Surgical Treatment of Malignant Pheochromocytoma and Paraganglioma: Retrospective Case Series.

INTRODUCTION: Pheochromocytoma and paraganglioma (PPGL) are rare neoplasms; about 10% are malignant. Literature regarding possible benefit from resection is extremely limited. METHODS: A 20 year review of all patients undergoing surgery for malignant PPGL at the Mayo Clinic Rochester Campus between 1994 and June 2014 was performed. RESULTS: We identified 34 patients undergoing surgery for malignant PPGL. Median follow up was 6 and 5 years survival was 90% (median 11 years). Complete resection (R0) was achieved in 14 patients (41%). Median disease-free survival was 4.6 years for patients with R0 resection (up to 12 years). Only eight patients (23%) were disease-free on last follow up. Elevated preoperative fractionated metanephrines or catecholamines were documented in 23 patients (68%); these normalized in 13 of 23 patients (56%) postoperatively-with symptom relief in 15 of 18 preoperatively symptomatic patients (79%). Among 23 patients with hormone-producing tumors, significant reduction in number of antihypertensive medications was also noted postoperatively; 11 patients have remained off all antihypertensives, 6 required 1 medication, 1 required 2, while 5 required full blockade with phenoxybenzamine and a beta-adrenergic blocker. CONCLUSION: Surgery plays a significant role in the management of selected malignant PPGL. Resection can be effective in normalizing or significantly reducing levels of catecholamines and metanephrines, and can improve hormone-related symptoms and hypertension. Surgical resection, either complete or incomplete, is associated with durable survival despite a high rate of tumor recurrence.

A multicenter randomized controlled trial comparing pancreatic leaks after TissueLink versus SEAMGUARD after distal pancreatectomy (PLATS) NCT01051856.

BACKGROUND: Pancreatic leak is common after distal pancreatectomy. This trial sought to compare TissueLink closure of the pancreatic stump to that of SEAMGUARD. METHODS: A multicenter, prospective, trial of patients undergoing distal pancreatectomy randomized to either TissueLink or SEAMGUARD. RESULTS: Enrollment was closed early due to poor accrual. Overall, 67 patients were enrolled, 35 TissueLink and 32 SEAMGUARD. The two groups differed in American Society of Anesthesiologist class and diagnosis at baseline and were relatively balanced otherwise. Overall, 37 of 67 patients (55%) experienced a leak of any grade, 15 (46.9%) in the SEAMGUARD arm and 22 (62.9%) in the TissueLink arm (P = 0.19). The clinically significant leak rate was 17.9%; 22.9% for TissueLink and 12.5% for SEAMGUARD (P = 0.35). There were no statistically significant differences in major or any pancreatic fistula-related morbidity between the two groups. CONCLUSIONS: This is the first multicentered randomized trial evaluating leak rate after distal pancreatectomy between two common transection methods. Although a difference in leak rates was observed, it was not statistically significant and therefore does not provide evidence of the superiority of one technique over the other. Choice should remain based on surgeon comfort, experience, and pancreas characteristics.

Surgical resection of synchronously metastatic adrenocortical cancer.

INTRODUCTION: Metastatic adrenocortical carcinoma (ACC) is rapidly fatal, with few options for treatment. Patients with metachronous recurrence may benefit from surgical resection. The survival benefit in patients with hematogenous metastasis at initial presentation is unknown. METHODS: A review of all patients undergoing surgery (European Network for the Study of Adrenal Tumors) stage IV ACC between January 2000 and December 2012 from two referral centers was performed. Kaplan-Meier estimates were analyzed for disease-free and overall survival (OS). RESULTS: We identified 27 patients undergoing surgery for stage IV ACC. Metastases were present in the lung (19), liver (11), and brain (1). A complete resection (R0) was achieved in 11 patients. The median OS was improved in patients undergoing R0 versus R2 resection (860 vs. 390 days; p = 0.02). The 1- and 2-year OS was also improved in patients undergoing R0 versus R2 resection (69.9 %, 46.9 % vs. 53.0 %, 22.1 %; p = 0.02). Patients undergoing neoadjuvant therapy (eight patients) had a trend towards improved survival at 1, 2, and 5 years versus no neoadjuvant therapy (18 patients) [83.3 %, 62.5 %, 41.7 % vs. 56.8 %, 26.6 %, 8.9 %; p = 0.1]. Adjuvant therapy was associated with improved recurrence-free survival at 6 months and 1 year (67 %, 33 % vs. 40 %, 20 %; p = 0.04) but not improved OS (p = 0.63). Sex (p = 0.13), age (p = 0.95), and location of metastasis (lung, p = 0.51; liver, p = 0.67) did not correlate with OS after operative intervention. Symptoms of hormonal excess improved in 86 % of patients. CONCLUSION: Operative intervention, especially when an R0 resection can be achieved, following systemic therapy may improve outcomes, including OS, in select patients with stage IV ACC. Response to neoadjuvant chemotherapy may be of use in defining which patients may benefit from surgical intervention. Adjuvant therapy was associated with decreased recurrence but did not improve OS.

Model to predict survival after surgical resection of intrahepatic cholangiocarcinoma: the Mayo Clinic experience.

BACKGROUND: The 7th edition of the American Joint Committee on Cancer (AJCC) staging system has recently been validated and shown to predict survival in patients with intrahepatic cholangiocarcinoma (ICC). The present study attempted to investigate the validity of these findings. METHODS: A single-centre, retrospective cohort study was conducted. Histopathological restaging of disease subsequent to primary surgical resection was carried out in all consecutive ICC patients. Overall survival was compared using Kaplan-Meier estimates and log-rank tests. RESULTS: A total of 150 patients underwent surgery, 126 (84%) of whom met the present study's inclusion criteria. Of these 126 patients, 68 (54%) were female. The median length of follow-up was 4.5 years. The median patient age was 58 years (range: 24-79 years). Median body mass index was 27 kg/m(2) (range: 17-46 kg/m(2) ). Staging according to the AJCC 7th edition categorized 33 (26%) patients with stage I disease, 27 (21%) with stage II disease, five (4%) with stage III disease, and 61 (48%) with stage IVa disease. The AJCC 7th edition failed to accurately stratify survival in the current cohort; analysis revealed significantly worse survival in those with microvascular invasion, tumour size of >5 cm, grade 4 disease, multiple tumours and positive lymph nodes (P < 0.001). A negative resection margin was associated with improved survival (P < 0.001). CONCLUSIONS: The AJCC 7th edition did not accurately predict survival in patients with ICC. A multivariable model including tumour size and differentiation in addition to the criteria used in the AJCC 7th edition may offer a more accurate method of predicting survival in patients with ICC.

Laparoscopic pancreatoduodenectomy does not completely mitigate increased perioperative risks in elderly patients.

BACKGROUND: Elderly patients undergoing open pancreatoduodenectomy (OPD) are at increased risk for surgical morbidity and mortality. Whether totally laparoscopic pancreatoduodenectomy (TLPD) mitigates these risks has not been evaluated. METHODS: A retrospective review of outcomes in patients submitted to pancreatoduodenectomy during 2007-2014 was conducted (n = 860). Outcomes in elderly patients (aged ≥70 years) were compared with those in non-elderly patients with respect to risk-adjusted postoperative morbidity and mortality. Differences in outcomes between patients submitted to OPD and TLPD, respectively, were evaluated in the elderly subgroup. RESULTS: In elderly patients, the incidences of cardiac events (odds ratio [OR] 3.21, P < 0.001), respiratory events (OR 1.68, P = 0.04), delayed gastric emptying (DGE) (OR 1.73, P = 0.003), increased length of stay (LoS, 1 additional day) (P < 0.001), discharge disposition other than home (OR 8.14, P < 0.001) and blood transfusion (OR 1.48, P = 0.05) were greater than in non-elderly patients. Morbidity and mortality did not differ between the OPD and TLPD subgroups of elderly patients. In elderly patients, OPD was associated with increased DGE (OR 1.80, P = 0.03), LoS (1 additional day; P < 0.001) and blood transfusion (OR 2.89, P < 0.001) compared with TLPD. CONCLUSIONS: Elderly patients undergoing TLPD experience rates of mortality, morbidity and cardiorespiratory events similar to those in patients submitted to OPD. In elderly patients, TLPD offers benefits by decreasing DGE, LoS and blood transfusion requirements.

Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches?

OBJECTIVE: To directly compare the oncologic outcomes of TLPD and OPD in the setting of pancreatic ductal adenocarcinoma. BACKGROUND: Total laparoscopic pancreaticoduodenectomy (TLPD) has been demonstrated to be feasible and may have several potential advantages over open pancreaticoduodenectomy (OPD), including lower blood loss and shorter hospital stay. Whether potential advantages could allow patients to recover in a timelier manner and pursue adjuvant treatment options remains to be answered. METHODS: We reviewed data for all patients undergoing TLPD (N = 108) or OPD (N = 214) for pancreatic ductal adenocarcinoma at our institution between January 2008 and July 2013. RESULTS: Neoadjuvant therapy, tumor size, node positivity, and margin-positive resection were not significantly different between the 2 groups. Median length of hospital stay was significantly longer in the OPD group (9 days; range, 5-73 days) than in the TLPD group (6 days; range, 4-118 days; P < 0.001). There was a significantly higher proportion of patients in the OPD group (12%) who had a delay of greater than 90 days or who did not receive adjuvant chemotherapy at all compared with that in the TLPD group (5%; P = 0.04). There was no significant difference in overall survival between the 2 groups (P = 0.22). A significantly longer progression-free survival was seen in the TLPD group than in the OPD group (P = 0.03). CONCLUSIONS: TLPD is not only feasible in the setting of pancreatic ductal adenocarcinoma but also has advantages such as shorter hospital stay and faster recovery, allowing patients to recover in a timelier manner and pursue adjuvant treatment options. This study also demonstrated a longer progression-free survival in patients undergoing TLPD than those undergoing OPD.

Concurrent MCL1 and JUN amplification in pseudomyxoma peritonei: a comprehensive genetic profiling and survival analysis.

Pseudomyxoma peritonei (PMP) is a rare abdominal malignancy. We hypothesized that next-generation exomic sequencing would identify recurrent mutations that may have prognostic or therapeutic implications. Ten patients were selected on the basis of availability of tissue and adequate follow-up. They were treated at our institution between September 2002 and August 2004. Using next-generation exomic sequencing, we tested for mutations in 236 cancer-related genes in formalin-fixed paraffin-embedded slides. MCL1 amplification was additionally tested with immunohistochemical staining. Detectable mutations were found in 8 patients (80%). Seven patients harbored a KRAS mutation, most commonly involving codon 12. Four GNAS mutations (R201H/R201C substitutions) were also detected. MCL1 and JUN were concurrently amplified in three patients. One patient with MCL1 and JUN amplification had concurrent amplification of MYC and NFKBIA. ZNF703 was amplified in one patient. Patients with MCL1 amplification were also found to express MCL1 with immunohistochemistry, but MCL1 expression was also detected in some patients without amplification. To our knowledge, we are the first to report MCL1 and JUN coamplification in PMP. Expression of MCL1 may not be completely dependent on amplification. The prognostic and therapeutic implications of these recurrent mutational events are the subject of ongoing investigation.

Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial.

IMPORTANCE: Although conventional bariatric surgery results in weight loss, it does so with potential short-term and long-term morbidity. OBJECTIVE: To evaluate the effectiveness and safety of intermittent, reversible vagal nerve blockade therapy for obesity treatment. DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind, sham-controlled clinical trial involving 239 participants who had a body mass index of 40 to 45 or 35 to 40 and 1 or more obesity-related condition was conducted at 10 sites in the United States and Australia between May and December 2011. The 12-month blinded portion of the 5-year study was completed in January 2013. INTERVENTIONS: One hundred sixty-two patients received an active vagal nerve block device and 77 received a sham device. All participants received weight management education. MAIN OUTCOMES AND MEASURES: The coprimary efficacy objectives were to determine whether the vagal nerve block was superior in mean percentage excess weight loss to sham by a 10-point margin with at least 55% of patients in the vagal block group achieving a 20% loss and 45% achieving a 25% loss. The primary safety objective was to determine whether the rate of serious adverse events related to device, procedure, or therapy in the vagal block group was less than 15%. RESULTS: In the intent-to-treat analysis, the vagal nerve block group had a mean 24.4% excess weight loss (9.2% of their initial body weight loss) vs 15.9% excess weight loss (6.0% initial body weight loss) in the sham group. The mean difference in the percentage of the excess weight loss between groups was 8.5 percentage points (95% CI, 3.1-13.9), which did not meet the 10-point target (P = .71), although weight loss was statistically greater in the vagal nerve block group (P = .002 for treatment difference in a post hoc analysis). At 12 months, 52% of patients in the vagal nerve block group achieved 20% or more excess weight loss and 38% achieved 25% or more excess weight loss vs 32% in the sham group who achieved 20% or more loss and 23% who achieved 25% or more loss. The device, procedure, or therapy-related serious adverse event rate in the vagal nerve block group was 3.7% (95% CI, 1.4%-7.9%), significantly lower than the 15% goal. The adverse events more frequent in the vagal nerve block group were heartburn or dyspepsia and abdominal pain attributed to therapy; all were reported as mild or moderate in severity. CONCLUSION AND RELEVANCE: Among patients with morbid obesity, the use of vagal nerve block therapy compared with a sham control device did not meet either of the prespecified coprimary efficacy objectives, although weight loss in the vagal block group was statistically greater than in the sham device group. The treatment was well tolerated, having met the primary safety objective. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01327976.

Role of major vascular resection in patients with intrahepatic cholangiocarcinoma.

BACKGROUND: Historically, direct vascular extension of intrahepatic cholangiocarcinoma (ICC) has often been considered a contraindication to resection. However, recent studies have suggested safety and efficacy of hepatectomy with major vascular resection in this patient population. The aim of this study was to investigate the short and long-term clinical outcomes of patients with ICC treated with hepatectomy with or without major vascular resection. METHODS: This retrospective cohort study included all patients with ICC who underwent major liver resection between 1997 and 2011. Clinical outcomes were compared between patients treated with major hepatectomy and vascular resection (VR) and those without vascular resection (NVR). Kaplan-Meier survival estimates were used to compare overall survival (OS) between patients in VR and NVR groups. RESULTS: A total of 121 patients (median age 60; 42 % male) underwent major hepatectomy for ICC. Major vascular resection was performed in 14 (12 %) patients (IVC = 9, PV = 5). Age, sex, American Society of Anesthesiology (ASA) class, tumor size, lymph node status, and CA-19 9 were comparable (all p ≥ 0.184) between VR and NVR groups. Major postoperative complications (Dindo-Clavien ≥3) occurred in four (29 %) patients in the VR group and 17 (16 %) in the NVR group (p = 0.263). Postoperative death occurred in one patient in the VR group due to liver failure. Median OS did not differ between patients treated with and without vascular resection (32 vs. 49 months, respectively, p = 0.268). CONCLUSIONS: Hepatectomy combined with IVC or PV resection can be safely performed in patients with ICC. Major vascular resection does not affect short and long-term outcomes in this patient population.

Immediate post-resection diabetes mellitus after pancreaticoduodenectomy: incidence and risk factors.

BACKGROUND: New-onset diabetes mellitus after a pancreaticoduodenectomy (PD) remains poorly defined. The aim of this study was to define the incidence and predictive factors of immediate post-resection diabetes mellitus (iPRDM). METHODS: Retrospective review of patients undergoing PD from January 2004 through to July 2010. Immediate post-resection diabetes mellitus was defined as diabetes requiring pharmacological treatment within 30 days post-operatively. Logistic regression was conducted to identify factors predictive of iPRDM. RESULTS: Of 778 patients undergoing PD, 214 were excluded owing to pre-operative diabetes (n= 192), declined research authorization (n= 14) or death prior to hospital discharge (n= 8); the remaining 564 patients comprised the study population. iPRDM occurred in 22 patients (4%) who were more likely to be male, have pre-operative glucose intolerance, or an increased creatinine, body mass index (BMI), pre-operative glucose, operative time, tumour size or specimen length compared with patients without iPRDM (P < 0.05). On multivariate analysis, pre-operative impaired glucose intolerance (P < 0.001), pre-operative glucose ≥ 126 (P < 0.001) and specimen length (P= 0.002) were independent predictors of iPRDM. A predictive model using these three factors demonstrated a c-index of 0.842. DISCUSSION: New-onset, post-resection diabetes occurs in 4% of patients undergoing PD. Factors predictive of iPRDM include pre-operative glucose intolerance, elevated pre-operative glucose and increased specimen length. These data are important for patient education and predicting outcomes after PD.

Adjunctive radiofrequency ablation of metastatic neuroendocrine cancer to the liver complements surgical resection.

BACKGROUND: Resection of liver metastases from neuroendocrine cancer (NEC) prolongs survival and provides durable symptom relief. Not all hepatic lesions are amenable to resection, particularly when there is multifocal involvement. In this study, it was hypothesized that ablation of concomitant non-resectable NEC liver metastases is safe and salvages patients who would not have been selected for cytoreductive surgery. METHODS: Patients who underwent adjuvant ablation of NEC liver metastases between 1995 and 2008 were reviewed. NEC was classified by patient and tumour characteristics. Regression and Kaplan-Meier models were used to compare variables and generate survival curves. RESULTS: Ninety-four patients underwent hepatic resection and intra-operative ablation of metastatic NEC. The median number of lesions ablated was 3, and median size was 1.4 cm. One abscess occurred at an ablation site. Local recurrence was detected in four patients (3.8%). Overall survival was 80% and 59% at 5 and 10 years. Age, gender, tumour type, grade, primary site and need for repeat ablation had no significant association with survival. The Ki67 proliferative index was a significant predictor of decreased survival. Symptom-free survival was 34% at 3 years and 16% at 5 years, independent of the tumour grade. CONCLUSION: Concurrent ablation of NEC metastases to the liver not amenable to resection is safe and increases the candidacy of patients for cytoreductive surgery. Ablation performed intra-operatively and repeated post-operatively as needed provides significant symptom control regardless of the tumour grade.

Role of operative therapy in treatment of metastatic gastrointestinal stromal tumors.

BACKGROUND: Operative resection of metastatic gastrointestinal stromal tumors (GIST) is controversial. Current treatment strategies rely on the response to tyrosine kinase inhibitors (TKIs), with resultant individualization of operative intervention. We investigated the role of operative therapy in patients with metastatic GIST. METHODS: This retrospective cohort study included all consecutive patients treated for metastatic and/or recurrent GIST from January 2002 to June 2011. The patients were stratified by the use of operative therapy and disease response to TKI therapy. Kaplan-Meier survival analyses with log-rank comparisons tested the effects of operative therapy and the response to TKIs on survival. RESULTS: Of the 438 patients treated for GIST during the study period, 87 (median age 61 y, interquartile range 50-71; 55% male) had metastatic GIST (84% metastatic, 3% recurrent, and 13% metastatic and recurrent). Of these patients, 54 (62%) underwent operative exploration. Subtotal resection for palliative debulking (R2 resection) were performed in 19 patients; 32 patients underwent R0 resection. Operative intervention was associated with improved overall survival (OS) compared with systemic therapy alone (1 y OS, 98% versus 80% and 5-y OS, 65% versus 11%, respectively; P < 0.001). A TKI was used before resection in 32 patients. The disease response was partial in 13 patients, stable in 10, and progressive in 9. The 1- and 5-y OS and progression-free survival were strongly associated with the preoperative response to TKI and an R0 resection (all P ≤ 0.002). CONCLUSIONS: Among patients with metastatic GIST, preoperative response to TKI therapy and margin-negative resection were strongly associated with improved progression-free and OS.

Gastrointestinal stromal tumour of the duodenum: single institution experience.

BACKGROUND: Primary gastrointestinal stromal tumours (GISTs) of the duodenum are rare. The aim of this study was to review the surgical management of GISTs in this anatomically complex region. METHODS: Retrospective review from January 1999 to August 2011 of patients with primary GISTs of the duodenum. RESULTS: Forty-one patients underwent resection of duodenal GISTs. All operations were performed with intent to cure with negative margins of resection. The most common location of origin was the second portion of the duodenum. Local excision (n= 19), segmental resection with primary anastomosis (n= 11) and a pancreatoduodenectomy (n= 11) were performed. Two patients underwent an ampullectomy with local excision. Peri-operative mortality and overall morbidity were 0 and 12, respectively. Patients with high-risk GISTs (P= 0.008) and those who underwent a pancreatoduodenectomy (P= 0.021) were at a greater risk for morbidity. The median follow-up was 18 months. Eight patients developed recurrence. High-risk GISTs and neoplasms with ulceration had the greatest risk for recurrence (P= 0.017, P= 0.029 respectively). The actuarial 3- and 5-year survivals were 85% and 74%, respectively. CONCLUSION: The choice and type of resection depends on the proximity to the ampulla of Vater, involvement of adjacent organs and the ability to obtain negative margins. The morbidity depends on the type of procedure for GIST.

Lymphadenectomy in the staging and treatment of intrahepatic cholangiocarcinoma: a population-based study using the National Cancer Institute SEER database.

OBJECTIVES: Although lymphatic spread is common in intrahepatic cholangiocarcinoma (ICC), lymphadenectomy is not widely performed as part of operative resection in this disease. The objectives of this study were to assess national trends for lymphadenectomy and its impact on survival in patients with ICC. METHODS: The National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) registry was queried to identify patients with ICC (n=4893) reported during 1988-2007. Kaplan-Maier and Cox proportional hazards regression were used to analyse survival. RESULTS: Five-year overall survival (OS) was 5.2%. Lymph node (LN) status was available for 48.9% (n=2391) of patients. Histologic LN evaluation was performed in 13.5% (n=658) of patients for a median of two (interquartile range: 1-3) LNs. During the study period, the frequency of histologic LN assessment (P=0.78) did not change in liver resection patients. In the 733 resected patients, positive vs. negative LN status was associated with worse 5-year OS of 8.4% vs. 25.9%, respectively (hazard ratio=1.8; P<0.001). CONCLUSIONS: Nodal status is an important prognostic factor for survival in patients diagnosed with ICC. In the USA, few patients undergo hepatic resection with lymphadenectomy; therefore, the clinical benefit of formal lymphadenectomy in ICC remains unknown.

Retrograde endoscopic cystgastrostomy for pancreatic pseudocyst drainage after a Prior Roux-en-Y gastric bypass.

A 47-year-old woman with a history of Roux-en-Y gastric bypass developed a pancreatic pseudocyst after an episode of acute necrotizing pancreatitis. She presented with intractable abdominal pain and weight loss. Computed tomography scan revealed an enlarging pancreatic fluid collection abutting the gastric antrum. The patient underwent exploratory laparotomy, at which a Whipple procedure was aborted due to severe fibrosis and necrosis of her pancreas. Retrograde peroral endoscopic pancreatic pseudocyst drainage was successfully performed through the defunctionalized stomach.

Intraductal papillary mucinous neoplasm of the biliary tract: a real disease?

BACKGROUND: Despite increasing numbers of reports, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is not yet recognized as a unique neoplasm. The aim of the present study was to define the presence of BT-IPMN in a large series of resected biliary neoplasms. METHODS: From May 1994 to December 2006, BT-IPMN cases were identified by reviewing pathology specimens of all resected cholangiocarcinomas and other biliary neoplasms when cystic, papillary or mucinous features were cited in pathology reports. RESULTS: BT-IPMN was identified in 23 out of 253 (9%) specimens using the strict histopathological criteria of IPMN. The most common presenting symptom was abdominal discomfort which was present in 15 patients (65%). Only one of the original operative pathology reports used the term IPMN; 16 (70%) used the terms cystic, mucinous and/or papillary. BT-IPMN was isolated to non-hilar extra-hepatic ducts in 12 (52%), intra-hepatic ducts in 6 (26%) and hilar extra-hepatic ducts in 5 patients (22%). Carcinoma was found in association with BT-IPMN in 19 patients (83%); 5-year survival was 38% after resection. CONCLUSION: BT-IPMN occurs throughout the intra- and extra-hepatic biliary system and can be identified readily as a unique neoplasm. Broader acceptance of BT-IPMN as a unique neoplasm may lead to a better understanding of the pathogenesis of biliary malignancies.

Implementation of prospective, surgeon-driven, risk-based pathway for pancreatoduodenectomy results in improved clinical outcomes and first year cost savings of $1 million.

BACKGROUND: Morbidity and costs after pancreatoduodenectomy remain increased, driven by postoperative pancreatic fistula (POPF). A risk-based pathway for pancreatoduodenectomy (RBP-PD) was implemented and the clinical and cost outcomes compared with that of our historic practice. METHODS: Prospective clinical and cost outcomes for our RBP-PD cohort treated from September 2014 to September 2015 were compared with a previously published cohort of pancreatoduodenectomies from January 2007 to February 2014. RESULTS: A total of 128 RBP-PD cases were compared with 808 historic controls. Apart from less blood loss, there were no significant clinical differences between the 2 groups. Overall POPF rate did not change. Average duration of stay decreased to 10 days from 12 (P < .001) despite similar readmission rates. Postsurgical interventional radiology procedures decreased to 18.0% from 26.4% (P = .048). Utilization of and duration of stay in monitored care decreased to 23.4% from 35.6% (P < .01) and to 1 day from 3 (P < .01). On multivariable analysis RBP-PD was independently associated with decreased odds of higher postoperative pancreatic fistula grade, monitored care, and prolonged duration of stay. Inpatient cost of care decreased $6,387 per patient (-11.1%, P = .016), and total 30-day costs decreased $8,565 per patient (-13.7%, P = .01), representing a total 30-day cost savings of $1.1 million. CONCLUSION: RBP-PD significantly improved patient outcomes, decreased costs of care, and likely has applicability for surgical care beyond pancreatoduodenectomy.

Decreasing pancreatic leak after distal pancreatectomy: saline-coupled radiofrequency ablation in a porcine model.

Despite marked improvements in pancreatic surgery, the high incidence and morbidity of pancreatic leak after resection has remained unchanged. The objective of this study was to evaluate the role of saline-coupled radiofrequency ablation (TissueLink) as an alternative to traditional methods of stump closure in an animal model of distal pancreatectomy. Forty swine were randomized after pancreatic transection and remnant stump was either oversewn in a traditional fashion (control) or treated with the device alone (TissueLink). Animals were killed and necropsied at 3 or 5 weeks postoperatively. Primary endpoints were the development of a pancreatic fistula defined as dye extravasation from the remnant duct, presence of undrained amylase-rich fluid collections/abscess, and greater than threefold drain/serum amylase after the third postoperative day. The incidence of pancreatic leak in the TissueLink group was 5.5 vs 42% in the control group (p = 0.01). There were no differences in operative time or other clinical parameters measured. Histologic analysis of the remnant pancreatic stumps confirmed our results. These data support our hypothesis that saline-coupled radiofrequency ablation leads to obliteration of ducts with a resultant decrease in pancreatic leak and subsequent complications. This technology may play a substantial role in preventing this dreaded complication in the clinical setting.

A two-decade spectrum of revisional bariatric surgery at a tertiary referral center.

BACKGROUND: Ineffective weight loss or complications of previous bariatric surgery often require revisional bariatric procedures. Our aim was to define the indications, operative approach, and outcomes of revisional bariatric procedures during 2 decades at a tertiary center. METHODS: From our prospective database (n = 1584), including 1985-2004, 218 patients (14%) underwent revisional bariatric procedures. Follow-up (mean 7 yr, range 1 mo to 19 yr) data obtained from patient records and questionnaires were current for 98%. Patients were grouped according to operative indications: group 1, unsatisfactory weight loss (n = 97); group 2, mechanical/symptomatic complications (n = 95); and group 3, severe nutritional/metabolic problems (n = 26). RESULTS: The operative mortality rate was 0.9% (1 case each of pulmonary embolus and cardiac arrest). The serious operative morbidity rate was 26% (wound infection in 13%, leak in 3%, pulmonary embolus in 2%, anemia/hemorrhage in 2%, pneumonia/prolonged ventilation in 2%, and other in 4%). Of the 218 patients, 94% underwent conversion to, or revision of, Roux-en-y gastric bypass. Group 1 achieved substantial weight reduction with a mean body mass index from 51 +/- 1 to 38 +/- 1 kg/m(2), the complications resolved in 88% of group 2, and the nutritional/metabolic problems resolved in 79% of group 3. Patients who underwent revisional surgery 1990 were more likely to present with mechanical/symptomatic/metabolic complications than for unsuccessful weight loss (P <.001). CONCLUSIONS: Revisional bariatric surgery is safe and effective in experienced centers. Complications (mechanical/symptomatic/nutritional) or unsatisfactory weight loss after primary bariatric procedures can be treated effectively with revision to Roux-en-y gastric bypass.

Complications and Outcomes Associated With Surgical Management of Renal Cell Carcinoma Involving the Liver: A Matched Cohort Study.

OBJECTIVE: To assess the safety and utility of more aggressive surgical resection of renal cell carcinoma involving the liver at the time of nephrectomy. MATERIALS AND METHODS: We identified 34 cases at our institution where patients underwent simultaneous nephrectomy and hepatic resection for direct hepatic invasion (n = 17) or metastatic renal cell carcinoma (n = 21). Perioperative outcomes and complication rates were compared with a matched referent cohort (n = 68) undergoing simultaneous nephrectomy and resection of non-hepatic locally invasive or metastatic disease. RESULTS: Of the 34 cases, 17 (50%) patients underwent hepatic resection for pT4 liver involvement and 21 (62%) patients underwent simultaneous nephrectomy and hepatic metastasectomy. Deep vein thrombosis occurred more frequently following hepatic resection (15% vs 1%, P = .02); however, no significant differences were noted in Clavien grade 3-4 complications (12% vs 3%, P = .10) or perioperative mortality (3% vs 0%, P = .67). Two-year cancer-specific and overall survival for patients undergoing hepatic resection and non-hepatic resection were 40% and 29% (hazard ratio: 0.72, P = .2) and 40% and 28% (hazard ratio: 0.80, P = .30), respectively. CONCLUSION: In carefully selected patients, hepatic resection at the time of nephrectomy is associated with a higher risk of deep vein thrombosis and may be associated with a trend toward an increased risk of short-term Clavien IV complications; however, perioperative and overall mortality are comparable with those in matched patients undergoing surgical resection of locally advanced or metastatic disease involving non-hepatic organs.