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Biliary strictures after liver transplantation are common and when refractive to endoscopic and percutaneous intervention require surgical revision. Robotic technology facilitates minimally invasive biliary reconstruction and has not previously been described following liver transplantation. Robotic biliary revisions were retrospectively compared to all the historical open cases over a time period from May 2013 to October 2020. During the study period there were 3 robotic and 4 open surgical biliary revisions with a follow up of at least 6 months. All cases were hepaticojejunostomies for late choledochocholedochostomy anastomotic strictures presenting > 4 weeks after transplant and refractive to at least 3 endoscopic and/or percutaneous interventions. Median (range) case time was longer in the robotic group, 373 minutes (286-373) compared to open group, 280 minutes (163-321). The median length of stay was shorter in the robotic group, 4 days (1-4) compared to open group 7 days (4-10). Morbidity included 2 wound infections in the open group (grade II), 1 infected hematoma in the robotic group (grade IIIa) and 1 bile leak on the open group (grade IIIa). There was no biliary stricture recurrence or mortality in either group. Robotic biliary revision is a safe alternative to traditional open biliary revision for refractive biliary strictures after liver transplantation.

Background Elevations in inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte ratio (PLR), are reportedly associated with decreased overall survival (OS) or recurrence-free survival (RFS) in patients with numerous cancers. A large multicenter sarcoma data set was used to determine if elevated NLR or PLR was associated with worse survival and can guide treatment selection. Materials and methods A total of 409 patients with a primary retroperitoneal sarcoma (n = 268) or truncal (n = 141) sarcoma from 2000 to 2015 were analyzed using the US Sarcoma Collaboration database. Binary NLR and PLR values were developed using receiver operating characteristic curves. Kaplan-Meier model and Cox proportional hazards model identified predictors of decreased OS and RFS. Point biserial analyses were used to correlate binary and continuous data. Results Neither elevated NLR nor PLR was predictive of decreased OS or RFS. These findings persisted despite exclusion of comorbid inflammatory conditions. Further, NLR and PLR were not correlated with tumor grade. In multivariate models, decreased RFS was associated with tumor factors (e.g., positive margins, tumor grade, tumor size, necrosis, positive nodes); decreased OS was associated with histologic subtype, male gender, and nodal involvement. Conclusions Although several small studies have suggested that elevated NLR and PLR are associated with decreased survival in patients with abdominal or truncal sarcoma, this large multicenter study demonstrates no association with decreased OS, decreased RFS, or tumor grade. Rather, survival outcomes are best predicted using previously established tumoral factors.

BACKGROUND. Insurance status predicts access to medical care in the USA. Previous studies have shown uninsured patients with some malignancies have worse outcomes than insured patients. The impact of insurance status on patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is unclear. PATIENTS AND METHODS. A retrospective cohort study of adult patients with resected GEP-NETs was performed using the US Neuroendocrine Tumor Study Group (USNETSG) database (2000–2016). Demographic and clinical factors were compared by insurance status. Patients C 65 years were excluded, as these patients are almost universally covered by Medicare. Kaplan–Meier and log-rank analyses were used for survival analysis. Logistic regression was used to assess factors associated with overall survival (OS). RESULTS. The USNETSG database included 2022 patients. Of those, 1425 were aged 18–64 years at index operation and were included in our analysis. Uninsured patients were more likely to have an emergent operation (7.9% versus 2.5%, p = 0.01) and less likely to receive postoperative somatostatin analog therapy (1.6% versus 9.9%, p = 0.03). OS at 1, 5, and 10 years was significantly higher for insured patients (96.3%, 88.2%, and 73.8%, respectively) than uninsured patients (87.7%, 71.9%, and 44.0%, respectively) (p < 0.01). On Cox multivariate regression analysis controlling for T/M stage, tumor grade, ASA class, and income level, being uninsured was independently associated with worse OS [hazard ratio (HR) 2.69, 95% confidence interval (CI) 1.32–5.48, p = 0.006]. CONCLUSIONS. Insurance status is an independent predictor of survival in patients with GEP-NETs. Our study highlights the importance of access to medical care, disparities related to insurance status, and the need to mitigate these disparities.

INTRO: Chromogranin A (CgA) may be prognostic for patients with neuroendocrine tumors; however, the clinical utility of this test is unclear. METHODS: Patients undergoing resection for pancreatic neuroendocrine tumors (pNET) were selected from the eight institutions of the US Neuroendocrine Tumor Study Group database. Cox regression was used to identify pre-operative variables that predicted recurrence-free survival (RFS), and those with p < 0.1 were included in a risk score. The risk score was tested in a unique subset of the overall cohort. RESULTS: In the entire cohort of 287 patients, median follow-up time was 37 months, and 5-year RFS was 73%. Cox regression analysis identified four variables for inclusion in the risk score: CgA > 5x ULN (HR 4.3, p = 0.01), tumor grade 2/3 (HR 3.7, p = 0.01), resection for recurrent disease (HR 6.2, p < 0.01), and tumor size > 4 cm (HR 4.5, p = 0.1). Each variable was assigned 1 point. Risk-score testing in the unique validation cohort of 63 patients revealed a 95% negative predictive value for recurrence in patients with zero points. DISCUSSION: This simple pre-operative risk scoring system resulted in a high degree of specificity for identifying patients at low-risk for tumor recurrence. This test can be utilized pre-operatively to aid informed decision-making.

BACKGROUND. Pancreatic neuroendocrine tumors (PNETs) are often indolent; however, identifying patients at risk for rapidly progressing variants is critical, particularly for those with small tumors who may be candidates for expectant management. Specific growth rate [Formula: see text] has been predictive of survival in other malignancies but has not been examined in PNETs. METHODS. A retrospective cohort study of adult patients who underwent PNET resection from 2000 to 2016 was performed utilizing the multi-institutional United States Neuroendocrine Study Group database. Patients with ≥ 2 preoperative cross-sectional imaging studies at least 30 days apart were included in our analysis (N = 288). Patients were grouped as “high [Formula: see text] ” or “low [Formula: see text].” Demographic and clinical factors were compared between the groups. Kaplan–Meier and log-rank analysis were used for survival analysis. Cox proportional hazard analysis was used to assess the impact of various clinical factors on overall survival (OS). RESULTS. High [Formula: see text] was associated with higher T stage at resection, shorter doubling time, and elevated HbA1c (all P ≤ 0.01). Patients with high [Formula: see text] had significantly decreased 5-year OS (63 vs 80%, P = 0.01) and disease-specific survival (72 vs 91%, P = 0.03) compared to those with low [Formula: see text]. In patients with small (≤ 2 cm) tumors (N = 106), high [Formula: see text] predicted lower 5-year OS (79 vs 96%, P = 0.01). On multivariate analysis, high [Formula: see text] was independently associated with worse OS (hazard ratio 2.67, 95% confidence interval 1.05–6.84, P = 0.04). CONCLUSION. High [Formula: see text] is associated with worse survival in PNET patients. Evaluating PNET [Formula: see text] may enhance clinical decision-making, particularly when weighing expectant management versus surgery in patients with small tumors.

Many surgeons advocate the use of neoadjuvant treatment for resectable pancreatic cancer, however little is known about variation in the utilization of neoadjuvant therapy (NAT) at the hospital level.The National Cancer Data Base was used to identify patients undergoing resection for pancreatic cancer between 2006 and 2014 at high-volume centers. Hospitals were grouped by NAT utilization using standard deviations (SD) from the mean as follows: high neoadjuvant utilizers ( 2 SDs above the mean, 40% of patients receiving NAT); medium-high (1-2 SDs, 27-40%), medium (0-1 SD, 14-26%); or low (- 1.1 to 0 SDs, 14%). Overall survival (OS) was compared across NAT utilization groups.Among 107 high-volume centers, 20,119 patients underwent resection. The proportion of patients receiving NAT varied widely among hospitals, ranging from 0 to 74%, with only five centers using NAT in 40% of patients. These five hospitals had the longest median OS at 28.9 months, compared with 21.1 months for low neoadjuvant utilizers (p 0.001). On multivariable analysis, high and medium-high NAT utilization predicted improved OS, with a hazard ratio (HR) of 0.68 (95% confidence interval [CI] 0.56-0.83, p 0.001) and 0.80 (95% CI 0.68-0.95, p = 0.010), respectively, compared with low utilizers. After excluding patients who underwent NAT, there remained an association of improved OS with high NAT utilization (HR 0.74, 95% CI 0.60-0.93, p = 0.009).High-volume hospitals that more commonly utilize NAT demonstrated longer survival for all patients treated at those centers. In addition to altering patient selection for surgery, high neoadjuvant utilization may be a marker of institutional factors that contribute to improved outcomes.

Background With the recent advances in oncological hepatic surgery, major liver resections became more widely utilized procedures. The era of modern hepatic surgery witnessed improvements in patients care in preoperative, intraoperative and postoperative aspects. This significantly improved surgical outcomes regarding morbidity and mortality. This review article focuses on the recent advances in oncological hepatic surgery. Data Sources This review includes only data from peer-reviewed articles and journals. PubMed database was utilized as the primary source of the supporting literature to this review article on the latest advances in oncological hepatic surgery. Comprehensive and high sensitivity search strategies were performed to search related studies exhaustively up till June 2016. We critically and independently assessed over 50 recent publications written on this topic according to the selection criteria and quality assessment standard. We paid particular attention to the studies published in high impact journals that address the use of the surgical techniques mentioned in the articles in well-known institutions. Results Among all utilized approaches aiming at the preoperative assessment of the liver function, Child-Turcotte-Pugh classification remains the most reliable tool correlating with survival outcome. Although the primary radiological tools including ultrasonography, computed tomography and magnetic resonance imaging remain on top of the menu of tests utilized in assessment of focal hepatic lesions, intraoperative ultrasonography projects to be a powerful additional tool in terms of sensitivity and specificity compared to the other conventional techniques in assessment of the liver in the operative setting, a procedure that can change the surgical strategy in 27.2% of the cases and consequently improve the oncological surgical outcome. In addition to the conventional surgical techniques of liver resection and portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy “ALPPS” projects to be an alternative option in patients with marginally resectable tumors with an inadequate size of future liver remnant with an accepted surgical oncological outcome. Conclusions Considering the clinicopathological nature of hepatic lesions, the comprehensive assessment and proper choice of the liver resection technique in highly selected patients is associated with improved surgical oncological outcome. Patients with underlying marginal future liver remnant volumes can now safely benefit from a wider range of surgical intervention, a breakthrough that significantly improved morbidity and mortality in this group of patients.

BACKGROUND AND OBJECTIVES: Negative consequences of tobacco use during cancer treatment are well-documented but more in-depth, patient-level data are needed to understand patient beliefs about continued smoking (versus cessation) during gastrointestinal (GI) cancer treatment. METHODS: We conducted semi-structured interviews with 10 patients who were active smokers being treated for GI cancers and 5 caregivers of such patients. All interviews were audio-recorded, transcribed verbatim, and uploaded to NVivo. We consensus coded data inductively using conventional content analysis and iteratively developed our codebook. We developed data matrices to categorize the themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active therapy. RESULTS: Our interviews revealed three consistent themes: (1) Smoking cessation is not necessarily desired by many patients who have received a cancer diagnosis; (2) Failure in past quit attempts may lead to feelings of hopeless about future attempts, especially during cancer treatment; (3) Patients perceived little to no access to smoking cessation treatment at the time of their cancer diagnosis. CONCLUSIONS: Well-designed systemic changes that promote the positive and efficacious effects of quitting smoking during cancer treatment, and that provide barrier-free access to such treatments may be helpful in promoting tobacco-free behavior during cancer treatment.

While surgery offers the best curative-intent treatment, many patients with biliary tract malignancies have poor long-term outcomes. We sought to apply a non-mixture cure model to calculate the cure fraction and the time to cure after surgery of patients with peri-hilar cholangiocarcinoma (PHCC) or gallbladder cancer (GBC). Using the Extrahepatic Biliary Malignancy Consortium, 576 patients who underwent curative-intent surgery for gallbladder carcinoma or peri-hilar cholangiocarcinoma between 1998 and 2014 at 10 major hepatobiliary institutions were identified and included in the analysis. A non-mixture cure model was adopted to compare mortality after surgery to the mortality expected for the general population matched by sex and age. The median and 5-year overall survival (OS) were 1.9 years (IQR, 0.9–4.9) and 23.9 % (95 % CI, 19.6–28.6). Among all patients with PHCC or GBC, the probability of being cured after surgery was 14.5 % (95 % CI, 8.7–23.2); the time to cure was 9.7 years and the median survival of uncured patients was 1.8 years. Determinants of cure probabilities included lymph node metastasis and CA 19.9 level (p ≤ 0.05). The cure fraction for patients with a CA 19.9

Background Currently, no serological prognostic marker exists for pancreatic neuroendocrine tumors (pNETs). Previous studies have suggested potential for chromogranin A (CgA); however, the prognostic capability of CgA remains controversial. Our purpose was to explore preoperative CgA levels in predicting outcomes in patients with resected pNETs. Materials and methods Patients with preoperative CgA levels who underwent resection of a pancreatic neuroendocrine tumor between July 2002 and May 2013 were identified from a prospective database. An elevated preoperative CgA was defined as a CgA laboratory value above the normal limit of the assay. All patients had pathologically confirmed primary pancreatic tumors. Outcomes were compared between elevated and normal CgA groups. Results A total of 38 patients were identified that met inclusion criteria. Of these, 45% were male, and the median age was 57 y (range, 17–81 y). All underwent resection with curative intent. Elevated preoperative CgA was present in 16 patients (42%). There were no differences in node positivity or margin status between the normal CgA and elevated CgA groups on univariate analysis. However, tumor size and grade were significantly different between the two groups. Both disease-free survival (DFS; P = 0.006) and overall survival ( P = 0.017) were negatively impacted by an elevated preoperative CgA (median follow-up; 40 mo). Conclusions In patients with resected pNETs, an elevated preoperative CgA level was negatively associated with DFS and OS and was the only independent predictor of DFS. These results indicate that preoperative CgA may be a clinically useful prognostic marker for patients undergoing pancreatic neuroendocrine tumor resection.

Data on prognostic implications of peri-operative blood transfusion around resection of colorectal cancer liver metastases (CRLM) are conflicting. This retrospective study assesses the association of transfusion with complications and disease-specific survival (DSS).Major hepatectomies for CRLM from 2000 to 2010 at three institutions were included. Transfusion was analyzed based on timing and volume.Of 456 patients, 140 (30.7%) received transfusions. Transfusion was associated with extended hepatectomy (28.6 vs 18.4%; p = 0.020), tumor size (5.7 vs 4.2 cm; p0.001), and operative blood loss (917 vs 390 mL; p0.001). Transfusion was independently associated with major complications (OR 2.61; 95% CI: 1.53-4.44; p0.001). Transfusion at any time was not associated with DSS; however, patients who specifically received blood post-operatively had reduced DSS (37.4 vs 42.7 months; p = 0.044). Increased volume of transfusion (≥3 units) was also associated with shortened DSS (Total: 37.4 vs 41.5 months, p = 0.018; Post-operative: 27.2 vs 40.3 months, p = 0.015). On multivariate analysis, however, transfusion was not independently associated with worsened DSS, regardless of timing and volume.Transfusion with major hepatectomy for colorectal cancer metastases is independently associated with increased complications but not disease-specific survival. Judicious use of transfusion per a blood utilization protocol in the peri-operative period is warranted.

While pancreatic ductal adenocarcinoma is the most common form of pancreatic cancer, many other histologic forms of pancreatic cancer are also recognized. These histologic variants portray unique characteristics in terms of patient demographics, tumor behavior, survival, and responsiveness to treatments. Patients who underwent surgical resection of the pancreas for non-metastatic, invasive pancreatic cancer between 2004 and 2014 were selected from the National Cancer Data Base and categorized by histologic variant according to WHO classification guidelines. Patient demographics, tumor variables, treatment characteristics, and survival were compared between histologic groups and subgroups. A total of 57,804 patients met inclusion and exclusion criteria and were grouped into eight major histologic categories. Survival analysis by the histologic group showed median overall survival of 20.2 months for ductal adenocarcinoma, 20.5 months for squamous cell carcinoma, 26.8 months for mixed acinar-neuroendocrine carcinomas, 52.6 months for cystic mucinous neoplasms with an associated invasive carcinoma, 67.5 months for acinar cell carcinoma, and 69.3 months for mesenchymal tumors. Median survival was not reached for neuroendocrine tumors and solid-pseudopapillary neoplasms, with 5-year overall survival rates of 84% and 97% respectively. Rare subtypes of pancreatic cancer present unique clinicopathologic characteristics and display distinct tumor biologies. This study presents data on demographic, prognostic, treatment, and survival outcomes between rare forms of pancreatic neoplasms in order to aid understanding of the natural history and behavior of these neoplasms, with the hope of serving as a reference in clinical decision-making and ability to provide accurate prognostic information to patients.

Background The goals of resection of functional neuroendocrine tumors (NETs) are two-fold: Oncological benefit and symptom control. The interaction between the two is not well understood. Methods All patients with functional NETs of the pancreas, duodenum, and ampulla who underwent curative-intent resection between 2000 and 2016 were identified. Using Cox regression analysis, factors associated with reduced recurrence-free survival (RFS) were identified. Results Two-hundred and thirty patients underwent curative-intent resection. Fifty-three percent were insulinomas, 35% gastrinomas, and 12% were other types. Twenty-one percent had a known genetic syndrome, 23% had lymph node (LN) positivity, 80% underwent an R0 resection, and 14% had no postoperative symptom improvement (SI). Factors associated with reduced RFS included noninsulinoma histology, the presence of a known genetic syndrome, LN positivity, R1 margin, and lack of SI. On multivariable analysis, only the failure to achieve SI following resection was associated with reduced RFS. Considering only those patients with an R0 resection, failure to achieve SI was associated with worse 3-year RFS compared with patients having SI (36% vs 80%; P = 0.006). Conclusions Failure to achieve symptomatic improvement after resection of functional NETs is associated with worse RFS. These patients may benefit from short-interval surveillance imaging postoperatively to assess for earlier radiographical disease recurrence.

Background Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings. Methods Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories. Results Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were “Application of Results to Patient Care,” “Clarification of Study Methodology,” “Facilitation of Author Insight,” and “Request for Additional Study-Specific Data.” The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes. Conclusions We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.

Patient satisfaction is a patient-centered outcome of particular interest. Previous work has suggested that global measures of satisfaction may not adequately evaluate surgical care, therefore the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey was developed. It remains unclear how traditional outcome measures, such as morbidity, impact patient satisfaction. Our aim was to determine whether National Surgical Quality Improvement Program-defined complications impacted satisfaction with the surgeon as measured by a surgery-specific survey, the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey.All patients undergoing a general surgical operation from June 2013-November 2013 were sent the surgery-specific Consumer Assessment of Healthcare Providers and Systems survey after discharge. Retrospective chart review was conducted using the National Surgical Quality Improvement Program variable definitions, and major complications were defined. Data were analyzed as a function of response to the overall surgeon-rating item, and those surgeons rated as the "best possible" or "topbox" were compared with those rated lower. Univariate and logistic regression were used to determine variable importance.A total of 529 patients responded, and 71.5% (378/529) rated the surgeon as topbox. The overall National Surgical Quality Improvement Program complication rate was 14.2% (75/529), with 26.7% of those (20/75) being major complications. On univariate analysis, patients who rated their surgeon more highly were somewhat older (59 vs 54 years: P.001), more often underwent elective surgery (81% vs 57%: P.001), and had an increased rate of operation for malignancy (31% vs 17%). Neither the complication rate (total or major) nor the number of complications were associated with satisfaction scores.When examined on a patient level with surgery-specific measures and outcomes, the presence of complications after an operation does not appear to be associated with overall patient satisfaction with surgeon care. This finding suggests that satisfaction may be an outcome distinct from traditional measures.

Background Patient satisfaction has been emphasized increasingly in all aspects of medicine, including the imposition of financial penalties for underperformance. Current measures of patient satisfaction, however, do not address aspects specific to the care of operative patients. Therefore, our aim was to examine the recently validated Consumer Assessment of Healthcare Providers and Systems (S-CAHPS) to determine which aspects of perioperative care are predictive of satisfaction with the surgeon. Methods All patients undergoing a general surgery operation at our institution during a 5-month period were sent a modified S-CAHPS within 3 days of discharge. Patients were then divided into 2 groups: those who rated their surgeon as the best possible and those giving a lower rating. Univariate and multivariate analyses were used to determine predictors of satisfaction with operative care. S-CAHPS results were then compared with other satisfaction measures in a subset of patients. Results The response rate was 45.3% (456/1,007). The average age was 59 ± 16 years, duration of stay was 4.1 ± 6.6 days, and 23% underwent unscheduled operations. A total of 72% of patients rated their surgeon as the best surgeon possible. On multivariate analysis, preoperative communication and attentiveness on the day of operation were the most important determinants of overall surgeon rating. S-CAHPS scores correlated with other standard measures of satisfaction (HCAHPS scores). Conclusion S-CAHPS is a novel operative satisfaction tool and is feasible to administer to patients undergoing general operative procedures. Surgeon characteristics most predictive of high patient satisfaction are effective preoperative communication and attentiveness on the day of operation.

Introduction Survival following resection of pancreas cancer is poor. It is uncertain whether outcome improved overtime. Due to the recent advances in surgical techniques, diagnostic evaluation, and systemic treatment, we sought to evaluate pancreas cancer outcome over time. Methods Prospectively collected data on patients who underwent pancreaticoduodenectomy for pathologically confirmed pancreatic adenocarcinoma from 1999 to 2012 were analyzed. Perioperative and long-term outcomes were analyzed, comparing patients from era 1 (1999–2005) to patients from era 2 (2006–2012). Results Two-hundred sixteen patients were evaluated, including 76 in era 1 and 140 in era 2. There was no difference in 30-day mortality (1.3%, era 1 vs. 1.4%, era 2; P = 0.95) or rates of overall 30-day morbidity (49%, era 1 vs. 62%, era 2; P = 0.06). On multivariable analysis after adjusting for perineural invasion, lymphovascular invasion, margin status, EBL, and venous resection, there was no difference in survival between eras (HR = 0.81, P = 0.27, CI = 0.57–1.16). Conclusions After adjusting for clinicopathological features, there was no association of improved outcome over time. However, despite an increasing prevalence of anatomically advanced and histologically aggressive tumors, perioperative outcomes such as blood loss and margin negativity improved over time, with no increase in 30-day mortality. J. Surg. Oncol. 2015;112:643–649. © 2015 Wiley Periodicals, Inc.

Background Data are lacking on long-term outcomes of patients undergoing major hepatectomy requiring bile duct resection (BDR) for the treatment of colorectal cancer liver metastases. Methods Patients who underwent major hepatectomy (≥3 segments) for metastatic colorectal cancer from 2000–2010 at three US academic institutions were included. The primary outcome was disease-specific survival (DSS). Results Of 429 patients, nine (2.1%) underwent BDR, which was associated with pre-operative portal vein embolization (25.0% vs. 4.3%; P = 0.049). There were no significant differences in age, ASA class, margin status, number of lesions, tumor size, cirrhosis, perineural invasion, or lymphovascular invasion. BDR was independently associated with increased postoperative major complications (OR: 6.22; 95%CI:1.44–26.97; P = 0.015). There were no differences in length of stay, reoperation, readmission, or 30-day mortality. Patients who underwent BDR had markedly decreased DSS (9.3 vs. 39.9 mo; P = 0.002). When accounting for differences between the two groups, the need for BDR was independently associated with reduced DSS (HR: 3.06; 95%CI:1.12–8.34; P = 0.029). Conclusion Major hepatectomy with concomitant bile duct resection is seldom performed in patients undergoing resection of colorectal cancer liver metastases and is associated with higher major morbidity and reduced disease-specific survival compared to major hepatectomy alone. Stringent selection criteria should be applied when patients may need bile duct resection during hepatectomy for colorectal cancer liver metastases. J. Surg. Oncol. 2015; 112:524–528. © 2015 Wiley Periodicals, Inc.

Background A 5 cm margin is advocated for distal gastric adenocarcinoma (GAC). The optimal proximal resection margin (PM) length for proximal GAC is not established. Methods Patients who underwent curative-intent resection for proximal GAC from 2000 to 2012 at 7 centers in the US Gastric Cancer Collaborative were included. PM length was sequentially dichotomized and analyzed at 0.5 cm increments (0.5–6.5 cm). Outcomes after negative margin (R0) and positive microscopic margin (R1) resections were compared. Primary endpoints were local recurrence (LR) and overall survival (OS). Results All patients (n = 162) had R0 distal margins. 151 (93.2%) had an R0-PM with mean length of 2.6 cm (median:1.7 cm; range:0.1–15 cm). A greater PM distance was not associated with LR or OS. An R1-PM was associated with higher N-stage (N3:73% vs. 26%; P = 0.007) and increased LR (HR6.1; P = 0.009) but not associated with decreased OS. On multivariate analysis, an R1-PM was also not independently associated with LR. Conclusions For resection of proximal gastric adenocarcinoma, proximal margin length is not associated with local recurrence or overall survival. An R1 margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing resection of proximal gastric adenocarcinoma, efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned. J. Surg. Oncol. 2015 111:203–207. © 2015 Wiley Periodicals, Inc.

Background Jejunostomy feeding tubes (J-tubes) are often placed during resection for gastric adenocarcinoma (GAC). Their effect on postoperative complications and receipt of adjuvant therapy is unclear. Methods Patients who underwent curative-intent resection of GAC at seven institutions of the U.S. Gastric Cancer Collaborative from 2000 to 2012 were identified. The associations of J-tubes with postoperative complications and receipt of adjuvant therapy were determined. Results Of 837 patients, 265 (32%) received a J-tube. Patients receiving J-tubes demonstrated greater incidence of preoperative weight loss, lower BMI, greater extent of resection, and more advanced TNM stage. J-tube placement was associated with increased infectious complications (36% vs. 19%; P

The prognosis and management of neuroendocrine carcinoma are largely driven by histologic grade as assessed by mitotic activity. The authors reviewed their institutional experience to determine whether the histologic grade of neuroendocrine carcinoma can differ between primary and metastatic tumors.This study examined patients who underwent operative resection of both primary and metastatic foci of neuroendocrine carcinoma. Resected tumors were independently reviewed and categorized as low, intermediate, or high grade as determined by mitotic count.The authors identified 20 patients with metastatic neuroendocrine carcinoma treated at their institution between 1997 and 2013 for whom complete pathologic review of primary and metastatic tumors was possible. Primary lesions were found in the small intestine (n = 12), pancreas (n = 7), ampulla (n = 1), stomach (n = 1), and rectum (n = 1). The timing of hepatic metastasis was synchronous in 15 cases and metachronous in 5 cases. The histologic grade was concordant between primary and metastatic tumors in 9 cases and discordant in 11 cases. Among the discordant cases, 7 had a higher metastatic grade than primary grade, and 4 had a lower metastatic grade than primary grade. Metachronous presentation was associated with a higher likelihood of grade discordance (p = 0.03). The histologic grade of all metachronous metastases differed from that of the primary tumors.There is a high prevalence of histologic grade discordance between primary and metastatic foci of neuroendocrine carcinoma, particularly among patients with a metachronous metastatic presentation. Given the importance of histologic grade in disease prognostication and treatment planning, this finding may be informative for the management of patients with metastatic neuroendocrine carcinoma.

The value of routine primary (intraoperative) drain placement after major hepatectomy remains unclear. We sought to determine if primary drainage led to decreased rates of complications, specifically, intra-abdominal biloma or infection requiring a secondary (postoperative) drainage procedure.All patients who underwent major hepatectomy (≥3 hepatic segments) at 3 institutions, from 2000 to 2012, were identified. Patients with biliary anastomoses were excluded. Primary outcomes were any complication, rate of secondary drainage procedures, bile leak, and 30-day readmission.There were 1,041 patients who underwent major hepatectomy without biliary anastomosis; 564 (54%) had primary drains placed at the surgeon's discretion. Primary drain placement was associated with increased complications (56% vs 44%; p0.001), bile leaks (7.3% vs 4.2%; p = 0.048), and 30-day readmissions (16.4% vs 8.0%; p0.001), but was not associated with a decrease in secondary drainage procedures (8.0% vs 5.9%; p = 0.23). Patients with primary drains demonstrated higher American Society of Anesthesioloigsts (ASA) class, greater blood loss, more transfusions, and larger resections. After accounting for these significant clinicopathologic variables on multivariate analysis, primary drain placement was not associated with increased risk of any complications. Primary drainage was, however, independently associated with increased risk of bile leak (hazard ratio [HR] 2.04; 95% CI1.02 to 4.09; p = 0.044) and 30-day readmission (HR 1.79; 95% CI1.14 to 2.80; p = 0.011). There still was no reduction in the need for secondary drainage procedures (HR 0.98; p = 0.96).Primary intraoperative drain placement after major hepatectomy does not decrease the need for secondary drainage procedures and may be associated with increased bile leaks and 30-day readmissions. Routine drain placement is not warranted.

Background Hospital readmission is becoming a quality measure, despite poor understanding of the risks of readmission. This study examines readmission risk factors after major hepatectomy and develops a predictive model. Study Design A retrospective review was performed on patients who had undergone major hepatectomy at 1 of 3 academic centers between the years 2000 and 2012. Clinicopathologic and perioperative data were analyzed for risk factors of 90-day readmission using logistic regression. A readmission risk score was developed and validated in a separate validation set to determine its predictive value. Results Of 1,184 hepatectomies performed, 17.3% of patients were readmitted within 90 days. Factors associated with readmission include operative blood loss (odds ratio [OR] = 1.00; 95% CI, 1.000–1.001), any postoperative complication (OR = 4.3; 95% CI, 1.8–10.4), a major postoperative complication (OR = 5.7; 95% CI, 3.2–10.2), postoperative pulmonary embolism (OR = 12.2; 95% CI, 1.9–78.4), no postoperative blood transfusion (OR = 3.3; 95% CI, 1.7–6.2), surgical site infection (OR = 5.3; 95% CI, 2.9–10.0), and post-hepatectomy hyperbilirubinemia (OR = 1.1; 95% CI, 1.1–1.2). A scoring system based on these risk factors accurately predicted readmission in the validation cohort. A score of >20 points had a positive predictive value of 30.8% and negative predictive value of 95.6%, and a score >50 had a positive predictive value of 50.9% and negative predictive value of 87.7%. This risk score accurately stratifies readmission risk. Conclusions The risk of hospital readmission within 90 days after major hepatectomy is high and is reliably predicted with a novel scoring system.

Objective: The study aim was to quantify the burden of complications of pancreatoduodenectomy (PD). Background: The Postoperative Morbidity Index (PMI) is a quantitative measure of the average burden of complications of a procedure. It is based on highly validated systems—ACS-NSQIP and the Modified Accordion Severity Grading System. Methods: Nine centers contributed ACS-NSQIP complication data for 1589 patients undergoing PD from 2005 to 2011. Each complication was assigned a severity weight ranging from 0.11 for the least severe complication to 1.00 for postoperative death, and PMI was derived. Contribution to total burden by each complication grade was used to generate a severity profile (“spectrogram”) for PD. Associations with PMI were determined by regression analysis. Results: ACS-NSQIP complications occurred in 528 cases (33.2%). The non–risk-adjusted PMI was 0.115 (SD = 0.023) for all centers and 0.113 (SD = 0.005) for the 7 centers that contributed at least 100 cases. Grade 2 complications were predominant in frequency, and the most common complication was postoperative bleeding/transfusion. Frequency and burden of complications differed markedly. For instance, severe complications (grades 4/5/6) accounted for only about 20% of complications but for more than 40% of the burden of complications. Organ space infection had the highest burden of any complication. The average burden in cases in which a complication actually occurred was 0.346. Conclusions: This study develops a quantitative non–risk-adjusted benchmark for postoperative morbidity of PD. The method quantifies the burden of types and grades of postoperative complications and should prove useful in identifying areas that require quality improvement.

Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear.Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments.693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000.MIDP is associated with$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP.

Objective The aim of this study was to identify and compare common reasons and risk factors for 30-day readmission after pancreatic resection. Background Hospital readmission after pancreatic resection is common and costly. Many studies have evaluated this problem and numerous discrepancies exist regarding the primary reasons and risk factors for readmission. Methods Multiple electronic databases were searched from 2002 to 2016, and 15 relevant articles identified. Overall readmission rate was calculated from individual study estimates using a random-effects model. Study data were combined and overall estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor. Multivariable data were qualitatively synthesized. Results The overall 30-day readmission rate was 19.1% (95% CI 17.4-20.7) across all studies. Infectious complications and gastrointestinal disorders, such as failure to thrive and delayed gastric emptying, together accounted for 58.9% of all readmissions. Demographic factors did not predict readmission. Heart disease (OR 1.37, 95% CI 1.12-1.67), hypertension (OR 1.44, 95% CI 1.09-1.91), and intraoperative blood transfusion (OR 1.45, 95% CI 1.15-1.83) were weak predictors of readmission, while any postoperative complications (OR 2.22, 95% CI 1.55-3.18) or severe complications (OR 2.84, 95% CI 1.65-4.89) were stronger predictors. Conclusions Readmission after pancreatic resection is common and can largely be attributed to infectious complications and inability to maintain adequate hydration and nutrition. Focus on outpatient resources and follow-up to address these issues will prove valuable in reducing readmissions.

While contemporary studies demonstrate decreasing complication rates following total pancreatectomy (TP), none have quantified the impact of post-TP complications. The Postoperative Morbidity Index (PMI)—a quantitative measure of postoperative morbidity—combines ACS-NSQIP complication data with severity weighting derived from Modified Accordion Grading System. We establish the PMI for TP in a multi-institutional cohort. Nine institutions contributed ACS-NSQIP data for 64 TPs (2005–2011). Each complication was assigned an Accordion severity weight ranging from 0.110 (grade 1/mild) to 1.00 (grade 6/death). PMI equals the sum of complication severity weights (“Total Burden”) divided by total number of patients. Overall, 29 patients (45.3 %) suffered 55 ACS-NSQIP complications; 15 (23.4 %) had >1 complication. Thirteen patients (20.3 %) were readmitted and one death (1.6 %) occurred within 30 days. Non-risk adjusted PMI was 0.151, while PMI for complication-bearing cases rose to 0.333. Bleeding/Transfusion and Sepsis were the most common complications. Discordance between frequency and burden of complications was observed. While grades 4–6 comprised only 18.5 % of complications, they contributed 37.1 % to the series’ total burden. This multi-institutional series is the first to quantify the complication burden following TP using the rigor of ACS-NSQIP. A PMI of 0.151 indicates that, collectively, patients undergoing TP have an average burden of complications in the mild to moderate severity range, although complication-bearing patients have a considerable reduction in health utility.

There are no validated methods to preoperatively identify patients with increased risk of discharge to skilled nursing facilities following resection of gastric cancer. We sought to identify preoperative predictors of non-home discharge to optimize transition of care to skilled nursing facility. Patients who underwent resection of gastric cancer from 2000 to 2012 from seven participating institutions of the US Gastric Cancer Collaborative were analyzed. Fisher’s exact tests, Student t tests, and logistic regression analyses identified preoperative variables associated with non-home discharge. A prediction tool was created and validated through c-indices. Survival analysis was conducted according to the methods of Kaplan and Meier. Out of the 918 patients identified, 93 (10 %) were discharged to nonhome location. Univariate analysis identified advancing age, American Society of Anesthesiology (ASA) score, hypertension, decreasing preoperative albumin, and lack of neoadjuvant chemotherapy as risk factors for non-home discharge (NHD). Multivariable analysis identified advanced age (odds ratio (OR) = 1.07, 95 % confidence interval (CI) = 1.04–1.10, p

Background Renal insufficiency adversely affects outcomes after cardiac and vascular surgery. The effect of preoperative renal insufficiency on outcomes after major hepatectomy is unknown. Study Design All patients who underwent major hepatectomy (≥3 segments) at 3 institutions from 2000 to 2012 were identified. Resections were performed using low central venous pressure anesthesia. Renal function was analyzed by preoperative serum creatinine (sCr) level. Primary outcomes were major complications (Clavien grade III to V), respiratory failure, renal failure requiring hemodialysis, and 90-day mortality. Results One thousand one hundred and seventy patients had preoperative sCr levels available. Renal function was analyzed using sCr dichotomized at 1.8 mg/dL, 1 SD higher than the mean value (0.97 ± 0.79 mg/dL) for the cohort. Twenty-two patients had sCr ≥1.8 mg/dL. Major complications occurred in 279 patients (23.8%), respiratory failure in 62 (5.3%), and renal failure in 31 (2.6%). Ninety-day mortality rate was 5.4%. On multivariate analysis, patients with sCr ≥1.8 mg/dL remained at significantly increased risk for major complications (hazard ratio = 3.94; 95% CI, 1.48–10.49; p = 0.006), respiratory failure (hazard ratio = 4.43; 95% CI, 1.33–14.80; p = 0.014), and renal failure (hazard ratio = 4.75; 95% CI, 1.19–18.97; p = 0.028). Serum Cr ≥1.8 mg/dL was not independently associated with 90-day mortality on multivariate analysis (p = 0.27). Conclusions Preoperative serum creatinine ≥1.8 mg/dL identifies patients at significantly increased risk of postoperative major complications, respiratory failure, and renal failure requiring dialysis. Patients are well selected for major hepatectomy, and few patients with substantial renal insufficiency are deemed operative candidates.

A proximal margin distance of 5 cm is advocated for resection of gastric adenocarcinoma (GAC). We assessed the prognostic value of proximal margin (PM) distance on survival outcomes after resection of distal GAC.All patients who underwent resection of distal GAC (antrum/body) from 2000 to 2012 at seven institutions of the U.S. Gastric Cancer Collaborative were included. Patients with positive distal margins or macroscopic residual disease were excluded. The prognostic value of PM distance (assessed in 0.5-cm increments) on overall (OS) and recurrence-free survival (RFS) was assessed by Kaplan-Meier and multivariate regression analysis.A total of 465 patients underwent resection of distal GAC. Of these, 435 had R0 resections; 30 patients had a positive PM. 143 patients had stage I, and 322 had stage II-III tumors. Median follow-up was 44 months. Average PM distance was 4.8 cm. Median OS for patients with PM of 3.1-5.0 cm (n = 110) was superior to patients with PM ≤ 3.0 cm (n = 176) (48.1 vs. 29.3 months; p = 0.01), while a margin5.0 cm (n = 179) offered equivalent survival to PM 3.1-5.0 cm (50.6 months, p = 0.72). The prognostic value of margin distance was stage specific. On multivariate analysis of stage I patients, PM 3.1-5.0 cm remained associated with improved OS [hazard ratio (HR), 0.16; 95 % confidence interval (95 % CI), 0.04-0.60; p = 0.01]. In stage II-III, neither PM 3.1-5.0 cm nor PM5.0 cm was significantly associated with OS; OS was dictated by T stage and nodal involvement.The prognostic value of proximal margin distance after resection of distal gastric cancer appears stage specific. In stage I, a 3.1- to 5.0-cm proximal margin is associated with the same improved OS as a5.0-cm margin. In stage II-III disease, other adverse pathologic factors more strongly impact survival than proximal margin distance.

103 Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins by additional gastric resection after a positive proximal margin frozen section (FS) is unknown. Methods: The US Gastric Cancer Collaborative includes all patients who had resection of GAC at 7 institutions by oncologic surgeons from 2000-2012. Intraoperative proximal margin FS data were classified as R0 or R1 based on final permanent section (PS); positive distal margins were excluded. Primary aim was to evaluate the impact on local recurrence (LR) of converting a positive proximal margin FS to an R0 final margin by additional resection. Secondary endpoints were recurrence-free (RFS) and overall survival (OS). Results: Of 860 pts, 520 had a proximal margin FS; 67 were positive. Of these 67, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 pts (86%), R1 in 25 (5%), and R1 converted to R0 in 48 (9%). Median FU was 44 mos. Although LR was decreased in the converted R1 to R0 group compared to the R1 group (10% vs 32%, p=0.01), when accounting for other pathologic variables on multivariate (MV) analysis, R1 to R0 conversion was not associated with decreased LR. Median RFS was similar between the R1 to R0 and R1 cohort (37 vs 31 mos; p=0.6) compared to 110 mos for the R0 group. Median OS was similar between the R1 to R0 conversion and R1 groups (36 vs 26 mos; p=0.14) compared to 50 mos for the R0 group. On MV analysis, increasing T-stage and positive lymph nodes were associated with worse OS; R1 to R0 conversion of the proximal margin was not associated with improved OS (p=0.5; Table). Conclusions: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection does not decrease local recurrence or improve recurrence-free or overall survival. This may guide decisions regarding the extent of resection. [Table: see text]

In this multi-institutional study of patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, we sought to identify factors associated with perioperative transfusion requirement as well as the association between blood transfusion and perioperative and oncologic outcomes. The surgical databases across six high-volume institutions were analyzed to identify patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 2005 to 2010. For statistical analyses, patients were then stratified by transfusion volume according to whether they received 0, 1–2, or >2 units of packed red blood cells. Among 697 patients identified, 42 % required blood transfusion. Twenty-three percent received 1–2 units, and 19 % received >2 units. Factors associated with an increased transfusion requirement included older age, heart disease, diabetes, longer operative time, higher blood loss, tumor size, and non-R0 margin status (all p 2 units (hazard ratio, 1.92, p = 0.009) and postoperative transfusions as independent factors associated with decreased disease-free survival. This multi-institutional study represents the largest series to date analyzing the effects of perioperative blood transfusion on patient outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma. While blood transfusion was not associated with increased rate of infectious complications, allogeneic blood transfusion did confer a negative impact on disease-free and overall survival.

Background Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. Methods Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008–2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. Results Forty-seven patients were included. Median age was 59 (20–75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30–78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13–947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14–17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). Conclusions These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.

In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.Patients undergoing PR from 2005-2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p0.001) and 4.5 vs. 2.0 % (p0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p0.001) and 8.6 vs. 2.2 % (p0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.

Current National Comprehensive Cancer Network guidelines recommend neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma to increase the likelihood of achieving R0 resection. A consensus has not been reached on the degree of venous involvement that constitutes borderline resectability. This study compares the outcome of patients who underwent pancreaticoduodenectomy with or without vein resection without neoadjuvant therapy. A multi-institutional database of patients who underwent pancreaticoduodenectomy was reviewed. Patients who required vein resection due to gross vein involvement by tumor were compared to those without evidence of vein involvement. Of 492 patients undergoing pancreaticoduodenectomy, 70 (14 %) had vein resection and 422 (86 %) did not. There was no difference in R0 resection (66 vs. 75 %, p = NS). On multivariate analysis, vein involvement was not predictive of disease-free or overall survival. This is the largest modern series examining patients with or without isolated vein involvement by pancreas cancer, none of whom received neoadjuvant therapy. Oncological outcome was not different between the two groups. These data suggest that up-front surgical resection is an appropriate option and call into question the inclusion of isolated vein involvement in the definition of “borderline resectable disease.”

Background Patient satisfaction is widely reported and impacts satisfaction despite a limited understanding of the clinical and structural determinants. Patients with diverticulitis are admitted to various services, with variable disease severities. They, therefore, represent a unique group to delineate relationships between these factors and satisfaction. We examined the factors that impact hospital satisfaction in patients with diverticulitis. Materials and methods Patients admitted between 2009 and 2012 were identified using International Classification of Diseases 9th Revision (ICD-9) codes. The primary outcome of patient satisfaction was the Press Ganey Survey overall hospitalization satisfaction question because of a high response rate. This is a precursor survey to the widely available Hospital Consumer Assessment of Healthcare Systems and Providers Survey. There was high concordance between these items. Clinical and structural variables were collected retrospectively. Patients were divided into two groups based on whether they gave the topbox response for the overall hospital rating. Results Sixty-six patients were identified (56% female, 63 ± 14 years, length of stay: 5 ± 5 d). Seventy-four percent patients rated the hospitalization as topbox. Forty-four percent were admitted to a surgical service, and 21% of all patients underwent an operation. When comparing the topbox to the nontopbox group, demographics and disease severity were similar. Treatment modality, admitting service, and outpatient intravenous antibiotics did not influence patient satisfaction. Conclusions Clinical and structural variables did not impact overall hospital satisfaction for patients admitted with diverticulitis. This indicates that less-tangible aspects of in-hospital care may be the primary determinants of hospital satisfaction in this group. Efforts aimed at defining these variables are needed to improve patient satisfaction.

The current guidelines do not delineate the types of providers that should participate in early breast cancer follow-up care (within 3 years after completion of treatment). This study aimed to describe the types of providers participating in early follow-up care of older breast cancer survivors and to identify factors associated with receipt of follow-up care from different types of providers. Stages 1–3 breast cancer survivors treated from 2000 to 2007 were identified in the Surveillance, Epidemiology and End results Medicare database (n = 44,306). Oncologist (including medical, radiation, and surgical) follow-up and primary care visits were defined using Medicare specialty provider codes and linked American Medical Association (AMA) Masterfile. The types of providers involved in follow-up care were summarized. Stepped regression models identified factors associated with receipt of medical oncology follow-up care and factors associated with receipt of medical oncology care alone versus combination oncology follow-up care. Oncology follow-up care was provided for 80 % of the patients: 80 % with a medical oncologist, 46 % with a surgeon, and 39 % with a radiation oncologist after radiation treatment. The patients with larger tumor size, positive axillary nodes, estrogen receptor (ER)-positive status, and chemotherapy treatment were more likely to have medical oncology follow-up care than older patients with higher Charlson comorbidity scores who were not receiving axillary care. The only factor associated with increased likelihood of follow-up care with a combination of oncology providers was regular primary care visits (>2 visits/year). Substantial variation exists in the types of providers that participate in breast cancer follow-up care. Improved guidance for the types of providers involved and delineation of providers’ responsibilities during follow-up care could lead to improved efficiency and quality of care.

ObjectivesCriteria for the selection of patients for adjuvant chemotherapy in intrahepatic cholangiocarcinoma (IHCC) are lacking. Some authors advocate treating patients with lymph node (LN) involvement; however, nodal assessment is often inadequate or not performed. This study aimed to identify surrogate criteria based on characteristics of the primary tumour.MethodsA total of 58 patients who underwent resection for IHCC between January 2000 and January 2010 at any of three institutions were identified. Primary outcome was overall survival (OS).ResultsMedian OS was 23.0months. Median tumour size was 6.5cm and the median number of lesions was one. Overall, 16% of patients had positive margins, 38% had perineural invasion (PNI), 40% had lymphovascular invasion (LVI) and 22% had LN involvement. A median of two LNs were removed and a median of zero were positive. Lymph nodes were not sampled in 34% of patients. Lymphovascular and perineural invasion were associated with reduced OS [9.6months vs. 32.7months (P= 0.020) and 10.7months vs. 32.7months (P= 0.008), respectively]. Lymph node involvement indicated a trend towards reduced OS (10.7months vs. 30.0months; P= 0.063). The presence of either LVI or PNI in node-negative patients was associated with a reduction in OS similar to that in node-positive patients (12.1months vs. 10.7months; P= 0.541). After accounting for adverse tumour factors, only LVI and PNI remained associated with decreased OS on multivariate analysis (hazard ratio4.07, 95% confidence interval 1.60–10.40; P= 0.003).ConclusionsLymphovascular and perineural invasion are separately associated with a reduction in OS similar to that in patients with LN-positive disease. As nodal dissection is often not performed and the number of nodes retrieved is frequently inadequate, these tumour-specific factors should be considered as criteria for selection for adjuvant chemotherapy.

hpb_432 228..235 Background: The effect of diabetes on survival after resection pancreatic ductal carcinoma (PDAC) is unclear. The present study was undertaken to determine whether pre-operative diabetes has any predictive value for survival. Methods: A retrospective review from seven centres was performed. Metabolic factors, tumour char- acteristics and outcomes of patients undergoing resection for PDAC were collected. Univariate and multivariable analyses were performed to determine factors associated with disease-free (DFS) and overall survival (OS). Results: Of the 509 patients in the present study, 31.2% had diabetes. Scoring systems were devised to predict OS and DFS based on a training set (n = 245) and were subsequently tested on an independent set (n = 264). Pre-operative diabetes (P 2c m (P = 0.001), metastatic nodal ratio >0.1 (P < 0.001) and R1 margin (P < 0.001) all correlated with DFS and OS on univariate analysis. Scoring systems were devised based on multivariable analysis of the above factors. Diabetes and the metastatic nodal ratio were the most important factors in each system, earning two points for OS and four points for DFS. These scoring systems significantly correlated with both DFS (P < 0.001) and OS (P < 0.001). Conclusion: Pre-operative diabetes status provides useful information that can help to stratify patients in terms of predicted post-operative OS and DFS.

Background Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection. Study Design Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as 3 /μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality. Results A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p=0.031), PLI (30% versus 6%, p=0.001), and 60-day mortality (22% versus 6%, p=0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p=0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p=0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p=0.009). Conclusions LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.

Evaluation of risk factors for adverse outcomes following distal pancreatectomy (DP) has been limited to data collected from retrospective, primarily single-institution studies. Using a large, multi-institutional prospectively collected dataset, we sought to define the incidence of complications after DP, identify the preoperative and operative risk factors for the development of complications, and develop a risk score that can be utilized preoperatively. The American College of Surgeons National Surgical Quality Improvement Program participant use file was utilized to identify patients who underwent DP from 2005 to 2008 by Current Procedural Terminology codes. Multivariate logistic regression analysis was performed to identify variables associated with 30-day morbidity and mortality. A scoring system was developed to allow for preoperative risk stratification. In 2,322 patients who underwent DP, overall 30-day complication and mortality were 28.1% and 1.2%, respectively. Serious complication occurred in 22.2%, and the most common complications included sepsis (8.7%), surgical site infection (5.9%), and pneumonia (4.7%). On multivariate analysis, preoperative variables associated with morbidity included male gender, high BMI, smoking, steroid use, neurologic disease, preoperative SIRS/sepsis, hypoalbuminemia, elevated creatinine, and abnormal platelet count. Preoperative variables associated with 30-day mortality included esophageal varices, neurologic disease, dependent functional status, recent weight loss, elevated alkaline phosphatase, and elevated blood urea nitrogen. Operative variables associated with both morbidity and mortality included high intraoperative transfusion requirement (≥3 U) and prolonged operation time (>360 min). Weighted risk scores were created based on the preoperatively determined factors that predicted both morbidity (p

The Hepp-Couinaud technique describes side-to-side HJ to the main left hepatic duct but a side-to-side approach is not consistently used when repairing other ducts. Compared with end-to-side repairs, side-to-side anastomoses require less dissection, theoretically preserving blood supply to the bile ducts, and usually permit wider anastomoses.We report the treatment results of 113 consecutive biliary injuries, with intention to perform side-to side anastomosis in all.113 biliary injuries, 109 associated with cholecystectomy, were treated from 1992-2006. Injury types were B (7 patients, 6%); C (11 patients, 10%); E1 (8 patients, 7%); E2 (37 patients, 33%); E3 (20 patients, 18%); E4 (24 patients, 21%); E5 (6 patients, 5%). 19% of repairs were early (within 1 week after cholecystectomy), 58% were delayed (at least 6 weeks after cholecystectomy), and 22% were reoperations for recurrent strictures. In 92% of cases, side-to-side repair was accomplished. 23/113 (20%) developed postoperative complications, with one postoperative death. Mean follow-up was 4.9 years. Excellent anastomotic function was achieved in 107/112 (95%). "Poor" anastomotic results occurred in 5 patients: 2 patients with E4 injuries had postoperative anastomotic stenting3 months, and 3 developed strictures requiring percutaneous dilation. There have been no reoperations for biliary strictures.HJ using side-to-side anastomosis has theoretical advantages and is usually possible. In some high right-sided injuries it could not be achieved. 95% excellent anastomotic function without intervention attests to the benefit of the method, especially as postoperative stenting3 months was considered to be a "poor" result.

Background Abnormalities of liver function tests (LFT) are sometimes taken as evidence of a less than optimal result after repair of a biliary injury. Rather than indicating liver or anastomotic dysfunction, moderate LFT elevations can be "normal" for these patients. This study's aim was to determine LFT reference values after biliary-enteric anastomosis for biliary injury repair in persons who have had an excellent postoperative course for > 6 months. Study Design Of 113 patients repaired, 73 were identified with the following characteristics: LFT available at ≥ 6 months after repair, no biliary tract symptoms, no underlying liver disease, and biliary injury sustained during cholecystectomy. Outside LFT results were standardized to Barnes-Jewish Hospital reference values. One set of LFT per patient was collected at the following times points after repair: 6 months to 2 years, 2 to 5 years, and > 5 years. Results For each distribution, the 97.5 th p97.5ercentile values for alkaline phosphatase (≥ 166 IU/L) and total bilirubin (≥ 1.3 mg/dL) were elevated relative to Barnes-Jewish Hospital standard values. Values for alanine aminotransferase and aspartate aminotransferase were more variable. Conclusions Moderate LFT elevations exceeding standard reference values are common after repair of a biliary injury in patients who have had excellent results. Alkaline phosphatase values fall with time after repair so that comparisons should take into account time from repair. Values ≤ 97.5 th percentile limits described here should not be taken as evidence of liver or anastomotic dysfunction.

Patient satisfaction is often measured using the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Our aim was to examine the structural and clinical determinants of satisfaction among inpatients with prolonged lengths of stays (LOS).Adult patients who were admitted between 2009 and 2012, had a LOS of 21 days or more, and completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey, were included. Univariate analyses assessed the relationship between satisfaction and patient/system variables. Recursive partitioning was used to examine the relative importance of the identified variables.One hundred one patients met inclusion criteria. The average LOS was 35 days and 58% were admitted to a surgical service. Satisfaction with physician communication was significantly associated with fewer consultations (P.01), nonoperative admission (P.001), no intensive care unit stay (P.01), nonsurgical service (P.01), and non-emergency room admissions (P = .03). Among these, having fewer consultations had the highest relative importance.In long stay patients, having fewer inpatient consultations was the strongest predictor of patient satisfaction with physician communication. This suggests that examination of patient-level data in clinically relevant subgroups may be a useful way to identify targets for quality improvement.