Non-neoplastic epithelial cysts of the pancreas: a rare, benign entity.

OBJECTIVES: With the increased use of cross-sectional radiologic imaging in recent years, cystic lesions of the pancreas are being diagnosed with greater frequency. While pseuodocysts have historically accounted for the majority of benign pancreatic cysts, there are a number of rare, benign cystic lesions of the pancreas that can mimic neoplastic cysts. The objective of this study was to review a single institution's experience with these benign cystic lesions of the pancreas. METHODS: We conducted a retrospective analysis of all patients who underwent surgical resection for pancreatic disease from 2005 to 2012 at our institution. Out of a total of 947 pancreatic resections, we identified those cases performed for cystic disease, and focused upon the clinicopathologic data of patients with non-neoplastic pancreatic cysts. RESULTS: Of the 947 pancreatic resections, 256 (27%) were performed for cystic disease. Sixteen cases (6.3%) out of the total of 256 pancreatic operations performed for cystic disease were found to have non-neoplastic cystic lesions of the pancreas. Preoperative imaging revealed primary lesions in all patients, eight of which were found incidentally. Of these lesions, 14 were suspected preoperatively to be mucinous neoplasms and two to harbor pancreatic adenocarcinoma. However, postoperative pathology revealed eight patients with ductal retention cysts, three squamoid cysts, one mucinous non-neoplastic cyst, one congenital ciliated foregut cyst, one lymphoepithelial cyst, and two endometrial cysts. Two patients had complications postoperatively, one pancreatic fistula and one SMV thrombosis. Both complications resolved with conservative management. CONCLUSIONS: Non-neoplastic epithelial pancreatic cysts are rare, benign lesions. In our institutional experience, these lesions are often indistinguishable from cystic neoplasms of the pancreas preoperatively. As such, many of these lesions are resected unknowingly. It is important for the clinician to be well informed of the nature of these lesions, in the hopes to avoid unnecessary resection whenever possible.

Does resident experience affect outcomes in complex abdominal surgery? Pancreaticoduodenectomy as an example.

OBJECTIVES: Understanding the factors contributing to improved postoperative patient outcomes remains paramount. For complex abdominal operations such as pancreaticoduodenectomy (PD), the influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood. METHODS: We reviewed perioperative outcomes after PD at a single high-volume center between 2006 and 2012. Resident participation and outcomes were collected in a prospectively maintained database. Resident experience was defined as postgraduate year (PGY) and number of PDs performed. RESULTS: Forty-three residents and four attending surgeons completed 686 PDs. The overall complication rate was 44 %; PD-specific complications (defined as pancreatic fistula, delayed gastric emptying, intraabdominal abscess, wound infection, and bile leak) occurred in 28 % of patients. The overall complication rates were similar when comparing PGY 4 to PGY 5 residents (55.3 vs. 43.0 %; p > 0.05). On univariate analysis, there was a difference in PD-specific complications seen between a PGY 4 as compared to a PGY 5 resident (44 vs. 27 %, respectively; p = 0.016). However, this was not statistically significant when adjusted for attending surgeon. Logistic regression demonstrated that as residents perform more cases, PD-specific complications decrease (OR = 0.97; p < 0.01). For a resident's first PD case, the predicted probability of a PD-specific complication is 27 %; this rate decreases to 19 % by resident case number 15. CONCLUSIONS: Complex cases, such as PD, provide unparalleled learning opportunities and remain an important component of surgical training. We highlight the impact of resident involvement in complex abdominal operations, demonstrating for the first time that as residents build experience with PD, patient outcomes improve. This is consistent with volume-outcome relationships for attending physicians and high-volume hospitals. Maximizing resident repetitive exposure to complex procedures benefits both the patient and the trainee.

Splenic vein thrombosis is associated with an increase in pancreas-specific complications and reduced survival in patients undergoing distal pancreatectomy for pancreatic exocrine cancer.

Distal pancreatectomy and splenectomy (DPS) is the procedure of choice for the surgical treatment of pancreatic exocrine cancer localized to the body and tail of the pancreas. Splenic vein thrombosis (SVT) can occur in patients with malignant pancreatic exocrine tumors secondary to direct tumor invasion or compression of the splenic vein by mass effect. This study examines the effect of preoperative SVT on postoperative outcomes. In this retrospective cohort study, we queried our pancreatic surgery database to identify patients who underwent DPS from October 2005 to June 2011. These cases were evaluated for evidence of preoperative SVT on clinical records and cross-sectional imaging (CT,MRI, endoscopic US). Outcomes for patients with and without SVT were compared. From an overall cohort of 285 consecutive patients who underwent DPS during the study period, data were evaluated for 70 subjects who underwent surgery for pancreatic exocrine cancer (27 with SVT, 43 without SVT). The preoperative demographics and co-morbidities were similar between the groups, except the average age was higher for those without SVT (p<0.05). The median estimated blood loss was significantly higher in the SVT group (675 versus 250 ml, p=<0.001).While the overall morbidity rates were similar between the two groups (48 % SVT versus 56% no SVT, p=NS), the group with SVT had a significantly higher rate of pancreas-specific complications, including pancreatic fistula (33 versus 7 %,p<0.01) and delayed gastric emptying (15 versus 0%, p<0.02). Hospital readmission rates were similar between the groups(30 versus 28 %, p=NS). Patients without SVT had a trend toward longer median survival (40 versus 20.8 months),although the difference was not statistically significant (p=0.1). DPS for pancreatic ductal adenocarcinoma can be performed safely in patients with SVT, but with higher intraoperative blood loss, increased pancreas-specific complications, and a trend towards lower long-term survival rates. This paper was presented as a poster at the 53rd annual meeting of the Society for Surgery of the Alimentary Tract and at the 46th annual meeting of the Pancreas Club, San Diego, CA, May 2012.

Preoperative imaging for resectable periampullary cancer: clinicopathologic implications of reported radiographic findings.

BACKGROUND: High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. METHODS: We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. RESULTS: There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). DISCUSSION: While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy.

BACKGROUND: The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254-257, 12). METHODS: We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period. RESULTS: Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage. CONCLUSIONS: Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.

Serum blood urea nitrogen and serum albumin on the first postoperative day predict pancreatic fistula and major complications after pancreaticoduodenectomy.

INTRODUCTION: Pancreaticoduodenectomy (PD) has a high morbidity rate. Previous work has shown that hypoalbuminemia on postoperative day 1 (POD) to be contributory to post-esophagectomy complications. We set out to determine the impact of blood urea nitrogen (BUN) and albumin on POD 1 for patients undergoing PD. METHODS: We examined 446 consecutive patients who underwent PD at the Thomas Jefferson University Hospital between January 1, 2000 and December 31, 2008. Complications were graded using the Clavien scale. We examined the incidence of complications based on POD 1 albumin <2.5 versus ≥2.5 mg/dl, as well as POD 1 BUN <10 vs. ≥10 g/dL. RESULTS: Patients with a BUN <10 had a significantly decreased risk of any complication (p < 0.001), serious complication (p < 0.001), and pancreatic fistula (p = 0.011). On multivariate analysis, BUN ≥ 10 was the most significant predictor of grade III or above complication (p = 0.0019, hazard ration (HR) = 2.7) and pancreatic fistula (p = 0.016, HR = 2.6). POD 1 albumin <2.5 mg/dl was also an independent predictor of serious complication (p = 0.01, HR = 2.3). Patients with both risk factors had a 31 % chance of developing serious complications and 18.5 % risk of developing pancreatic fistula, while those patients with neither risk factor had a 6.5 and 3.6 % risk, respectively. CONCLUSION: Serum albumin and BUN on POD 1 are important predictors of perioperative morbidity following PD. These low-cost and easily accessible tests can be used as a prognostic tool to predict adverse surgical outcomes.

A dual-institution randomized controlled trial of remnant closure after distal pancreatectomy: does the addition of a falciform patch and fibrin glue improve outcomes?

OBJECTIVE: The objective of the study was to assess the efficacy of two pancreatic remnant closure techniques following distal pancreatectomy: (1) stapled or sutured closure versus (2) stapled or sutured closure plus falciform patch and fibrin glue reinforcement in the setting of a prospective randomized trial, with the primary endpoint being pancreatic fistula. Pancreatic stump leak following left-sided pancreatic resection (distal pancreatectomy) remains common. Despite multiple and varied techniques for closure, the reported leak rate varies up to 30 %. A retrospective analysis by Iannitti et al. (J Am Coll Surg 203(6):857-864, 2006) detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fibrin glue. METHODS: Between April 2008 and October 2011, all willing patients scheduled to undergo distal pancreatectomy at the authors' institutions were consented and enrolled at the preoperative office visit. Patients were intraoperatively stratified as having hard or soft glands and randomized to one of two groups: (1) closure utilizing stapling or suturing (SS) versus (2) stapled or sutured plus falciform ligament patch and fibrin glue (FF). The trial design and power analysis (α = 0.05, ß = 0.2, power 80 %, chi-square test) hypothesized that the FF intervention would reduce the primary endpoint (pancreatic fistula) from 30 % to 15 % and targeted an accrual goal of 190 patients. Secondary endpoints included length of postoperative hospital stay, 30-day mortality, hospital readmission, and ISGPF fistula grade (A, B, and C). RESULTS: The trial accrued 109 patients, 55 in the SS group and 54 in the FF group. Enrollment was closed prior to the target accrual, following an interim analysis and futility calculation. Due to insufficient enrollment, patients stratified as having a hard gland were excluded (n = 8) from analysis, leaving 101 patients in the soft stratum. The overall pancreatic leak rate was 19.8 % (20 patients) for patients with soft glands. Patients randomized to the FF group had a leak rate of 20 %, as compared with 19.6 % in the SS group (p = 1.000). Fistula grades in both groups were identical: 1A, 8B, and 1C in the FF group as compared to 1A, 8B, and 1C in the SS group. Complication rates were comparable between the two groups. The median length of postoperative hospital stay was 5 days in both groups. There was a trend towards a higher 30-day readmission rate in the FF group (28 % vs. 17.6 %, p = 0.243). CONCLUSION: The addition of a falciform ligament patch and fibrin glue to standard stapled or sutured remnant closure did not reduce the rate or severity of pancreatic fistula in patients undergoing distal pancreatectomy (ClinicalTrials.gov NCT00889213).

A progressive postresection walking program significantly improves fatigue and health-related quality of life in pancreas and periampullary cancer patients.

BACKGROUND: As patients with pancreas and periampullary cancer (PPC) experience improved survival rates and longevity, the focus shifts toward living life while surviving cancer. Fatigue is the most commonly reported symptom in all cancer patients. Exercise has been found to effectively decrease fatigue levels and improve physical functioning in cancer patients. STUDY DESIGN: One hundred two patients with resected PPC consented to participate in this study and were randomized to either an intervention group (IG) or a usual care group (UCG). Subjects completed visual analog scales, the FACIT-Fatigue Scale and the Short Form-36v2 after surgery and again 3 to 6 months after hospital discharge. RESULTS: Patients in the IG and UCG were comparable with regard to demographics, comorbidities, cancer type and staging, type of resection, preoperative fatigue and pain levels, adjuvant therapy, and baseline walking distance. Patients in the IG had significantly improved scores on the FACIT-Fatigue Scale at study completion, improved fatigue and pain scores, as well as overall physical functioning and mental health composite scores. At study completion, participants in the IG were walking twice as far and were significantly more likely to have continued walking or another form of exercise as compared with the UCG. Using hierarchical cluster analysis, 3 mutually exclusive symptom groupings were identified in the cohort. Kaplan-Meier survival analysis did not indicate an overall survival benefit for the IG. CONCLUSIONS: This is the first prospective, randomized controlled trial to report that participation in a home walking program confers a significant benefit in resected PPC patients with regard to fatigue levels, physical functioning, and health-related quality of life.

Sarcoid-reaction mimicking metastatic malignant hepatopancreatobiliary tumors: report of two cases and review of the literature.

INTRODUCTION: Sarcoidosis is a multisystem chronic granulomatous disease found predominantly in the lungs and lymph nodes. Its pathologic hallmark is the presence of systemic non-caseating granulomas; however, a variation of this disease known as "sarcoid-like reaction" has been described in patients with underlying cancer. REPORT: Sarcoid-like reactions in patients with hepatopancreatobiliary (HPB) tumors are rare findings, with only 15 cases having been reported in the English language literature. These reactions can be found in local lymph nodes or in distant organs, and when present in patients with cancer, they can mimic metastatic disease on imaging, potentially resulting in incorrect cancer staging and management. DISCUSSION: We describe two cases of patients with HPB tumors who had distant organ disease on cross-sectional imaging suspicious for metastases, which on further workup were found to be sarcoid-like reactions. We also discuss malignancy-induced sarcoid-like reactions and provide a review of the literature of sarcoid-like reactions in the setting of HPB tumors.

Perioperative surgical care bundle reduces pancreaticoduodenectomy wound infections.

BACKGROUND: Pancreaticoduodenectomy (PD) is a complex surgical procedure with a historically high morbidity rate. The goal of this study was to determine if the implementation of a 12-measure perioperative surgical care bundle (SCB) was successful in reducing infectious and other complications in patients undergoing PD compared with a routine preoperative preparation group (RPP). METHODS: In this retrospective cohort study utilizing the HPB surgery database at the Thomas Jefferson University, we analyzed clinical data from 233 consecutive PDs from October 2005 to May 2008 on patients who underwent RPP, and compared them with 233 consecutive PDs from May 2008 to May 2010 following the implementation of the SCB. The SCB was the product of multidisciplinary discussion and extensive literature review. RESULTS: The RPP group and the SCB group had similar demographic characteristics. The overall rate of postoperative morbidity was similar between groups (42.1% versus 37.8%). However, wound infections were significantly lower in the SCB group (15.0% versus 7.7%, P = 0.01).The rates of other common complications, as well as postoperative hospital length of stay, readmissions, and 30-d postoperative mortality were similar between groups. CONCLUSIONS: The implementation of a SCB was followed by a significant decline in wound infection in patients undergoing PD.

Reoperative completion pancreatectomy for suspected malignant disease of the pancreas.

BACKGROUND: Completion pancreatectomy (CP) is a reoperative procedure to excise remnant pancreatic tissue after a prior pancreatic resection. In this study, we document our institution's experience with CP for recurrent malignant disease of the pancreas, describing indications for surgery, procedures performed, and patient outcomes. METHODS: We performed a retrospective review of 861 patients from the pancreatic surgery database in the Department of Surgery of Thomas Jefferson University from October 2005 to December 2010 to identify all cases of CP performed for suspected malignant disease. RESULTS: Eleven patients underwent reoperative CP at our institution from 2005 to 2010. The median time interval between the initial operation and CP was 32 mo. A combination of clinical symptoms, elevated tumor markers, and imaging studies were used for diagnosis of recurrent disease. Pancreatic ductal adenocarcinoma was the most common pathology, found in six patients. The postoperative complication rate was 18% and the median postoperative hospital length of stay was 6 d. There were no 30-d readmissions and no perioperative deaths. The 1-y survival rate following CP was 71% with an overall median survival of 17.5 mo. CONCLUSIONS: CP is a safe and effective option for a highly selected group of patients with suspected recurrent malignant disease of the remnant pancreas. Morbidity and mortality rates are within acceptable limits and similar to initial pancreatic resection. Eligibility depends heavily upon the absence of distant metastatic disease, technical factors for resection, and patient performance status.

The novel triad of dorsal agenesis of the pancreas with concurrent pancreatic ductal adenocarcinoma and nonalcoholic chronic calcific pancreatitis: a case series and review of the literature.

INTRODUCTION: Dorsal agenesis of the pancreas (DAP) is a rare congenital anomaly, with only 44 cases having been reported in the English literature since 1966. MATERIALS AND METHODS: A retrospective review of our IRB-approved pancreatic surgery database was performed from November 2005 to November 2010 searching for cases of DAP. DISCUSSION: Disorders in the retinoic acid (Raldh) and hedgehog (Hh) signaling pathways, which appear to play a role in the development of DAP, have been implicated in other diseases of the pancreas such as pancreatic ductal adenocarcinoma (PDA) and nonalcoholic chronic calcific pancreatitis (NCCP). CONCLUSION: In this report, we describe three cases of DAP in the setting of PDA, two of which include the third component of NCCP. We provide a discussion of the clinical features of this novel triad and address the molecular pathways that relate to these respective diseases.

Preoperative mechanical bowel preparation does not offer a benefit for patients who undergo pancreaticoduodenectomy.

BACKGROUND: Mechanical bowel preparations (MBPs) are commonly administered preoperatively to patients who undergo pancreaticoduodenectomy (PD); however, their effectiveness over a clear liquid diet (CLD) preparation remains unclear. The aim of this study was to determine whether MBP offers an advantage to patients who undergo PD. METHODS: In this retrospective review, we analyzed the clinical data from 100 consecutive PDs performed on patients who received preoperative MBP from March 2006 to April 2007, and we compared them with 100 consecutive patients who received a preoperative CLD from May 2007 to March 2008. RESULTS: No differences were observed between the MBP and CLD groups in the rates of pancreatic fistula (13% vs 14%; P = 1.0), intra-abdominal abscess (11% vs 13%; P = .83), or wound infection (9% vs 8%; P = 1.0). Trends toward increased urinary tract infections (13% vs 5%; P < .08) and Clostridium difficile infections were found in the MBP group (6% vs 1%; P = .12). The median duration of postoperative hospital stay was 7 days in each group, and the 12-month survival rates were equivalent (74% vs 75%; P = 1.0). CONCLUSION: There is no clinical benefit to the administration of a preoperative MBP for patients undergoing PD.

Identifying pancreatic cancer patients for targeted treatment: the challenges and limitations of the current selection process and vision for the future.

Recent preclinical data have demonstrated that pancreatic adenocarcinoma (PDA) cells with defects in the Fanconi anemia/BRCA2 pathway are hypersensitive to interstrand crosslinking agents. The challenge is to efficiently identify patients who will benefit from these therapies. Patients were chosen for this study by evaluating personal history, ethnic background and family history of pancreatic malignancy. Molecular assays were performed on tissue samples. Patient A developed PDA in the context of a known BRCA2 frameshift mutation (2157delG), suspected because of her personal and multigenerational family history of breast cancer. She was treated with surgical resection, and targeted chemotherapy. Patient A continues to be disease free 32 months after her diagnosis and treatment. Patient B developed PDA in the context of a strong family history of PDA and Ashkenazi Jewish heritage. Genetic analysis on critical DNA repair genes revealed no alterations. This patient did not receive a tailored treatment regimen. This study highlights the challenge of treating PDA patients and selecting those eligible for targeted therapy. The current targeted treatment options for PDA are reviewed. A new multidisciplinary approach for stratifying PDA patients for promising targeted adjuvant therapy and familial risk counseling is proposed.

Optimal technical management of stump closure following distal pancreatectomy: a retrospective review of 215 cases.

BACKGROUND: Pancreatic fistula (PF) is a major source of morbidity following distal pancreatectomy (DP). Our aim was to identify risk factors related to PF following DP and to determine the impact of technique of transection and stump closure. METHODS: We performed a retrospective review of 215 consecutive patients who underwent DP. Perioperative and postoperative data were collected and analyzed with attention to PF as defined by the International Study Group of Pancreatic Fistula. RESULTS: PF developed in 36 patients (16.7%); fistulas were classified as Grade A (44.4%), B (44.4%), or C (11.1%). The pancreas was transected with stapler (n = 139), cautery (n = 70), and scalpel (n = 3). PF developed in 19.8% of remnants which were stapled/oversewn and 27.7% that were stapled alone (p = 0.4). Of the 69 pancreatic remnants transected with cautery and oversewn, a fistula developed in 4.3% (p = 0.004 compared to stapled/oversewn; p = 0.006 compared to stapled/not sewn). The median length of postoperative hospital stay was significantly increased in patients who developed PF (10 vs. 6 days, p = 0.002) CONCLUSION: The method of transection and management of the pancreatic remnant plays a critical role in the formation of PF following DP. This series suggests that transection using electrocautery followed by oversewing of the pancreatic remnant has the lowest risk of PF.

Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma.

BACKGROUND: Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. OBJECTIVE: The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. METHODS: We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. RESULTS: We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. CONCLUSIONS: Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.

Implementation of a critical pathway for distal pancreatectomy at an academic institution.

OBJECTIVE: This study was designed to identify quantifiable parameters to track performance improvements brought about by the implementation of a critical pathway for complex alimentary tract surgery. BACKGROUND: Distal pancreatectomy is among the more complex general surgical procedures. This is primarily due to the possibility of blood loss from visceral vessels, splenic injury, and significant postoperative complications. The introduction of the laparoscopic approach to the distal pancreas has introduced a further level of surgical expertise required to fully address the clinical needs of this diverse patient population. Critical pathways have been one of the key tools used to achieve consistently excellent outcomes at high-quality, high-volume institutions. It remains to be determined if implementation of a critical pathway at an academic institution with prior moderate experience with distal pancreatectomy will result in performance gains and improved outcomes. METHODS: Between January 1, 2003 and August 15, 2007, 111 patients underwent distal pancreatectomy. Forty patients underwent resection during the 34-month period before the implementation of a critical pathway on October 15, 2005 and 71 during the 20 months after pathway implementation. Patients undergoing both open and laparoscopic procedures were included. Peri- and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes. RESULTS: The two groups were not significantly different with respect to age, sex, race, diagnosis, operative blood loss, or mean operative duration. Postoperative length of hospital stay was significantly shorter when comparing pre- to postpathway implementation (10.2 days versus 6.7 days, P < or = 0.037). The rate of readmission to the hospital after discharge was significantly lower post pathway (25% versus 7%, P < or = 0.027). Hospital costs were also reduced. CONCLUSION: Implementation of a critical pathway for a complex procedure can be demonstrated to improve short-term outcomes at an academic institution. This improvement can be quantified and tracked and has implications for better utilization of resources and overall cost containment while maintaining or improving upon an already high level of care.

Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution--the first step in multidisciplinary team building.

BACKGROUND: Pancreaticoduodenectomy (PD) is a complex general surgical procedure originally associated with significant perioperative morbidity and mortality. Multiple studies have now shown that this operation can be performed quite safely at high-volume institutions that develop a particular expertise. Critical pathways are among the key tools used to achieve consistently excellent outcomes at these institutions. It remains to be determined if implementation of a critical pathway at an academic institution with earlier moderate experience with PD will result in performance gains and improved outcomes. This study was designed to track performance improvements brought about by the implementation of a critical pathway for complex alimentary tract surgery. STUDY DESIGN: Between January 1, 2004, and October 15, 2006, 135 patients underwent PD: 44 before implementation of a critical pathway on October 15, 2005, and 91 after. Perioperative and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes. RESULTS: Compared with the prepathway group, the postpathway group had a significantly shorter postoperative length of stay (13 versus 7 days, p < or = 0.0001) and operative time. Mean total hospital charges were significantly reduced, from $240,242 +/- $32,490 to $126,566 +/- $4,883 (p < or = 0.0001). CONCLUSIONS: Implementation of a critical pathway for a complex procedure can be demonstrated to improve short-term outcomes at an academic institution. This improvement can be quantified and tracked and has implications for better use of resources (greater operating room and hospital bed availability) and overall cost containment.

1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience.

Pancreaticoduodenectomy (PD) with the possible addition of neoadjuvant or adjuvant therapy is the standard of care in the United States for adenocarcinoma originating in the pancreatic head, neck, and uncinate process. We reviewed 1423 patients who underwent a PD for a malignancy originating in the pancreas at our institution between 1970 and 2006. We examined 1175 PDs for ductal adenocarcinomas in greater detail. Eighteen different histological types of pancreatic cancer were identified; the most common diagnoses included ductal adenocarcinoma, neuroendocrine carcinoma, and IPMN with invasive cancer. Patients with ductal adenocarcinoma were analyzed in detail. The median age was 66 years, with patients in the present decade significantly older (68 years), on average, than patients in the three prior decades (e.g., 60 years in 1970, P = 0.02). The median tumor diameter was 3 cm; 42% of the resections had positive margins and 78% had positive lymph nodes. The perioperative morbidity was 38%. The median postoperative stay declined over time, from 16 days in the 1980s to 8 days in the 2000s (P < 0.001). The perioperative mortality declined from 30% in the 1970s to 1% in the 2000s (P < 0.001). The median survival for all patients with ductal adenocarcinoma was 18 months (1-year survival = 65 %, 2-year survival = 37%, 5-year survival = 18%). In a Cox proportional hazards model, pathological factors having a significant impact on survival included tumor diameter, resection margin status, lymph node status, and histologic grade. This is the largest single-institution experience with PD for pancreatic cancer. Patients who have cancers with favorable pathological features have a statistically significant improved long-term survival.

Hospital readmission after pancreaticoduodenectomy.

Data exist on the morbidity and mortality of patients undergoing pancreaticoduodenectomy (PD), but there are few reports about hospital readmissions after this procedure. Our aim was to evaluate the number of and reasons for readmission after PD and the factors influencing readmission. We reviewed the initial hospitalization and readmissions for 1643 patients undergoing PD compared patients requiring readmission to patients that did not require readmission. Twenty-six percent of patients were readmitted a total of 678 times after PD. Patients readmitted were younger than those not readmitted (61.8 versus 64.6 years, P < 0.0001). Vessel resection, abscess formation, wound infection, postoperative percutaneous biliary stents, estimated blood loss >1000 ml, and age < or =65 years were independently associated with readmission. The length of stay for all patients decreased over time, from 10.5 days in 1996 to 7 days in 2003. The percentage of patients being readmitted also decreased from 33% in 1996 to 20% (P = 0.004) in 2003. The readmission rate after PD was 26%. Younger age, blood loss, postoperative complications, and vessel resection were independent risk factors for readmission. The early hospital readmission rate has not increased in association with a decreased LOS, supporting the idea that reduction in LOS did not lead to increased readmission rates.