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Background: Our previous case series suggested that a 1-week, low-calorie and low-fat diet was associated with decreased intraoperative blood loss in patients undergoing liver surgery., Objective: The current study evaluates the effect of this diet in a randomized controlled trial., Methods: We randomly assigned 60 patients with a body mass index ≥25 kg/m(2) to no special diet or an 800-kcal, 20 g fat, and 70 g protein diet for 1 week before liver resection. Surgeons were blinded to diet assignment. Hepatic glycogen stores were evaluated using periodic acid Schiff (PAS) stains., Results: Ninety four percent of the patients complied with the diet. The diet group consumed fewer daily total calories (807 vs 1968 kcal, P < 0.001) and fat (21 vs 86 g, P < 0.001) than the no diet group. Intraoperative blood loss was less in the diet group: mean blood loss 452 vs 863 mL (P = 0.021). There was a trend towards decreased transfusion in the diet group (138 vs 322 mL, P = 0.06). The surgeon judged the liver to be easier to manipulate in the diet group: 1.86 versus 2.90, P = 0.004. Complication rate (20% vs 17%), length of stay (median 5 vs 4 days) and mortality did not differ between groups. There was no difference in hepatic steatosis between groups. There was less glycogen in hepatocytes in the diet group (PAS stain score 1.61 vs 2.46, P < 0.0001)., Conclusions: A short-course, low-fat, and low-calorie diet significantly decreases bleeding and makes the liver easier to manipulate in hepatic surgery.

Background: Because of the malignant potential, resection has been recommended for some intraductal papillary mucinous neoplasms (IPMN). We hypothesize that a large cancer database could be used to evaluate national resection rates and survival for malignant IPMN., Materials and Methods: Using the Surveillance Epidemiology and End Results (SEER) database, 1988-2003, cases of malignant IPMN were identified using histology codes. Age-adjusted incidence rates were calculated; Cochran-Armitage tests evaluated trends over time. Predictors of resection were evaluated using χ(2) and logistic regression. Kaplan-Meier curves and Cox models were constructed to evaluate survival., Results: Of 1834 patients, 209 (11.4%) underwent resection. Annual age-adjusted incidence decreased over the study time-course (P<0.05), while annual proportion of patients presenting with localized lesions and the proportion being resected increased (P<0.05). Predictors of resection on multivariate analysis included localized stage [versus distant, adjusted odds ratio (OR) 31; 95% confidence interval (CI) 17-56], and more recent diagnosis [referent 1988-1991; 2000-2003, OR 3.0 (95%CI 1.7-5.3)]. Median survival for resected patients was 16 mo versus 3 mo without resection (P<0.0001). After adjusting for age, gender, stage, year, and tumor location, surgical resection remained a significant predictor of survival [hazard ratio 0.44 (95% CI 0.36-0.54), P<0.0001]., Conclusions: In this population-based cohort, detection of malignant IPMNs is decreasing, with an increasing proportion of patients diagnosed at local stages and undergoing resection. Increased awareness of IPMN may be contributing to earlier detection, which might include benign/premalignant lesions, and greater utilization of resection for appropriate candidates; thus, we may be improving survival for this most treatable form of pancreatic cancer., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Adrenalectomy remains the definitive therapy for most adrenal neoplasms. Introduced in the 1990s, laparoscopic adrenalectomy is reported to have lower associated morbidity and mortality. This study aimed to evaluate national adrenalectomy trends, including major postoperative complications and perioperative mortality., Methods: The Nationwide Inpatient Sample was queried to identify all adrenalectomies performed during 1998-2006. Univariate and multivariate logistic regression were performed, with adjustments for patient age, sex, comorbidities, indication, year of surgery, laparoscopy, hospital teaching status, and hospital volume. Annual incidence, major in-hospital postoperative complications, and in-hospital mortality were evaluated., Results: Using weighted national estimate, 40,363 patients with a mean age of 54 years were identified. Men made up 40% of these patients, and 77% of the patients were white. The majority of adrenalectomies (83%) were performed for benign disease. The annual volume of adrenalectomies increased from 3,241 in 1998 to 5,323 in 2006 (p < 0.0001, trend analysis). The overall in-hospital mortality was 1.1%, with no significant change. Advanced age (< 45 years as the referent; ≥ 65 years: adjusted odds ratio [AOR], 4.10; 95%; confidence Interval [CI], 1.66-10.10) and patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.33; 96% CI, 2.34-8.02) were independent predictors of in-hospital mortality. Indication, year, hospital teaching status, and hospital volume did not independently affect perioperative mortality. Major postoperative in-hospital complications occurred in 7.2% of the cohort, with a significant increasing trend (1998-2000 [5.9%] vs 2004-2006 [8.1%]; p < 0.0001, trend analysis). Patient comorbidities (Charlson score 0 as the referent; Charlson score ≥ 2: AOR, 4.77; 95% CI, 3.71-6.14), recent year of surgery (1998-2000 as the referent; 2004-2006: AOR, 1.40; 95% CI, 1.09-1.78), and benign disease (malignant disease as the referent; benign disease: AOR, 1.98; 95% CI, 1.55-2.53) were predictive of major postoperative complications at multivariable analyses, whereas laparoscopy was protective (no laparoscopy as the referent; laparoscopy: AOR, 0.62; 95% CI, 0.47-0.82)., Conclusion: Adrenalectomy is increasingly performed nationwide for both benign and malignant indications. In this study, whereas perioperative mortality remained low, major postoperative complications increased significantly.

Objectives: To develop a population-based risk score for stratifying patients by risk of in-hospital mortality following procedural intervention for hepatic neoplasm., Background: There has been growing support for the value of surgical management of hepatic neoplastic disease, both primary and metastatic. Advances in surgical and ablative technologies have contributed to a decrease in the mortality associated with these procedures. However, multiple patient-, disease- and treatment-related factors can contribute to perioperative morbidity and mortality., Methods: Using the Nationwide Inpatient Sample from 1998 to 2005, a retrospective cohort of patient-discharges for hepatic procedures with a concurrent diagnosis of hepatic primary or metastatic neoplasm to the liver was assembled. Procedures were categorized as lobectomy, wedge resection, or enucleation/ablation. Logistic regression and bootstrap methods were used to create an integer score for estimating the risk of in-hospital mortality using patient demographics, comorbidities, procedure type, tumor type, and hospital characteristics. A randomly selected sample of 80% of the cohort was used to create the risk score. Testing was conducted in the remaining 20% validation-set., Results: In total, 12,969 patient-discharges were identified. Overall in-hospital mortality was 3.45%. Predictive characteristics incorporated into the model included: age, sex, Charlson comorbidity score, procedure type, hospital type, and type of neoplasm. Integer values were assigned to these, and used to calculate an additive score. Five clinically relevant groups were assembled to stratify risk, with a 36-fold gradient in mortality. Rates in the groups were as follows: 0.9%, 2.5%, 6.8%, 17.6%, and 35.9%. In the derivation set, as well as in the validation set, the simple score discriminated well, with c-statistics of 0.76 and 0.70, respectively., Conclusions: An integer-based risk score can be used to predict in-hospital mortality after hepatic procedure for neoplasm, and may be useful for preoperative risk stratification and patient counseling.

Introduction: National studies on in-hospital pancreatic outcomes have focused on mortality. Non-fatal morbidity affects a greater proportion of patients., Methods: The Nationwide Inpatient Sample 1998-2006 was queried for discharges after pancreatectomy. Rates of major complications (myocardial infarction, aspiration pneumonia, pulmonary compromise, perforation, infection, deep vein thrombosis/pulmonary embolism, hemorrhage, or reopening of laparotomy) were assessed. Predictors of complication(s) were evaluated using logistic regression. Their independent effect on in-hospital mortality, length of stay, and discharge disposition was assessed., Results: Of 102,417 patient discharges, 22.7% experienced a complication. Complication rates did not decline significantly over time, while mortality rates did. Independent predictors of complications included age >or=75 [referent, 19-39; adjusted odds ratio (OR) 1.34, 95% confidence interval (CI) 1.2-1.5, p < 0.0001], total pancreatectomy (vs proximal, OR 1.29, 95%CI 1.1-1.5, p = 0.0025), and low hospital resection volume (vs high, OR 1.61, 95%CI 1.4-1.8, p < 0.0001). Complications were a significant independent predictor of death (OR 7.76, 95%CI 6.7-8.8, p < 0.0001), prolonged hospital stay (OR 6.94, 95%CI 6.2-7.7, p < 0.0001), and discharge to another facility (OR 0.28, 95%CI 0.26-0.3, p < 0.0001)., Conclusions: Despite improvements in mortality, complication rates remain substantial and largely unchanged. They predict in-hospital mortality, prolonged hospital stay, and delayed return to home. The impact on healthcare costs and quality of life deserves further study.

Background: Pancreatic resection can be performed to ameliorate the sequelae of chronic pancreatitis in selected patients. The perceived risk of pancreatectomy may limit its use. Using a national database, this study compared mortality after pancreatic resections for chronic pancreatitis with those performed for neoplasm., Study Design: Patient discharges with chronic pancreatitis or pancreatic neoplasm were queried from the Nationwide Inpatient Sample, 1998 to 2006. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used., Results: There were 11,048 pancreatic resections. Malignant neoplasms represented 64.2% of the sample; benign neoplasms and pancreatitis comprised 17.1% and 18.7%, respectively. In-hospital mortality rates were 2.2% and 1.7% for the pancreatitis and benign tumor cohorts, respectively, compared with 5.9% for the malignancy cohort (overall p < 0.01). A multivariable logistic regression examined differences in mortality among diagnoses while adjusting for patient and hospital characteristics; covariates included patient gender, race, age, comorbidities, type of pancreatectomy, payor, hospital teaching status, hospital size, and hospital volume. After adjustment, patients undergoing resection for pancreatitis were at a significantly lower risk of in-hospital mortality when compared with those with malignant neoplasm (odds ratio, 0.43; 95% CI, 0.28 to 0.67)., Conclusions: Pancreatectomies for chronic pancreatitis have lower in-hospital mortality than those performed for malignancy and similar rates as resection for benign tumors. Pancreatic resection, which can improve quality of life in chronic pancreatitis patients, can be performed with moderate mortality rates and should be considered in appropriate patients.

Objective: To analyze in-hospital mortality after pancreatectomy using a large national database., Summary and Background Data: Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic cancer. The goal of this study was to define factors affecting outcomes after pancreatectomy for neoplasm., Methods: A retrospective analysis was performed using all patients undergoing pancreatic resections for neoplastic disease identified from the Nationwide Inpatient Sample from 1998 to 2003. Crude in-hospital mortality was analyzed by chi. A multivariable model was constructed to adjust for age, sex, hospital teaching status, hospital surgical volume, year of resection, payer status, and selected comorbid conditions., Results: In all, 279,445 patient discharges were identified with a primary diagnosis of pancreatic neoplasm. A total of 39,463 (14%) patients underwent resection during that hospitalization. In-hospital mortality was 5.9% with a significant decrease from 7.8% to 4.6% from 1998 to 2003 by trend analysis (P < 0.0001). Resections done at low (<5 procedures/year)- and medium (5-18/year)-volume centers had higher mortality compared with those at high (>18/year)-volume centers (low-volume odds ratio = 3.3; 95% confidence interval, 2.3-4.; medium-volume, odds ratio = 2.1; 95% confidence interval, 1.5-3.0). The proportion of procedures performed at high volume centers increased from 30% to 39% over the 6-year time period (P < 0.0001) by trend test., Conclusions: This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatectomy for neoplastic disease from 1998 to 2003. In addition, a greater proportion of pancreatectomies were performed at high-volume centers in 2003. The regionalization of pancreatic surgery may have partially contributed to the observed decrease in mortality rates.

Hypothesis: That factors affecting outcomes of surgical resection in the treatment of gastric cancer can be identified using a large US database., Design: Retrospective observational study., Setting: The Nationwide Inpatient Sample from January 1, 1998, through December 31, 2003., Patients: We included 13 354 patient discharges (approximately 66 096 nationally by weighted analysis) who underwent gastric resection for neoplasm., Main Outcome Measure: In-hospital mortality. Univariate analyses were performed by means of chi(2) tests. A multivariate logistic regression was performed to determine which variables were independently predictive of in-hospital mortality., Results: During the study period, 50 738 patients (approximately 250 420 nationally) were discharged with the diagnosis of gastric neoplasm. Of those, 13 354 (26.3%) underwent gastric resection during their hospitalization. In-hospital mortality for patients undergoing surgery was 6.0%, without significant change from 1998 through 2003. Factors predictive of significantly increased in-hospital mortality included low annual hospital surgical volume (lowest [or= 11 gastrectomies per year], 6.8% vs 4.9%; adjusted odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8]), older patient age (50-69 vs <50 years, 4.0% vs 2.1%; adjusted OR, 1.5; 95% CI, 1.1-2.2) (>or =70 vs <50 years, 8.6% vs 2.1%; adjusted OR, 2.9; 95% CI, 2.0-4.3), male sex (male vs female, 6.7% vs 5.0%; adjusted OR, 1.3; 95% CI, 1.1-1.5), and procedure type (total gastrectomy vs all other resections, 8.0% vs 5.3%; adjusted OR, 1.4; 95% CI, 1.2-1.7)., Conclusions: Higher annual surgical volume is predictive of lower in-hospital mortality for patients undergoing gastric resection for neoplasm. Other factors significantly associated with superior outcomes after gastric resection included diagnosis type, procedure type, younger age, female sex, and fewer comorbid conditions.