Background
Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared ...fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC.
Methods
Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot’s triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected.
Results
Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m
2
, respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min,
p
< 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C.
Conclusions
NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.
Background
The impact of emergency department admission prior to pancreatic resection on perioperative outcomes is not well described. We compared patients who underwent pancreatic cancer surgery ...following admission through the emergency department (ED-surgery) with patients receiving elective pancreatic cancer surgery (elective) and outcomes.
Study Design
The Nationwide Inpatient Sample database was used to identify patients undergoing pancreatectomy for cancer over 5 years (2008–2012). Demographics and hospital characteristics were assessed, along with perioperative outcomes and disposition status.
Results
A total of 8158 patients were identified, of which 516 (6.3%) underwent surgery after admission through the ED. ED-surgery patients were more often socioeconomically disadvantaged (non-White 39% vs. 18%, Medicaid or uninsured 24% vs. 7%, from lowest income area 33% vs. 21%; all
p
< .0001), had higher comorbidity (Elixhauser score > 6: 44% vs. 26%,
p
< .0001), and often had pancreatectomy performed at sites with lower annual case volume (< 7 resections/year: 53% vs. 24%,
p
< .0001). ED-surgery patients were less likely to be discharged home after surgery (70% vs. 82%,
p
< .0001) and had higher mortality (7.4% vs. 3.5%,
p
< .0001). On multivariate analysis, ED-surgery was independently associated with a lower likelihood of being discharged home (aOR 0.55 (95%CI 0.43–0.70)).
Conclusion
Patients undergoing pancreatectomy following ED admission experience worse outcomes compared with those who undergo surgery after elective admission. The excess of socioeconomically disadvantaged patients in this group suggests factors other than clinical considerations alone drive this decision. This study demonstrates the need to consider presenting patient circumstances and preoperative oncologic coordination to reduce disparities and improve outcomes for pancreatic cancer surgery.
Background
For patients with metastatic pancreatic cancer, FOLFIRINOX (fluorouracil 5-FU, leucovorin LV, irinotecan IRI, and oxaliplatin) has shown improved survival rates compared with gemcitabine ...but with significant toxicity, particularly in patients with a high tumor burden. Because of reported response rates exceeding 30 %, the authors began to use a modified (m) FOLFIRINOX regimen for patients with advanced nonmetastatic disease aimed at downstaging for resection. This report describes their experience with mFOLFIRINOX and aggressive surgical resection.
Methods
Between January 2011 and August of 2013, 43 patients with borderline resectable pancreatic cancer (BRPC,
n
= 18) or locally advanced pancreatic cancer (LAPC,
n
= 25) were treated with mFOLFIRINOX (no bolus 5-FU, no LV, and decreased IRI). Radiation was used based on response and intended surgery. Charts were retrospectively reviewed to assess response, toxicities, and extent of resection when possible.
Results
The most common grade 3/4 toxicity was diarrhea in six patients (14 %) with no grade 3/4 neutropenia or thrombocytopenia. Resection was attempted in 31 cases (72 %) and accomplished in 22 cases (51.1 %) including 11 of 25 LAPC cases (44 %). Vascular resection was required in 4 cases (18 %), with R0 resection in 86.4 % of the resections. Complications occurred in 6 cases (27 %), with no perioperative deaths. The median progression-free survival period was 18 months if the resection was achieved compared with 8 months if no resection was performed (
p
< 0.001).
Conclusion
Neoadjuvant mFOLFIRINOX is an effective, well-tolerated regimen for patients with advanced nonmetastatic pancreatic cancer. When mFOLFIRINOX is coupled with aggressive surgery, high resection rates are possible even when the initial imaging shows locally advanced disease. Although data are still maturing, resection appears to offer at least a progression-free survival advantage.
Background
Cancers of the ampulla of Vater, distal common bile duct, and pancreas are known to have dismal prognosis. It is often reported that ampullary cancers are less aggressive relative to the ...other periampullary carcinomas. We sought to evaluate predictors of survival for periampullary cancers following pancreaticoduodenectomy to identify biologic behavior.
Methods
We reviewed the records of all patients who underwent pancreaticoduodenectomy for periampullary carcinoma between 1992 and 2007 at the Ohio State University Medical Center. Demographics, treatment, and outcome/survival data were analyzed. Kaplan–Meier survival curves were created and compared by log-rank analysis. Multivariate analysis was undertaken using Cox proportional-hazards method.
Results
346 consecutive periampullary malignancies (249 pancreatic cancers, 79 ampullary carcinomas, 18 extrahepatic cholangiocarcinomas) treated by pancreaticoduodenectomy were identified. Pancreatic cancer histology correlated with the shortest median survival (17.1 months), followed by cholangiocarcinoma (17.9 months) and ampullary carcinoma (44.3 months) (
P
< 0.001). Potential predictors of decreased survival on univariate analysis included site of origin, preoperative jaundice, microscopic positive margin, nodal metastasis, lymphovascular invasion, neural invasion, and poor differentiation. Only nodal metastasis (median 16.2 versus 29.9 months,
P
< 0.001) and neural invasion (median 17.7 versus 47.9 months,
P
< 0.00001) significantly predicted outcome on multivariate analysis.
Conclusions
Although ampullary cancers have the best prognosis overall, when controlled for tumor stage, only presence of neural invasion and nodal metastasis predict poor survival following pancreaticoduodenectomy. Biological behavior remains the most important prognostic indicator in periampullary cancers amenable to resection, regardless of site of origin.
Background The incidence of pancreatic cancer is age related; patients older than the age of 65 represent 60% of all cases. We assessed our institution's experience and outcomes with pancreatic ...resection for malignancy in patients in their ninth decade. Study Design We reviewed records of patients undergoing pancreatic resection for malignancy at our institution between 1990 and 2007. Demographics, laboratory, treatment, and outcomes data were gathered. Comparisons were made between patients older and younger than the age of 80. Survival was analyzed using the Kaplan-Meier method and comparisons between groups were performed using the log-rank test. Regression methods were used to evaluate predictors of outcomes. Results There were 517 pancreatic resections for cancer reviewed. Of these, 27 patients were 80 years or older (age range 80 to 91 years), compared with 490 patients less than 80 (range 20 to 79 years). The distribution of clinical characteristics was similar between the 2 groups. The majority of patients undergoing pancreatic resection harbored a mass in the head of the pancreas, so the most common procedure was pancreaticoduodenectomy (n = 398, 78%). There were no significant differences in complication rates for younger and older groups (59% vs 52%, respectively, p = 0.4), median length of stay (11 vs 12 days, p = 0.33), or perioperative mortality rates (3.7% vs 3.7%, p = 1.0). Overall survival between the 2 groups was similar (21.9 vs 33.3 months, p = 0.18). Conclusions Pancreatectomy for malignancy is a safe option for the elderly. Patients older than age 80 achieved similar results, with similar rates of perioperative complications and mortality. Pancreatectomy for cancer offers a similar survival benefit in both groups.
Introduction
Robotic-assisted surgery is gaining popularity in general surgery. Our objective was to evaluate and compare operative outcomes and total costs for robotic cholecystectomy (RC) and ...laparoscopic cholecystectomy (LC).
Methods and Procedures
A retrospective review was performed for all patients who underwent single-procedure RC and LC from January 2011 to July 2015 by a single surgeon at a large academic medical center. Demographics, diagnosis, perioperative variables, postoperative complications, 30-day readmissions, and operative and hospital costs were collected and analyzed between those patient groups.
Results
A total of 237 patients underwent RC or LC, and comprised the study population. Ninety-seven patients (40.9 %) underwent LC, and 140 patients (50.1 %) underwent RC. Patients who underwent RC had a higher body mass index (
p
= 0.03), lower rates of coronary artery disease (
p
< 0.01), and higher rates of chronic cholecystitis (
p
< 0.01). There were lower rates of intraoperative cholangiography (
p
< 0.01) and conversion to an open procedure (
p
< 0.01), however longer operative times (
p
< 0.01) for patients in the RC group. There were no bile duct injuries in either group, no difference in bile leak rates (
p
= 0.65), or need for reoperation (
p
= 1.000). Cost analysis of outpatient-only procedures, excluding cases with conversion to open or use of intraoperative cholangiography, demonstrated higher total charges (
p
< 0.01) and cost (
p
< 0.01) and lower revenue (
p
< 0.01) for RC compared to LC, with no difference in total payments (
p
= 0.34).
Conclusions
Robotic cholecystectomy appears to be safe although costlier in comparison with laparoscopic cholecystectomy. Further studies are needed to understand the long-term implications of robotic technology, the cost to the health care system, and its role in minimally invasive surgery.
Abstract Background Previous studies have demonstrated correlations between personality traits and job performance and satisfaction. Evidence suggests that personality differences exist between ...surgeons and nonsurgeons, some of which may develop during medical training. Understanding these personality differences may help optimize job performance and satisfaction among surgical trainees and be used to identify individuals at risk of burnout. This study aims to identify personality traits of surgeons and nonsurgeons at different career points. Materials and methods We used The Big Five Inventory, a 44-item measure of the five factor model. Personality data and demographics were collected from responses to an electronic survey sent to all faculty and house staff in the Departments of Surgery, Medicine, and Family Medicine at The Ohio State University College of Medicine. Data were analyzed to identify differences in personality traits between surgical and nonsurgical specialties according to level of training and to compare surgeons to the general population. Results One hundred ninety-two house staff and faculty in surgery and medicine completed the survey. Surgeons scored significantly higher on conscientiousness and extraversion but lower on agreeableness compared to nonsurgeons (all P < 0.05). Surgery faculty scored lower in agreeableness compared with that of surgery house staff ( P = 0.001), whereas nonsurgeon faculty scored higher on extraversion compared with that of nonsurgeon house staff ( P = 0.04). Conclusions There appears to be inherent personality differences between surgical and nonsurgical specialties. The use of personality testing may be a useful adjunct in the residency selection process for applicants deciding between surgical and nonsurgical specialties. It may also facilitate early intervention for individuals at high risk for burnout and job dissatisfaction.
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