Risk factors and outcomes for cholangitis after hepatic resection.

INTRODUCTION: There is a paucity in the literature in regard to the incidence, risk factors, and outcomes for post-operative cholangitis following hepatic resection. METHODS: Retrospective review of the ACS NSQIP main and targeted hepatectomy registries for 2012-2016. RESULTS: A total of 11,243 cases met the selection criteria. The incidence of post-operative cholangitis was 0.64% (151 cases). Multivariate analysis identified several risk factors associated with the development of post-operative cholangitis, stratified out by pre-operative and operative factors. The most significant risk factors were biliary anastomosis and pre-operative biliary stenting with odds ratios (OR) of 32.39 (95% CI 22.91-45.79, P value < 0.0001) and 18.32 (95% CI 10.51-31.94, P value < 0.0001) respectively. Cholangitis was significantly associated with post-operative bile leaks, liver failure, renal failure, organ space infections, sepsis/septic shock, need for reoperation, longer length of stay, increased readmission rates, and death. CONCLUSION: Largest analysis of post-operative cholangitis following hepatic resection. While a rare occurrence, it is associated with significantly increased risk for severe morbidity and mortality. The most significant risk factors were biliary anastomosis and stenting.

High-risk liver patients are not associated with adverse events following pancreaticoduodenectomy.

INTRODUCTION: Pancreaticoduodenectomy performed with underlying hepatic disease has been reported to have increased adverse events postoperatively. This study aimed to further evaluate that association. METHODS: Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) main and targeted pancreatectomy registries for 2014-2016. High-risk liver patients were defined by MELD scores, received neoadjuvant chemotherapy, and had hepatosteatosis; two separate subgroups of MELD ≥9 and ≥ 11. High-risk liver patients were then compared to control cases via propensity score matching. RESULTS: There were 156 and 132 cases that met the high-risk liver criteria for the MELD cutoffs of ≥9 and ≥ 11 respectively. Propensity score matching left 2527 cases for final adjusted analysis. On both univariate and multivariate analysis high-risk liver patients were not associated with increased adverse events following Whipple resection. Lack of association with increased adverse events held for both the ≥9 and ≥ 11 MELD score cohorts. CONCLUSION: High-risk liver patients defined by MELD scores, neoadjuvant chemotherapy utilization, and hepatosteatosis were not associated with any increased incidence of adverse events following pancreaticoduodenectomy. Patients with underlying high-risk liver disease in this study did not appear to pose as a contraindication for oncologic resection of pancreatic adenocarcinoma.

Effect of preoperative liver-directed therapy prior to hepatic resection.

INTRODUCTION: Hepatobiliary malignancies present with advanced disease precluding upfront resection. Liver-directed therapy (LDT), particularly Y-90 radioembolization and transarterial chemoembolization (TACE), has become increasingly utilized to facilitate attempt at oncologic resection. However, the safety profile of preoperative LDT is limited. METHODS: Retrospective review of the ACS NSQIP main and targeted hepatectomy registries for 2014-2016. Primary objective was evaluation of outcomes between preoperative LDT cases and those that received upfront resection. RESULTS: A total of 8923 cases met selection criteria. 192 cases (2.15%) received either Y-90 or TACE prior to hepatectomy. Multivariate analysis for all study patients revealed preoperative LDT significantly increased the risk of perioperative transfusion (OR 2.19, 95% CI 1.445-3.328, P < 0.0001), sepsis (OR 2.21, 95% CI 1.104-4.411, P = 0.022), and liver failure (OR 2.72, 95% CI 1.562-4.747, P < 0.0001). Subgroup analysis found for primary hepatobiliary malignancies LDT only increased the risk for liver failure. While for secondary hepatic tumors LDT significantly increased perioperative transfusion, sepsis, cardiac failure, renal failure, liver failure, and mortality. The complication profile also significantly increased with advanced T stage. Conversely, on propensity score matching preoperative LDT did not significantly increase perioperative complications. CONCLUSION: Preoperative LDT has the potential to convert inoperable hepatic tumors into resectable disease but there is a general increased risk for significant postoperative complications, most notable liver failure. However, on controlled analysis preoperative LDT does not increase perioperative complications and should not be considered a contraindication to resection.

Utilization of chemoradiation therapy provides strongest protective effect for avoidance of postoperative pancreatic fistula following pancreaticoduodenectomy: A NSQIP analysis.

BACKGROUND: The utilization of neoadjuvant therapy (NAT) before performing pancreaticoduodenectomy for malignancy has been well established as a protective factor for the prevention of postoperative pancreatic fistula (POPF). However, there is a paucity of published data evaluating the specific NAT regimen that is the most protective against POPF development. We evaluated the differences between neoadjuvant chemotherapy (CT) and chemoradiation therapy (CRT) with regard to the effect on POPF rates. METHODS: The main and targeted pancreatectomy American College of Surgeons National Surgical Quality Improvement Program registries for 2014-2016 were retrospectively reviewed. A total of 10,665 pancreaticoduodenectomy cases were present. The primary outcome was POPF development. The factors that have previously been shown to be associated with or suspected to be associated with POPF were evaluated. The factors included NAT, sex, age, body mass index (BMI), diabetes, smoking, steroid therapy, preoperative weight loss, preoperative albumin level, perioperative blood transfusions, wound classification, American Society of Anesthesiologists classification, duct size (<3 mm, 3-6 mm, and >6 mm), gland texture (soft, intermediate, and hard), and anastomotic technique. The factors identified to be statistically significant were then used for propensity score matching to compare POPF development between the cases utilizing CT versus CRT. RESULTS: A total of 10,117 cases met the inclusion criteria. The development of POPF was significantly associated, on multivariate analysis, with a lack of NAT, male sex, higher BMI, nondiabetic status, nonsmoker status, decreased weight loss, preoperative albumin level, decreased duct size, and soft gland texture. NAT, duct size, and gland texture had the strongest associations with the development of POPF (p < .0001). The overall 1765 cases (17.45%) received NAT and the POPF rate for cases with NAT was 10.20% versus 20.10% for cases without NAT (p < .0001). A total of 1031 cases underwent CT and 734 cases underwent CRT, respectively. A total of 708 paired cases were selected for analysis based on propensity score matching. The POPF rates were 11.20% versus 3.50% for CT and CRT, respectively (p < .0001). There was no difference in the frequencies of specific POPF grades. The decreased POPF rate with CRT correlated with firmer gland texture rates. CONCLUSIONS: To our knowledge, this is the largest analysis of specific NAT regimens with regard to the development of POPF following pancreaticoduodenectomy. CRT provided the strongest protective effect. That protective effect is most likely due to increased fibrosis in the pancreatic parenchyma from radiation therapy. These findings provide additional support to consider CRT over CT alone in the treatment of pancreatic cancer when NAT will be utilized.

Improved hemostasis with major hepatic resection in the current surgical era.

BACKGROUND: Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections. METHODS: Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era. RESULTS: A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001). CONCLUSIONS: The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.

Nonoperative management after neoadjuvant therapy for rectal cancer: A single institution experience over 5 years.

BACKGROUND: Nonoperative or "watch and wait" strategies have emerged as a potential option for patients with rectal cancer that obtain a complete clinic response (cCR) after neoadjuvant therapy. We sought to evaluate our patients that experienced a cCR and their outcomes after non-operative management. METHODS: We performed a retrospective review of patients at our center with rectal cancer from 2012 to 2016. We then identified patients that had a documented "complete clinical response" of their tumors after different neoadjuvant treatments and underwent non-operative management. Patients were followed on a surveillance schedule that included physical exam, endoscopy and imaging. RESULTS: A total of 29 patients elected to undergo nonoperative management with a mean patient age of 67 years old. All patients were treated with neoadjuvant long course chemoradiotherapy. Seven patients were treated with initial induction chemotherapy followed by chemoradiation and 11 received consolidation chemotherapy. During a median follow-up of 27.6 months, there were 6 (21%) recurrences (1 = local, 1 = local and distant, 4 distant). Of the 6 total recurrences, 5 patients were candidates for salvage surgical resection. CONCLUSION: Neoadjuvant treatment strategies may facilitate durable rates of cCR. Continued responses after these treatments could possibly enable more patients to undergo nonoperative management. We believe nonoperative management can be offered to patients seeking rectal preservation, but more research is required to select the appropriate patients. For those patients experiencing recurrence, the majority of patients can be salvaged surgically.

Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era.

BACKGROUND: Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate. METHODS: The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI. RESULTS: The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001). CONCLUSIONS: The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.

Update on the diagnosis and management of malignant phyllodes tumors of the breast.

Malignant phyllodes tumors of the breast are a rare entity. They occur infrequently but most often in younger women in comparison to typical epithelial-based breast cancers. Treatment of these tumors is not without controversy and in this review we will present an update on the diagnosis and management of malignant phyllodes tumors of the breast.

Perioperative hepatocyte growth factor (HGF) infusions improve hepatic regeneration following portal branch ligation (PBL) in rodents.

BACKGROUND: As hepatic surgery has become safer and more commonly performed, the extent of hepatic resections has increased. When there is not enough expected hepatic reserve to facilitate primary resection of hepatic tumors, a clinical adjunct to facilitating primary resection is portal vein embolization (PVE). PVE allows the hepatic remnant to increase to an appropriate size prior to resection via hepatocyte regeneration; however, PVE is not always successful in facilitating adequate regeneration. One of the strongest trophic factors for hepatocyte regeneration is hepatocyte growth factor (HGF). The purpose of this study was to improve hepatic regeneration with perioperative HGF infusions in an animal model that mimics PVE. METHODS: Portal branch ligation (PBL) in rodents is equivalent to PVE in humans. We performed left-sided PBL in Sprague-Dawley rodents with the experimental group receiving perioperative HGF infusions. Baseline and postoperative liver volumetrics were obtained with CT scanning methods as performed in clinical practice. Baseline and postoperative liver functions were assessed via indocyanine green (ICG) elimination testing. RESULTS: HGF infused rodents had statistically significant increase in all postoperative liver volumetrics. Most clinically relevant were increased right liver volumes (RLV), 14.10 versus 7.85 cm3 (p value 0.0001), and increased degree of hypertrophy (DH %), 159.23 versus 47.11 % (p value 0.0079). HGF infused rodents also had a quick return to baseline liver function, 2.38 days compared to 6.13 days (p value 0.0001). CONCLUSION: Perioperative HGF infusions significantly increase hepatic regeneration following PBL in rodents. Perioperative HGF infusions following PVE are a possible adjunct to increase the amount of patients able to successfully undergo primary resection for hepatic tumors. Further basic science is warranted in examining the use of HGF infusions to increase hepatic regeneration and translating that basic science work to clinical practice.

Institutional Improvement in Weight Loss after Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is a recent addition to the bariatric surgery armamentarium. It has been demonstrated to be an efficacious stand-alone bariatric procedure in regard to weight loss. This study evaluates the progress of our initial experience with LSG. Retrospective review of prospective data from 2008 to 2010. Compared data between our first operative year of experience with LSG (2008) and our third year of experience (2010). Data compared for up to three years postoperatively. End points were percentage of excess body weight loss (%EWL) and percentage of excess body mass index loss (%EBL). Institutional improvement in %EWL and %EBL rates as our collective experience increased with LSG. Mean increase in %EWL of 14 per cent and mean increase of %EBL of 22 per cent. In our first year performing LSG the institutional weight loss was <50 per cent EWL, which is often cited as a benchmark level for "success" after bariatric surgery. By our third year of experience with LSG we achieved an institutional weight loss >50 per cent EWL. Institutional improvement in weight loss results with LSG as the collective experience increased. Several factors could have contributed to this observation to include a surgical mentorship program and the institution of formal nutritional education. This study demonstrates that institutional experience is a significant factor in weight loss results with LSG.

Formal Nutritional Education Improves Weight Loss in Bariatric Patients Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an increasingly performed procedure in the bariatric surgery armamentarium. This study evaluates our experience with LSG at Dwight D. Eisenhower Army Medical Center (DDEAMC) during the time period of 2008-2010. We found that the inclusion of formal nutritional education significantly increased our weight loss results following LSG. METHODS: This is a retrospective review from our LSG caseload from 2008 to 2010. During that time, we performed 159 LSG. In our review, we performed comparative data of all operative years during 2008-2010 for up to 3 years postoperatively. Our main focus was in regard to weight loss as measured by percentage of excess body weight loss (%EWL), percentage of total weight loss (%TWL), and percentage of excess BMI loss (%EBL). We also evaluated the effect of LSG on diabetes mellitus (DM) and hypertension (HTN) postoperatively. RESULTS: We found an improvement in our %EWL, %TWL, and %EBL rates in our LSG cases following the inclusion of formal nutritional education. There was a mean increase in %EWL of 15 %, %TWL of 7 %, and %EBL of 21 %, which were statistically significant, that was present at all postoperative years of follow-up. We determined the only variable that changed in our bariatric program starting in 2010 was the inclusion of formal nutritional education. We also found a statistically significant improvement in resolution of HTN with the inclusion of formal nutritional education. CONCLUSIONS: The addition of formal nutritional education can enhance weight loss following bariatric surgery. We have shown a significant improvement in weight loss results following LSG with the implementation of formal nutritional education; this is the only study to our knowledge evaluating formal nutritional education and LSG.

Randomized trial of OFIRMEV versus placebo for pain management after laparoscopic sleeve gastrectomy.

BACKGROUND: OFIRMEV is an intravenous form of acetaminophen approved by the Food and Drug Administration for use as an antipyretic and treatment of mild to moderate pain alone or in conjunction with opioid medications. Intravenous APAP use in postsurgical pain management has been reported to decrease opioid usage, time to rescue dose, and subjective pain. OBJECTIVES: We used a placebo-controlled, randomized double-blind study to test the efficacy of OFIRMEV in decreasing opioid use and subjective pain after laparoscopic sleeve gastrectomy. SETTING: U.S. military training hospital. METHODS: Thirty-four patients who met criteria were enrolled and randomly assigned to 2 separate limbs of the study. The OFIRMEV and placebo groups had similar mean age ranges (48±11 and 50±11 yr) and a female/male ratio of 5:1 and 6:1, respectively. The patients received an intraoperative dose and then postoperative administration of intravenous OFIRMEV 1 g or placebo every 6 hours for 24 hours in addition to fentanyl via patient-controlled analgesia. Subjective pain scores, the total amount of fentanyl used, time to rescue of first narcotic dose, and total postanesthesia care unit (PACU) narcotic use were measured during the first 24 hours after surgery. RESULTS: Subjective pain score was significantly decreased compared with baseline at 12, 16, and 20 hours after surgery in OFIRMEV-treated patients but not in the placebo group. However, total narcotic use, time to rescue of first narcotic dose, and total PACU narcotic dose were not statistically different between the 2 groups. CONCLUSION: Intravenous OFIRMEV use caused a modest but statistically significant decrease in subjective pain without affecting narcotic use after laparoscopic sleeve gastrectomy. (Surg Obes Relat Dis 2015;0:000-00.) © 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Selective Pulmonary Artery Perfusion With Blood Flow Occlusion Delivers Concentrated Levels of Chemotherapy to Ipsilateral Hilar and Mediastinal Lymph Nodes.

BACKGROUND: Although survival is historically low for patients presenting with N2 lung cancer, patients who respond to chemotherapy have up to a 30% chance for long term survival or cure. Selective pulmonary artery perfusion (SPAP) has been examined in several animal studies as a method for delivering chemotherapy in non-small cell lung cancer; however, there is a paucity of data regarding the effect of SPAP on regional lymph nodes. METHODS: Left SPAP was performed using gemcitabine on five swine and compared with standard central venous infusion in controls. Samples were taken from lung, kidney, liver, plasma, and lymph nodes. Tissue was measured for gemcitabine concentration using mass spectroscopy. RESULTS: Left SPAP resulted in significantly higher gemcitabine concentration than standard infusion in hilar and mediastinal lymph nodes while plasma gemcitabine concentration was not significantly different. CONCLUSION: SPAP is a viable technique for concentrating a chemotherapeutic agent in the mediastinal and hilar lymph nodes. This could potentially increase the response to chemotherapy and render more patients to be surgical candidates who present with N2 disease.