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285 Background: Margin-negative (R0) surgical resection is the only potentially curative therapy for pancreatic cancer. For patients deemed borderline resectable (BL), neoadjuvant chemoradiotherapy (NCRT) increases the likelihood of subsequent R0 resection and improves overall survival. Prognostic factors for achieving resection following NCRT have yet to be clearly identified. Methods: 50 consecutive patients diagnosed with BL pancreatic cancer by a multidisciplinary tumor board from 2008-12 were retrospectively identified. Pre- and post-NCRT CT scans and surgical specimens were centrally reviewed by a blinded radiologist and pathologist, respectively. Results: 29 patients underwent resection following NCRT, while 21 remained unresectable. Between the two groups, age, gender, mean RT dose, and proportion of pancreatic head tumors were not significantly different. Lack of the following factors was favorably associated with resection: SMV/PV encasement (p=0.01), SMA involvement (p=0.02), ascites (p=0.01), and questionable/overt metastases (p=0.01). Notably, celiac artery involvement/encasement, common hepatic artery encasement, and percentage change in tumor volume were not significant predictors of resectability (all p>0.05). Additionally, tumor volume and degree of individual vessel involvement did not significantly change from scans before and after NCRT (all p>0.05). Median OS was 22.9 vs.13.0 months in resected and unresected patients, respectively (p

Body. Reduced proliferative capacity and response to growth factors have been found in aged animal models. Our aim was to compare cutaneous wound closure in old versus young animals and to see if delivery of KGF-1 could increase healing in the elderly mice. Methods. Four age groups of BALBc mice were used: 6 weeks, 6 months, 1 year, and 2 years. We assessed closure of 5-mm full-thickness wounds on the backs of 41 mice by calculating wound areas (pixels) using image analysis software based on NIH image (Scion Image, Frederick, MD). We earlier set electroporation (EP) parameters to six 100-s pulses of 1750 V/cm (ECM830, BTX Genetronics, San Diego, CA). We utilized electroporation to increase transfection efficiency of a DNA expression vector for KGF (KGF-1, Invitrogen, Carlsbad, CA) using the gWIZ vector controlled by the CMV promoter. Results were presented as means ± SEM. For significance between groups we used Student’s t-test or ANOVA as appropriate. Results. Aging delays wound healing in our animal model. Wound sizes were statistically different without treatment between mice 6 weeks, 6 months, and 1 year (P < 0.001) as shown by the average wound size calculated in pixels at day 12 (6 weeks: 49.93 ± 26, 6 months: 195.25 ± 52, 1 year: 500.60 ± 140). After treatment with KGF-1+EP the wound sizes between the groups were not statistically different anymore (P = 0.604). In addition, the wounds of the aged mice treated with KGF-1 + EP closed significantly faster than the untreated wounds (44.23 versus 82.69% of closed wounds at day 12, P < 0.001). Conclusion. Our aged animal model demonstrated delayed wound closure and electroporation assisted delivery of KGF-1 expression vector restored healing at a rate close to that of young animals. Download full-size image

96 Background: Multidisciplinary clinics (MDC) are a burgeoning method of administering timely and comprehensive oncologic care. The continuity of care achievable with MDCs, in addition to their costs, are not well-described. We compared retention rates and charges for MDC patients to patients with individual referrals at the same academic center. Methods: The geographic origins of 482 MDC patients and 3,766 non-MDC patients, all referred for pancreatic cancer treatment between 2008-2010, were defined as “local,” “adjacent states,” and “non-adjacent states.” Proportions of patients in each group who presented initially and subsequently returned were compared using chi-squared tests. Multivariate adjustment was performed for disease stage and other clinical risk factors. Gross charges per patient were determined using billing data. Results: Overall, the MDC retained a higher percentage of patients for subsequent treatment than the non-MDC group (60.8% vs. 53.6%; p=0.003), as well as all three individual regions. Multivariate adjustment results are not yet available, but will be at the time of the meeting. Mean charges per patient were 11% higher for the non-MDC group. Conclusions: The MDC achieved higher patient retention, suggesting improved continuity of care. Total charges were higher for the non-MDC group, suggesting that MDCs may be more cost-effective. [Table: see text] [Table: see text]

Article-at-a-Glance Background Briefings and debriefings, previously shown to be a practical and feasible strategy to improve interdisciplinary communication and teamwork in the operating room (OR), was then assessed as a strategy to prospectively surface clinical and operational defects in surgical care—and thereby prevent patient harm. Methods A one-page, double-sided briefing and debriefing tool was used by surgical teams during cases at the William Beaumont Hospital Royal Oak (Royal Oak, Michigan) campus to surface clinical and operational defects during the study period (October 2006–May 2010). Defects were coded into six categories (with each category stratified by briefing or debriefing period) during the first six months, and refinement of coding resulted in expansion to 16 defect categories and no further stratification. A provider survey was used in January 2008 to interview a sample of 40 caregivers regarding the perceived effectiveness of the tool in surfacing defects. Findings The teams identified a total of 6,202 defects—an average of 141 defects per month—during the entire study period. Of 2,760 defects identified during the six-defect coding period, 1,265 (46%) surfaced during briefings, and the remaining 1,495 (54%) during debriefings. Equipment (48%) and communication (31%) issues were most prominent. Of 3,442 defects identified during the 16-defect coding period, the most common were Central Processing Department (CPD) instrumentation (22%) and Communication/Safety (15%). Overall, 70 (87%) of the 80 responses were in agreement that briefings were effective for surfacing defects, as were 59 (76%) of the 78 responses for debriefings. Conclusions Briefings and debriefings were a practical and effective strategy to surface potential surgical defects in the operating rooms of a large medical center.

The ability to predict outcomes following a kidney transplant is limited by the complex physiologic decline of kidney failure, a latent factor that is difficult to capture using conventional comorbidity assessment. The frailty phenotype is a recently described inflammatory state of increased vulnerability to stressors resulting from decreased physiologic reserve and dysregulation of multiple physiologic systems. We hypothesized that frailty would be associated with delayed graft function, based on putative associations between inflammatory cytokines and graft dysfunction. We prospectively measured frailty in 183 kidney transplant recipients between December 2008 and April 2010. Independent associations between frailty and delayed graft function were analyzed using modified Poisson regression. Preoperative frailty was independently associated with a 1.94-fold increased risk for delayed graft function (95% CI, 1.13-3.36; P = .02). The assessment of frailty may provide further insights into the pathophysiology of allograft dysfunction and may improve our ability to preoperatively risk-stratify kidney transplant recipients.

Introduction: Older patients with pancreatic cancer are often not offered pancreaticoduodenectomy (PD) due to potentially high perioperative risk and prolonged post-operative recovery. These patients may have undetected vulnerabilitities related to frailty that may adversely affect surgical outcomes. Methods: PD-eligible patient over 50 were enrolled onto this IRB-approved prospective observational study. Extensive perioperative clinical information including Vulnerable Elder Survey (VES-13), short physical performance battery (SPPB), and Fried's Criteria for frailty were collected. Complications were prospectively recorded and graded according to established guidelines (Clavien scores). Quality of life (QoL) measures were taken at baseline and at 1, 3, and 6-months post-PD. Results: Seventyeight patients were enrolled from 10/1/2007-9/1/2010: 53 had a PD (median age 68 years;range 46-85) and 25 were inoperable or declined PD. Significant preoperative vulnerability was identified in resected patients; VES-13 >3 in 24%; SPPB

Introduction: Older patients with pancreatic cancer are often not offered pancreaticoduodenectomy (PD) due to potentially high perioperative risk and prolonged post-operative recovery. These patients may have undetected vulnerabilitities related to frailty that may adversely affect surgical outcomes. Methods: PD-eligible patient over 50 were enrolled onto this IRB-approved prospective observational study. Extensive perioperative clinical information including Vulnerable Elder Survey (VES-13), short physical performance battery (SPPB), and Fried's Criteria for frailty were collected. Complications were prospectively recorded and graded according to established guidelines (Clavien scores). Quality of life (QoL) measures were taken at baseline and at 1, 3, and 6-months post-PD. Results: Seventyeight patients were enrolled from 10/1/2007-9/1/2010: 53 had a PD (median age 68 years;range 46-85) and 25 were inoperable or declined PD. Significant preoperative vulnerability was identified in resected patients; VES-13 >3 in 24%; SPPB

The objective of this study was to identify leading practices to promote environmentally friendly and efficient efforts in the provision of surgical health care. Health care is the second leading contributor to waste in the United States. Despite widespread enthusiasm for "going green" in the US economy, little substantive information is available to the medical community, to our knowledge. We explore safe and efficient strategies for hospitals and providers to protect the environment while delivering high-quality care. We performed a systematic review of the literature using relevant PubMed search terms and surveyed a panel of hospital managers and chief executive officers of health care organizations pursuing green initiatives. Recommendations were itemized and reviewed by a 7-member panel to generate a consensus agreement. We identified 43 published articles and used interview data from the panel. The following 5 green recommendations for surgical practices were identified: operating room waste reduction and segregation, reprocessing of single-use medical devices, environmentally preferable purchasing, energy consumption management, and pharmaceutical waste management. The medical community has a large opportunity to implement green practices in surgical units. These practices can provide significant benefits to the health care community and to the environment. Additional research and advocacy are needed to further explore green practices in health care.

Preoperative briefings have the potential to reduce operating room (OR) delays through improved teamwork and communication.Pre-post study.Tertiary academic center.Surgeons, anesthesiologists, nurses, and other OR personnel.An OR briefings program was implemented after training all OR staff in how to conduct preoperative briefings through in-service training sessions. During the preoperative briefings, the attending surgeon led OR personnel in a 2-minute discussion using a standardized format designed to familiarize caregivers with each other and the operative plan before each surgical procedure.The OR Briefings Assessment Tool was distributed to OR personnel at the end of each operation. Survey items questioned OR personnel about unexpected delays during each procedure and the relationship between communication breakdowns and delays. Responses were compared before and after the initiation of the preoperative briefings program.The use of preoperative briefings was associated with a 31% reduction in unexpected delays; 36% of OR personnel reported delays in the preintervention period, and 25% reported delays in the postintervention period (P.04). Among surgeons alone, an 82% reduction in unexpected delays was observed (P.001). A 19% reduction in communication breakdowns leading to delays was also associated with the use of briefings (P.006).Preoperative briefings reduced unexpected delays in the OR by 31% and decreased the frequency of communication breakdowns that lead to delays. Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost.

An unstable angina guideline was published in 1994 by the Agency for Health Care Policy and Research, Bethesda, Md. However, the relationship between guideline-concordant care and patient outcomes is unknown.To determine whether guideline-concordant care is associated with improved outcomes.The study sample consisted of 275 consecutive nonreferral patients hospitalized with primary unstable angina. One-year survival and survival free of myocardial infarction were compared between patients who received care concordant with 8 selected guideline recommendations and patients who received discordant care.Care concordant with the 8 key guideline recommendations was associated with improved 1-year survival (95% vs 81%; log-rank P.001) and survival free of myocardial infarction (91% vs 74%; P.001), compared with guideline-discordant care. Patients in high-risk subgroups had the largest survival benefit associated with guideline-concordant care (aged -65 years, 91% vs 74% [P=.005]; heart failure at presentation, 91% vs 68% [P=.10]). Aspirin therapy was the single recommendation most strongly associated with improved 1-year survival (94% vs 78%; P=.002).Care as outlined in the unstable angina clinical practice guideline is associated with improved 1-year outcomes. Subgroups of patients at highest risk and recommendations firmly based on randomized clinical trial data were most strongly associated with better outcomes. These findings support the use of an evidence-based approach to guideline development and assessment of quality of care in patients with primary unstable angina.

Objective To assess the implications of positive cytology for malignant cells (positive results) from peritoneal washings in the management of patients with pancreatic cancer. Design Retrospective cohort study. Setting Referral practice in a university hospital. Patients A total of 32 consecutive pancreatic cancer patients with positive results from peritoneal washings during a 4-year period, 17 with visible biopsy-proven intra-abdominal metastases at the time of laparoscopy or laparotomy and 15 without visible metastases. A treatment-matched control group of 30 patients was randomly selected from a group of 105 patients with negative cytology for malignant cells (negative results) from peritoneal-fluid cytology. Interventions Eight of 17 patients with visible metastases underwent treatment with chemotherapy, radiation, or both; 13 of the 15 patients with no visible metastases underwent further treatment, including pancreatic resection in 2 patients and external beam radiation in 13 patients (3 with intraoperative radiation therapy). Main Outcome Measures Time to metastases and mortality. Results Median survival among patients with and without visible metastasis was 7.8 months and 8.6 months, respectively ( P =.95), despite the fact that patients without visible metastases received more treatment. Patients without visible metastases at presentation were found to have metastatic disease as documented by computed tomographic scan or subsequent laparotomy at a median time of 2.9 months. The survival of treatment-matched patients with negative cytology was significantly longer (median, 13.5 months; P= .04). Conclusions Pancreatic cancer patients with peritoneal micrometastases have a dismal outcome even without macroscopic metastases. Since these patients do not benefit from local therapy, the finding of a positive result from peritoneal-fluid cytologic testing contraindicates further irradiation or surgery, except for specific complications.

BackgroundAs indications for liver resection expand, objective measures to assess the risk of peri-operative morbidity are needed. The impact of sarcopenia on patients undergoing liver resection for colorectal liver metastasis (CRLM) was investigated.MethodsSarcopenia was assessed in 259 patients undergoing liver resection for CRLM by measuring total psoas area (TPA) on computed tomography (CT). The impact of sarcopenia was assessed after controlling for clinicopathological factors using multivariate modelling.ResultsMedian patient age was 58 years and most patients (60%) were male. Forty-one (16%) patients had sarcopenia (TPA ≤ 500mm2/m2). Post-operatively, 60 patients had a complication for an overall morbidity of 23%; 26 patients (10%) had a major complication (Clavien grade ≥3). The presence of sarcopenia was strongly associated with an increased risk of major post-operative complications [odds ratio (OR) 3.33; P= 0.008]. Patients with sarcopenia had longer hospital stays (6.6 vs. 5.4 days; P= 0.03) and a higher chance of an extended intensive care unit (ICU) stay (>2 days; P= 0.004). On multivariate analysis, sarcopenia remained independently associated with an increased risk of post-operative complications (OR 3.12; P= 0.02). Sarcopenia was not significantly associated with recurrence-free [hazard ratio (HR) = 1.07] or overall (HR = 1.05) survival (both P > 0.05).ConclusionsSarcopenia impacts short-, but not long-term outcomes after resection of CRLM. While patients with sarcopenia are at an increased risk of post-operative morbidity and longer hospital stay, long-term survival is not impacted by the presence of sarcopenia.