A standardized care plan is associated with shorter hospital length of stay in patients undergoing pancreaticoduodenectomy.

BACKGROUND: In this retrospective review, we evaluate a standardized care plan (SCP) for patients undergoing pancreaticoduodenectomy, which included selective placement of feeding jejunostomy tubes (FJTs) and a perioperative fast-track recovery pathway (FTRP). METHODS: A review of 242 patients undergoing pancreaticoduodenectomy was completed. Patients treated pre- and post-SCP implementation were compared. Univariate comparison followed by multivariable linear regression were performed to identify predictors of hospital length of stay (HLOS). RESULTS: SCP patients (n = 100) were slightly older but otherwise similar to pre-SCP patients (n = 142). FJT placement occurred less frequently in SCP patients (38 versus 94%, P < 0.001). All SCP patients were initiated on the FTRP. Among SCP patients, an oral diet was introduced earlier (5 versus 8.5 d, P < 0.001) and HLOS was shorter (11 versus 13 d, P = 0.015). Readmission rates were similar. Following adjustment with linear regression, we confirmed SCP status as a predictor of HLOS. To assess SCP components, HLOS was evaluated separately based on FTRP status and FJT placement. Although both were highly associated with HLOS, neither was independently predictive in multivariable analysis. CONCLUSIONS: Implementation of an SCP resulted in shorter HLOS without an increase in readmissions. Future studies are necessary to identify specific components of SCPs that most influence outcomes.

Open versus minimally invasive resection of gastric GIST: a multi-institutional analysis of short- and long-term outcomes.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Overall surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of GIST are limited to small, single-institution experiences. METHODS: A total of 397 patients who underwent open surgery (n = 230) or MIS (n = 167) for a gastric GIST between 1998 and 2012 were identified from a multicenter database. The impact of MIS approach on recurrence and survival was analyzed using propensity-score matching by comparing clinicopathologic factors between patients who underwent MIS versus open resection. RESULTS: There were 19 conversions (10 %) to open; the most common reasons for conversion were tumor more extensive than anticipated (26 %) and unclear anatomy (21 %). On multivariate analysis, smaller tumor size and higher body mass index (BMI) were associated with receipt of MIS. In the propensity-matched cohort (n = 248), MIS resection was associated with decreased length of stay (MIS, 3 days vs open, 8 days) and fewer ≥ grade 3 complications (MIS, 3 % vs open, 14 %) compared with open surgery. High rates of R0 resection and low rates of tumor rupture were seen in both groups. After propensity-score matching, there was no difference in recurrence-free or overall survival comparing the MIS and the open group (both p > 0.05). CONCLUSIONS: An MIS approach for gastric GIST was associated with low morbidity and a high rate of R0 resection. The long-term oncological outcome following MIS was excellent, and therefore the MIS approach should be considered the preferred approach for gastric GIST in well-selected patients.

Elevated catecholamines and hepatic artery vasospasm in porcine small-for-size liver graft.

BACKGROUND: Elevated levels of norepinephrine (NE) have been reported in recipients of small-for-size liver (SFS) grafts in the perioperative period. The aim of the study is to test the hypothesis that although circulating catecholamines are elevated in recipients of SFS grafts, they are not the primary agents responsible for the hepatic artery (HA) vasospasm. METHODS: Female porcine recipients receiving a 20% (n = 10) partial liver graft were compared with a control group, using 60% partial liver transplanted grafts (n = 9). Hepatic blood flow (PVF, HAF) and levels of plasma catecholamines (epinephrine and NE) were measured at designated time points through postoperative day (POD) 7. Phentolamine (PA), an α-adrenergic blocker, was administered at doses of 1 to 112.5 ug/kg/min through an indwelling HA to the recipients of 20% group on POD1 (n = 5). RESULTS: In the 20% group following reperfusion, HA vasospasm was found at 10, 60, and 90 min, and persisted on POD 3 and POD 7. Plasma NE levels increased after reperfusion in 20% and 60% groups and peaked at 6 h with 10- to 13-fold increased levels compared with baseline. In the 20% group, NE levels remained elevated up to POD 7. PA infusion at low (1-10 ug/kg/min) and high (12.5-112.5 ug/kg/min) doses did not reverse the reduced HAF observed in 20% group recipients. CONCLUSION: Elevated serum NE does not appear to be the primary factor mediating HA vasospasm in the porcine SFS graft.

24 Hours or Less Stay After Laparoscopic Minor Hepatectomy.

BACKGROUND: Laparoscopic liver resections can result in decreased length of stay. We looked at our hospital experience with 24 hours or less stay after minor laparoscopic liver resections. METHODS: Patients who underwent laparoscopic minor hepatectomy (less than 3 hepatic segments resection) and stayed 24 hours or less in the hospital were selected from prospectively kept hepatobiliary surgery database. All were managed according to the established enhanced recovery after surgery protocol. RESULTS: 14 cases were identified and included 3 bisegmentectomies and 11 segmental resections. Length of surgery was between 29 and 210 minutes (median 80.5 minutes), and median blood loss was 50 cc (range 20-400 cc). 4 patients were discharged home the same day with 10 staying overnight. CONCLUSIONS: Selected group of patients undergoing minor laparoscopic hepatectomy can be discharged home the same day or less than 24 hours after surgery.

The role of endoscopic ultrasound and cyst fluid analysis in the initial evaluation and follow-up of incidental pancreatic cystic lesions.

PURPOSE: To assess the role of endoscopic ultrasound (EUS) in the initial evaluation and follow-up of incidental pancreatic cystic lesions (PCL). METHODS: Retrospective analysis of patients with incidental PCL on imaging who were evaluated by EUS and had a minimal follow-up of 1 year. RESULTS: There were 62 patients (40 females and 22 males). The mean patient age was 67.7 years (range, 30-89). The Median follow-up was 24 months (range, 12-72). The mean PCL size was 21.6 mm. In all, 13 patients underwent surgery (20.9%). Diagnosis included a mucinous cystic tumour (7), mucinous adenocarcinoma (2), intraductal papillary mucinous neoplasm (1) and a cystic neuroendocrine tumour (1). The overall malignancy rate among patients who underwent surgery was 15.3% (two patients). The mean carcinoembryonic antigen (CEA) level from PCL fluid analysis was also significantly higher in surgically treated group (7760) vs. the stable group (184.7) vs. the enlarging PCL group (361.1). A CEA level above 192 ng/ml predicted mucinous PCL with a sensitivity of 90%. CONCLUSIONS: EUS with cystic fluid analysis can be successfully used to rule out pancreatic neoplasms and to follow-up incidentally discovered PCL.

Internal iliac vein transposition for vascular reconstruction after resection of an external iliac vein leiomyosarcoma.

Primary vein leiomyosarcoma is rare type of a vascular sarcoma and arises from the spindle cells of the venous wall. The tumor may present difficulty of vascular reconstruction after en block resection. We present a case of internal iliac vein transposition for vascular reconstruction after resection of an external iliac vein leiomyosarcoma.To our knowledge, this is first report of the external iliac vein replacement with the ipsilaterally transposed internal iliac vein.

Postoperative complications are main reason for noncompliance with enhanced recovery after surgery program in patients undergoing hepatectomy and pancreatectomy.

BACKGROUND AND AIM: Enhanced recovery after surgery (ERAS) protocols are reported to improve postoperative outcomes in patients undergoing a routine protocol and postoperative outcomes in patients undergoing hepatic and pancreatic resections at our institution. METHODS: A total of 99 consecutive patients at a single institution managed with a similar ERAS protocol were divided into the "early" (50 patients) and "late" (49 patients) cohorts. Both cohorts were statistically identical in demographics and range of surgical procedures performed. Postoperative complications, readmission, reoperation rates, and length of stay were analyzed. Categorical variables were statistically compared using Fisher's exact test and continuous variables using t-test and Mann-Whitney U-test when appropriate. RESULTS: There were 32 hepatectomies/18 pancreatectomies in the "early" cohort and 22 hepatectomies/29 pancreatectomies in the "late" cohort. The overall complication rate was 38.8%, with a 30-day readmission rate and reoperation rate of 16.1 and 5%, respectively. There was one mortality (1%). Group-specific overall complication rate (40 vs 38.7%, P = 0.8), readmission rate (20 vs 12.2%, P = 0.4), reoperation rate (6 vs 4%, P = 1.0), and mortality (2 vs 0%, P = 1.0) were not statistically significant between both groups. CONCLUSIONS: Despite similar rates of adherence to the established ERAS 24 protocol, there was no improvement in median length of stay (7 days) between the "early" and "late" groups. The only reason for noncompliance with the ERAS protocol was development of surgery-related complications.

Adenosine restores the hepatic artery buffer response and improves survival in a porcine model of small-for-size syndrome.

The aim of the study is to define the role of the HABR in the pathophysiology of the SFS liver graft and to demonstrate that restoration of hepatic artery flow (HAF) has a significant impact on outcome and improves survival. Nine pigs received partial liver allografts of 60% liver volume, Group 1; 8 animals received 20% LV grafts, Group 2; 9 animals received 20% LV grafts with adenosine infusion, Group 3. HAF and portal vein flow (PVF) were recorded at 10 min, 60 min and 90 min post reperfusion, on POD 3 and POD 7 in Group 1, and daily in Group 2 and 3 up to POD 14. Baseline HAF and PVF (ml/100 g/min) were 29 +/- 12 (mean +/- SD) and 74 +/- 8 respectively, with 28% of total liver blood flow (TLBF) from the HA and 72% from the PV. PVF peaked at 10 mins in all groups, increasing by a factor of 3.8 in the 20% group compared to an increase of 1.9 in the 60% group. By POD 7-14 PVF rates approached baseline values in all groups. The HABR was intact immediately following reperfusion in all groups with a reciprocal decrease in HAF corresponding to the peak PVF at 10 min. However in the 20% group HAF decreased to 12 +/- 8 ml/100 g/min at 90 min and remained low out to POD 7-14 despite restoration of normal PVF rates. Histopathology confirmed evidence of HA vasospasm and its consequences, cholestasis, centrilobular necrosis and biliary ischemia in Group 2. HA infusion of adenosine significantly improved HAF (p < .0001), reversed pathological changes and significantly improved survival (p = .05). An impaired HABR is important in the pathophysiology of the SFSS. Reversal of the vasospasm significantly improves outcome.

Pancreatoduodenectomy in patient with perforated duodenal diverticulum and peritonitis: Case report.

INTRODUCTION: Duodenal diverticula are quite prevalent in general population, seen on up to 5% of radiology studies and up to 22% of autopsy examinations. PRESENTATION OF THE CASE: 70 years old female was admitted to the hospital with epigastric pain, fevers and elevated white cell count. Abdominal CT scan demonstrated evidence of perforated duodenal diverticulitis which failed to improve with IV antibiotics. Emergent pancreatoduodenectomy was performed with full recovery and uncomplicated hospital stay. DISCUSSIONS: Conservative therapy with antibiotics and bowel rest is successful in majority cases of perforation. Failure of conservative therapy demands surgical management. Variety of surgical approaches ranging from simple diverticulectomy to segmental resection, duodenal exclusion/bypass to pancreatoduodenectomy are available. CONCLUSION: Pancreatoduodenectomy is an option when complicated duodenal diverticulum is not resolved with conservative or interventional therapy.Pancreatoduodenectomy is an option when complicated duodenal diverticulum is not resolved with conservative or interventional therapy. This report has been written in concordance with the SCARE criteria Agha et al. [1].

Impact of enhanced recovery after surgery protocols on postoperative morbidity and mortality in patients undergoing routine hepatectomy: review of the current evidence.

BACKGROUND: Enhanced recovery protocols are widely used in many areas of general surgery but had a limited penetration in perioperative management of patients undergoing liver resection. Recently, multiple publications described application of enhanced recovery after surgery (ERAS) program to hepatectomy patients but their definitive role is not established or accepted by hepatobiliary surgeons. METHODS: A comprehensive literature review of published series in English language medical sources detailing ERAS program application for hepatectomy for the period of 2006-2016 is performed. RESULTS: ERAS protocols are feasible and safe. They reduce length of stay in patients undergoing routine hepatectomy without negative impact on morbidity and mortality. There is potential for reduction of Clavien grade I-II complications, while major and surgical complications are similar to traditional care management group. CONCLUSIONS: Application of ERAS program to patient undergoing hepatectomy reduces length of hospital stay without affecting perioperative morbidity or mortality and may represent a new standard of care for patients undergoing routine liver resection.

Giant Retroperitoneal Sarcoma.

Retroperitoneal sarcomas are rare tumors, having an annual incidence of 0.3 to 0.4 new cases per 100,000 occupants. R0 resection is the cornerstone of therapy, with local control being integral for a favorable prognosis. We present a case of giant retroperitoneal liposarcoma treated with complete surgical resection.

Adherence to Guidelines for Adjuvant Imatinib Therapy for GIST: A Multi-institutional Analysis.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Adjuvant imatinib therapy improves recurrence-free and overall survival following surgery for patients with high-risk GIST; however, the factors associated with use of adjuvant imatinib therapy are unclear, and adherence to adjuvant imatinib has not been investigated. We sought to determine the clinicopathologic predictors of therapy with adjuvant imatinib following surgical resection for GIST and to determine the utilization of adjuvant imatinib in patients who underwent surgical resection of primary GIST in 2009 or later as recommended by National Comprehensive Cancer network (NCCN) guidelines. METHODS: A multi-institutional cohort including 171 patients who underwent surgery for primary GIST at seven high-volume cancer centers in the USA and Canada between January 2009-December 2012 was used in this study. Receipt of adjuvant imatinib therapy was ascertained, and factors associated with imatinib therapy were analyzed. RESULTS: Following surgery for primary GIST, tumor size (<5.0 cm: ref; 5.0-9.9 cm: odds ratio (OR) 2.36, 95 % confidence interval (CI) 0.74-7.55; >10.0 cm: OR 9.15, 95 % CI 2.28-36.75; p = 0.007), mitotic rate (≤5/50 mitoses per 50 high powered field [HPF]: ref; 6-10/50 HPF: OR 24.91, 95 % CI 3.64-170.35; >10/50 HPF: OR 5.80, 95 % CI 3.64-170.35; p < 0.001), and neoadjuvant therapy (OR 9.52; 95 % CI 2.51-36.14; p = 0.001) were associated with receipt of adjuvant imatinib therapy. Overall, 75 % of patients received appropriate treatment, 23 % of patients were undertreated, and 2 % of patients were overtreated as compared to NCCN guidelines. Adjuvant imatinib therapy was administered in only 53 % of patients for which the NCCN guidelines recommended adjuvant therapy. CONCLUSION: The clinicopathologic factors associated with use of adjuvant imatinib therapy in patients following resection of primary GIST are consistent with established risk factors for recurrence. Adjuvant imatinib therapy remains underutilized in patients with intermediate and high-risk GIST and in patients who receive neoadjuvant therapy. Barriers to adjuvant imatinib therapy in this group of patients needs to be further explored.

Conditional disease-free survival after surgical resection of gastrointestinal stromal tumors: a multi-institutional analysis of 502 patients.

IMPORTANCE: Gastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery. OBJECTIVES: To assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada. MAIN OUTCOMES AND MEASURES: Disease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated. RESULTS: Overall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed. CONCLUSIONS AND RELEVANCE: Conditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.

Surgical management of the succinate dehydrogenase-associated familial paraganglioma syndromes.

Paragangliomas are rare neuroendocrine tumors arising from the neural crest cells in the extra-adrenal location. Paragangliomas can be sporadic or associated with a range of endocrine and genetic syndromes in 25% to 30% of all cases. Specifically, succinate dehydrogenase gene mutations are involved in the development of paraganglioma syndromes type 1 through type 4. In this article, we will describe 2 cases of succinate dehydrogenase-associated familial paraganglioma syndrome and provide a review of the existing literature on the condition's etiologic factors, diagnosis, and management.

Images in surgery: retroperitoneal ganglioneuroma.

Ganglioneuroma is a differentiated tumor of the sympathetic nervous system. We describe a case of retroperitoneal ganglioneuroma without vascular invasion that was resected using laparotomy access. We also provide a short review of the ganglioneuroma as a clinical entity.

Micro-laparoscopic cholecystectomy: an alternative to single-port surgery.

INTRODUCTION: Recent advances in minimally invasive surgery aimed at diminishing incision size have led to the development of single-port surgery (SPS). SPS has an increased level of complexity and requires a higher level of surgical skill compared to traditional laparoscopy. We explored micro-laparoscopy as an alternative to routine laparoscopic cholecystectomy. METHODS: The study is a retrospective review of consecutive elective laparoscopic cholecystectomies performed by a single surgeon at a community teaching hospital over 24 months. All surgeries were performed using a 5-mm trocar for the umbilical port and 3-mm trocars for other ports in standard configuration. RESULTS: Seventy-nine cholecystectomies were performed by micro-laparoscopy during the 24-month period. Three cases required upgrade in trocar size for technical reasons, resulting in a completion rate of 96%. Intraoperative cholangiography was performed in 70 cases (89%). There were no conversions to open surgery. There were no intra- or postoperative complications, and all patients were discharged on the day of surgery. CONCLUSION: Micro-laparoscopic cholecystectomy is safe, feasible, and represents an alternative to other minimally invasive techniques. Future developments in surgical technology will allow the use of even smaller instruments, diminishing the surgical "footprint" even further and contributing to better cosmesis and decreased postoperative pain in cholecystectomy patients.

HPB surgery can be safely performed in a community teaching hospital.

INTRODUCTION: There is ongoing debate about feasibility of performing hepatobiliopancreatic (HPB) cases in low-volume, community hospitals. We decided to analyze outcomes of HPB surgical cases done in our community hospital and compare it with published data from academic centers and/or national data. MATERIALS AND METHODS: We reviewed all HPB cases (liver, pancreas, and bile duct cases) performed in an 8-year-period (2001-2009) by HPB-fellowship-trained general surgeon (P.F.S.) at the Danbury Hospital, CT, USA. All electronic files of the patients, who underwent HPB surgery, were reviewed, and all pertinent clinical information was retrieved. Complications and mortality were recorded for length of hospital stay and 30 days after discharge. All complications were graded according to Clavien classification. Pancreatic specific complications--pancreatic fistula/leak and delayed gastric emptying--were graded using International Study Group on Pancreatic Fistula and International Study Group of Pancreatic Surgery definitions. RESULTS: There were 140 HPB cases. These included 33 pancreatoduodenectomies, 29 distal pancreatectomies, 52 hepatic cases, and 26 cases of other cases involving pancreas and biliary tract. Overall complication rate was 36.4%. Using Clavien classifications, there were 26 grade 1 complications, 21 grade 2 complications, and four grade 3 complications. Two patients underwent reoperation for postoperative complications. Overall mortality was 0.7% (one patient). Pancreas-specific complications included 6% pancreatic leak rate after pancreatoduodenectomy and 24.1% leak rate for distal pancreatectomy. CONCLUSION: HPB surgery could be safely performed in community setting, with morbidity and mortality comparable to high-volume centers.