Glenohumeral morphological predictors of recurrent shoulder instability following arthroscopic Bankart repair.

PURPOSE: The purpose of this study was to evaluate glenohumeral morphological features on a magnetic resonance arthrogram (MRA) to determine risk factors for recurrence of anterior shoulder instability following arthroscopic Bankart repair (ABR). METHODS: A retrospective review of patients who underwent ABR between 2012 and 2017 was performed to identify patients who had recurrence of instability following stabilisation (Group 1). These were pair-matched in a 2:1 ratio for age, gender and sport with a control (Group 2) who underwent ABR without recurrence. Preoperative MRAs were evaluated for risk factors for recurrence, with glenoid bone loss and Hill-Sachs lesions also measured. Multilinear and multilogistic regression models were used to evaluate factors affecting recurrence. RESULTS: Overall, 72 patients were included in this study, including 48 patients without recurrence and 24 patients with recurrent instability. There was a significant difference between the two groups in mean glenoid bone loss (Group 1: 7.3% vs. Group 2: 5.7%, p < 0.0001) and the rate of off-track Hill-Sachs lesions (Group 1: 20.8% vs. Group 2: 0%, p = 0.0003). Of the variables analysed in logistic regression, increased glenoid anteversion (p = 0.02), acromioclavicular (AC) degeneration (p = 0.03) and increased Hill-Sachs width were associated with increased risk of failure. Increased chondral version (p = 0.01) and humeral head diameter in the anteriorposterior view were found to be protective and associated with a greater likelihood of success. CONCLUSION: Glenoid anteversion was a risk factor for recurrent instability, whereas increased chondral version and humeral head diameter were associated with higher rates of success following ABR. Glenoid bone loss, presence of an off-track Hill-Sachs lesion, increased Hill-Sachs width and AC degeneration were also associated with failure. These findings should be used by surgeons to stratify risk for recurrence following ABR. LEVEL OF EVIDENCE: Level III.

Neoadjuvant therapy does not impact the biliary microbiome in patients with pancreatic cancer.

BACKGROUND: Pancreatic adenocarcinoma (PDAC) often impinges on the biliary tree and obstruction necessitates stent placement increasing the risk of surgical site infections (SSIs). We sought to explore the impact of neoadjuvant therapy on the biliary microbiome and SSI risk in patients undergoing resection. METHODS: A retrospective analysis was performed on 346 patients with PDAC who underwent resection at our institution from 2008 to 2021. Univariate and multivariate methods were utilized for analysis. RESULTS: Biliary stenting rates were similar between groups but resulted in increased bile culture positivity (97% vs. 15%, p < 0.001). Culture positivity did not differ between upfront resection or neoadjuvant chemotherapy (NAC) (77% vs. 80%, p = 0.60). NAC-alone versus neoadjuvant chemoradiotherapy did not impact biliary positivity (80% vs. 79%, p = 0.91), nor did 5-fluorouracil versus gemcitabine-based regimens (73% vs. 85%, p = 0.19). While biliary stenting increased incisional SSI risk (odds ratios [OR]: 3.87, p = 0.001), NAC did not (OR: 0.83, p = 0.54). Upfront resection, NAC, and chemoradiotherapy were not associated with biliary organism-specific changes or antibiotic resistance patterns. CONCLUSIONS: Biliary stenting is the greatest predictor for positive biliary cultures and SSIs in resected PDAC patients. Neither NAC nor radiotherapy impact bile culture positivity, speciation, rates, or antibiotic resistance patterns, and perioperative antibiotic prophylaxis should not differ.

Intensive care unit observation after pancreatectomy: Treating the patient or the surgeon?

BACKGROUND: Routine intensive care unit admission (ICUA) is commonplace following pancreatectomy, particularly pancreaticoduodenectomy. The value of this practice in avoiding failure-to-rescue is poorly studied. METHODS: We queried our institutional National Surgical Quality Improvement Project database for patients undergoing pancreatectomy from 2013 to 2020. Postoperative dispositions, ICU courses, and hospital cost data in United States Dollars (USD) were captured. Data were analyzed with multivariable logistic regression. RESULTS: Six-hundred-thirty-seven patients were identified; 404 (63%) underwent pancreaticoduodenectomy. Postoperatively, 398 (99%) pancreaticoduodenectomies and 110 (47%) distal pancreatectomies had ICUA; two-thirds (n = 318, 63%) did not require immediate postoperative ICU-level interventions at ICUA. Of these, 17 (5.3%) subsequently required ICU-level interventions during initial ICUA, most commonly antiarrhythmic infusion (n = 12). Thirty-day and 90-day mortality in patients requiring immediate ICU-level interventions was 5% (n = 10) and 8% (n = 16) versus 0.3% (n = 1) and 1.2% (n = 4) in those without, respectively. Hospital length of stay was significantly longer with initial ICU-level interventions (median 11 vs. 9 days, p < 0.001), as were total ICU costs (mean 8683 vs. 14611 USD, p < 0.001). CONCLUSION: At high-volume pancreas centers, patients without immediate postoperative ICU-level interventions are very low risk for failure-to-rescue. Ward admission with a low threshold for care escalation presents a significant opportunity for cost-savings and un-burdening ICUs.

Intraoperative Bile Culture in Pancreaticoduodenectomy: Teaching Old Dogma New Tricks.

INTRODUCTION: Biliary stents increase surgical site infections (SSIs) following pancreaticoduodenectomy due to bactibilia and contaminated intraoperative bile spillage. Intraoperative bile culture (IOBC) is performed to guide empiric therapy for SSIs; however, its utility is poorly studied. We sought to evaluate IOBC and the interplay between stenting, bactibilia, and SSI following pancreaticoduodenectomy. METHODS: Patients undergoing pancreaticoduodenectomy from January 2008 to April 2020 were identified through our institutional National Surgical Quality Improvement Project (NSQIP) database; patients without IOBC were excluded. Odds of SSI were analyzed with multivariable logistic regression. RESULTS: Four-hundred-eighty-three patients were identified. One-hundred-eighty-nine (39%) patients had plastic stents and 154 (32%) had metal stents. Three-hundred-twenty-nine (96%) patients with stents had bactibilia versus 18 (13%) without stents (P < 0.001). The biliary microbiome and antibiotic resistance patterns in patients with metal and plastic stents were nearly identical. Of 159 NSQIP-defined SSIs, most were incisional (n = 92, 58%). Bactibilia and stent presence were associated with incisional (OR 3.69 and 3.39, both P < 0.001) but not organ space SSI (P > 0.1); however, stent type was not (P > 0.5). Of the 73 speciated SSI cultures, an IOBC-identified organism was present in 42 (58%), while at least one organism not found in the IOBC was present in 49 (67%). CONCLUSION: Bactibilia is associated with incisional but not organ space SSI following pancreaticoduodenectomy and is strongly associated with stent presence. Stent type does not independently influence the biliary microbiome or SSI risk. IOBC has a poor ability to predict causative organisms in SSIs following pancreaticoduodenectomy and is not recommended for routine use.

The power of suction: Theory and practice in closed suction vs gravity drains and postoperative pancreatic fistulas.

BACKGROUND: Postoperative pancreatic fistula (POPF) is a feared complication in pancreatic resection. Gravity drainage (GD) is hypothesized to reduce POPF versus closed-suction drainage (CSD). We sought to evaluate this theory. METHODS: Six-hundred-twenty-nine patients undergoing pancreatic resection between 2013 and 2020 were analyzed with multivariable logistic regression for the outcomes of POPF and clinically-relevant POPF (crPOPF). RESULTS: Three-hundred-ninety-seven patients (63.1%) underwent pancreaticoduodenectomy and 232 (36.9%) underwent distal pancreatectomy. Suction drains were placed in 588 patients (93.5%) whereas 41 (6.5%) had GDs. One-hundred-twenty-five (27.6%) experienced a POPF; 49 (10%) crPOPFs. On multivariable analysis, suction drainage was not associated with increased risk of POPF (OR 0.76, 95% CI 0.30-1.93, P = 0.57) or crPOPF (OR 0.99, 95% CI 0.30-3.26, P = 0.98). CONCLUSION: Suction drainage does not promote POPF when compared to GDs. Drain type should be determined by surgeon preference, while taking into account nursing and patient-specific considerations especially when patients are discharged with drains.

Risk factors for postoperative pancreatic fistula in the Era of pasireotide.

INTRODUCTION: Postoperative pancreatic fistulas (POPFs) remain common; POPFs frequently require intervention, termed clinically-relevant POPFs (crPOPFs). Pasireotide is increasingly used to prevent POPF, however, risk factors for POPF in this population remain unexplored. METHODS: Patients undergoing pancreatectomy with perioperative pasireotide from 2013 to 2020 were identified from our institutional National Surgical Quality Improvement Project database. Logistic regression was utilized to identify risk factors associated with POPF. RESULTS: One-hundred patients were identified; 26 (26%) underwent distal pancreatectomy with the remainder undergoing pancreaticoduodenectomy. Thirty (30%) experienced POPF, with 21 crPOPFs. Only current smoking was significantly associated with crPOPF (OR 3.79, p = 0.04). Of 30 patients with a firm gland, none experienced crPOPF. Twenty-five received a partial course of pasireotide; 7/25 (28%) crPOPFs occurred versus 14/75 (19%) in patients receiving a full course (p = 0.38). CONCLUSION: Shortened courses of pasireotide do not increase crPOPF risk; selective discontinuation may be suitable in low-risk patients. Smoking cessation should be encouraged.