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One of the most common surgical procedures performed in the USA is the cholecystectomy. Understanding biliary anatomy, which includes the gallbladder and extrahepatic biliary tree, is essential for every general surgeon. This quiz includes clinically relevant anatomy and radiology questions for the current and future surgeon at every level of training, and we hope it will be a useful adjunct to one's review.

Context Total pancreatectomy with islet autotransplantation (TPIAT) is a definitive management for intractable pain in patients with chronic pancreatitis (CP). Islet autotransplantation (IAT) allows for the preservation of beta cells to prevent complications of long-term diabetes. Objective Our study follows TPIAT recipients for up to 12 years to determine the efficacy of the procedure completed with an off-site islet isolation facility. Methods Patient demographics, mixed meal tolerance test measures, glycosylated hemoglobin, insulin requirements, and homeostatic model assessment for insulin resistance values were collected prior to surgery and at the most recent follow-up assessment. Results Forty-four patients (median age, 46.0 years; range, 20-78 years) underwent TPIAT for CP. At an overall median follow-up time of 845.5 days (range, 195-4470 days) 8 patients were insulin independent and 36 patients were insulin dependent. At the most recent follow-up time point, islet yield per kilogram was the strongest indicator of insulin independence. Homeostatic model assessment for insulin resistance values were comparable between insulin independent and dependent cohorts. Conclusions Our long-term follow-up data suggest that IAT can effectively reduce insulin requirements and improve postoperative glycemic control.

Primary sclerosing cholangitis (PSC) is a progressive liver disease for which there is no effective therapy. Hepatocytes and cholangiocytes from a PSC patient were cocultured with mesenchymal stem cells (MSCs) to assess in vitro change. A single patient with progressive PSC was treated with 150 million MSCs via direct injection into the common bile duct. Coculture of MSCs with cholangiocytes and hepatocytes showed in vitro improvement. Local delivery of MSCs into a single patient with progressive PSC was safe. Radiographic and endoscopic evaluation showed stable distribution of multifocal structuring in the early postoperative period. MSCs may be effective for the treatment of PSC.

Background A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. Methods Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. Results The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). Conclusions Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.

The COVID-19 pandemic required rapid adaptation of multidisciplinary tumor board conferences to a virtual setting; however, there are little data describing the benefits and challenges of using such a platform.An anonymous quality improvement survey was sent to participants of tumor board meetings at a large academic institution. Participants answered questions pertaining to the relative strengths and weaknesses of in-person and virtual settings.A total of 335 responses (23.3% response rate) were recorded, and 253 met inclusion criteria. Respondents represented 25 different tumor board meetings, with colorectal, breast, and liver (18.6%, 17.0%, and 13.0%, respectively) being the most commonly attended. Virtual tumor boards were equivalent to in-person across 9 of 10 domains queried, while a virtual format was preferred for participation in off-site tumor boards. The lack of networking opportunities was ranked by physicians to be a significant challenge of the virtual format. Consistent leadership and organization, engaged participation of all attendees, and upgrading technology infrastructure were considered critical for success of virtual meetings.The implementation of virtual tumor board meetings has been associated with numerous challenges. However, improving several key aspects can improve participant satisfaction and ensure excellent patient care.

OBJECTIVES Islet cultures are routinely performed in total pancreatectomy with islet autotransplantation (TPIAT), and the need for empiric antibiotic treatment based on culture results is unknown. We evaluated the effect of postoperative antibiotic treatment for positive islet cultures on clinical infection. METHODS Seventy-nine patients undergoing TPIAT were reviewed. Prophylactic perioperative ceftriaxone and metronidazole were administered, and transplanted islet preparations included ciprofloxacin. Postoperative antibiotics were not routinely given for positive cultures unless a clinical infection was suspected. The primary end point was 30-day infectious complications. RESULTS Fifty-one patients (65%) had a positive culture. Overall, 39 patients (87%) had organisms susceptible to our perioperative antibiotic regimen. There was no difference in the infectious complication rate between those with positive compared with negative cultures (16% vs 29%, P = 0.17). Patients with a positive culture had similar 30-day postoperative infectious complication rates whether receiving postoperative antibiotics (n = 7) or not (14% vs 16%, P = 0.91). Only 1 patient had a correlation of clinical and islet cultures. CONCLUSIONS Beyond prophylactic antibiotics, empiric antibiotic treatment for a positive culture is not warranted and provides a rationale for the abandonment of routine cultures in TPIAT.

Total pancreatectomy with islet autotransplantation (TP-IAT) is an uncommon surgical procedure with unique perioperative management. We evaluated the short- and long-term morbidity and mortality of TP-IAT to optimize surgical technique and heparin dosing during islet autotransplantation.Eighty patients with chronic pancreatitis undergoing TP-IAT were reviewed. Primary outcome was to evaluate morbidity and mortality based on operative technique: classic (resection of antrum) vs pylorus-preserving. Secondary outcome was to evaluate the effect of heparin dosing (60 vs ≥ 60 units/kg) during islet autotransplantation on postoperative hemorrhage and portal vein thrombosis (PVT) rates.There was no 90-day mortality, and median length of stay was 9 days. All patients underwent an open operation with 53 (66%) pylorus-preserving resections. The 30-day morbidity rate was 39%, with no difference between operative technique (p = 0.82). The median dose was different for each heparin group (60: 52 units/kg vs ≥ 60: 66 units/kg, p 0.0001). No difference was observed in postoperative hemorrhage rates between heparin groups (60: 9% vs ≥ 60: 9%, p = 0.97), with no known incidence of PVT. Median follow-up was 36 months (IQR, 14-71). Morbidity30 days after TP-IAT was 43% with a higher rate in the pylorus-preserving group (55% vs 15%, p 0.0001), mainly attributed to marginal ulcer formation (15% vs 0%, p = 0.03).A classic TP-IAT technique should be universally adopted to achieve optimal outcomes, particularly to prevent the formation of marginal ulcers. When considering PVT versus postoperative hemorrhage risk, a lower heparin dose nearing 50 units/kg is optimal. These findings highlight potential areas for future improvement.

OBJECTIVE The purpose of this study is to identify perceptions of academic surgeons regarding academic productivity and assess its relationship to clinical productivity. We hypothesized that these perceptions would vary based on respondent characteristics including clinical activity and leadership roles. DESIGN This retrospective, survey-based study was performed from August 26, 2019 to September 26, 2019. SETTING The setting was academic surgical departments across the US. PARTICIPANTS The survey instrument was administered to faculty members of the Association of Program Directors in Surgery. A total of 105 academic surgeons responded. RESULTS Most respondents were Program Directors (59%) of general surgery programs. Of the participants, 30% identified as Professor, 36% as Associate Professor, and 15% as Assistant Professor. Respondents agreed that multiple academic pursuits or factors should count towards academic productivity including the following (in descending order): completing a first-authored manuscript (98.8%), completing a senior-authored manuscript (97.7%), chairing a national committee (94.1%), serving on a national committee (88.2%), completing a second-authored manuscript (88.0%), completing a first lecture (83.7%), completing a middle-authored manuscript (71.8%), completing a lecture (whether or not repeated) (70.9%), impact factor of journal (60.7%), and attendance at grand rounds (57.0%). Perspectives did not vary significantly based on surgeon demographics, clinical setting, or leadership role (p > 0.05). CONCLUSIONS Perceptions regarding what constitutes academic productivity and merit a reduction in clinical expectation are remarkably similar across multiple surgeon characteristics including demographics, academic title, leadership role, and practice environment.

Pancreas-sparing duodenectomy (PSD) offers definitive therapy for duodenal polyposis associated with familial adenomatous polyposis (FAP). We reviewed the long-term complications of PSD and evaluated the incidence of high-grade dysplasia (HGD) and cancer in the remaining upper gastrointestinal tract. Forty-seven FAP patients with duodenal polyposis undergoing PSD from 1992 to 2019 were reviewed. Long-term was defined as > 30 days from PSD. All patients were treated with an open technique, and 43 (91.5%) had Spigelman stage III or IV duodenal polyposis. Median follow-up was 107 months (IQR, 26–147). There was no 90-day mortality. Seven patients died at a median of 10.5 years (IQR, 5.4–13.3) after PSD, with one attributed to gastric cancer. Pancreatitis occurred in 10 patients (21.3%), and two required surgical intervention. Seven patients (14.9%) developed an incisional hernia, and all underwent definitive repair. Forty-one patients (87.2%) had postoperative surveillance endoscopy over a median follow-up of 111 months (IQR, 42–138). Three patients (6.4%) developed adenocarcinoma (two gastric, one jejunal), and four (8.5%) had adenomas with HGD (two gastric, two jejunal) with a median of 15 years (IQR, 9–16) from PSD. One patient with gastric adenocarcinoma and all patients with HGD or adenocarcinoma of the jejunum required surgical intervention. PSD can be performed with a low but definable risk of long-term morbidity. Risk of gastric and jejunal carcinoma rarely occurs and was diagnosed decades after PSD. This demonstrates the need for lifelong endoscopic surveillance and educates us on the risk of carcinoma in the remaining gastrointestinal tract.

OBJECTIVES Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established. METHODS Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients. RESULTS The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001). CONCLUSIONS Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.

Objectives Smoking and alcohol use are risk factors for acute and chronic pancreatitis, and their role on anxiety, depression, and opioid use in patients who undergo total pancreatectomy and islet autotransplantation (TPIAT) is unknown. Methods We included adults enrolled in the Prospective Observational Study of TPIAT (POST). Measured variables included smoking (never, former, current) and alcohol abuse or dependency history (yes vs no). Using univariable and multivariable analyses, we investigated the association of smoking and alcohol dependency history with anxiety and depression, opioid use, and postsurgical outcomes. Results Of 195 adults studied, 25 were current smokers and 77 former smokers, whereas 18 had a history of alcohol dependency (of whom 10 were current smokers). A diagnosis of anxiety was associated with current smoking (P = 0.005), and depression was associated with history of alcohol abuse/dependency (P = 0.0001). However, active symptoms of anxiety and depression at the time of TPIAT were not associated with smoking or alcohol status. Opioid use in the past 14 days was associated with being a former smoker (P = 0.005). Conclusions Active smoking and alcohol abuse history were associated with a diagnosis of anxiety and depression, respectively; however, at the time of TPIAT, symptom scores suggested that they were being addressed.

Background This study aimed to assess the correlation between validated measures of physical status in a prehabilitation regimen with an established frailty score and analyze changes in these measures after completion of a directed prehabilitation program among patients undergoing elective pancreatic resection. Methods Adult patients undergoing pancreatic resection from 2019−2021 were enrolled in a pilot prehabilitation program. Three validated measures of physical status were used: the 6-minute walk test, grip strength, and chair-stand test. The prehabilitation program comprised 7,500 steps, 30 grip strength exercises, and 100 chair-stand exercises daily. Patients’ frailty score was calculated using the Modified Johns Hopkins Frailty score. Changes in physical status measures after prehabilitation and postoperative outcomes were compared. Results Thirty-two patients with a median age of 69.0 years (interquartile range = 59.5−76.3 years) were included. Patients’ median duration of participation was 21.5 days (interquartile range = 16−29 days). There was a negative correlation between increasing frailty score and baseline the 6-minute walk test (R2 = 0.17) and chair-stand test (R2 = 0.18). Patients’ mean the 6-minute walk test decreased at the end of the prehabilitation program, while grip strength and chair-stand test were unchanged. When stratified by low or intermediate and high frailty scores, the differences in the 6-minute walk test and chair-stand test were unchanged. Hospital duration of stay, complications, and 90-day readmission rates were not different between frailty groups (P > .05). Conclusion Correlation of physical status measures with frailty score suggests only one of these measures is sufficient to estimate patients’ preoperative physical status. A longer, more comprehensive prehabilitation program or an expedited operation are likely the best strategies to improve patient outcomes.

Familial adenomatous polyposis affects primarily the colon but can also involve other locations within the gastrointestinal tract, including the duodenum. The aim of this study was to describe a single center experience with pancreas-sparing duodenectomy for familial adenomatous polyposis and to compare outcomes with pancreatoduodenectomy performed for duodenal polyp disease.A retrospective review of a prospectively maintained database identified patients who had undergone pancreas-sparing duodenectomy during the period 2001 to 2016. This population was matched 1:1 with a cohort of patients undergoing pancreatoduodenectomy for duodenal adenomas, both sporadic and familial, during the same time period. Baseline demographics and perioperative (short- and long-term) outcomes were compared.A total of 88 patients were included; 44 in each group. The pancreas-sparing duodenectomy cohort was younger (52.6 vs 64.3 years; P.001) and more patients had undergone prior colectomy (100% vs 32%; P.001) or additional prior abdominal surgery (27% vs 9% (P.001). Median operative times were greater for pancreatoduodenectomy (391 vs 460 min; P = .002). There was no difference in any of the early postoperative complications. There was 1 30-day mortality in the pancreatoduodenectomy group secondary to aspiration. Late acute pancreatitis was more common after pancreas-sparing duodenectomy (16% vs 0%; P = .012) and exocrine pancreatic insufficiency was more common after pancreatoduodenectomy (30% vs 11%; P = .034).Pancreas-sparing duodenectomy is a reasonable option for duodenal cancer prophylaxis in familial adenomatous polyposis with high-risk features. The perioperative safety profile is comparable to pancreatoduodenectomy done for similar indications, and pancreas-sparing duodenectomy has a favorable long-term with a lesser incidence of exocrine impairment.

Background The effects of varying levels of pre-operative opioids on post-operative outcomes following elective laparoscopic cholecystectomy is largely unknown. Methods Patients who underwent elective laparoscopic cholecystectomy from 2012 to 2019 were reviewed and categorized by the number of outpatient opioid prescriptions received in the 90 days preceding surgery: none (Naive), one (1 Rx), two (2 Rx), or three or more (Chronic). Operative time, hospital length of stay, and 30-day readmission rate were analyzed. Results Of the 11911 patients identified, 2958 (24.8%) used opioids pre-operatively. Among patients with an overnight admission, the Naive, 1 Rx, and 2 Rx cohorts had a shorter length of stay compared to the Chronic cohort. The Naive group had the lowest 30-day readmission rate (5.0%) followed by the 1 Rx (5.9%), 2 Rx and Chronic groups (9.1% and 8.7%, respectively) (p Conclusions Prevalence of pre-operative opioid use is high and warrants surgeon assessment to minimize adverse post-operative outcomes.

BACKGROUND Chemotherapy for pancreatic adenocarcinoma (PDAC) has significantly improved in recent years. While the involvement of the hepatic artery lymph node (HALN; station 8a lymph node) likely represents advanced disease, a comparison to patients with metastases on modern chemotherapy is lacking. METHODS Patients who underwent pancreatoduodenectomy with HALN sent for pathologic review at a single institution from 2003 to 2018 were reviewed. Patients who presented with liver-only metastases at the time of PDAC diagnosis (Stage IV) and received chemotherapy were identified. Multivariate Cox proportional hazards regression modeling was utilized and overall survival (OS) was estimated using Kaplan-Meier analysis. RESULTS Of the 112 patients with a HALN sent for analysis, 17 (15%) were positive and 13 (76%) received chemotherapy. Ninety-four stage IV patients were identified and were significantly more likely to have received a multiagent rather than single-agent chemotherapy regimen compared to HALN positive patients (79.8% vs. 38.5%, p

Gallbladder adenocarcinoma has a poor prognosis as it is often diagnosed incidentally, and patients have a high risk for residual and occult metastatic disease. Expert guidelines recommend definitive surgery for ≥T1b tumors; however, surgical management is inconsistent. This study evaluates the factors that affect the completion of radical resection with portal lymphadenectomy and its impact on survival. A retrospective review of patients who underwent surgery for gallbladder cancer from 2008 to 2017 at an academic institution was performed. Patients were analyzed based on whether they underwent definitive surgical resection. Patient factors and clinical decision-making were analyzed; overall survival was compared using Kaplan-Meier analysis. Seventy-five patients with ≥T1b tumors were identified, of who 32 (42.7%) underwent definitive resection. Fifty-four (72%) patients had gallbladder cancer identified as an incidental diagnosis following laparoscopic cholecystectomy. Among patients who did not undergo definitive resection, the underlying factors were varied. Only 24 (55.8%) patients in the non-definitive resection group were seen by surgical oncology. Among patients who underwent re-operation for definitive resection, 12 (38.7%) were upstaged on final pathology. Of the 43 patients who did not undergo definitive resection, 4 (9.3%) had metastatic disease identified during attempted re-resection. Patients who underwent definitive resection had a significantly longer median overall survival compared to those who did not (4.3 v. 1.9 years, p = 0.02). Patients undergoing definitive resection have a significantly improved survival, including as part of a re-operative strategy. Universal referral to a surgical specialist is a modifiable factor resulting in increased definitive resection rates.

This review serves as an update on the status of robotic pancreatic surgery. It will focus on major changes in the adoption, safety, patient selection, and procedural refinements in robotic pancreatic surgery over the past 5 years. While the findings of this review support the notion that adoption of robotic pancreatic surgery is growing, it is still challenged by the long learning curve. A curriculum has been constructed and disseminated to address this issue. Furthermore, multiple international meetings have been organized to set helpful recommendations and guidelines. Robotic pancreatic surgery is a growing platform that is expected to expand with further advancements in technology and increased adoption of the new generation of Hepato-Pancreato-Biliary Surgeons.

Lymph node ratio (LNR) and margin status have prognostic significance in pancreatic cancer. Herein we examined the pathologic and clinical outcomes in patients with borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT) and pancreaticoduodenectomy.Patients who underwent treatment between January 1, 2012 and June 30, 2017 were included. Sequential patients in the BRPC group were compared to a propensity score matched cohort of patients with radiographically resectable pancreatic cancer who underwent upfront surgical resection. The BRPC group was also compared to sequential patients with radiographically resectable pancreatic cancer who required vein resection (VR) during upfront surgery.There were 50 patients in the BRPC group, 50 patients in the matched control group, and 38 patients in the VR group. Negative margins (R0) were seen in 72%, 64%, and 34% of the BRPC, control, and VR groups, respectively (P = 0.521 for BRPC vs. control; P = 0.002 for BRPC vs. VR), with 24% of the BRPC group requiring a vascular resection. Nodal stage was N0 in 64%, 20%, and 18% of the BRPC, control, and VR groups, respectively (P0.001 for BRPC vs. control or VR). When nodal status was stratified into four groups (N0, or LNR ≤ 0.2, 0.2-0.4, ≥ 0.4), the BRPC group had a more favorable distribution (P0.001). The median overall survival were 28.8, 38.6, and 19.0 months for the BRPC, control, and VR groups, respectively (log-rank P = 0.096).NAT in BRPC was associated with more R0 and N0 resections and lower LNR compared to patients undergoing upfront resection for resectable disease.

Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019).Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety.Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Background Hereditary diffuse gastric cancer is associated with E-cadherin (CDH1) germline mutations. The implications of CDH1 mutations detected with multigene panels in those without family history of HDGC are uncertain. Methods A registry of patients who underwent genetic counseling for CDH1 mutation was queried for the period 2011–2017. Results Twenty-one patients with CDH1 mutation were identified. The most common indication for CDH1 genetic screening was family history of hereditary diffuse gastric cancer (known risk) in 10 patients (48%); 11 patients (52%), however, were diagnosed by multigene cancer panels (unknown risk). Nine of the 21 patients underwent total gastrectomy, and 5 others had metastatic gastric cancer at presentation. In the gastrectomy group, 5 of the 9 patients (56%) were known to have gastric cancer based on preoperative screening endoscopy, but final pathologic examinations indicated diffuse gastric cancer in 8 of the 9 patients. The 11 patients with unknown risk for CDH1 mutation tended to be older (median 41 vs 24 years) and more likely to have metastatic disease and to die of the disease (43% vs 29%) compared with patients with family history of hereditary diffuse gastric cancer. Conclusion CDH1 mutation–associated hereditary diffuse gastric cancer is a biologically aggressive variant of gastric cancer that appears to behave similarly in patients detected only by multigene panels. The detection of CDH1 mutation at a minimum warrants genetic counseling and preferably total gastrectomy.

To evaluate the prevalence, natural history, and severity of polyposis of the duodenal bulb and jejunum after duodenectomy in patients with FAP.Advanced duodenal polyposis stage in FAP requires consideration of duodenal resection to prevent cancer; pylorus-preserving approach of pancreas-sparing duodenectomy (PSD) is preferred. Post-duodenectomy data indicate polyps occur in the duodenal bulb and the post-anastomotic jejunum, but limited data exists regarding their significance.We identified consecutive FAP patients After duodenal resection, including pancreaticoduodenectomy, PSD, or segmental duodenectomy, at Cleveland Clinic. Medical records were used to determine time to diagnosis of duodenal bulb or jejunal polyps, length of follow up, and severity of polyposis including maximal Spigelman stage (SS) of jejunal polyposis (neo-SS).64 patients with FAP underwent duodenectomy and endoscopic follow up. 28% underwent pancreaticoduodenectomy, 61% PSD, and 11% segmental duodenectomy. Postoperatively, 38/64 (59%) were diagnosed with jejunal polyposis, with median time to diagnosis of 55 months and follow up time of 127 months. Jejunal polyposis was advanced in 21% (neo- SS III or IV). Fifty percent were treated endoscopically, 1 patient required surgery. Jejunal polyp-free survival after duodenectomy differed by surgery type (P = 0.008). A total of 55/64 patients underwent a pylorus-preserving procedure, and 6/55 (11%) developed duodenal bulb polyps. All bulb polyps were large (20 mm) and found after PSD. Endoscopic resection was unsuccessful in 5 patients, but no surgical intervention was required.Polyposis occurs in the remaining duodenal and jejunal mucosa in the majority of patients after surgical duodenectomy. Jejunal polyposis is advanced in 1 in 5 patients, but rarely requires surgery. Endoscopic management of jejunal polyposis seems feasible but has proven difficult for duodenal bulb polyps.

Background Perceived excess morbidity during the early learning curve of minimally-invasive pancreaticoduodenectomy (MIPD) has limited widespread adoption. It was hypothesized that robot-assisted reconstruction (RA) after MIPD allows anastomotic outcomes equivalent to open pancreaticoduodenectomy (PD). Methods Intent to treat analysis of centrally audited data accrued during early adoption of RA-MIPD at five centers. Results CUSUM analysis of operating times at each center identified 92 RA-MIPD during the early learning curve. Mean age was 65 ± 12 years with body mass index 25.8 ± 5.0. Surgical indications included malignant (60%) and premalignant (38%) lesions. Median operating time was 504 min (interquartile range 133) with 242 ml median estimated blood loss (IQR 398) and twelve (13%) conversions to open PD. Major complication rate (Clavien-Dindo III/IV) was 24% with 2 (2.2%) deaths and ten (10.9%) reoperations. Nine (9.9%) clinically significant pancreatic fistulae were observed (4 grade B; 5 grade C). Margin negative resection rate for malignancy was 90% (75% for PDA) with mean harvest of 16 ± 8 lymph nodes. Conclusions These multicenter data during the early learning curve for RA-MIPD do not demonstrate excess anastomotic morbidity compared to open. Further studies are required to determine whether surgeon proficiency and evolving technique improve anastomotic outcomes compared to open.

Aim Preoperative chemoradiation for non-metastatic pancreatic cancer patients has been associated with improved outcomes; however, direct comparisons to adjuvant therapy are limited. Methods Single institution data were obtained for non-metastatic pancreatic cancer patients treated with concurrent chemoradiation +/- resection from 2011-2014. Univariate analyses were performed to evaluate clinical and pathologic outcomes. Results Fifty-two well matched patients met inclusion criteria (neoadjuvant chemoradiation = 21, adjuvant chemoradiation = 11, definitive = 20). Pretreatment median tumor size was 2.6 cm and 2.5 cm after neoadjuvant chemoradiation but 3.2 cm on pathology with treatment effect in 95% of specimens. Clinical node positivity at diagnosis for the neoadjuvant and adjuvant chemoradiation groups was similar (29% and 27% respectively, p=0.12). Twenty-one of the 36 neoadjuvant patients (58%) underwent complete resection. In the neoadjuvant versus adjuvant chemoradiation groups, positive margins were decreased (3% vs. 63%, p

Necrosis significantly increases rates of morbidity and mortality in acute pancreatitis. Hospitalists and general internists are on the front lines in identifying severe cases and consulting the appropriate specialists for optimal multidisciplinary care.

Surgeons have an ethical obligation to ensure all patients, regardless of their personal characteristics, receive the same quality of care. Established surgeons also have an obligation to ensure equal treatment for their peers and for those who would like to join the field. The commitment to ethical hiring and working standards entails making certain all individuals have the same opportunities free from discriminatory practices. The world of business has long realized the positive implications of having a diverse and inclusive workforce. Studies have shown a positive correlation between increased racial and gender diversity and company performance. Diversity can lead to an increase in knowledge by sharing ideas with individuals who come from different life experiences and breakdown cultural barriers. We have already begun to see the impact of ignoring the importance of diversity within healthcare, including surgery. Healthcare disparities are defined by the NIH (National Institutes of Health) as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.” Healthcare disparities persist despite decades acknowledging their existence, and they are pernicious and prevalent in surgery. One proposed method to help reduce or eliminate healthcare disparities is to increase the diversity of the workforce treating the patients, which would in turn reduce potential bias the patients face in the healthcare setting. Implicit bias can play a key role in interactions with patients and colleagues and needs to be explored on an individual basis. Cultural competence training can also provide surgeons the ability to effectively communicate with not only a diverse population of patients but also a diverse surgical workforce. All surgeons regardless of their role can have a positive impact on diversity as it relates to patient care and the surgical workforce.

Background Delays in time to treatment initiation (TTI) for new cancer diagnoses cause patient distress and may adversely affect outcomes. We investigated trends in TTI for common solid tumors treated with curative intent, determinants of increased TTI and association with overall survival. Methods and findings We utilized prospective data from the National Cancer Database for newly diagnosed United States patients with early-stage breast, prostate, lung, colorectal, renal and pancreas cancers from 2004–13. TTI was defined as days from diagnosis to first treatment (surgery, systemic or radiation therapy). Negative binomial regression and Cox proportional hazard models were used for analysis. The study population of 3,672,561 patients included breast (N = 1,368,024), prostate (N = 944,246), colorectal (N = 662,094), non-small cell lung (N = 363,863), renal (N = 262,915) and pancreas (N = 71,419) cancers. Median TTI increased from 21 to 29 days (P

Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD).Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011-1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes.Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5-133.3, P = 0.01], reduced blood loss (mean difference = -181 mL, 95% CI -355-(-7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47-0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (12 lymph nodes harvested).Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.

Background To assess the effect of frailty on morbidity and mortality after partial pancreatectomy. Methods A retrospective analysis of National Surgical Quality Improvement Project from 2005–2010 was conducted. A modified frailty index was created based on previously validated methodology. Patients were classified as nonfrail, low frailty, intermediate frailty, and frail. Outcomes of pancreatoduodenectomy and distal pancreatectomy were examined. Results In the study, 13,020 patients were analyzed (8,729 pancreatoduodenectomy and 4,291 distal pancreatectomy). Among the pancreatoduodenectomy and distal pancreatectomy patients, frail patients regardless of the degree of frailty were older, more likely male, had a greater body mass index, lower serum albumin, and greater weight loss compared with the nonfrail patients (all P ≤ .05). Postoperatively, a stepwise increased risk of grade 4 complications (Clavien/Dindo) and mortality was noted from nonfrail to frail patients. Every 1-point increase in modified frailty index was associated with a significantly increased risk of grade 4 complications (∼2–6 times) and mortality (∼2–10 times) from low-frail to frail (adjusted for age, sex, body mass index, albumin, weight loss, and type of pancreatectomy). An abbreviated frailty index incorporating 8 variables was as predictive as the modified frailty index ( P = .68). Conclusion An 11-point frailty index as measured in National Surgical Quality Improvement Project predicts serious complications and death after pancreatectomy. A modification of this index with 8 factors continues to have similar predictive ability. Consideration of frailty may be beneficial prior to the pancreatic surgeon and particularly in discussion of operative risk and selection of patients who might receive benefit from pre-operative optimization.

Superior mesenteric artery syndrome (SMAS) is a rare condition caused by partial obstruction of the third portion of the duodenum by the SMA anteriorly and aorta posteriorly. Laparoscopic duodenojejunostomy has been described as a safe and feasible surgical intervention with favorable short-term outcomes. However, descriptions of intermediate outcomes are lacking in the literature. A retrospective chart review was performed on patients who underwent minimally invasive duodenojejunostomy from March 2005 to August 2015 at our healthcare system with greater than 6-month follow-up. Eighteen patients with mean age of 31.2 were identified. There were 4 men and 14 women. Patients’ diagnosis was made by clinical presentation with radiographic confirmation. Mean weight loss preoperatively was 13.9 kg, representing 24.1 % total body weight loss. There were no intraoperative complications. Postoperatively, 2 patients developed prolonged ileus. One underwent exploratory laparotomy and washout for presumed leak, but none was identified. Three patients were readmitted within 30 days; 2 for intolerance to enteral intake with dehydration, and 1 for closed-loop obstruction requiring laparoscopic lysis of adhesions. The average and median length of follow-up were 27.7 and 26.0 months, respectively. Patients gained an average of 2.2 kg with an increase in body mass index of from 19.6 to 20.4 m/kg2. Although 14 of 18 patients reported initial symptom improvement, at latest follow-up, only 6 patients reported symptomatic improvement or resolution. Three were diagnosed with global dysmotility, and 1 underwent intestinal transplant. Two were diagnosed with gastroparesis, and 1 underwent a laparoscopic gastric electric stimulator placement and pyloroplasty. There were no mortalities. Duodenojejunostomy is the most common surgical intervention in management of SMAS. Our intermediate follow-up reveals infrequent improvement and rare resolution of preoperative symptomatology. Patients had a modest average weight gain postoperatively. This may suggest that different preoperative workup and treatment is indicated.