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Objective: To quantify the rate of progression in surveilled cysts and assess what factors should indicate delayed resection. Background: Side-branch intraductal papillary mucinous neoplasms (SB-IPMNs) are increasingly discovered, making it challenging to identify which patients require resection, thus avoiding inappropriate treatment. Most incidental lesions are surveyed, yet the consequences of that decision remain uncertain. Methods: A prospectively maintained database of pancreatic cystic neoplasms was queried for patients with SB-IPMN. Patients with ≥ 2 imaging studies >6 months apart were included. Clinically relevant progression (CR-progression) was defined by symptoms, worrisome/high-risk stigmata, or invasive cancer (IC). Growth ≥ 5 mm in 2 years is considered CR-progression; size ≥3 cm alone is not. Results: Between 1997 and 2023, 1337 patients were diagnosed with SB-IPMN. Thirty-seven (2.7%) underwent up-front surgery; 1000 (75.0%) had >6 months of surveillance. The rate of CR-progression was 15.3% (n = 153) based on size increase (n = 63, 6.3%), mainduct involvement (n = 48, 4.8%), symptoms (n = 8, 5.0%), or other criteria (n = 34, 3.4%). At a median follow-up of 6.6 years (interquartile range: 3.0-10.26), 17 patients (1.7%) developed IC. Those with CR-progression developed IC in 11.1% (n = 17) and highgrade dysplasia (HGD) in 6.5% (n = 10). Nearly half of the cancers were not contiguous with the surveyed SB-IPMN. Size ≥3 cm was not associated with HGD/IC (P = 0.232). HGD/IC was least common in CR-progression determined by size growth (6.3%) versus main-duct involvement (24%) or other (43%, P < 0.001) Patients with CR-progression demonstrated improved survival (overall survival) with resection on time-to-event (P < 0.001) and multivariate Cox regression (hazard ratio = 0.205, 0.096-0.439, P < 0.001) analyses. Overall survival was not improved with resection in all patients (P = 0.244). Conclusions: CR-progression for SB-IPMNs is uncommon, with the development of cancer anywhere in the pancreas being rare. Initial size should not drive resection. Long-term and consistent nonoperative surveillance is warranted, with surgery currently reserved for CR-progression, knowing that the majority of these still harbor low-grade pathology. [ABSTRACT FROM AUTHOR]

Introduction: Cholecystoenteric stenting is an alternative treatment for cholecystitis. However, complications with this approach can render a need for surgical intervention. Methods: A case series of three patients undergoing surgery for a cholecystoenteric stent-related complication. Results: Patient 1 was a 42-year-old male with history of lung transplant who had a cholecystoenteric stent placed for acalculous cholecystitis. One year later the stent became occluded with return of symptoms. Endoscopic replacement failed. A laparoscopic cholecystectomy with modified Graham patch was performed. Patient 2 is a 73-year-old female with acalculous cholecystitis in the setting of metastatic colon cancer on FOLFOX. Antibiotic treatment failed. A cholecystoenteric stent was attempted, but the stent dislodged during deployment. The fistula tract was clipped, and a percutaneous cholecystostomy drain was placed, which noted a leak at the gallbladder infundibulum. The patient deteriorated clinically and was taken emergently for an open cholecystectomy. Patient 3 was a 71-year-old male with history of ischemic cardiomyopathy who had a cholecystogastric stent placed for necrotizing gallstone pancreatitis. The stent migrated into the gastrointestinal tract and he developed post-prandial pain. A cholecystectomy and modified Graham patch repair of the gastrotomy was performed. This failed as the gastrotomy was too close to the pylorus. He underwent re-operation with Heineke--Mikulicz pyloroplasty. All patients recovered without any cardiopulmonary complications. Conclusion: With the increasing utility of cholecystoenteric stents, surgeons should be aware of the complications and have a plan for managing the duodenotomy or gastrotomy. Shared-medical decision-making involving surgeons should be applied when placing these stents. [ABSTRACT FROM AUTHOR]

Introduction: Pancreatic acinar cell carcinoma (pACC) is a rare malignancy with unique clinical and molecular features. The role of chemotherapy in pACC management is not well established., Methods: The National Cancer Database (NCDB) for pACC was used. Cox regression was used in resected pACC patients to identify significant overall survival (OS) predictors. Patients were then divided based on these risk factors into propensity-matched group of surgery versus surgery + chemotherapy and Kaplan-Meier analysis was performed with log-rank tests to compare OS., Results: The NCDB 2004-2020 included 1592 pACC patients, 1553 were selected. Median age was 66 and 1090 (70.2%) were males. 622 (40.1%) received chemotherapy only, 257 (16.5%) had surgery only, and 365 (23.5%) had both. 189 Patients who received surgery were only matched to peers who had surgery + chemotherapy. The median OS for surgery only was 57.8 ± 6.0 versus 54.2 ± 9.9 months for surgery + chemotherapy (p = 0.836). Cox regression identified nodal and margin status as independent predictors of OS. Therefore, subgroups of patients with node-negative, node-positive, margin-negative, and margin-positive resections were similarly matched 1:1 for the receipt of surgery only versus surgery + chemotherapy. Only patients with node-positive disease had a significant OS benefit with the addition of chemotherapy (44.2 ± 7.3 vs. 27.5 ± 10.5 months; p = 0.036)., Conclusion: Our analysis suggests that surgical resection remains the cornerstone of therapy for pACC. Node status and margin status are the primary prognosticators. The addition of chemotherapy provides an OS benefit only in node-positive disease., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Background: Most studies on surgical site infections (SSIs) use the US Centers for Disease Control and Prevention (CDC) guidelines, which excludes inflammation or cellulitis without fever. The aim of this study was to evaluate antibiotic prescription trends in the post-operative period among patients undergoing breast operation. We explore the outcomes of patients receiving antibiotic agents outside of the CDC-defined SSI. Patients and Methods: A retrospective review of patients undergoing breast operation from January 2021 to May 2021 was conducted. Solely reconstructive and cosmetic cases were excluded. The primary outcome was the prevalence of antibiotic prescription in the absence of CDC-defined SSI, excluding routine prophylactic antibiotic agents, with analysis of associated factors. Results: A total of 754 breast surgical procedures were included. Seventy-seven patients (10.2%) were prescribed outpatient antibiotic agents. CDC-defined SSI occurred in 5.3% (n = 40), mostly involving tissue expander/implant-based reconstruction (47.5%, n = 19). However, 37 (4.9%) did not progress to meet the CDC criteria for SSI. Patients prescribed outpatient antibiotic agents without CDC-defined SSI did not have increased rates of diabetes mellitus, obesity, or current smoking. These patients were more likely to have a surgical drain (48.6% vs. 28.4%, p = 0.02), plastic surgery involvement (32.4% vs. 18.0%, p = 0.048), and a post-operative seroma (32.4% vs. 8.1%, p < 0.001) and or or cellulitis (18.9% vs. 0%, p < 0.001). Conclusion: Patients are prescribed antibiotic agents after breast operation based on clinical judgment for indications other than CDC-defined SSI. Post-operative wound morbidity including seroma and cellulitis could be contributing to these antibiotic prescriptions. Further study is needed to determine whether providers are preemptively treating SSIs appropriately or over-treating non-infectious wound complications.

Purpose: Postoperative pancreatic fistula (POPF) remains a devastating complication of pancreatoduodenectomy (PD). Minimally invasive PD (MIPD), including laparoscopic (LPD) and robotic (RPD) approaches, have comparable POPF rates to open PD (OPD). However, we hypothesize that the likelihood of having a more severe POPF, as defined as clinically relevant POPF (CR-POPF), would be higher in an MIPD relative to OPD., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset (2014-2020) was reviewed for any POPF after OPD. Propensity score matching (PSM) compared MIPD to OPD, and then RPD to LPD., Results: Among 3,083 patients who developed a POPF, 2,843 (92.2%) underwent OPD and 240 (7.8%) MIPD; of these, 25.0% were LPD (n = 60) and 75.0% RPD (n = 180). Grade B POPF was observed in 45.4% (n = 1,400), and grade C in 6.0% (n = 185). After PSM, MIPD patients had higher rates of CR-POPF (47.3% OPD vs. 54.4% MIPD, p = 0.037), as well as higher reoperation (9.1% vs. 15.3%, p = 0.006), delayed gastric emptying (29.2% vs. 35.8%, p = 0.041), and readmission rates (28.2% vs. 35.1%, p = 0.032). However, CR-POPF rates were comparable between LPD and RPD (56.8% vs. 49.3%, p = 0.408)., Conclusion: The impact of POPF is more clinically pronounced after MIPD than OPD with a more complex postoperative course. The difference appears to be attributed to the minimally invasive environment itself as no difference was noted between LPD and RPD. A clear biological explanation of this clinical observation remains missing. Further studies are warranted.

OBJECTIVE. The purpose of this study was to quantify abdominal CT predictors of endoscopically refractory, uncontrolled variceal hemorrhage requiring portal venous intervention. MATERIALS AND METHODS. From 2009 to 2018, 64 patients with endoscopically refractory variceal hemorrhage requiring portal venous intervention (variceal hemorrhage group) and 67 patients without hemorrhage but with symptomatic, pressure gradient-proven portal hypertension (control group) underwent CT. CT scans were retrospectively reviewed for the following: varix size, variceal intraluminal protrusion, liver and spleen volumes, and portal vein diameter. RESULTS. Gastric variceal protrusion was found to be a strong CT parameter associated with refractory hemorrhage (mean depth, 0.75 mm in variceal hemorrhage group vs -2.91 mm in control group; p = 0.001). Gastric varix size was also associated with variceal hemorrhage (mean diameter, 8.03 vs 6.51 mm; p = 0.001). However, this trend was not observed in the sizes of the esophageal varices (mean diameter, 6.28 vs 6.43 mm; p = 0.370). Larger spleen volume (mean, 1312 vs 1152 cm 3 ; p = 0.029) and liver volume (mean, 1514 vs 1143 cm 3 ; p = 0.004) were also found to be predictors of variceal hemorrhage. Significant CT threshold findings included gastric variceal protrusion depth more than 0 mm (odds ratio [OR], 6.44), gastric varix size more than 6 mm (OR, 3.89), spleen volume more than 1000 cm 3 (OR, 2.63), and liver volume more than 1000 cm 3 (OR, 2.82). CONCLUSION. Quantitative imaging parameters on abdominal CT, such as intraluminal protrusion of gastric varices, gastric varix size, and larger spleen and liver volumes, were predictive of portal venous intervention, whereas esophageal varix size was not.