RESUMEN
BACKGROUND: Use of extended pharmacologic thromboprophylaxis after major abdominopelvic cancer surgery should depend on best-available scientific evidence and patients' informed preferences. We developed a risk-stratified patient decision aid to facilitate shared decision-making and sought to evaluate its effect on decision-making quality regarding use of extended thromboprophylaxis. METHODS: We enrolled patients undergoing major abdominopelvic cancer surgery at an academic tertiary care centre in this pre-post study. We evaluated change in decisional conflict, readiness to decide, decision-making confidence, and change in patient knowledge. Participants were provided the appropriate risk-stratified decision aid (according to their Caprini score) in either the preoperative or postoperative setting. A sample size calculation determined that we required 17 patients to demonstrate whether the decision aid meaningfully reduced decisional conflict. We used the Wilcoxon matched-pairs signed ranks test for interval scaled measures. RESULTS: We included 17 participants. The decision aid significantly reduced decisional conflict (median decisional conflict score 2.37 [range 1.00-3.81] v. 1.3 [range 1.00-3.25], p < 0.01). With the decision aid, participants had high confidence (median 86.4 [range 15.91-100]) and felt highly prepared to make a decision (median 90 [range 55-100]). Median knowledge scores increased from 50% (range 0%-100%) to 75% (range 25%-100%). CONCLUSION: Our risk-stratified, evidence-based decision aid on extended thromboprophylaxis after major abdominopelvic surgery significantly improved decision-making quality. Further research is needed to evaluate the usability and feasibility of this decision aid in the perioperative setting.
Asunto(s)
Toma de Decisiones Conjunta , Técnicas de Apoyo para la Decisión , Humanos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Medición de Riesgo , Complicaciones Posoperatorias/prevención & control , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Neoplasias Abdominales/cirugía , Adulto , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificaciónRESUMEN
OBJECTIVE: To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND: Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS: Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS: Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%]. CONCLUSION: IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.
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Transfusión Sanguínea , Hepatectomía , Humanos , Transfusión de Sangre Autóloga , Transfusión de Eritrocitos , HígadoRESUMEN
OBJECTIVE: To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy. BACKGROUND: SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery. METHODS: Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative. RESULTS: Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals. CONCLUSIONS: SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.
Asunto(s)
Pancreatectomía , Sepsis , Humanos , Pancreatectomía/efectos adversos , Pancreaticoduodenectomía , Complicaciones Posoperatorias/etiología , Estudios de Factibilidad , Estudios Retrospectivos , Sepsis/etiología , Readmisión del PacienteRESUMEN
OBJECTIVE: To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis. BACKGROUND: Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined. METHODS: Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent. RESULTS: Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888). CONCLUSIONS: Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.
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Profilaxis Antibiótica , Infección de la Herida Quirúrgica , Humanos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/tratamiento farmacológico , Profilaxis Antibiótica/métodos , Pancreaticoduodenectomía/efectos adversos , Cefoxitina/uso terapéutico , Fístula Pancreática/etiología , Fístula Pancreática/prevención & control , Combinación Piperacilina y Tazobactam/uso terapéutico , Estudios Retrospectivos , Antibacterianos/uso terapéuticoRESUMEN
Importance: Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood. Objective: To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics. Design, Setting, and Participants: Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment. Intervention: The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care). Main Outcomes and Measures: The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program. Results: The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32). Conclusions and Relevance: In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy. Trial Registration: ClinicalTrials.gov Identifier: NCT03269994.
Asunto(s)
Cefoxitina , Sepsis , Masculino , Adulto , Humanos , Anciano , Cefoxitina/uso terapéutico , Piperacilina/uso terapéutico , Pancreaticoduodenectomía/efectos adversos , Fístula Pancreática/tratamiento farmacológico , Ácido Penicilánico/uso terapéutico , Antibacterianos/uso terapéutico , Combinación Piperacilina y Tazobactam/uso terapéutico , Infección de la Herida Quirúrgica/prevención & control , Sepsis/tratamiento farmacológicoRESUMEN
BACKGROUND: Margin-negative (R0) resection is the strongest positive prognostic factor in perihilar cholangiocarcinoma (PHC). Due to its anatomic location, the caudate lobe is frequently involved in PHC. This review aimed to examine the impact of caudate lobe resection (CLR) in addition to hepatectomy and bile duct resection for patients with PHC. METHODS: The MEDLINE, EMBASE, and Cochrane databases were systematically reviewed from inception to October 2021 to identify studies comparing patients undergoing surgical resection with hepatectomy and bile duct resection with or without CLR for treatment of PHC. Outcomes included the proportion of patients achieving R0 resection, overall survival (OS), and perioperative morbidity. RESULTS: Altogether, 949 studies were screened. The review included eight observational studies reporting on 1137 patients. The patients who underwent CLR had a higher likelihood of R0 resection (odds ratio [OR], 5.85; 95% confidence interval [CI], 2.64-12.95) and a better OS (hazard ratio [HR], 0.65; 95% CI, 0.54-0.79) than those who did not. The use of CLR did not increase the risk of perioperative morbidity (OR, 1.03; 95% CI, 0.65-1.63). CONCLUSIONS: Given the higher likelihood of R0 resection, improved OS, and no apparent increase in perioperative morbidity, this review supports routine caudate lobectomy in the surgical management of PHC. These results should be interpreted with caution given the lack of high-quality prospective data and the high probability of selection bias.
Asunto(s)
Neoplasias de los Conductos Biliares , Colangiocarcinoma , Tumor de Klatskin , Neoplasias de los Conductos Biliares/patología , Colangiocarcinoma/cirugía , Hepatectomía , Humanos , Tumor de Klatskin/patología , Márgenes de Escisión , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Perihilar cholangiocarcinoma (PHC) is a rare malignancy that arises at the biliary confluence. Achieving a margin-negative resection (R0) is challenging given the anatomic location of tumors and remains the most important prognostic indicator of long-term survival. The objective of this study is to review the impact of intraoperative revision of positive biliary margins in PHC on oncologic outcomes. PATIENTS AND METHODS: Electronic databases were searched from inception to October 2021. Studies comparing three types of patients undergoing resection of PHC with intraoperative frozen section of the proximal and/or distal bile ducts were identified: those who were margin-negative (R0), those with an initially positive margin who had revised negative margins (R1R0), and those with a persistently positive margin with or without revision of a positive margin (R1). The primary outcome was overall survival (OS). Secondary outcomes included risk of postoperative complication. RESULTS: A total of 449 studies were screened. Ten retrospective observational studies reporting on 1955 patients were included. Patients undergoing successful revision of a positive proximal and/or distal bile duct margin (R1R0) had similar OS to those with a primary margin-negative resection (R0) [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.72-1.19, p = 0.56, I2 = 84%], and significantly better OS than patients with a positive final bile duct margin (R1) (HR 0.52, 95% CI 0.34-0.79, p = 0.002, I2 = 0%). There was no increase in the risk of postoperative complications associated with additional resection, although postoperative morbidity was inconsistently reported. CONCLUSIONS: This review supports routine intraoperative biliary margin evaluation during resection of PHC with revision if technically feasible.
Asunto(s)
Neoplasias de los Conductos Biliares , Colangiocarcinoma , Tumor de Klatskin , Neoplasias de los Conductos Biliares/patología , Colangiocarcinoma/cirugía , Secciones por Congelación , Humanos , Tumor de Klatskin/patología , Márgenes de Escisión , Recurrencia Local de Neoplasia/patología , Estudios RetrospectivosRESUMEN
BACKGROUND: Surgical site infections (SSI) cause significant morbidity. Prophylactic negative pressure wound therapy (NPWT) may promote wound healing and decrease SSI. The objective is to evaluate the effect of prophylactic NPWT on SSI in patients undergoing pancreatectomy. METHODS: Electronic databases were searched from inception until April 2022. Randomized controlled trials (RCTs) comparing prophylactic NPWT to standard dressings in patients undergoing pancreatectomy were included. The primary outcome was the risk of SSI. Secondary outcomes included the risk of superficial and deep SSI and organ space infection (OSI). Random effects models were used for meta-analysis. RESULTS: Four single-centre RCTs including 309 patients were identified. Three studies were industry-sponsored, and two were at high risk of bias. There was no significant difference in the risk of SSI in patients receiving NPWT vs. control (14% vs. 21%, RR = 0.72, 95%CI = 0.32-1.60, p = 0.42, I2 = 53%). Likewise, there was no significant difference in the risk of superficial and deep SSI or OSI. No significant difference was found on subgroup analysis of patients at high risk of wound infection or on sensitivity analysis of studies at low risk of bias. CONCLUSION: Prophylactic NPWT does not significantly decrease the risk of SSI among patients undergoing pancreatectomy. Insufficient evidence exists to justify the routine use of NPWT.
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Terapia de Presión Negativa para Heridas , Humanos , Terapia de Presión Negativa para Heridas/efectos adversos , Infección de la Herida Quirúrgica/prevención & control , Vendajes , Cicatrización de Heridas , Pancreatectomía/efectos adversosRESUMEN
BACKGROUND: Post-operative pancreatic fistula (POPF) is the most significant cause of morbidity following distal pancreatectomy. Hemopatch™ is a thin, bovine collagen-based hemostatic sealant. We hypothesized that application of Hemopatch™ to the pancreatic stump following distal pancreatectomy would decrease the incidence of clinically-significant POPF. METHODS: We conducted a prospective, single-arm, multicentre phase II study of application of Hemopatch™ to the pancreatic stump following distal pancreatectomy. The primary outcome was clinically-significant POPF within 90 days of surgery. A sample size of 52 patients was required to demonstrate a 50% relative reduction in Grade B/C POPF from a baseline incidence of 20%, with a type I error of 0.2 and power of 0.75. Secondary outcomes included incidence of POPF (all grades), 90-day mortality, 90-day morbidity, re-interventions, and length of stay. RESULTS: Adequate fixation Hemopatch™ to the pancreatic stump was successful in all cases. The rate of grade B/C POPF was 25% (95%CI: 14.0-39.0%). There was no significant difference in the incidence of grade B/C POPF compared to the historical baseline (p = 0.46). The 90-day incidence of Clavien-Dindo grade ≥3 complications was 26.9% (95%CI: 15.6-41.0%). CONCLUSION: The use of Hemopatch™ was not associated with a decreased incidence of clinically-significant POPF compared to historical rates. (NCT03410914).
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Pancreatectomía , Fístula Pancreática , Animales , Bovinos , Humanos , Páncreas , Pancreatectomía/efectos adversos , Fístula Pancreática/epidemiología , Fístula Pancreática/etiología , Fístula Pancreática/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD. METHODS: All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF). RESULTS: In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44-0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance. CONCLUSIONS: The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.
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Drenaje/métodos , Enfermedades Pancreáticas/cirugía , Fístula Pancreática/etiología , Pancreaticoduodenectomía , Anciano , Bases de Datos Factuales , Drenaje/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fístula Pancreática/prevención & control , Pancreaticoduodenectomía/efectos adversos , Cavidad Peritoneal/cirugía , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation.
Asunto(s)
Drenaje , Pancreatectomía , Humanos , Tiempo de Internación , Páncreas/cirugía , Pancreatectomía/efectos adversos , Fístula Pancreática/epidemiología , Fístula Pancreática/etiología , Pancreaticoduodenectomía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis. METHODS: Consecutive patients who underwent liver resection at one institution (2010-2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression. RESULTS: A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H2O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068-0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64-5.18, p = 0.0003), preoperative hemoglobin < 125 g/L (OR 6.02, 95% CI 3.44-10.56, p < 0.0001), and underlying liver disease (OR 2.24, 95% CI 1.27-3.95, p = 0.0051) were significantly associated with perioperative RBC transfusion. CONCLUSION: Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.
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Pérdida de Sangre Quirúrgica/prevención & control , Transfusión de Eritrocitos/estadística & datos numéricos , Hepatectomía/efectos adversos , Hipovolemia/etiología , Flebotomía/métodos , Presión Venosa Central/fisiología , Transfusión de Eritrocitos/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Hipovolemia/fisiopatología , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de RiesgoAsunto(s)
Transfusión de Eritrocitos , Accidente Cerebrovascular , Humanos , Flebotomía , Hígado/cirugíaRESUMEN
BACKGROUND AND OBJECTIVES: Although race and socioeconomic status have been shown to affect outcomes in pancreatic ductal adenocarcinoma (PDAC), the impact of rural residence on the delivery of adjuvant therapy (AT) has not been studied. METHODS: Patients with resected PDAC were identified using the National Cancer Database (NCDB). Individuals were classified as living in a metro area, urban/rural adjacent to a metro area (URA), and urban/rural remote (URR) area. Multivariate logistic regression was used to assess geographic inhabitance as a predictor of receiving AT. RESULTS: A total of 32 521 individuals who underwent pancreatectomy for PDAC were identified. Univariate analysis demonstrated individuals in URR areas were less likely to receive adjuvant chemotherapy (ACT) than those living in URA or metro areas (55.3% vs 55.6% vs 58.8%, P = 0.011). However on multivariate analysis URR inhabitance was no longer a predictor of ACT (OR = 0.911 P = 0.125) or ART (OR = 0.953 P = 0.462). Cox proportional hazard modeling demonstrated URR inhabitance remained independently associated with poor OS (HR 1.076; 95% CI [1.008, 1.149], P < 0.029). CONCLUSIONS: URR inhabitance does not impact access to AT, however it is independently associated with a decreased OS. Attention must be focused on optimizing oncologic care to patients with disparate access to healthcare.
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Adenocarcinoma/terapia , Carcinoma Ductal Pancreático/terapia , Quimioterapia Adyuvante/estadística & datos numéricos , Pancreatectomía , Radioterapia Adyuvante/estadística & datos numéricos , Población Rural , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Factores de Edad , Anciano , Carcinoma Ductal Pancreático/mortalidad , Carcinoma Ductal Pancreático/patología , Bases de Datos Factuales , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud , Humanos , Masculino , Márgenes de Escisión , Medicaid , Pacientes no Asegurados/estadística & datos numéricos , Análisis Multivariante , Estadificación de Neoplasias , Modelos de Riesgos Proporcionales , Grupos Raciales , Tiempo de Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: There is significant interest and controversy surrounding the effect of restrictive fluid management on outcomes in major gastrointestinal surgery. This has been most studied in colorectal surgery, although the literature relating to pancreaticoduodenectomy (PD) patients is growing. The aim of this paper was to generate a comprehensive review of the available evidence for restrictive perioperative fluid management strategies and outcomes in PD. METHODS: MEDLINE/PubMed, Embase, and the Cochrane Library were searched from inception to April 2017. A review protocol was utilized and registered with PROSPERO. Primary citations that evaluated perioperative fluid management in PD, including those as part of a clinical pathway, were considered. The primary outcome was postoperative pancreatic fistula (POPF). Secondary outcomes included delayed gastric emptying (DGE), complication rate, length of stay (LOS), mortality, and readmission. RESULTS: A total of six studies involving 846 patients were included (2009-2015), of which four were RCTs. Pooled analysis of RCTs and high-quality observational studies found no effect of restrictive intraoperative fluid management on POPF, DGE, complication rate, LOS, mortality, and readmission. Only one study assessed postoperative fluid management exclusively and found prolonged LOS in patients in the restricted fluid group. CONCLUSION: Based on results of RCTs and high-quality observational studies, intraoperative fluid restriction in PD has not been shown to significantly affect postoperative outcomes. There are too few studies assessing postoperative fluid management to draw conclusions at this time.
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Pancreatectomía/efectos adversos , Pancreatectomía/métodos , Fístula Pancreática/etiología , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/métodos , Anastomosis Quirúrgica/efectos adversos , Vaciamiento Gástrico , Gastroparesia/etiología , Humanos , Tiempo de Internación , Readmisión del Paciente , Complicaciones Posoperatorias/etiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
BACKGROUND: The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has not be quantified. The aim of this study was to determine the uptake of the ISGPF definition and evaluate its use in the surgical literature. METHODS: A sample of primary studies, review articles, and textbooks were identified through screening of literature searches. Included citations were assessed for their definition of POPF and use of the ISGPF criteria. RESULTS: From 2006 to 2009, 6%-63% of primary papers were compliant with the ISGPF definition compared to 84%-98% from 2010 onwards. Of the primary studies compliant with the ISGPF criteria, 36% focused on grade B and C fistula and 15% did not report grade A fistula. 88% of European papers used the criteria compared to 77% and 72% of Asian and North American papers, respectively (p = 0.033). 46% of review articles and textbooks did not define POPF. Among those that defined POPF, 74% cited the ISGPF definition exclusively while 26% mentioned other definitions. CONCLUSION: The ISGPF criteria have been widely adopted and accepted as the standard for defining POPF, although the utility of grade A fistulas is questionable.
Asunto(s)
Fístula Pancreática/clasificación , Fístula Pancreática/diagnóstico , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/diagnóstico , Adhesión a Directriz , Humanos , Fístula Pancreática/etiología , Complicaciones Posoperatorias/etiología , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en MedicinaRESUMEN
BACKGROUND: Both fistula risk score (FRS) and drain amylase in postoperative day 1 (POD1DA) have been promoted as tools to guide placement and removal of surgical drains following pancreaticoduodenectomy (PD). However, their individual utility has not been compared. METHODS: A consecutive cohort of PD patients from 2013 to 2015 were identified from a prospectively collected institutional database. Pearson correlation coefficients and receiver operating characteristic (ROC) curves were calculated for FRS (negligible/low vs. moderate/high) and POD1DA of 600 U/L and 5000 U/L as predictors of clinically relevant postoperative pancreatic fistula (CR-POPF). RESULTS: The incidence of CR-POPF was 27% in 216 patients. Sensitivity and specificity of FRS, POD1DA >600 U/L, and POD1DA >5000 U/L for predicting CR-POPF were 83% and 55%, 94% and 60%, 33% and 90%. The ROC area under the curve (AUC) for POD1DA >600 U/L (0.764) and FRS (0.749) were not significantly different (p = 0.713). However, POD1DA >5000 U/L (0.615) was significantly worse at predicting CR-POPF (p = 0.015). When FRS and POD1DA >600 U/L were combined; there was no improvement (p = 0.624). DISCUSSION: FRS and POD1DA are equally accurate in predicting CR-POPF. Patients with negligible/low FRS or POD1DA <600 U/L should be considered for drain removal.
Asunto(s)
Amilasas/metabolismo , Pruebas Enzimáticas Clínicas , Técnicas de Apoyo para la Decisión , Drenaje/métodos , Fístula Pancreática/etiología , Pancreaticoduodenectomía/efectos adversos , Anciano , Área Bajo la Curva , Biomarcadores/metabolismo , Bases de Datos Factuales , Remoción de Dispositivos , Drenaje/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fístula Pancreática/diagnóstico , Fístula Pancreática/prevención & control , Valor Predictivo de las Pruebas , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Fistula Risk Score (FRS) is a previously developed tool to assess the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD). METHODS: Prospectively collected databases from 4 university affiliated and non-affiliated HPB centers in United States and Canada were used. The influence of individual baseline characteristics, FRS and FRS group on CR-POPF was assessed in univariate and multivariate analyses. FRS calculator performance was assessed using a C-statistic. RESULTS: 444 patients were identified. Pathology, soft pancreas texture and pancreatic duct size were associated with CR-POPF rates (p < 0.001 for each); EBL was not (p = 0.067). The negligible risk group consisted of 50 (11.3%) patients, low risk of 118 (26.6%), moderate 234 (52.7%) and high risk group of 42 (9.5%) patients. The overall rate of CR-POPF was 20%. Of the patients in the negligible risk group, 2% developed CR-POPF, 13.6% of the low risk, 23.1% moderate and 42.9% in the high risk group (p < 0.001). Overall C-statistic was 0.719. CONCLUSION: FRS is robust and able to stratify the risk of developing CR-POPF following PD in diverse North American academic and non-academic institutions. The FRS should be used in research and to guide clinical management of patients post PD in these institutions.