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Objective: To evaluate the efficacy of transanastomotic pancreatic duct internal stenting in the reduction of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy. Design: Retrospective study. Setting: Mayo Clinic. Patients: Between January 1, 1999, and September 30, 2010, 553 patients underwent pancreaticoduodenectomy by a single surgeon. Main Outcome Measures: Rates of POPF, morbidity, and mortality between stent and no-stent groups. Results: The clinically relevant POPF (International Study Group on Pancreatic Fistula definition grade B or C) rates in the stent and no-stent groups were similar (9.6% [43 of 449 patients] and 12.5% [13 of 104 patients], respectively; P=.38). Postoperative outcomes and morbidity were also similar between the 2 groups. Mortality was 0.7% (3 of 449 patients) for the stent group and 1.0% (1 of 104 patients) for the no-stent group. Four patients (0.9%) required endoscopic retrieval of the anastomotic stent. In subset analysis, the clinically relevant POPF rates in patients with a small pancreatic duct (⩽3 mm; n=167) were similar in the stent and no-stent groups (17.7% [23 of 130 patients] and 24.3% [9 of 37 patients], respectively; P=.38). In patients with a soft pancreatic gland (n=64), rates of clinically relevant pancreatic fistulae were also similar in the stent and no-stent groups (31.7% [13 of 41 patients] and 17.4% [4 of 23 patients], respectively; P=.20). Conclusions: Internal transanastomotic pancreatic duct stenting does not decrease the frequency or severity of POPF. The effect of stenting on long-term anastomotic patency warrants further investigation. [ABSTRACT FROM AUTHOR]

The Patient Protection and Affordable Care Act (PPACA), called the Affordable Care Act (ACA) or "ObamaCare" for short, was enacted in 2010. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract (SSAT) hosted a debate with an expert panel to discuss the ACA and its impact on surgical care after the first year of patient enrollment. The purpose of this debate was to focus on the impact of ACA on the public and surgeons. At the core of the ACA are insurance industry reforms and expanded coverage, with a goal of improved clinical outcomes and reduced costs of care. We have observed supportive and opposing views on ACA. Nonetheless, we will witness major shifts in health care delivery as well as restructuring of our relationship with payers, institutions, and patients. With the rapidly changing health care landscape, surgeons will become key members of health systems and will likely need to lead transition from solo-practice to integrated care systems. The full effects of the ACA remain unrealized, but its implementation has begun to change the map of the American health care system and will surely impact the practice of surgery. Herein, we provide a synopsis of the "pro" and "con" arguments for the expected and unexpected consequences of the ACA on society and surgeons.

Background: Over the last 30 years, numerous developments in the management of chronic pancreatitis have occurred, leading to multiple surgical and non-surgical options., Patients and Methods: All patients who underwent pancreatoduodenectomy for chronic pancreatitis from January 1976 to July 2013 were reviewed. Surviving patients were contacted for a follow-up questionnaire and Short Form (SF)-12 Quality of Life Survey administration., Results: A total of 166 patients were identified (cohort 1:1976-1997(N = 105) and cohort 2:1998-2013(N = 61)). Prior to pancreatoduodenectomy, a higher proportion of patients in cohort 2 had undergone endoscopic stenting, 67 vs 10 % (p < 0.001) and/or celiac plexus block 15 and 5 % (p = 0.026). Median follow-up for all survey respondents was 15 years. On the SF-12, mean physical component score was 43.8 ± 11.8 and mental component score was 54.3 ± 7.9. Patients were significantly lower on the physical component score (p < 0.001) and significantly better on the mental component score (p = 0.001) than the general US population. Mean pain score out of 10 was significantly lower after surgery 1.6 ± 2.6 than before surgery 7.9 ± 3.5 (p < 0.001). Diabetes developed in 28 % of patients who were not diabetic prior to surgery., Conclusion: Although practice has changed so that patients have a longer time from presentation until surgery as less-invasive techniques are attempted, pancreatoduodenectomy appears to provide effective long-term pain relief and acceptable quality of life in appropriately selected patients with chronic pancreatitis and intractable pain.

Background: A delayed post-pancreatoduodenectomy haemorrhage is associated with a significant increase in peri-operative mortality. Endovascular techniques are frequently used for a delayed haemorrhage. However, limited data exists on the short- and long-term outcomes of this approach. A retrospective review over a 10-year period at a quaternary-referral pancreatic centre was performed., Methods: Between 2002-2012, 1430 pancreatoduodenectomies were performed, and 32 patients had a delayed haemorrhage (occurring >24 h post-operatively) managed by endovascular techniques. The clinicopathological variables related to a haemorrhage were investigated., Results: A total of 42 endovascular procedures were performed at a median of 25 days, with the majority of delayed haemorrhages occurring after 7 days. There were four deaths (13%) with three occurring in patients with a grade C haemorrhage. Seven patients (22%) experienced rebleeding, and two patients developed hepatic abscesses., Conclusion: A delayed haemorrhage post-pancreaticoduodenectomy can be managed by endovascular techniques with acceptable morbidity and mortality. Rebleeding and hepatic abscesses may occur and can be managed non-operatively in most cases. The association of a delayed haemorrhage with a pancreatic fistula makes this a challenging clinical problem., (© 2015 International Hepato-Pancreato-Biliary Association.)

Background: Elderly patients undergoing open pancreatoduodenectomy (OPD) are at increased risk for surgical morbidity and mortality. Whether totally laparoscopic pancreatoduodenectomy (TLPD) mitigates these risks has not been evaluated., Methods: A retrospective review of outcomes in patients submitted to pancreatoduodenectomy during 2007-2014 was conducted (n = 860). Outcomes in elderly patients (aged ≥70 years) were compared with those in non-elderly patients with respect to risk-adjusted postoperative morbidity and mortality. Differences in outcomes between patients submitted to OPD and TLPD, respectively, were evaluated in the elderly subgroup., Results: In elderly patients, the incidences of cardiac events (odds ratio [OR] 3.21, P < 0.001), respiratory events (OR 1.68, P = 0.04), delayed gastric emptying (DGE) (OR 1.73, P = 0.003), increased length of stay (LoS, 1 additional day) (P < 0.001), discharge disposition other than home (OR 8.14, P < 0.001) and blood transfusion (OR 1.48, P = 0.05) were greater than in non-elderly patients. Morbidity and mortality did not differ between the OPD and TLPD subgroups of elderly patients. In elderly patients, OPD was associated with increased DGE (OR 1.80, P = 0.03), LoS (1 additional day; P < 0.001) and blood transfusion (OR 2.89, P < 0.001) compared with TLPD., Conclusions: Elderly patients undergoing TLPD experience rates of mortality, morbidity and cardiorespiratory events similar to those in patients submitted to OPD. In elderly patients, TLPD offers benefits by decreasing DGE, LoS and blood transfusion requirements., (© 2015 International Hepato-Pancreato-Biliary Association.)

The ability to escape apoptosis is a hallmark of cancer-initiating cells and a key factor of resistance to oncolytic therapy. Here, we identify FAM96A as a ubiquitous, evolutionarily conserved apoptosome-activating protein and investigate its potential pro-apoptotic tumor suppressor function in gastrointestinal stromal tumors (GISTs). Interaction between FAM96A and apoptotic peptidase activating factor 1 (APAF1) was identified in yeast two-hybrid screen and further studied by deletion mutants, glutathione-S-transferase pull-down, co-immunoprecipitation and immunofluorescence. Effects of FAM96A overexpression and knock-down on apoptosis sensitivity were examined in cancer cells and zebrafish embryos. Expression of FAM96A in GISTs and histogenetically related cells including interstitial cells of Cajal (ICCs), "fibroblast-like cells" (FLCs) and ICC stem cells (ICC-SCs) was investigated by Northern blotting, reverse transcription-polymerase chain reaction, immunohistochemistry and Western immunoblotting. Tumorigenicity of GIST cells and transformed murine ICC-SCs stably transduced to re-express FAM96A was studied by xeno- and allografting into immunocompromised mice. FAM96A was found to bind APAF1 and to enhance the induction of mitochondrial apoptosis. FAM96A protein or mRNA was dramatically reduced or lost in 106 of 108 GIST samples representing three independent patient cohorts. Whereas ICCs, ICC-SCs and FLCs, the presumed normal counterparts of GIST, were found to robustly express FAM96A protein and mRNA, FAM96A expression was much reduced in tumorigenic ICC-SCs. Re-expression of FAM96A in GIST cells and transformed ICC-SCs increased apoptosis sensitivity and diminished tumorigenicity. Our data suggest FAM96A is a novel pro-apoptotic tumor suppressor that is lost during GIST tumorigenesis., (© 2015 UICC.)

Background: A clinical risk score for pancreatic fistula (CRS-PF) was recently reported to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). An independent external validation has not been performed. Our hypothesis was that CRS-PF predicts POPF after both laparoscopic and open PD., Study Design: The CRS-PF was calculated from a retrospective review of patients undergoing PD from January 2007 to February 2014. Postoperative pancreatic fistula was graded using International Study Group of Pancreatic Fistula criteria. Grade B and C leaks were defined as clinically significant. Performance was measured based on sensitivity, specificity, positive and negative predictive value, accuracy, and R(2)., Results: There were 808 patients who met inclusion criteria; 539 (66.7%) had open and 269 (33.3%) had laparoscopic PD. The CRS-PF was high risk in 134 patients, intermediate in 492, low in 135, and negligible in 47. Postoperative pancreatic fistula occurred in 191 (23.6%) patients (grade A, 3.8%; B, 14.2%; and C, 5.6%), and it increased with risk category (R(2) = 0.935 all, 0.898 open, and 0.968 laparoscopic). High and intermediate risk categories were combined and classified as "test positive," and negligible and low risk categories were combined and classified "test negative," resulting in a CRS-PF with a sensitivity of 95% and a negative predictive value of 96% for predicting POPF. Contrary to previous studies, grade A POPF increased with increasing CRS-PF and POPF did not correlate with estimated blood loss (R(2) = 0.04)., Conclusions: The CRS-PF was validated independently by predicting POPF for both laparoscopic and open PD. Predictive performance was at least as good for laparoscopic PD as for open PD. Lack of correlation with estimated blood loss suggests CRS-PF might be tailored for improved performance. The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background & Aims: In gastrointestinal muscles, v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog (KIT) is predominantly expressed by interstitial cells of Cajal (ICC) and platelet-derived growth factor receptor-α (PDGFRA) polypeptide is expressed by so-called fibroblast-like cells. KIT and PDGFRA have been reported to be coexpressed in ICC precursors and gastrointestinal stromal tumors (GISTs), which originate from the ICC lineage. PDGFRA signaling has been proposed to stimulate growth of GISTs that express mutant KIT, but the effects and mechanisms of selective blockade of PDGFRA are unclear. We investigated whether inhibiting PDGFRA could reduce proliferation of GIST cells with mutant KIT via effects on the KIT-dependent transcription factor ETV1., Methods: We studied 53 gastric, small intestinal, rectal, or abdominal GISTs collected immediately after surgery or archived as fixed blocks at the Mayo Clinic and University of California, San Diego. In human GIST cells carrying imatinib-sensitive and imatinib-resistant mutations in KIT, PDGFRA was reduced by RNA interference (knockdown) or inhibited with crenolanib besylate (a selective inhibitor of PDGFRA and PDGFRB). Mouse ICC precursors were retrovirally transduced to overexpress wild-type Kit. Cell proliferation was analyzed by methyltetrazolium, 5-ethynyl-2'-deoxyuridine incorporation, and Ki-67 immunofluorescence assays; we also analyzed growth of xenograft tumors in mice. Gastric ICC and ICC precursors, and their PDGFRA(+) subsets, were analyzed by flow cytometry and immunohistochemistry in wild-type, Kit(+/copGFP), Pdgfra(+/eGFP), and NOD/ShiLtJ mice. Immunoblots were used to quantify protein expression and phosphorylation., Results: KIT and PDGFRA were coexpressed in 3%-5% of mouse ICC, 35%-44% of ICC precursors, and most human GIST samples and cell lines. PDGFRA knockdown or inhibition with crenolanib efficiently reduced proliferation of imatinib-sensitive and imatinib-resistant KIT(+)ETV1(+)PDGFRA(+) GIST cells (50% maximal inhibitory concentration = 5-32 nM), but not of cells lacking KIT, ETV1, or PDGFRA (50% maximal inhibitory concentration >230 nM). Crenolanib inhibited phosphorylation of PDGFRA and PDGFRB, but not KIT. However, Kit overexpression sensitized mouse ICC precursors to crenolanib. ETV1 knockdown reduced KIT expression and GIST proliferation. Crenolanib down-regulated ETV1 by inhibiting extracellular-signal-regulated kinase (ERK)-dependent stabilization of ETV1 protein and also reduced expression of KIT and PDGFRA., Conclusions: In KIT-mutant GIST, inhibition of PDGFRA disrupts a KIT-ERK-ETV1-KIT signaling loop by inhibiting ERK activation. The PDGFRA inhibitor crenolanib might be used to treat patients with imatinib-resistant, KIT-mutant GIST., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The 7th edition of the American Joint Committee on Cancer (AJCC) staging system has recently been validated and shown to predict survival in patients with intrahepatic cholangiocarcinoma (ICC). The present study attempted to investigate the validity of these findings., Methods: A single-centre, retrospective cohort study was conducted. Histopathological restaging of disease subsequent to primary surgical resection was carried out in all consecutive ICC patients. Overall survival was compared using Kaplan-Meier estimates and log-rank tests., Results: A total of 150 patients underwent surgery, 126 (84%) of whom met the present study's inclusion criteria. Of these 126 patients, 68 (54%) were female. The median length of follow-up was 4.5 years. The median patient age was 58 years (range: 24-79 years). Median body mass index was 27 kg/m(2) (range: 17-46 kg/m(2) ). Staging according to the AJCC 7th edition categorized 33 (26%) patients with stage I disease, 27 (21%) with stage II disease, five (4%) with stage III disease, and 61 (48%) with stage IVa disease. The AJCC 7th edition failed to accurately stratify survival in the current cohort; analysis revealed significantly worse survival in those with microvascular invasion, tumour size of >5 cm, grade 4 disease, multiple tumours and positive lymph nodes (P < 0.001). A negative resection margin was associated with improved survival (P < 0.001)., Conclusions: The AJCC 7th edition did not accurately predict survival in patients with ICC. A multivariable model including tumour size and differentiation in addition to the criteria used in the AJCC 7th edition may offer a more accurate method of predicting survival in patients with ICC., (© 2014 International Hepato-Pancreato-Biliary Association.)

Anoctamin-1 (Ano1) is a widely expressed protein responsible for endogenous Ca(2+)-activated Cl(-) currents. Ano1 is overexpressed in cancer. Differential expression of transcriptional variants is also found in other diseases. However, the mechanisms underlying regulation of Ano1 are unknown. This study identifies the Ano1 promoter and defines a mechanism for regulating its expression. Next-generation RNA sequencing (RNA-seq) analysis in human gastric muscle found a new exon upstream of the reported exon 1 and identified a promoter proximal to this new exon. Reporter assays in human embryonic kidney 293 cells showed a 6.7 ± 2.1-fold increase in activity over empty vector. Treatment with a known regulator of Ano1 expression, IL-4, increased promoter activity by 1.6 ± 0.02-fold over untreated cells. The promoter region contained putative binding sites for multiple transcription factors including signal transducer and activator of transcription 6 (STAT6), a downstream effector of IL-4. Chromatin immunoprecipitation (ChIP) experiments on T84 cells, which endogenously express Ano1, showed a 2.1 ± 0.12-fold increase in binding of STAT6 to P0 after IL-4 treatment. These results were confirmed by mutagenesis, expression, and RNA interference techniques. This work allows deeper understanding of the regulation of Ano1 in physiology and as a potential therapeutic target in a variety of diseases., (© FASEB.)

Background: Major vascular resection when necessary for margin control during pancreaticoduodenectomy is relatively universal with perioperative and oncological outcomes that are similar to those of patients undergoing a PD without venous involvement. The present study compares total laparoscopic pancreaticoduodenectomy (TLPD) versus open pancreaticoduodenectomy (OPD) with major vascular resection., Methods: We reviewed data for all patients undergoing TLPD or OPD with vascular resection at Mayo Clinic Rochester, between the dates of July 2007 and July 2013., Results: A total of 31 patients undergoing TLPD and 58 patients undergoing OPD with major vascular resection were identified. Mean operative blood loss was significantly less in the laparoscopic (842 cc) compared to the open group (1,452 cc) (p < 0.001), as was median hospital stay, 6 (4-118) versus 9 (6-73) days, respectively (p = 0.006). There was no significant difference in the total number of complications (lap 35%, open 48%) (p = 0.24) or severe complications (≥III) (lap 6.4%, open 3.4%) (p = 0.51) in the two groups. In-hospital mortality or 30-day mortality was not statistically different between the laparoscopic and open groups, 3.2 and 3.4%, respectively (p = 0.96). Patency of the reconstructed vessels on postoperative imaging was not significantly different between the TLPD (93%) and OPD groups (91%) (p = 0.76). In patients with a diagnosis of adenocarcinoma, there was no significant difference in overall survival between the two groups (p = 0.22)., Conclusion: The present study clearly demonstrates that not only is TLPD with major vascular resection feasible and safe but that it can achieve results that are similar in morbidity and mortality as well as oncologic outcome compared to patients undergoing OPD with major vascular resection.

Background: Population shifts among surgeons and the general populous will contribute to a predicted general surgeon shortage by 2020. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract designed and conducted a survey to assess perceptions and possible solutions from important stakeholders: practicing surgeons of the society, general surgery residents, and medical students., Results: Responses from 1,208 participants: 658 practicing surgeons, 183 general surgery residents, and 367 medical students, were analyzed. There was a strong perception of a current and future surgeon shortage. The majority of surgeons (59.3 %) and residents (64.5 %) perceived a current general surgeon shortage, while 28.6 % of medical students responded the same. When asked of a perceived general surgery shortage in 20 years, 82.4, 81.4, and 51 % said "yes", respectively. There were generational differences in responses to contributors and solutions for the impending shortage. Surgeons placed a high value on improving reimbursement, tort reform, and surgeon burnout, while residents held a strong interest in a national loan forgiveness program and improving lifestyle barriers., Conclusion: Our survey offers insight into possible solutions to ward off a surgeon shortage that should be addressed with programmatic changes in residency training and by reform of the national health care system.

Objective: To directly compare the oncologic outcomes of TLPD and OPD in the setting of pancreatic ductal adenocarcinoma., Background: Total laparoscopic pancreaticoduodenectomy (TLPD) has been demonstrated to be feasible and may have several potential advantages over open pancreaticoduodenectomy (OPD), including lower blood loss and shorter hospital stay. Whether potential advantages could allow patients to recover in a timelier manner and pursue adjuvant treatment options remains to be answered., Methods: We reviewed data for all patients undergoing TLPD (N = 108) or OPD (N = 214) for pancreatic ductal adenocarcinoma at our institution between January 2008 and July 2013., Results: Neoadjuvant therapy, tumor size, node positivity, and margin-positive resection were not significantly different between the 2 groups. Median length of hospital stay was significantly longer in the OPD group (9 days; range, 5-73 days) than in the TLPD group (6 days; range, 4-118 days; P < 0.001). There was a significantly higher proportion of patients in the OPD group (12%) who had a delay of greater than 90 days or who did not receive adjuvant chemotherapy at all compared with that in the TLPD group (5%; P = 0.04). There was no significant difference in overall survival between the 2 groups (P = 0.22). A significantly longer progression-free survival was seen in the TLPD group than in the OPD group (P = 0.03)., Conclusions: TLPD is not only feasible in the setting of pancreatic ductal adenocarcinoma but also has advantages such as shorter hospital stay and faster recovery, allowing patients to recover in a timelier manner and pursue adjuvant treatment options. This study also demonstrated a longer progression-free survival in patients undergoing TLPD than those undergoing OPD.

Introduction: Multiple reports have cited the looming shortage of physicians over the next decades related to increasing demand, an aging of the population, and a stagnant level in the production of new physicians. General surgery shares in this problem, and the specialty is "stressed" by a declining workforce related to increasing specialization that leaves gaps in emergency, trauma, and rural surgical care., Summary: The Society of Surgery of the Alimentary Tract (SSAT) Public Policy and Advocacy Committee sponsored panel discussions regarding the general surgery workforce shortage at the Digestive Disease Week 2012 and 2013 meetings. The 2012 panel focused on defining the problem. This is the summation of the series with the solutions to the general surgery workforce shortage as offered by the 2013 panel.

Anaplastic pancreatic cancer (APC) is a rare undifferentiated variant of pancreatic ductal adenocarcinoma with poor overall survival (OS). The aim of this study was to evaluate the clinical outcomes of APC compared with differentiated pancreatic ductal adenocarcinoma. We conducted a retrospective review of all patients treated at the Mayo Clinic with pathologically confirmed APC from 1987 to 2011. After matching with control subjects with pancreatic ductal adenocarcinoma, OS was evaluated using Kaplan-Meier estimates and log-rank test. Sixteen patients were identified with APC (56.3% male, median age 57 years). Ten patients underwent exploration of whom eight underwent pancreatectomy. Perioperative morbidity was 60 per cent with no mortality. The median OS was 12.8 months. However, patients with APC who underwent resection had longer OS compared with those who were not resected, 34.1 versus 3.3 months (P = 0.001). After matching age, sex, tumor stage, and year of operation, the median OS was similar between patients with APC and those with ductal adenocarcinoma treated with pancreatic resection, 44.1 versus 39.9 months, (P = 0.763). Overall survival for APC is poor; however, when resected, survival is similar to differentiated pancreatic ductal adenocarcinoma.

Background: We aimed to identify staging parameters associated with survival in patients with hilar cholangiocarcinoma., Methods: Clinicopathologic characteristics were obtained retrospectively for all resected patients with Bismuth-Corlette III cholangiocarcinoma between 1993 and 2011. Patients were stratified by the American Joint Commission on Cancer (AJCC) (7th edition) and Memorial Sloan-Kettering Cancer Center (MSKCC) staging systems. Survival analyses tested the effects of clinicopathologic factors and staging covariates on recurrence-free and overall survival., Results: Eighty patients (mean age 63 ± 11 years, 63% male) underwent anatomic hepatectomy with bile duct resection/reconstruction for Bismuth-Corlette IIIa (53%) and IIIb (47%) cholangiocarcinoma. The median follow-up was 26 months (interquartile range = 12 to 50 months), and the median time to recurrence was 15 months (interquartile range = 6 to 38 months). Neither AJCC nor MSKCC staging systems were associated with recurrence-free survival (all P ≥ .059). MSKCC T-stage but not the AJCC staging system was associated with overall survival (P ≤ .026)., Conclusions: MSKCC T-stage classification but not AJCC staging is independently associated with overall survival for patients after resection of hilar cholangiocarcinoma., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To test whether or not the association between inflammation and pancreatic ductal adenocarcinoma (PC) is facilitated by host susceptibility, specifically by genetic polymorphisms in inflammation-related genes., Summary Background Data: Inflammation has been linked to PC. Reports have cited an increased expression of proinflammatory mediators, such as NF-κB and COX, in PC but not in normal adjacent tissue, suggesting a possible role in carcinogenesis. We sought to further understand the role that genetic variants in the NF-κB inflammatory pathway play in the development and progression of PC., Methods: We genotyped 1536 tag single nucleotide polymorphisms (SNPs) in 102 candidate genes of multiple inflammatory pathways in 1308 white patients with PC who were divided into 3 groups on the basis of the extent of disease: resected for cure (n = 400), locally advanced/unresected (n = 443), and metastatic (n = 465). Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression models. Statistical significance was set at less than 0.001 to control for multiple testing., Results: Median age was 67 (28.0-91.0) years, and 57% were men. Median survival for each of the 3 groups (resected, locally advanced, and metastatic) was 23.7, 9.4, and 6.6 months, respectively (P < 0.0001). In the resected group, carriers of a minor allele for either rs3824872 (MAPK8IP1) or rs8064821 (SOCS3) were associated with a 10- and 6-month survival advantage compared with noncarriers in patients with resected disease, with an additional 2-year survival if both minor alleles were present. With locally advanced disease, SNP rs1124736 (IGF1R) was associated with improved survival if they had a copy of the G allele, hazard ratio of 0.57 (95% confidence interval: 0.42-0.77); P = 0.0002. In addition, 4 SNPs in patients with metastatic disease were found to be associated with worse survival and 2 associated with improved overall survival, but the differences in survival were deemed not clinically significant., Conclusions: SNPs in the inflammatory pathway genes MAPK8IP1 and SOCS3 were associated with increased overall survival in patients undergoing potentially curative resection and may be used in the future as markers to predict survival. Future research is needed to determine the functional relevance of these loci.

Background: New-onset diabetes mellitus after a pancreaticoduodenectomy (PD) remains poorly defined. The aim of this study was to define the incidence and predictive factors of immediate post-resection diabetes mellitus (iPRDM)., Methods: Retrospective review of patients undergoing PD from January 2004 through to July 2010. Immediate post-resection diabetes mellitus was defined as diabetes requiring pharmacological treatment within 30 days post-operatively. Logistic regression was conducted to identify factors predictive of iPRDM., Results: Of 778 patients undergoing PD, 214 were excluded owing to pre-operative diabetes (n= 192), declined research authorization (n= 14) or death prior to hospital discharge (n= 8); the remaining 564 patients comprised the study population. iPRDM occurred in 22 patients (4%) who were more likely to be male, have pre-operative glucose intolerance, or an increased creatinine, body mass index (BMI), pre-operative glucose, operative time, tumour size or specimen length compared with patients without iPRDM (P < 0.05). On multivariate analysis, pre-operative impaired glucose intolerance (P < 0.001), pre-operative glucose ≥ 126 (P < 0.001) and specimen length (P= 0.002) were independent predictors of iPRDM. A predictive model using these three factors demonstrated a c-index of 0.842., Discussion: New-onset, post-resection diabetes occurs in 4% of patients undergoing PD. Factors predictive of iPRDM include pre-operative glucose intolerance, elevated pre-operative glucose and increased specimen length. These data are important for patient education and predicting outcomes after PD., (Published 2012. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Anaplastic pancreatic cancer (APC) is a rare subtype of pancreatic ductal adenocarcinoma (PDA) that can carry a worse overall survival (OS) when compared with other variants. However, the presence of osteoclast-like giant cells (OCGCs) in APC specimens can predict improved OS. The aim of this study was to evaluate the OS of patients with APC (with and without OCGCs) compared with patients with other subtypes of PDA using a population-based registry., Study Design: We identified all patients in the Surveillance, Epidemiology and End Results (SEER) database with pathologically confirmed APC and PDA diagnosed between 1988 and 2008. Overall survival was evaluated using Kaplan-Meier and Cox proportional hazard regression., Results: The study cohort included 5,859 (94.3%) patients with PDA and 353 (5.7%) with APC. Overall survival for all patients with APC was significantly worse than for patients with PDA (hazard ratio [HR] = 1.9; 95% CI, 1.7-2.1; p < 0.001); however, in the subgroup of resected patients, APC (n = 81) had similar OS to PDA (n = 3,517) (HR = 0.9; 95% CI, 0.7-1.2; p = 0.37). Patients with APC tumors with OCGCs (n = 11) demonstrated improved OS when compared with all other APC variants without OCGCs (n = 342) (HR = 0.3; 95% CI, 0.1-0.7; p = 0.004), but this survival difference was not observed in the subgroup of resected patients (HR = 0.5; 95% CI, 0.2-1.4; p = 0.18)., Conclusions: Anaplastic pancreatic cancer is a rare malignancy with poor OS. The diagnosis of APC with OCGCs is predictive of improved OS compared with other patients with APC. This survival benefit, however, is not observed in patients with resected disease., (Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Primary gastrointestinal stromal tumours (GISTs) of the duodenum are rare. The aim of this study was to review the surgical management of GISTs in this anatomically complex region., Methods: Retrospective review from January 1999 to August 2011 of patients with primary GISTs of the duodenum., Results: Forty-one patients underwent resection of duodenal GISTs. All operations were performed with intent to cure with negative margins of resection. The most common location of origin was the second portion of the duodenum. Local excision (n= 19), segmental resection with primary anastomosis (n= 11) and a pancreatoduodenectomy (n= 11) were performed. Two patients underwent an ampullectomy with local excision. Peri-operative mortality and overall morbidity were 0 and 12, respectively. Patients with high-risk GISTs (P= 0.008) and those who underwent a pancreatoduodenectomy (P= 0.021) were at a greater risk for morbidity. The median follow-up was 18 months. Eight patients developed recurrence. High-risk GISTs and neoplasms with ulceration had the greatest risk for recurrence (P= 0.017, P= 0.029 respectively). The actuarial 3- and 5-year survivals were 85% and 74%, respectively., Conclusion: The choice and type of resection depends on the proximity to the ampulla of Vater, involvement of adjacent organs and the ability to obtain negative margins. The morbidity depends on the type of procedure for GIST., (© 2012 International Hepato-Pancreato-Biliary Association.)

Primary pancreatic cystic neoplasms are being recognized with increasing frequency due to modern imaging techniques. In addition to the more common cystic neoplasms-serous cystadenoma, primary mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm-there are many other less common neoplasms that appear as cystic lesions. These cystic neoplasms include solid pseudopapillary neoplasm of the pancreas (the most common rare cystic neoplasm), cystic neuroendocrine neoplasm, cystic degeneration of otherwise solid neoplasms, and then the exceedingly rare cystic acinar cell neoplasm, intraductal tubular neoplasm, angiomatous neoplasm, lymphoepithelial cysts (not true neoplasms), and few others of mesenchymal origin. While quite rare, the pancreatic surgeon should at the least consider these unusual neoplasms in the differential diagnosis of potentially benign or malignant cystic lesions of the pancreas. Moreover, each of these unusual neoplasms has their own natural history/tumor biology and may require a different level of operative aggressiveness to obtain the optimal outcome., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Introduction: The impact of the number of lymph node (LN) evaluated pathologically on accurate staging is unknown. Our primary aim was to determine a minimum number of evaluated LN needed to provide accurate staging of pancreatic cancer., Methods: Four hundred ninety-nine patients underwent a curative pancreatectomy for pancreatic adenocarcinoma cancer from 1981-2007. The probability of understaging a patient as N0 was estimated based on the number of LN evaluated. The prognostic value of LN ratio (LNR) was assessed., Results: Survival for node-negative (pN0) patients with <11 LN examined was worse than for pN0 patients with ≥11 LNs with a hazard ratio (95 % CI) of 1.33 (1.1-1.7, p = 0.01) with 3-year survivals of 32 vs. 50%, respectively. Three-year survival for pN1 patients with <11 nodes evaluated was similar to pN1 patients with ≥11 nodes (25 vs. 30%). LNR ≥ 0.17 predicted worse survival with hazard ratio of 1.76 (1.3-2.4, p = 0.001) than LNR < 0.17; 3-year survivals were 37 vs. 19%., Conclusion: Patients with "N0" disease with <11 LN evaluated pathologically have worse survival, suggesting that metastatic nodes were missed by evaluating too few nodes. For pN1 patients, LNR stratifies survival of patient cohorts more accurately. Adequate staging of pancreatic cancer requires pathologic evaluation of ≥11 LNs.

Background & Aims: The incidence of intraductal papillary mucinous neoplasm (IPMN) is believed to be increasing; we investigated whether this is the result of increasing burden of disease or more diagnostic scrutiny., Methods: In a retrospective cohort study, we calculated a trend in reported incidence of IPMN using data collected from Olmsted County, Minnesota, from 1985 to 2005. Total IPMN cases from the Olmsted database were identified through a keyword and International Classification of Diseases, 9th revision, search using a database from the Rochester Epidemiology Project, with all cases verified by subsequent chart review. The subsequent rate of IPMN-related carcinoma was calculated using data from the national Surveillance Epidemiology and End Results-9 database, reflecting trends from 1982 to 2007. Cases of IPMN-related carcinoma were identified in the Surveillance Epidemiology and End Results-9 database by limiting the search to histology codes for noninvasive and invasive IPMN., Results: Between 1985 and 2005, there was a 14-fold increase in the age- and sex-adjusted incidence of IPMN, from 0.31 to 4.35 per 100,000 persons. From 2000 to 2001, the rate of reported carcinoma increased from 0.008 to 0.032 per 100,000 persons, but stabilized afterward, with a rate of 0.06 per 100,000 persons in 2007. Mortality from all causes of pancreatic cancer was stable between 1975 and 2007 (approximately 11 deaths per 100,000 individuals)., Conclusions: The incidence of IPMN has increased in the absence of an increase in IPMN-related or overall pancreatic cancer-related mortality, so it likely results from an increase in diagnostic scrutiny, rather than greater numbers of patients with clinically relevant disease., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

The Patient Protection and Affordable Care Act signed into law in March 2010, has led to sweeping changes to the US health care system. The ensuing pace of change in health care regulation is unparalleled and difficult for physicians to keep up with. Because of the extraordinary challenges that have arisen, the public policy committee of the Society for Surgery of the Alimentary tract conducted a symposium at their 52nd Annual Meeting in May 2011 to educate participants on the myriad of public policy changes occurring in order to best prepare them for their future. Expert speakers presented their views on policy changes affecting diverse areas including patient safety, patient experience, hospital and provider fiscal challenges, and the life of the practicing surgeon. In all areas, surgical leadership was felt to be critical to successfully navigate the new health care landscape as surgeons have a long history of providing safe, high quality, low cost care. The recognition of shared values among the diverse constituents affected by health care policy changes will best prepare surgeons to control their own destiny and successfully manage new challenges as they emerge.

Background: The aim of our study was to compare the outcomes of periampullary and extra-ampullary duodenal adenocarcinomas and segmental duodenal resection versus pancreatoduodenectomy and to evaluate prognostic factors., Methods: We performed a retrospective review of all adults treated for duodenal adenocarcinoma by operative resection at a large tertiary referral center from 1994 to 2009., Results: One hundred twenty-four patients had an operation for duodenal adenocarcinoma over a 15-year period (periampullary, n = 25, and extra-ampullary, n = 99). Ninety-nine patients (80%) underwent curative resection, including 24 (96%) with periampullary and 75 (76%) with extra-ampullary carcinomas. The average number of lymph nodes sampled was eight with segmental resection and 12 with pancreatoduodenectomy (p < 0.001). Five-year overall survivals were 37% for the entire cohort (n = 124), 37% in the extra-ampullary group, and 38% in the periampullary group. Tumor size (p = 0.20), positive nodes (p = 0.60), segmental resection versus pancreatoduodenectomy (p = 0.55), adjuvant therapy (p = 0.23), and R(1) versus R(0) resection (p = 0.21) were not associated with survival. In contrast, advanced T stage and pathologic grade were associated with poor survival., Conclusion: Extra-ampullary and periampullary duodenal adenocarcinomas have similar survival after resection. For distal duodenal tumors, survival is improved by curative resection without being compromised by limited resection. The number of lymph nodes sampled was significantly less with segmental resection than pancreatoduodenectomy.

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAID) show indisputable promise as cancer chemoprevention agents. However, studies have been inconsistent as to whether aspirin has a protective effect in development of pancreatic cancer. To further evaluate the association between aspirin, NSAID, and acetaminophen use with pancreatic cancer risk, we used a clinic-based case-control study of 904 rapidly ascertained histologically or clinically documented pancreatic ductal adenocarcinoma cases, and 1,224 age- and sex-matched healthy controls evaluated at Mayo Clinic from April 2004 to September 2010. Overall, there is no relationship between non-aspirin NSAID or acetaminophen use and risk of pancreatic cancer. Aspirin use for 1 d/mo or greater was associated with a significantly decreased risk of pancreatic cancer (OR = 0.74, 95% CI: 0.60-0.91, P = 0.005) compared with never or less than 1 d/mo. Analysis by frequency and frequency-dosage of use categories showed reduced risk (P = 0.007 and 0.022, respectively). This inverse association was also found for those who took low-dose aspirin for heart disease prevention (OR = 0.67, 95% CI: 0.49-0.92, P = 0.013). In subgroup analyses, the association between aspirin use and pancreatic cancer was not significantly affected by pancreatic cancer stage, smoking status, or body mass index. Our data suggest that aspirin use, but not non-aspirin NSAID use, is associated with lowered risk of developing pancreatic cancer.

Objectives: Although lymphatic spread is common in intrahepatic cholangiocarcinoma (ICC), lymphadenectomy is not widely performed as part of operative resection in this disease. The objectives of this study were to assess national trends for lymphadenectomy and its impact on survival in patients with ICC., Methods: The National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) registry was queried to identify patients with ICC (n=4893) reported during 1988-2007. Kaplan-Maier and Cox proportional hazards regression were used to analyse survival., Results: Five-year overall survival (OS) was 5.2%. Lymph node (LN) status was available for 48.9% (n=2391) of patients. Histologic LN evaluation was performed in 13.5% (n=658) of patients for a median of two (interquartile range: 1-3) LNs. During the study period, the frequency of histologic LN assessment (P=0.78) did not change in liver resection patients. In the 733 resected patients, positive vs. negative LN status was associated with worse 5-year OS of 8.4% vs. 25.9%, respectively (hazard ratio=1.8; P<0.001)., Conclusions: Nodal status is an important prognostic factor for survival in patients diagnosed with ICC. In the USA, few patients undergo hepatic resection with lymphadenectomy; therefore, the clinical benefit of formal lymphadenectomy in ICC remains unknown., (© 2011 International Hepato-Pancreato-Biliary Association.)

Background: Bloating, flatulence, early satiety, and dysphagia resolve in more than 90% of patients early after fundoplication. Gastric dysfunction can persist, however, and a small number of patients develop severe gastric dysfunction (gastroparesis). Management of gastroparesis after antireflux procedures is generally conservative, but gastroparesis can become refractory to medical therapy. The aim of this study was to assess the role of gastric resection in the management of the unusual patient with severe postfundoplication gastric dysfunction., Methods: From January 1990 to October 2010, a total of 5,129 gastric resections were performed at our institution. From this cohort, we identified nine patients with postfundoplication gastric dysfunction managed with gastric resection. Clinical records were reviewed retrospectively for preoperative evaluation, perioperative course, and long-term outcomes., Results: Over 20 years, nine patients were treated with gastric resection for debilitating gastric dysfunction after antireflux surgery. Seven of the nine patients were female; the median preoperative body mass index was 25 kg/m(2) (18-31 kg/m(2)). Median follow-up was 23 months (1-97 months). Preoperatively, five patients required enteral feeding. Postoperatively, although there were no deaths, one patient required operative drainage of a subphrenic abscess, one developed temporary respiratory failure, and one was readmitted for partial small bowel obstruction. Six of the nine patients maintain their nutrition orally, but three are maintained with enteral nutrition. Only two patients are subjectively asymptomatic., Conclusions: Outcomes after gastric resection for postfundoplication gastric dysfunction are poor, with three of the nine patients requiring supplemental nutrition and seven of the nine having persistent symptoms.

Background: Mirizzi syndrome (MS) is characterized by extrinsic compression of the common hepatic duct by stones impacted in the cystic duct or gallbladder neck. Open cholecystectomy (OC) has been the standard treatment; however, laparoscopy has challenged this approach., Study Design: The objective of this study was to review our clinical experience with MS since the introduction of laparoscopic cholecystectomy (LC) and determine the impact of alternative approaches. We conducted a retrospective review of patients with MS from January 1987 to December 2009., Results: There were 36 patients with MS among 21,450 cholecystectomies (frequency 0.18%). Seventeen were women. The most common presenting symptoms were abdominal pain (n = 23) and jaundice (n = 19). Preoperative diagnostic studies included ultrasonography (n = 27), CT (n = 24), and endoscopic retrograde cholangiopancreatography (n = 32). Cholecystectomy was performed in 35 patients; LC was initiated in 15 and OC in 21. Conversion rate from LC to OC was 67%. Five patients who had successful LC had type I MS. Of the patients who underwent LC with conversion or OC, 14 had type I and 16 had type II MS. The cystic duct for type I and the bile duct for type II MS were managed diversely according to surgeon's preference. There was no operative mortality. Morbidity was 31% with Clavien class I in 2, IIIa in 4, IIIb in 1, and IV in 3 patients. Mean hospitalization was 9 days (range 2 to 40 days). Mean follow-up was 37 months (range 1 to 187 months)., Conclusions: Low incidence and nonspecific presentation of MS precludes referral and substantive individual experience. Although LC may be applicable in selected patients with type I MS, OC remains the standard of care., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Intraductal papillary mucinous neoplasms (IPMNs) represent about 25% of all primary pancreatic cystic neoplasms and are increasingly recognized during the last two decades. They are characterized by intraductal proliferation of neoplastic mucinous cells forming papillary projections into the pancreatic ductal system, which is typically dilated and contains globules of mucus. IPMNs may be multifocal and have malignant potential. Modern imaging is essential in establishing preoperative diagnosis and in differentiating different subtypes of IPMNs (i.e., main-duct vs. branch-type disease). Endoscopic retrograde or magnetic resonance cholangiopancreatography accurately delineate the morphologic changes of the pancreatic ductal system. Endoscopic ultrasonography (usually used in conjunction with image-guided FNA and analysis of the aspirated material) is commonly used for differential diagnosis of IPMNs from other pancreatic cystic lesions. Surgical resection (usually anatomic pancreatectomy, depending on the location of the disease) is the treatment of choice. Total pancreatectomy may occasionally be required in selected patients, but is associated with formidable long-term morbidity. A conservative approach has recently been proposed for carefully selected patients with branch-duct IPMNs. Recurrences following surgical resection can be observed, especially in patients with multifocal disease or in the presence of underlying malignancy., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Primary pancreatic cystic neoplasms have been recognized increasingly during the two recent decades and include mainly serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Serous cystic neoplasms represent about 30% of all cystic neoplasms of the pancreas and are characterized by their microcystic appearance (on imaging, macroscopically, and microscopically) and their benign biologic behavior. Modern diagnostic methodology allows the preoperative diagnosis with an acceptable accuracy. Currently, indications for resection of serous cystic neoplasms of the pancreas include the presence of symptoms, size > 4 cm (because these 'large' neoplasms have a more rapid growth rate and probably will soon become symptomatic), and any uncertainty about the diagnosis of a serous versus a mucinous cystic neoplasm. Resection should also be considered for lesions in the body/tail of the pancreas. Conservative treatment is a reasonable option in selected patients (for example in the presence of small, asymptomatic lesions in the pancreatic head, especially in the frail or elderly patient)., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Mucinous cystic neoplasms (MCNs) of the pancreas represent one of the most common primary pancreatic cystic neoplasms, accounting for approximately half of these cases. MCNs are observed almost exclusively in women, and most commonly are located in the body/tail of the pancreas. In contrast to SCNs, MCNs have malignant potential. Proliferative changes (hyperplasia with or without atypia, borderline changes, non-invasive or carcinomas in-situ, and invasive carcinomas) can often be observed within the same neoplasm. Several risk factors for the presence of underlying malignancy within an MCN have recently been recognized. Cross-sectional imaging is of key importance for the diagnostic evaluation of patients with a cystic pancreatic lesion. Cyst fluid examination (cytology, biochemical/genetic analysis) is possible by using fine needle aspiration of the MCN, usually under endoscopic guidance, and may provide useful information for the differential diagnosis. Since MCNs have malignant potential, surgical resection is the treatment of choice., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Recent reports support an association between chronic inflammation and progression to pancreatic cancer (PC)., Methods: This case-control, candidate gene association study evaluated 1,354 Caucasian patients with pancreatic ductal adenocarcinoma and 1,189 healthy Caucasian controls. We genotyped 1,538 single nucleotide polymorphism (SNP) in 102 genes from inflammatory pathways involving NF-κB. Primary tests of association assumed a multiplicative (log-additive) genotype effect; secondary analyses examined dominant, additive, and recessive SNP effects., Results: After adjusting for known risk factors for PC, single SNP analysis revealed an association between four SNPs in NOS1 and one in the CD101 gene with PC risk. These results, however, were not replicated in a PC case-control and cohort population., Conclusion: NOS1 and CD101 may be associated with a risk of PC; however, these findings did not replicate in other PC populations. Future research is needed into the possible role of NOS1 and CD101 for PC., Impact: This research shows a lack of association between genetic variation in 102 inflammation-related genes and PC. Future research is needed into the possible role of other inflammation-related genes and PC risk., (©2011 AACR.)

Intraductal papillary mucinous neoplasm (IPMN) was first recognized in the 1980s with increasing publications over the last decade as the incidence increased sharply, especially at tertiary-care referral centers. Population-based studies have estimated the age and sex-adjusted cumulative incidence of IPMN to be 2.04 per 100 000 person-years (95% confidence interval: 1.28-2.80). It is now understood that IPMN can be classified anywhere along the spectrum of the adenoma to carcinoma sequence and often harbors mutations in genes such as KRAS early in the disease process. Many patients are diagnosed incidentally after imaging of the abdomen for other diagnostic purposes. Patients that present with a history of symptoms such as pancreatitis and abdominal pain are at high risk of harboring a malignancy. Clinicopathologic features such as involvement of the main pancreatic duct, presence of mural nodules, and side branch disease > 3.0 cm in size may indicate that there is an underlying invasive component to the IPMN. In addition, the incidence of extra-pancreatic neoplasms is higher in patients with IPMN, with reported rates of 25% to 50%. There are no current screening recommendations to detect and diagnose IPMN but once the diagnosis is made, screening for extrapancreatic neoplasms such as colon polyps and colorectal cancer should be considered. Surgical resection is the recommend treatment for patients with high-risk features while close observation can be offered to patients without worrisome signs and symptoms of carcinoma.

Background: Hepatic epithelioid haemangioendothelioma (HEH) is a rare vascular neoplasm with unpredictable clinical behaviour., Aim: To compare overall survival (OS) and disease-free survival (DFS) between liver resection (LR) and orthotopic liver transplantation (OLT) for the treatment of HEH., Methods: Retrospective review of 30 patients with HEH treated at Mayo Clinic during 1984 and 2007., Results: Median age was 46 years with a female predominance of 2:1. Treatment included LR (n= 11), OLT (n= 11), chemotherapy (n= 5) and no treatment (n= 3). LR was associated with a 1-, 3- and 5-year OS of 100%, 86% and 86% and a DFS of 78%, 62% and 62%, respectively. OLT was associated with a 1-, 3- and 5-year OS of 91%, 73% and 73% and a DFS 64%, 46% and 46%, respectively. Metastases were present in 37% of patients but did not significantly affect OS. Important predictors of a favourable OS and DFS were largest tumour ≤ 10 cm and multifocal disease with ≤ 10 nodules., Conclusion: LR and OLT achieve comparable results in the treatment of HEH. LR is appropriate for patients with resectable disease and favourable prognostic factors. OLT is appropriate for patients with unresectable disease and possibly those with unfavourable prognostic factors. Metastases may not be a contraindication to surgical treatment., (© 2010 International Hepato-Pancreato-Biliary Association.)

Benign pathologies of the liver often include several cystic diseases, such as simple cysts, autosomal dominant polycystic liver disease, and Caroli's disease. The differential of hepatic cysts also includes infectious pathologies, such as pyogenic liver abscess, hydatid cysts, and parasitic infections if the appropriate clinic setting. Understanding of the various causes, clinical presentation, and treatment options is required to ensure the appropriate surgical management of these patients., (Copyright 2010 Elsevier Inc. All rights reserved.)

Hypothesis: Laparoscopic distal pancreatectomy (LDP) provides outcome advantages compared with open distal pancreatectomy (ODP)., Design: Single-institutional, retrospective review from January 1, 2004, to May 1, 2009., Setting: Tertiary referral center., Patients: Patients undergoing LDP (n = 100) were matched by age, pathologic diagnosis, and pancreatic specimen length to a cohort undergoing ODP (n = 100)., Main Outcome Measures: Perioperative outcomes and overall 30-day morbidity and mortality. Univariate and multivariate analyses were performed using logistic or linear regression as appropriate., Results: Patients in the LDP group did not differ from those in the ODP group in age (mean, 59.0 vs 58.6 years; P = .85), sex (60% vs 50% female; P = .16), body mass index (calculated as weight in kilograms divided by height in meters squared) (mean, 27.4 vs 27.9; P = .44), or American Society of Anesthesiologists score of 3 or higher (58% vs 52%; P = .39). Tumor size was greater in the ODP group than in the LDP group (mean, 4.0 vs 3.3 cm; P = .02). The LDP group as compared with the ODP group demonstrated decreased blood loss (mean, 171 vs 519 mL; P < .001) and shorter duration of hospital stay (mean, 6.1 vs 8.6 days; P < .001). There were no differences between the LDP and ODP groups in operative time (mean, 214 vs 208 minutes; P = .50), pancreatic leak rate (17% vs 17%; P > .99), overall 30-day morbidity (34% vs 29%; P = .45), and 30-day mortality (3% vs 1%; P = .62)., Conclusions: The laparoscopic approach to distal pancreatectomy appears to provide advantages of reduced blood loss and length of hospital stay in selected patients compared with the open approach. Overall complication rates appear similar. Patient selection bias and limits of a retrospective analysis warrant prospective validation.

Objective: To estimate the frequency of extrapancreatic neoplasms in patients with IPMN compared with those with ductal pancreatic cancer and a general referral population., Summary Background Data: Several studies have reported an increased risk of extrapancreatic neoplasms in patients with IPMN, but these studies focused only on those patients who underwent resection and excluded those patients treated nonoperatively., Methods: All patients diagnosed with IPMN at Mayo Clinic from 1994 to 2006 were identified. Two control groups consisting of Group 1-patients with a diagnosis of ductal pancreatic adenocarcinoma (1:1) and Group 2-a general referral population (3:1) were matched for gender and age at diagnosis, year of registration, and residence. Logistic regression was used to assess the risk of a diagnosis of extrapancreatic neoplasms among cases versus controls., Results: There were 471 cases, 471 patients in Group 1, and 1413 patients in Group 2. The proportion of IPMN patients having any extrapancreatic neoplasm diagnosed before or coincident to the index date was 52% (95% CI, 47%-56%), compared with 36% (95% CI, 32%-41%) in Group 1 (P < 0.001), and 43% (95% CI, 41%-46%) in Group 2 (P = 0.002). Benign neoplasms most frequent in the IPMN group were colonic polyps (n = 114) and Barrett's neoplasia (n = 18). The most common malignant neoplasms were nonmelanoma skin (n = 35), breast (n = 24), prostate (n = 24), colorectal cancers (n = 19), and carcinoid neoplasms (n = 6)., Conclusions: Patients with IPMN have increased risk of harboring extrapancreatic neoplasms. Based on the frequency of colonic polyps, screening colonoscopy should be considered in all patients with IPMN.

Background: Despite increasing numbers of reports, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is not yet recognized as a unique neoplasm. The aim of the present study was to define the presence of BT-IPMN in a large series of resected biliary neoplasms., Methods: From May 1994 to December 2006, BT-IPMN cases were identified by reviewing pathology specimens of all resected cholangiocarcinomas and other biliary neoplasms when cystic, papillary or mucinous features were cited in pathology reports., Results: BT-IPMN was identified in 23 out of 253 (9%) specimens using the strict histopathological criteria of IPMN. The most common presenting symptom was abdominal discomfort which was present in 15 patients (65%). Only one of the original operative pathology reports used the term IPMN; 16 (70%) used the terms cystic, mucinous and/or papillary. BT-IPMN was isolated to non-hilar extra-hepatic ducts in 12 (52%), intra-hepatic ducts in 6 (26%) and hilar extra-hepatic ducts in 5 patients (22%). Carcinoma was found in association with BT-IPMN in 19 patients (83%); 5-year survival was 38% after resection., Conclusion: BT-IPMN occurs throughout the intra- and extra-hepatic biliary system and can be identified readily as a unique neoplasm. Broader acceptance of BT-IPMN as a unique neoplasm may lead to a better understanding of the pathogenesis of biliary malignancies.

Study Aims: To determine if neoadjuvant FOLFOX/FOLFIRI is associated with improved disease-free survival (DFS) or overall survival (OS) in patients with colorectal metastases (CRM) to the liver., Methods: Ninety-nine patients (from 457 eligible) with CRM that underwent hepatic resection during 2000 to 2005 were included. Group 1 (n = 44) patients received neoadjuvant FOLFOX/FOLFIRI, and Group 2 (n = 55) did not receive neoadjuvant therapy., Results: There were 58% men. The median age for Group 1 was 58 and Group 2, 64 (p = 0.03). OS for Group 1 at 1, 3, and 5 years was 93%, 62%, and 51%, respectively, with a median OS of 5.8 years. In Group 2 survival at 1l, 3, and 5 years was 90%, 63%, and 45%, respectively, with a median OS of 3.7 years (HR 1.06, p = 0.87). The DFS for Group 1 at 1, 3, and 5 years was 51%, 20%, and 20%, with a median DFS of 1.1 years and Group 2 at 1, 3, and 5 years was 58%, 32%, and 32% (median DFS-1.2 years; HR = 1.24, p = 0.45)., Conclusions: Neoadjuvant FOLFOX/FOLFIRI was employed more frequently in younger patients with CRM; however, neoadjuvant chemotherapy for CRM was not significantly associated with an increase in OS or DFS, despite additional adjuvant therapy.

Objectives: Intraductal mucinous papillary neoplasm (IPMN) is being recognized with increasing frequency around the world. The true incidence, however, remains unknown. Our goal was to determine the incidence of IPMN in a population study., Methods: We used the records-linkage system of the Rochester Epidemiology Project to ascertain age- and sex-adjusted incidence rates of IPMN in Olmsted County, Minn, from January 1, 1984, to December 31, 2005. We also evaluated the number of prevalent cases as of December 31, 2005., Results: We identified 28 incident cases of IPMN. The age- and sex-adjusted cumulative incidence for IPMN in Olmsted County is 2.04 cases per 100,000 persons (95% confidence interval [CI], 1.28-2.80) from 1984 to 2005. Point prevalence on December 31, 2005, was 25.96 cases per 100,000 persons (95% CI, 14.53-37.38 cases) or 1 per 3852. Restricting to county residents 60 years and older, the point prevalence is 99.10 cases per 100,000 persons (95% CI, 54.40-143.79 cases) or one per 1009 persons. Thirty-two percent of patients were treated surgically. The 5-year survival rate after diagnosis was 59.6%., Conclusions: The incidence of IPMN in Olmsted County is low but increasing. Most patients do not die of complications related to the disease.

Background: The study of long-term complications after pancreaticoduodenectomy (PD) for malignant disease has been problematic given the paucity of patients with long-term survival after diagnosis and surgical resection. We therefore studied patients who were surgically treated with a PD for a benign diagnosis to evaluate long-term anastomotic durability., Methods: A retrospective analysis of 122 patients who had PD performed in the interval 1993-2003 inclusive for benign pancreatic diseases was undertaken. Long-term morbidity and mortality (specifically biliary, pancreaticojejunostomy [PJ], and gastrojejunostomy [GJ] strictures) were evaluated., Results: Gender was equally represented with 53% female and 47% male. The median age at surgery was 55 years (range 15-81 years). The three most frequent diagnoses were chronic pancreatitis (40%), intraductal papillary mucinous neoplasm (16%), and cystic neoplasms (9%). Median follow-up in the 95 patients alive at last follow-up was 4.1 years (10 days-12.6 years). The 5- and 10-year survival rates were 83% (76, 91%) and 62% (49%, 78%), respectively. The observed survival was significantly lower than the expected survival in an age- and gender-matched U.S. white population, p<0.001 (one-sample log-rank test). The 5- and 10-year cumulative probability of biliary stricture was 8% (2%, 14%) and 13% (4%, 22%), respectively. For pancreatic strictures the 5- and 10-year rates were 5% (0%, 9%) and 5% (0%, 9%), respectively. No GJ strictures were noted. The management of biliary strictures was primarily with dilatation and stent (78%) and less commonly operative intervention (22%). Pancreatic strictures required surgery alone (25%), surgery followed by endoscopic intervention (25%), or endoscopic therapy alone (50%)., Conclusion: Intervention for anastomotic strictures after pancreaticoduodenectomy is uncommon. Biliary strictures can usually be treated nonoperatively with dilation and stent. Our study likely underestimates the incidence of stricture formation. Prospective imaging studies may be warranted for a more accurate assessment of the rate of long-term anastomotic complications.

Several definitions for pancreatic leakage after pancreaticodoudenectomy exist, and the reported range of 2-50% underscores this variation. The goal was to determine if drain data alone was predictive of a leak and validate International Study Group on Pancreatic Fistula (ISGPF) leak criteria. Participating surgeons entered de-identified data into a web-based database designed to collect Whipple-related data. Definitions used were the ISGPF definition, > or = 3 days, amylase 3x normal; and Sarr's definition, > or = 5 days, amylase 5x normal, > 30 ml. We compared how well these two definitions were at detecting a leak and its complications. There were 1,507 cases submitted from 16 international institutions. A pancreaticoduodenectomy (PPPD) was performed in 76.2%. Drain placement occurred in 98.0%. Using the ISGPF definition, the pancreatic leak rate was 26.7 and 14.3% with the Sarr definition. There were more grades A and B leaks detected by the ISGPF definition. Both determined grade C leaks equally. Both definitions correlated with an increased length of stay (LOS), need for percutaneous drains, reoperation, and delayed gastric emptying (DGE). Neither was associated with an increased risk of intensive care unit (ICU) stay or 30-day mortality. The ISGPF was able to capture more patients with clinically relevant leaks than Sarr's criteria; however, the ability to detect a leak by drain data alone is imperfect.

The concept that complex surgical procedures should be performed at high-volume centers to improve surgical morbidity and mortality is becoming widely accepted. We wanted to determine if there were differences in the treatment of patients with gastric cancer between community cancer centers and teaching hospitals in the United States. Data from the 2001 Gastric Cancer Patient Care Evaluation Study of the National Cancer Data Base comprising 6,047 patients with gastric adenocarcinoma treated at 691 hospitals were assessed. The mean number of patients treated was larger at teaching hospitals (14/year) when compared to community centers (5-9/year) (p<0.05). The utilization of laparoscopy and endoscopic ultrasonography were significantly more common at teaching centers (p<0.01). Pathologic assessment of greater than 15 nodes was documented in 31% of specimen at community hospitals and 38% at teaching hospitals (p<0.01). Adjusted for cancer stage, chemotherapy and radiation therapy were utilized with equal frequency at all types of treatment centers. The 30-day postoperative mortality was lowest at teaching hospitals (5.5%) and highest at community hospitals (9.9%) (p<0.01). These data support previous publications demonstrating that patients with diseases requiring specialized treatment have lower operative mortality when treated at high-volume centers.