Rare, long-term complication after pancreatoduodenectomy-a case report of cecal volvulus.

Complications after pancreatoduodenectomy are common, and range widely in timing of presentation, relation to pancreatobiliary pathology, and necessity of operative intervention. We present a case of a 74-year-old male with history of pancreatoduodenectomy for pancreatic adenocarcinoma who presented 11 months after index operation with cecal volvulus and required emergent right hemicolectomy. Prior history of pancreatoduodenectomy with mobilization of the right colon likely predisposed him to development of this surgical emergency. Patients have altered gastrointestinal anatomy after pancreatoduodenectomy and special care is necessary to protect the afferent biliopancreatic limb during intraoperative exploration, and particularly if right colectomy is necessary.

Global Survey on Pancreatic Surgery During the COVID-19 Pandemic.

OBJECTIVE: The aim of this study was to clarify the role of pancreatic surgery during the COVID-19 pandemic to optimize patients' and clinicians' safety and safeguard health care capacity. SUMMARY BACKGROUND DATA: The COVID-19 pandemic heavily impacts health care systems worldwide. Cancer patients appear to have an increased risk for adverse events when infected by COVID-19, but the inability to receive oncological care seems may be an even larger threat, particularly in case of pancreatic cancer. METHODS: An online survey was submitted to all members of seven international pancreatic associations and study groups, investigating the impact of the COVID-19 pandemic on pancreatic surgery using 21 statements (April, 2020). Consensus was defined as >80% agreement among respondents and moderate agreement as 60% to 80% agreement. RESULTS: A total of 337 respondents from 267 centers and 37 countries spanning 5 continents completed the survey. Most respondents were surgeons (n = 302, 89.6%) and working in an academic center (n = 286, 84.9%). The majority of centers (n = 166, 62.2%) performed less pancreatic surgery because of the COVID-19 pandemic, reducing the weekly pancreatic resection rate from 3 [interquartile range (IQR) 2-5] to 1 (IQR 0-2) (P < 0.001). Most centers screened for COVID-19 before pancreatic surgery (n = 233, 87.3%). Consensus was reached on 13 statements and 5 statements achieved moderate agreement. CONCLUSIONS: This global survey elucidates the role of pancreatic surgery during the COVID-19 pandemic, regarding patient selection for the surgical and oncological treatment of pancreatic diseases to support clinical decision-making and creating a starting point for further discussion.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

OBJECTIVE: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Endoscopic Management of Pancreatic Fluid Collections.

Pancreatic fluid collections (PFCs) may develop due to inflammation secondary to acute and/or chronic pancreatitis, trauma, surgery, or obstruction from solid or cystic neoplasms. PFCs can be drained percutaneously, surgically, or endoscopically with endoscopic ultrasound-guided cyst gastrostomy and/or transpapillary drainage through endoscopic retrograde cholangiopancreatography. There has been a paradigm shift in the endoscopic management of PFCs in the past few years with newer techniques including utilization of self-expanding metal stents and multiport devices. This review is a comprehensive update on the classification of PFC, indications for drainage, optimal approach, and techniques.

Cancer Survivorship: Defining the Incidence of Incisional Hernia After Resection for Intra-Abdominal Malignancy.

BACKGROUND: Cancer survivorship focuses largely on improving quality of life. We aimed to determine the rate of ventral incisional hernia (VIH) formation after cancer resection, with implications for survivorship. METHODS: Patients without prior VIH who underwent abdominal malignancy resections at a tertiary center were followed up to 2 years. Patients with a viewable preoperative computed tomography (CT) scan and CT within 2 years postoperatively were included. Primary outcome was postoperative VIH on CT, reviewed by a panel of surgeons uninvolved with the original operation. Factors associated with VIH were determined using Cox proportional hazards regression. RESULTS: 1847 CTs were reviewed among 491 patients (59 % men), with inter-rater reliability 0.85 for the panel. Mean age was 60 ± 12 years; mean follow-up time 13 ± 8 months. VIH occurred in 41 % and differed across diagnoses: urologic/gynecologic (30 %), colorectal (53 %), and all others (56 %) (p < 0.001). Factors associated with VIH (adjusting for stage, age, adjuvant therapy, smoking, and steroid use) included: incision location [flank (ref), midline, hazard ratio (HR) 6.89 (95 %CI 2.43-19.57); periumbilical, HR 6.24 (95 %CI 1.84-21.22); subcostal, HR 4.55 (95 %CI 1.51-13.70)], cancer type [urologic/gynecologic (ref), other {gastrointestinal, pancreatic, hepatobiliary, retroperitoneal, and others} HR 1.86 (95 %CI 1.26-2.73)], laparoscopic-assisted operation [laparoscopic (ref), HR 2.68 (95 %CI 1.44-4.98)], surgical site infection [HR 1.60 (95 %CI 1.08-2.37)], and body mass index [HR 1.06 (95 %CI 1.03-1.08)]. CONCLUSIONS: The rate of VIH after abdominal cancer operations is high. VIH may impact cancer survivorship with pain and need for additional operations. Further studies assessing the impact on QOL and prevention efforts are needed.

Interhospital transfer for acute surgical care: does delay matter?

BACKGROUND: Delays to definitive care are associated with poor outcomes after trauma and medical emergencies. It is unknown whether inter-hospital transfer delays affect outcomes for nontraumatic acute surgical conditions. METHODS: We performed a retrospective cohort study of patient transfers for acute surgical conditions within a regional transfer network from 2009 to 2013. Delay was defined as more than 24 hours from presentation to transfer request and categorized as 1 or 2+ days. The primary outcome was post-transfer death or hospice. Bivariate and multivariable logistic regression were performed. RESULTS: The cohort included 2,091 patient transfers. Delays of 2 or more days were associated with death or hospice in unadjusted analyses, but there was no difference after adjustment. Predictors of post-transfer death or hospice included older age, higher comorbidity scores, and greater severity of illness. CONCLUSIONS: Delays in transfer request were not associated with post-transfer mortality or discharge to hospice, suggesting effective triage of nontraumatic acute surgical patients.

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery.

BACKGROUND: Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN: A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS: Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS: In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Previous Methicillin-Resistant Staphylococcus aureus Infection Independent of Body Site Increases Odds of Surgical Site Infection after Ventral Hernia Repair.

BACKGROUND: Methicillin-resistant Staphylococcus aureus infections can be difficult to manage in ventral hernia repair (VHR). We aimed to determine whether a history of preoperative MRSA infection, regardless of site, confers increased odds of 30-day surgical site infection (SSI) after VHR. STUDY DESIGN: A retrospective cohort study of patients undergoing VHR with class I to III wounds between 2005 and 2012 was performed using Vanderbilt University Medical Center's Perioperative Data Warehouse. Preoperative MRSA status, site of infection, and 30-day SSI were determined. Univariate and multivariate analyses adjusting for confounding factors were performed to determine whether a history of MRSA infection was independently associated with SSIs. RESULTS: A total of 768 VHR patients met inclusion criteria, of which 46% were women. There were 54 (7%) preoperative MRSA infections (MRSA positive); 15 (28%) soft tissue, 9 (17%) bloodstream, 4 (7%) pulmonary, 3 (6%) urinary, and 5 (9%) other. Overall SSI rate was 10% (n = 80), SSI rate in the MRSA-positive group was 33% (n = 18), compared with 9% (n = 62) in controls (p < 0.001). Multivariate analysis demonstrated that a history of MRSA infection significantly increased odds of 30-day SSI after VHR by 2.3 times (95% CI, 1.1-4.8; p = 0.035). Other factors associated with postoperative SSI were performance of myofascial release, increasing BMI, length of operation, open repair, and clean-contaminated wound classification. CONCLUSIONS: A history of site-independent MRSA infection confers significantly increased odds of 30-day SSI after VHR. Additional investigation is needed to determine perioperative treatment regimens that might decrease odds of SSI in VHR, and optimal prosthetic types and techniques for this population.

The importance of surgeon-reviewed computed tomography for incisional hernia detection: a prospective study.

Patients with incisional hernias or abdominal pain are frequently referred with abdominal computed tomography (CT) scans. The purpose of this study was to determine the sensitivity and specificity of a CT radiology report for the detection of incisional hernias. General surgery patients with a history of an abdominal operation and a recent viewable abdominal CT scan were enrolled prospectively. Patients with a stoma, fistula, or soft tissue infection were excluded. The results of the radiology reports were compared with blinded, surgeon-interpreted CT for each patient. Testing characteristics including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. One hundred eighty-one patients were enrolled with a mean age of 54 years. Sixty-eight per cent were women. Hernia prevalence was 55 per cent, and mean hernia width was 5.2 cm. The radiology report had a sensitivity and specificity of 79 per cent and 94 per cent, respectively, for hernia diagnosis. The PPV and NPV were 94 and 79 per cent, respectively. Reliance on the CT report alone underestimates the presence of incisional hernia. Referring physicians should not use CT as a screening modality for detection of hernias. Referral to a surgeon for evaluation before imaging may provide more accurate diagnosis and potentially decrease the cost of caring for this population.

Comparative Evaluation of Dynamic Abdominal Sonography for Hernia and Computed Tomography for Characterization of Incisional Hernia.

IMPORTANCE: Previous work has demonstrated that dynamic abdominal sonography for hernia (DASH) is accurate for the diagnosis of incisional hernia. The usefulness of DASH for characterization of incisional hernia is unknown. OBJECTIVE: To determine whether DASH can be objectively used to characterize incisional hernias by measurement of mean surface area (MSA). DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted. A total of 109 adults with incisional hernia were enrolled between July 1, 2010, and March 1, 2012. Patients with a stoma, fistula, or soft-tissue infection were excluded. INTERVENTIONS: DASH was performed by a surgeon to determine the maximal transverse and craniocaudal dimensions of the incisional hernia. A separate surgeon, blinded to the DASH results, performed the same measurements using computed tomography (CT). MAIN OUTCOMES AND MEASURES: The MSA was calculated, and the difference in MSA by DASH and CT was compared using the Wilcoxon signed rank test. Subset analysis was performed with patients stratified into nonobese, obese, and morbidly obese groups. We hypothesized that there was no significant difference between MSA as measured by DASH compared with CT. RESULTS: A total of 109 patients were enrolled (mean age, 56 years; mean body mass index, 32.2 [calculated as weight in kilograms divided by height in meters squared]; and 67.0% women). The mean (SD) MSA measurements were similar between the modalities: DASH, 41.8 (67.5) cm2 and CT, 44.6 (78.4) cm2 (P = .82). The MSA measurements determined by DASH and CT were also similar for all groups when stratified by body mass index. There were 15 patients who had a hernia 10 cm or larger in transverse dimension. The mean body mass index of this group was 39.2, and the MSA measurements by DASH and CT were similar (P = .26). CONCLUSIONS AND RELEVANCE: DASH can be used to objectively characterize hernias by MSA, with accuracy demonstrated in the obese population and in patients whose hernias were very large (≥10 cm in diameter). DASH offers the advantages of real-time imaging and no ionizing radiation and may obviate the need for the patient to schedule additional imaging appointments.

Defining intraoperative hypothermia in ventral hernia repair.

BACKGROUND: Intraoperative normothermia, a single measurement of core body temperature≥36°C, is an important quality metric outlined by the World Health Organization for the reduction of surgical site infections (SSIs). Hypothermia has been linked to SSI in colorectal and trauma patients, but the effect in ventral hernia repair (VHR) is unknown. MATERIALS AND METHODS: Patients who underwent VHR at a single institution between 2005 and 2012 were included. Temperature data were matched with National Surgical Quality Improvement Program SSI data. Novel definitions of hypothermia were explored: patient temperature nadir, percentage of time spent at the nadir, mean temperature, and time spent <36°C. Multivariable regression models were performed. RESULTS: Five hundred fifty-three patients were included with temperature recorded every 8-15 min. Mean temperature nadir was 35.7°C (±1.3°C [standard deviation]) and was not associated with SSI (odds ratio [OR], 0.938; 95% confidence interval, 0.778-1.131). The percentage of readings spent at the nadir was 31% (±31%) and was not predictive of SSI (OR, 1.471; 95% CI, 0.983-2.203). As mean temperature increased, the risk of SSI increased (OR, 1.115; 95% CI, 0.559-2.225). Percentage of temperature readings<36°C was 29% (±38%) and was not associated with SSI (OR, 1.062; 95% CI, 0.628-1.796). In all models, body mass index, smoking, and length of surgery were predictive of SSI. CONCLUSIONS: Our results demonstrate no association between temperature and SSI in VHR. Efforts to reduce SSI should focus on factors such as smoking cessation, weight loss, and length of surgery. Our study suggests that maintenance of perioperative normothermia may only decrease SSIs in certain at-risk populations.

Prospective evaluation of surgeon physical examination for detection of incisional hernias.

BACKGROUND: Surgeon physical examination is often used to monitor for hernia recurrence in clinical and research settings, despite a lack of information on its effectiveness. This study aims to compare surgeon-reviewed CT with surgeon physical examination for the detection of incisional hernia. STUDY DESIGN: General surgery patients with an earlier abdominal operation and a recent viewable CT scan of the abdomen and pelvis were enrolled prospectively. Patients with a stoma, fistula, or soft-tissue infection were excluded. Surgeon-reviewed CT was treated as the gold standard. Patients were stratified by body mass index into nonobese (body mass index <30) and obese groups. Testing characteristics and real-world performance, including positive predictive value and negative predictive value, were calculated. RESULTS: One hundred and eighty-one patients (mean age 54 years, 68% female) were enrolled. Hernia prevalence was 55%. Mean area of hernias was 44.6 cm(2). Surgeon physical examination had a low sensitivity (77%) and negative predictive value (77%). This difference was more pronounced in obese patients, with sensitivity of 73% and negative predictive value 69%. CONCLUSIONS: Surgeon physical examination is inferior to CT for detection of incisional hernia, and fails to detect approximately 23% of hernias. In obese patients, 31% of hernias are missed by surgeon physical examination. This has important implications for clinical follow-up and design of studies evaluating hernia recurrence, as ascertainment of this result must be reliable and accurate.

Disease-based mortality after percutaneous endoscopic gastrostomy: utility of the enterprise data warehouse.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) remains a mainstay of enteral access. Thirty-day mortality for PEG has ranged from 16 to 43 %. This study aims to discern patient groups that demonstrate limited survival after PEG placement. The Enterprise Data Warehouse (EDW) concept allows an efficient means of integrating administrative, clinical, and quality-of-life data. On the basis of this concept, we developed the Vanderbilt Procedural Outcomes Database (VPOD) and analyzed these data for evaluation of post-PEG mortality over time. METHODS: Patients were identified using the VPOD from 2008 to 2010 and followed for 1 year after the procedure. Patients were categorized according to common clinical groups for PEG placement: stroke/CNS tumors, neuromuscular disorders, head and neck cancers, other malignancies, trauma, cerebral palsy, gastroparesis, or other indications for PEG. All-cause mortality at 30, 60, 90, 180, and 360 days was determined by linking VPOD information with the Social Security Death Index. Chi-square analysis was used to determine significance across groups. RESULTS: Nine hundred fifty-three patients underwent PEG placement during the study period. Mortality over time (30-, 60-, 90-, 180-, and 360-day mortality) was greatest for patients with malignancies other than head and neck cancer (29, 45, 57, 66, and 72 %) and least for cerebral palsy or patients with gastroparesis (7 % at all time points). Patients with neuromuscular disorders had a similar mortality curve as head and neck cancer patients. Stroke/CNS tumor patients and patients with other indications had the second highest mortality, while trauma patients had low mortality. CONCLUSIONS: PEG mortality was much higher in patients with malignancies other than head and neck cancer compared to previously published rates. PEG should be used with great caution in this and other high-risk patient groups. This study demonstrates the power of an EDW-based database to evaluate large numbers of patients with clinically meaningful results.

The chosen few: disproportionate resource use in ventral hernia repair.

The objectives of this study were to determine if disproportionately small numbers of patients use more resources for ventral hernia repair (VHR) and to identify factors associated with this group. Patients undergoing VHR were identified using national 2009 Healthcare Cost and Utilization Project data. Mean total hospital charges (THCs) were calculated and patients were divided into high charges (HC, greater than 50% mean THC) and low charges (LC, 50% or less mean THC) groups. Multivariate analysis was used to identify factors associated with the HC group. We estimated 181,000 hospitalizations for VHR in 2009 with mean THC of $54,000. Fifteen per cent of patients comprised the HC group with 85 per cent in the LC group. The HC group had higher THC ($173,000 vs $32,000; P < 0.05), increased mean length of stay (16.0 vs 4.1 days, P < 0.05), and higher mortality (6.3 vs 0.6%, P < 0.05). Risk factors for HC included congestive heart failure (odds ratio [OR], 2.2; 95% confidence interval [CI], 2.0 to 2.5), chronic lung disease (OR, 1.3; 95% CI, 1.2 to 1.4), Asian race (OR, 2.5; 95% CI, 1.7 to 3.7), nonelective operation (OR, 1.9; 95% CI, 1.6 to 2.3), and male gender (OR, 1.2; 95% CI, 1.1 to 1.3). For inpatient VHR, a remarkably small proportion of patients use disproportionately high hospital resources. The identified risk factors can help surgeons predict patients who are likely to consume large amounts of resources.

Clinical decision making in the management of pancreatic cystic neoplasms.

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

Comparative effectiveness of dynamic abdominal sonography for hernia vs computed tomography in the diagnosis of incisional hernia.

BACKGROUND: Diagnosis and characterization of incisional hernia are often established by CT, which incurs radiation exposure and substantial cost in clinical practice. The purpose of this study was to determine the comparative effectiveness of surgeon-performed Dynamic Abdominal Sonography for Hernia (DASH) vs CT for incisional hernia evaluation. STUDY DESIGN: Patients with previous abdominal operations and recent CT imaging were enrolled prospectively; patients with stomas, fistula, or soft tissue infection were excluded. In the clinic setting, DASH was performed with prerequisite training of the American College of Surgeons Ultrasound for Surgeons Basic Course. Clinical evidence of hernia, results of DASH examination, and radiologist documentation of incisional hernia were compared with the gold standard of surgeon-interpreted CT. Testing characteristics of sensitivity and specificity were compared and predictive values were calculated. Inter-rater reliability was performed by comparing DASH results in a subgroup of patients with 3 different evaluators. RESULTS: There were 181 patients enrolled, with a mean age of 54 years, and 68% were women. In patients in whom hernias were identified, the mean hernia size was 44.6 cm(2) (range 0.2 to 468.3 cm(2)). The DASH examination showed high sensitivity (98%) and specificity (88%). Hernia prevalence was 55% in this population, resulting in positive and negative predictive values of 91% and 97%, respectively. Four patients had clinically detectable hernias that were not seen on CT but were discovered with DASH. Inter-rater reliability for DASH was high, with an observed intraclass correlation coefficient of 0.79. CONCLUSIONS: The DASH examination is an accurate alternative to CT scan for diagnosing abdominal wall hernias, with additional benefits of no radiation exposure and instant bedside interpretation. The use of DASH to detect hernia recurrence can greatly facilitate long-term follow-up of hernia patients.

Quality assessment in pancreatic surgery: what might tomorrow require?

INTRODUCTION: The Institute of Medicine (IOM) defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability. We asked experts in pancreatic surgery (PS) whether improved quality metrics are needed, and how they could align to contemporary IOM healthcare quality domains. METHODS: We created and distributed a web-based survey to pancreatic surgeons. Respondents ranked 62 proposed PS quality metrics on level of importance (LoI) and aligned each metric to one or more IOM quality domains (multi-domain alignment (MDA)). LoI and MDA scores for a given quality metric were averaged together to render a total quality score (TQS) normalized to a 100-point scale. RESULTS: One hundred six surgeons (21 %) completed the survey. Ninety percent of respondents indicated a definite or probable need for improved quality metrics in PS. Metrics related to mortality, to rates and severity of complications, and to access to multidisciplinary services had the highest TQS. Metrics related to patient satisfaction, costs, and patient demographics had the lowest TQS. The least represented IOM domains were equitability, efficiency, and patient-centeredness. CONCLUSIONS: Experts in pancreatic surgery have significant consensus on 12 proposed metrics of quality that they view as both highly important and aligned with more than one IOM healthcare quality domain.

Surgical management of late sequelae in survivors of an episode of acute necrotizing pancreatitis.

BACKGROUND: After surviving an episode of acute necrotizing pancreatitis (ANP), a variety of late sequelae develop and require nonoperative or operative interventions. Persistent pancreatic fistula, fluid collections, recurrent pancreatitis, sepsis, pain, and intolerance of po intake are seen. STUDY DESIGN: We have maintained records for all patients hospitalized from 1993 through 2010 with a diagnosis of ANP. Once discharged from hospital, patients were managed with routine clinic follow-up at close intervals and later at 6-month intervals. Using ERCP or magnetic resonance cholangiopancreatography, all patients' pancreatic ducts were classified as type I (normal), type II (stricture), or type III (disconnected). Patients were monitored for the complications mentioned. Operations performed >8 weeks after the initial episode of ANP were defined as late and evaluated for operative mortality, morbidity, success in resolving symptoms/collections, and length of stay. RESULTS: One hundred and ninety-seven patients with ANP were included. Seventy-one late operations were performed (59 drainage procedures/12 resections). Operative mortality was 1%, morbidity was 19%, and mean length of stay was 6.3 ± 5.6 days. Poor po intake was seen in 80% of operated patients and total parenteral nutrition dependence in 42%. Duct type correlated with pancreatic debridement, persistent fluid collection/fistula, pain, po intake intolerance, and late operation. Late operation successfully resolved symptoms and/or fluid collections in 96%. Recurrent pancreatitis was improved in 87% and eliminated in 78%. CONCLUSIONS: Patients who require late operation after surviving an episode of ANP are more likely to have sustained ductal injuries and are likely to require operation for either pain or for inability to tolerate po intake. Operation can be performed safely with a low mortality.