An assessment of perioperative outcomes for open, laparoscopic, and robot-assisted pancreaticoduodenectomy in New York State.

BACKGROUND: Minimally invasive techniques for pancreaticoduodenectomy (PD) are increasing in practice, however, data remains limited regarding perioperative outcomes. Our study sought to compare patients undergoing open pancreaticoduodenectomy (OPD) with those undergoing laparoscopic (LPD) or robot-assisted pancreaticoduodenectomy (RPD). METHODS: Patients who underwent PD during 2016-2018 were identified from the New York State Planning and Research Cooperative System database. RESULTS: Of the 1954 patients identified, 1708 (87.4%) underwent OPD, 165 (8.4%) underwent LPD, and 81 (4.2%) underwent RPD. The majority of patients were White (63.8%), males (53.3%) with a mean age of 65.4 years. RPD patients had a lower median Charlson Comorbidity Index (2) than OPD (3) or LPD (3, p = 0.01) and had a lower 30-day rate of complications (35.8% vs. 48.3% vs. 43.6% respectively, p = 0.05). After propensity-score matching, however, there were no differences between the groups regarding overall complications, surgical site infections, anastomotic leaks, or mortality (p = NS for all). OPD demonstrated a longer length of stay (median 8 days) compared to LPD (7 days) or RPD (7 days, p < 0.01). CONCLUSIONS: Patients undergoing LPD and RPD have a shorter length of hospital stay compared to OPD and there was no difference in overall morbidity or mortality when matched to similar patients.

SPECT/CT Adds Distinct Lymph Node Basins and Influences Radiologic Findings and Surgical Approach for Sentinel Lymph Node Biopsy in Head and Neck Melanoma.

BACKGROUND: Planar lymphoscintigraphy (PL) has a lower detection rate of sentinel lymph nodes (SLNs) in head and neck melanoma compared with other sites. We assessed situations when single-photon emission computed tomography/computed tomography (SPECT/CT) identified nodes not seen by PL. We also evaluated the impact of SPECT/CT on surgical approach and oncologic outcomes. METHODS: Patients who underwent SLN biopsy (SLNB) for head and neck melanoma with PL and SPECT/CT between November 2011 and December 2016 were included. Surgeons and radiologists completed a real-time survey inquiring about the utility of SPECT/CT. Patients were divided into two groups: patients with nodal basins identified by both PL and SPECT/CT ('PL + SPECT/CT'), and patients in whom SPECT/CT identified additional nodal basins not seen on PL ('SPECT/CT only'). Patient demographics and long-term outcomes including follow-up duration, recurrence, and survival are described. RESULTS: In the PL + SPECT/CT group, 73 (61.9%) patients were included and 45 (38.1%) patients were included in the SPECT/CT-only group. SPECT/CT added 51 basins to those seen on PL, primarily in the supraclavicular region (43.1%). Eighteen patients had positive node(s) in the PL + SPECT/CT group compared with two patients in the SPECT/CT-only group. Surgeons reported that 81% of the time, SPECT/CT influenced the location of incision for SLNB. CONCLUSIONS: SPECT/CT influences the location of incision and contributes most to identification of nodes in the supraclavicular region. It also detects additional SLN basins when compared with PL. Further studies are necessary to determine when these additional basins require sampling.

Implications of Hyperthermic Intraperitoneal Chemotherapy Perfusion-Related Hyperglycemia.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) administration can be associated with hyperglycemia during perfusion. Little is known about this effect, and no previous studies have examined patient characteristics associated with perfusion-related hyperglycemia. METHODS: We retrospectively identified consecutive patients at a single institution treated with HIPEC from 8/2003 to 10/2016 who had intraoperative blood glucose measured. Hypertonic 1.5% dextrose-containing peritoneal dialysate was used as carrier solution in all patients. Comparisons were made using parametric [Student's t test, analysis of variance (ANOVA)], and nonparametric tests (χ 2, Kruskal-Wallis) where appropriate. RESULTS: There were 85 patients identified, with average age of 53 ± 12 years, 69 (81%) with appendiceal or colorectal peritoneal cancer. Most patients were perfused with mitomycin C (69%) or oxaliplatin (24%). Intraoperative hyperglycemia (> 180 mg/dL) affected the majority of patients (86%), with values up to 651 mg/dL. Insulin was required for treatment in 66% of patients. Peak hyperglycemia occurred within an hour of perfusion in 91%, and resolved by postoperative day one in 91% of patients. Glucose > 309 mg/dL (highest quartile) was associated with longer operating time (p = 0.03) and with use of oxaliplatin compared with mitomycin C (p = 0.01). No association was found with other comorbidities, peritoneal carcinomatosis index score, or postoperative outcomes. CONCLUSIONS: Most patients experience hyperglycemia during HIPEC. This is not clearly associated with patient factors, and may be due to use of dextrose-containing carrier solution. Since perioperative hyperglycemia has potential negative impact, use of dextrose-containing carrier solution should be questioned and is worth investigating further.

Perioperative outcomes and survival following neoadjuvant stereotactic body radiation therapy (SBRT) versus intensity-modulated radiation therapy (IMRT) in pancreatic adenocarcinoma.

BACKGROUND AND OBJECTIVES: To compare outcomes in patients receiving neoadjuvant stereotactic body radiation therapy (SBRT) with those receiving intensity-modulated radiation therapy (IMRT) for pancreatic adenocarcinoma. METHODS: We analyzed patients receiving neoadjuvant SBRT for borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) (2012-2016). Differences in baseline characteristics, perioperative outcomes, progression-free survival (PFS), and overall survival (OS) were compared. RESULTS: Seventy-five (82.4%) patients received SBRT and 16 (17.6%) received IMRT. There were no differences in surgical resection rates in the SBRT (n = 38, 50.7%) and IMRT (n = 11, 68.8%) groups (P = 0.188). Among resected patients, there was no difference in postoperative outcomes or pathologic outcomes including lymph node status, margin status, lymphovascular and perineural invasion, or pathologic response to neoadjuvant treatment (P > 0.05). Among all patients, median PFS and OS were 9.9 and 23.5 months in the SBRT group, respectively, and 15.3 and 21.8 months in the IMRT group, respectively (P > 0.05). Similarly, there was no difference in PFS or OS between groups when stratified by BRPC, LAPC, and surgically resected patients (P > 0.05). CONCLUSIONS: In the neoadjuvant setting, SBRT and IMRT appear to have similar rates of resection, perioperative outcomes, and survival outcomes, but additional studies with increased sample size and longer follow up are needed.

Comparison of laparoscopic to open pancreaticoduodenectomy in elderly patients with pancreatic adenocarcinoma.

INTRODUCTION: The purpose of the study is to compare perioperative and survival outcomes in elderly patients undergoing laparoscopic pancreaticoduodenectomy (LPD) to those undergoing open pancreaticoduodenectomy (OPD). METHODS: Patients aged ≥ 75 years with pancreatic adenocarcinoma undergoing LPD or OPD were identified from the NCDB (2010-2013). Baseline characteristics and perioperative outcomes were compared using a χ 2 and Student's t test. The Kaplan-Meier method was used to generate survival curves, and differences were tested using a log-rank test. A multivariate cox proportional hazard model was applied to estimate the hazard ratio (HR) of LPD on overall survival (OS). RESULTS: We identified 1768 patients aged ≥ 75 years who underwent LPD (n = 248, 14.0%) or OPD (n = 1520, 86.0%). The majority of patients in the LPD group had their surgery at facilities performing less than 5 LPDs per year (n = 165, 66.5%). 90-day mortality was significantly lower in the LPD compared to the OPD (7.2 vs. 12.2%, p = 0.049). The laparoscopic conversion rate was 30% (n = 74) and was associated with higher readmission rates (13.5 vs. 8.1%), 30-day mortality (8.0 vs. 3.8%), and 90-day mortality (10.4 vs. 6.0%), but these did not reach statistical significance. Median OS was significantly longer in the LPD group (19.8 vs. 15.6 months, p = 0.022). After adjusting for patient and tumor-related characteristics, there was a trend towards improved survival in the LPD group (HR 0.85, 95% CI 0.69-1.03). CONCLUSION: The vast majority of the NCDB participating facilities perform less than 5 LPD cases per year, which was associated with an increased risk of perioperative mortality. Overall 90-day mortality was significantly lower in the LPD group and there was a trend towards improved OS in the LPD group compared to the OPD group after adjusting for patient and tumor-related characteristics. Studies with increased sample size and longer follow-up are needed before definitive conclusions can be made.

Laparoscopic pancreaticoduodenectomy: changing the management of ampullary neoplasms.

BACKGROUND: The purpose of this study is to present the largest reported series comparing open pancreaticoduodenectomy (OPD) to total laparoscopic pancreaticoduodenectomy (TLPD) in patients with ampullary neoplasms. METHODS: Patients undergoing OPD or TLPD for ampullary neoplasms from June 2012 to August 2016 were retrospectively identified. Perioperative outcomes were compared using a Wilcoxon rank-sum test, Student's t test, and Chi square analysis where appropriate. Kaplan-Meier estimates for progression-free survival (PFS) and overall survival (OS) were compared between the groups using the log-rank test. RESULTS: We identified 47 patients with ampullary neoplasms (adenocarcinoma n = 36, neuroendocrine tumor n = 7, undifferentiated n = 1, adenoma n = 3) undergoing OPD (n = 25) and TLPD (n = 22). The proportion of patients being offered TLPD has progressively increased every year over 5 years: 0% (2012) to 50% (2015). There were no differences in baseline variables between the two groups. TLPD was associated with less blood loss (300 vs. 500 mL, p < 0.001) and shorter operative times (314 vs. 359 min, p = 0.024). No patient required conversion to an open procedure and there were no perioperative deaths in either group. TLPD was associated with lower rates of intra-abdominal abscess (0 vs. 16.0%, p = 0.049), but there were no differences in rates of pancreatic fistula, bile leak, delayed gastric emptying, wound infection, length of stay, and readmission (all p > 0.05). Among patients with adenocarcinoma, there was no difference in pathological features between the two groups (p > 0.05) and all patients had negative margins. At a median follow up of 25 months, there was no difference in PFS or OS between the two groups. CONCLUSIONS: TLPD in patients with ampullary neoplasms results in improved perioperative outcomes while having equivalent short and long-term oncologic outcomes compared to the traditional open approach.

Perioperative and Survival Outcomes Following Neoadjuvant FOLFIRINOX versus Gemcitabine Abraxane in Patients with Pancreatic Adenocarcinoma.

CONTEXT: Neoadjuvant chemotherapy is increasingly used in borderline resectable and locally advanced pancreatic cancer to facilitate surgical resection. OBJECTIVE: To compare progression free survival and overall survival in patients receiving neoadjuvant FOLFIRINOX with those receiving gemcitabine/abraxane. DESIGN: Retrospective cohort study. SETTING: University of Colorado Hospital from 2012-2016. PARTICIPANTS: Patients with pancreatic adenocarcinoma. INTERVENTIONS: Neoadjuvant FOLFIRINOX or gemcitabine/abraxane. OUTCOME MEASURES: Perioperative outcomes, progression free survival, and overall survival were compared between groups. A multivariate Cox proportional hazard model was applied to evaluate survival outcomes. RESULTS: We identified 120 patients: 83 (69.2%) FOLFIRINOX and 37 (30.8%) gemcitabine/abraxane. The FOLIFRINOX group was younger and had a lower ECOG performance status (p<0.05). Patients in the FOLFIRINOX group were more likely to undergo surgical resection compared to gemcitabine/abraxane (66.3% vs. 32.4%, p=0.002). Among all patients, median follow up was 16.9 months and FOLFIRINOX was associated with improved PFS (15.3 vs. 8.2 months, p=0.006), but not overall survival (23.5 vs. 18.7 months, p=0.228). In these patients, insulin-dependent diabetes was associated with a worse progression free survival and overall survival and surgical resection was protective. Among surgically resected patients, median follow up was 21.1 months and there was no difference in progression free survival (19.5 vs. 15.1 months) or overall survival (27.4 vs. 19.8 months) between the FOLFIRINOX and gemcitabine/abraxane groups, respectively (p>0.05). Insulin-dependent diabetes and a poor-to-moderate pathologic response was associated with worse progression free survival and overall survival. CONCLUSION: Neoadjuvant FOLFIRINOX may improve progression free survival by increasing the proportion of patients undergoing surgical resection. Improved understanding of the role for selection bias and longer follow up are needed to better define the impact of neoadjuvant FOLFIRINOX on overall survival.

Implications of Sentinel Lymph Node Drainage to Multiple Basins in Head and Neck Melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) for head and neck melanoma is challenging due to unpredictable drainage. We sought to determine the frequency of drainage to multiple lymphatic basins and asked if this was associated with prognosis in a large, single-center cohort. METHODS: We queried patients diagnosed with head and neck melanomas who had a SLNB performed from January 1998 to April 2016. Demographic and clinical characteristics were compared using Student's t test, Pearson chi-square analysis, log-rank test, Wilcoxon-Mann-Whitney test, and Kaplan-Meier curves. RESULTS: We identified 269 patients with head and neck melanoma that had SLNBs performed in the following locations: 223 neck, 92 parotid/preauricular, 29 occipital/posterior auricular, 1 axilla. There were 68 (25%) patients who had drainage to multiple basins. These patients were similar to those with single basin drainage in age, gender distribution, Breslow depth, and percent with a positive SLNB (all p > 0.05). Fewer patients with drainage to multiple basins had a completion lymph node dissection (CLND, p = 0.03). A trend toward increased 3-year locoregional recurrence was seen for patients with drainage to multiple basins in univariate analysis (27% vs. 18%, p = 0.10) but was lost in multivariate analysis (p = 0.49), possibly because of higher recurrence rates in patients with positive nodes but no CLND (p = 0.02). No difference was detected for distant recurrence or overall survival based on SLN drainage. CONCLUSIONS: Head and neck melanoma SLNB drainage to multiple basins is common. Drainage to multiple basins does not seem to be associated with increased sentinel lymph node positivity, locoregional recurrence, distant recurrence, or survival.

Is Chemical Pyloroplasty Necessary for Minimally Invasive Esophagectomy?

BACKGROUND: Many centers use botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies as prophylaxis against delayed gastric emptying. No previous studies have compared botulinum toxin injection with no pyloric intervention for patients treated with a combined laparoscopic and thoracoscopic approach. The authors hypothesized that chemical pyloroplasty does not improve outcomes for these patients. METHODS: The study investigated patients undergoing minimally invasive esophagectomies from September 2009 to June 2015. Delayed gastric emptying was defined as inability to tolerate a soft diet by postoperative day 10, as corroborated by esophagram, upper endoscopy, or both. Data were compared using Student's t test, χ 2 analysis, and Mann-Whitney U test where appropriate. RESULTS: The study identified 71 patients treated with minimally invasive esophagectomy: 35 patients with chemical pyloroplasty treated from September 2009 to January 2014 and 36 patients without pyloric intervention from February 2014 to June 2015. The groups were statistically similar in age, gender distribution, T stage, percentage of patients receiving neoadjuvant therapy, body mass index, preoperative weight loss, preoperative serum albumin, and preoperative placement of feeding tubes (all p > 0.05). The overall incidence of delayed gastric emptying was low in both groups: 8.6% (3/35) of the patients with chemical pyloroplasty versus 5.6% (2/36) of the patients with no pyloric intervention (p = 0.62). The two groups also did not differ significantly in the development of aspiration pneumonia or the need for pyloric intervention. CONCLUSIONS: In a well-matched cohort study with a historical control group, use of botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies was not associated with improved outcomes related to the pylorus versus no pyloric intervention. Although preliminary, these data suggest that chemical pyloroplasty is not necessary in minimally invasive esophagectomy.

Impact of neoadjuvant chemoradiation on perioperative outcomes in patients with rectal cancer.

BACKGROUND AND OBJECTIVES: Neoadjuvant chemoradiation for rectal cancer is associated with lower local recurrence rates. The objective of this study is to assess the impact of neoadjuvant therapy on perioperative complications in patients with rectal cancer. METHODS: Using the ACS-NSQIP database (2005-2012), a propensity score was used to match 3592 patients with rectal cancer receiving neoadjuvant therapy to 3592 patients undergoing surgery alone. The association between neoadjuvant chemoradiation and perioperative outcomes was evaluated. RESULTS: Among all patients, overall morbidity was significantly higher in the neoadjuvant therapy group (n = 1170, 29.9%) compared to the surgery alone (n = 2350, 26.4%; P < 0.0001), but 30-day mortality was lower in the neoadjuvant group (n = 27, 0.7%) compared to the surgery alone group (n = 112, 1.3%; P = 0.0043). However, in propensity-matched patients, there was no difference in overall morbidity (OR 0.912, 95% CI 0.825-1.008) or 30-day mortality (OR 0.639, 95% CI 0.38-1.05). Overall morbidity and 30-day mortality were 29.3% (n = 1054) and 0.7% (n = 25) in the neoadjuvant group, respectively, compared to 31.3% (n = 1124) and 1.1% (n = 39) in the surgery alone group, respectively. CONCLUSION: Patients with newly diagnosed rectal cancer could be evaluated for neoadjuvant therapy prior to surgical resection without the fear of upfront therapy causing a significant increase in perioperative complications.

The Multidisciplinary Approach to GI Cancer Results in Change of Diagnosis and Management of Patients. Multidisciplinary Care Impacts Diagnosis and Management of Patients.

BACKGROUND: The multidisciplinary approach to GI cancer is becoming more widespread as a result of multimodality therapy. At the University of Colorado Hospital (UCH), we utilize a formal multidisciplinary approach through specialized clinics across a variety of settings, including pancreas and biliary cancer, esophageal and gastric cancer, liver cancer and neuroendocrine tumors (NET), and colorectal cancer. Patients with these suspected diagnoses are seen in a multidisciplinary clinic. We evaluated whether implementation of disease-specific multidisciplinary programs resulted in a change in diagnosis and/or change in management for these patients. METHODS: Data from 1747 patients were prospectively collected from inception of each multidisciplinary program through December 31, 2015. Change in diagnosis was defined as a change in radiographic or endoscopic findings that resulted in a change in cancer stage or clinical diagnosis and/or a change in pathologic diagnosis. Reports of incidental findings unrelated to primary diagnosis on radiographic evaluation were also assessed, but not included in overall change in diagnosis findings. We further evaluated if patients had a change in the management of their disease compared with outside recommendations. RESULTS: Of 1747 patients evaluated, change occurred in 38 % (pancreas and biliary), 13 % (esophageal and gastric); 22 % (liver and NET), and 16 % (colorectal). Change in management for each multidisciplinary program occurred in 35 % (pancreas and biliary), 20 % (esophageal and gastric), 27 % (liver and NET), and 13 % (colorectal). CONCLUSIONS: The use of a multidisciplinary clinic to manage GI cancer has a substantial impact in change in diagnosis and/or management in more than one-third of patients evaluated.

SPECT/CT Improves Detection of Metastatic Sentinel Lymph Nodes in Patients with Head and Neck Melanoma.

BACKGROUND: A positive sentinel lymph node (SLN) is the most important prognostic factor for predicting survival in cutaneous melanoma. This study aimed to evaluate how the addition of single-photon emission computed tomography (SPECT) and computed tomography (CT) to planar lymphoscintigraphy (PL) alters SLN identification, yield, and localization of metastatic nodes in head and neck melanoma. METHODS: This retrospective review examined patients undergoing SLN biopsy for cutaneous melanoma of the head and neck between July 2003 and December 2015. Patient demographics and pathologic outcomes were compared for patients undergoing SPECT-CT versus PL. A multivariable logistic regression analysis was used to identify factors associated with the identification of a positive SLN. RESULTS: Among 176 patients undergoing SLN biopsy, 91 underwent PL and 85 underwent SPECT-CT and PL. The patients in the SPECT-CT group were older than the PL patients (p = 0.050) but the groups did not differ in gender (p = 0.447), Breslow thickness (p = 0.744), or total number of SLNs identified (p = 0.633). As shown by the multivariate regression analysis, only Breslow thickness [odds ratio (OR) 1.47; 95 % confidence interval (CI) 1.17-1.84] and SPECT-CT (OR 3.58; 95 % CI 1.24-10.4) were associated with a positive SLN. CONCLUSION: The use of SPECT-CT for patients with head and neck cutaneous melanoma significantly increases the likelihood of retrieving a positive SLN. Long-term follow-up evaluation is needed for further definition of the impact that SPECT-CT has on recurrence and survival.

Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study.

BACKGROUND AND AIMS: The exact cutoff value at which pancreatic cyst fluid carcinoembryonic antigen (CEA) level distinguishes pancreatic mucinous cystic neoplasms (MCNs) from pancreatic nonmucinous cystic neoplasms (NMCNs) is unclear. The aim of this multicenter retrospective study was to evaluate the diagnostic accuracy of cyst fluid CEA levels in differentiating between MCNs and NMCNs. METHODS: Consecutive patients who underwent EUS with FNA at 3 tertiary care centers were identified. Patients with histologic confirmation of cyst type based on surgical specimens served as the criterion standard for this analysis. Demographic characteristics, EUS morphology, FNA fluid, and cytology results were recorded. Multivariate logistic regression analysis to identify predictors of MCNs was performed. Receiver-operating characteristic (ROC) curves were generated for CEA levels. RESULTS: A total of 226 patients underwent surgery (mean age, 61 years, 96% white patients, 39% female patients) of whom 88% underwent Whipple's procedure or distal pancreatectomy. Based on surgical histopathology, there were 150 MCNs and 76 NMCNs cases. The median CEA level was 165 ng/mL. The area under the ROC curve for CEA levels in differentiating between MCNs and NMCNs was 0.77 (95% confidence interval, 0.71-0.84, P < .01) with a cutoff of 105 ng/mL, demonstrating a sensitivity and specificity of 70% and 63%, respectively. The cutoff value of 192 ng/mL yielded a sensitivity of 61% and a specificity of 77% and would misdiagnose 39% of MCN cases. CONCLUSIONS: Cyst fluid CEA levels have a clinically suboptimal accuracy level in differentiating MCNs from NMCNs. Future studies should focus on novel cyst fluid markers to improve risk stratification of pancreatic cystic neoplasms.

Trabectedin: novel insights in the treatment of advanced sarcoma.

Soft tissue sarcomas are a heterogenous group of malignancies with relatively high mortality rates. The outlook for these patients has been poor, with only a few drugs showing measurable activity. Trabectedin is a new alkylating agent with significant activity in sarcomas, but particularly in liposarcomas and leiomyosarcomas, both as a single agent or in combination with other drugs. Phase I and II studies of trabectedin have shown measurable benefit. Currently there are several Phase III trials which have completed accrual to better study its use as a single agent or in combination therapy, although outcomes have not yet been reported. Trabectedin (Yondelis) is approved for the treatment of sarcomas by the EMEA, but is not yet approved by the FDA, pending the results of the currently maturing phase III trials.

Metastatic papillary gallbladder carcinoma with a unique presentation and clinical course.

CONTEXT: Papillary gallbladder adenocarcinoma (PGA) represents 5% of malignant gallbladder tumors. Metastatic disease frequently involves lymph nodes or other structures in the hepatoduodenal ligament. CASE REPORT: A Fifty-nine-year-old female with right upper quadrant pain and a giant gallbladder on ultrasound was found to have a segment 6 liver lesion during an attempted laparoscopic cholecystectomy. After appropriate staging, she underwent an open cholecystectomy and extended right hepatic lobectomy with portal lymph node dissection. Pathology demonstrated well-to-moderately differentiated PGA with identical morphology and immunohistochemistry in the liver resection specimen with negative margins. Despite adjuvant chemotherapy, she developed increased uptake in the head of the pancreas on PET scan. Endoscopic ultrasound with fine needle aspiration demonstrated metastatic PGA. She underwent an attempted Whipple operation but due to repeatedly positive pancreatic duct margins, she ended up with a total pancreatectomy and splenectomy. Final pathology showed metastatic PGA along the entire length of the pancreatic duct with only a single focus of tumor invasion into the pancreatic parenchyma. She developed a new liver metastases six months later that was unresponsive to FOLFOX therapy and she died of metastatic disease 33 months from her initial diagnosis. CONCLUSION: To our knowledge, this is the first report of metastatic PGA recurring along the entire pancreatic duct with disease confined to the pancreas only. We hypothesize that papillary tumor cells spread to pancreatic duct via the common bile duct and remained dormant for several years. An aggressive surgical approach may prolong survival in well-selected patients with PGA's.

Liver resection versus ablation in geriatric populations - Does one method impart improved in-hospital mortality?

Objectives: This study aimed to compare surgical resection versus ablation for managing liver malignancies in patients 65 and older. Material and Methods: Cases with liver tumors were extracted from the NSQIP database for patients aged ≥65 years. Following propensity score matching, multivariate Cox regression was used for 30-day morbidity and mortality for liver resection and ablation. Results: Following a propensity score matching, 1048 patients were 1:1 matched for comorbid conditions. Patients stayed in the hospital three days longer after resection (p<0.001). Mortality was lower after ablation (p= 0.013). This difference was more prominent in patients with primary liver tumors (p= 0.008). Group A had a 10-fold lower risk of developing an abdominal abscess, a fourfold decrease in hospital-associated pneumonia (p= 0.001) and reintubation, a 10-fold reduction in bleeding requiring transfusion (p<0.001), and a three-fold decrease in risk of developing sepsis (p<0.001). Conclusion: Despite being a generally sicker patient population with worse underlying liver function, ablative techniques were associated with a lower risk of adverse outcomes when compared to more aggressive resection of primary malignant tumors of the liver.

The risk of major elective vascular surgical procedures in patients with end-stage renal disease.

OBJECTIVE: To examine the postoperative complications and death rate of major elective vascular surgery procedures in patients with end-stage renal disease (ESRD). BACKGROUND DATA: Patients with ESRD undergoing elective major vascular surgical procedures are thought to have a high rate of postoperative complications and death. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program database was used to select ESRD and non-ESRD patients who had elective major vascular surgical procedures between 2004 and 2008. Multivariable logistic regression analysis was used to examine the impact of ESRD on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiology class, and recent operations (within the past 30 days). RESULTS: ESRD patients undergoing elective major vascular surgery were significantly more likely than non-ESRD patients to develop surgical site infection, unplanned intubation, ventilator dependence, combined pulmonary outcome, and a need for reoperation within 30 days of surgery. Importantly, ESRD patients undergoing elective major vascular surgery were also at higher risk for composite outcome and death within 30 days from surgery. ESRD patients above age 65 years undergoing elective major vascular surgery had far worse 30-day outcomes when compared with the younger ESRD cohort. Examining these data by their anatomic site (carotid, aortic, and peripheral) demonstrated elevated rates of postoperative complications and death in patients with ESRD undergoing open abdominal aortic aneurysm repair, carotid endarterectomies, and peripheral vascular operations compared with the non-ESRD cohort. Endovascular abdominal aortic aneurysm repair in ESRD patients had complications and death rates comparable with non-ESRD patients. CONCLUSIONS: Patients with ESRD undergoing elective vascular surgery have a significantly elevated risk of postoperative complications and death after major vascular surgical operations--particularly in patients over age 65. These data, in combination with well-established reduced survival for the older ESRD population, call into question the utility of most carotid and aortic operations in these patients in the absence of symptoms or a rapidly enlarging aneurysm.

Slower walking speed forecasts increased postoperative morbidity and 1-year mortality across surgical specialties.

OBJECTIVE: The purpose of this study was to determine the relationship between the Timed Up and Go test and postoperative morbidity and 1-year mortality, and to compare the Timed Up and Go to the standard-of-care surgical risk calculators for prediction of postoperative complications. METHODS: In this prospective cohort study, patients 65 years and older undergoing elective colorectal and cardiac operations with a minimum of 1-year follow-up were included. The Timed Up and Go test was performed preoperatively. This timed test starts with the subject standing from a chair, walking 10 feet, returning to the chair, and ends after the subject sits. Timed Up and Go results were grouped as fast ≤ 10 seconds, intermediate = 11-14 seconds, and slow ≥ 15 seconds. Receiver operating characteristic curves were used to compare the 3 Timed Up and Go groups to current standard-of-care surgical risk calculators at forecasting postoperative complications. RESULTS: This study included 272 subjects (mean age of 74 ± 6 years). Slower Timed Up and Go was associated with increased postoperative complications after colorectal (fast 13%, intermediate 29%, and slow 77%; P < 0.001) and cardiac (fast 11%, intermediate 26%, and slow 52%; P < 0.001) operations. Slower Timed Up and Go was associated with increased 1-year mortality following both colorectal (fast 3%, intermediate 10%, and slow 31%; P = 0.006) and cardiac (fast 2%, intermediate 3%, and slow 12%; P = 0.039) operations. Receiver operating characteristic area under curve of the Timed Up and Go and the risk calculators for the colorectal group was 0.775 (95% CI: 0.670-0.880) and 0.554 (95% CI: 0.499-0.609), and for the cardiac group was 0.684 (95% CI: 0.603-0.766) and 0.552 (95% CI: 0.477-0.626). CONCLUSIONS: Slower Timed Up and Go forecasted increased postoperative complications and 1-year mortality across surgical specialties. Regardless of operation performed, the Timed Up and Go compared favorably to the more complex risk calculators at forecasting postoperative complications.

Sequential radiofrequency ablation and surgical debulking for unresectable colorectal carcinoma: thermo-surgical ablation.

BACKGROUND AND OBJECTIVES: Despite decreasing frequency, local recurrences of unresectable colorectal cancer (CRC) remain difficult problems. These patients have few treatment options with conventional therapy. Preliminary results of sequential radiofrequency ablation (RFA) and surgical debulking (thermo-surgical ablation) suggest this technique may have benefit. METHODS: We reviewed a prospective database of patients undergoing thermo-surgical ablation for unresectable colorectal carcinoma from 2003 to 2011. RESULTS: Sixteen patients were treated with unresectable, recurrent abdomino-pelvic colorectal carcinoma: 11 in pelvis; 4 with isolated aortic/retroperitoneal disease; and 1 with pelvic and peri-adrenal/retroperitoneal disease. Eleven patients had recurrent rectal cancer and five had recurrent colon cancer. Median overall and 3-year actuarial survivals were 15 months and 24%, respectively. Median and 3-year PFS was 12 months and 19%, respectively. Three patients without disease have survived 0.75, 4.0, and 7.0 years. Two patients died at 5.0 and 5.5 years. A disease-free interval (DFI) of >24 months after initial resection was associated with longer overall survival (60 months vs. 4 months; P = 0.001). CONCLUSIONS: Thermo-surgical debulking appears to have a role in the treatment of some patients with recurrent, unresectable CRC; those patients with DFI >24 months after initial surgery benefited the most.

Intraductal oncocytic papillary neoplasm of the pancreas: report of a case requiring completion pancreatectomy.

CONTEXT: Cystic tumors of the pancreas have been diagnosed with increasing frequency. Intraductal oncocytic papillary neoplasm is a rare type of cystic pancreatic tumor. Intraductal oncocytic papillary neoplasm is considered a distinct entity with the potential of developing into invasive carcinoma and it should be differentiated from other cystic tumors of the pancreas, including mucinous cystic neoplasm and other forms of intraductal papillary mucinous neoplasm (IPMN). Histologically, the formation of oncocytic cells and the complex morphology of the papillae distinguish intraductal oncocytic papillary neoplasm from IPMN. While the number of publications addressing the diagnosis, management and follow-up of patients with IPMN has been increasing, the behavior differences between IPMN and intraductal oncocytic papillary neoplasm have not been elucidated, secondary to very limited clinical experience. CASE REPORT: Here, we are presenting a case of a patient with the diagnosis of intraductal oncocytic papillary neoplasm of the pancreas developing into invasive cancer. CONCLUSION: This case stresses the necessity for lifelong surveillance of the remnant pancreas following partial pancreatectomy for intraductal oncocytic papillary neoplasm, due to the risk of developing multifocal disease.