Does mesenteric venous imaging assessment accurately predict pathologic invasion in localized pancreatic ductal adenocarcinoma?

BACKGROUND: Accurate prediction of mesenteric venous involvement in pancreatic ductal adenocarcinoma (PDAC) is necessary for adequate staging and treatment. METHODS: A retrospective cohort study was conducted in PDAC patients at a single institution. All patients with resected PDAC and staging CT and EUS between 2003 and 2014 were included and sub-divided into "upfront resected" and "neoadjuvant chemotherapy (NAC)" groups. Independent imaging re-review was correlated to venous resection and venous invasion. Sensitivity, specificity, positive and negative predictive values were then calculated. RESULTS: A total of 109 patients underwent analysis, 60 received upfront resection, and 49 NAC. Venous resection (30%) and vein invasion (13%) was less common in patients resected upfront than those who received NAC (53% and 16%, respectively). Both CT and EUS had poor sensitivity (14-44%) but high specificity (75-95%) for detecting venous resection and vein invasion in patients resected upfront, whereas sensitivity was high (84-100%) and specificity was low (27-44%) after NAC. CONCLUSIONS: Preoperative CT and EUS in PDAC have similar efficacy but different predictive capacity in assessing mesenteric venous involvement depending on whether patients are resected upfront or received NAC. Both modalities appear to significantly overestimate true vascular involvement and should be interpreted in the appropriate clinical context.

What is a better predictor of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD): postoperative day one drain amylase (POD1DA) or the fistula risk score (FRS)?

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.

Predicting Successful Laparoendoscopic Transhiatal Esophagectomy (THE) by Mediastinal Height Measurement.

BACKGROUND: Laparoendoscopic transhiatal esophagectomy (THE) provides advantages over traditional THE by not only avoiding laparotomy but by also allowing more precise esophageal mobilization. Occasionally, the length of the gastric conduit is insufficient to allow delivery into the neck after laparoscopic mobilization and requires laparotomy to complete the procedure. We hypothesize that the need for laparotomy will correlate with the measurement of mediastinal height (distance from thoracic vertebrae T1-T12) on chest CT. METHODS: Medical records of all patients who underwent attempted laparoendoscopic-assisted THE at a tertiary referral center between March 1, 2003 and January 31, 2019 were reviewed. Patients' mediastinal height was measured using computed tomography (CT) imaging of the chest by investigators and analyzed for correlation between mediastinal height and successful completion of a totally laparoendoscopic procedure. RESULTS: A total of 21 cases met inclusion criteria: 9 successful laparoendoscopic THE procedures and 12 failed laparoendoscopic THE procedures (those requiring addition of a mini-laparotomy or thoracotomy). The mean mediastinal length for successful laparoendoscopic surgery was 23.5 cm, whereas the mean mediastinal length for failed laparoscopic surgeries was 24.8 cm (P = .03). Patient's overall height was not found to correlate with the need for conversion. CONCLUSIONS: Shorter mediastinal length is associated with successful laparoendoscopic or laparoscopic THE. This information is readily available to clinicians from routine preoperative staging studies (chest CT) and may be used to potentially predict the success rate of a totally laparoendoscopic approach and aid in patient selection. Further prospective evaluation of these findings is warranted.

Large lymphoepithelial cyst of pancreas: a rare entity managed using lumen-apposing metal stent-case report and review of the literature.

Lymphoepithelial cysts (LECs) are extremely rare nonmalignant cysts of the pancreas. Asymptomatic LECs are managed conservatively, but symptomatic LECS have traditionally been managed with surgical resection. We report the first case of symptomatic infected LEC of the pancreas successfully managed with EUS guided endoscopic drainage with lumen-apposing metal stent. We also review the relevant literature and discuss the diagnosis and management of this rare cyst of the pancreas.

2019 update of the WSES guidelines for management of Clostridioides (Clostridium) difficile infection in surgical patients.

In the last three decades, Clostridium difficile infection (CDI) has increased in incidence and severity in many countries worldwide. The increase in CDI incidence has been particularly apparent among surgical patients. Therefore, prevention of CDI and optimization of management in the surgical patient are paramount. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of CDI in surgical patients according to the most recent available literature. The update includes recent changes introduced in the management of this infection.

Patient Hand-Off iNitiation and Evaluation (PHONE) study: A randomized trial of patient handoff methods.

BACKGROUND: As residency work hour restrictions have tightened, transitions of care have become more frequent. Many institutions dedicate significant time and resources to patient handoffs despite the fact that the ideal method is relatively unknown. We sought to compare the effect of a rigorous formal handoff approach to a minimized but focused handoff process on patient outcomes. METHODS: A randomized prospective trial was conducted at a large teaching hospital over ten months. Patients were assigned to services employing either formal or focused handoffs. Residents were trained on handoff techniques and then observed by trained researchers. Outcome data including mortality, negative events, adverse events, and length of stay were collected and compared between formal and focused handoff groups using t-tests and a multivariate regression analysis. RESULTS: A total of 5157 unique patient-admissions were stratified into the two study groups. Focused handoffs were significantly shorter and included fewer patients (mean 6.3 patients discussed over 6.7 min vs. 35.2 patients over 20.6 min, both p < 0.001). Adverse events occurred during 16.7% of patient admissions. While overall length of stay was slightly shorter in the formal handoff group (5.50 days vs 5.88 days, p = 0.024) in univariate analysis only, there were no significant differences in patient outcomes between the two handoff methods (all p > 0.05). CONCLUSIONS: This large randomized trial comparing two contrasting handoff techniques demonstrated no clinically significant differences in patient outcomes. A minimalistic handoff process may save time and resources without negatively affecting patient outcomes.

The Effects of Metabolic Surgery on Fatty Liver Disease and Nonalcoholic Steatohepatitis.

Nonalcoholic fatty liver disease (NAFLD) is an under-recognized but increasingly important manifestation of the metabolic syndrome. Bariatric surgery, both through direct weight loss and more indirect effects on insulin resistance and improvements in inflammatory proteins, can have a profound effect on NAFLD, resulting in improvement or resolution of even high-grade liver disease.

Impact of seductive details on the acquisition and transfer of laparoscopic suturing skills: Emotionally interesting or cognitively taxing?

BACKGROUND: A common strategy to increase learner engagement is to interweave educational material with interesting but slightly tangential tidbits of information (eg, "war stories" and funny anecdotes), known as seductive details. Our objective was to examine the impact of seductive details on initial acquisition and transfer of basic laparoscopic surgical skills. METHODS: Novices (first- to fourth-year medical students) were randomized into control (N = 47) or seductive details (N = 42) groups. Curricula consisted of a baseline skills assessment (Fundamentals of Laparoscopic Surgery Task 1), instructional video on intracorporeal laparoscopic suturing (Fundamentals of Laparoscopic Surgery Task 5), multiple choice quiz, practice, and assessment on both primary and transfer tasks. Two separate instructional videos were used for Task 5; 20% of the seductive details group's instructional video consisted of seductive details, whereas the control group's video included no seductive details. Participants completed questionnaires of mental workload and task engagement after training. We also conducted a mediation analysis, which is a statistical approach to identify causal paths among a group of variables. RESULTS: Baseline skill scores (control: 112 ± 52; standard deviation: 118 ± 56; 0 = lowest possible score; 600 = highest possible score) and knowledge scores (control: 76 ± 19; standard deviation: 74 ± 16; 0 = lowest possible score; 100 = highest possible score) were similar for both groups. The control group demonstrated better (higher) performance on both the primary (434 ± 193 vs 399 ± 133, P < .05) and transfer (184 ± 74 vs 149 ± 91, P < .05) suturing tasks. Mental workload, as measured by the National Aeronautics and Space Administration-Task Load Index, was more demanding (higher) for the seductive details group (3.8 ± 0.5 vs 3.4 ± 0.7, P < .01; 1 = low workload; 5 = high workload) and was investigated as the possible mechanism by which group assignment impacted performance. Mediational paths using hierarchical regression were significant (P < .05), suggesting that trainees in the seductive details group performed worse because of their increased workload. CONCLUSION: Our findings suggest that the inclusion of seductive details may be detrimental to the acquisition and transfer of laparoscopic surgical skills due to increased mental workload for trainees.

Liver disease in the morbidly obese: a review of 1000 consecutive patients undergoing weight loss surgery.

BACKGROUND: Liver disease among the morbidly obese is increasingly prevalent, contributing to significant morbidity. Obesity-related liver pathologies including nonalcoholic steatohepatitis (NASH) have become a leading cause for liver transplant. However, risk factors for developing severe liver disease in the morbidly obese remain unknown. The objective of this study was to determine the frequency of abnormal liver pathology and any relationship to patient-related factors. METHODS: One thousand consecutive patients undergoing weight loss surgery were reviewed. All patients had a liver biopsy at the time of surgery. Frequency of benign pathology, steatosis, NASH, and fibrosis on pathologic examination of liver biopsy specimens were recorded. Pathologic findings were compared and analyzed to age and body mass index (BMI) of all patients. RESULTS: All patients in the study population had a BMI>35 kg/m2. Of these patients, 80.2% had liver disease related to obesity on pathology, including 65.9% with steatosis (grade 1-3), and 14.3% with NASH and/or fibrosis. Mean BMI of patients with liver disease was 48.1 compared to a BMI of 47.7 with benign pathology (P=.523). Mean age of patients with and without abnormal pathology was 48.3 and 47.3, respectively (P=.294). CONCLUSION: Liver disease is highly prevalent in the obese, but is not associated with increased age or BMI. Although all morbidly obese patients appear at significant risk for developing severe liver pathology, further risk factors are unknown.

WSES guidelines for management of Clostridium difficile infection in surgical patients.

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Patience is a virtue: an argument for delayed surgical intervention in fulminant Clostridium difficile colitis.

Recently, the incidence and severity of Clostridium difficile infection (CDI) has increased. In cases of fulminant infection, surgery is a viable therapeutic option but associated with high mortality. We sought to examine factors associated with mortality in a large sample of patients with severe CDI that underwent surgery. A retrospective study was conducted in patients with severe CDI undergoing colectomy. Demographics, risk factors, comorbidities, clinical and laboratory data, and time between admission/diagnosis of CDI and colectomy were collected. Conventional markers of severity were evaluated as predictors of mortality. Sixty-four cases were included for analysis. The overall observed mortality rate was 45.3 per cent. Few conventional markers of severity were significantly associated with mortality. Risk factors that correlated with postsurgical mortality were vasopressor use (odds ratio, 3.08; 95% confidence interval, 1.00 to 9.92) and shorter time between diagnosis and surgery (median time, 2 vs 3 days, P = 0.009). This study suggests that a delay in surgery after diagnosis of severe CDI may improve overall outcomes. The finding regarding timing of surgery is contrary to traditional teaching and may be the result of improved medical treatment and stabilization before surgery. Consideration should be given to the importance of timing of colectomy in fulminant CDI, whereas prospective studies should be conducted to elucidate causal relationships.

The relationship between confidence and competence in the development of surgical skills.

BACKGROUND: Confidence is a crucial trait of any physician, but its development and relationship to proficiency are still unknown. This study aimed to evaluate the relationship between confidence and competency of medical students undergoing basic surgical skills training. METHODS: Medical students completed confidence surveys before and after participating in an introductory workshop across 2 samples. Performance was assessed via video recordings and compared with pretraining and posttraining confidence levels. RESULTS: Overall, 150 students completed the workshop over 2 years and were evaluated for competency. Most students (88%) reported improved confidence after training. Younger medical students exhibited lower pretraining confidence scores but were just as likely to achieve competence after training. There was no association between pretraining confidence and competence, but confidence was associated with demonstrated competence after training (p < 0.001). CONCLUSIONS: Most students reported improved confidence after a surgical skills workshop. Confidence was associated with competency only after training. Future training should investigate this relationship on nonnovice samples and identify training methods that can capitalize on these findings.

Fulminant Clostridium difficile infection: An association with prior appendectomy?

AIM: To examine if fulminant Clostridium difficile infections (CDI) resulting in colectomy was associated with a prior appendectomy and whether any association affected the severity of the disease. METHODS: A retrospective chart review was performed on patients who underwent colectomy for CDI between 2001 and 2011. The appendectomy rate was calculated based on the absence of an appendix on the surgical pathology report. This was compared to an established lifetime risk of appendectomy in the general population. A chart review was performed for mortality and traditional markers of CDI disease severity. Fisher's exact test was used to calculate the likelihood of association between prior appendectomy, mortality, and clinical markers of severity of infection. RESULTS: Fifty-five specimens were identified with pseudomembranous colitis consistent with CDI. All patients had a clinical history consistent with CDI and 45 of 55 (81.8%) specimens also had microbiological confirmation of CDI. Appendectomy was observed in 24 of 55 specimens (0.436, 99%CI: 0.280-0.606). This was compared to the lifetime incidence of appendectomy of 17.6%. The rate of appendectomy in our sample was significantly higher than would be expected in the general population (43.6% vs 17.6%, P < 0.01). Disease severity did not differ based on presence or absence of an appendix and no association was detected between prior appendectomy and mortality (OR = 0.588, 95%CI: 0.174-1.970). CONCLUSION: The rate of appendectomy in the patients whose CDI led to colectomy, was significantly higher than the calculated lifetime risk, suggesting an association of appendectomy and severe CDI resulting in colectomy. Larger prospective studies are needed to assess any potential causal relationships affecting fulminant CDI.