Leadership proficiency in surgery: lessons from the COVID-19 pandemic.

Summary: The coronavirus disease 2019 (COVID-19) pandemic has accentuated the importance of leadership training for health care professionals, particularly surgeons. Surgeons are expected to lead and thrive in multidisciplinary teams. There is, however, a critical gap in teaching residents about fundamental leadership principles, such as developing productive and vision-driven teams, conflict resolution and emotional intelligence. We discuss the merits of leadership training for surgical residents and future directions for implementing a leadership curriculum for Canadian residency programs in the competency by design era.

Rapid Ground Transport of Trauma Patients: A Moderate Distance From Trauma Center Improves Survival.

BACKGROUND: There is debate within the emergency medical services (EMS) community over the value of calling a helicopter for trauma patients within a moderate distance/<45 min, of a trauma center. Helicopter EMS (HEMS) generally have a wider scope and more advanced training than the ground EMS (GEMS). GEMS, on the other hand, have the benefit of being able to immediately initiate rapid transport to the trauma center without the delay involved with HEMS flying to the scene, landing, and assuming patient care. METHODS: We retrospectively analyzed patients brought to a level I trauma center who were admitted with blunt traumatic injuries between 2010 and 2015 in the Trauma Quality Improvement Program database. Two analyses were performed, one in which the patient's reported initial scene vitals met criteria for step one of the Centers for Disease Control's 2011 National Field Triage Guidelines (NFTG) and the other in which the patient's initial scene vitals met those same guidelines and/or had a pulse greater than 110 beats per minute. Patients were categorized on scene to emergency department (ED) transport mode, either HEMS or GEMS. Inclusion criteria were a HEMS response time to the scene that was between 15 and 45 min with a transport time from the scene to the ED that was between 10 and 35 min or a GEMS transport time from the scene to the ED that was between 15 and 45 min. Statistical significance (P < 0.05) was established through logit regression. Mortality rates were then calculated within each transport mode-based population. RESULTS: Four hundred subjects were included in the analysis of patients meeting the first step of the NFTG, with 212 HEMS patients and 188 in the GEMS group. HEMS had a higher mortality rate at 0.184 and GEMS at 0.101, which was statistically significant (P = 0.019). When 606 subjects meeting the first step of the NFTG or with a pulse greater than 110 beats per minute were analyzed, the results were statistically significant (P < 0.001), with the HEMS category having a higher mortality rate at 0.154 and the GEMS category having a lower mortality at 0.056. CONCLUSIONS: Our data demonstrate that scene-to-ED time is paramount, and rapid ground transport should be used in blunt trauma patients when the scene is up to a moderate ground distance away from the trauma center and there would be a moderate-to-prolonged HEMS response time. In both analyses, hemodynamically unstable trauma patients had lower rates of mortality following ground transport. We recognize that there may be a subset of patients at these distances who could benefit from HEMS response, particularly if the flight crew can offer more advanced and specialized techniques; however, every effort should be made to minimize the scene-to-ED time, and HEMS response, scene, and transport time must be considered. This study only analyzed the patients within a moderate distance of the trauma center and at longer distances or in different environments; HEMS transport may indeed minimize the scene to ED time.

Up-front hepatic resection for metastatic colorectal cancer results in favorable long-term survival.

BACKGROUND: Hepatic metastasis from colorectal cancer (CRC) is best managed with a multimodal approach; however, the optimal timing of liver resection in relation to administration of perioperative chemotherapy remains unclear. Our strategy has been to offer up-front liver resection for patients with resectable hepatic metastases, followed by post-liver resection chemotherapy. We report the outcomes of patients based on this surgical approach. METHODS: A retrospective review of all patients undergoing liver resection for CRC metastases over a 5-year period (2002-2007) was performed. Associations between clinicopathologic factors and survival were evaluated by the Cox proportional hazard method. RESULTS: A total of 320 patients underwent 336 liver resections. Median follow-up was 40 (range 8-80) months. The majority (n=195, 60.9%) had metachronous disease, and most patients (n=286, 85%) had a major hepatectomy (>3 segments). Thirty-six patients (11%) received preoperative chemotherapy, predominantly for downstaging unresectable disease. Ninety-day mortality was 2.1%, and perioperative morbidity occurred in 68 patients (20.2%). Actual disease-free survival at 3 and 5 years was 46.2% and 42%, respectively. Actual overall survival (OS) at 3 and 5 years was 63.7% and 55%, respectively. Multivariate analysis identified four factors that were independently associated with differences in OS (hazard ratio; 95% confidence interval): size of metastasis>6 cm (2.2; 1.3-3.5), positive lymph node status of the primary CRC (N1 (2.0; 1.0-3.8), N2 (2.4; 1.2-4.9)), synchronous disease (2.1; 1.3-3.5), and treatment with chemotherapy after liver resection (0.42; 0.23-0.75). CONCLUSIONS: Up-front surgery for patients with resectable CRC liver metastases, followed by chemotherapy, can lead to favorable OS.

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

OBJECTIVES: To assess the relationship between changes in clinician attitude and changes in postoperative outcomes following a checklist-based surgical safety intervention. DESIGN: Pre- and post intervention survey. SETTING: Eight hospitals participating in a trial of a WHO surgical safety checklist. PARTICIPANTS: Clinicians actively working in the designated study operating rooms at the eight hospitals. SURVEY INSTRUMENT: Modified operating-room version Safety Attitudes Questionnaire (SAQ). MAIN OUTCOME MEASURES: Change in mean safety attitude score and correlation between change in safety attitude score and change in postoperative outcomes, plus clinician opinion of checklist efficacy and usability. RESULTS: Clinicians in the preintervention phase (n=281) had a mean SAQ score of 3.91 (on a scale of 1 to 5, with 5 representing better safety attitude), while the postintervention group (n=257) had a mean of 4.01 (p=0.0127). The degree of improvement in mean SAQ score at each site correlated with a reduction in postoperative complication rate (r=0.7143, p=0.0381). The checklist was considered easy to use by 80.2% of respondents, while 19.8% felt that it took a long time to complete, and 78.6% felt that the programme prevented errors. Overall, 93.4% would want the checklist used if they were undergoing operation. CONCLUSIONS: Improvements in postoperative outcomes were associated with improved perception of teamwork and safety climate among respondents, suggesting that changes in these may be partially responsible for the effect of the checklist. Clinicians held the checklist in high regard and the overwhelming majority would want it used if they were undergoing surgery themselves.

A surgical safety checklist to reduce morbidity and mortality in a global population.

BACKGROUND: Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery. METHODS: Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. RESULTS: The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). CONCLUSIONS: Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

What surgeons tell their patients about the intraoperative role of residents: a qualitative study.

BACKGROUND: The issue of residents operating and disclosure to patients about this have not been explored from staff surgeons' perspectives. METHODS: A preliminary survey was sent to all active surgeons at the University of Toronto. A qualitative interview study followed. Thirty-nine face-to-face interviews were conducted with surgeons. Interviews were transcribed and subjected to thematic analysis by 3 reviewers. RESULTS: Four encompassing themes emerged: (1) surgeons are comfortable allowing residents to operate independently with graded responsibility, (2) surgeons do not voluntarily inform patients about the involvement of residents in their operation, (3) residents are seen as important assets in a teaching hospital and are beneficial to patient care, and (4) surgeons recognize the trust their patients place in them. CONCLUSIONS: Surgeons recognize their patient care and teaching responsibilities and the trust that is placed in them. Patients might benefit from a discussion with their surgeon about the role of residents in their surgery.

Recurrent pyogenic cholangitis with hepatolithiasis--the role of surgical therapy in North America.

PURPOSE: To determine role of surgical intervention for Recurrent Pyogenic Cholangitis with hepatolithiasis at a North American hepatobiliary center. METHODS: Retrospective analysis of 42 patients presenting between 1986 and 2005. RESULTS: Mean age is 54.3 years (24-87). Twenty-seven patients (64%) underwent surgery, after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous intervention in 19/27 patients. Surgical procedures were: 10 common bile duct explorations with choledochojejunostomy and a Hutson loop and 17 hepatectomies (10 with, 7 without Hutson loop). Liver resection was indicated for lobar atrophy or stones confined to single lobe. Operative mortality was zero; complication rates for hepatectomy and common bile duct exploration were comparable (35% vs. 30%). Median follow-up was 24 months (3-228). Of 21 patients with Hutson loops, only seven (33%) needed subsequent loop utilization, with three failures. At last follow-up, 4/27 (15%) surgical patients had stone-related symptoms requiring percutaneous intervention, compared to 4/11 (36%) surviving nonoperative patients. Cholangiocarcinoma was identified in 5/42 (12%) patients; four were unresectable and one was an incidental in-situ carcinoma in a resected specimen. CONCLUSION: Surgery is a valuable part of multidisciplinary management of recurrent pyogenic cholangitis with hepatolithiasis. Hepatectomy is a useful option for selected cases. Hutson loops are useful in some cases for managing stone recurrence. Cholangiocarcinoma risk is elevated in this disease.

Focal chronic pancreatitis mimicking pancreatic head carcinoma: are there suggestive features on ultrasound?

OBJECTIVE: Painless jaundice is one of the most common presentations of pancreatic head cancer. Chronic pancreatitis can also occasionally present with a mass or mass-like process in the pancreatic head, with the subsequent development of jaundice. In this retrospective review, we evaluate the clinical and imaging features of 22 patients presenting with painless jaundice, initially thought to have pancreatic head cancer and ultimately proven to have chronic focal pancreatitis, to determine whether there are any features on cross-sectional imaging to suggest the correct diagnosis. METHODS: Patients (n = 22) were identified from the medical and imaging records of more than 400 patients with an original diagnosis of pancreatic cancer who were seen at our institution from 1995 to 2003. Of the patients, 17 were men and 5 were women (age range 25 to 82 years, mean age 54 years). RESULTS: Initial ultrasound showed a large, hypoechoic, well-defined mass in the pancreatic head, varying in size from 3 to 7.5 cm; 14 of 22 masses were > 5 cm in maximal diameter. Diagnosis of focal pancreatitis was proven by surgical pathology in 14 cases and suggested by percutaneous biopsy in 3 cases; for all patients, prolonged imaging follow-up (at least 1 year) showed no disease progression or evidence of malignancy. The mean follow-up in our study group was 31 months (range 12 to 72 months). CONCLUSION: Male sex, large size of the pancreatic head mass (mean diameter 5.5 cm), and lack of atrophy of the pancreatic body and tail were the only features associated with chronic inflammation rather than neoplasm as an explanation for a pancreatic head mass. Chronic pancreatitis should be considered in the differential diagnosis of focal pancreatic masses, even in the absence of supporting clinical evidence.

Recurrence after liver resection for hepatocellular carcinoma: risk factors, treatment, and outcomes.

BACKGROUND: Tumor recurrence remains the major cause of death after curative resection for hepatocellular carcinoma (HCC). The purpose of this study was to identify risk factors for the recurrence of HCC and to examine long-term outcomes after resection. METHODS: From July 1992 to July 2004, 193 consecutive patients who underwent hepatic resection as primary therapy with curative intent for HCC were included in this single-center analysis. The perioperative mortality rate was 5%. Time to recurrence (disease-free survival) and overall survival were determined by Kaplan-Meier analysis. Demographic, tumor, and treatment characteristics were tested for their prognostic significance by univariate and multivariate analysis with the log-rank test and the Cox proportional hazards model, respectively. RESULTS: Median overall survival for the entire cohort was 71 +/- 11 months; disease-free survival was 34 months (range, 1-149 months). After a median follow-up time of 34 months, 98 patients (51%) experienced recurrent cancer; initial tumor recurrence was confined to the liver in 86 patients (88%). With the use of multivariate analysis, preoperative vascular invasion detected on radiologic imaging studies; postoperative vascular invasion found on pathologic assessment, and intermediate and poor tumor differentiation and tumor size and number were significant predictors of disease-free survival. Of the 98 patients who had tumor recurrence, 53 patients (54%) underwent additional therapy (ablation, 31 patients; re-resection, 11 patients; transarterial chemoembolization, 8 patients; liver transplantation, 3 patients) with improvement in survival. CONCLUSION: Despite recurrences in >50% of patients, long-term survival can be achieved after resection of HCC. Identification of risk factors, close follow-up evaluation, and early detection are mandatory because recurrences that are confined to the liver may be amenable to treatment with an additional survival benefit.

Chemotherapy for colorectal cancer prior to liver resection for colorectal cancer hepatic metastases does not adversely affect peri-operative outcomes.

BACKGROUND: Systemic chemotherapy is being used increasingly in patients with colorectal cancer. The effects of prior systemic adjuvant or palliative chemotherapy on morbidity following hepatic resection for metastases are not well defined. OBJECTIVES: To assess the peri-operative impact of systemic chemotherapy on liver resection for colorectal cancer hepatic metastases. METHODS: Ninety-six resections for colorectal cancer hepatic metastases performed from July 2001 to July 2003 (93% > or =2 segments) were reviewed. Pre-operative demographics, peri-operative features, and post-operative outcomes were collected prospectively. Type of chemotherapy and the temporal relationship of chemotherapy to the liver resection were analyzed. RESULTS: Fifty-three of 96 patients (55%) received a mean of 5.7 cycles (6.1 months) of systemic chemotherapy prior to hepatic resection, with a median interval of 12 months from end of chemotherapy to liver resection (range 1-75 months). Thirty-five received 5-fluorouracil/leucovorin (5-FU/LV) alone, nine had irinotecan (CPT-11) in addition to 5-FU/LV, and nine were not specified. Pre-operative age, sex, co-morbidities, ASA score, biochemical and liver enzyme profiles, tumor number, and extent and technique of hepatic resection were the same in the chemotherapy and non-chemotherapy cohorts. Mean tumor size was smaller (4.5 cm vs. 5.8 cm) and synchronous metastases were half as common (25% vs. 49%) in the chemotherapy group. Liver resection operative time was equivalent (270 min) in the two groups. Higher estimated blood loss (EBL) (1,000 ml vs. 850 ml), but fewer transfusions (23% vs. 15%) were associated with the chemotherapy group. Although not statistically significant, post-operative liver enzyme peaks were higher in the chemotherapy group (AST = 402 U/L vs. 302 U/L, P = 0.09 and ALT = 433 U/L vs. 312 U/L, P = 0.1). Peak changes in INR and serum bilirubin did not differ. Complications and length of stay (LOS) did not differ between the groups. The only post-operative death was in the non-chemotherapy group. Interestingly, hepatic steatosis was present in 28% of the non-chemotherapy cases and 57% of the chemotherapy resection specimens (P = 0.005) and was marked (>30%) in 7% and 10%, respectively. Further analysis of the chemotherapy group based on the interval between completion of chemotherapy and the hepatic resection (<6 months, 7-12 months, 1-2 years, and >2 years) revealed a trend towards worse outcomes in most categories for those in the >2 years cohort. When comparing the 5-FU/LV alone, to the CPT-11 group there were no significant differences except higher intra-operative blood loss in the group receiving 5-FU/LV alone (1,295 ml vs. 756 ml, P = 0.01). CONCLUSION: Despite variations in biochemical function and hepatic steatosis, short-term clinical outcomes are not affected by the administration of chemotherapy prior to hepatic resection. Furthermore, there is no detrimental effect of close timing of chemotherapy prior to resection, and there are no appreciable differences between irinotecan containing regimes and more traditional 5-FU-only based therapies, although the subset sample sizes were small in this study.

Impact of regional lymph node evaluation in staging patients with periampullary tumors.

BACKGROUND: Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival. METHODS: Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes. RESULTS: Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023). CONCLUSIONS: For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy.

The business case for patient safety.

The leadership team at University Health Network describes why it decided to pursue a new information technology initiative to substantially reduce human and system errors and omissions associated with medication management.

Survival after hepatic resection for colorectal metastases: a 10-year experience.

BACKGROUND: Metastatic colorectal cancer is a major cause of cancer death in North America. Hepatic resection offers the potential for cure in selected patients. We report the long-term outcomes of patients who underwent hepatic resection for colorectal metastases over a 10-year period at a single hepatobiliary surgical oncology center. METHODS: All patients who underwent liver resection for metastatic colorectal cancer between 1992 and 2002 were identified. Data were retrospectively obtained through chart review. Major outcome variables were disease-free survival and overall survival. Risk factors for disease recurrence and mortality were identified by multivariate analysis by using the Cox proportional hazard method. RESULTS: A total of 423 hepatectomies were performed for metastatic colorectal cancer. Most operations (n = 276; 65%) were major (four or more segments) hepatectomies. Perioperative morbidity occurred in 74 (17%) patients. There were seven (1.6%) perioperative deaths. The disease-free survival at 1, 5, and 10 years was 64%, 27%, and 22%, respectively. The overall survival at 1, 5, and 10 years was 93%, 47%, and 28%, respectively. Multivariate analysis identified four negative predictive factors for overall survival (hazard ratio; 95% confidence interval): a positive surgical margin (2.9; 1.5-5.3), large metastases (>5 cm; 1.5; 1.1-2.0), multiple metastases (1.4; 1.1-1.9), and age >60 years (1.4; 1.1-1.9). CONCLUSIONS: Hepatic resection for metastatic colorectal cancer is safe and provides good long-term overall survival rates of 47% at 5 years and 28% at 10 years. An aggressive approach is justified by the low operative mortality rate and good long-term survival, even in individuals with multiple bilobar metastases.

Surgical resection of hepatic and pulmonary metastases from colorectal carcinoma.

BACKGROUND: Patients with hepatic and pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. We examined the longterm outcomes of patients who underwent both lung and liver resections for colorectal metastases over a 10-year period. STUDY DESIGN: Four hundred twenty-three hepatectomies were performed for metastatic CRC between 1992 and 2002 at two university-affiliated hospitals. Patients who underwent both lung and liver resections for metastatic CRC were studied. Demographic, perioperative, and survival data were evaluated by retrospective chart review. Disease-free survival (DFS) and overall survival (OS) were evaluated by Kaplan-Meier analysis and survival curves were compared using the log-rank test. RESULTS: Thirty-nine patients underwent both lung and liver resections for metastatic CRC. Eleven patients (28%) underwent staged liver and lung metastasectomy from synchronously identified metastases. Twenty-eight patients (72%) underwent sequential metastasectomy because of recurrent disease. The median disease-free and overall survivals after initial metastasectomy were 19.8 and 87 months, respectively. Serial metastasectomy was common in this patient population. The mean number of metastasectomies performed was 2.6 per patient (range 1 to 4). There was no difference in overall survival for patients with synchronous versus metachronous presentation of liver and lung metastases (p=0.45). The site of first recurrence after initial metastasectomy was, most commonly, the lung (n=19, 49%), followed by the liver (n=8, 21%). Nineteen patients (49%) underwent subsequent resections for recurrences. Seven patients (18%) underwent 2 or more liver resections for recurrent disease, and 12 (31%) underwent multiple lung resections. CONCLUSIONS: An aggressive multidisciplinary surgical approach should be undertaken for recurrent CRC metastases. In selected patients, serial metastasectomy for recurrent metastatic disease is safe and results in excellent longterm survival after CRC resection.

Factors associated with early recurrence after resection for hepatocellular carcinoma and outcomes.

BACKGROUND: Early recurrence (ER) (<1 year) after liver resection is one of the most important factors that impact the prognosis of patients with hepatocellular carcinoma (HCC). We sought to determine factors associated with ER of HCC and examine the outcomes thereafter. STUDY DESIGN: From March 2001 to June 2003, 56 patients underwent hepatic resection for HCC at University of Toronto and were prospectively followed with median followup of 24 months. Patients with ER were compared with those who remained disease free for more than 1 year. Patient characteristics, tumor stage, and operative procedures were evaluated for their prognostic significance by univariate and multivariable analysis. Time to recurrence and time to death were analyzed using Kaplan-Meier survival curves and compared using log-rank analysis. RESULTS: The initial procedure in all patients was surgical hepatectomy. ER occurred in 21 patients (38%), 31 (55%) remained disease free for more than 1 year, and 4 (7%) were omitted from evaluation because of early (<30 days) death. Median survival after initial hepatic resection for those with ER was 27 months, and 2-year survival was 54%. There were no deaths in the group that remained disease free for more than 1 year (100% 2-year survival, p < 0.05). By multivariate analysis, vascular invasion and positive microscopic margins were significant predictors when all 4 variables were considered in the model (p < 0.05). After ER, 11 of 21 patients (52%) underwent additional therapy with significant improvement in median survival (33 months) compared with those not eligible for conventional therapy (18 months, p = 0.05). CONCLUSIONS: ER after liver resection for HCC is the leading cause of death during the first 2 years after potentially curative resection. ER will develop in approximately 75% of patients with either vascular invasion or positive margins. For patients with these predictive factors additional treatment might be advised.

Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma.

BACKGROUND: Complete resection offers the only potential cure for ampullary carcinoma. We analyzed factors that contribute to treatment failure and survival in patients who underwent pancreaticoduodenectomy for ampullary carcinoma. STUDY DESIGN: We retrospectively reviewed all patients who underwent pancreaticoduodenectomy between August 1994 and August 2003 for ampullary carcinoma. Demographic, clinical, and pathologic data were collected. Chi-square analysis was used for categorical data and the t-test was used for continuous variables. Kaplan-Meier analyses were compared using the log-rank test to examine patient survival. RESULTS: Forty-three patients (24 men) aged 63.7 +/- 11.4 years (standard deviation) were followed for a mean of 23.9 months (median 660 days, range 18 to 2,249 days). Jaundice (n = 33) and weight loss (n = 13) were the most common presenting symptoms. Stage (p < 0.01) and degree of differentiation (p < 0.029) were significant predictors of failure by univariate analysis. But only stage (p < 0.04) was a significant predictor by multivariate analysis. Further analysis revealed that nodal status (p < 0.001), but not tumor grade, was a significant predictor of treatment failure. Neither demographic nor clinical variables were significant predictors. Five-year overall and disease-free survival rates were 67.4% and 51.4%, respectively. Both metastases and disease recurrence had significant impact on patient survival. CONCLUSIONS: Tumor stage is associated with treatment failure after pancreaticoduodenectomy for ampullary carcinoma and may identify candidates for adjuvant therapy. Because an aggressive surgical approach can be adopted safely with the best chance for cure, we recommend that pancreaticoduodenectomy be offered to all patients with ampullary tumors when malignancy or dysplasia is in question.

Water-jet dissection for parenchymal division during hepatectomy.

BACKGROUND: High-pressure water-jet dissection was originally developed for industry where ultra-precise cutting and engraving were desirable. This technology has been adapted for medical applications with favorable results, but little is understood about its performance in hepatic resections. Blood loss may be limited by the thin laminar liquid-jet effect that provides precise, controllable, tissue-selective dissection with excellent visualization and minimal trauma to surrounding fibrous structures. PATIENTS AND METHODS: The efficacy of the Water-jet system for hepatic parenchymal dissection was examined in a consecutive case series of 101 hepatic resections (including 22 living donor transplantation resections) performed over 11 months. Perioperative outcomes, including blood loss, transfusion requirements, complications, and length of stay (LOS), were assessed. RESULTS: Three-quarters of the cases were major hepatectomies and 22% were cirrhotic. Malignancy was the most common indication (77%). Median operative time was 289 min. Median estimated blood loss (EBL) was 900 ml for all cases, and only 14% of patients had >2000 ml EBL. Furthermore, EBL was 1000 ml for major resections, 775 ml for living donor resections, 600 ml in cirrhotic patients, and 1950 ml for steatotic livers. In all, 14% of patients received heterologous packed red blood cell (PRBC) transfusions for an average of 0.59 units per case. Median LOS was 7 days. EBL, transfusion requirements, and LOS were slightly increased in the major resection cohort. There was one mortality (1%) overall. These results are equivalent to, or better than, those from our contemporary series of resections performed with ultrasonic dissection. CONCLUSION: Water-jet dissection minimizes large blood volume loss, requirements for transfusion, and complications. This initial experience suggests that this precision tool is safe and effective for hepatic division, and compares favorably to other established methods for hepatic parenchymal transection.

Transduodenal resection of peri-ampullary lesions.

Transduodenal resection (TDR) of lesions near the ampulla of Vater is an alternative to the Whipple pancreaticoduodenectomy. A retrospective analysis was performed to determine the long-term outcome and the utility of intraoperative frozen section examinations in aiding operative decision making in patients undergoing TDR. From 1992 to 2002, 19 patients with an average age of 64.2 years (range: 33-84 years) underwent a transduodenal resection of a peri-ampullary lesion; median follow-up was 47 months (range: 2-100 months). Pathology of the lesions was as follows: 11 with benign ampullary adenomas, including 4 with familial adenomatous polyposis (FAP); 7 with peri-ampullary adenocarcinomas; and 1 with a benign stricture. Survival for the entire cohort is 100%. In 12 cases an intraoperative frozen section was performed. The specificity and positive predictive value of the intraoperative histology were both 100%, and the sensitivity and negative predictive value were 57% and 38%, respectively. Three of the 4 patients with FAP have recurrent adenomatous change; 2 of the 7 with carcinoma have metastatic adenocarcinoma. Transduodenal resection of peri-ampullary lesions appears to be a safe alternative to radical resection for benign adenomas and selected carcinoma. Intraoperative frozen section assessment is recommended in cases of potential adenocarcinoma.

An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center.

OBJECTIVE: To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer. SUMMARY BACKGROUND DATA: Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached. METHODS: A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64). RESULTS: Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate. CONCLUSIONS: A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer.