P = .006) and 20% (P = .12) in group B. The mean preoperative, postoperative, and delta MELD scores were 7.0, 13.0, and 5.0, respectively, in group A compared with 9.6, 16.8, and 7.2 in group B (P = NS). In group A, none of the MELD score parameters accurately predicted perioperative outcomes despite a higher number of patients who had major hepatic resection. In group B, a preoperative MELD score of 9 or greater was associated with a higher overall perioperative morbidity (84% vs 41%, P = .03). Perioperative mortality (n = 6; 13%) was significantly higher in patients with a postoperative MELD score of 15 or higher (P = .02) and a delta MELD score of 10 or higher (P = .03). CONCLUSIONS Perioperative MELD score fails to predict perioperative outcomes after hepatic resection for hepatocellular carcinoma in patients without cirrhosis. Other predictive parameters need to be developed for this group of patients.

A suitable animal model for laparoscopic hepatic resection training

BackgroundThere is a growing interest in using laparoscopy for hepatic resection. However, structured training is lacking in part because of the lack of an ideal animal training model. We sought to identify an animal model whose liver anatomy significantly resembled that of the human liver and to assess the feasibility of learning laparoscopic hepatic inflow and outflow dissection and parenchyma transection on this model.MethodsThe inflow and outflow structures of the sheep liver were demonstrated via surgical dissection and contrast studies. Laparoscopic left major hepatic resections were performed.ResultsThe portal hepatis of all 12 sheep (8 for anatomic study and 4 for laparoscopic hepatic resection) resembled that of human livers. The portal vein (PV) was located posteriorly; the common hepatic artery (CHA) and the common bile duct (CBD) were located anterior medially and anterior laterally with respect to the portal hepatis. The main PV bifurcated into a short right and a long left PV. The extrahepatic right PV then bifurcated into right posterior and anterior sectoral PV. The CBD and CHA bifurcated into left and right systems. The cystic duct originated from the right hepatic duct. The cystic artery originated from the right HA in 11/12 animals. The left hepatic vein drained directly into the inferior vena cava (IVC). The middle and the right hepatic veins formed a short common channel before entering the IVC. Multiple venous tributaries drained directly into IVC. Familiarity with sheep liver anatomy allowed laparoscopic left hepatic lobe (left medial and lateral segments) resection to be performed with accuracy and preservation of the middle hepatic vein.ConclusionsThe surgical anatomy of sheep liver resembled that of human liver. Laparoscopic major hepatic resection can be performed with accuracy using this information. Sheep is therefore an ideal animal model for advanced surgical training in laparoscopic hepatic resection.