Five-Year Actual Overall Survival in Resected Pancreatic Cancer: A Contemporary Single-Institution Experience from a Multidisciplinary Perspective.

BACKGROUND: Successful surgical resection combined with effective perioperative therapy is essential for maximizing long-term survival for pancreatic adenocarcinoma. PATIENTS AND METHODS: All patients with pancreatic adenocarcinoma who underwent curative resection at our institution from January 2003 to May 2010 were reviewed. Demographic and clinical details were retrospectively collected from medical records and cancer registry data. RESULTS: Overall, 176 patients were included in the analysis (148 with de novo resectable disease and 28 with borderline resectable disease at presentation). Among 106 patients who received all perioperative therapy at our institution, 94% received neoadjuvant and/or adjuvant treatment in addition to resection. Actual all-cause 5-year overall survival (OS) for all 176 patients was 30.7%, with a median OS of 33.9 months [95% confidence interval (CI) 28.1-39.6 months]. For patients who received all perioperative therapy at our institution, actual all-cause 5-year disease-free survival (DFS) was 32.1%, with a median DFS of 28.8 months (95% CI 20.1-43.6 months). Of these patients, 67/106 (63%) recurred: 8 (8%) locoregional only; 52 (49%) systemic only; and 7 (7%) combined recurrence. No difference in survival rates or recurrence patterns was seen between resectable and borderline resectable patients. In multivariate analysis, tumor differentiation (poor vs. non-poor) and lymph node ratio >20% produced a useful clinical model. CONCLUSION: The actual OS rates for resected pancreatic cancer shown in this study are reflective of those currently achievable at a tertiary medical center dedicated to this patient population. In considering these results, both frequency and type of adjuvant/neoadjuvant therapy administered in the context of the clinical experience/management techniques of providers administering these treatments will be discussed.

Interferon-based Adjuvant Chemoradiation for Resected Pancreatic Head Cancer: Long-term Follow-up of the Virginia Mason Protocol.

OBJECTIVE: To report the long-term impact of adjuvant interferon-based chemoradiation therapy (IFN-CRT) after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). BACKGROUND: In 2003, we reported an actuarial 5-year overall survival (OS) of 55% (22 months median follow-up) using adjuvant IFN-CRT after PD. As the original cohort is now 10 years distant from PD, we sought to examine their actual survival, describe patterns of recurrence, and determine prognostic factors. METHODS: From 1995 to 2002, 43 patients underwent PD for PDAC and received adjuvant IFN-CRT consisting of external-beam irradiation, continuous 5-fluorouracil infusion, weekly intravenous bolus cisplatin, and subcutaneous interferon-α. Survival was calculated by the method of Kaplan and Meier, and prognostic factors were compared using a log-rank test and a Cox proportional hazards model. RESULTS: With all patients at least 10 years from PD, the 5-year actual survival was 42% and 10-year actual survival was 28% with median OS of 42 months (95% confidence interval: 22-110 months). Nine patients survived beyond 10 years with 7 currently alive without evidence of disease. Initial recurrence included 4 local, 17 distant, and 4 combined sites at a median of 25 months. IFN-CRT was interrupted in 70% of patients because of grade 3 or 4 toxicity, whereas 42% of patients required hospitalization. Adverse prognostic factors included lymph node ratio of 50% or more, Eastern Cooperative Oncology Group performance status of 1 or higher, and IFN-CRT treatment interruption. CONCLUSIONS: Adjuvant IFN-CRT after PD can provide long-term survival in resected PDAC. Further studies should focus on patient and tumor factors to maximize benefit and minimize toxicity.

Better Outcomes if Percutaneous Drainage Is Used Early and Proactively in the Course of Necrotizing Pancreatitis.

PURPOSE: To compare outcomes after percutaneous catheter drainage (PCD) for acute necrotizing pancreatitis versus those in a randomized controlled trial as a reference standard. MATERIALS AND METHODS: Between September 2010 and August 2014, CT-guided PCD was the primary treatment for 39 consecutive patients with pancreatic necrosis. The indication for PCD was the clinical finding of uncontrolled pancreatic juice leakage rather than infected necrosis. Subsequent to PCD, the drains were proactively studied with fluoroscopic contrast medium every 3 days to ensure patency and position. Drains were ultimately maneuvered to the site of leakage. These 39 patients were compared with 43 patients from the Pancreatitis, Necrosectomy versus Step-up Approach (PANTER) trial. RESULTS: The CT severity index was similar between studies (median of 8 in each). Time from onset of acute pancreatitis to PCD was shorter in the present series (median, 23 d vs 30 d). The total number of procedures (PCD and subsequent fluoroscopic drain studies) per patient was greater in the present series (mean, 14 vs 2). More patients in the PANTER trial had organ failure (62% vs 84%), required open or endoscopic necrosectomy (0% vs 60%), and experienced in-hospital mortality (0% vs 19%; P < .05 for all). CONCLUSIONS: Even though patients in the present series had a similar CT severity index as those in the PANTER trial, the former group showed lower incidences of organ failure, need for necrosectomy, and in-hospital mortality. The use of a proactive PCD protocol early, before the development of severe sepsis, appeared to be effective.

A percutaneous drainage protocol for severe and moderately severe acute pancreatitis.

BACKGROUND: According to the revised Atlanta classification, severe and moderately severe acute pancreatitis (AP) includes patients with pancreatic and peripancreatic collections with or without organ failure. These collections suggest the presence of pancreatic juice leakage. The aim of this study was to evaluate the efficacy of a percutaneous catheter drainage (PCD) protocol designed to control leakage and decrease disease severity. METHODS: Among 663 patients with clinical AP, 122 were classified as moderately severe or severe AP (all had collections). The computed tomography severity index (CTSI) score was calculated. The indication for PCD was based on progressive clinical signs and symptoms. Drain patency, position, and need for additional drainage sites were assessed using CT scans and drain studies initially every 3 days using a proactive protocol. Drain fluid was examined for amylase concentration and microbiological culture. Clinicopathological variables for patients with and without PCD were compared. Since there was no mortality, we used prolonged drainage time to measure the success of PCD. Within the group treated with PCD, variables that resulted in prolonged drainage time were analyzed. RESULTS: PCD was used in 47/122 (39 %) patients of which 33/47 (70 %) had necrosis. PCD cases had a median CTSI of 8 and were classified as moderately severe AP (57 %) and severe AP (43 %). Inhospital mortality was zero. Surgical necrosectomy was not required for patients with necrosis. Independent risk factors for prolonged drainage time were persistent organ failure >48 h (P = 0.001), CTSI 8-10 (P = 0.038), prolonged duration of amylase-rich fluid in drains (P < 0.001), and polymicrobial culture fluid in drains (P = 0.015). CONCLUSIONS: A proactive PCD protocol persistently maintaining drain patency advanced to the site of leak controlled the prolonged amylase in drainage fluid resulting in a mortality rate of zero.

Intraductal papillary mucinous neoplasms of the pancreas: making a disposition using the natural history.

The process of Intraductal papillary mucinous neoplasms (IPMN) follows the adenoma-to-carcinoma sequence. If it progresses to malignancy about 5 years is required. Even though the process is slow IPMN provides the clinician with the opportunity to avoid malignancy if the patient is at risk. The natural history as observed through Kaplan Meier event curves for occurrence of malignancy show the process to malignancy is much faster (50% within 2 years) if pancreatitis-like symptoms are present or if the main pancreatic duct (MPD) is involved. Almost all decisions to resect (95% in our experience) are based on the presence of symptoms or the MPD location. Cyst size is used infrequently. Every patient with an IPMN should always have a planned follow-up and the frequency depends on the perceived risk of malignancy-immediate imaging if becomes symptomatic to every 2 to 3 years if asymptomatic side branch lesions. The natural history provides modern guidelines for making decisions in patients with a newly discovered IPMN.

Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience.

BACKGROUND: There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years). OBJECTIVE: To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD). DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009). INTERVENTIONS: Endoscopic balloon dilation and stent placement, percutaneous biliary drainage. MAIN OUTCOME MEASUREMENTS: Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures). RESULTS: Mean age was 63 ± 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%). LIMITATIONS: Retrospective, single-center study. CONCLUSIONS: GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors.

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period.

BACKGROUND: Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. OBJECTIVE: To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. DESIGN: A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. SETTING: Tertiary referral center. PATIENTS: One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. INTERVENTIONS: Endoscopic management of ampullary lesions. MAIN OUTCOME MEASUREMENTS: The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. RESULTS: One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. CONCLUSIONS: Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

The state of the highest level of evidence: an overview of systematic reviews of pancreaticobiliary disease customized for the gastroenterologist and GI surgeon.

Trends emerged as randomized controlled trials (RCTs) on pancreaticobiliary disease were reviewed by each panel of experts. There were few RCTs. Although studies observed statistical differences between their treatment groups, many of them were underpowered. The studies with the most patients were sponsored by industry-on adjuvant therapy and biliary stents. Two subjects did not have an RCT [necrotizing pancreatitis and intraductal papillary mucinous tumors (IPMN) of the pancreas]. Constant heterogeneity between RCTs was observed. A good example was the 22 variations in study designs noted between the 5 RCTs of the adjuvant chemotherapy panel. Some of these RCTs had no inclusion criteria while a more recent trial utilized very specific measures. Many trials had insufficient follow-up (6 months in one study of chronic pancreatitis surgery). Each randomized controlled trial may have reached a different conclusion than another one on the same topic although they had similar results (adjuvant treatment for resected pancreatic cancer). From this review of the highest level of evidence in the literature for pancreaticobiliary disease, it is apparent that the lack of quantity and quality of the highest level of evidence provides us with a challenge to improve the quality of our literature. Cooperation is required, which might begin by an international consensus on definitions, inclusion criteria, and the minimum length of follow-up.

Treatment of chronic pancreatitis with endotherapy or surgery: critical review of randomized control trials.

The goal of this Society for Surgery of the Alimentary Tract postgraduate course was to review critically the highest level of published evidence focused on treating the disabling chronic abdominal pain due to chronic pancreatitis. Just eight randomized controlled trials (RCTs) have been reported since 1995. All are from Europe. These eight RCTs utilized 380 patients to compare a diverse variety of surgical resections, surgical drainage vs. endotherapy (trans-ampullary pancreatic stents for drainage), or endotherapy with or without shock wave lithotripsy. Therefore, these trials contained a paucity of patients for each treatment compared. Heterogeneity was evident after analysis of the study designs because they used a diverse set of inclusion and exclusion criteria usually not based on objective criteria such as ductal anatomy. All but one had short follow-up. Because of the lack of homogeneity for these study designs that were somewhat underpowered, the RCTs on the treatment of chronic pancreatitis to relieve disabling abdominal pain must be read carefully. In addition to RCTs, the case series still remains a valuable part of our literature.

Biliary Stenosis and Gastric Outlet Obstruction: Late Complications After Acute Pancreatitis With Pancreatic Duct Disruption.

OBJECTIVES: Pancreatic duct disruption (PDD) after acute pancreatitis can cause pancreatic collections in the early phase and biliary stenosis (BS) or gastric outlet obstruction (GOO) in the late phase. We aimed to document those late complications after moderate or severe acute pancreatitis. METHODS: Between September 2010 and August 2014, 141 patients showed pancreatic collections on computed tomography. Percutaneous drainage was primarily performed for patients with signs or symptoms of uncontrolled pancreatic juice leakage. Pancreatic duct disruption was defined as persistent amylase-rich drain fluid or a pancreatic duct cut-off on imaging. Clinical course of the patients who developed BS or GOO was investigated. RESULTS: Among the 141 patients with collections, 33 patients showed PDD in the pancreatic head/neck area. Among them, 9 patients (27%) developed BS 65 days after onset and required stenting for 150 days, and 5 patients (15%) developed GOO 92 days after onset and required gastric decompression and jejunal tube feeding for 147 days (days shown in median). All 33 patients recovered successfully without requiring surgical intervention. CONCLUSIONS: Anatomic proximity of the bile duct or duodenum to the site of PDD and severe inflammation seemed to contribute to the late onset of BS or GOO. Conservative management successfully reversed these complications.

Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible. METHODS: After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact. RESULTS: DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management. CONCLUSION: The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.

Presidential address: adjusting the art and the science of surgery.

Why are there so many opinions for surgical treatments? Why do surgeons not agree on the same definitions? To adjust the art and science of surgery, we should understand the reason behind this Tower of Babel and ourselves by grasping the three biological lessons of history. These lessons are instincts of man--our instincts have not changed for as long as there has been recorded history. The lessons were elucidated by Will and Ariel Durant and these are competition, selection, and reproduction. How might they be applied to improving our surgical science? First, competition has always forced individuals or small groups to strengthen themselves with cooperation. Cooperate or not survive. Cooperation increases with social development and technology. Next, we must realize that nature relishes diversity. We are all born unequal and diverse. The second biological lesson is selection; which individual among a diverse group of individuals will succeed (by improving)? Therefore, by nature, man's instincts provide diverse opinions and bias. This creates a myopic view when surgeons try to discern the truth. The results are the trendy bandwagons that divert us, like tonsillectomy. Too much diversity is bad, and a balance is required. Man's third lesson of history is reproduction. Better stated is that nature loves quantity. We naturally give priority to quantity over quality. To obtain quality rather than just quantity, we need the antidotes for competition and diversity--that would be cooperation using the Deming guidelines of leadership, profound knowledge, and technology. One example of this urge for quantity and diversity is our lack of standardized definitions. These three biological lessons can be summarized by viewing competition as an impediment for quality improvement in the complex challenges of modern healthcare. Cooperation (trust) is the antidote to the bandwagon effect of unproven treatments. Cooperation and technology can be joined to establish a successful team using the global technology of the internet ("Club Web"). To improve, we must measure real cases in a registry and generate a standard set of definitions and benchmarks. A focus group that trusts each other through the common interest of a disease or organ could succeed. Only then does comparison (and improvement) become possible.

Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1,507 patients: a report from the Pancreatic Anastomotic Leak Study Group.

Several definitions for pancreatic leakage after pancreaticodoudenectomy exist, and the reported range of 2-50% underscores this variation. The goal was to determine if drain data alone was predictive of a leak and validate International Study Group on Pancreatic Fistula (ISGPF) leak criteria. Participating surgeons entered de-identified data into a web-based database designed to collect Whipple-related data. Definitions used were the ISGPF definition, > or = 3 days, amylase 3x normal; and Sarr's definition, > or = 5 days, amylase 5x normal, > 30 ml. We compared how well these two definitions were at detecting a leak and its complications. There were 1,507 cases submitted from 16 international institutions. A pancreaticoduodenectomy (PPPD) was performed in 76.2%. Drain placement occurred in 98.0%. Using the ISGPF definition, the pancreatic leak rate was 26.7 and 14.3% with the Sarr definition. There were more grades A and B leaks detected by the ISGPF definition. Both determined grade C leaks equally. Both definitions correlated with an increased length of stay (LOS), need for percutaneous drains, reoperation, and delayed gastric emptying (DGE). Neither was associated with an increased risk of intensive care unit (ICU) stay or 30-day mortality. The ISGPF was able to capture more patients with clinically relevant leaks than Sarr's criteria; however, the ability to detect a leak by drain data alone is imperfect.

Pancreatic anastomotic leak after the Whipple procedure is reduced using the surgical microscope.

BACKGROUND: Pancreatic anastomotic leakage (Leak) is the most common major complication after pancreaticoduodenectomy (PD). In this study we tested the hypothesis that better vision would improve the technical performance of this anastomosis and result in a lower Leak rate. METHODS: A retrospective review of 266 consecutive patients who underwent PD with pancreaticojejunostomy between 1996 and 2003 was carried out. In the first 196 patients we had used an end-to-side, internally-stented, duct-to-mucosa pancreaticojejunostomy aided by surgical Loupes at 2.5x magnification (Loupes group). In the next 70 patients we substituted the surgical microscope at 12.5x for the surgical Loupes (microscope group). Risk factors associated with Leak were determined for all 266 cases and then the outcomes for each group were compared. RESULTS: Leak was observed in 11.7% of patients (31 of 266). Uni- and multivariate analysis showed 3 independent risk factors for Leak: (1) male gender (odds ratio [OR], 3.10); (2) a pancreatic duct size of less than or equal to 3 mm (OR, 7.75); and (3) not using the microscope (OR, 7.43). The Leak rate in the Loupes group was 15% (29 of 196) and in the microscope group 2.9% (2 of 70, P = .008). The mean hospital length of stay was longer in the Loupes group (11.3 days) as compared to the microscope group (9.0 days, P < .001). In the high-risk subset for Leak with duct size less than or equal to 3 mm (n = 147), the Leak rate was 23% in the Loupes group vs 4.2% in the microscope group (P = .027). CONCLUSION: The enhanced vision provided by the surgical microscope allowed precise construction of the anastomosis resulting in a significant decrease in Leak, particularly when a patient was at risk for Leak, ie, pancreatic duct less than or equal to 3 mm.

Exocrine function following the whipple operation as assessed by stool elastase.

What impact does pancreaticoduodenectomy (PD) have on exocrine function? Does the pancreatic anastomosis remain patent? When stool elastase became available for testing in November 2001, we began preoperative assessment and then increasingly employed postoperative measurements. From December 2001 until March 2006, 182 patients underwent PD by the same surgeon. Preoperative stool elastase was measured in 138 (76%) patients and was repeated postoperatively at 3 +/- 1 month, 12 +/- 2 months, and 24 +/- 3 months. At the same time periods, an abdominal CT scan was used to assess patency of the pancreatic anastomosis as implied by pancreatic duct dilation in the remnant (dilation = duct >3 mm or, if duct dilated preoperatively, then duct that failed to decrease in size). All cases were reconstructed with duct-to-mucosa pancreaticojejunostomy. Stool elastase was expressed as normal (>200 microg/gram stool), moderately reduced (100-200 microg/gram), or severely reduced (<100 microg/gram). Preoperative stool elastase values were "normal" in 78% (pancreatic cancer 32% normal vs. all other groups >78%; P < or = 0.001). As compared with preoperative values, the percent of cases with reduced elastase levels at 3 months, 1 year, and 2 years postoperatively was 48%, 73%, and 50%, respectively. The CT scans at the time of the 69 stool elastase measurements after PD showed pancreatic duct dilation in the pancreatic remnant in 9 of 69 (9%) stools but was not more frequent in the group with decreased elastase. Based on cases elastase, one third of patients about to have PD will have exocrine insufficiency, an observation most common among the patients with pancreatic cancer (68%). Stool elastase levels are further depressed in the majority of cases after PD from parenchymal loss because we could not implicate an occluded pancreatic anastomosis. These results suggest that, after PD, exocrine supplementation should be given to all patients with pancreatic cancer, especially those with impending adjuvant therapy. To further improve the long-term results after PD, each surgeon should assess the effect of their own type of pancreaticoenteric technique on exocrine function.

The usefulness of drain data to identify a clinically relevant pancreatic anastomotic leak after pancreaticoduodenectomy?

Pancreatic anastomotic leak (leak) remains a persistent problem after pancreaticoduodenectomy (PD). Recent reports indicate a mean occurrence of 10% with a range of 2%-28% of patients. However, valid comparisons for these studies cannot be made because the definition of leak is variable, and many patients deemed to have a leak are not sick. The aim of this study was to determine the meaning of the volume and amylase content of the effluent from surgical drains by comparing these values to actual clinical outcomes. From January 1996 to July 2002, 207 consecutive patients underwent PD. We considered a leak to be present if greater than 30 ml/day of drainage was observed from drains and if that drainage contained an amylase-rich fluid (greater than 5X serum) on or after postoperative day (POD) 5. Cases were then divided into three groups-no leak, chemical leak only (leak but asymptomatic), and a clinical leak group (leak that required therapeutic intervention, reoperation, readmission, or prolonged length of stay). Then the drainage volume and its amylase concentration for every postoperative day were compared between the three groups. There were no operative or hospital deaths, and the mean length of stay (LOS) was 11.2 +/- 6.1 days. Prolonged LOS was set at greater than 17 days (one standard deviation beyond the mean LOS for all cases). Leak was observed in 14% of cases (n = 29) and the patients were subsequently divided into these groups: no leak (n = 178), chemical leak only (n = 12), and clinical leak (n = 17). Surprisingly, the daily drain amylase values did not differ between the chemical leak group and the clinical leak group. The daily volume of drainage on POD 5-8 for the clinical leak group was significantly greater than the volumes of the other two groups, so that a combination of greater than 200 ml/day of drainage on POD 5 with an amylase greater than 5X serum had a positive predictive value (PPV) of 84% and a negative predictive value (NPV) of 99% for a clinically relevant leak. We used broad criteria from drainage effluent to include as many potential leaks as possible. This broad definition of leak selected 14% of the PD patients as having a leak; within this group, all of the clinical complications of leak occurred. By increasing the volume criteria from greater than 30 ml per day to greater than 200 ml per day, the PPV was increased from 59% to 84% while keeping NPV at 99%. Drain data based on the volume and amylase criteria of this study may be useful for early detection of a leak that will have clinical impact. This study's criteria for leak may be a good definition to design a clinical trial.

Pancreatic necrosis: paradigm of a multidisciplinary team.

Although we recommend the team approach for the treatment of pancreatic necrosis, we cannot support our method with evidence-based medicine. The few reports available (presented in this article) suggest an improvement by avoiding surgery in many cases and with a low mortality. Two important prerequisites are necessary to begin this team method. First is the assembly of a team, which requires years of recruitment using influence and leadership at centers of expertise in the treatment of pancreatic necrosis. Second, and possibly just as difficult as team assembly, is the design and use of a common algorithm that allows the reporting of data supported with the "power of n."

Epidural anesthesia dysfunction is associated with postoperative complications after pancreatectomy.

BACKGROUND: Epidural anesthesia is an accepted measure of pain control after major abdominal surgery. However, if the epidural anesthesia is unsuccessful, a variety of adverse effects can occur - excessive stress response, poor patient mobilization, increased opioid use, and hypotension due to vasodilation. The aim of this study was to evaluate the influence of epidural dysfunction on outcomes after pan-createctomy. METHODS: Between August 2010 and October 2014, 72 patients underwent open pancreatectomy with epidural anesthesia. Epidural dysfunction was defined as either hypo-function due to inadequate pain control (requirement of epidural replacement, conversion to intravenous continuous opioid infusion, or intravenous bolus opioid use) or hyper-function (hypotension or oliguria). We then analyzed for an association between epidural dysfunction and surgical outcomes. RESULTS: Epidural dysfunction occurred in 49% after pancreatectomy - hypo-function in 35% and hyper-function in 14%. Epidural dysfunction was independently associated with the development of overall (P < 0.001), pancreas-related (P = 0.041), and non-pancreas-related complications (P = 0.001). Hypo-function alone was independently associated with both pancreas-related (P = 0.015) and non-pancreas-related complications (P = 0.004). Hyper-function was independently associated with non-pancreas-related complications (P = 0.002). CONCLUSIONS: Outcomes after pancreatic resection can be improved by increasing the success rate of epidural anesthesia.

Pancreatic necrosectomy: definitions and technique.

Pancreatic necrosis implies a permanent condition in which a portion of the pancreas loses its blood supply. This condition is irreversible, yet many cases of "necrosis" will, after recovery, culminate in a patient with a normal pancreas by computed tomography or endoscopic retrograde cholangiopancreatography. The problem is in our definitions. An understanding of this disease through its related definitions is required before judgment deems "necrosectomy to be appropriate." These definitions are of pancreatic ductal disruption, peripancreatic fluid collections, pseudocyst, pancreatic abscess, and pancreatic necrosis. The technique of necrosectomy removes mature "necrosum" and is described in this article. Once necrosectomy is completed, the surgeon still depends on the continued support of interventional radiology through regular exchange of large-bore pancreatic drains. In our institution, many of these drain sites are placed at some time before necrosectomy. Once the team method has been implemented, the following improved outcomes will result--lowered need for necrosectomy and single digit mortality.