ADAMTSL2 protein and a soluble biomarker signature identify at-risk non-alcoholic steatohepatitis and fibrosis in adults with NAFLD.

BACKGROUND & AIMS: Identifying fibrosis in non-alcoholic fatty liver disease (NAFLD) is essential to predict liver-related outcomes and guide treatment decisions. A protein-based signature of fibrosis could serve as a valuable, non-invasive diagnostic tool. This study sought to identify circulating proteins associated with fibrosis in NAFLD. METHODS: We used aptamer-based proteomics to measure 4,783 proteins in 2 cohorts (Cohort A and B). Targeted, quantitative assays coupling aptamer-based protein pull down and mass spectrometry (SPMS) validated the profiling results in a bariatric and NAFLD cohort (Cohort C and D, respectively). Generalized linear modeling-logistic regression assessed the ability of candidate proteins to classify fibrosis. RESULTS: From the multiplex profiling, 16 proteins differed significantly by fibrosis in cohorts A (n = 62) and B (n = 98). Quantitative and robust SPMS assays were developed for 8 proteins and validated in Cohorts C (n = 71) and D (n = 84). The A disintegrin and metalloproteinase with thrombospondin motifs like 2 (ADAMTSL2) protein accurately distinguished non-alcoholic fatty liver (NAFL)/non-alcoholic steatohepatitis (NASH) with fibrosis stage 0-1 (F0-1) from at-risk NASH with fibrosis stage 2-4, with AUROCs of 0.83 and 0.86 in Cohorts C and D, respectively, and from NASH with significant fibrosis (F2-3), with AUROCs of 0.80 and 0.83 in Cohorts C and D, respectively. An 8-protein panel distinguished NAFL/NASH F0-1 from at-risk NASH (AUROCs 0.90 and 0.87 in Cohort C and D, respectively) and NASH F2-3 (AUROCs 0.89 and 0.83 in Cohorts C and D, respectively). The 8-protein panel and ADAMTSL2 protein had superior performance to the NAFLD fibrosis score and fibrosis-4 score. CONCLUSION: The ADAMTSL2 protein and an 8-protein soluble biomarker panel are highly associated with at-risk NASH and significant fibrosis; they exhibited superior diagnostic performance compared to standard of care fibrosis scores. LAY SUMMARY: Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease worldwide. Diagnosing NAFLD and identifying fibrosis (scarring of the liver) currently requires a liver biopsy. Our study identified novel proteins found in the blood which may identify fibrosis without the need for a liver biopsy.

Open innovation facilitates department-wide engagement in quality improvement: experience from the Massachusetts General Hospital.

BACKGROUND: Quality improvement (QI) initiatives commonly originate 'top-down' from senior leadership, as staff engagement is often sporadic. We describe our experience with a technology-enabled open innovation contest to encourage participation from multiple stakeholders in a Department of Surgery (DoS) to solicit ideas for QI. We aimed to stimulate engagement and to assist DoS leadership in prioritizing QI initiatives. METHODS: Observational study of a process improvement. The process had five phases: anonymous online submission of ideas by frontline staff; anonymous online crowd-voting to rank ideas on a scale whether the DoS should implement each idea (1 = No, 3 = Maybe, 5 = Yes); ideas with scores ≥ 95th percentile were invited to submit implementation plans; plans were reviewed by a multi-disciplinary panel to select a winning idea; an award ceremony celebrated the completion of the contest. RESULTS: 152 ideas were submitted from 95 staff (n = 850, 11.2%). All Divisions (n = 12) and all staff roles (n = 12) submitted ideas. The greatest number of ideas were submitted by faculty (27.6%), patient service coordinators (18.4%), and residents (17.8%). The most common QI category was access to care (20%). 195 staff (22.9%) cast 3559 votes. The mean score was 3.5 ± 0.5. 10 Ideas were objectively invited to submit implementation plans. One idea was awarded a grand prize of funding, project management, and leadership buy-in. CONCLUSION: A web-enabled open innovation contest was successful in engaging faculty, residents, and other critical role groups in QI. It also enabled the leadership to re-affirm a positive culture of inclusivity, maintain an open-door policy, and also democratically vet and prioritize solutions for quality improvement.

Population Level Analysis of Adhesive Small Bowel Obstruction: Sustained Advantage of a Laparoscopic Approach.

OBJECTIVE: The objective of this study was to determine the effects of open versus laparoscopic surgery on the development of adhesive small bowel obstruction (aSBO). SUMMARY BACKGROUND DATA: aSBO is a significant contributor to short and long-term postoperative morbidity. Laparoscopy has demonstrated a protective effect in colorectal surgery, but these effects have not been generalized to other abdominal procedures. METHODS: Population level California state data (1995-2010) was analyzed. We identified patients who underwent Roux-en-Y gastric bypass (RYGB), cholecystectomy, partial colectomy, appendectomy, and hysterectomy. The primary outcome was aSBO. Clinical, patient, and hospital characteristics were assessed using Kaplan-Meir methodology and Cox regression analysis adjusting for demographics, comorbidities, and operative approach. RESULTS: We included 1,612,629 patients with a median follow-up of 6.3 years. The 5-year incidence rate of aSBO was higher after open surgery compared with laparoscopic surgery for each procedure (RYGB 2.1% vs. 1.5%, P < 0.001; cholecystectomy 2.2% vs. 0.65%, P < 0.001; partial colectomy 5.5% vs. 2.8%, P < 0.001; appendectomy 0.58% vs. 0.35%, P < 0.001; and hysterectomy 0.89% vs. 0.54%, P < 0.001). The period of greatest risk for aSBO formation was within the first 2-years. In multivariate analysis, an open approach was associated with an increased risk of aSBO for each procedure [RYGB hazard ratio (HR) 1.24, P < 0.001; cholecystectomy HR 1.89, P < 0.001; partial colectomy HR 1.49, P < 0.001; appendectomy HR 1.45, P < 0.001; and hysterectomy HR 1.16, P < 0.001). CONCLUSIONS: Laparoscopy is associated with a significant and sustained reduction in the rate of aSBO. The period of greatest risk for aSBO is within the first 2 years after surgery.

Computer Vision Analysis of Intraoperative Video: Automated Recognition of Operative Steps in Laparoscopic Sleeve Gastrectomy.

OBJECTIVE(S): To develop and assess AI algorithms to identify operative steps in laparoscopic sleeve gastrectomy (LSG). BACKGROUND: Computer vision, a form of artificial intelligence (AI), allows for quantitative analysis of video by computers for identification of objects and patterns, such as in autonomous driving. METHODS: Intraoperative video from LSG from an academic institution was annotated by 2 fellowship-trained, board-certified bariatric surgeons. Videos were segmented into the following steps: 1) port placement, 2) liver retraction, 3) liver biopsy, 4) gastrocolic ligament dissection, 5) stapling of the stomach, 6) bagging specimen, and 7) final inspection of staple line. Deep neural networks were used to analyze videos. Accuracy of operative step identification by the AI was determined by comparing to surgeon annotations. RESULTS: Eighty-eight cases of LSG were analyzed. A random 70% sample of these clips was used to train the AI and 30% to test the AI's performance. Mean concordance correlation coefficient for human annotators was 0.862, suggesting excellent agreement. Mean (±SD) accuracy of the AI in identifying operative steps in the test set was 82% ±â€Š4% with a maximum of 85.6%. CONCLUSIONS: AI can extract quantitative surgical data from video with 85.6% accuracy. This suggests operative video could be used as a quantitative data source for research in intraoperative clinical decision support, risk prediction, or outcomes studies.

Outcomes in operative management of pancreatic cancer.

Pancreatic cancer is a highly lethal malignancy that often presents at an advanced stage. Surgical resection can prolong survival and offers the only potential for cure. However, pancreatectomy is associated with significant morbidity and mortality. This article reviews perioperative outcomes, post-resection long-term survival, and innovations in the surgical management of pancreatic cancer.

National trends in pancreaticoduodenal trauma: interventions and outcomes.

OBJECTIVES: Pancreaticoduodenal trauma (PDT) is associated with substantial mortality and morbidity. In this study, contemporary trends were analysed using national data. METHODS: The Nationwide Inpatient Sample for 1998-2009 was queried for patients with PDT. Interventions including any operation (Any-Op) and pancreas-specific surgery (PSURG) were identified. Trends in treatment and outcomes were determined [complications, length of stay (LoS), mortality] for the Any-Op, PSURG and non-operative (Non-Op) groups. Analyses included chi-squared tests, Cochran-Armitage trend tests and logistic regression. RESULTS: A total of 27 216 patients (nationally weighted) with PDT were identified. Over time, the frequency of PDT increased by 8.3%, whereas the proportion of patients submitted to PSURG declined (from 21.7% to 19.8%; P = 0.0004) and the percentage of patients submitted to non-operative management increased (from 56.7% to 59.1%; P = 0.01). In the Non-Op group, mortality decreased from 9.7% to 8.6% (P < 0.001); morbidity and LoS remained unchanged at ∼40% and ∼12 days, respectively. In the PSURG group, mortality remained stable at ∼15%, complications increased from 50.2% to 71.8% (P < 0.0001) and LoS remained stable at ∼21 days. For all PDT patients, significant independent predictors of mortality included: the presence of combined pancreatic and duodenal injuries; penetrating trauma, and age >50 years. Having any operation (Any-Op) was associated with mortality, but PSURG was not a predictor of death. CONCLUSIONS: The utilization of operations for PDT has declined without affecting mortality, but operative morbidity increased significantly over the 12 years to 2009. The development of an evidence-based approach to invasive manoeuvres and an early multidisciplinary approach involving pancreatic surgeons may improve outcomes in patients with these morbid injuries.

Outcomes following resection of pancreatic cancer.

Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long-term survival after resection.

Comparison of Short-term Safety of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in the United States: 341 cases from MBSAQIP-accredited Centers.

BACKGROUND: One anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited. OBJECTIVE: To compare the short-term safety outcomes of the three primary bariatric procedures. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited hospitals in the United States and Canada. METHODS: Using the 2015-2019 MBSAQIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length. RESULTS: A total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1-2 d] versus 2 d [IQR 1-2 d], P < .001) and a similar hospitalization length to the SG cohort ([1-2 d], P = .46). CONCLUSION: Using the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety.

Expression of IGF-1 receptor and GH receptor in hepatic tissue of patients with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

OBJECTIVE: The GH and IGF-1 axis is a candidate disease-modifying target in nonalcoholic fatty liver disease (NAFLD) given its lipolytic, anti-inflammatory and anti-fibrotic properties. IGF-1 receptor (IGF-1R) and GH receptor (GHR) expression in adult, human hepatic tissue is not well understood across the spectrum of NAFLD severity. Therefore, we sought to investigate hepatic IGF-1R and GHR expression in subjects with NAFLD utilizing gene expression analysis (GEA) and immunohistochemistry (IHC). DESIGN: GEA (n = 318) and IHC (n = 30) cohorts were identified from the Massachusetts General Hospital NAFLD Tissue Repository. GEA subjects were categorized based on histopathology as normal liver histology (NLH), steatosis only (Steatosis), nonalcoholic steatohepatitis (NASH) without fibrosis (NASH F0), and NASH with fibrosis (NASH F1-4) with GEA by the Nanostring nCounter assay. IHC subjects were matched for age, body mass index (BMI), sex, and diabetic status across three groups (n = 10 each): NLH, Steatosis, and NASH with fibrosis (NASH F1-3). IHC for IGF-1R, IGF-1 and GHR was performed on formalin-fixed, paraffin-embedded hepatic tissue samples. RESULTS: IGF-1R gene expression did not differ across NAFLD severity while IGF-1 gene expression decreased with increasing NAFLD severity, including when controlled for BMI and age. GHR expression did not differ by severity of NAFLD based on GEA or IHC. CONCLUSIONS: IGF-1R and GHR expression levels were not significantly different across NAFLD disease severity. However, expression of IGF-1 was lower with increasing severity of NAFLD. Additional research is needed regarding the contribution of the GH/IGF-1 axis to the pathophysiology of NAFLD and NASH.

Distinct Hepatic Gene-Expression Patterns of NAFLD in Patients With Obesity.

Approaches to manage nonalcoholic fatty liver disease (NAFLD) are limited by an incomplete understanding of disease pathogenesis. The aim of this study was to identify hepatic gene-expression patterns associated with different patterns of liver injury in a high-risk cohort of adults with obesity. Using the NanoString Technologies (Seattle, WA) nCounter assay, we quantified expression of 795 genes, hypothesized to be involved in hepatic fibrosis, inflammation, and steatosis, in liver tissue from 318 adults with obesity. Liver specimens were categorized into four distinct NAFLD phenotypes: normal liver histology (NLH), steatosis only (steatosis), nonalcoholic steatohepatitis without fibrosis (NASH F0), and NASH with fibrosis stage 1-4 (NASH F1-F4). One hundred twenty-five genes were significantly increasing or decreasing as NAFLD pathology progressed. Compared with NLH, NASH F0 was characterized by increased inflammatory gene expression, such as gamma-interferon-inducible lysosomal thiol reductase (IFI30) and chemokine (C-X-C motif) ligand 9 (CXCL9), while complement and coagulation related genes, such as C9 and complement component 4 binding protein beta (C4BPB), were reduced. In the presence of NASH F1-F4, extracellular matrix degrading proteinases and profibrotic/scar deposition genes, such as collagens and transforming growth factor beta 1 (TGFB1), were simultaneously increased, suggesting a dynamic state of tissue remodeling. Conclusion: In adults with obesity, distinct states of NAFLD are associated with intrahepatic perturbations in genes related to inflammation, complement and coagulation pathways, and tissue remodeling. These data provide insights into the dynamic pathogenesis of NAFLD in high-risk individuals.

Use of noninvasive scores for advanced liver fibrosis can guide the need for hepatic biopsy during bariatric procedures.

BACKGROUND: Patients with obesity are at increased risk for nonalcoholic fatty liver disease (NAFLD). The effectiveness of noninvasive screening tests for ruling out advanced fibrosis (stage 3-4) is unknown. OBJECTIVES: To determine the prevalence of advanced fibrosis in patients undergoing routine liver biopsy during bariatric surgery and assess the effectiveness of existing noninvasive risk calculators. SETTING: Academic medical center in the United States. METHODS: Routine liver biopsies were obtained during first-time bariatric surgery (January 2001-December 2017). Patient demographic characteristics, co-morbidities, and preoperative laboratory values were compiled. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were compared between 3 noninvasive risk calculators for advanced fibrosis: the fibrosis-4 index, NAFLD fibrosis score, and aminotransferase-to-platelet ratio index (APRI). RESULTS: Among 2465 patients, the prevalence of advanced fibrosis (stage 3-4) was 3.4%. The mean age was 45.5 years, and the mean body mass index was 46.8. The sensitivity of noninvasive risk calculators ranged from 85% (NAFLD fibrosis score) to 24% (APRI). The NAFLD fibrosis score performed best in screening out advanced fibrosis, with an NPV of 99%. The PPV ranged from 9% to 65%. In this study cohort, the use of the NALFD fibrosis score correctly ruled out advanced fibrosis in 893 (36%) patients, with 13 false negatives. CONCLUSIONS: The prevalence of advanced fibrosis in individuals undergoing routine first-time bariatric procedures is 3.4%. Use of the NALFD fibrosis score can rule out advanced fibrosis in one-third of this population, and guide surgical decision-making.

Trends in adrenalectomy: a recent national review.

BACKGROUND: Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality. METHODS: The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998-2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated. RESULTS: Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p < 0.0001, trend analysis). The overall in-hospital mortality was 1.1%, with no significant change. Advanced age (< 45 years as the referent; ≥ 65 years: adjusted odds ratio [AOR], 4.10; 95%; confidence Interval [CI], 1.66-10.10) and patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.33; 96% CI, 2.34-8.02) were independent predictors of in-hospital mortality. Indication, year, hospital teaching status, and hospital volume did not independently affect perioperative mortality. Major postoperative in-hospital complications occurred in 7.2% of the cohort, with a significant increasing trend (1998-2000 [5.9%] vs 2004-2006 [8.1%]; p < 0.0001, trend analysis). Patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.77; 95% CI, 3.71-6.14), recent year of surgery (1998-2000 as the referent; 2004-2006: AOR, 1.40; 95% CI, 1.09-1.78), and benign disease (malignant disease as the referent; benign disease: AOR, 1.98; 95% CI, 1.55-2.53) were predictive of major postoperative complications at multivariable analyses, whereas laparoscopy was protective (no laparoscopy as the referent; laparoscopy: AOR, 0.62; 95% CI, 0.47-0.82). CONCLUSION: Adrenalectomy is increasingly performed nationwide for both benign and malignant indications. In this study, whereas perioperative mortality remained low, major postoperative complications increased significantly.

Surgeon factors are strongly correlated with who receives a sleeve gastrectomy versus a Roux-en-Y gastric bypass.

BACKGROUND: Sleeve gastrectomy (SG) has replaced Roux-en-Y gastric bypass (RYGB) as the most common bariatric operation. While SG constitutes ∼70% of all bariatric volume, we hypothesize that the distribution of SG versus RYGB varies widely at the level of the surgeon and that surgeon rather than patient factors are the primary driver of the procedure performed. OBJECTIVES: To determine the distribution of bariatric procedures performed at the surgeon level. SETTING: Population-level analysis using the Statewide Planning and Research Cooperative System (SPARCS) for New York State (2004-2014). METHODS: Identified surgeons performing SG and RYGB using billing codes. Logistic regression performed to determine the impact of surgeon, patient, and hospital factors on receiving a RYGB. RESULTS: Of the 142 surgeons who perform >5 bariatric operations per year, 32 (22.5%) performed a SG in ≥95% of their bariatric cases in the year 2014. In logistic regression, diabetes (odds ratio [OR] 1.45; P < .001) and gastroesophageal reflux disease (OR 1.36; P < .001) were associated with receiving a RYGB. However, the most correlated factor was whether the surgeon had a RYGB case volume >66th percentile in the preceding year (OR 33.8; P < .001). In pseudo-R2 analysis, 83% of the power of the regression could be explained by surgeon factors alone. CONCLUSIONS: While the percentage of SG in this cohort closely matches the national average, there is wide variation at the surgeon level with a significant proportion predominantly performing a single procedure. Surgeon factors are more strongly correlated with procedure selection compared to patient or hospital factors.

Risk factors and prevalence of liver disease in review of 2557 routine liver biopsies performed during bariatric surgery.

BACKGROUND: Obesity is a known risk factor for nonalcoholic fatty liver disease (NAFLD). However, among individuals undergoing bariatric surgery, the prevalence and risk factors for NAFLD, as well as distinct phenotypes of steatosis, nonalcoholic steatohepatitis (NASH), and fibrosis remain incompletely understood. OBJECTIVES: To determine the prevalence and risk factors for steatosis, NASH, and fibrosis in individuals undergoing routine bariatric surgery. SETTING: Academic medical center in the United States. METHODS: Liver wedge biopsies were performed at the time of surgery between 2001 and 2017. Pathology reports were reviewed, and individuals were grouped by NAFLD phenotype. Covariates including demographic characteristics, co-morbidities, and preoperative laboratory values were compared between groups using Student's t test, Pearson's χ2, and logistic regression. RESULTS: Liver biopsies were obtained in 97.7% of first-time bariatric procedures, representing 2557 patients. Mean age was 45.6 years, mean body mass index was 46.7, and most were non-Hispanic white (76.1%) and female (71.6%). On histologic review 61.2% had steatosis and 30.9% NASH. Fibrosis was identified in 29.3% of individuals, and 7.8% had stage ≥2 fibrosis. On logistic regression, elevated aspartate aminotransferase (odds ratio [OR] 1.87; P < .001) and elevated alanine aminotransferase (OR 1.62; P < .001) were independently associated with fibrosis. Elevated hemoglobin A1C of 5.7% to 6.5% (OR 1.29; P < .01) and >6.5% (OR 3.23; P < .001) were also associated with fibrosis. A similar trend was seen for NASH. CONCLUSIONS: NASH and/or fibrosis is present in nearly one third of patients undergoing routine bariatric surgery. Risk factors include diabetes, elevated liver enzymes, and diabetes. Risk assessment and aggressive screening should be considered in patients undergoing bariatric surgery.

Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries.

BACKGROUND: Elderly Americans are at increased risk of head trauma, particularly fall related. The effect of warfarin on head trauma outcomes remains controversial. METHODS: Medicare beneficiaries with head injuries from 2009 to 2011 were identified by International Classification of Diseases (ICD)-9 code. Preinjury warfarin use was determined using Part D claims. Multiple logistic regression models determined the association of preinjury warfarin on need for hospitalization, intensive care unit care, and occurrence of intracranial hemorrhage. Association between warfarin and in-hospital mortality was assessed using a Cox proportional hazard model. RESULTS: Of 11,078 head injured patients, 5.2% were injured while on warfarin. Preinjury warfarin increased the odds of intracranial hemorrhage by 40% and doubled the risk of 30-day in-hospital mortality after adjusting for demographic and clinical factors. CONCLUSIONS: Warfarin at the time of head injury increases the risk of adverse outcomes in Medicare beneficiaries with head injuries. Caution should be used when initiating anticoagulation in elderly Americans at risk for trauma.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view.

INTRODUCTION: Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear. METHODS: Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost. RESULTS: Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs. CONCLUSION: Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Is it worth looking? Abdominal imaging after pancreatic cancer resection: a national study.

INTRODUCTION: Abdominal imaging is often performed after pancreatic cancer resection. We attempted to quantify the volume and estimate the cost of complex imaging after pancreatectomy nationwide, and to determine whether their frequent use confers benefit. METHODS: Patients with pancreatic adenocarcinoma who underwent resection were identified in Surveillance, Epidemiology and End Results-Medicare (1991-2005). Claims for abdominal imaging ≤5 years after resection were analyzed. Patients receiving annual CT scans were identified. Univariate and multivariate analyses were performed. To assess frequency of annual CT scanning in patients with superior survival, the top decile was further analyzed. RESULTS: Eleven thousand eight hundred fifty studies were performed on 2,217 patients. Ten thousand five hundred forty-two (89%) were CT scans. The median number of scans doubled from three in 1991 to six in 2005 (p < 0.0001). Among patients with sufficient survival to allow for analysis, 51.3% received annual CT scans, while only 32.4% of top-performing patients received annual scans. Univariate analysis of the 10% of patients with superior survival did not reveal any significant benefit associated with annual imaging. CONCLUSION: Utilization of complex imaging after pancreatic cancer resection has increased substantially among Medicare beneficiaries, driven primarily by an increasing number of CT scans. Our study demonstrated no significant survival benefit among patients who received scans on a routine basis.

Perioperative mortality after pancreatectomy: a risk score to aid decision-making.

BACKGROUND: Undergoing a pancreatectomy obligates the patient to risks and benefits. For complex operations such as pancreatectomy, the objective assessment of baseline risks may be useful in decision-making. We developed an integer-based risk score estimating in-hospital mortality after pancreatectomy, incorporating institution-specific mortality rates to enhance its use. METHODS: Pancreatic resections were identified from the Nationwide Inpatient Sample (1998-2006), and categorized as proximal, distal, or nonspecified by the International Classification of Diseases, 9th edition. Logistic regression and bootstrap methods were used to estimate in-hospital mortality using demographics, diagnosis, comorbidities (Charlson index), procedure, and hospital volume; 80% of this cohort was selected randomly to create the score and 20% was used for validation. Score assignments were subsequently individually fitted to risk distributions around specific mortality rates. RESULTS: Sixteen thousand one hundred sixteen patient discharges were identified. Nationwide in-hospital mortality was 5.3%. Integers were assigned to predictors (age group, Charlson index, sex, diagnosis, pancreatectomy type, and hospital volume) and applied to an additive score. Three score groups were defined to stratify in-hospital mortality (national mortality, 1.3%, 4.9%, and 14.3%; P < .0001), with sufficient discrimination of derivation and validation sets (C statistics, 0.72 and 0.74). Score groups were shifted algorithmically to calculate risk based on institutional data (eg, with institutional mortality of 2.0%, low-, medium-, and high-risk patient groups had 0.5%, 1.9%, and 5.4% mortality, respectively). A web-based tool was developed and is available online (http://www.umassmed.edu/surgery/panc_mortality_custom.aspx). CONCLUSION: To maximize patient benefit, objective assessment of risk for major procedures is necessary. We developed a Surgical Outcomes Analysis and Research risk score predicting pancreatectomy mortality that combines national and institution-specific data to enhance decision-making. This type of risk stratification tool may identify opportunities to improve care for patients undergoing specific operative procedures.