Portal venous thrombosis after distal pancreatectomy: clinical outcomes.

AIM: Outcomes of patients developing portal vein (PV) thrombosis (PVT) after distal pancreatectomy (DP) are unknown. The goal of this study was to identify risk factors for PVT and describe the long-term outcomes in these patients. METHODS: Patients undergoing DP without repair or reconstruction of the PV between 2001 and 2011 were included. Patients that showed evidence of PVT on pre-operative imaging were excluded from the study. Location and extent of thrombosis was determined by post-operative computed tomography or ultrasound imaging in all patients. Evidence of systemic thrombosis (if present) in addition to PVT was also documented. RESULTS: In the study period, 991 patients underwent DP and 21 (2.1%) patients were diagnosed with PVT. Pancreatic neoplasm was the most frequent indication for operation (n = 11). Thrombus occurred in the main PV in 15 and the right branch of the PV in 8 patients. Complete PV occlusion occurred in nine patients with a median time to diagnosis of 16 days (range 5-85 days). Seventeen patients were anticoagulated for a median duration of 6 months (range 3.3-36 months) after the diagnosis of PVT. Over a median follow-up of 22 months, resolution of PVT occurred in seven patients. Predictors of non-resolution of PVT included anesthesia time >180 min (p = 0.025), DM type II (p = 0.03), BMI >30 Kg/m(2) (p = 0.03), occlusive PVT (p < 0.001), or thrombus in a sectoral branch (p = 0.02). Anticoagulation therapy did not influence the frequency of thrombus resolution and was complicated by gastrointestinal hemorrhage in four patients. There was no mortality as a direct result of PVT or anticoagulation. CONCLUSION: PVT after distal pancreatectomy is a rare complication. Serious complications as a direct result of PVT in this setting are uncommon and are not dependent on thrombus resolution. Although anticoagulation does not appear to influence the rate of PVT resolution in this small retrospective series, we support the use of anticoagulation until larger, controlled studies define clear advantages or disadvantages.

Correlation of staging systems to survival in patients with resected hilar cholangiocarcinoma.

BACKGROUND: We aimed to identify staging parameters associated with survival in patients with hilar cholangiocarcinoma. METHODS: Clinicopathologic characteristics were obtained retrospectively for all resected patients with Bismuth-Corlette III cholangiocarcinoma between 1993 and 2011. Patients were stratified by the American Joint Commission on Cancer (AJCC) (7th edition) and Memorial Sloan-Kettering Cancer Center (MSKCC) staging systems. Survival analyses tested the effects of clinicopathologic factors and staging covariates on recurrence-free and overall survival. RESULTS: Eighty patients (mean age 63 ± 11 years, 63% male) underwent anatomic hepatectomy with bile duct resection/reconstruction for Bismuth-Corlette IIIa (53%) and IIIb (47%) cholangiocarcinoma. The median follow-up was 26 months (interquartile range = 12 to 50 months), and the median time to recurrence was 15 months (interquartile range = 6 to 38 months). Neither AJCC nor MSKCC staging systems were associated with recurrence-free survival (all P ≥ .059). MSKCC T-stage but not the AJCC staging system was associated with overall survival (P ≤ .026). CONCLUSIONS: MSKCC T-stage classification but not AJCC staging is independently associated with overall survival for patients after resection of hilar cholangiocarcinoma.

Immediate post-resection diabetes mellitus after pancreaticoduodenectomy: incidence and risk factors.

BACKGROUND: New-onset diabetes mellitus after a pancreaticoduodenectomy (PD) remains poorly defined. The aim of this study was to define the incidence and predictive factors of immediate post-resection diabetes mellitus (iPRDM). METHODS: Retrospective review of patients undergoing PD from January 2004 through to July 2010. Immediate post-resection diabetes mellitus was defined as diabetes requiring pharmacological treatment within 30 days post-operatively. Logistic regression was conducted to identify factors predictive of iPRDM. RESULTS: Of 778 patients undergoing PD, 214 were excluded owing to pre-operative diabetes (n= 192), declined research authorization (n= 14) or death prior to hospital discharge (n= 8); the remaining 564 patients comprised the study population. iPRDM occurred in 22 patients (4%) who were more likely to be male, have pre-operative glucose intolerance, or an increased creatinine, body mass index (BMI), pre-operative glucose, operative time, tumour size or specimen length compared with patients without iPRDM (P < 0.05). On multivariate analysis, pre-operative impaired glucose intolerance (P < 0.001), pre-operative glucose ≥ 126 (P < 0.001) and specimen length (P= 0.002) were independent predictors of iPRDM. A predictive model using these three factors demonstrated a c-index of 0.842. DISCUSSION: New-onset, post-resection diabetes occurs in 4% of patients undergoing PD. Factors predictive of iPRDM include pre-operative glucose intolerance, elevated pre-operative glucose and increased specimen length. These data are important for patient education and predicting outcomes after PD.

Distance bias and surgical outcomes.

BACKGROUND: A body of research has found that patients who travel a significant distance to obtain medical treatment experience better outcomes, a phenomenon termed "distance bias." This study uses risk-adjusted surgical outcomes data to analyze distance bias in a population of patients treated surgically at a tertiary care institution. METHODS: We used risk-adjusted surgical outcomes data from the National Surgical Quality Improvement Project at the Mayo Clinic to calculate observed and expected risk of a severe complication. Operations were stratified into quintiles based on the distance traveled by the patient. RESULTS: The average age of patients in our cohort was 56.7 years, and 59.2% were female; patients traveled an average of 226 miles for treatment. Patients living closest to the Mayo Clinic (quintile 1) had lower observed and expected risks of a severe complication relative to patients in quintiles 2-5. Patients from quintile 1 had outcomes which were better than predicted [observed:expected risk ratio of 0.82 (range, 0.63-0.99)]. Patients traveling intermediate distances (quintile 2) had outcomes which were worse than predicted [observed:expected risk ratio of 1.18 (range, 1.00-1.42)]. Operations performed on patients from greater distances (quintiles 3-5) had an observed risk of severe complications which was similar to expected. DISCUSSION: The phenomenon of distance bias which has previously been documented in medical and oncologic treatment is not demonstrated in this study. An opposite phenomenon may be more pertinent, where patients who are treated locally are less likely to have a severe complication and have outcomes which are better than predicted.

Splenectomy for massive splenomegaly: long-term results and risks for mortality.

OBJECTIVE: To evaluate long-term outcomes after splenectomy for massive splenomegaly in a series of 222 consecutive patients. BACKGROUND: Splenectomy for massive splenomegaly (>1500 g) provides palliation but is associated with a high rate of perioperative complications in a population of patients with advanced hematological malignancies. Predictive factors for survival and whether the palliative goals are achieved in the long-term are not well defined. METHODS: Patients with various hematological disorders who underwent splenectomy between 1998 and 2009 were followed until death or for at least 2 years. Linear and logistic regression analyses were used to ascertain the impact of demographical factors, diagnoses, and preoperative transfusion parameters on the postoperative survival. RESULTS: Splenectomy for massive splenomegaly was performed most commonly for non-Hodgkin lymphoma (48%) and myeloid metaplasia (31%). Mean ± standard deviation splenic weight was 2731 ± 1393 g (range, 1500-13,085 g). Average operating time was 115 minutes, with a range from 46 to 346 minutes. Thirty-day mortality was 1.8%, and the complication rate was 20%. The most common complications were hemorrhage (9%) and portal venous thrombosis (9.9%). Relief from pressure-related symptoms was achieved in 98.5%, and durable remission of anemia and thrombocytopenia persisted in half of the patients at 2 years. Sex, age, and intraoperative blood loss were not significantly associated with survival. Preoperative need for red blood cell and platelet transfusions were the most significant risk factors associated with decreased survival. CONCLUSIONS: Splenectomy for massive splenomegaly can be performed safely and offers durable palliation. Preoperative transfusion requirement is an indicator of hematological disease severity and predictor of decreased survival.

Gastrointestinal stromal tumour of the duodenum: single institution experience.

BACKGROUND: Primary gastrointestinal stromal tumours (GISTs) of the duodenum are rare. The aim of this study was to review the surgical management of GISTs in this anatomically complex region. METHODS: Retrospective review from January 1999 to August 2011 of patients with primary GISTs of the duodenum. RESULTS: Forty-one patients underwent resection of duodenal GISTs. All operations were performed with intent to cure with negative margins of resection. The most common location of origin was the second portion of the duodenum. Local excision (n= 19), segmental resection with primary anastomosis (n= 11) and a pancreatoduodenectomy (n= 11) were performed. Two patients underwent an ampullectomy with local excision. Peri-operative mortality and overall morbidity were 0 and 12, respectively. Patients with high-risk GISTs (P= 0.008) and those who underwent a pancreatoduodenectomy (P= 0.021) were at a greater risk for morbidity. The median follow-up was 18 months. Eight patients developed recurrence. High-risk GISTs and neoplasms with ulceration had the greatest risk for recurrence (P= 0.017, P= 0.029 respectively). The actuarial 3- and 5-year survivals were 85% and 74%, respectively. CONCLUSION: The choice and type of resection depends on the proximity to the ampulla of Vater, involvement of adjacent organs and the ability to obtain negative margins. The morbidity depends on the type of procedure for GIST.

Role of operative therapy in treatment of metastatic gastrointestinal stromal tumors.

BACKGROUND: Operative resection of metastatic gastrointestinal stromal tumors (GIST) is controversial. Current treatment strategies rely on the response to tyrosine kinase inhibitors (TKIs), with resultant individualization of operative intervention. We investigated the role of operative therapy in patients with metastatic GIST. METHODS: This retrospective cohort study included all consecutive patients treated for metastatic and/or recurrent GIST from January 2002 to June 2011. The patients were stratified by the use of operative therapy and disease response to TKI therapy. Kaplan-Meier survival analyses with log-rank comparisons tested the effects of operative therapy and the response to TKIs on survival. RESULTS: Of the 438 patients treated for GIST during the study period, 87 (median age 61 y, interquartile range 50-71; 55% male) had metastatic GIST (84% metastatic, 3% recurrent, and 13% metastatic and recurrent). Of these patients, 54 (62%) underwent operative exploration. Subtotal resection for palliative debulking (R2 resection) were performed in 19 patients; 32 patients underwent R0 resection. Operative intervention was associated with improved overall survival (OS) compared with systemic therapy alone (1 y OS, 98% versus 80% and 5-y OS, 65% versus 11%, respectively; P < 0.001). A TKI was used before resection in 32 patients. The disease response was partial in 13 patients, stable in 10, and progressive in 9. The 1- and 5-y OS and progression-free survival were strongly associated with the preoperative response to TKI and an R0 resection (all P ≤ 0.002). CONCLUSIONS: Among patients with metastatic GIST, preoperative response to TKI therapy and margin-negative resection were strongly associated with improved progression-free and OS.

Modified Appleby procedure for resection of tumors of the pancreatic body and tail with celiac axis involvement.

BACKGROUND: Involvement of the celiac axis by pancreatic tumors of the body and tail is no longer considered an absolute contraindication to resection. In highly selected patients, resection is possible, relying on collateral circulation through the gastroduodenal artery to maintain liver perfusion. Our approach to intraoperative assessment and resection is described herein.

Metastatic nonfunctioning pancreatic neuroendocrine carcinoma to liver: surgical treatment and outcomes.

BACKGROUND: The surgical treatment of metastatic, nonfunctional pancreatic neuroendocrine carcinoma (nPNEC) is not well defined. Existing series are confounded by inclusion of patients with metastatic functional tumors or gastrointestinal carcinoid. Our hypothesis was that the surgical treatment of metastatic nPNEC provides favorable perioperative and oncologic outcomes. STUDY DESIGN: We performed a retrospective review of all patients undergoing surgical treatment of metastatic nPNEC to the liver from 1987 through 2008 at the Mayo Clinic. Data are presented as medians with ranges. RESULTS: Seventy-two patients were identified, with a median age of 57 years (range 28 to 77 years) and median body mass index (BMI) of 26 kg/m(2) (range 18 to 40 kg/m(2)). Operative intent of resection was curative in 39 (54%) or palliative (≥ 90% tumor debulking) in 32 (44%). Median number of tumors treated and median tumor size were 8 (range 1 to 30) and 4.5 cm (range 0.3 to 20 cm), respectively. Tumor grade was 1 or 2 in 97%, and angioinvasion was identified in 55 (76%) patients. Postoperative morbidity and mortality were 50% and 0%, respectively. Among the 72 patients, overall survivals at 1, 5 and 10 years were 97.1%, 59.9%, and 45.0%, respectively. Among the 39 patients with a complete (R0) resection, the 1- and 5-year disease-free survivals were 53.7% and 10.7%, respectively. For patients undergoing debulking of ≥ 90% tumor burden, the 1- and 5-year survivals free of progression were 58.1% and 3.5%, respectively. CONCLUSIONS: Surgical treatment of metastatic nPNEC to the liver with curative intent or for palliative ≥ 90% debulking provides favorable oncologic outcomes. Despite a high incidence of tumor recurrence, 5-year survival rates are encouraging and appear to justify an aggressive surgical approach in these patients.

Tumor characteristics and survival analysis of incidental versus suspected gallbladder carcinoma.

INTRODUCTION: Over half of all gallbladder carcinoma (GBC) is discovered incidentally after cholecystectomy for benign disease. There are scant data comparing presentation and outcome for patients with incidental versus suspected GBC. The goal of this study is to determine the clinical differences between these two entities. STUDY DESIGN: Patients with GBC were identified retrospectively from records at academic healthcare institutions in Temuco, Chile; Atlanta, GA; and Rochester, MN between 1984 and 2008. Overall survival was compared for patients with and without preoperative suspicion using Kaplan-Meier curves and a multivariate Cox proportional hazards model. RESULTS: Of 571 patients, 128 (22.4%) had preoperative suspicion of malignancy, and 443 (77.6 %) were discovered incidentally. Incidental tumors were of lower stage, better differentiated, and with lower rates of metastases. Median survival for incidentally discovered GBC was 32.3 versus 5.8 months for suspected GBC (p<0.0001). In a Cox proportional hazards model controlling for operation extent, T stage, differentiation, and other factors, preoperative suspicion remains a strong risk factor (odds ratio, 2.0; confidence interval, 1.5-2.9; p<0.0001). CONCLUSIONS: Tumor characteristics differed significantly between patients with incidentally discovered versus preoperatively suspected GBC. Incidental GBC has a significantly better median survival.

15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas.

BACKGROUND: The aim of our study was to compare the outcomes of periampullary and extra-ampullary duodenal adenocarcinomas and segmental duodenal resection versus pancreatoduodenectomy and to evaluate prognostic factors. METHODS: We performed a retrospective review of all adults treated for duodenal adenocarcinoma by operative resection at a large tertiary referral center from 1994 to 2009. RESULTS: One hundred twenty-four patients had an operation for duodenal adenocarcinoma over a 15-year period (periampullary, n = 25, and extra-ampullary, n = 99). Ninety-nine patients (80%) underwent curative resection, including 24 (96%) with periampullary and 75 (76%) with extra-ampullary carcinomas. The average number of lymph nodes sampled was eight with segmental resection and 12 with pancreatoduodenectomy (p < 0.001). Five-year overall survivals were 37% for the entire cohort (n = 124), 37% in the extra-ampullary group, and 38% in the periampullary group. Tumor size (p = 0.20), positive nodes (p = 0.60), segmental resection versus pancreatoduodenectomy (p = 0.55), adjuvant therapy (p = 0.23), and R(1) versus R(0) resection (p = 0.21) were not associated with survival. In contrast, advanced T stage and pathologic grade were associated with poor survival. CONCLUSION: Extra-ampullary and periampullary duodenal adenocarcinomas have similar survival after resection. For distal duodenal tumors, survival is improved by curative resection without being compromised by limited resection. The number of lymph nodes sampled was significantly less with segmental resection than pancreatoduodenectomy.

Frequency of subtypes of biliary intraductal papillary mucinous neoplasm and their MUC1, MUC2, and DPC4 expression patterns differ from pancreatic intraductal papillary mucinous neoplasm.

BACKGROUND: Biliary intraductal papillary mucinous neoplasm (B-IPMN) has been proposed as a unique clinicopathologic disease with distinct histopathologic features, although wide acceptance remains controversial. A recent consensus conference classified pancreatic IPMN (P-IPMN) into 4 subtypes (ie, gastric, intestinal, pancreatobiliary, oncocytic) based on morphologic appearance and mucin (MUC) staining properties. The aim of this study was to determine whether B-IPMN has similar histopathologic and immunologic subtypes to P-IPMN. STUDY DESIGN: Specific immunostaining for MUC1, MUC2, and deleted for pancreas cancer, locus 4 were performed on specimens from 19 patients with a histopathologic diagnosis of B-IPMN. Immunostaining patterns of B-IPMN were correlated with histopathology. RESULTS: Based on histopathology, the following subtypes of B-IPMN were identified: pancreatobiliary n = 9 (47%), intestinal n = 8 (42%), oncocytic n = 2 (11%), and gastric n = 0 (0%). Pancreatobiliary and oncocytic subtypes of B-IPMN were positive for MUC1 and negative for MUC2, and intestinal subtypes were positive for MUC2 and negative for MUC1. Thirteen of the 19 B-IPMN were associated with invasive carcinoma; loss of deleted for pancreas cancer, locus 4 was found in 6 of 13 invasive components and in 3 of 19 noninvasive components of B-IPMN. Five-year survival for patients with resected B-IPMN and invasive carcinoma was 38%, which is similar to that for resected P-IPMN with invasive carcinoma. CONCLUSIONS: Histopathologic subtypes and type-specific MUC expression patterns of B-IPMN resemble those of P-IPMN. MUC1 expression and/or absence of MUC2 expression, which correlate with aggressive features of P-IPMN, were found in B-IPMN and correlate with invasive B-IPMN. Loss of deleted for pancreas cancer, locus 4 parallels the findings observed in P-IPMN. These findings provide additional support that B-IPMN is a unique entity with similarities to main duct P-IPMN.

Neoadjuvant treatment of duodenal adenocarcinoma: a rescue strategy.

AIM: To evaluate the role of neoadjuvant chemoradiation therapy and rescue surgery in the management of unresectable or recurrent duodenal adenocarcinoma. METHODS: Retrospective review of all adults treated with neoadjuvant therapy and rescue surgery for locally unresectable or locally recurrent duodenal adenocarcinoma from 1994 to 2010. RESULTS: Ten patients received various forms of neoadjuvant therapy prior to operative exploration for potential resection. Six patients presented with locally unresectable disease, while four had local recurrences. Six patients had vascular encasement, three had retroperitoneal extension with vascular invasion, and one had invasion of surrounding organs. Of the six patients with locally advanced disease, preoperative therapy consisted of chemotherapy alone (3) or chemoradiotherapy (3). Of the four patients with local recurrences, preoperative therapy consisted of chemotherapy alone (1), chemoradiotherapy alone (1), chemoradiotherapy after chemotherapy (1), and chemoradiotherapy followed by combination chemotherapy (1). Nine of ten patients became resectable after neoadjuvant therapy. Clinically, two patients had complete responses, and four had partial responses. Histopathology revealed complete pathologic response in two patients and near-complete pathologic response in one (<1 mm of residual disease). Currently, five patients are alive (range 18-83 months postoperatively). All have no evidence of disease. CONCLUSION: Neoadjuvant therapy may convert locally unresectable duodenal adenocarcinoma to resectable disease with subsequent prolonged survival.

Surveillance strategies for gastrointestinal stromal tumors.

Although only 10-30% of gastrointestinal stromal tumors (GISTs) are clinically malignant, all have some degree of malignant potential. The management of high risk patients should be evidence based. However, prospective data and a consensus for guidelines concerning the screening of asymptomatic high risk patients and surveillance following multidisciplinary treatment do not exist. This review provides an overview of GIST, with an emphasis on the available data regarding screening and surveillance of certain populations with GISTs.

Evaluation of adjuvant chemoradiation therapy for ampullary adenocarcinoma: the Johns Hopkins Hospital-Mayo Clinic collaborative study.

BACKGROUND: The role of adjuvant chemoradiation therapy for ampullary carcinoma is unknown. Previous literature suggests that certain populations with high risk factors for recurrence may benefit from adjuvant chemoradiation. We combined the experience of two institutions to better delineate which patients may benefit from adjuvant chemoradiation. METHODS: Patients who underwent curative surgery for ampullary carcinoma at the Johns Hopkins Hospital (n=290; 1992-2007) and at the Mayo Clinic (n=130; 1977-2005) were reviewed. Patients with <60 days of follow-up, metastatic disease at surgery, or insufficient pathologic data were excluded. The final combined study consisted of 186 patients (n=104 Johns Hopkins, n=82 Mayo). Most patients received 5-FU based chemoradiation with conformal radiation. Cox proportional hazards models were used for survival analysis. RESULTS: Median overall-survival was 39.9 months with 2- and 5-year survival rates of 62.4% and 39.1%. On univariate analysis, adverse prognostic factors for overall survival included T3/T4 stage disease (RR=1.86, p=0.002), node positive status (RR=3.18, p<0.001), and poor histological grade (RR=1.69, p=0.011). Patients who received adjuvant chemoradiation (n=66) vs. surgery alone (n=120) showed a higher rate of T3/T4 stage disease (57.6% vs. 30.8%, P<0.001), lymph node involvement (72.7% vs. 30.0%, P<0.001), and close or positive margins (4.6% vs. 0.0%, P=0.019). Five year survival rates among node negative and node positive patients were 58.7% and 18.4% respectively. When compared with surgery alone, use of adjuvant chemoradiation improved survival among node positive patients (mOS 32.1 vs. 15.7 mos, 5 yr OS: 27.5% vs. 5.9%; RR=0.47, P=0.004). After adjusting for adverse prognostic factors on multivariate analysis, patients treated with adjuvant chemoradiation demonstrated a significant survival benefit (RR=0.40, P<0.001). Disease relapse occurred in 37.1% of all patients, most commonly metastatic disease in the liver or peritoneum. CONCLUSIONS: Node-positive patients with resected ampullary adenocarcinoma may benefit from 5-FU based adjuvant chemoradiation. Since a significant proportion of patients develop metastatic disease, there is a need for more effective systemic treatment.

Management and outcomes of primary coloduodenal fistulas.

PURPOSE: Primary coloduodenal fistula (CDF) is a rare entity. We review our experience with the management and outcomes of CDF. METHODS: This is a retrospective review from 1975 to 2005 of patients with primary CDF. Patients were followed through clinic visits and mail correspondence with a mean (±SE) follow-up of 56 ± 14 months. RESULTS: Twenty-two patients were diagnosed at a mean age of 54 ± 3 years with primary CDF: benign (n = 14) or malignant (n = 8). Benign CDF were due to Crohn's disease (n = 9) or peptic ulcer disease (n = 5); malignant CDF was primarily due to colon cancer (n = 7) plus 1 patient with lymphoma. Indications for operative intervention included intractable symptoms (n = 15), gastrointestinal bleeding (n = 14), and to rule out malignancy (n = 8). Complete resection of malignant CDF with negative margins was achieved in half of patients after en bloc resection. Palliative bypass was performed in those patients with unresectable disease. Thirteen patients with benign CDF had resection of the fistula-2 of these patients required a duodenal bypass. There were no perioperative deaths, and the morbidity rate was 38%. Median survival for patients with malignant CDF was 20 months (range 1-150 months). Two patients with malignant CDF had >5-year survival. All patients with benign CDF who underwent fistula resection had resolution of fistula-related symptoms with one recurrence. CONCLUSION: Benign CDF is amenable to operative therapy with resolution of symptoms and a low recurrence rate. Complete resection of malignant CDF can impart survival benefit.

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

BACKGROUND: Evaluating surgical outcomes is an important tool to compare providers and institutions and to drive process improvements. Differing methodologies, however, may provide conflicting measurements of similar clinical outcomes making comparisons difficult. ACS-NSQIP is a validated, risk-adjusted, clinically derived data methodology to compare observed to expected outcomes after a wide variety of operations. The AHRQ-PSI are a set of computer algorithms to identify potential adverse in-patient events using secondary ICD-9-CM diagnosis and procedure codes from hospital discharge abstracts. METHODS: We compared the ACS-NSQIP and AHRQ-PSI methods for hospital general surgical (n = 6565) or vascular surgical inpatients procedures (n = 1041) at a tertiary-care academic institution from April 2006 to June 2009 on 7 adverse event types. RESULTS: ACS-NSQIP inpatient adverse events were identified in 564 (7.4%) patients. AHRQ-PSIs were identified in 268 (3.5%) patients. Only 159 (2.1%) patients had inpatient events identified by both methods. Using ACS-NSQIP as the clinically based standard the sensitivity of the specific AHRQ-PSI ranged from 0.030 for infections to 0.535 for PE/DVT. Positive predictive values of AHRQ-PSI ranged from 18% for hemorrhage/hematoma to 89% for renal failure. Greater agreement at greater ASA class and wound classification was observed. CONCLUSION: AHRQ-PSI algorithms identified less than a third of the ACS-NSQIP clinically important adverse events. Furthermore, the AHRQ-PSI identified a large number of events with no corresponding clinically important adverse outcomes. The sensitivity of the AHRQ-PSI for detecting clinically relevant adverse events identified by the ACS-NSQIP varied widely. The AHRQ-PSI as applied to postoperative patients is a poor measure of quality performance.

Mayo Clinic consensus recommendations for the depth of excision in primary cutaneous melanoma.

Currently, no data from randomized controlled clinical trials are available to guide the depth of resection for intermediate-thickness primary cutaneous melanoma. Thus, we hypothesized that substantial variability exists in this aspect of surgical care. We have summarized the literature regarding depth of resection and report the results of our survey of surgeons who treat melanoma. Most of the 320 respondents resected down to, but did not include, the muscular fascia (extremity, 71%; trunk, 66%; and head and neck, 62%). However, significant variation exists. We identified variability in our own practice and have elected to standardize this common aspect of routine surgical care across our institution. In light of the lack of evidence to support resection of the deep muscular fascia, we have elected to preserve the muscular fascia as a matter of routine, except when a deep primary melanoma or thin subcutaneous tissue dictates otherwise.

Hepatic resection for the carcinoid syndrome in patients with severe carcinoid heart disease: does valve replacement permit safe hepatic resection?

BACKGROUND: Hepatic resection of metastatic carcinoid cancer can prolong survival and control symptomatic endocrinopathy. Decompensated carcinoid heart disease (CHD) can develop in some patients with metastatic carcinoid cancers, which can preclude operation for resectable hepatic metastases. We hypothesized that outcomes after hepatic resection for patients with the carcinoid syndrome after valve replacement for CHD would be similar to carcinoid patients without CHD. STUDY DESIGN: We compared the survival and symptom control after hepatic resection for patients undergoing valve replacement for CHD to carcinoid patients without CHD matched for age, sex, and extent of hepatectomy. RESULTS: Fourteen patients with earlier valve replacement for CHD were compared with 28 carcinoid patients without CHD. All patients had hepatic resection for metastatic carcinoid disease and carcinoid syndrome. Mean age, sex distribution, and extent of hepatectomy (major hepatectomy, 78%) was similar between groups. Mean interval from valve replacement to hepatectomy was 101 days. There was no operative mortality. Major operative morbidity, inclusive of operative blood loss and cardiorespiratory events, occurred in 28.5% and 14.2% for CHD and non-CHD groups, respectively (p = 0.16). Symptom-free survival for CHD and non-CHD groups was 69% and 81% at 1 year (p = 0.22) and 61% and 44% (p = 0.17) at 5 years, respectively. Octreotide-free survival after hepatectomy 69% and 84% (p = 0.15) at 1 year and 62% and 52% (p = 0.29) 5 years, respectively. Overall survival CHD and non-CHD groups 100% at 1 year and 100% and 70% (p = 0.002) 5 years. CONCLUSIONS: Valve replacement for severe CHD is safe and hepatic resection is associated with similar outcomes as patients without CHD undergoing hepatic resection for carcinoid syndrome. Identifying resectable hepatic metastases from carcinoids in patients with severe CHD should prompt valve replacement and interval hepatic resection.

Patterns of pancreatic resection differ between patients with familial and sporadic pancreatic cancer.

BACKGROUND: Although the increased risk of developing pancreatic cancer (PC) in families with a strong history of the disease is well known, characteristics and outcomes of patients with familial PC is not described well. AIMS: This study aims to evaluate outcomes following resection in patients with familial PC. METHODS: We studied 208 patients who underwent resection of PC from 2000 to 2007 and had prospectively completed family history questionnaires for the Biospecimen Resource for Pancreas Research at our institution. We compared clinical characteristics and outcomes of familial and sporadic PC patients. RESULTS: Familial (N = 15) and sporadic PC patients (N = 193) did not have significantly different demographics, pre-operative CA19-9, pre-operative weight loss, R0 status, or T-staging (all p ≥ 0.05). Familial PC patients had lower pre-operative total serum bilirubin concentrations (p = 0.03) and lesions outside of the pancreatic head more frequently (p = 0.02) than sporadic PC patients. There was no difference in survival at 2 years between familial and sporadic PC patients (p = 0.52). CONCLUSIONS: Familial PC patients appear to develop tumors outside of the pancreatic head more frequently than sporadic PC patients. This difference in tumor distribution may be due to a broader area of cancer susceptibility within the pancreas for familial PC patients.