Postoperative Proton Pump Inhibitors are associated with a significantly higher rate of delayed gastric emptying after pancreatoduodenectomy.

BACKGROUND: Proton pump inhibitors (PPIs) are effective in reducing marginal ulcers after pancreatoduodenectomy. However, their impact on perioperative complications has not been defined. METHODS: We retrospectively analyzed the effect of postoperative PPIs on 90-day perioperative outcomes in all patients who underwent pancreatoduodenectomy at our institution from April 2017 to December 2020. RESULTS: 284 patients were included; 206 (72.5%) received perioperative PPIs, 78 (27.5%) did not. The two cohorts were similar in demographics and operative variables. Postoperatively, the PPI cohort had significantly higher rates of overall complications (74.3% vs. 53.8%) and delayed gastric emptying (28.6% vs. 11.5%), p < 0.05. However, no differences in infectious complications, postoperative pancreatic fistula, or anastomotic leaks were seen. On multivariate analysis, PPI was independently associated with a higher risk of overall complications (OR 2.46, CI 1.33-4.54) and delayed gastric emptying (OR 2.73, CI 1.26-5.91), p = 0.011. Four patients developed marginal ulcers within 90-days postoperatively; all were in the group who received PPIs. CONCLUSION: Postoperative proton pump inhibitor use was associated with a significantly higher rate of overall complications and delayed gastric emptying after pancreatoduodenectomy.

Video Interviews and Surgical Applicants' Ability to Assess Fit to Residency Programs.

INTRODUCTION: Due to the COVID-19 pandemic, the recruitment cycle for the 2021 Match was performed virtually. This Association for Surgical Education (ASE)-sponsored survey set out to study applicants' ability to assess the factors contributing to fit through video interviews. METHODS: An IRB-approved, online, anonymous survey was distributed to surgical applicants at a single academic institution and through the ASE clerkship director distribution list between the rank order list certification deadline and Match Day. Applicants used 5-point Likert-type scales to rate factors for importance to fit and their ease of assessment through video interviewing. A variety of recruitment activities were also rated by applicants for their perceived helpfulness in assessment of fit. RESULTS: One hundred and eighty-three applicants responded to the survey. The three most important factors for applicant fit were how much the program cared, how satisfied residents seem with their program, and how well residents get along. Resident rapport, diversity of the patient population, and quality of the facilities were hardest to assess through video interviews. In general, diversity-related factors were more important to female and non-White applicants, but not more difficult to assess. Interview day and resident-only virtual panels were the most helpful recruitment activities, while virtual campus tours, faculty-only panels, and a program's social media were the least helpful. CONCLUSIONS: This study provides valuable insight into the limitations of virtual recruitment for surgical applicants' perception of fit. These findings and the recommendations herein should be taken into consideration by residency program leadership to ensure successful recruitment of diverse residency classes.

4,300 steps per day prior to surgery are associated with improved outcomes after pancreatectomy.

BACKGROUND: Decreased preoperative physical fitness and low physical activity have been associated with preoperative functional reserve and surgical complications. We sought to evaluate daily step count as a measure of physical activity and its relationship with post-pancreatectomy outcomes. METHODS: Patients undergoing pancreatectomy were given a remote telemonitoring device to measure their preoperative levels of physical activity. Patient activity, demographics, and perioperative outcomes were collected and compared in univariate and multivariate logistic regression analysis. RESULTS: 73 patients were included. 45 (61.6%) patients developed complications, with 17 (23.3%) of those patients developing severe complications. These patients walked 3437.8 (SD 1976.7) average daily steps, compared to 5918.8 (SD 2851.1) in patients without severe complications (p < 0.001). In logistic regression analysis, patients who walked less than 4274.5 steps had significantly higher odds of severe complications (OR = 7.5 (CI 2.1, 26.8), p = 0.002). CONCLUSION: Average daily steps below 4274.5 before surgery are associated with severe complications after pancreatectomy. Preoperative physical activity levels may represent a modifiable target for prehabilitation protocols.

Increased Morbidity and Mortality After Hepatectomy for Colorectal Liver Metastases in Frail Patients is Largely Driven by Worse Outcomes After Minor Hepatectomy: It's Not "Just a Wedge".

BACKGROUND: Frailty is associated with postoperative mortality, but its significance after hepatectomy for colorectal liver metastases (CRLM) is poorly defined. This study evaluated the impact of frailty after hepatectomy for CRLM. METHODS: The study identified 8477 patients in National Surgical Quality Improvement Program databases from 2014 to 2019 and stratified them by frailty score using the risk analysis index as very frail (>90th percentile), frail (75th-90th percentile), or non-frail (< 75th percentile). Multivariate regression models determined the impact of frailty on perioperative outcomes, including by the extent of hepatectomy. RESULTS: The procedures performed were 2752 major hepatectomies (left hepatectomy, right hepatectomy, trisectionectomy) and 5725 minor hepatectomies (≤2 segments) for 870 (10.3%) very frail, 1680 (19.8%) frail, and 5927 (69.9%) non-frail patients. Postoperatively, the very frail and frail patients experienced more complications (very frail [41.8%], frail [35.1%], non-frail [31.0%]), which resulted in a longer hospital stay (very-frail [5.7 days], frail [5.8 days], non-frail [5.1 days]), a higher 30-day mortality (very-frail [2.2%], frail [1.3%], non-frail [0.5%]), and more discharges to a facility (very frail [6.8%], frail [3.7%], non-frail [2.6%]) (p < 0.05) although they underwent similarly extensive (major vs. minor) hepatectomies. In the multivariate analysis, frailty was independently associated with complications (very-frail [odds ratio {OR}, 1.70], frail [OR, 1.25]) and 30-day mortality (very-frail [OR, 4.24], frail [OR, 2.41]) (p < 0.05). After minor hepatectomy, the very frail and frail patients had significantly higher rates of complications and 30-day mortality than the non-frail patients, and in the multivariate analysis, frailty was independently associated with complications (very frail [OR, 1.97], frail [OR, 1.27]) and 30-day mortality (very frail [OR, 6.76], frail [OR, 3.47]) (p < 0.05) after minor hepatectomy. CONCLUSIONS: Frailty predicted significantly poorer outcomes after hepatectomy for CRLM, even after only a minor hepatectomy.

Cause and outcome of aborting a difficult laparoscopic cholecystectomy due to severe inflammation: a study of operative notes.

BACKGROUND: Upon encountering a difficult cholecystectomy in which, after a reasonable trial of dissection, anatomical identification has not been attained due to severe inflammation, and the risk of additional dissection is deemed to be hazardous, "bail-out" strategies are encouraged safety valves. One strategy is to abort the cholecystectomy and refer the patient to a HPB center for further management. METHODS: A retrospective review was conducted of cholecystectomies performed by HPB surgeons at our center between 2005 and 2019. We identified 63 patients who had an aborted cholecystectomy because of acute or chronic cholecystitis and were referred for additional care. Of these, operative notes and other clinical records were available for 43 patients who were included in this study. RESULTS: 42 cholecystectomies (98%) were started laparoscopically. 25 patients (58%) had chronic cholecystitis, and 18 (42%) had acute cholecystitis. 40 cases (93%) fell into the highest level of difficulty on the Nassar scale (Grade 4). Procedures were aborted at the following stages of dissection: in 10 patients (23%), none of the gallbladder was identified; in another 11 (26%), only the dome of gallbladder was identified; the body of the gallbladder was exposed in 13 (30%); and dissection of the hepatocystic triangle was attempted unsuccessfully in 9 (21%). Following referral to our center, 30 patients (70%) were managed with total cholecystectomy while in 13 cases (30%), subtotal cholecystectomy was performed. CONCLUSION: Aborting cholecystectomy and referring the patient to an HPB center is rarely needed but is an effective bail-out strategy for general surgeons encountering highly difficult operative conditions due to inflammation.

Applicants' perception of fit to residency programmes in the video-interview era: A large multidisciplinary survey.

INTRODUCTION: 'Fit' refers to an applicants' perceived compatibility to a residency programme. A variety of structural, identity-related and relational factors contribute to self-assessments of fit. The 2021 residency recruitment cycle in the USA was performed virtually due to the COVID-19 pandemic. Little is known about how video-interviewing may affect residency applicants' ability to gauge fit. METHODS: A multidisciplinary, anonymous survey was distributed to applicants at a large academic institution between rank order list (ROL) certification deadline and Match Day 2021. Using Likert-type scales, applicants rated factors for importance to 'fit' and their ease of assessment through video-interviewing. Applicants also self-assigned fit scores to the top-ranked programme in their ROL using Likert-type scales with pairs of anchoring statements. RESULTS: Four hundred seventy-three applicants responded to the survey (25.7% response rate). The three most important factors to applicants for assessment of fit (how much the programme seemed to care, how satisfied residents seem with their programme and how well the residents get along) were also the factors with the greatest discrepancy between importance and ease of assessment through video-interviewing. Diversity-related factors were more important to female applicants compared with males and to non-White applicants compared with White applicants. Furthermore, White male applicants self-assigned higher fit scores compared with other demographic groups. CONCLUSION: There is a marked discrepancy between the most important factors to applicants for fit and their ability to assess those factors virtually. Minoritised trainees self-assigned lower fit scores to their top-ranked programme, which should raise concern amongst medical educators and highlights the importance of expanding current diversity, equity and inclusion efforts in academic medicine.

18 F-FDG positron emission tomography-computed tomography has a low positive predictive value for detecting occult recurrence in asymptomatic patients with high-risk Stages IIB, IIC, and IIIA melanoma.

BACKGROUND AND OBJECTIVES: High recurrence rates of Stages II and IIIA melanoma make close follow-up essential, especially with new adjuvant therapies for metastatic disease. However, there are currently no consensus guidelines for routine imaging for Stages IIB, IIC, and IIIA melanoma. The study's aim is to determine the utility of 18 F-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting asymptomatic recurrence of melanoma after primary surgical resection. METHODS: This retrospective cohort study included 158 patients with the American Joint Committee on Cancer 8th edition Stages IIB, IIC, or IIIA cutaneous melanoma who underwent an 18 F-FDG PET/CT from 2010 to 2020. We retrospectively analyzed clinical data after a median follow-up time of 39 months. RESULTS: We calculated a positive predictive value (PPV) of 32% (95% confidence interval: 11%-53%) for 154 routine PET/CTs, including six true positives and 13 false positives (FPs). PPV was 33% for Stage IIB, 50% for Stage IIC, and 14% for Stage IIIA. FPs were mostly benign or inflammatory foci (75%), and some other malignancies were found (21%). CONCLUSIONS: This cohort of patients imaged for high-risk melanoma demonstrated a high FP rate and low PPV. These findings suggest that routine surveillance with 18 F-FDG PET/CT may not be indicated for monitoring recurrence in this population.

Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay.

BACKGROUND/PURPOSE: There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. METHODS: Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. RESULTS: 494 patients underwent open pancreaticoduodenectomy - 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p = 0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p < 0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p = 0.615). CONCLUSION: ERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.

Inability to manage non-severe complications on an outpatient basis increases non-white patient readmission rates after pancreaticoduodenectomy: A large metropolitan tertiary care center experience.

BACKGROUND: Pancreaticoduodenectomy (PD) has a high rate of readmission, and racial disparities in care could be an important contributor. METHODS: Patients undergoing PD were prospectively followed, and their complications graded using the Modified Accordion Grading System (MAGS). Patient factors and perioperative outcomes for patients with and without postoperative readmission were compared in univariate and multivariate analysis by severity. RESULTS: 837 patients underwent PD, the overall 90-day readmission rate was 27.5%. Non-white race was independently associated with readmission (OR 1.83, p = 0.007). 51.3% of readmissions were for non-severe complications (MAGS <3). Non-white race was independently associated with MAGS non-severe readmission (OR 2.13, p = 0.006), but not MAGS severe readmission. CONCLUSIONS: Non-white patients are more likely to be readmitted, particularly for non-severe complications. Follow up protocols should be tailored to address race disparities in the rates of readmission as readmission for less severe complications could potentially be avoidable.

Development of a novel intraoperative difficulty score for minimally invasive cholecystectomy.

BACKGROUND: The rate of biliary injuries from minimally invasive cholecystectomy has remained high for over two decades. To improve outcomes there are multiple bail-out methods described, including aborting the procedure, converting to open, or performing a sub-total cholecystectomy. However, the intraoperative difficulty threshold for when a bail-out method should be implemented is poorly understood. METHODS: From 1/2014 to 2/2019 cholecystectomy videos were collected, de-identified, edited to include the 2-3 minutes when the gallbladder was first visualized, and accelerated. They were then rated on a 5-point difficulty scale. Inter-coder reliability was evaluated using Krippendorff's alpha and regression models were used to evaluate the scores ability to predict the need for a bail-out technique. RESULTS: 62 videos were analyzed with a median length after editing of 37.5 (29.0-43.3) seconds. A median time of 46.2 (38.3-53.4) seconds was required for grading. The bail-out rate was 42.9%. The inter-coder reliability between 2 surgeons and 8 non-clinical reviewers was 0.675 with an average difficulty score of 3.0 (SD = 1.01). Regression models showed that the scale was able to significantly predict conversion (ß=0.56,p<.01). CONCLUSION: This novel difficulty score was able to predict conversion to a bail-out technique early in the course of minimally invasive cholecystectomy.

Re-defining a high volume center for pancreaticoduodenectomy.

BACKGROUND: The purpose of this study was to re-evaluate the previously utilized definitions of high volume center for pancreaticoduodenectomy to determine/establish an objective, evidence based threshold of hospital volume associated with improvement in perioperative mortality. METHODS: Patients who underwent pancreaticoduodenectomy were identified using the National Cancer Database from 2004 to 2015. The relationship between hospital volume and 90-day mortality was assessed using a logistic regression model. Receiver Operator Characteristic analysis was performed and Youden's statistic was utilized to calculate the optimal cut offs. RESULTS: 42,402 patients underwent elective Pancreaticoduodenectomy at 1238 unique hospitals. A logistic regression was performed which showed a significant inverse linear association between institutional volume and overall 90 day mortality. The maximum improvement in 90 day mortality is seen if the average annual hospital volume was greater than 9 (OR = 0.647 (0.595-0.702), p < 0.0001). When analysis is limited to hospitals that performed >9 cases per year, the maximum improvement in 90 day mortality was noticed at 36 cases per year (OR = 0.458 (0.399-0.525), p < 0.0001). CONCLUSIONS: Based on our results, we recommend defining low, medium, and high volume centers for pancreaticoduodenectomy as hospitals with average annual volume less than 9, 9 to 35, and more than 35 cases per year, respectively.

Thunderbeat™ Integrated Bipolar and Ultrasonic Forceps in the Whipple Procedure: A Prospective Randomized Trial.

Thunderbeat™ is a device that uses both ultrasonic and advanced bipolar energies to achieve hemostasis. It has been evaluated in a variety of clinical contexts, but no literature exists regarding its application to pancreatic surgery. Using a prospective, randomized controlled trial, we evaluated its safety and efficacy in the Whipple procedure. Thirty-two participants were enrolled in the study. The Thunderbeat™ device during the Whipple procedure showed similar safety profile compared to standard of care.

The safety of hepatectomy after transarterial radioembolization: Single institution experience and review of the literature.

BACKGROUND AND OBJECTIVES: The liver is a frequent site of malignancy, both primary and metastatic. The treatment goal of patients with liver cancer may include transarterial radioembolization (TARE). There are limited reports on the safety of hepatectomy following TARE. Our study's purpose is to review patients who have received TARE followed by hepatectomy. METHODS: A retrospective study was performed on patients diagnosed with any liver cancer from 2013 to 2019 who underwent TARE followed by hepatectomy. Postoperative complications were prospectively collected. Descriptive statistics and the Kaplan-Meier test were used to assess survival outcomes. RESULTS: Twelve patients were treated with a TARE followed by a hepatectomy (nine with ≥4 segments resected). Diagnoses included: six HCC, four cholangiocarcinoma, one metastatic neuroendocrine tumor, and one metastatic colorectal cancer. There were no 90-day post-hepatectomy mortalities and the overall morbidity was 66% (16% severe ≥MAGS 3). Hepatectomy-specific complications after hepatectomy included two (16%) bile leaks and no post-hepatectomy liver failures. The median recurrence free survival was 26 months. Overall survival at 1-year was 78% and at 3 years was 47%. CONCLUSIONS: Our results support the safety of hepatectomy in select patients after TARE. Additional comparison to patients who receive hepatectomy as a first-line treatment for liver cancers should be investigated.

Extending Enhanced Recovery after Surgery Protocols to the Post-Discharge Setting: A Phone Call Intervention to Support Patients after Expedited Discharge after Pancreaticoduodenectomy.

The goal of this pilot study was to track patient outcomes after an expedited discharge after enhanced recovery after surgery (ERAS) pathway for pancreaticoduodenectomy (PD). A quantitative content analysis approach was used. All PD patients in a single academic medical center between February 2017 and June 2018 were called twice by specialized physician extenders after discharge. A semi-structured interview approach was used to identify patient's symptoms or concerns, proactively educate them, and provide outpatient management when indicated. A detailed narrative of the conversation was documented. Ninety patients (mean age 66.3; 58.1% males) were included in the study. Of all, 88.9 per cent of the patients received follow-up phone calls in accordance with our PD ERAS protocol. Among the 80 patients called, 71 (88.8%) reported at least one symptom, issue, or self-care need. The most common issues involved bowel movements and nutrition. A total of 147 interventions were performed to address patient needs including medication management, local care coordination, and outpatient referral to a healthcare provider. The intervention led to the identification of 15 patients for earlier evaluation. This identification was associated with the total number of reported symptoms (X² = 15.6, P = 0.004). Most patients require additional care after discharge after traditional ERAS pathways. ERAS transitional care protocols uncovered an unmet need for additional patient support after PD.

Tumor-insular Complex in Neoadjuvant Treated Pancreatic Ductal Adenocarcinoma Is Associated With Higher Residual Tumor.

The tumor microenvironment in pancreatic ductal adenocarcinoma (PDAC) plays a vital role in treatment response, and therefore, patient survival. We and others have observed an intimate association of neoplastic ductal cells with non-neoplastic islet cells, recapitulating the ductoinsular complex. We define this phenomenon as tumor-insular complex (TIC). Herein, we describe the clinicopathologic characteristics of TIC in neoadjuvant treated PDAC cases for the first time. We retrospectively reviewed the pathology of 105 cases of neoadjuvant treated PDAC resected at our institution. TIC was noted in 35 cases (33.3%), the mean tumor bed size was 2.7±1.0 cm, mean percentage of residual tumor 40±28% and mean Residual Tumor Index (RTI) (an index previously established as a prognostic parameter by our group) was 1.1±1.0. TIC was significantly associated with perineural invasion (P=0.001), higher tumor bed size (P=0.007), percentage of residual tumor (P=0.009), RTI (P=0.001), ypT stage (P=0.045), and poor treatment response, grouped by a previously established criteria (P=0.010). Using our prior binary reported prognostic cutoff for RTI of ≤0.35 and >0.35, TIC was associated with a RTI >0.35 (P=0.002). Moreover, patients who did not receive neoadjuvant radiation were associated with a higher frequency of TIC (P=0.003). In this cohort, RTI but not TIC was also shown to be a significant independent prognosticator for recurrence-free survival and overall survival on multivariate analysis. In conclusion, TIC is significantly associated with a more aggressive neoplasm which shows a poor treatment response. Further studies will be needed to better understand the tumor biology of TICs.

A 22-year experience with pancreatic resection for metastatic renal cell carcinoma.

BACKGROUND: The pancreas is a rare site of metastases, although metastatic renal cell carcinoma (mRCC) is the most commonly reported secondary tumor. Pancreatectomy has been described in selected patients with localized metastases, but long-term benefit remains poorly defined. METHODS: A retrospective review of a prospectively maintained database was performed to evaluate the outcomes of patients undergoing pancreatectomy for mRCC at a tertiary care center from 1995-2017. Postoperative complications were evaluated using the Modified Accordion Grading System (MAGS) and Kaplan-Meier curves and log-rank tests were utilized for survival analysis. RESULTS: 29 patients underwent pancreatectomy for mRCC including 15 distal pancreatectomies (DP), 10 pancreaticoduodenectomies (PD) and 4 total-pancreatectomies (TP). The mean age was 67 ± 8 years, and 15 were male. The median time from index nephrectomy to pancreatectomy was 8 (IQR: 3.72-12.2) years. There was no 90 Day post-pancreatectomy mortalities and the morbidity incidence included 13 Minor MAGS and 8 Severe MAGS complications respectively. Post-pancreatectomy disease specific survival at 2- and 4-years were 89% and 80% with 12 patients being alive at last follow up. CONCLUSIONS: Pancreatic resection can be safely performed in select patients with localized mRCC with favorable long-term outcomes.

Composite Length of Stay, An Outcome Measure of Postoperative and Readmission Length of Stays in Pancreatoduodenectomy.

PURPOSE: Postoperative length of stay (PLOS) and readmission rate are pancreatoduodenectomy (PD) outcome measures, which are reported individually but may be interrelated. The purpose of this study was to evaluate how well a composite length of stay measure (CLOS) that included PLOS and readmission length of stay describes outcomes. To do so, we evaluated how well CLOS correlated to postoperative complications absolutely and compared to PLOS. METHODS: A total of 668 PDs performed between 2011 and 2018 were evaluated. CLOS was calculated from PLOS and readmission length of stay. Complication severity was judged by the Modified Accordion Grading System (MAGS). Multinomial logistical regression models (MLRM) were used to investigate the relationship between either PLOS or CLOS and complications. Multilevel and pairwise area under curves (AUC) using SAS macro %MultAUC were provided for both models. RESULTS: A total of 432 of 668 patients (65%) developed complications. One hundred seventy-seven patients (27%) were readmitted. Mean PLOS was 10.2 days (7.1 SD) and mean CLOS was 12.3 days (10.1 SD). PLOS and CLOS both were correlated linearly to MAGS grade. Spearman correlation coefficient for CLOS vs. MAGS of 0.68 was higher than that of 0.49 for PLOS vs. MAGS. Multilevel AUC from MLRM using PLOS was 0.66, but multilevel AUC from MLRM using CLOS was 0.71. DISCUSSION: CLOS provides an accurate estimate of hospital day utilization per patient for PD, reflecting not only the basal hospital recovery time for PD but the added time needed because of readmissions due to complications. It is tightly correlated to number and severity of postoperative complications.

A diagnosis reconsidered: the symptomatic gallbladder remnant.

BACKGROUND: Patients can present with symptomatic gallbladder disease after cholecystectomy due to a remnant gallbladder. This is a rare problem and challenging diagnosis with limited prior characterization; thus, we present a large series of patients with a gallbladder remnant. METHODS: A retrospective review was performed of all patients presenting with symptomatic gallbladder remnant at a tertiary care center from 2002 to 2016. Data on presenting symptoms, diagnostic tests, treatments, and follow-up were collected. RESULTS: Thirty-one patients diagnosed and treated for a symptomatic gallbladder remnant were identified. The most common presenting symptoms included right upper quadrant pain (87%) and nausea (55%). The median time from symptom presentation to definitive diagnosis was 60 days. Diagnostic modalities utilized in the evaluation of these patients demonstrated that endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography were effective with sensitivities of 85% and 90%, respectively. Twenty-three (76.2%) patients underwent completion cholecystectomy, which proved to be definitive treatment. Additionally, eight (25.8%) patients were non-operative candidates and underwent endoscopic retrograde cholangiopancreatography and sphincterotomy, three of whom developed recurrent symptoms. CONCLUSION: A symptomatic gallbladder remnant after cholecystectomy is infrequently seen; however, the diagnosis should be considered in patients with recurrent biliary symptoms after cholecystectomy. Completion cholecystectomy can be challenging but is highly effective for definitive treatment.

Long-Term Endocrine and Exocrine Insufficiency After Pancreatectomy.

PURPOSE: To identify peri-operative risk factors and time to onset of pancreatic endocrine/exocrine insufficiency. METHODS: We retrospectively analyzed a single institutional series of patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) between 2000 and 2015. Endocrine/exocrine insufficiencies were defined as need for new pharmacologic intervention. Cox proportional modeling was used to identify peri-operative variables to determine their impact on post-operative pancreatic insufficiency. RESULTS: A total of 1717 patient records were analyzed (75.47% PD, 24.53% DP) at median follow-up 17.88 months. Average age was 62.62 years, 51.78% were male, and surgery was for malignancy in 74.35% of patients. Post-operative endocrine insufficiency was present in 20.15% (n = 346). Male gender (p = 0.015), increased body mass index (BMI) (p < 0.001), tobacco use (p = 0.011), family history of diabetes (DM) (p < 0.001), personal history of DM (p ≤ 0.001), and DP (p ≤ 0.001) were correlated with increased risk. Mean time to onset was 20.80 ± 33.60 (IQR: 0.49-28.37) months. Post-operative exocrine insufficiency was present in 36.23% (n = 622). Race (p = 0.014), lower BMI (p < 0.001), family history of DM (p = 0.007), steatorrhea (p < 0.001), elevated pre-operative bilirubin (p = 0.019), and PD (p ≤ 0.001) were correlated with increased risk. Mean time to onset was 14.20 ± 26.90 (IQR: 0.89-12.69) months. CONCLUSIONS: In this large series of pancreatectomy patients, 20.15% and 36.23% of patients developed post-operative endocrine and exocrine insufficiency at a mean time to onset of 20.80 and 14.20 months, respectively. Patients should be educated regarding post-resection insufficiencies and providers should have heightened awareness long-term.

Residual Tumor Index: A Prognostically Significant Pathologic Parameter in Neoadjuvant-treated Pancreatic Ductal Adenocarcinoma.

In the setting of neoadjuvant therapy (NAT) for pancreatic ductual adenocarcinoma (PDAC), accurate measurement of tumor size, and consequently, staging based on AJCC eighth edition, is difficult. Attempts to address the limitations of tumor size in the NAT setting have included correlation of residual tumor percent with survival. However, only cases with complete pathologic response or minimal residual disease have shown better prognosis compared with all other groups. To date, no studies have simultaneously evaluated the prognostic value of tumor size and tumor regression in the setting of PDAC status post NAT (NAT-PDAC). Our aim was to study the prognostic value of residual tumor index (RTI), a metric combining residual tumor percent and tumor bed size as an interaction term (% residual tumor×tumor bed size [cm]). In a cohort of 105 cases of NAT-PDAC, we show that RTI supersedes the prognostic value of AJCC eighth edition T staging via multivariate cox regression. At a binary cutoff of 0.35 for RTI, the hazard ratio for recurrence-free survival is 3.26 (95% confidence interval, 1.51-7.04), P<0.01. We further identified cutoffs of ≤0.2, 0.2 to 2 and >2 that stratified our cases into 3 groups via RTI, which were statistically significant in Kaplan-Meier curve analysis of recurrence-free survival (P<0.01) and overall survival (P<0.01). RTI represents a novel metric for combining the prognostic value of tumor size and residual tumor in NAT-PDAC.