Pancreatic adenocarcinoma: effects of neoadjuvant therapy on post-pancreatectomy outcomes - an American College of Surgeons National Surgical Quality Improvement Program targeted variable review.

BACKGROUND: As the incidence of pancreatic adenocarcinoma increases, so has the utilization of neoadjuvant therapy. The objective of this study was to evaluate outcomes in patients undergoing neoadjuvant therapy or surgery first for pancreatic adenocarcinoma. METHODS: The ACS-NSQIP 2014-2015 targeted pancreatectomy variables were queried for patients with pancreatic adenocarcinoma who underwent resection. Outcomes of those receiving neoadjuvant therapy were compared to surgery first using a multivariate, logistic regression model. RESULTS: 3408 patients underwent pancreatectomy; 2596 proximal pancreatectomies, 741 distal pancreatectomies, 64 total pancreatectomies and 7 other pancreatic procedures were performed. Of the 3408 patients identified, 934 (27.5%) received neoadjuvant therapy: 496 chemotherapy alone, 28 radiation alone, and 410 combined chemotherapy/radiation therapy. Overall morbidity and mortality were similar between patients receiving neoadjuvant therapy versus those who underwent surgery first. Neoadjuvant treatment was associated with lower rates of pancreatic fistulas (10.2% vs. 13.2%, P = 0.017), but higher intra/postoperative transfusion rates (27.4% vs. 20.3%, P < 0.0001). CONCLUSIONS: Neoadjuvant therapy appeared to be safe prior to operative intervention as no difference in overall postoperative morbidity or mortality rates were identified. There were increased intra/postoperative transfusions in the neoadjuvant therapy group, but neoadjuvant therapy was associated with lower rates of pancreatic fistulas.

Changing trends and outcomes in the use of percutaneous cholecystostomy tubes for acute cholecystitis.

BACKGROUND: Percutaneous cholecystostomy tube (PCT) placement serves as a treatment option for acute cholecystitis in elderly and critically ill patients. The objective of this study was to compare PCT and cholecystectomy outcomes over time. METHODS: PCTs placed from April 1, 1998, to December 31, 2009 (time period 2) were retrospectively reviewed. Patients who underwent cholecystectomies served as matched controls. Institutional data from March 1, 1989, to March 31, 1998 (time period 1) were reviewed to compare trends. RESULTS: A total of 143 patients successfully underwent PCT placement in time period 2. When compared with patients undergoing cholecystectomy, PCT patients had a higher rate of cardiovascular disease (66% vs 26%, P = 0.001), diabetes (27% vs 13%, P = 0.001), and a higher mean Charlson comorbidity index (3.27 vs 1.07, P = 0.001). Compared with the first time period, patients undergoing PCT in the second time period had lower American Society of Anesthesiologist's classifications (American Society of Anesthesiologist's class I, II: 0% vs 18%, P = 0.001). Thirty-day mortality decreased from 36% to 12% in patients undergoing PCT (P = 0.001). CONCLUSIONS: Among patients with acute cholecystitis, percutaneous cholecystostomy tubes were placed in older patients with increased comorbidities compared to cholecystectomy. Mortality rates after PCT decreased over time.

Diagnosis and Treatment of New-Onset Perioperative Atrial Fibrillation.

This article reviews medical and surgical risk factors for developing atrial fibrillation (AF), the most common sustained dysrhythmia in the United States. Evidence for assessment and management of patients with AF, including AF newly identified in the preoperative clinic, immediately preoperatively, intraoperatively, and unstable AF, is presented. A stepwise approach to guide anesthetic decision-making in the assessment of newly identified preoperative AF is proposed. Anesthetic considerations, including the potential impacts of anesthetic and vasopressor selection, and current evidence related to rate control and rhythm control via pharmacologic or electrical cardioversion as well as anticoagulation strategies are discussed.

Temporal Artery Biopsy: When Is It Worth the Headache?

BACKGROUND: Temporal artery biopsy is ordered when clinical symptoms and an elevated C-reactive protein values and/or erythrocyte sedimentation rates suggest giant cell arteritis. The percentage of temporal artery biopsies positive for giant cell arteritis is low. The objectives of our study were to analyze the diagnostic yield of temporal artery biopsies at an independent academic medical center and to develop a risk stratification model for triaging patients for possible temporal artery biopsy. METHODS: We retrospectively reviewed the electronic health records of all patients who underwent temporal artery biopsy in our institution from January 2010 through February 2020. We compared clinical symptoms and inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) values of patients whose specimens were positive for giant cell arteritis with those of patients with negative specimens. Statistical analysis included descriptive statistics, chi-square test, and multivariable logistic regression. A risk stratification tool, which included point assignments and measures of performance, was developed. RESULTS: Of 497 temporal artery biopsies for giant cell arteritis performed, 66 were positive and 431 were negative. Jaw/tongue claudication, elevated inflammatory marker values, and age were associated with a positive result. Using our risk stratification tool, 3.4% of low-risk patients, 14.5% of medium-risk patients, and 43.9% of high-risk patients were positive for giant cell arteritis. CONCLUSIONS: Jaw/tongue claudication, age, and elevated inflammatory markers were associated with positive biopsy results. Our diagnostic yield was much lower when compared with a benchmark yield determined in a published systematic review. A risk stratification tool was developed based on age and the presence of independent risk factors.

Perioperative quality metrics for one step breast cancer surgery: a patient-centered approach.

BACKGROUND AND OBJECTIVES: Patient-centered care is recommended by the Institute of Medicine to build a better healthcare system. The aim of this study was to audit patient-centered quality measures (QM) to create a breast center report card that could be provided to patients for education and informed consent. METHODS: An IRB approved retrospective review of 695 patients undergoing sentinel lymph node biopsy for breast cancer was conducted to audit the components of one step surgery and other QM. RESULTS: The intraoperative sensitivity to detect node positive patients was 25% (2/8), 27% (9/34), and 87% (68/78) for pN0(i+), pN1mi, pN1 patients, respectively. The re-excision lumpectomy rate was 15% (72/471) and the one step surgery success rate, which included lumpectomy and mastectomy patients, was 86% (598/695). Patient self-assessment of "very good to excellent" cosmesis and pain control were 77% (103/134) and 83% (60/72). Local recurrence rate was 2% (12/695) at a mean 3.1-year follow-up. CONCLUSIONS: The components of care that contribute to a patient-centered assessment of breast cancer surgery are measurable. "Bundling" of QM creates a perioperative report card that aids patients' informed consent and provides a framework for future comparative effectiveness studies.

Reduction of surgical site infections in colorectal surgery: A 10-year experience from an independent academic medical center.

BACKGROUND: Surgical site infections (SSI) are a source of patient morbidity and increased cost. In 2007, our organization discovered an SSI rate of 18% after colorectal surgery (CRS), corresponding to an ACS NSQIP benchmarked high outlier. METHODS: From 2007 to 2016, surgeons championed a stepwise, multidisciplinary improvement pathway for SSI reduction. NSQIP was used to track SSI rates and estimate cost savings. RESULTS: From 2007 to 2016, 1508 patients underwent CRS at our facility. In 2007, our SSI rate was 18%. In 2016, the SSI rate was 7%, corresponding to a NSQIP benchmarked exemplary performance. 54 patients avoided the morbidity of a SSI. The expense of SSI reduction implementation was $180,000. Cost savings was estimated at $1.3 million. CONCLUSIONS: Our approach reduced SSI rates by 58% over ten years. We observed a significant morbidity reduction and cost savings. Our strategy could be adopted within other medical centers focused on CRS SSI improvement.

Outcomes of Anterior Exposure for Spinal Surgery at an Independent Academic Medical Center.

INTRODUCTION: Anterior exposure for spinal surgery has expanded and is used for common spinal procedures, including anterior lumbar interbody fusion, disc replacement, and vertebral corpectomy. With this approach, vascular injuries have been reported ranging from 1% to 25%. The impact of resident participation on intraoperative and postoperative outcomes within an independent academic medical center has not been widely reported. The objective of this study was to determine the incidence of complications during anterior exposure spinal surgery at an independent academic medical center. METHODS: After institutional review board approval, we conducted a retrospective review of medical records of patients who underwent elective anterior exposure for spinal surgery from 2000 through 2014. RESULTS: The study included 335 patients; 60.3% were female. Thirty-day postoperative complications included surgical site infection (4.2%), urinary tract infection (2.7%), need for blood transfusion (2.1%), retrograde ejaculation (1.2%), and deep vein thrombosis (0.9%). There were 12 vascular injuries overall (3.6%); 2.7% were major vascular injuries. Surgery residents participated in 34% of cases. Resident involvement increased over the course of the study. There was no difference in operative time or complications with resident involvement. CONCLUSIONS: The overall incidence of major vascular injury was 2.7%. Levels of exposure and blood loss were associated with vascular injury. Overall postoperative complication rates as well as major vascular injury rates compared favorably to published benchmarks. Complication rates were unaffected by surgical resident involvement.

Superior mesenteric vein aneurysm rupture.

Aneurysmal disease in the venous system is uncommon. The majority of venous aneurysms occur in peripheral vessels. Visceral venous aneurysms (VVA) are rare, the most common being portal mesenteric vein aneurysms. Because of their rare nature, limited information concerning the natural history, presentation, and management of VVA is known. Many VVA are asymptomatic; others cause mass effect or other complications. Rupture is a rare complication, occurring in only 2.2% of VVA. To date, only 17 descriptions of superior mesenteric vein (SMV) aneurysms have been reported. We report the first case of a ruptured SMV aneurysm.