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Borderline resectable adenocarcinoma of the pancreas involves the major vascular structures adjacent to the pancreas and has traditionally led to poor resection rates and survival. Newer chemotherapy regimens have demonstrated improved response and resection rates. We performed a retrospective review of borderline resectable pancreatic cancers who presented to a community cancer program to determine the effect of neoadjuvant chemotherapy to improve resection rates and overall survival.Records of all patients diagnosed with adenocarcinoma of the pancreas from January 1, 2015 to December 31, 2019 were reviewed to determine stage at presentation, resectablility status, treatment methods, surgical resection and survival. Borderline resectable status was determined by preoperative imaging in agreement with published criteria from the National Comprehensive Cancer Network (NCCN) Guidelines 2.2021. Data was collected and analyzed by standard t-test. This study was approved by the institution's IRB.During this time period 322 patients were diagnosed with ductal adenocarcinoma of the pancreas of which 151 (47%) were unresectable, 31 (10%) were locally advanced, 70 (22%) were borderline resectable, and 69 (21%) were resectable at the time of presentation. 36 (51%) of the borderline resectable patients underwent neoadjuvant chemotherapy at our institution with either FOLFIRINOX or gemcitibine/nab-Paclitaxel regimens and served as the basis for this analysis. After neoadjuvant chemotherapy 24 (68%) of the borderline-resectable patients were deemed suitable for surgical exploration. At exploration, 15 (64%) were resected with 9 (60%) achieving margin-free resection on final pathology. The overall survival of those that underwent resection was increased by 19.6 months compared to those that did not undergo surgery (35.4 versus 15.8 mos, p 0.01). Overall morbidity after resection was 46% (33% class 1 or 2, 13% class 3) with 0% mortality at 90 days.Use of neoadjuvant chemotherapy for borderline resectable adenocarcinoma of the pancreas results in improved resection rates and overall survival in resected patients. This management strategy for ductal adenocarcinoma of the pancreas is safe and feasible in a community-based cancer program.

Background Specialty procedures constitute one eighth of rural surgery practice. Currently, general surgeons intending to practice in rural hospitals may not get adequate training for specialty procedures, which they will be expected to perform. Better definition of these procedures will help guide rural surgery training. Methods Current Procedural Terminology codes for all surgical procedures for 81% of North Dakota and South Dakota rural surgeons were entered into the Dakota Database for Rural Surgery. Specialty procedures were analyzed and compared with the Surgical Council on Resident Education curriculum to determine whether general surgery training is adequate preparation for rural surgery practice. Results The Dakota Database for Rural Surgery included 46,052 procedures, of which 5,666 (12.3%) were specialty procedures. Highest volume specialty categories included vascular, obstetrics and gynecology, orthopedics, cardiothoracic, urology, and otolaryngology. Common procedures in cardiothoracic and vascular surgery are taught in general surgical residency, while common procedures in obstetrics and gynecology, orthopedics, urology, and otolaryngology are usually not taught in general surgery training. Conclusions Optimal training for rural surgery practice should include experience in specialty procedures in obstetrics and gynecology, orthopedics, urology, and otolaryngology.

Background Data regarding the practice patterns of surgeons are derived from indirect information and may not reflect practice patterns in rural surgery. The aim of this study was to analyze all procedures performed by rural surgeons in North Dakota and South Dakota in 2006. Methods All surgeons in the Dakotas were identified by state American College of Surgeons databases. Rural urban commuting area codes were used to identify rural surgeons. Current Procedural Terminology codes from clinic, outpatient, and inpatient procedures performed during 2006 were obtained. Results Data were obtained from 81% of rural surgeons. A total of 46,052 Current Procedural Terminology procedure codes were analyzed. Rural surgeons averaged 1,071 procedures/year, composed of 25.6% general surgery, 39.8% endoscopy, 17.9% minor surgery, and 12.3% surgical specialty procedures. Surgeons in small and large rural communities differed in total procedures per year (1,346 vs 988). Significant differences existed in the types of procedures performed by surgeons in large and small rural communities (P Conclusions Rural surgeons perform a high volume of procedures, with endoscopic and minor surgical procedures comprising over 55% of their practices. Understanding rural surgeons' caseload will help guide the training of rural surgeons.

Background Recent literature suggests implantable central venous access ports (ICVAPs) can be placed by interventional radiologists with fewer complications and lower expenses when compared with surgeons. An analysis of outcomes and expenses of ICVAP placement by service was conducted. Methods Three hundred sixty-eight ICVAPs were placed over 3 years at a 230-bed community teaching hospital. A retrospective review of these procedures was conducted. Data recorded for each procedure included patient demographics, reason for placement, indwelling port days, complications, billed charges, and reimbursement. Results Two hundred seventy-six (75%) ICVAPs were placed by interventional radiologists, while surgeons placed the remaining 92 ports (25%). Short-term complications were identified in 7 interventional radiologist–placed ports (2.5%) and 1 surgically placed port (1.1%), P = .42. Billed charges were greater for interventional radiologist–placed ports ($5,301 vs $4,552, P = .0001). In contrast, reimbursement was greater for surgically placed ports: interventional radiologist 31.3% of charges, surgery 42.8%, P = .049. Conclusion Reimbursement and charges demonstrated significant differences between surgeons and interventional radiologists. Prior assertions that ports placed by interventional radiologists are less expensive with fewer complications may no longer be valid.

BACKGROUND: Peritoneal carcinomatosis has a typical natural history of bowel obstruction and death. Significant evidence suggests that cytoreduction with heated intraperitoneal chemotherapy (HIPEC) improves long-term survival for these tumors. METHODS: A retrospective case series of patients who underwent initial HIPEC treatment was performed at 2 moderate-volume centers. Clinicopathologic data were reviewed and univariate analyses performed to determine predictors of periprocedural complications. RESULTS: Twenty-eight patients underwent HIPEC procedures. The most common pathologies were colonic adenocarcinoma and pseudomyxoma peritonei. The median preoperative peritoneal cancer index was 9.5. Thirteen patients had 34 complications, with no postoperative deaths. Pleural effusion and wound infection were the most common complications. Preoperative performance status and the extent of disease were predictive of complications. CONCLUSIONS: Cytoreduction and HIPEC can be done at moderate-volume centers with morbidity and mortality rates comparable with published results from large-volume centers. Preoperative performance status and the extent of disease predict postoperative complications.