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Background: Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption. Methods: A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results. Results: Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training. Conclusions: This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities. [ABSTRACT FROM AUTHOR]

Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data are available about how this translates into successful incorporation in faculty practice. All operations performed during the first three years of practice of a surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, a metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative time benchmarks. The major complications, defined as a Clavien-Dindo of 3 or more, were similar across the experience and comparable to published series. Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice. [ABSTRACT FROM AUTHOR]

There is limited data on surgical site infection (SSI) in developing countries. The aim of this study was to investigate the incidence and risk factors of SSI following general surgical operations in Türkiye. This multicenter cohort study was conducted at 10 centers. Patients who underwent thyroid/parathyroid, breast, hernia and abdominal surgery between September 2017 and March 2018 were included in the study. Center for Disease Control and Prevention 2016 (CDC-2016) criteria was used for the diagnosis of SSI. Patients were followed for 30 days (90 days for mesh patients). Out of 1871 patients included, SSI occurred in 181 (9.7%) patients. Of these SSI, 101 (55.8%) were superficial, 41 (22.7%) deep, and 39 (21.5%) organ/space SSI. SSI incidence was seen to be high (>15.0%) following some surgeries (40.0% in pancreas, 39.1% in biliary duct, 30.3% in small bowel, 27.9% in colorectal, 27.3% in esophagus, 24.1% in liver, 15.7% in gastric). SSI incidences were generally ˂5.0% after some surgeries (4.4% in hernia, 4.2% in gallbladder, 3.3% in morbid obesity, 1.4% in breast, 0.8% in thyroid/parathyroid, and zero in spleen and surrenal). In univariate analysis, age ≥60 years, female sex, preoperative weight loss, presence of comorbidities, preoperative albumin ˂3.5 g/dL and hemoglobin ˂12 g/dL, wound classification, ASA score, general anesthesia, emergency surgery, open surgery, operation time ≥4 hours, intraoperative blood loss ≥400 ml, perioperative blood transfusion, drain placement, distant infection and malignant disease were associated with SSI. In multivariate analysis preoperative weight loss, clean-contaminated wound, general anesthesia, emergency surgery, open surgical technique, prolonged operation duration (≥4 hours), drain placement, and distant infection were found to be independent variable for SSI risk. In order to reduce the incidence of SSI, patients with a weight loss of 10% or more in six months preoperatively should be identified, and nutritional status of the patients should be corrected preoperatively, laparoscopic technique should be preferred in abdominal surgeries, and drain placement should be avoided, especially in clean-contaminated wounds. [ABSTRACT FROM AUTHOR]

Simple Summary: This review examines the available data that have been reported on diversity within the field of hepatobiliary and pancreas surgery in the United States. The authors review the barriers surmounted by successful hepatobiliary and pancreas surgeons from backgrounds that are historically underrepresented in medicine. The authors found that barriers exist at each point of training: starting from admission into medical school, continuing into surgical residency programs and surgical fellowship programs, and into surgical practice. A pattern emerged that revealed the attrition of underrepresented students at each progression toward hepatobiliary and pancreas surgical practice. The authors further review challenges inherent to workforce homogeneity and introduce evidence-based solutions that promote the achievement of excellence via diversity, equity, and inclusion in hepatopancreatobiliary surgery and beyond. Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician–patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate every stage of surgical innovation and generate high-quality research evidence, the IDEAL (Idea, Development, Exploration, Assessment, Long-term study) framework was developed. This study aimed to explore the application of the IDEAL framework in hepatopancreatobiliary surgery and identify factors limiting its dissemination. Methods: We conducted a citation search of 8 core IDEAL framework articles in PubMed, Embase, Web of Science, and Scopus databases from 2009 to 2022. Two independent reviewers screened and selected articles related to hepatopancreatobiliary surgery. Results: A total of 1621 articles were identified through citation search. Following screening, 132 articles were finally retained, including 75 original studies (57%) and 57 secondary studies (43%). Of the original studies, only 10 articles (13%) accurately applied the IDEAL framework in methodology, distributed as follows: 1 in pre-IDEAL stage (0), 2 in Idea stage (1), 7 in Development stage (2a), 1 in Exploration stage (2b), and no articles in Assessment and Long-term study stages (3, 4). In the secondary studies, 36 articles (63%) mentioned and discussed the IDEAL framework, and all supported its application. Conclusions: The application of the IDEAL framework in hepatopancreatobiliary surgery is increasingly widespread, as evidenced by its substantial citation in numerous articles. However, the utilization of the IDEAL framework remains predominantly confined to the early stages of innovation in hepatopancreatobiliary surgery, coupled with instances of misapplication stemming from insufficient comprehension of the framework. Further efforts are necessary to extend the impact of the IDEAL framework and provide surgeons with comprehensive guidance for its judicious implementation. [ABSTRACT FROM AUTHOR]

This text summarizes a study published in the Journal of Gastrointestinal Surgery that examines the prevalence and predictors of transport-delayed medical care among HPB cancer patients in the United States. The study finds that 3.7% of HPB cancer patients reported delaying medical care due to lack of transportation. Non-White, lower-income, and uninsured patients were more likely to experience transport-delayed care. The study suggests interventions such as ridesharing services or reimbursement of travel costs to address transportation barriers. However, the study acknowledges limitations and the need for further research. The authors declare no conflicts of interest and the research did not receive specific funding. [Extracted from the article]

Background: Surgical site infections (SSI) are one of the most common hospital acquired infections and result in increased morbidity, mortality and financial burden on health services. The incidence of SSIs are not clearly defined and infection rates as varied as 20%–40% have been reported. The aim of this study was to systematically review the incidence and risk factors of SSI following HPB surgery. Methods: The database of Medline (via PubMed) was systematically searched from 2013–2022. Articles were screened using the PRISMA statement and those that met the inclusion criteria were included in the study. Results: Sixteen studies were eligible for inclusion in this systematic review. The average incidence of SSI was 29.8%. Key risk factors identified included male gender, open surgery, preoperative biliary stenting and obesity. Conclusions: The incidence of SSI following HPB surgery varied, but it is generally high. A variety of pre-disposing patient factors can affect infection rates following HPB surgery. The results from this study suggest that perhaps laparoscopic surgery should be used where possible, and that there should be an awareness that gender, obesity and the use of stents may increase the incidence of SSIs following these operations.

Background: Pancreatic adenocarcinoma has a predisposition to invade the neural tissue surrounding the superior mesenteric artery (SMA). Before the advent of neoadjuvant chemotherapy (NAC), any invasion of this tissue was often considered as unresectable disease. Currently, patients who respond favourably to NAC have potentially resectable disease. There is debate over the exact technique of removing this shell of tumour tissue surrounding the SMA, and whether it is comparable to arterial resection and reconstruction., Methods: We describe a technique of en bloc arterial divestment in which an endovascular stapler combined with sharp dissection is used to divide the shell of periadventitial SMA tissue., Conclusions: In patients with locally advanced disease, the technique of arterial divestment can be safely performed where the tumour is not invading below the external elastic lamina. This allows complete tumour resection without incurring the higher morbidity and mortality associated with SMA resection., (© 2024 Wiley Periodicals LLC.)

Purpose: Laparoscopic liver resection (LLR) has gained acceptance as an effective treatment for colorectal liver metastases (CRLM) in selected patients, providing similar oncologic outcomes compared to open liver resection (OLR). The aim of this study was to determine prognostic factors for survival outcomes associated with LLR for CRLM. Methods: A single-center retrospective analysis of a prospectively maintained database was performed. The inclusion period ranged from September 2011 until mid-March 2020. Results: Two hundred consecutive LLRs were included. The 5-year overall survival (OS) and disease-free survival (DFS) rates equalled 54.8% and 49%, respectively. A pushing (HR = 5.42, 95% CI 1.56–18.88, p = 0.008), as well as a replacement (3.87, 1.05–14.2, p = 0.04) growth pattern of the CRLM, poor differentiation of the primary colorectal cancer (CRC) (3.72, 1.72–8.07, p < 0.001) and administration of neoadjuvant chemotherapy (NAC) (2.95, 1.28–6.8, p = 0.01) were identified as independent predictors of a worse OS. Requirement of more than 6 cycles of NAC (6.17, 2.37–16.03, p < 0.001), a replacement (4.96, 1.91–12.87, p < 0.001), as well as a pushing (4.3, 1.68–11, p = 0.002) growth pattern of the CRLM and poor differentiation of the primary CRC (2.61, 1.31–5.2, p = 0.006) were identified as independent predictors of a worse DFS. Conclusion: LLR for CRLM offers adequate long-term oncologic outcomes. OS and DFS rates are negatively affected by the administration of NAC and by pathological features, including the differentiation grade of the primary CRC and the histological growth pattern of the CRLM. [ABSTRACT FROM AUTHOR]

Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80 years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Patients ≥80 years old in a single HPB ERAS program (September 2015-July 2018) were prospectively tracked in the ERAS Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, P=.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions. [ABSTRACT FROM AUTHOR]

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Background: Surgical site infections (SSI) are one of the most common hospital acquired infections and result in increased morbidity, mortality and financial burden on health services. The incidence of SSIs are not clearly defined and infection rates as varied as 20%-40% have been reported. The aim of this study was to systematically review the incidence and risk factors of SSI following HPB surgery. Methods: The database of Medline (via PubMed) was systematically searched from 2013-2022. Articles were screened using the PRISMA statement and those that met the inclusion criteria were included in the study. Results: Sixteen studies were eligible for inclusion in this systematic review. The average incidence of SSI was 29.8%. Key risk factors identified included male gender, open surgery, preoperative biliary stenting and obesity. Conclusions: The incidence of SSI following HPB surgery varied, but it is generally high. A variety of pre-disposing patient factors can affect infection rates following HPB surgery. The results from this study suggest that perhaps laparoscopic surgery should be used where possible, and that there should be an awareness that gender, obesity and the use of stents may increase the incidence of SSIs following these operations. [ABSTRACT FROM AUTHOR]

Background: Prehabilitation encompasses multidisciplinary interventions to improve health and lessen incidence of surgical deterioration by reducing physiologic stress and functional decline. This study presents an interim analysis to demonstrate prehabilitation for hepatopancreatobiliary (HPB) surgical patients.Methods: In 2018, a structured prehabilitation pilot program was implemented. Eligibility required HPB malignancy, neoadjuvant chemotherapy, and residence within hour drive. Patients were enrolled into the 4-month program. The fitness component was composed of timed up and go test and grip strength with exercise recommendations. Nutrition involved evaluation of sarcopenic obesity, glucose management, and smoking and alcohol counseling. Psychological services included psychosocial assessments and advanced care planning, with social work referrals. Component were evaluated monthly by a physician using laboratory results, nutritional data and questionnaires, psychological assessments, and validated fitness tests. Nurse navigators spoke with patients weekly to monitor compliance.Results: At 12 months, nineteen patients were enrolled. Ten completed prehabilitation, neoadjuvant chemotherapy and underwent their surgical procedure. There were no differences found after prehabilitation in functional status, physical performance, psychosocial assessments, or nutrition. Frailty, as assessed by Fried frailty criteria, improved significantly after prehabilitation (P < .0001). Symptom severity and laboratory values did not change. Length of stay was 6.5 days and all patients were discharged to home. There was 1 readmission for transient ischemic attack and 90-day mortality rate was 0%.Discussion: Prehabilitation to improve recovery is a promising concept encompassing a wide array of multidisciplinary assessments and interventions. It may demonstrate a protective effect on physiologic decline from chemotherapy and may reverse frailty phenotypes. [ABSTRACT FROM AUTHOR]

Background: Gram-negative bloodstream infection (GNBSI) is a threat to public health in terms of mortality and antibiotic resistance. The hepatopancreatobiliary (HPB) cohort accounts for 15%–20% of GNBSI, yet few strategies have been explored to reduce HPB GNBSI. Aim: To identify clinical factors contributing to HPB GNBSI and strategies for its prevention. Methods: We performed a retrospective analysis of 433 cases of HPB GNBSI presenting to four hospitals between April 2015 and May 2019. We extracted key data from hospital and primary care records including: the underlying source of GNBSI; previous documentation of biliary disease; and any previous surgical or non-surgical management. Findings: Out of 433 cases of HPB GNBSI, 388 had clear evidence of HPB origin. The source of GNBSI was related to gallstone disease in 282 of the 388 cases (73%) and to HPB malignancy in 70 cases (18%). Of the gallstone-related cases, 117 had previously been diagnosed with symptomatic gallstones. Of the 117 with a previous presentation, 93 could have been prevented with a laparoscopic cholecystectomy at the first presentation of gallstones, while 18 could have been prevented if intraoperative biliary tract imaging had been performed during a prior cholecystectomy. Of the 70 malignant cases, five could have been prevented through earlier biliary stenting, use of metal stents instead of plastic stents or earlier pancreaticoduodenectomy. Discussion: The incidence of HPB GNBSI could be reduced by up to 30% by the implementation of alternative management strategies in this cohort. [ABSTRACT FROM AUTHOR]

Introduction The Nutritional Risk Screening 2002 (NRS 2002) is a reliable tool for assessing patients' nutritional status and for identifying those who may benefit from nutritional support before undergoing surgery. However, its application and correlation with post-operative outcomes for Nepalese patients undergoing gastrointestinal and hepatopancreatobiliary oncosurgeries remain unexplored. The objective of this study was to correlate the NRS 2002's nutritional risk with post-operative complications classified by the Clavien-Dindo Classification. Methods A prospective analytical study was conducted at Kathmandu Medical College and Teaching Hospital, with 74 adults who underwent gastrointestinal and hepatopancreatobiliary oncosurgeries between 1st March 2021 and 30th August 2022. The study was conducted following ethical clearance from the Institutional Review Committee of the Hospital. A convenience sampling method was used. Data were analyzed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States). Results Among the 122 patients admitted during the study period, 74 met the inclusion criteria. Using the NRS-2002, 37.8% were found to be at nutritional risk. Such patients had a higher risk of complications and extended hospital stays, supported by an odds ratio of 1.647 (95% confidence interval: 1.223 -2.219) and a p-value of <0.001. Nutritional risk emerged as an independent predictor of post-operative complications. Conclusion The study suggests the potential of NRS-2002 as a significant predictor of outcomes after surgeries for gastrointestinal and hepatopancreatobiliary malignancies in the South Asian context, particularly in Nepal. Tools such as NRS 2002 play a pivotal role in early risk identification, which could subsequently influence both pre-operative and post-operative care strategies, ultimately enhancing patient outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Kathmandu Medical College Public Ltd. Institutional Review Committee issued approval 3112202002. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Limbu et al.)

Introduction: Early readmissions (30 days) have been used as a measure of health care quality. The purpose of our study was to evaluate patterns of readmission for a longer period (up to 2 years) following Hepatopancreatobiliary (HPB) surgery in the state of New York.Methods: The State Planning and Research Cooperative System database was utilized to identify patients undergoing complex HPB procedures between 2010 and 2012. Patients were followed for 2 years following surgery to identify all-cause readmissions. Factors for readmissions included patient demographics, comorbidities, perioperative complications, surgery type, and academic status. Multivariable generalized linear mixed models were performed to evaluate risk factors for readmissions.Results: There were 6207 complex HPB procedures with 1272 (20.49%) unplanned 30-day readmissions, 816 (13.15%) unplanned 31-90-day readmissions, 1678 (27.03%) unplanned 91-day to 1-year readmissions, and 1404 (22.62%) 1-2-year readmissions. After adjusting for other possible confounding factors, risk factors for 30-day readmissions include surgery type, as pancreatectomy and gallbladder patients are more likely to have a 30-day readmission than hepatectomy patients, facility type, as academic centers are more likely to have a readmission, male gender, presence of any comorbidity, and peri-operative complications. Risk factors for 31-90-day readmissions include race, insurance group, any comorbidity or any peri-operative complication, and 30-day readmissions. Risk factors for 91-day to 1-year readmissions include male gender, race, any comorbidity, 30-day readmissions, and 31-90 days' readmissions. Risk factors for 1-2-year readmissions include presence of any comorbidity, and previous 91-day to 1-year readmissions.Conclusion: The 30-day readmission window is an inadequate, but predictive, measure of total readmission following complex HPB procedures. [ABSTRACT FROM AUTHOR]

Background: Computed tomography (CT)-assessed sarcopenia indexes have been reported to predict postoperative morbidity and mortality; however conclusions drawn from different indexes and studies remain controversial. Aim: The purpose of this meta-analysis was to evaluate various CT-assessed sarcopenia indexes as predictors of risk for major complications in patients undergoing hepatopancreatobiliary surgery for malignancy. Methods: Medline/PubMed, Web of Science, and Embase databases were systematically searched to identify relevant studies published before June 2018. PRISMA guidelines for systematic reviews were followed. The pooled risk ratio (RR) for major postoperative complications (Clavien-Dindo ≥III) was estimated in patients with sarcopenia versus patients without sarcopenia. Data extracted were meta-analyzed using Review Manager (version 5.3). Results: Twenty-eight studies comprising 6,656 patients were included in this study. CT-assessed sarcopenia indexes, such as skeletal muscle index (SMI, RR 1.36; 95% CI 1.14–1.63; p = 0.0008; I2 = 24%), psoas muscle index (PMI, RR 1.35; 95% CI 1.15–1.58; p = 0.0002; I2 = 0%), muscle attenuation (MA, RR 1.40; 95% CI 1.14–1.73; p = 0.002; I2 = 4%), and intramuscular adipose tissue content (IMAC, RR 1.63; 95% CI 1.28–2.09; p < 0.0001; I2 = 0%) were all predictors of postoperative major complications, although moderate heterogeneity existed and cutoffs for these indexes to define sarcopenia varied. Conclusions: All commonly used CT-assessed sarcopenia indexes, such as SMI, PMI, MA, and IMAC can predict the risk of major postoperative complications; however, a consensus on the cutoffs for these indexes to define sarcopenia is still lacking. [ABSTRACT FROM AUTHOR]

Background The patient-provider relationship (PPR) is an important element of health care delivery and may influence patient outcomes. The objective of the present study was to identify clinical predictors of PPR among patients with hepatopancreatobiliary (HPB) diseases and assess the association of PPR and health care utilization. Materials and Methods The Medical Expenditure Panel Survey database from 2008-2014 was used to identify adult patients with HPB diagnoses. A PPR score of “poor,” “average,” and “optimal” was calculated from the Consumer Assessment of Healthcare Providers and Systems Survey. Predictors of poor PPR and the association of PPR and health care utilization were assessed. Results Among 592 patients, PPR was optimal (210, 35.4%), average (270, 45.5%), or poor (114, 19.2%). Patients without insurance (36.3%) or with Medicaid (28.8%) were more likely to report poor PPR versus patients with private insurance (14.0%) or Medicare (15.4%) ( P = 0.03). Poor (24.3%)- and low (21.5%)-income patients were more likely to report poor PPR versus middle (12.8%)- or high-income (14.0%) patients ( P = 0.03). Poor mental health was also more common among patients with poor PPR (13.4%) versus average (5.4%) or optimal (3.7%) PPR ( P = 0.02), and this association between poor PPR and poor mental health remained significant on multivariable analysis (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.20-4.92). Poor PPR was associated with increased emergency room utilization on univariate (OR 2.50, 95% CI 1.21-5.14), but not multivariate (OR 2.18, 95% CI 0.92-5.15) analysis. Conclusions Among patients with HPB diseases, PPR was associated with insurance type, socioeconomic status, and mental health scores. Patients reporting poor PPR were more likely to be high utilizers of the emergency room. Efforts to improve the PPR are needed and should be focused on these high-risk populations. [ABSTRACT FROM AUTHOR]

Background & Aims: Parenteral nutrition (PN) is commonly utilized to support patients in the perioperative period of major gastrointestinal (GI) surgeries. This study sought to evaluate PN utilization based on malnutrition status and duration of PN use in a single academic institution to evaluate baseline ASPEN recommendation concordance and identify opportunities for quality improvement., Methods: Patients who had undergone major GI surgical oncology operations and received PN were identified over six months. The medical charts were reviewed for clinicopathologic variables, nutrition status, and the initiation and duration of PN. The cohort was stratified by PN recommendation concordance, and intergroup comparisons were made to identify factors associated with non-concordant utilization of PN., Results: Eighty-one patients were identified, 38.3% of patients were initiated on PN due to dysmotility. Other indications were: intra-abdominal leak (27.2%), mechanical obstruction (18.5%), and failure to thrive (16.0%). Non-concordant PN utilization was identified in 67.9% (55/81) of patients. The most frequent reason for non-concordance was initiation outside the recommended time frame due to severity of malnutrition; well-nourished patients started "too soon" accounted for 29.0% (16/55), and 61.8% started "too late," most of whom were moderately or severely malnourished (34/55). In 16.0% (13/81) of the overall cohort, PN was administered for fewer than five days., Conclusions: PN use during the perioperative period surrounding major GI oncologic operations is clinically nuanced and frequently not concordant with established ASPEN recommendations. Quality improvement efforts should focus on reducing delayed PN initiation for nutritionally at-risk patients without increasing premature PN use in well-nourished patients., Competing Interests: Conflicts of interest None declared., (Published by Elsevier Ltd.)

Background: Guidelines recommend 28 days venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major abdominal surgery for cancer. Overall adherence with these recommendations is poor, but little is known about feasibility and tolerability from a patient perspective.Methods: An institution-wide policy for routine administration of 28 days of post-operative LMWH following major hepatic or pancreatic resection for cancer was implemented in April 2013. Patients having surgery from July 2013 to June 2015 were approached to participate in an interview examining adherence and experience with extended duration LMWH.Results: There were 100 patients included, with 81.4 % reporting perfect adherence with the regimen. The most frequent reasons for non-adherence were that a healthcare provider stopped the regimen or because of poor experience with injections. Most patients were able to correctly recall the reason for being prescribed LMWH (82.6 %), and 78.4 % of patients performed all injections themselves. Over half the patients (55.7 %) did not find the injections bothersome.Conclusion: Patients reported high adherence and a manageable experience with post-operative extended-duration LMWH in an ambulatory setting following liver or pancreas resection. These findings suggest that patient adherence is not a major contributor to poor compliance with VTE prophylaxis guidelines. [ABSTRACT FROM AUTHOR]

Background: Delta hemoglobin (ΔHb) is defined as the difference between the preoperative Hb and the lowest post-operative Hb level. We sought to define the impact of ΔHb relative to nadir Hb levels on the likelihood of transfusion, as well as characterize the impact of ΔHb and nadir Hb on morbidity among a large cohort of patients undergoing complex hepatopancreatobiliary (HPB) surgery.Methods: Patients who underwent pancreatic or hepatic resection between January 1, 2009 and June 30, 2015 at Johns Hopkins Hospital were identified. Data on the perioperative ΔHb, nadir Hb, as well as blood utilization were obtained and analyzed. Multivariable logistic regression models were used to identify the factors associated with ΔHb and the impact of ΔHb on perioperative morbidity. A Bayesian model was used to evaluate the correlation of ΔHb and nadir Hb with the likelihood of transfusion, as well as the impact on morbidity.Results: A total of 4363 patients who underwent hepatobiliary (n = 2200, 50.4 %) or pancreatic (n = 2163, 49.6 %) surgery were identified. More than one quarter of patients received at least one unit of packed red blood cells (PRBC) (n = 1187, 27.2 %). The median nadir Hb was 9.2 (IQR 7.9-10.5) g/dL resulting in an average ΔHb of 3.4 mg/dL (IQR 2.2-4.7) corresponding to 26.3 %. Both ΔHb and nadir Hb strongly influenced provider behavior with regards to use of transfusion. Among patients with the same nadir Hb, ΔHb was strongly associated with use of transfusion; among patients who had a nadir Hb ≤6 g/dL, the use of transfusion was only 17.9 % when the ΔHb = 10 % versus 49.1 and 80.9 % when the ΔHb was 30 or 50 %, respectively. Perioperative complications occurred in 584 patients (13.4 %) and were more common among patients with a higher value of ΔHb, as well as patients who received PRBC (both P < 0.001).Conclusions: The combination of the Hb trigger with ΔHb was associated with transfusion practices among providers. Larger ΔHb values, as well as receipt of transfusion, were strongly associated with risk of perioperative complication following HPB surgery. [ABSTRACT FROM AUTHOR]

Background: Preoperative weight loss and abnormal serum-albumin have traditionally been associated with reduced survival. More recently, a correlation between postoperative complications and reduced long-term survival has been reported and the significance of the relative proportion of skeletal muscle, visceral and subcutaneous adipose tissue has been examined with conflicting results. We investigated how preoperative body composition and major non-fatal complications related to overall survival and compared this to established predictors in a large cohort undergoing upper abdominal surgery. Methods: From 2001 to 2006, 447 patients were included in a Norwegian multicenter randomized controlled trial in major upper abdominal surgery. Patients were now, six years later, analyzed as a single prospective cohort and overall survival was retrieved from the National Population Registry. Body composition indices were calculated from CT images taken within three months preoperatively. Results: Preoperative serum-albumin <35 g/l (HR = 1.52, p = 0 .014) and weight loss >5 % (HR = 1.38, p = 0.023) were independently associated with reduced survival. There was no association between any of the preoperative body composition indices and reduced survival. Major postoperative complications were independently associated with reduced survival but only as long as patients who died within 90 days were included in the analysis. Conclusions: Our study has confirmed the robust significance of the traditional indicators, preoperative serum-albumin and weight loss. The body composition indices did not prove beneficial as global indicators of poor prognosis in upper abdominal surgery. We found no association between non-fatal postoperative complications and long-term survival. [ABSTRACT FROM AUTHOR]

Hepatopancreatobiliary (HPB) emergencies include an ample range of conditions with overlapping clinical presentations and diverse therapeutic options. The most common etiologies are related to cholelithiasis (acute cholecystitis, pancreatitis, and cholangitis) and non-traumatic injuries (common bile duct or duodenal). Although the true incidence of HPB emergencies is difficult to determine due to selection and reporting biases, a population-based report showed a decline in the global incidence of all severe complications of cholelithiasis, primarily based on a reduction in acute cholecystitis. Even though patients may present with overlapping symptoms, treatment options can be varied. The treatment of these conditions continues to evolve and patients may require endoscopic, surgical, and/or percutaneous techniques. Thus, it is essential that a multidisciplinary team of HPB surgeons, interventional gastroenterologists and radiologists are available on an as needed basis to the Acute Care Surgeon. This focused manuscript is a contemporary review of the literature surrounding HPB emergencies in the context of the acute care surgeon. The main aim of this review is to offer an update of the diagnosis and management of HPB issues in the acute care setting to improve the care of patients with potential HPB emergencies. [ABSTRACT FROM AUTHOR]

Background and aim Acute pancreatitis is a common inflammation of the pancreas which can be severe and even potentially mortal. High rates of mortality showed the importance of immediate identification of patients at high risk and led the clinicians to refer to various scoring systems. Our aim was to investigate a clinical predictive model using the Model for End-Stage Liver Disease-Sodium (MELD-sodium) scoring system, adapting it to acute pancreatitis patients referring to the systemic inflammatory nature of the disease and potential multi-organ failures in severe form. Methods Our multicenter study was designed retrospectively. The medical records were reviewed for the period of two years. Demographics, biochemical results, MELD-sodium scores and mortality rates were analysed. Results MELD-sodium score was found to be statistically correlated with both mortality and the severity of pancreatitis (p<0.001) and significant difference between both mild and severe (p<0.001), moderate and severe groups (p<0.001). Mortality was found to be significantly higher in patients with MELD-Na score when the cut-off value was accepted as '≥11'. Conclusion We found that MELD-sodium score was significantly associated with both severity of disease and mortality rates and also significantly effective between both mild/severe and moderate/severe groups which may be a guide for future multi-center reviews with larger patient and control groups, which can define the potential role of this non-invasive and easy-to-use predictive model in acute pancreatitis patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Nayci et al.)

Background: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program.Study Design: Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored.Results: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences.Conclusions: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Upper gastrointestinal tract malignancies are among the most challenging cancers with regard to response to treatment and prognosis. Cancers of the esophagus, stomach, pancreas, liver, and biliary tree have dismal 5-year survival, and very modest improvements in this rate have been made in recent times. Oncolytic viruses are being developed to address these malignancies, with a focus on high safety profiles and low off-target toxicities. Each viral platform has evolved to enhance oncolytic potency and the clinical response to either single-agent viral therapy or combined viral treatment with radiotherapy and chemotherapy. A panel of genomic alterations, chimeric proteins, and pseudotyped capsids are the breakthroughs for vector success. This article revisits developments for each viral platform to each tumor type, in an attempt to achieve maximum tumor selectivity. From the bench to clinical trials, the scope of this review is to highlight the beginnings of translational oncolytic virotherapy research in upper gastrointestinal tract malignancies and provide a bioengineering perspective of the most promising platforms., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Aim: The face of hepatopancreatobiliary (HPB) training has changed over the past decade. The growth of focused HPB fellowships, which are vetted with a rigorous accreditation process through the Fellowship Council (FC), has established them as an attractive mode of training in HPB surgery. This study looks at the volumes of HPB cases performed during these fellowships in North America., Methods: After approval by the FC research committee, data from all HPB fellowships that had 3 years worth of complete fellow case log data were tabulated and reported (n = 12). For 2-year fellowships, the fellow logs were tabulated at the completion of both years. Those programs that had transplant experience (n = 9) were reported., Results: Data for the current fellows' case numbers show that graduating fellows have a median of 26 biliary cases, 19 major liver cases (hemilivers), 28 other liver cases, 40 pancreaticoduodenectomies,18 distal pancreatectomies, and 9 other pancreas cases. The programs that provided transplantation experience had 10 cases for each fellow., Conclusion: This study validates that FC-accredited HPB fellowships have a robust exposure to complex HPB surgery. Fellows completing these fellowships should be well versed in the management and surgical treatment of HPB patients., (Copyright © 2014. Published by Elsevier Inc.)

Background & Aims: Hepatocellular cancer (HCC) commonly complicates chronic liver disease and increases in incidence have been reported despite falling prevalences of viral hepatitis., Methods: Following the introduction of centralised specialist teams to manage patients with cancer in England, we characterised the demographics of patients with HCC referred to the Newcastle-upon-Tyne Hospitals NHS Foundation Trust between 2000 and 2010. Regional HCC mortality data was from Public Health England., Results: HCC related mortality in the region rose 1.8 fold in 10 years, from 2.0 to 3.7 per 100,000. 632 cases were reviewed centrally, with 2-3 fold increases in referrals of patients with associated hepatitis C, alcoholic liver disease or no chronic liver disease and a >10 fold increase in HCC associated with non-alcoholic fatty liver disease (NAFLD). By 2010 NAFLD accounted for 41/118 (34.8%) cases. Irrespective of associated etiologies, metabolic risk factors were present in 78/118 (66.1%) cases in 2010, associated with regional increases in obesity and diabetes. Median overall survival was just 10.7 months. Although patients with NAFLD associated HCC were older (71.3 yr vs. 67.1 yr; p<0.001) and their cancers less often detected by surveillance, their survival was similar to other etiologies. This was attributed to significantly higher incidental presentation (38.2%) and lower prevalence of cirrhosis (77.2%)., Conclusions: HCC related mortality is increasing, with typical patients being elderly with metabolic risk factors. The prognosis for most of the cases is poor, but older patients with co-morbidities can do well, managed, within a specialist multidisciplinary team if their cancer is detected pre-symptomatically., (Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)