Faculty Bibliography

BACKGROUND:Resident participation during hepatic and pancreatic resections varies. The impact of resident participation on surgical outcomes in hepatic and pancreatic operations is poorly defined. METHODS:We identified 25,511 patients undergoing a hepatic or pancreatic resection between 2006 and 2012 using the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes. RESULTS:Pancreatic resections (n = 16,045; 62.9%) were more common than liver resections (n = 9,466; 37%). Residents participated in the majority of cases (n = 21,857; 86%), with most involvement at the senior level (postgraduate year ≥ 3, n = 21,147; 97%). Resident participation resulted in slightly longer mean operative times (hepatic, 9 minutes; pancreatic, 22 minutes; both P < .01). Need for perioperative transfusion, hospital duration of stay, and reoperation rates were unaffected by resident participation (all P > .05). Resident participation resulted in a higher risk of overall morbidity (odds ratio [OR], 1.14; 95% CI, 1.05-1.24; P = .001), but not major morbidity (OR, 1.05; 95% CI, 0.93-1.20; P = .40) after liver and pancreas resection. Resident participation resulted in lower odds of 30-day mortality after liver and pancreas resections (OR, 0.75; 95% CI, 0.60-0.94; P = .01). CONCLUSION/CONCLUSIONS:Although resident participation resulted in slightly longer operative times and a modest increase in overall complications after liver and pancreatic resection, other metrics such as duration of stay, major morbidity, and mortality were unaffected. These data have important implications for educating patients regarding resident participation in these complex cases.

BACKGROUND:Though cystic pancreatic neoplasms (CPNs) are being increasingly detected, their evaluation and management are still debated and have lead to publication of multiple guidelines for diagnostic work-up, indications for resection, and non-operative management with follow-up strategies of CPNs. AIMS/OBJECTIVE:To analyze available guidelines in order to evaluate their overall quality and clinical applicability, indications for surgical resection and its extent, modalities and timing of follow-up when non-operative management is indicated. METHODS:After a systematic search of the English literature, we selected eight guidelines for assessment according to the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) II instrument. RESULTS:One guideline received the lower AGREE score regarding the "scope and purpose", "rigor of development" and "clarity and presentation" domains, whereas one received the best score for "stakeholder involvement" domain. No differences were found among different guidelines regarding the "applicability". The overall quality assessment score showed that only two guidelines were significantly lower than the others. According to the practical utilization recommendation score, four guidelines were considered as having full applicability in clinical practice. CONCLUSION/CONCLUSIONS:Existing guidelines provide adequate guidance, at least with the present knowledge, for the management of cystic pancreatic lesions; however, not any one was satisfactory to all aspects related to the management of CPN. An update of the existing guidelines should be considered if and when more evidence-based data are available.

BACKGROUND:Interest in laparoscopic liver resection (LLR) has grown since the International 'Louisville Statement' regarding laparoscopic liver surgery was published in 2009. However, limited population-based data on LLR utilization patterns and outcomes are available. METHODS:LLR data from the Nationwide Inpatient Sample (NIS, 2000-2012) and the National Surgical Quality Improvement Project (NSQIP, 2005-2012) were compared before and after the Louisville Statement in 2009. RESULTS:In total, 1131 and 642 LLR were identified from NIS and NSQIP, respectively. Three-quarters of patients underwent LLR for a malignant indication (NIS primary malignancy, 29.6% versus metastasis, 45.1%; NSQIP primary malignancy, 35.5% versus metastasis, 46.1%). The annual volume of LLR increased from 2000-2008 versus 2009-2012 (NIS: 63 versus 168, P < 0.001; NSQIP: 52 versus 127; both P = 0.001). The peri-operative mortality associated with LLR was 2.8% in NIS and 2.2% in NSQIP. The morbidity was 38.1% in NIS and 30.7% in NSQIP. Mortality and morbidity did not change over time (both P > 0.050). After 2009, LLR was associated with a shorter length of stay (LOS) (NIS: 5 versus 6 days, P = 0.007). CONCLUSION/CONCLUSIONS:Since the Louisville Statement in 2009, utilization of LLR has increased. LLR is associated with a modest decrease in LOS and appears to be safe with mortality and morbidity similar to open surgery.

BACKGROUND & AIMS/OBJECTIVE:The management of pancreatic cysts poses challenges to both patients and their physicians. We investigated whether a combination of molecular markers and clinical information could improve the classification of pancreatic cysts and management of patients. METHODS:We performed a multi-center, retrospective study of 130 patients with resected pancreatic cystic neoplasms (12 serous cystadenomas, 10 solid pseudopapillary neoplasms, 12 mucinous cystic neoplasms, and 96 intraductal papillary mucinous neoplasms). Cyst fluid was analyzed to identify subtle mutations in genes known to be mutated in pancreatic cysts (BRAF, CDKN2A, CTNNB1, GNAS, KRAS, NRAS, PIK3CA, RNF43, SMAD4, TP53, and VHL); to identify loss of heterozygozity at CDKN2A, RNF43, SMAD4, TP53, and VHL tumor suppressor loci; and to identify aneuploidy. The analyses were performed using specialized technologies for implementing and interpreting massively parallel sequencing data acquisition. An algorithm was used to select markers that could classify cyst type and grade. The accuracy of the molecular markers was compared with that of clinical markers and a combination of molecular and clinical markers. RESULTS:We identified molecular markers and clinical features that classified cyst type with 90%-100% sensitivity and 92%-98% specificity. The molecular marker panel correctly identified 67 of the 74 patients who did not require surgery and could, therefore, reduce the number of unnecessary operations by 91%. CONCLUSIONS:We identified a panel of molecular markers and clinical features that show promise for the accurate classification of cystic neoplasms of the pancreas and identification of cysts that require surgery.

INTRODUCTION/BACKGROUND:The clinico-radiological characteristics and the natural history of postoperative omental infarct (OI) in patients who underwent distal pancreatectomy (DP) and splenectomy have not been defined. MATERIALS AND METHODS/METHODS:Twelve patients who underwent DP over a period of 2 years and were postoperatively diagnosed with OI based on computed tomography (CT) findings were identified. RESULTS:A total of 12 patients were diagnosed with an OI based on their postoperative imaging. Seven (58.3 %) patients had previously undergone laparoscopic DP, one (8.3 %) had undergone a robotic DP, and in one (8.3 %), a laparoscopic DP was converted to an open procedure. The remaining three (25.1 %) were treated with open DP. In five (41.6 %) patients, the diagnosis of OI was made during routine follow-up. One patient underwent surgical resection of OI, and two had drains placed in the mass. Nine patients were managed conservatively. During the study period, on review of CT imaging, the minimum prevalence of postoperative OI after DP was found to be 22.8 %. A review of literature identified nine articles that reported a total of 34 patients who were diagnosed with OI after abdominal surgery. CONCLUSION/CONCLUSIONS:The management of an asymptomatic postoperative OI should be conservative while an early invasive intervention should be performed in patients who are symptomatic or have infected OI.

The history of pancreatic cancer surgery, though fraught with failure and setbacks, is punctuated by periods of incremental progress dependent upon the state of the art and the mettle of the surgeons daring enough to attempt it. Surgical anesthesia and the aseptic techniques developed during the latter half of the 19(th) century were instrumental in establishing a viable setting for pancreatic surgery to develop. Together, they allowed for bolder interventions and improved survival through the post-operative period. Surgical management began with palliative procedures to address biliary obstruction in advanced disease. By the turn of the century, surgical pioneers such as Alessandro Codivilla and Walther Kausch were demonstrating the technical feasibility of pancreatic head resections and applying principles learned from palliation to perform complicated anatomical reconstructions. Allen O. Whipple, the namesake of the pancreaticoduodenectomy (PD), was the first to take a systematic approach to refining the procedure. Perhaps his greatest contribution was sparking a renewed interest in the surgical management of periampullary cancers and engendering a community of surgeons who advanced the field through their collective efforts. Though the work of Whipple and his contemporaries legitimized PD as an accepted surgical option, it was the establishment of high-volume centers of excellence and a multidisciplinary approach in the later decades of the 20(th) century that made it a viable surgical option. Today, pancreatic surgeons are experimenting with minimally invasive surgical techniques, expanding indications for resection, and investigating new methods for screening and early detection. In the future, the effective management of pancreatic cancer will depend upon our ability to reliably detect the earliest cancers and precursor lesions to allow for truly curative resections.

BACKGROUND:Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis. The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy (PD). METHODS:We searched PubMed, EMBASE, the Cochrane Library and Web of Science databases until the end of December, 2014. Studies comparing outcomes of external vs. internal stent placement in PD were eligible for inclusion. Included literature was extracted and assessed by two independent reviewers. RESULTS:Seven articles were identified for inclusion: three randomized controlled trials (RCTs) and four observational clinical studies (OCS). The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula (PF) in total [odds ratio (OR) =0.69; 95% confidence interval (CI), 0.48-0.99; P=0.04], PF in soft pancreas (OR =0.30; 95% CI, 0.16-0.56; P=0.0002) and delayed gastric emptying (DGE) (OR =0.58; 95% CI, 0.38-0.89; P=0.01) compared with internal stents. There were no significant differences in other postoperative outcomes between two stenting methods, including postoperative morbidity (OR =0.93; 95% CI, 0.39-2.23; P=0.88), overall mortality (OR =0.70; 95% CI, 0.22-2.25; P=0.55), and intra-abdominal collections (OR =0.67; 95% CI, 0.26-1.71; P=0.40). CONCLUSIONS:Based upon this meta-analysis, the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE. Due to the limited number of original studies, more RCTs are needed to further support our result and clarify the issue.

The majority of patients with curative resection of pancreatic ductal adenocarcinoma recur within 5 years of resection. However, the prognosis associated with different patterns of recurrence has not been well studied. A retrospective review of patients who underwent curative surgical resection of pancreatic cancer was performed. Of the 209 patients, 174 patients developed recurrent disease. Of these 174, 28(16.1%) had recurrent disease limited to lung metastases, 20(11.5%) had recurrence in the lung plus one or more other sites excluding the liver, 73(42.0%) had liver metastasis alone or liver metastasis with any other site except lung, 28(16.1%) local recurrence only, and 25(14.3%) peritoneal recurrence alone or together with local recurrence. Patients with recurrence limited to lung had a 8.5 months(Mo) median survival from recurrence to death, which was significantly better than the survival associated with recurrence in the liver(5.1Mo), in the peritoneum(2.3Mo) or locally(5.1Mo) in multivariable analyses. Among all groups, the time from surgery to the diagnosis of recurrence in patients who recurred in only in the lung was also the longest. However, 75% of patients were found to have indeterminate lung nodules on their surveillance CT scans prior to the diagnosis of recurrence in lung. This delayed diagnosis of lung recurrence may have a negative impact on survival after recurrence. In conclusion, pancreatic cancer with lung recurrence has a significantly better prognosis than recurrence in other sites. Further studies are needed to investigate how different diagnostic and treatment modalities affect the survival of this unique subpopulation of pancreatic cancer patients.