An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for development of pancreatic cancer. As ...a fourth leading cause of death in the United States, pancreatic cancer is commonly treated with a pancreatico-duodenectomy (PD), or Whipple procedure. Data regarding the effects of obesity on post-operative complication rate primarily comes from specialized centers, however the results are mixed. Our aim is to elucidate the effects that obesity has on outcomes after PD for pancreatic head cancer using a national prospectively maintained clinical database.
The 2010–2015 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) Participant Use Files (PUF) were used as the data source. We identified cases in which PD was performed (CPT code 48150) in the setting of a postoperative diagnosis of pancreatic cancer (ICD9 code 157.0). We excluded cases that had emergency admissions, BMI ≤18.5 kg/m2, intraoperative wound classification of III or IV, and disseminated cancer. Cases with missing BMI, preoperative albumin, operative time, LOS data were also excluded. Multiple imputation for missing sex, race, functional status, and ASA classification using chained equations was performed.16 Patients that had BMI ≥30 kg/m2 were considered obese, and patients with BMI <30 kg/m2 were used as control.
3484 patients underwent pancreaticoduodenectomy for pancreatic cancer. 860 patients were identified as obese. Propensity score analysis was performed matching age, sex, race, functional status, presence of dyspnea, diabetes, hypertension, acute renal failure, dialysis dependence, ascites, steroid use, bleeding disorders, history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), weight loss, American Society of Anesthesiologists (ASA) classification, and preoperative albumin levels. After matching, obese patients had higher risk of 30-day postoperative complications compared to control, including organ space wound infections (OR 1.38, 95% CI 1.07–1.79, p = 0.0128), returning to the operating room (OR 1.39, 95% CI 1.01–1.91, p = 0.0461), failure to extubate for greater than 48 h (OR 1.60, 95% CI 1.09–2.34, p = 0.0153), death (OR 1.68, 95% CI 1.01–2.78, p = 0.0453), septic shock (OR 2.22, 95% CI 1.46–3.38, p = 0.0002), pulmonary embolism (OR 2.42, 95% CI 1.07–5.45, p = 0.0332), renal insufficiency (OR 2.67, 95% CI 1.33–5.38, p = 0.0058). Sensitivity analysis yielded similar results with the exception of risk for return to the operating room, death, and pulmonary embolism, P > .05.
In this large observational study using a national clinical database, obese patients undergoing PD for head of pancreas cancer had increased risk of postoperative complications and mortality in comparison to controls.
•Large observational study based on national clinical database comparing outcomes of obese patients undergoing Whipple procedure.•Obesity linked to decreased survival following Whipple procedure.•Obesity in patients undergoing Whipple procedure for malignancy is associated with increased risk of major postoperative complications.
To test the hypothesis that pancreatic ductal anatomy may predict the likely success of percutaneous drainage of pseudocysts of the pancreas.
Various modalities are currently applied to pseudocysts, ...with little or no data to aid in the choice of management strategy. Pancreatic ductal anatomy was assessed and a system to categorize ductal changes was established.
Patients with a diagnosis of pancreatic pseudocyst were evaluated from 1985 to 2000. Two hundred fifty-three patients have been included in this series. Pancreatic ductal anatomy was defined using endoscopic retrograde cholangiopancreatography and categorized as a normal duct, a stricture, or complete cut-off of the pancreatic duct. Communication between the duct and cyst was noted.
Among the 253 patients, 68 (27%) had spontaneous resolution. Fifty of the remaining 185 had percutaneous drainage and 148 (13 of whom failed to respond to percutaneous drainage) had surgery. There were no deaths in either group. Mean length of time with catheter drainage among all percutaneous drainage patients was 79.2 +/- 19.6 days. Patients with normal pancreatic ducts and those with strictures but no communication between the duct and the cyst who had percutaneous drainage had a much shorter length of hospital stay (6.1 +/- 4.6 days) than patients with strictures and duct-cyst communication and patients with complete cut-off of the duct (33.5 +/- 5.2 days and 39.1 +/- 7.9 days, respectively). Length of drainage also correlated with ductal anatomy. All patients with chronic pancreatitis failed to respond to percutaneous drainage.
Pancreatic ductal anatomy provides a clear correlation with the failure and successes of pseudocysts managed by percutaneous drainage as well as predicting the total length of drainage. Percutaneous drainage is best applied to patients with normal ducts and is acceptably applied to patients with stricture but no cyst-duct communication.
To determine whether surgical intervention prevents recurrent acute exacerbations in chronic pancreatitis (CP).
The primary goal of surgical intervention in the treatment of CP has been relief of ...chronic unrelenting abdominal pain. A subset of patients with CP have intermittent acute exacerbations, often with increasing frequency and often unrelated to ongoing ethanol abuse. Little data exist regarding the effectiveness of surgery to prevent acute attacks.
From 1985 to 1999, all patients identified with a diagnosis of CP were recruited to participate in an ongoing program of serial clinic visits and functional and clinical evaluations. Patients were offered surgery using standard criteria. Data were gathered regarding ethanol abuse, pain, narcotic use, and recurrent acute exacerbations requiring hospital admission before and after surgery. Patients were broadly categorized as having severe unrelenting pain alone (group 1), severe pain with intermittent acute exacerbations (group 2), and intermittent acute exacerbations only (group 3).
Two hundred fifty-nine patients were recruited. One hundred eighty-five patients underwent 199 surgical procedures (124 modified Puestow procedure LPJ, 29 distal pancreatectomies DP, and 46 pancreatic head resections PHR; 14 performed after failure of LPJ). There were no deaths. The complication rate was 4% for LPJ, 15% for DP, and 27% for PHR. Ethanol abuse was causative in 238 patients (92%). Mean follow-up was 81 months. There were 104 patients in group 1 (86 who underwent surgery), 71 patients in group 2 (64 who underwent surgery), and 84 in group 3 (49 who underwent surgery). No patient without surgery had spontaneous resolution of symptoms. Postoperative pain relief (freedom from narcotic analgesics) was achieved in 153 of 185 patients (83%) overall: 106 of 124 (86%) for LPJ, 19 of 29 (67%) for DP, and 42 of 46 (91%) for PHR. The mean rate of acute exacerbations was 6.3 +/- 2.1 events per year before surgery in group 2 and 7.8 +/- 1.8 events per year in group 3. After surgery, no acute exacerbations occurred in 42 of 64 (66%) group 2 patients and in 40 of 49 (82%) group 3 patients. The mean number of episodes of acute exacerbation after surgery was 1.6 +/- 2.3 events in group 2 and 1.1 +/- 1.9 events in group 3. Only four patients in group 2 and one patient in group 3 had an equal or increased frequency of attacks after surgery. Preventing attacks was most effective with LPJ (58/64, 91%) and least effective for DP (6/18, 33%).
Surgical intervention prevents recurrent acute exacerbations. The overall frequency of events was reduced in nearly all patients. Therefore, surgical intervention is indicated in patients with CP whose disease is characterized by recurrent acute exacerbations.
Standard management of gallstone-associated acute pancreatitis calls for cholecystectomy to be performed during the same hospitalization after acute symptoms have subsided. However, infectious ...complications are common when cholecystectomy is performed sooner than 3 weeks after severe acute pancreatitis. Fluid collections, common in patients with moderate to severe acute pancreatitis, are additionally problematic. No previous study has examined the role of peripancreatic fluid collections and subsequent pseudocyst in outcomes after cholecystectomy in these patients.
We compare results of delaying cholecystectomy after moderate to severe acute pancreatitis with early cholecystectomy.
Since 1987, all patients with moderate to severe gallstone-associated acute pancreatitis and associated fluid collections were addressed. Moderate to severe acute pancreatitis was defined as > 5 Ranson prognostic indicators. Fluid collection was established by computed tomography (CT) scan. Patients were evaluated for duration of hospitalization, complications of cholecystectomy, resolution or persistence of pseudocysts, nonoperative interventions performed on pseudocysts, intercurrent episodes of acute pancreatitis during the monitoring period, episodes of sepsis, and mortality.
A total of 187 patients with moderate to severe gallstone-associated acute pancreatitis survived their acute stage; 151 had peripancreatic fluid collections. Seventy-eight of the 187 had early cholecystectomy, 62 of whom had fluid collections; 109 were monitored before cholecystectomy, 89 of whom had fluid collections. Fluid collections resolved without intervention in 36 (40%) of 89 in the monitored group and in 13 (21%) of 62 in the early cholecystectomy group. Percutaneous drainage was performed in 16 (18%) of 89 in the monitored group and in 31 (50%) of 62 in the early cholecystectomy group. Sepsis occurred in 6 (7%) of 89 in the monitored group and 29 (47%) of 62 in the early cholecystectomy group. Complications of cholecystectomy occurred in 6 (5.5%) of 109 of the monitored patients and in 34 (44%) of 78 in the early cholecystectomy group. Fifty-three patients in the monitored group and 49 patients in the early cholecystectomy group required operative pseudocyst-enterostomy. This procedure was combined with cholecystectomy in the monitored patients. Mean hospitalization was longer in the early operation group.
Cholecystectomy should be delayed in patients who survive an episode of moderate to severe acute biliary pancreatitis and demonstrate peripancreatic fluid collections or pseudocysts until the pseudocysts either resolve or persist beyond 6 weeks, at which time pseudocyst drainage can safely be combined with cholecystectomy.
The authors provide a prospective evaluation of long-term results after bilioenteric anastomoses for benign biliary stricture.
With the advent of laparoscopic techniques, the frequency of bile duct ...injury after operation has increased. Reports on the operative management of these injuries have not provided long-term follow-up. Over a similar period, reports of both endoscopic and invasive radiographic methods as primary treatment for bile duct stricture have compared success rates to antiquated surgical reports.
A protocol whereby preoperative radiographic (e.g., cholangiogram, computed tomographic scan, ultrasound), biochemical (e.g., alkaline phosphatase, and total bilirubin), and clinical evaluation was combined with ongoing postoperative evaluation and follow-up at approximately 6-month intervals. A total of 111 patients were evaluated from 1985 to 1995. Patients were categorized in three groups: 1) those with postoperative injuries during open and laparoscopic gallbladder surgery (31 patients), 2) those undergoing operation for pain associated with chronic pancreatitis who have distal common bile duct stenoses (64 patients), and 3) those with nonchronic pancreatitis-associated benign bile duct strictures (16 patients).
Mean follow-up was 60 months. Overall preoperative alkaline phosphatase was 640 units/L with a range of 280 to 1860 units/L. All patients had abnormally elevated alkaline phosphatase. Only 3 of 111 patients have had mild persistent elevation after operation. Clinical jaundice, present in 49 of 111 patients, was resolved uniformly by operative decompression. Total bilirubin was elevated abnormally in 56 of 111 patients and also was uniformly corrected by operation.
These data support the careful combined use of endoscopy, invasive radiology, and surgery in the management of benign strictures of the biliary tree. These data further suggest a success rate for surgical management that, over long-term follow-up, appears to exceed that found using alternative measures. Alternative methods should measure their success rates against success rates currently achieved by operative management.
This study evaluated the effect of operative drainage of the main pancreatic duct (MPD) on functional derangements associated with chronic pancreatitis (CP).
The author previously reported delayed ...functional impairment in an evaluation of the impact of operative drainage in patients with CP. The author now reports on a prospective study of 143 patients with this diagnosis.
Each patient underwent 1) ERCP, 2) the Bentiromide PABA, 3) 72-hour fecal fat test, 4) oral glucose tolerance test (OGTT) and 5) fat meal (LIPOMUL)--stimulated pancreatic polypeptide release (PP). All patients were stratified as mild/moderate (M/M) or severe CP on the basis of a 5-point system that was developed by the author. Patients were studied at 16-month intervals.
All 143 patients underwent initial and follow-up evaluations in a mean follow-up of 47.3 months; 83 of 143 patients had M/M grade at initial evaluation. Eighty-seven patients underwent (MPD) decompression to relieve abdominal pain. In a separate prospective 17 patients with a diagnosis of CP, a grade of M/M and non-disabling abdominal pain were randomized to operative or non-operative treatment; 9 of these randomized patients were operated upon and 8 were not. No patient improved their grade during follow-up; 47 of 83 M/M patients had operative drainage and 36 did not. This grade was preserved in 41 of 47 (87%) operated patients but in only 8 of the 36 non-operated patients (22%). In the randomized trial, seven of nine operated patients retained their functional status in follow-up, whereas only two of eight patients (25%) randomized to non-operation preserved their functional grade.
These data in this large study as well as among a previous randomized sample, support a policy of early operative drainage before the development of irreversible functional impairment in patients with chronic pancreatitis and associated dilation of the main pancreatic duct.
The purpose of our study was to review and report the patient selection, techniques, and results of percutaneous drainage of pancreatic abscesses by retrospective review.
Fifty-nine patients (46 men ...and 13 women) with a mean age of 44 years old had 80 pancreatic abscesses that were drained percutaneously under radiologic guidance (CT, n = 77; sonography, n = 2; and fluoroscopy, n = 1). Abscesses had a wide spectrum of causes, with alcoholic pancreatitis being most common, trauma second most common, and gallstones third. Ten patients had undergone surgery for pancreatic necrosis or abscess. Patients with pancreatic pseudocysts, necrosis, or acute fluid collections were excluded from this study.
Of the 59 patients, 51 (86%) were cured with percutaneous drainage and antibiotic therapy. Of the patients who were not cured with percutaneous drainage, seven required surgery and one underwent repeat percutaneous drainage. In the 59 patients, complications included non-life-threatening bleeding in three patients. Ten of 59 patients (17%) had fistulas that spontaneously formed into the gastrointestinal tract. The duration of catheterization ranged from 4 to 119 days, with a mean duration of 33 days. The rate of mortality at 30 days after completion of percutaneous drainage was 8% (5 of 59).
Percutaneous drainage was an effective therapy for this defined group of patients with pancreatic abscesses. Factors leading to the relatively high success rate described in this study likely included selection of patients; catheters of adequate size, number, and location; careful follow-up with appropriate catheter manipulations; and an integrated, cooperative approach whereby surgeons were willing to permit drainage to effect its benefits, rather than operating prematurely.
In a prospective study, 85 patients with chronic pancreatitis have been subjected to evaluation by morphologic analysis (endoscopic retrograde cholangiopancreatography), by exocrine function tests ...(bentiromide PABA and 72-hour fecal fat testing), and by endocrine function tests (oral glucose tolerance test and fat-stimulated release of pancreatic polypeptide). All patients were graded on a five-point system, with 1 point assessed for an abnormal result in each of the five tests performed. Zero score denoted mild disease; 1-2 points signaled moderate disease; and 3-5 points indicated severe disease. In 68 patients, both an initial and late (mean follow-up period of 14 months) evaluation were performed. Forty-one patients underwent modified Puestow side-to-side Roux-en-Y pancreaticojejunostomy. The Puestow procedure alone was performed in 18 patients. Eight patients also had drainage of pseudocysts, seven also had a biliary bypass, and eight had pseudocyst drainage plus bypass, in addition to the Puestow. There were no deaths. Of the 68 patients who were studied twice, 30 had operations and 38 did not. None of the patients with severe disease improved their grade during follow-up. Of 24 patients who did not undergo operation, 17 (71%) who were graded mild/moderate progressed to a severe grade at follow-up. By contrast, only three of the 19 patients operated on (16%) and who were initially graded as mild/moderate progressed to severe disease at follow-up testing. More than 75% of all of the patients had a history of weight loss. Twenty-six of 30 patients operated on (87%) (all of whom had lost weight before surgery) gained a mean 4.2 kg (range 1.4-2.7 kg) after surgery, compared with no significant weight change (range -3.6-2.7 kg) among patients not operated on. These findings support a policy of early operation for chronic pancreatitis, perhaps even in the absence of disabling abdominal pain.
To compare the clinical outcome of needle aspiration versus percutaneous catheter drainage of sterile fluid collections in patients with acute pancreatitis.
We reviewed the clinical and imaging data ...of patients with acute pancreatic fluid collections from 1998 to 2003. Referral for fluid sampling was based on elevated white blood cell count and fevers. Those patients with culture-negative drainages or needle aspirations were included in the study. Fifteen patients had aspiration of 10-20 ml fluid only (group A) and 22 patients had catheter placement for chronic evacuation of fluid (group C). We excluded patients with grossly purulent collections and chronic pseudocysts. We also recorded the number of sinograms and catheter changes and duration of catheter drainage. The CT severity index, Ranson scores, and maximum diameter of abdominal fluid collections were calculated for all patients at presentation. The total length of hospital stay (LOS), length of hospital stay after the drainage or aspiration procedure (LOS-P), and conversions to percutaneous and/or surgical drainage were recorded as well as survival.
The CT severity index and acute Ransom scores were not different between the two groups (p = 0.15 and p = 0.6, respectively). When 3 crossover patients from group A to group C were accounted for, the duration of hospitalization did not differ significantly, with a mean LOS and LOS-P of 33.8 days and 27.9 days in group A and 41.5 days and 27.6 days in group C, respectively (p = 0.57 and 0.98, respectively). The 60-day mortality was 2 of 15 (13%) in group A and 2 of 22 (9.1%) in group C. Kaplan-Meier survival curves for the two groups were not significantly different (p = 0.3). Surgical or percutaneous conversions occurred significantly more often in group A (7/15, 47%) than surgical conversions in group C (4/22, 18%) (p = 0.03). Patients undergoing catheter drainage required an average of 2.2 sinograms/tube changes and kept catheters in for an average of 52 days. Aspirates turned culture-positive in 13 of 22 patients (59%) who had chronic catheterization. In group A, 3 of the 7 patients converted to percutaneous or surgical drainage had infected fluid at the time of conversion (total positive culture rate in group A 3/15 or 20%).
There is no apparent clinical benefit for catheter drainage of sterile fluid collections arising in acute pancreatitis as the length of hospital stay and mortality were similar between patients undergoing aspiration versus catheter drainage. However, almost half of patients treated with simple aspiration will require surgical or percutaneous drainage at some point. Disadvantages of chronic catheter drainage include a greater than 50% rate of bacterial colonization and the need for multiple sinograms and tube changes over an average duration of about 2 months.
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