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1.
Ann Surg Oncol ; 2020 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-32356271

RESUMO

BACKGROUND: Diagnosis of depression may be associated with adverse outcomes following surgery. The aim of this study is to investigate whether depression is associated with an increased readmission rate following elective pancreatectomy, which is currently unknown. METHODS: The 2014 Nationwide Readmissions Database was used to evaluate whether diagnosis of depression was associated with 30-day readmission following elective pancreatectomy in adult patients. Univariate and multivariate logistic regression models were adjusted for clustering by facility. A secondary analysis was performed to evaluate whether the risk of diagnosis of depression on 30-day readmission rates was modified by length of stay (median 8 days). All multivariate models were adjusted for patient-level characteristics. RESULTS: There were an estimated 11,992 patients who underwent elective pancreatectomy. Mean age was 63 years, and 48.9% were male. Approximately 10.2% (n = 1223) had diagnosis of depression. Depression was associated with higher odds of 30-day readmission following elective pancreatectomy on univariate [odds ratio (OR) 1.26, 95% confidence interval (CI) 1.01-1.59; P = 0.043] and multivariate analyses (OR 1.29, 95% CI 1.01-1.65; P = 0.039). Although length of stay > 8 days was independently associated with higher odds of 30-day readmission (P = 0.005), length of stay did not alter the association between diagnosis of depression and odds of readmission (P = 0.90). CONCLUSIONS: Diagnosis of depression was associated with higher odds of 30-day readmission following pancreatectomy, regardless of length of stay. Enhanced focus on evaluation and optimization of perioperative mental health is warranted to identify patients at high risk for readmission and reduce the burden related to readmission following pancreatic surgery.

2.
Ann Surg ; 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32404659
3.
7.
Ann Surg Oncol ; 2020 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-32307617

RESUMO

BACKGROUND: The authors hypothesized that in resected pancreatic adenocarcinoma (PDAC), pathologic characteristics, oncologic outcomes, prognostic factors, and the accuracy of the American Joint Committee on Cancer (AJCC) staging system might differ based on tumor location. METHODS: Patients undergoing pancreatectomy for PDAC at two academic institutions from 2000 to 2015 were retrieved. A comparative analysis between head (H-PDAC) and body-tail (BT-PDAC) tumors was performed using uni- and multivariable models. The accuracy of the eighth AJCC staging system was analyzed using C-statistics. RESULTS: Among 1466 patients, 264 (18%) had BT-PDAC, which displayed greater tumor size but significantly lower rates of perineural invasion and G3/4 grading. Furthermore, BT-PDAC was associated with a lower frequency of nodal involvement and a greater representation of earlier stages. The recurrence-free survival and disease-specific survival times were longer for BT-PDAC (16 vs 14 months [p = 0.020] and 33 vs 26 months [p = 0.026], respectively), but tumor location was not an independent predictor of recurrence or survival in the multivariable analyses. The recurrence patterns did not differ. Certain prognostic factors (i.e., CA 19.9, grading, R-status, and adjuvant treatment) were common, whereas others were site-specific (i.e., preoperative pain, diabetes, and multivisceral resection). The performances of the AJCC staging system were similar (C-statistics of 0.573 for H-PDAC and 0.597 for BT-PDAC, respectively). CONCLUSIONS: Despite differences in pathologic profile found to be in favor of BT-PDAC, tumor location was not an independent predictor of recurrence or survival after pancreatectomy. An array of site-specific prognostic factors was identified, but the AJCC staging system displayed similar prognostic power regardless of primary tumor location.

8.
J Am Coll Surg ; 2020 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-32251846

RESUMO

BACKGROUND: A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared to open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis (NP). We sought to determine if transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage (PD), endoscopic transgastric necrosectomy (ETN), video-assisted retroperitoneal debridement (VARD), sinus tract endoscopic necrosectomy (STE), or a combination of techniques, with selective use of OSN. STUDY DESIGN: Observational cohort study with retrospective comparison at a single tertiary referral center (2006-2019). 88 patients were treated with OSN and 91 were treated with a MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary outcome was 90-day mortality. RESULTS: There was no difference in baseline characteristics. 90-day mortality was 2% with MIS compared to 10% with OSN (p=0.03). One-year mortality was 3% with MIS compared to 15% with OSN (p=0.012). The rate of organ failure was lower with MIS (30% vs 45%, p=0.029), but there was a higher bleeding rate (19% vs 9%) (p=0.064). In the MIS group, 9% were treated with PD, 32% with ETN, 8% with VARD, 15% with STE, and 27% with a combination of techniques. CONCLUSION: Adoption of a multidisciplinary MIS-based approach to NP resulted in a 5-fold decrease in mortality compared to OSN.

9.
Am J Surg ; 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32265013

RESUMO

BACKGROUND: Cancer center accreditation is designed to identify centers that provide high-quality cancer care. This also guides patients and referring physicians towards centers of excellence for specialized care. We sought to examine if cancer center accreditation was associated with improved long-term oncologic outcomes in patients with pancreatic adenocarcinoma. METHODS: Using the SEER-Medicare database, we identified patients who underwent pancreatectomy for pancreatic adenocarcinoma from 1996 to 2013. Hospitals were categorized into three groups: National Cancer Institute-designated (NCI-designated) centers, Commission on Cancer (CoC)-accredited centers, and "non-accredited" (NA) centers. Multilevel mixed-effects models were used to calculate adjusted examined lymph nodes, disease-specific survival (DSS), and overall survival (OS). RESULTS: We identified 5,118 patients who underwent pancreatectomy at 632 hospitals (41.0% NA, 49.6% CoC, 9.4% NCI). NCI-designated centers had a greater median number of lymph nodes examined compared with CoC-accredited or NA centers (14 vs. 10 vs. 11.0 nodes, respectively; p < 0.001). Patients treated at NCI centers had a higher 5-year DSS compared to those treated at CoC or NA centers (31.2% vs. 23.6% vs. 23.0%, respectively; p < 0.001). Finally, patients treated at NCI centers had a higher 5-year OS compared to those treated at CoC or NA centers (23.5% vs. 18.9% vs. 17.9%, respectively; p < 0.001). The associations held true when adjusted analyses were performed. CONCLUSION: Patients with resected pancreatic cancer treated at NCI-designated centers were associated with improved long-term oncologic outcomes. There was no difference between CoC-accredited centers compared with NA centers. Meticulous validation of accreditation is warranted globally prior to implementation.

10.
Surgery ; 2020 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-32249092

RESUMO

BACKGROUND: The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS: Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS: Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION: Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.

11.
Surgery ; 2020 Mar 14.
Artigo em Inglês | MEDLINE | ID: mdl-32183994

RESUMO

BACKGROUND: The International Study Group for Pancreatic Surgery provides globally accepted definitions for reporting of complications after pancreatic surgery. This International Study Group for Pancreatic Surgery project aims to provide a standardized framework for reporting of the results of operative treatment for chronic pancreatitis. METHODS: An International Study Group for Pancreatic Surgery project circulation list was created with pre-existing and new members and including gastroenterologists in addition to surgeons. A computerized search of the literature was undertaken for articles reporting the operative treatment of chronic pancreatitis. The results of the literature search were presented at the first face-to-face meeting of this International Study Group for Pancreatic Surgery project group. A document outlining proposed reporting standards was produced by discussion during an initial meeting of the International Study Group for Pancreatic Surgery. An electronic questionnaire was then sent to all current members of the International Study Group for Pancreatic Surgery. Responses were collated and further discussed at international meetings in North America, Europe, and at the International Association of Pancreatology World Congress in 2019. A final consensus document was produced by integration of multiple iterations. RESULTS: The International Study Group for Pancreatic Surgery consensus standards for reporting of surgery in chronic pancreatitis recommends 4 core domains and the necessary variables needed for reporting of results: clinical baseline before operation; the morphology of the diseased gland; a new, standardized, operative terminology; and a minimum outcome dataset. The 4 domains combine to give a comprehensive framework for reports. CONCLUSION: Adoption of the 4 domains of the International Study Group for Pancreatic Surgery reporting standards for surgery for chronic pancreatitis will facilitate comparison of results between centers and help to improve the care for patients with this debilitating disease.

12.
Pancreatology ; 2020 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-32222340

RESUMO

BACKGROUND: There is limited data on the efficacy of adjuvant therapy (AT) in patients with invasive intraductal papillary mucinous neoplasms of the pancreas (IPMN). This single center retrospective cohort study aims to assess the impact of AT on survival in these patients. METHODS: Patients undergoing surgery for invasive IPMN between 1993 and 2018 were included in the study. We compared the clinicopathologic features and evaluated overall survival (OS) using multivariate Cox regression adjusting for adjuvant therapy, age, T and N stage, perineural and lymphovascular invasion. We also assessed survival differences between surgery alone and AT in node negative (N0) and node positive (N+) subgroups. RESULTS: 103 patients were included in the study; 69 underwent surgery alone while 34 also received AT. Patients in the AT group were significantly younger, presented at higher T and N stages and had more perineural and lymphovascular invasion. Median OS in the surgery alone group was 134 months and 65 months in the AT group, p = 0.052. On multivariate analysis, AT was not associated with improved OS; hazard ratio (HR) = 1.03 (0.52-2.05). In N0 patients, compared to surgery alone, AT was associated with a worse median OS (65 vs 167 months, p = 0.03), whereas in N+ patients there was a non-significant improvement (50.5 vs 20.4 months, p = 0.315). CONCLUSION: AT did not improve survival in the overall cohort even after multivariate analysis. N0 patients have excellent survival, and AT should probably be avoided in them, whereas it may be considered in patients with N+ disease.

13.
Pancreatology ; 2020 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-32222341

RESUMO

BACKGROUND/OBJECTIVES: We sought to identify the reliability of AJCC clinical staging was in comparison to pathologic staging in surgically resected patients with pancreatic cancer. METHODS: We used the National Cancer Database Pancreas from 2004 to 2016 and evaluated patients who underwent resection for PDAC with all documented components of clinical and pathologic stage. We first evaluated the distribution of overall clinical stage and pathologic stage and then evaluated for stage migration by assessing the number of patients who shifted from a clinical stage group to a respective pathologic stage group. To further characterize the migratory pattern, we assessed the distribution of clinical and pathologic T-stage and N-stage. RESULTS: In our cohort of 28,338 patients who underwent resection for PDAC, AJCC clinical staging did not reliably predict pathologic stage. Stage migration after resection was responsible for discrepancies between the distribution of overall clinical stage and pathologic stage. The predominant migration was from patients with clinical stage I disease to pathologic stage II disease. Most patients with clinical T1 and T2 disease were upstaged to pathologic T3 disease and over half of patients with clinical N0 disease were upstaged to pathologic N1 disease after resection. DISCUSSION: Clinical staging appears to overrepresent early T1, T2, and N0 disease, and underrepresent T3 and N1 disease.

14.
Am J Surg ; 219(4): 557-562, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32007235

RESUMO

BACKGROUND: The "white-flight" phenomenon of the mid-20th century contributed to the perpetuation of residential segregation in American society. In light of recent reports of racial segregation in our healthcare system, could a contemporary "white-flight" phenomenon also exist? METHODS: The New York Statewide Planning and Research Cooperative System was used to identify all Manhattan and Bronx residents of New York city who underwent elective cardiothoracic, colorectal, general, and vascular surgeries from 2010 to 2016. Primary outcome was borough of surgical care in relation to patient's home borough. Multivariable analyses were performed. RESULTS: White patients who reside in the Bronx are significantly more likely than racial minorities to travel into Manhattan for elective surgical care, and these differences persist across different insurance types, including Medicare. CONCLUSIONS: Marked race-based differences in choice of location for elective surgical care exist in New York city. If left unchecked, these differences can contribute to furthering racial segregation within our healthcare system.


Assuntos
Comportamento de Escolha , Grupos de Populações Continentais/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Área de Atuação Profissional/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Participação do Paciente , Fatores Raciais , Estados Unidos
15.
Histopathology ; 2020 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-32031712

RESUMO

INTRODUCTION: In the adjuvant setting, when compared to gemcitabine, patients with pancreatic ductal adenocarcinoma (PDAC) treated with FOLFIRINOX show superior survival. Herein, we quantitatively assess pathologic tumor response to chemoradiation in pancreatectomy specimen and reassess guidelines for tumor regression grading. METHODS: We evaluated 92 patients with borderline resectable/locally advanced PDAC following pancreatectomy and neoadjuvant treatment with FOLFIRINOX and radiation. Demographic data, CAP tumor regression grade (TRG), and overall survival (OS) was recorded. A quantitative analysis of residual tumor was performed on the slide with the highest tumor burden to derive a tumor to tumor bed ratio. RESULTS: On univariate analysis, only lymph node status (p=0.043), and CAP TRG (p=0.038) correlated with OS. Sixteen percent of patients showed complete pathologic response. The optimal tumor to tumor bed ratio cut point was 11.6% and on a multivariate model was the only pathologic parameter that correlated with OS (p=0.016) (Hazard Ratio 2.27). CONCLUSIONS: The high proportion of patients with PDAC showing complete and near complete pathologic response supports the use of FOLFIRINOX and radiation in the neoadjuvant setting. Several traditional pathology parameters fail to predict OS in patients treated with chemoradiation while a quantitative tumor to tumor bed ratio is a powerful predictor of OS. The data supports a two-tiered approach to TRG based on tumor to tumor bed ratio and quantitative analysis merits further consideration.

17.
Pancreatology ; 20(1): 125-131, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31706821

RESUMO

BACKGROUND: The risk of pancreatic ductal adenocarcinoma (PDAC) is increased in patients with diabetes mellitus (DM), particularly in those with new-onset DM. However, the impact of DM on outcomes following pancreatic surgery is not fully understood. We sought to explore the effects of DM on post-resection outcomes in patients undergoing either upfront resection or following neoadjuvant treatment (NAT). METHODS: Resections for PDAC between 2007 and 2016 were identified from a prospectively-maintained database. Data on demographics, pathology, and perioperative outcomes were compared between patients with or without DM. Survival analysis was performed using Kaplan-Meier curves and adjusted for confounders by a Cox-proportional hazards model. RESULTS: 662 patients were identified, of whom 277 (41.8%) had DM. Diabetics were more likely to be male, had higher BMI, and higher ASA-scores. At pathology, DM was associated with larger tumors (30 vs. 26 mm; p = 0.041), higher rates of lymph-node involvement (69% vs. 59%; p = 0.031) and perineural invasion (88% vs. 82%; p = 0.026). Despite having similar rates of complications, diabetics experienced higher 30-day mortality (3.2% vs. 0.8%; p = 0.019). Median overall survival was worse in diabetic patients (18 vs. 34 months; p < 0.001); this effect was more pronounced in patients with NAT (18 vs. 54 months; p < 0.001). At multivariate analysis, DM was confirmed as an independent predictor of post-resection survival. CONCLUSION: DM is a common comorbidity in PDAC and is associated with unfavorable pathology, as well as worse postoperative and oncologic outcomes. The blunted effect on survival is more pronounced in patients who undergo resection following NAT.

18.
Pancreas ; 49(1): 128-134, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31856088

RESUMO

OBJECTIVES: Pancreatic ductal adenocarcinoma (PDAC) is characterized by early metastatic spread in more than 50% of patients. In this study, we sought to understand the migratory properties of (non)metastatic PDAC cells and determine whether the migration of cancer stem cell (CSC) populations accounts for the aggressive nature of this disease. METHODS: The migratory abilities of primary and metastatic PDAC cell lines were investigated using a microfluidic device and time-lapse photography. The velocity, time of delay of mobilization, and number of migratory cells were analyzed. Cancer stem cell subpopulations were isolated by fluorescence-activated cell sorting and their migratory properties compared with their non-CSC counterparts. RESULTS: Primary cancer cells exhibited higher velocities, greater number of migratory cells, and a shorter time of delay of mobilization in comparison to metastatic cell lines. Characterization of CSC populations revealed primary PDAC cell lines were composed of fewer CD133 and CD24CD44 CSC subpopulations than metastatic cells. Moreover, migratory analysis of CSC subpopulations revealed lower velocities, fewer migratory cells, and a greater time of delay of mobilization than non-CSC. CONCLUSIONS: Primary cancer cells demonstrate enhanced migratory abilities in comparison to metastatic PDAC cells. Those differences may result from lower CSC subpopulations in primary cells because CSC populations demonstrated impaired migratory abilities in contrast to non-CSC.

19.
Ann Surg ; 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31804389

RESUMO

OBJECTIVE: To evaluate the influence of consensus guidelines on the management of intraductal papillary mucinous neoplasms (IPMN) and the subsequent changes in pathologic outcomes. BACKGROUND: Over time, multiple guidelines have been developed to identify high-risk IPMN. We hypothesized that the development and implementation of guidelines should have increased the percentage of resected IPMN with high-risk disease. METHODS: Memorial Sloan-Kettering (MSK), Johns Hopkins (JH), and Massachusetts General Hospital (MGH) databases were queried for resected IPMN (2000-2015). Patients were categorized into main-duct (MD-IPMN) versus branch-duct (BD-IPMN). Guideline-specific radiographic/endoscopic features were recorded. High-risk disease was defined as high-grade dysplasia/carcinoma. Fisher's exact test was used to detect differences between institutions. Logistic regression evaluated differences between time-points [preguidelines (pre-GL, before 2006), Sendai (SCG, 2006-2012), Fukuoka (FCG, after 2012)]. RESULTS: The study included 1210 patients. The percentage of BD-IPMN with ≥1 high-risk radiographic feature differed between centers (MSK 69%, JH 60%, MGH 45%; P < 0.001). In MD-IPMN cohort, the presence of radiographic features such as solid component and main pancreatic duct diameter ≥10 mm also differed (solid component: MSK 38%, JH 30%, MGH 18%; P < 0.001; duct ≥10 mm: MSK 49%, JH 32%, MGH 44%; P < 0.001). The percentage of high-risk disease on pathology, however, was similar between institutions (BD-IPMN: P = 0.36, MD-IPMN: P = 0.48). During the study period, the percentage of BD-IPMN resected with ≥1 high-risk feature increased (52% pre-GL vs 67% FCG; P = 0.005), whereas the percentage of high-risk disease decreased (pre-GL vs FCG: 30% vs 20%). For MD-IPMN, there was not a clear trend towards guideline adherence, and the rate of high-risk disease was similar over the time (pre-GL vs FCG: 69% vs 67%; P = 0.63). CONCLUSION: Surgical management of IPMN based on radiographic criteria is variable between institutions, with similar percentages of high-risk disease. Over the 15-year study period, the rate of BD-IPMN resected with high-risk radiographic features increased; however, the rate of high-risk disease decreased. Better predictors are needed.

20.
J Am Coll Surg ; 2019 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-31857209

RESUMO

BACKGROUND: Surgeons are prone to feelings of sadness, guilt, and anxiety when involved in major adverse events. We aimed to create and evaluate a second victim peer support program for surgeons and surgical trainees. STUDY DESIGN: The second victim peer-support program was an intervention performed in the Department of Surgery at a tertiary care academic medical center. Surgical attendings and trainees participated as peer supporters or affected peers. In this work, we describe the design of the program and its one-year impact. The program's impact was evaluated through 1) the number of interventions attempted and realized, and 2) feedback received from all participants using an anonymous qualitative and quantitative survey. RESULTS: The program was established using 5 steps: 1) creation of a conceptual framework, 2) choice of peer supporters, 3) training of peer supporters, 4) multi-faceted identification of major adverse events, and 5) design of a systematic intervention plan. In one year, the program had 47 interventions distributed evenly between attendings and trainees; 19% of affected peers opted out of receiving support. Most participants expressed satisfaction with the program's confidentiality, the safe/trusting environment it provided, and the timeliness of the intervention (89%, 73%, and 83%, respectively); 81% suggested that the program had a positive impact on the department's "safety and support" culture and would recommend the program to a colleague. Several areas for improvement were identified, including the need to improve identification of events requiring outreach, and the desire for increased awareness of the program throughout the department. CONCLUSIONS: We successfully designed, implemented, and assessed the impact of the first surgery-specific peer support program in the US. Our one-year experience suggests that the program is highly utilized and well-received, albeit with opportunities for improvement.

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