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583 Background: At least 15% of patients diagnosed with localized pancreatic cancer are medically unfit for surgical resection or systemic therapy. Traditionally, these patients are enrolled in palliative care with symptom management alone. With local progression of their disease, they may experience pain, obstruction, weight loss and nausea. Radiosurgery is a localized high dose conformal therapy allowing for noninvasive treatment of pancreatic cancer. This study retrospectively examines the role of palliative radiosurgery as monotherapy for elderly patients who are not candidates for standard of care therapy. Methods: From 2017-2021, 28 patients over the age of 80 with biopsy confirmed pancreatic adenocarcinoma and localized disease by imaging were retrospectively evaluated. All had been deemed not to be candidates for surgical resection or systemic chemotherapy. Outcomes were reviewed to evaluate patient characteristics, local control, quality of life, ECOG status and survival duration. Results: Median patient age was 84 years (range 80-99). All 28 patients received SBRT radiosurgery to the pancreas with 35-40Gy in 5 fractions with photon LINAC platform. Mean ECOG score was 1.2 at time of treatment. At 6 month follow up, 18 patients were alive with a mean ECOG of 1.4. Four patients reported grade 2 acute GI toxicity in the first three months with no late toxicity reported. Eight patients developed local progression while fourteen patients developed distant metastatic disease. Six patients at least one year out from treatment have no evidence of disease progression. Median overall survival is 10.8 months. Conclusions: Pancreatic radiosurgery is a safe and effective method of palliative therapy for elderly patients who are not candidates for surgical resection or systemic therapy. It can provide durable local control, relief of pain and obstructive symptoms, is well tolerated with minimal toxicity and provides favorable survival when compared to palliative care alone.

In 2018, pancreatic ductal adenocarcinoma (PDAC) was the 3rd highest cause cancer related death in the United States. Worldwide estimates in 2018 indicate 458,918 cases diagnosed with 432,242 deaths. Standard therapy for decades for localized PDAC has been to pursue surgical resection for localized disease. For the individuals who are diagnosed with localized PDAC and undergo surgical resection, historical survival has been reported to be around 24 months. While recent advancements in the use of multiagent systemic therapy has allowed for greater survival benefit, adjuvant therapy does have limitations. Recently, neo-adjuvant therapy for PDAC has become more accepted in practice. Areas covered: In this review, we will discuss the current guidelines for treatment of localized PDAC, the pros and cons of neo-adjuvant versus adjuvant therapy for PDAC, the utilization of available biomarkers for the management of PDAC, and future possibilities for clinical trials. Expert commentary: Neo-adjuvant therapy for localized PDAC has tremendous promise in leading to greater survival by treating for micro-metastatic disease along with selecting for patients for better outcomes. Further work based upon molecular insights will lead to better biomarkers for treatment assessment along with improvements in treatment.

4631 Background: Localized PDAC management has recently evolved. Due to concerns over micro metastases at diagnosis the use of neoadjuvant chemotherapy for PDAC has become more common. Typical therapies involve the use of multiagent systemic chemotherapies with or without radiation therapy. In retrospective studies, Cancer Antigen 19-9 (CA 19-9) normalization in borderline resectable (BR) and locally advanced (LA) PDAC has been associated with greater OS. The addition of cisplatin (C) to gemcitabine (G) and paclitaxel protein bound (A), has shown promising clinical data in a previously reported study in advanced PDAC [JAMA Oncol. 2020;6(1):125-132]. We conducted a prospective, phase 2 clinical trial of patients with resectable (R), BR, and LA PDAC utilizing a regimen combining A + G + C + paricalcitol (P) with the primary endpoint of CA 19-9 normalization (NCT03138720). Methods: Eligibility criteria include patients with histologically confirmed R, BR, or LA PDAC, elevated CA 19-9, and a KPS ≥ 70% with normal end organ function. Doses are A 125 mg/m2, G 1000 mg/m2, C 25 mg/ m2, P at a fixed dose of 25 µg on days 1, 8 of a 21-day cycle (all treatment IV). Primary objective is to evaluate CA 19-9 normalization with the neoadjuvant chemotherapy. Secondary objectives are to assess R0 rate, pathologic complete response (pCR), safety and tolerability, radiologic response rate, and 2 year overall survival (OS) from date of study entry. Exploratory objectives include evaluating imaging biomarkers and vascular involvement by tumor in relation to therapy. Results: To date 24 of the planned 24 patients have been enrolled. 13 male, 11 female; age range 49 to 84 yo. Patient classifications is 8 R; 7 BR; 9 LAPC. Median baseline CA 19-9 156 (range 45-3674). Most common drug related grade (gr) 3-4 adverse events (AEs) are: thrombocytopenia gr 3 29%, gr 4 25%, anemia gr 3 45.8%, gr 4 4.2%, and hypophosphatemia gr 3 8.3%. CA 19-9 normalization occurred in 50% (12/24) who have completed at least 1 cycle of treatment. To date, 14 individuals went to surgery, with 13/14 achieving R0, (1 pCR). Overall response rate in measurable patients is 38% (1 CR, 8 PR). Median OS and 2-year survival data are not yet matured. Conclusions: In patients with non-metastatic PDAC, the use of A+G+C+P resulted in a CA 19-9 normalization rate in 50% of individuals. The study is ongoing and OS data is maturing. Clinical trial information: NCT03138720 .

Background: Localized PDAC management has recently evolved. Due to concerns over micrometastases at diagnosis, the use of neoadjuvant chemotherapy for PDAC has become more common. Typical therapies involve the use of multiagent systemic chemotherapy with or without radiation therapy. Cancer antigen 19-9 (CA 19-9) normalization in borderline resectable (BR) and locally advanced (LA) PDAC has been associated with greater OS. The addition of cisplatin (C) to gemcitabine (G) and paclitaxel protein bound (A) has shown promising clinical data in a previously reported study in advanced PDAC (J Clin Oncol 2017;35:suppl 4S; abstract 341). We conducted a prospective, phase 2 clinical trial of patients with resectable, BR, and LA PDAC utilizing a regimen combining A + G + C + paricalcitol (P) with the primary endpoint of CA 19-9 normalization (NCT03138720). Methods: Eligibility criteria include patients with histologically confirmed resectable, BR, or LA PDAC, elevated CA 19-9, and a KPS ≥ 70% with normal end organ function. Doses are A 125 mg/m2, G 1000 mg/m2, C 25 mg/ m2, P at a fixed dose of 25 μg on days 1, 8 of a 21-day cycle (all treatment IV). Primary objective is to evaluate CA 19-9 normalization with the neoadjuvant chemotherapy. Secondary objectives are to assess R0 rate, pathologic complete response (pCR), safety and tolerability, radiologic response rate, and 2-year overall survival (OS) from date of study entry. Exploratory objectives include evaluating imaging biomarkers and vascular involvement by tumor in relation to therapy. Results: To date, 21 of the planned 24 patients have been enrolled: 11 male, 10 female; age range 49 to 85 yo. Patient classifications are 7 R; 7 BR; 7 LAPC. Most common drug-related grade (gr) 3-4 adverse events (AEs) are thrombocytopenia gr 3 40%, gr 4 33%, anemia gr 3 60%, and hypophosphatemia 13%. Of the 21, 16 are evaluable for maximum percent decrease in CA 19-9. CA 19-9 normalization occurred in 44% (7/16) who have completed at least 1 cycle of treatment. To date, 9 individuals went to surgery, with 8/9 achieving R0 (no pCR). Overall response rate in measurable patients is 26% (4/15 PR). Median OS and 2-year survival data are not yet matured. Conclusions: In patients with nonmetastatic PDAC, the use of A+G+C+P resulted in a CA 19-9 normalization rate in 44% of individuals. The study is ongoing and OS data are maturing. (Supported by grants from the HonorHealth Foundation and Marley Foundation.) Citation Format: Erkut Borazanci, Gayle Jameson, Courtney Snyder, Frank Tsai, Michael Gordon, Sunil Sharma, Carol Guarnieri, Amar Thosani, Syed Rahmanuddin, Ronald Korn, Steven Sckolnik, Paula Sedivy, Susan Haag, Kevin Gosselin, Daniel Von Hoff, Albert Amini. Paclitaxel protein bound plus gemcitabine plus cisplatin and paricalcitol neoadjuvant therapy for localized pancreatic ductal adenocarcinoma (PDAC) [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2019 Sept 6-9; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2019;79(24 Suppl):Abstract nr B05.

We present the case of a young female on oral contraceptives (OCs) who was diagnosed with focal nodular hyperplasia (FNH) and remained on oral contraceptives. Months later, the patient presented with acute abdominal pain and intratumoral hemorrhage in the liver. The patient was taken to the operating room (OR) and was diagnosed with a ruptured hepatic adenoma (HA). We review the key diagnostic features of FNH and HA, the different management guidelines including use of OCs, and potential surgical indications. HA compared to FNH has a significantly higher rate of sequelae despite being a benign lesion, thus providers must accurately distinguish between the two diagnoses to prevent potential morbidity and mortality.

Surgical oncologists (SO) and hepatobiliary (HPB) surgeons frequently care for patients with advanced diseases near the end of life, yet little is known about their training, comfort, and readiness in the provision of palliative care. This study sought to assess the quality, adequacy, and extent of palliative care training and the readiness of SO and HPB fellows in delivering palliative care.A self-administered survey was distributed to all fellows enrolled in Society of Surgical Oncology (SSO) and HPB fellowships during the 2013-2014 academic year. The survey assessed attitudes, training, experience, and readiness of fellows in caring for patients at the end of life. Descriptive analysis was performed, and Chi square, Student's t test, and the Mann-Whitney U test were used to compare mean or median values as appropriate.The response rate was 47.2 %, and 50.9 % of the fellows reported exposure to a palliative care specialty service during their fellowship. Of the study participants, 75 % observed their faculty discussing the side effects of surgery compared with 54 % who observed faculty communication with patients regarding end-of-life goals (p0.01). On the other hand, 40 % of the fellows were never observed by faculty discussing symptoms management, goals of care, or hospice referral with patients, and 56.7 % never received feedback on their palliative skills.The fellows rated the quality of their palliative care education as poor compared with other aspects of their fellowship training, implying the lack and need of palliative care teaching. Surgical oncology and HPB fellows and ultimately patients may benefit from increased clinical and didactic palliative care training.

The role of adjuvant radiotherapy in the treatment of ampullary carcinoma (AC) remains unclear. We hypothesized that adjuvant radiotherapy (RT) does not improve survival following resection for AC. The SEER database was queried for patients with non-metastatic AC who underwent surgery (S) from 2004 to 2010. Propensity score (PS) modeling was applied to create balanced cohorts of patients that would be equally likely to receive RT. Cox proportional hazard models were used to compare survival. Of 1,287 patients, 329 (25.6 %) received adjuvant RT. Unadjusted median overall survival (OS) for patients receiving adjuvant RT compared to S alone was 27 vs. 36 months (p = 0.14). Patients receiving RT were younger (63 vs. 69 years, p

This article summarizes the current literature in treatment of unresectable biliary tract and primary liver tumors. Locoregional therapies including radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave ablation, transarterial chemoembolization, hepatic artery infusion, radioembolization ((90)Y), and bland embolization are discussed and clinical trials compared. Palliative strategies including surgical, percutaneous, and endoscopic techniques to decompress the biliary system and improve symptoms are also summarized. Systemic chemotherapy and sorafenib used in conjunction with locoregional therapies or as sole therapeutic options are discussed.

Although the differential diagnosis for chest wall masses is broad, the vast majority are abscesses, lipomas, or sebaceous cysts. Post-operative chest wall masses can also include infection, hematoma, seroma, cancer recurrence, metastasis, and lung hernia. Bedside ultrasound has been well documented to be beneficial in the differentiation of superficial pathology.[1,2] Pleurocutaneous fistula is a pathologic communication between the pleural space and subcutaneous tissues of the chest wall. Pleurocutaneous fistula is a rare complication of tube thoracostomy, video-assisted thoracic surgery (VATS) procedures, and various pulmonary infections. There are multiple case reports of pleurocutaneous fistulas occurring after tube thoracostomy as well as secondary to pulmonary infections including tuberculosis.[3–7] VATS is becoming an increasingly common surgery for treatment of lung carcinoma, spontaneous pneumothorax, and various indications in the trauma setting. Several cases series documenting VATS complications describe pleurocutaneous fistulas after VATS procedures.[8,9] Point of care ultrasound (POCUS) is increasing in use as a diagnostic tool in the emergency department.[1,2,10–13] Here we present a case that highlights the intersection of a rare complication of a common procedure and the value of ultrasound in the diagnosis of undifferentiated masses and dyspnea in the emergency department.

Purpose Pharmacists’ impact in reducing the time interval from intubation to sedative and analgesic use during trauma patient resuscitations is investigated. Methods A retrospective cohort study was conducted at a level 1 trauma center to compare medication-use outcomes in consecutive cases in which trauma patients underwent rocuronium-assisted rapid-sequence intubation (RSI) and subsequent sedation and analgesia with or without a pharmacist’s participation on the resuscitation team. The primary and secondary outcomes were, respectively, the time to sedative provision and the time to analgesic provision after intubation. Results Relative to resuscitation cases not involving a pharmacist, the presence of the pharmacist during RSI was associated with decreased mean times to provision of postintubation sedation (9 minutes versus 28 minutes, p = 0.007) and analgesia (21 minutes versus 44 minutes, p = 0.057). The cumulative proportions of patients receiving appropriate sedation 5, 10, and 15 minutes after intubation were 11%, 26%, and 41% in the pharmacist-absent group and 33%, 53%, and 63% in the pharmacist-present group ( p = 0.009, 0.008, and 0.045, respectively); for postintubation analgesic use, the corresponding figures were 9%, 14%, and 23% in the pharmacist-absent group and 17%, 30%, and 43% in the pharmacist-present group ( p = 0.236, 0.066, and 0.039, respectively). Conclusion The presence of a pharmacist during RSI procedures was associated with decreased times to postintubation sedative and analgesic use, indicating that pharmacist participation in trauma-resuscitation responses can facilitate appropriate drug therapy.

BACKGROUND Stable patients with thoracoabdominal penetrating or blunt trauma resulting in diaphragmatic injuries represent a challenging dilemma. Laparoscopy has emerged as the most reliable and efficient diagnostic and treatment modality for such patients. OBJECTIVE The aim of this study was to analyze our novel surgical technique for the management of penetrating diaphragmatic injuries in stable patients. MATERIALS AND METHODS In this retrospective study, we analyzed data that had been prospectively collected on a new surgical repair technique established at our institution. We reviewed the records of 7 hemodynamically stable trauma patients with thoracoabdominal penetrating trauma resulting in diaphragmatic injuries. RESULTS The 7 patients (5 with stab wounds, 2 with gunshot wounds) underwent laparoscopic exploration and laparoscopic-assisted minithoracotomy for the repair of diaphragmatic injuries. The mean length of stay was 4.4 days (range, 1 to 8 d). There were no tension pneumothoraces, missed injuries, or other procedure-related complications. CONCLUSIONS If complete laparoscopic repair is not possible, laparoscopic-assisted repair of diaphragmatic injuries using minithoracotomy is a viable option. In our 7 patients, the results were good, with no morbidity.

Background The purpose of this study was to evaluate the effect of epidural analgesia use on postoperative complications in patients undergoing pancreaticoduodenectomy. Methods This retrospective cohort study used the 2009 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. Patients who underwent pancreaticoduodenectomy were grouped on the basis of whether they received epidural analgesia. The effect of epidural use on the composite end point of major complications including death was investigated using a generalized linear model. Results Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, and 11.0% of these patients received epidural analgesia. After controlling for various potential confounders, results of the multivariate regression indicated that epidural analgesia use was associated with lower odds of composite complications including death (odds ratio, .61; 95% confidence interval, .37–.99; P = .044). Conclusions In patients who underwent pancreaticoduodenectomy, epidural analgesia was associated with significantly lower postoperative composite complications.

BACKGROUND:Damage control resuscitation advocates correction of coagulopathy; however, options are limited and expensive. The use of prothrombin complex concentrate (PCC), also known as factor IX complex, can quickly accelerate reversal of coagulopathy at relatively low cost. The purpose of this stu

Purpose The use of hypertonic saline injection in trauma patients is discussed. Summary Patients with hemorrhage, burns, and traumatic brain injury (TBI) may develop hypovolemic shock and require resuscitation. Compared with conventional isotonic crystalloids, hypertonic saline has several advantages, including hemodynamic, immune-modulating, and antiinflammatory effects, for use in trauma patients for resuscitation. In addition, hypertonic saline is also used in patients with TBI to reduce intracranial pressure (ICP). Overall, studies have not shown a difference in mortality or other clinically important outcomes with the use of hypertonic saline for resuscitation in trauma patients; however, most of these studies were not adequately powered to show significant differences. A recent Cochrane review concluded that there is no evidence that hypertonic crystalloids are better than isotonic or near-isotonic crystalloids for fluid resuscitation in trauma patients. Two recent trials that were adequately powered to investigate a mortality endpoint were halted for futility. A few small randomized controlled studies found that hypertonic saline was more effective than mannitol as a hyperosmolar agent for ICP reduction. Recent guidelines from the American Burn Association have suggested that hypertonic saline may be used for burn shock resuscitation by experienced providers with close monitoring to avoid excessive hypernatremia. One of the main concerns with the use of hypertonic saline is its potential to cause central pontine myelinolysis due to a rapid increase in serum sodium levels. Conclusion There is no evidence that hypertonic saline provides any additional benefit over isotonic crystalloid solutions for trauma resuscitation. Hypertonic saline may be more effective than mannitol at reducing ICP in patients with TBI.

Background: Pancreatic ductal adenocarcinoma (PDAC) accounts for ~95% of pancreatic cancer cases and is currently the 3rd leading cause of adult cancer deaths in the US. Due to the lack of methods for early detection and limited treatment options, PDAC has a dismal 5-year survival rate at just Methods: Freshly harvested human or mouse PDAC tumors were mechanically and enzymatically dissociated to single cells using a Miltenyi gentleMACS Tissue Dissociator. The 10X Genomics Chromium Single Cell 3′ Solution was employed for capture, amplification and labeling of mRNA from single cells and for library preparation. scRNA-Seq was performed on Illumina HiSeq 2500. Custom R packages were used for clustering and bioinformatics data analyses. Results: Viability of single cell suspensions used for library preps from all samples was >81%. By unsupervised clustering of the scRNA-Seq matrix and using known signature genes for various cell types we revealed the cellular heterogeneity in a human PDAC to identify distinct cell types. These included epithelial tumor cells (EPCAM+, KRT19+); CD133+ tumor stem cells; CAFs (COL5A1+, COL6A2+, SPARC+); endothelial cells CDH5+ VWF+; and CD45 (PTPRC)+ immune cells also positive for CD3D, CD2, FCGR2A; and cells undergone EMT (CDH2+, ITGA5+, SNAI2+). Using a similar strategy, mouse PDAC diversity was represented by epithelial and EMT tumor cells, CAFs, endothelial cells, macrophages and MDSCs. KRAS and glycolysis signaling pathways in epithelial tumor cells, while hypoxia in the EMT cluster were up regulated. KPC tumors differed in the extent of immune cell infiltration, with a low influx in the smaller versus large tumor, both perhaps representing distinct stages of tumor progression. Conclusions: Our data supports high throughput scRNA-Seq of solid tumors like PDAC as a powerful method to probe and elucidate the underlying tumor heterogeneity. Understanding diversity and complexity of the PDAC TME in individual tumors may help identify unique therapeutic targets and potentially inform treatment/maintenance strategies for patients with advanced disease. Citation Format: Pawan Noel, Wei Lin, Erkut Borazanci, Albert Amini, Ruben Muñoz, Emily Rodela, Serina Ng, Daniel Von Hoff, Haiyong Han. Single cell RNA sequencing of pancreatic ductal adenocarcinoma reveals tumor heterogeneity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5353.

Postpancreatectomy hemorrhage (PPH) should be a rare complication, but when it occurs, it is a major cause of morbidity and mortality after pancreaticoduodenectomy (PD). PPH can be divided into early (first 24 h) or late (usually 10 days or more after PD or distal pancreatectomy). Early PPH is caused by technical failure of appropriate hemostasis or an underlying perioperative coagulopathy. Late PPH is typically caused by complications of the operation, most commonly a pancreatic leak (which is the etiology of pseudoaneurysm formation). Early PPH can be prevented by direct ligation of the inferior pancreaticoduodenal arteries (IPDA) arising from the superior mesenteric artery (SMA); mass ligation of the tissue to the right of the SMA can result in bleeding from the IPDAs within the first 24 h after PD. Late PPH can be prevented by the use of a pedicled falciform ligament flap to protect the vessels from possible pancreatic fistula and related fluid collections. The occurrence of a sentinel bleed is a key sign before the onset of delayed/late PPH.

Objective To determine the difference between rocuronium and succinylcholine with regard to post-intubation sedative initiation in the emergency department. Methds This was a retrospective cohort study conducted in a tertiary care emergency department (ED) in the USA. Consecutive adult patients intubated in the ED using succinylcholine or rocuronium for paralysis were included. Data collected included patient demographics, vital signs, medications used post-intubation and times of drug administration. Patients were divided into two groups based on the type of paralytic used for rapid sequence intubation: (1) rocuronium or (2) succinylcholine. All patients received etomidate for induction of sedation. Time between intubation and post-intubation sedative use was compared between the two groups using an unpaired Student9s t test. Main results A total of 200 patients were included in the final analyses (100 patients in each group). There were no significant differences between the groups with regard to patient demographics, vital signs or other baseline characteristics. After intubation, 77.5% (n=155) of patients were initiated on a sedative infusion of propofol (n=148) or midazolam (n=7). The remaining patients received sedation as bolus doses only. Mean time between intubation and post-intubation sedative use was significantly greater in the rocuronium group compared with the succinylcholine group (27 min vs 15 min, respectively; p Conclusions Patients intubated with rocuronium had greater delays in post-intubation sedative initiation compared with succinylcholine.

This article summarizes the current literature in treatment of unresectable biliary tract and primary liver tumors. Locoregional therapies including radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave ablation, transarterial chemoembolization, hepatic artery infusion, radioembolization ((90)Y), and bland embolization are discussed and clinical trials compared. Palliative strategies including surgical, percutaneous, and endoscopic techniques to decompress the biliary system and improve symptoms are also summarized. Systemic chemotherapy and sorafenib used in conjunction with locoregional therapies or as sole therapeutic options are discussed.

Background: The management of hepatic hemangiomas remains ill defined. This study sought to investigate the indications, surgical management and outcomes of patients who underwent a resection for hepatic hemangiomas. Methods: A retrospective review from six major liver centres in the United States identifying patients who underwent surgery for hepatic hemangiomas was performed. Clinico-pathological, treatment and peri-operative data were evaluated. Results: Of the 241patients who underwent a resection, the median age was 46 years (interquartile range (IQR): 39-53) and 85.5% were female. The median hemangioma size was 8.5 cm (IQR: 6-12.1). Surgery was performed for abdominal symptoms (85%), increasing hemangioma size (11.3%) and patient anxiety (3.7%). Life-threatening complications necessitating a hemangioma resection occurred in three patients (1.2%). Clavien Grade 3 or higher complications occurred in 14 patients (5.7%). The 30- and 90-day mortality was 0.8% (n = 2). Of patients with abdominal symptoms, 63.2% reported improvement of symptoms post-operatively. Conclusion: A hemangioma resection can be safely performed at high-volume institutions. The primary indication for surgery remains for intractable symptoms. The development of severe complications associated with non-operative management remains a rare event, ultimately challenging the necessity of additional surgical indications for a hemangioma resection.

Context While perioperative mortality after pancreaticoduodenectomy is decreasing, key factors remain to be elucidated. Objective The purpose of this study was to investigate inpatient mortality after pancreaticoduodenectomy in the Nationwide Inpatient Sample (NIS), a representative inpatient database in the USA. Methods Patient discharge data (diagnostic and procedure codes) and hospital characteristics were investigated for years 2009 and 2010. The inclusion criteria were a procedure code for pancreaticoduodenectomy, elective procedure, and a pancreatic or peripancreatic cancer diagnosis. Chi-square test determined statistical significance. A logistic regression model for mortality was created from significant variables. Results Two-thousand and 958 patients were identified with an average age of 65±12 years; 53% were male. The mean length of stay was 15±12 days with a mortality of 4% and a complication rate of 57%. Eighty-six percent of pancreaticoduodenectomy occurred in teaching hospitals. Pancreaticoduodenectomy performed in teaching hospitals in the first half of the academic year were associated with higher mortality than in the latter half (5.5% vs. 3.4%, P=0.005). On logistic regression analysis, non-surgical complications are the largest predictor of death (PConclusions The timing of pancreaticoduodenectomy for cancer remained more predictive of mortality than age or length of stay; only complications were more predictive of death than time of year. This suggests that there remains a clinically and statistically significant learning curve for trainees in identifying complications; further study is needed to prove that identification of complications leads to a decrease in mortality rate by taking corrective actions., JOP. Journal of the Pancreas, Vol 14, No 6 (2013): November - p. 603-693

The analgesic response and safety of intravenous morphine versus fentanyl for adult trauma patients who presented to the emergency department (ED) were evaluated. Median pain reduction on the numeric rating scale (0-10; 0 = no pain and 10 = worst possible pain) after opioid administration was similar between the groups (2 vs 2; P = .67). The lowest postdose pain score was recorded sooner in the fentanyl group than in the morphine group (22 vs 47 minutes, respectively; P < .001). There were no significant differences in drug-induced adverse effects between groups. Fentanyl produced a similar but more rapid analgesic response compared with morphine in trauma patients.

Background: Clostridium perfringens bacteremia accompanied by extensive intravascular hemolysis is an almost inescapably fatal infection. Methods: Case report and literature review. Results: A 52-year-old man with a recent history of liver transplantation developed sepsis and severe hemolytic anemia. The patient had multiple organ dysfunction syndrome and required aggressive transfusion, antibiotics, and continuous hemodialysis. Blood cultures grew C. perfringens. With appropriate resuscitation and antibiotic treatment, the patient had a complete, although complicated recovery. Conclusion: This is the first reported case of a liver transplant patient developing fulminant C. perfringens sepsis with hemolysis. This infection usually kills patients within hours of presentation. Early recognition and aggressive treatment is necessary to avoid this outcome.

BackgroundConcerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD.MethodsAll the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared.ResultsThere were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05–0.61, P < 0.005] or a PD (HR 0.23; 95% CI 0.15–0.36, P < 0.001).ConclusionPatients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.