Faculty Bibliography

Introduction: Gallstone pancreatitis (GP) is an inflammatory process resulting from gallstone obstruction of the common bile duct. Methods: We conducted a retrospective chart review of 200 consecutively- admitted GP patients who presented to the ED between 1/1/2007 and 6/7/2010d100 at Bellevue Hospital Center (BHC), 100 at New York University Langone Medical Center (NYU). Statistical analyses were performed using Student's t test, chi-square test, and/or log-rank test. Results: Ethnic minority patients comprised 87% BHC patients and 28% NYU patients. Sex distribution was 59% female at BHC and 40% female at NYU. BHC patients were aged 42 years on average, as compared to 62 years at NYU. Median household income was $32,600 at BHC and $53,000 at NYU. BHC patients were uninsured or governmentally insured, while NYU patients were governmentally or commercially insured. The difference in number of non-English-speaking patientswas not significant. BHC patients waited 3 days longer from symptoms to presentation (2.7, 95%CI=1.0-4.4, p<0.01). NYUpatients presented with a median lipase of 3,532dmore than double the 1,490 median lipase of BHC patients. The differences between centers in likelihood of experiencing multiple attacks prior to presentation and in Charlson Co-morbidity Index scores were not significant. BHC patients waited 1 hour longer from presentation to first labs (0.6, 95%CI=0.3- 0.9, p<0.0001), 4 hours longer from presentation to admission (3.6, 95% CI=1.8-5.4, p<0.001), and 4 hours longer from presentation to abdominal CT (4.2, 95%CI=2.5-5.9, p<0.0001). BHC performed 1.6 imaging studies per patient; NYU performed 1.9. NYU GP patients were 12 times more likely to undergo MRCP (OR=11.6, p<0.0001), but the difference in total bilirubin levels between the two populations was not significant. Among surgical patients, those at BHC were 4 times more likely to undergo operation on the same admission (OR=3.7, p<0.001). Among same-admission patients, those at BHC waited 3 days longer for surgery (2!

Introduction: Portal/mesenteric vein resection (PVR) is technically challenging and adds potential morbidity to a pancreaticoduodenectomy (PD). We reviewed our experience with PD for pancreatic adenocarcinoma to evaluate both short and long term outcomes following PVR. Methods: From our institutional pancreatic adenocarcinoma database, we identified 223 patients who underwent pancreaticoduodenectomy (PD) with (Group I n= 20) or without (Group II n= 203) PVR during the period 1990-2011. The study end-points were overall morbidity, 30-day mortality, length of post-operative stay (LOS), overall survival (OS). Differences between groups were evaluated using t-test or chi-squared test. OS for each group was estimated with Kaplan-Meier method and compared using the log-rank statistics. Results: The two groups were similar in terms of gender, age, ethnicity, underlying comorbidities and performance status (see table 1). One patient in Group I and 8 in Group II were deemed borderline resectable (5.0% vs. 3.9%, p = 0.8) and underwent neo-adjuvant treatment. Duration of surgery was longer in Group I (532 vs. 456 min, p = 0.04), but there were no differences in operative blood losses (1047 vs. 991 ml, p = 0.8), length of stay (13.9 vs. 14.4 days, p = 0.8), overall morbidity (55% vs. 38%, p = 0.14). There were only 2 post-operative deaths, both in the Group II (p = 0.7). Pathology revealed similar TNM stage and rates of resections with negative margins (85% vs. 75%, p = 0.8). At median follow-up of 14 months there was no significant difference in OS (20.5 vs. 15.8 months, p = 0.6) Conclusions: In our experience, post-operative and long-term outcomes were not adversely affected by PVR. PVR should be offered to patients with pancreatic cancer involving portal or mesenteric veins. (Table Presented)

Introduction: Increasing evidence suggests that the ratio of number of nodes harboring metastatic cancer to the total number of lymph node examined (lymph node ratio, LNR) affects survival after pancreatic resection for adenocarcinoma. We reviewed impact of lymph node status and LNR in our population of patients undergoing pancreatic resection for adenocarcinomMa.e thods: From our institutional pancreatic adenocarcinoma database, we identified 273 patients who underwent pancreatectomy during the period 1990-2011. of those, 51 had no nodes harvested in the specimen (No LN) and 86 had negative nodes (N0). Among those with positive nodes LNR wa<=s 0.1 in 27, <= 0.2 in 30, <= 0.3 in 21, <= 0.4 in 18 and > 0.4 in 40. Overall median survival was the study end point. Results: The 7 groups were similar in terms of gender, age, ECOG, primary procedure, and status of resection margins (see Table 1). T stage was higher in patients with elevated LNR (p=0.02). Survival was lower for patients with positive nodes (p < 0.01). This difference remained significant when excluding from analysis patients without harvested nodes (p = 0.005). Patient with LNR <= 0.1 had survival similar to N0 patients (20.1 vs. 20.0, p = 0.09). We observed a trend toward a worse survival in patients with higher LNR, which did not reach statistical significanCcoen. clusions: In our experience patients with LNR < 0.1 appeared to have survival similar to those with negative nodes. However LNR did not improve survival prognostication across patients with positive nodes. (Table Presented)

Background: A pancreaticoduodenectomy (PD) offers the only chance of a cure for pancreatic cancer and can be performed with low mortality and morbidity. However, little is known about outcomes of a PD in octogenarians. Methods: Differences in two groups of patients (Group Y, <80 and Group O, >/=80 year-old) who underwent a PD for pancreatic adenocarcinoma were analysed. Study end-points were length of post-operative stay, overall morbidity, 30-day mortality and overall survival. Results: There were 175 patients in Group Y (mean age 64 years) and 25 patients in Group O (mean age 83 years). Octogenarians had worse Eastern Cooperative Oncology Group (ECOG) Performance Status (PS >/=1: 90% vs. 51%) and American Society of Anesthesiology (ASA) score (>2: 71% vs. 47%). The two groups were similar in underlying co-morbidities, operative time, rates of portal vein resection, intra-operative complications, blood loss, pathological stage and status of resection margins. Octogenarians had a longer post-operative stay (20 vs. 14 days) and higher overall morbidity (68% vs. 44%). There was a single death in each group. At a median follow-up of 13 months median survival appeared similar in the two groups (17 vs. 13 months). Conclusions: As 30-day mortality and survival are similar to those observed in younger patients, a PD can be offered to carefully selected octogenarians.

BACKGROUND: Simulation-based training provides a low-stress learning environment where real-life emergencies can be practiced. Simulation can improve surgical education and patient care in crisis situations through a team approach emphasizing interpersonal and communication skills. OBJECTIVE: This study assessed the effects of simulation-based training in the context of trauma resuscitation in teams of trainees. METHODS: In a New York State-certified level I trauma center, trauma alerts were assessed by a standardized video review process. Simulation training was provided in various trauma situations followed by a debriefing period. The outcomes measured included the number of healthcare workers involved in the resuscitation, the percentage of healthcare workers in role position, time to intubation, time to intubation from paralysis, time to obtain first imaging study, time to leave trauma bay for computed tomography scan or the operating room, presence of team leader, and presence of spinal stabilization. Thirty cases were video analyzed presimulation and postsimulation training. The two data sets were compared via a 1-sided t test for significance (p < 0.05). Nominal data were analyzed using the Fischer exact test. RESULTS: The data were compared presimulation and postsimulation. The number of healthcare workers involved in the resuscitation decreased from 8.5 to 5.7 postsimulation (p < 0.001). The percentage of people in role positions increased from 57.8% to 83.6% (p = 0.46). The time to intubation from paralysis decreased from 3.9 to 2.8 minutes (p < 0.05). The presence of a definitive team leader increased from 64% to 90% (p < 0.05). The rate of spine stabilization increased from 82% to 100% (p < 0.08). After simulation, training adherence to the advanced trauma life support algorithm improved from 56% to 83%. CONCLUSIONS: High-stress situations simulated in a low-stress environment can improve team interaction and educational competencies. Providing simulation training as a tool for surgical education may enhance patient care

BACKGROUND & AIMS: The cellular mediators of acute pancreatitis are incompletely understood. Dendritic cells (DCs) can promote or suppress inflammation, depending on their subtype and context. We investigated the roles of DC in development of acute pancreatitis. METHODS: Acute pancreatitis was induced in CD11c.DTR mice using caerulein or L-arginine; DCs were depleted by administration of diphtheria toxin. Survival was analyzed using Kaplan-Meier method. RESULTS: Numbers of major histocompatibility complex II(+)CD11c(+) DCs increased 100-fold in pancreata of mice with acute pancreatitis to account for nearly 15% of intrapancreatic leukocytes. Intrapancreatic DCs acquired a distinct immune phenotype in mice with acute pancreatitis; they expressed higher levels of major histocompatibility complex II and CD86 and increased production of interleukin-6, membrane cofactor protein-1, and tumor necrosis factor-alpha. However, rather than inducing an organ-destructive inflammatory process, DCs were required for pancreatic viability; the exocrine pancreas died in mice that were depleted of DCs and challenged with caerulein or L-arginine. All mice with pancreatitis that were depleted of DCs died from acinar cell death within 4 days. Depletion of DCs from mice with pancreatitis resulted in neutrophil infiltration and increased levels of systemic markers of inflammation. However, the organ necrosis associated with depletion of DCs did not require infiltrating neutrophils, activation of nuclear factor-kappaB, or signaling by mitogen-activated protein kinase or tumor necrosis factor-alpha. CONCLUSIONS: DCs are required for pancreatic viability in mice with acute pancreatitis and might protect organs against cell stress

Introduction: Surgery offers the only chance for cure in patients with pancreatic cancer. Currently, pancreaticoduodenectomy can be performed with a mortality of under 5% and a morbidity of 40-50%. Little, however, is known about outcomes of pancreaticoduodenectomy (PD) in octogenarians. This manuscript details outcomes after PD for adenocarcinoma in patients 80 years and older. Methods: From our comprehensive pancreatic adenocarcinoma database of 248 patients, we identified 200 patients who underwent PD (1990-2009). We categorized patients into two groups, according to age at time of surgery: Group I (>= 80 year-old) and Group II (< 80 year-old). The study end-points were length of post-operative stay (LOS), overall morbidity, 30-day mortality, overall survival (OS). Differences between groups were evaluated using t-test or chi-squared test. Survival was compared using Kaplan-Meier analysis and log-rank test. Results: There were 25 patients in group I (mean age 83.1) and 175 patients in Group II (mean age 64.4). Octogenarians had worse ECOG performance status (PS >= 1 in 90% vs. 50.8%, p < 0.01) and ASA score (ASA 3- 4 in 70.8% vs. 47.4%, p < 0.01). The two groups were similar in regard to underlying co-morbidities (including coronary artery disease, COPD, diabetes, chronic renal failure), operative time, rates of portal vein resection, intraoperative complications, blood loss, pathologic AJCC stage, status of resection margins. Octogenarians had longer LOS (20 vs. 13.7 days, p=0.01) and higher overall morbidity (68% vs. 44%, p=0.03). There was a single death in each group (p=0.23). At median follow-up of 13 months older patients had a median OS of 17.3 months compared to 13.1 months in younger patients (p=0.06). Conclusions: Surgical morbidity and LOS are significantly increased in octogenarians. However 30-day mortality was not significantly increased and OS was superior (but not statistically significant) when compared to younger patients. The decision for PD should be individualized and offered to carefully selected octogenarians

Background: The AJCC staging for pancreatic cancer is relatively non-discriminatory for prediction of survival after resection. At the Moffitt Cancer Center a prognostic score for patients with localized pancreatic cancer (AJCC <= IIb) has been developed. In the Moffitt Prognostic Index (MPI) patients are grouped in 5 risk categories on the basis of extra-pancreatic tumor extension, degree of differentiation and lymphatic invasion. The aim of this study is to assess the MPI's predictive value in an independent cohort of patients who underwent pancreaticoduodenectomy (PD) at the New York University. Methods From our retrospective pancreatic adenocarcinoma database of 248 patients, we identified and grouped by MPI category patients with AJCC stage <= IIb who underwent PD (1990-2009). Differences between groups were evaluated using ANOVA and chi-squared test. Overall survival (OS) for each group was estimated using the Kaplan-Meier method and compared using the log-rank statistic. Results Among 131 patients with stage Ia-IIb cancer, MPI could be calculated for 126 (96%). Only few patients fell in MPI lower-risk groups 1- 4 (respectively 1, 4, 3, 22), while the majority (96, 76.1%) fell in MPI group 5 (poor prognosis). The 5 groups were similar in demographics, underlying comorbidities, laboratory data, ASA score and ECOG performance status. There were no differences in operative time, blood loss, intra- and post-operative complications, length of stay, 30-day mortality. Pathology revealed more advanced stage in groups 3 to 5 (p=0.001). At mean follow-up of 18 months, there was no difference in median OS across MPI groups (respectively 19, 6, 16, 17, 12 months, p=0.91). Of note, AJCC staging did correlate with median OS (respectively 43, 12, 16, 11 months in stages Ia to IIb, p = 0.004). Conclusions In our experience the MPI performed worse than AJCC staging as a prognostic tool. The clustering of patients in the worst-prognosis group defied the very purpose of prognosis discrimination. Furthermore, in our experience MPI did not correlate with overall survival in patients undergoing DP for earlystage (<= IIb) pancreatic cancer