Long-Term Survival Outcomes after Operative Management of Chronic Pancreatitis: Two Decades of Experience.

BACKGROUND: Chronic pancreatitis is a debilitating, life-altering disease; however, the long-term outcomes after operative intervention have not been established. STUDY DESIGN: Patients who underwent operative intervention at a single institution between 2000 and 2020 for chronic pancreatitis were included, and survival was assessed using the National Death Index. RESULTS: A total of 493 patients who underwent 555 operative interventions for chronic pancreatitis during 2 decades were included. Of these patients, 48.5% underwent total pancreatectomy ± islet autotransplantation, 21.7% underwent a duodenal preserving pancreatic head resection and/or drainage procedure, 16.2% underwent a pancreaticoduodenectomy, and 12.8% underwent a distal pancreatectomy. The most common etiology of chronic pancreatitis was idiopathic (41.8%), followed by alcohol (28.0%) and known genetic polymorphisms (9.9%). With a median follow-up of 83.9 months, median overall survival was 202.7 months, with a 5- and 10-year overall survival of 81.3% and 63.5%. One hundred sixty-five patients were deceased, and the most common causes of death included infections (16.4%, n=27), cardiovascular disease (12.7%, n=21), and diabetes-related causes (10.9%, n=18). On long-term follow-up, 73.1% (n=331) of patients remained opioid free, but 58.7% (n=266) had insulin-dependent diabetes. On multivariate Cox proportional hazards modeling, only persistent opioid use (hazard ratio 3.91 [95% CI 2.45 to 6.24], p < 0.01) was associated with worse overall survival. CONCLUSIONS: Our results represent the largest series to date evaluating long-term survival outcomes in patients with chronic pancreatitis after operative intervention. Our data give insight into the cause of death and allow for the development of mitigation strategies and long-term monitoring of comorbid conditions.

Predicting endocrine function after total pancreatectomy and islet cell autotransplantation: A novel approach utilizing computed tomography texture analysis.

BACKGROUND: Islet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. METHODS: All patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day. RESULTS: Sixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08-4.80; P = .02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P < .01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56-20.19; P = .01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775). CONCLUSION: Computed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation.

Total pancreatectomy and islet cell autotransplantation: a 10-year update on outcomes and assessment of long-term durability.

BACKGROUND: Total pancreatectomy and islet cell autotransplantation (TPIAT) offers an effective, lasting solution for the management of chronic pancreatitis up to 5-years post-operatively. Our aim was to assess durability of TPIAT at 10-years. METHODS: Patients undergoing TPIAT for chronic pancreatitis eligible for 10-year follow-up were included. Primary outcomes, including endocrine function and narcotic requirements, were reported at 5-, 7.5-, and 10-years post-operatively. RESULTS: Of the 231 patients who underwent TPIAT, 142 met inclusion criteria. All patients underwent successful TPIAT with an average of 5680.3 islet equivalents per body weight. While insulin independence tended to decrease over time (25.7% vs. 16.0% vs. 10.9%, p = 0.11) with an increase in HbA1C (7.6% vs. 8.2% vs. 8.4%, p = 0.09), partial islet function persisted (64.9% vs. 68.0% vs. 67.4%, p = 0.93). Opioid independence was achieved and remained durable in the majority (73.3% vs. 72.2% vs. 75.5%, p = 0.93). Quality of life improvements persisted, with 85% reporting improvement from baseline at 10-years. Estimated median overall survival was 202.7 months. CONCLUSION: This study represents one of the largest series reporting on long-term outcomes after TPIAT, demonstrating excellent long-term pain control and durable improvements in quality of life. Islet cell function declines over time however stable glycemic control is maintained.

Is There a Benefit to Adjuvant Chemotherapy in Resected, Early Stage Pancreatic Ductal Adenocarcinoma?

BACKGROUND: The role of systemic therapy for Stage IA pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of our study was to evaluate the impact of adjuvant chemotherapy (AC) on survival in patients with early stage disease. METHODS: The National Cancer Database was queried from 2006 to 2017 for resected pT1N0M0 (Stage 1A) PDAC. Exclusion criteria included neoadjuvant therapy, radiation, or those who suffered a 90-day mortality. RESULTS: Of the 1526 patients included in the study, 42.2% received AC and 57.8% underwent surgery alone. Patients who received AC were younger, had fewer comorbidities, and were more likely to have private insurance, compared with those treated with surgery alone. Patients who received AC had longer median overall survival (OS) compared with those who underwent surgery alone (105.7 months vs 72.0 months, p < 0.01). Subset analyses based on individual "good" prognostic features (size ≤ 1.0 cm, lymphovascular invasion negative, well/moderately differentiated, margin negative resection) demonstrated improved OS with AC. Following propensity score matching based on key clinicopathologic features, AC remained associated with improved median OS (83.7 months vs 59.8 months, p < 0.01). However, in the cohort with body/tail tumors (101.2 months vs 95.0 months, p = 0.19) and those with all "good" prognostic features (95.9 months vs 90.6 months, p = 0.15), AC was not associated with improved survival. CONCLUSIONS: In resected, Stage IA PDAC, AC is associated with improved overall survival in the vast majority of patients; however, in select cohorts the role of AC is unclear. Further study is needed to tailor treatment to individual patients with PDAC.

Systemic Therapy for Resected Pancreatic Adenocarcinoma: How Much is Enough?

BACKGROUND: Systemic therapy is an essential part of treatment for pancreatic ductal adenocarcinoma (PDAC). However, not all patients receive every cycle of chemotherapy and even if they do, the impact of reduced dose density (DD) on survival is not known. PATIENTS AND METHODS: A single institutional prospective database was queried for patients with PDAC who underwent curative resection between 2009 and 2018. The primary outcome was DD, defined as the percentage of total planned chemotherapy actually received and associated survival. RESULTS: Of the 126 patients included, 38.9% underwent a neoadjuvant approach, which was associated with a greater median number of completed chemotherapy cycles (5 cycles versus 4 cycles, p < 0.01) and a higher median total DD (93.0% versus 65.0%, p < 0.01), compared with an adjuvant treatment approach. In both groups, adjuvant chemotherapy completion rates were low, with only 55 patients completing all adjuvant cycles. After sequential survival analysis, patients who received a DD ≥ 80% had improved median overall survival (OS) (27.1 months versus 18.6 months, p = 0.01), compared with patients who achieved a DD < 80%. On multivariate Cox proportional-hazards modeling, only the presence of lymphovascular invasion (HR: 1.77, 95% CI: 1.04-2.99, p = 0.04) and DD < 80% (HR: 1.91, 95% CI: 1.23-3.00, p = 0.01) were associated with decreased OS. CONCLUSIONS: In this cohort study, patients who received ≥ 80% DD had significantly better OS. DD should be considered an important prognostic metric in pancreatic cancer, and strategies are needed to improve chemotherapy tolerance to improve patient outcomes.

Radiation therapy in borderline resectable pancreatic cancer: A review.

BACKGROUND: Borderline resectable pancreatic cancer constitutes a complex clinical entity, presenting the clinician with a locally aggressive disease that has a proclivity for distant spread. The benefits of radiation therapy, such as improved local control and improved survival, have been questioned. In this review we seek to summarize the existing evidence on radiation therapy in borderline resectable pancreatic cancer and highlight future areas of research. METHODS: A comprehensive review of PubMed for clinical studies reporting outcomes in borderline resectable pancreatic cancer was performed in June 2021, with an emphasis placed on prospective studies. RESULTS: Radiologic "downstaging" in borderline resectable pancreatic cancer is a rare event, although some evidence shows increased clinical response to neoadjuvant chemotherapy over radiation therapy. Margin status seems to be equivalent between regimens that use neoadjuvant chemotherapy alone and regimens that include neoadjuvant radiation therapy. Local control in borderline resectable pancreatic cancer is likely improved with radiation therapy; however, the benefit of improved local control in a disease marked by systemic failure has been questioned. Although some studies have shown improved survival with radiation therapy, differences in the delivery and tolerance of chemotherapy between the neoadjuvant and adjuvant setting confound these results. When the evidence is evaluated as a whole, there is no clear survival benefit of radiation therapy in borderline resectable pancreatic cancer. CONCLUSION: Once considered a staple of therapy, the role of radiation therapy in borderline resectable pancreatic cancer is evolving as systemic therapy regimens continues to improve. Increased clinical understanding of disease phenotype and response are needed to accurately tailor therapy for individual patients and to improve outcomes in this complex patient population.

Recover Wisely From COVID-19: Responsible Resumption of Nonurgent Radiology Services.

RATIONALE AND OBJECTIVES: Following state and institutional guidelines, our Radiology department launched the "Recover Wisely" for all nonurgent radiology care on May 4, 2020. Our objective is to report our practice implementation and experience of COVID-19 recovery during the resumption of routine imaging at a tertiary academic medical center. MATERIALS AND METHODS: We used the SQUIRE 2.0 guidelines for this practice implementation. Recover Wisely focused on a data driven, strategic rescheduling and redesigning patient flow process. We used scheduling simulations and meticulous monitoring and control of outpatient medical imaging volumes to achieve a linear restoration to our pre-COVID imaging studies. We had a tiered plan to address the backlog of rescheduled patients with gradual opening of our imaging facilities, while maintaining broad communication with our patients and referring clinicians. RESULTS: Recover Wisely followed our anticipated linear modeling. Considering the last 10 weeks in the recovery, outpatient growth was linear with an increase of approximately 172 cases per week, (R2 =0.97). We achieved an overall recovery of 102% in week 10, as compared to average weekly pre-COVID outpatient volumes. The modalities recovered as follows in outpatient volumes: CT (113%), MRI (101%), nuclear medicine including PET (138%), mammograms (97%), ultrasound (99%) and interventional radiology (106%). When compared to identical 2019 calendar weeks (May 4, 2020-July 10, 2020), the total 2020 radiology volume was 11% reduced from the 2019 volume. The reduction in total weighted relative value units was 8% in this time period, as compared to 2019. CONCLUSION: Our department utilized a data-driven, team approach based on our guiding principles to "Recover Wisely." We created and implemented a methodology that achieved a linear increase in outpatient studies over a 10-week recovery period.

Rescheduling Nonurgent Care in Radiology: Implementation During the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: To meet hospital preparedness for the coronavirus disease 2019 pandemic, the Centers for Disease Control and Prevention and ACR recommended delay of all nonemergent tests and elective procedures. The purpose of this article is to report our experience for rescheduling nonemergent imaging and procedures during the pandemic at our tertiary academic institution. METHODS: We rescheduled the nonemergent imaging and procedures in our hospitals and outpatient centers from March 16 to May 4, 2020. We created a tiered priority system to reschedule patients for whom imaging could be delayed with minimal clinical impact. The radiologists performed detailed chart reviews for decision making. We conducted daily virtual huddles with discussion of rescheduling strategies and issue tracking. RESULTS: Using a snapshot during the rescheduling period, there was a 53.4% decrease in imaging volume during the period of March 16 to April 15, 2020, compared with the same time period in 2019. The total number of imaging studies decreased from 38,369 in 2019 to 17,891 in 2020 during this period. Although we saw the largest reduction in outpatient imaging (72.3%), there was also a significant decrease in inpatient (40.5%) and emergency department (48.9%) imaging volumes. DISCUSSION: The use of multiple communication channels was critical in relaying the information to all our stakeholders, patients, referring physicians, and the radiology workforce. Teamwork, quick adoption, and adaptation of changing strategies was important given the fluidity of the situation.

Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis.

BACKGROUND: A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes. METHODS: Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated. RESULTS: Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15). CONCLUSIONS: Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.

Does radiologic response correlate to pathologic response in patients undergoing neoadjuvant therapy for borderline resectable pancreatic malignancy?

BACKGROUND AND OBJECTIVES: In patients with borderline resectable pancreas cancers, clinicians frequently consider radiographic response as the primary driver of whether patients should be offered surgical intervention following neoadjuvant therapy (NT). We sought to determine any correlation between radiographic and pathologic response rates following NT. METHODS: Between 2005 and 2015, 38 patients at a tertiary care referral center underwent NT followed by pancreaticoduodenectomy for borderline resectable pancreas cancer. Radiographic response after the completion of NT and pathologic response after surgery were graded according to RECIST and Evans' criteria, respectively. RESULTS: Preoperatively, 50% of patients underwent chemotherapy alone and 50% underwent chemotherapy and chemoradiation. Radiographically, one patient demonstrated a complete radiologic response, 68.4% (n = 26) of patients had stable disease (SD), 26.3% (n = 10) demonstrated a partial response, and one patient had progressive. Among patients without radiographic response, 77.7% (n = 21) achieved a R0 resection. Of patients with SD on imaging, 26.9% (n = 7) had Evans grade IIB or greater pathologic response. CONCLUSIONS: Our data indicate that approximately one-fourth of patients who did not have a radiologic response had a grade IIB or greater pathologic response. In the absence of metastatic progression, lack of radiographic down-staging following NT should not preclude surgery.

Completion pancreatectomy and islet cell autotransplantation as salvage therapy for patients failing previous operative interventions for chronic pancreatitis.

PURPOSE: Traditional decompressive and/or pancreatic resection procedures have been the cornerstone of operative therapy for refractory abdominal pain secondary to chronic pancreatitis. Management of patients that fail these traditional interventions represents a clinical dilemma. Salvage therapy with completion pancreatectomy and islet cell autotransplantation (CPIAT) is an emerging treatment option for this patient population; however, outcomes after this procedure have not been well-studied. METHODS: All patients undergoing CPIAT after previous decompressive and/or pancreatic resection for the treatment of chronic pancreatitis at our institution were identified for inclusion in this single-center observational study. Study end points included islet yield, narcotic requirements, glycemic control, and quality of life (QOL). QOL was assessed using the Short Form (SF)-36 health questionnaire. RESULTS: Sixty-four patients underwent CPIAT as salvage therapy. The median age at time of CPIAT was 38 years (interquartile range [IQR], 14.7-65.4). The most common etiology of chronic pancreatitis was idiopathic pancreatitis (66%; n = 42) followed by genetically linked pancreatitis (9%; n = 6) and alcoholic pancreatitis (8%; n = 5). All of these patients had previously undergone prior limited pancreatic resection or decompressive procedure. The majority of patients (50%; n = 32) underwent prior pancreaticoduodenectomy, whereas the remainder had undergone distal pancreatectomy (17%; n = 11), Frey (13%; n = 8), Puestow (13%; n = 8), or Berne (8%; n = 5) procedures. Median time from initial surgical intervention to CPIAT was 28.1 months (IQR, 13.6-43.0). All of these patients underwent a successful CPIAT. Mean operative time was 502.2 minutes with average hospital duration of stay of 13 days. Islet cell isolation was feasible despite previous procedures with a mean islet yield of 331,304 islet cell equivalents, which totaled an islet cell autotransplantation of 4,737 ± 492 IEQ/kg body weight. Median patient follow-up was 21.2 months (IQR, 7.9-36.8). Before CPIAT, all patients required a mean of 120.8 morphine equivalent milligrams per day (MEQ/d), which improved to 48.5 MEQ (P < .001 compared with preoperative requirements) at most recent follow-up. Of these patients, 44% (n = 28) achieved narcotic independence. All patients were able to achieve stable glycemic control with a mean insulin requirement of 16 units per day. Of these patients, 20% (n = 13) were insulin independent after CPIAT. Mean postoperative glycosylated hemoglobin was 7.8% (range, 4.6-12.5). Islet cell viability was confirmed with endocrine testing and mean C-peptide levels 6 months after CPIAT were 0.91 ng/mL (range, 0.1-3.0). The SF-36 QOL survey administered postoperatively demonstrated improvement in all tested modules. CONCLUSION: This study is the first to examine the results of salvage therapy with CPIAT for patients with refractory chronic pancreatitis. Patients undergoing CPIAT achieved improved postoperative narcotic requirements, stable glycemic control, and improved QOL.

Total pancreatectomy with islet cell autotransplantation as the initial treatment for minimal-change chronic pancreatitis.

OBJECTIVES: Patients with minimal-change chronic pancreatitis (MCCP) are traditionally managed medically with poor results. This study was conducted to review outcomes following total pancreatectomy with islet cell autotransplantation (TP/IAT) as the initial surgical procedure in the treatment of MCCP. METHODS: All patients submitted to TP/IAT for MCCP were identified for inclusion in a single-centre observational study. A retrospective chart review was performed to identify pertinent preoperative, perioperative and postoperative data. RESULTS: A total of 84 patients with a mean age of 36.5 years (range: 15-60 years) underwent TP/IAT as the initial treatment for MCCP. The most common aetiology of chronic pancreatitis in this cohort was idiopathic (69.0%, n = 58), followed by aetiologies associated with genetic mutations (16.7%, n = 14), pancreatic divisum (9.5%, n = 8), and alcohol (4.8%, n = 4). The most common genetic mutations pertained to CFTR (n = 9), SPINK1 (n = 3) and PRSS1 (n = 2). Mean ± standard error of the mean preoperative narcotic requirements were 129.3 ± 18.7 morphine-equivalent milligrams (MEQ)/day. Overall, 58.3% (n = 49) of patients achieved narcotic independence and the remaining patients required 59.4 ± 10.6 MEQ/day (P < 0.05). Postoperative insulin independence was achieved by 36.9% (n = 31) of patients. The Short-Form 36-Item Health Survey administered postoperatively demonstrated improvement in all tested quality of life subscales. CONCLUSIONS: The present report represents one of the largest series demonstrating the benefits of TP/IAT in the subset of patients with MCCP.

Surgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients.

BACKGROUND: This study aims to review surgical outcomes of pediatric patients undergoing total pancreatectomy with islet cell autotransplantation (TP/IAT) for the treatment of chronic pancreatitis (CP). METHODS: All pediatric patients (≤18 years old) undergoing TP/IAT over a 10-year period (December 2002-June 2012) were identified for inclusion in a single-center, observational cohort study. Retrospective chart review was performed to identify pertinent preoperative, perioperative, and postoperative data, including narcotic usage, insulin requirements, etiology of pancreatitis, previous operative interventions, operative times, islet cell yields, duration of hospital stay, and overall quality of life. Quality of life was assessed using the Short Form-36 health questionnaire. RESULTS: Fourteen pediatric patients underwent TP/IAT for the treatment of CP at the University of Cincinnati with a mean age of 15.9 years (range, 14-18) and a mean body mass index of 21.8 kg/m(2) (range, 14-37). Of the patients, 50% (n = 7) were male and 29% had undergone previous pancreatic operations (1 each of Whipple, Puestow, Frey, and Berne procedures). Etiology of pancreatitis was idiopathic for 57% (n = 8); the remainder had identified genetic mutations predisposing to pancreatitis (CFTR, n = 4; SPINK1, n = 1; PRSS1, n = 1). Mean operative time was 532 minutes (range, 360-674) with an average hospital duration of stay of 16 days (range, 7-37). Islet cell isolation resulted in mean islet cell equivalents (IEQ) of 500,443 in patients without previous pancreatic surgery versus 413,671 IEQ in patients with prior pancreatic surgery (P = .12). Median patient follow-up was 9 months from surgery (range, 1-78). Preoperatively, patients required on average 32.7 morphine equivalent mg per day (MEQ), which improved to 13.9 MEQ at most recent follow-up. Eleven patients (79%) were narcotic independent. None of the patients were diabetic preoperatively. All of the patients were discharged after the operation with scheduled insulin requirements (mean, 17 U/d). This requirement decreased to a mean of 10.1 U/d at most recent follow-up visit. Four patients (29%) progressed to insulin independence. All patients in this series achieved stable glycemic control postoperatively and there was no incidence of "brittle" diabetes. Quality-of-life surveys showed improvement in all tested modules. CONCLUSION: This study represents one of the largest series examining TP/IAT in the pediatric population. Pediatric patients benefitted from TP/IAT with a decrease in postoperative narcotic requirements, stable glycemic control, and improved quality of life.

Ductus arteriosus aneurysm with massive thrombosis of pulmonary artery and fetal hydrops.

Ductus arteriosus aneurysm (DAA) is a rare cardiovascular lesion usually diagnosed within the first 2 months of life, or less frequently in the 3rd trimester, by antenatal sonography. The true in utero incidence of DAA is unknown, as most affected fetuses are asymptomatic at birth. Potential complications include thromboembolism, rupture, and death. We report a unique lethal case of a large DAA detected by mid-2nd trimester fetal echocardiography, complicated by stricture and massive occlusive thrombosis extending into the pulmonary artery branches. Stricture and thrombosis of the DAA led to interruption of fetal circulation, cardiac failure, and fetal hydrops, ultimately resulting in fetal demise.

Factors associated with recidivism following pancreaticoduodenectomy.

OBJECTIVES: Factors related to readmission after pancreaticoduodenectomy (PD) may include postoperative morbidity and the functional status of the patient. This study aimed to retrospectively review our institution's experience of readmission of patients who had undergone Whipple procedure PD. METHODS: Recidivism was defined as readmission to the primary or a secondary hospital within, respectively, 30 days, 30-90 days or 90 days postoperatively. Associations between recidivism, perioperative factors and patient characteristics were evaluated. RESULTS: During the past 5 years, 30-day, 30-90-day and 90-day recidivism rates were 14.5%, 18.5% and 27.4%, respectively. The most common reasons for readmission included dehydration and/or malnutrition (37.5% of readmissions) and pain (12.5%). Patients who underwent PD for chronic pancreatitis were more likely to be readmitted within 90 days of surgery than patients who underwent PD for malignancy (P < 0.01). Intraoperative transfusion was also associated with 30-90-day and 90-day recidivism (P < 0.01). Preoperative comorbidities, including Charlson Comorbidity Index score, number of pre-discharge complications, type of Whipple reconstruction, preoperative biliary stenting, need for vascular reconstruction and patient body mass index were not associated with recidivism. CONCLUSIONS: Our data confirm previous reports indicating high rates of readmission after PD. To our knowledge, this report is the first to demonstrate chronic pancreatitis as an independent risk factor for readmission.

Total pancreatectomy and islet cell autotransplantation as a means of treating patients with genetically linked pancreatitis.

BACKGROUND: For patients with severe chronic pancreatitis, total or completion pancreatectomy with islet cell autotransplantation (IAT) can alleviate pain and avoid the complications of diabetes. Several genetic mutations, specifically, PRSS1, CFTR, and SPINK1, are associated with chronic pancreatitis. Few reports have focused on the benefit of this operation for this subset of patients. METHODS: Between February 2000 and July 2009, 118 patients were treated with total pancreatectomy and IAT for chronic pancreatitis. Patients with known genetic mutations were then selected for further analysis. RESULTS: Of the 188 patients, 16 (13.6%) patients were identified as having genetic mutations, including CFTR (n = 10), PRSS1 (n = 4), and SPINK1 (n = 2) mutations. Mean patient age was 31.4 years (range, 15-59) with an equal male-to-female ratio (50:50). Preoperatively, patients required an average of 185 ± 60 morphine equivalents (MEQ) (median, 123 MEQ) for preoperative pain control. No patients were taking insulin before operation. After resection with IAT, patients were discharged from the hospital with a daily average of 22 ± 4 units of insulin with 6 (38%) patients requiring fewer than 15 units of insulin at the time of discharge. At a mean follow-up of 22 months, mean insulin requirements decreased to 15 U/d (P = .0172). A total of 7 (44%) patients required 15 or fewer units daily, and 4 (25%) patients were completely insulin-independent. Average daily narcotic usage at most recent follow-up decreased to 70 MEQ (median, 0) with 10 (63%) patients currently narcotic-independent. Analyses of the 36-item short-form health survey and the McGill Pain Questionnaire demonstrated a significant improvement in quality-of-life parameters and pain assessment. CONCLUSION: In patients who suffer from genetically linked chronic pancreatitis, pancreatic resection with IAT should be considered as an early therapeutic option to decrease chronic abdominal pain while preserving endogenous endocrine function.

Meniscal gymnastics: common and uncommon locations of meniscal flip and flop.

The majority of knee magnetic resonance imaging examinations are performed for meniscal evaluations. Displaced meniscal tears including free meniscal fragments are an important diagnosis as most of these tears are unstable and require surgical intervention. Magnetic resonance imaging can be an invaluable tool in the arthroscopic search for a free meniscal fragment. In addition to the commonly seen bucket-handle tears flipped into the intercondylar notch, it is important to be aware of less common locations where menisci may be displaced. First, we briefly summarize the basic meniscal anatomy and some of the more common tear patterns. We then investigate the broad range of meniscal migration.

Intraoperative margin re-resection for colorectal liver metastases.

OBJECTIVE: Evaluate recurrence and survival in patients who underwent intraoperative margin re-resection for colorectal cancer liver (CRC) metastases. DESIGN: Retrospective analysis. SETTING: University Hospital, Cincinnati, Ohio. Academic medical center. PARTICIPANTS: Cohort of 118 patients who underwent resection of CRC liver metastases between 1992 and 2004. All patients were divided into 3 groups: resection margin (MOR) less than 1 cm (n = 64), MOR greater than 1 cm (n = 33), and re-resection margin (re-MOR) greater than 1 cm (n = 21). RESULTS: Patients with a margin greater than 1 cm, when compared with re-MOR greater than 1 had decreased incidence of liver and distant recurrence (p < 0.05) as well as improved disease-free survival (39.2 vs 22.9 months, p = 0.023). Differences in overall survival (58.6 vs 44.2 months, p = 0.14) were not significant. CONCLUSION: Intraoperative re-resection is associated with an increased risk of local and distant recurrence, which may be a reflection of both inadequate surgery and underlying tumor biology.

Review of the abdominal manifestations of cystic fibrosis in the adult patient.

Cystic fibrosis is a common inherited fatal disease. As the life expectancy of affected individuals continues to increase with advances in disease management, this disease is no longer limited to the pediatric population. Currently, 40% of patients with cystic fibrosis are adults. In addition, patients may not present until adulthood and frequently have extrapulmonary symptoms. Abdominal manifestations are common and affect multiple organ systems. Hepatobiliary manifestations include fatty infiltration of the liver, gallbladder abnormalities, bile duct abnormalities, focal biliary fibrosis, and multinodular cirrhosis. Manifestations in the pancreas include acute pancreatitis, fatty replacement, calcifications, cysts, duct abnormalities, and carcinoma. Gastrointestinal manifestations include gastroesophageal reflux, peptic ulceration of the gastric and duodenal mucosa, distal intestinal obstruction syndrome, intussusception, appendicitis, fibrosing colonopathy, pneumatosis intestinalis, rectal mucosal prolapse, malignancies, and pseudomembranous colitis. Renal manifestations include nephrolithiasis, as well as secondary renal complications such as interstitial nephritis due to antibiotic therapy and amyloidosis. Awareness of these manifestations is important to successfully guide management of cystic fibrosis in adult patients.

Clinical significance of bacterial cultures from 28 autologous islet cell transplant solutions.

PURPOSE: Total pancreatectomy and autologous islet cell transplantation are being investigated as a novel surgical treatment for patients with chronic pancreatitis. Preliminary data has demonstrated the presence of enteric bacteria in solutions used to harvest islet cells. Subsequently, we started culturing autologous islet solutions to determine whether any concordance existed between these cultures and postoperative infectious complications. METHODS: A retrospective analysis evaluated microbiologic cultures between July 2000 and November 2003; 33 patients underwent total or completion pancreatectomy and islet cell transplantation. Five patients were excluded due to incomplete culture data. Aerobic, anaerobic and fungal cultures were performed on all islet preparation solutions. Patient charts were examined for postoperative infectious complications. Microbiologic data from these infections was compared to pretransplant islet cultures. Islet cells from each patient were tested in vitrofor both function and viability. RESULTS: Of the 28 patients, 25 (89.3%) had bacterial culture-positive media solutions. Only 4 patients (14.3%) had an infectious complication from which bacteria was isolated that corresponded to bacteria in their islet cell preparation. In vitro islet cell viability was greater than 95% in the pretransplant aliquots. CONCLUSION: These results suggest that transplantation of bacterial-positive islet cell solutions does not appear to increase the risk of postoperative infectious complications or impact islet cell viability. Therefore, prolonged antibiotic treatment against these specific bacteria beyond the perioperative period does not seem warranted.