Background
Historically, pre-operative biliary stenting has been associated with higher infectious complication rates following pancreatoduodenectomy. However, alleviation of biliary obstruction is ...necessary for consideration of pre-operative chemotherapy, which may improve disease-free survival, or for mitigation of symptoms while awaiting surgery. Our aim is to compare contemporary post-operative complication risk among patients with pre-operative endoscopic retrograde cholangiopancreatography (ERCP) stenting compared to those without.
Methods
Patients who underwent a pancreatoduodenectomy for pancreatic cancer with biliary obstruction within the ACS-NSQIP registry from 2014 to 2017 were identified. The primary outcome was to compare the risk of 30-day complication (composite outcome) between patients with and without pre-operative ERCP stenting. Propensity score matching was used to ensure balanced baseline characteristics and log-binomial regression models were used to estimate risk ratios for overall perioperative complication between groups.
Results
From 6073 patients with obstructive jaundice undergoing pancreatoduodenectomy for pancreatic cancer, 92% (5564) were eligible for the study. After performing a propensity score matching on 20 baseline characteristics, 952 patients without stenting were matched to up to four patients who received pre-operative ERCP stenting (
n
= 3467) for a matched cohort of 4419. A total of 1901 (55%) patients with pre-operative ERCP stenting experienced a post-operative complication compared to 501 (53%) patients without stenting (risk ratio 1.04, 95% CI 0.97–1.11,
p
= 0.23).
Conclusion
Pre-operative ERCP stenting was not associated with an increased risk of post-operative complication in patients undergoing pancreatoduodenectomy with obstructive jaundice. Biliary stenting may be safely considered for symptom relief and to potentially facilitate pre-operative chemotherapy for pancreatic cancer.
•Cross-border healthcare has ensured care for citizens throughout the European Union.•European cross-border healthcare has continued during the COVID-19 pandemic.•North American cross-border ...healthcare is rare but need is ever present.•Acting in isolation during COVID-19 Canada and the United States closed the border.•Cross-border healthcare would be beneficial for North America.
Cross-border healthcare is an international agreement for the provision of out of country healthcare for citizens of partnered countries. The European Union (EU) has established itself as a world leader in cross-border healthcare. During the Coronavirus disease of 2019 (COVID-19) pandemic, the EU used this system to maximize utilization of resources. Countries with capacity accepted critically ill patients from overwhelmed nations, borders remained open to healthcare workers and those seeking medical care in an effort to share the burden of this pandemic. Significant research into the challenges and successes of cross-border healthcare was completed prior to COVID-19, which demonstrated significant benefit for patients.
In North America, the response to the COVID-19 crisis has been more isolationist. The Canada-United States border has been closed and bans placed on healthcare workers crossing the border for work. Prior to COVID-19, cross-border healthcare was rare in North America despite its need. We reviewed the literature surrounding cross-border healthcare in the EU, as well as the need for a similar system in North America. We found the EU cross-border healthcare agreements are generally mutually beneficial for participating countries. The North American literature suggested a cross-border healthcare system is feasible. A number of challenges could be identified based on the EU experience. A prior agreement may have been beneficial during the COVID-19 crisis as many Canadian healthcare institutions-maintained capacity to accept critically ill patients.
ObjectivesGallstone disease is a common reason for emergency department (ED) presentation. Surgeons often prefer radiology department ultrasound (RUS) over point of care ultrasound (POCUS) because of ...perceived of unreliability. Our study was designed to test the hypothesis that POCUS is sufficient to guide the management of surgeons treating select cases of biliary disease as compared to RUS.MethodsThis was a prospective cohort study. Patients who presented to the ED with abdominal pain and findings of biliary disease on POCUS were included. The surgeon was then presented the case with POCUS only and recorded their management decision. Patients then proceeded to RUS, were followed through their stay, and analysis was performed to analyze the proportion of patients where the introduction of the RUS changed the management plan.Results100 patients were included in this study, and all received both POCUS and RUS. Depending on the surgeons’ POCUS based management decisions, the patients were divided into three groups: (1) surgery, (2) duct clearance, (3) no surgery. Total bilirubin was 34±22 mmol/L in the duct clearance group vs 8.4±6.5 mmol/L and 16±12 mmol/L in the surgery and no surgery groups, respectively (p<0.05). POCUS results showed 68 patients would have been offered surgery, 21 offered duct clearance, and 11 no surgery. In 90% of cases, the introduction of RUS did not change management. The acute care surgeons elected to operate on patients more frequently than other surgical subspecialties (p<0.05).ConclusionsThis study showed that fewer than 10% of patients with biliary disease seen on POCUS had a change in surgical decision-making based on the addition of RUS imaging. In uncomplicated cases of biliary disease, relying on POCUS imaging for surgical decision-making has the potential to improve patient flow.Level of evidenceII Prospective Cohort Study.
Recent literature has raised concerns regarding the risk of adverse psychiatric events among bariatric surgery patients. However, the relationship between weight loss therapy and psychiatric outcomes ...is confounded by baseline psychosocial characteristics in observational studies. To understand the impact of bariatric surgery on the risk of adverse mental health outcomes, we conducted a systematic review and meta‐analysis of randomized controlled trials that compared surgical and non‐surgical treatments and assessed mental health quality of life (QoL). We evaluated the PubMed, EMBASE, Web of Science PsycINFO, Clinicaltrials.gov and Cochrane databases through 7 March 2018. Pooled standardized mean differences (SMDs) for mental health QoL scores were estimated using random effects models. Eleven randomized trials with 731 participants were included in the final analyses. Surgery was not associated with an improvement in mental health QoL from baseline as compared to non‐surgical intervention (SMD: 0.02, 95% confidence interval CI −0.22 to 0.25). Final mental health QoL scores were similar for surgically and non‐surgically treated patients (SMD: 0.37, 95% CI −0.07 to 0.81). Subgroup analyses assessing the effect of specific surgical interventions, and varying lengths of follow‐up did not identify a beneficial effect of bariatric surgery on mental health QoL outcomes. These results, in conjunction with the fact that individuals who choose bariatric surgery tend to have high‐risk baseline characteristics, suggest that intensive mental health follow‐up following surgery should be routinely considered.
The role of liver resection for non-colorectal, non-neuroendocrine, non-sarcoma (NCNNNS) metastases is ill-defined. This study aimed to examine the oncologic outcomes of liver resection in such ...patients.
A retrospective analysis of liver resection for NCNNNS metastases was performed at two large centers. Liver resection was offered selectively in patients with stable disease. Oncologic outcomes were examined using the Kaplan-Meier method.
Fifty-two patients underwent liver resection for NCNNNS metastases. Overall 5-year survival was 58%. Five-year survival was 85% for breast metastases, 66% for ocular melanoma, 83% for other melanomas, 50% for gastro-esophageal metastases, and 0% for renal cell carcinoma metastases. A contemporary colorectal liver metastasis cohort had a survival of 63% (p=0.89).
Liver resection is an effective option in the management of selected patients with NCNNNS metastases which have been deemed stable. Five-year survival rates were comparable to that of a contemporary cohort of patients with colorectal liver metastases in carefully selected patients. Further, larger studies are required to help identify potential prognostic variables and aid in decision-making in this heterogeneous population.
Retinal vein occlusion is a frequent cause of visual loss for which few effective therapies are available. Anticoagulation with low molecular weight heparin might be of value in its treatment. We ...conducted a systematic review and meta analysis of randomized trials evaluating the effect of low molecular weight heparin in patients with retinal vein occlusion. Data sources included MEDLINE, EMBASE, HealthSTAR, the Cochrane Library, Lilacs, the Investigative Ophthalmology and Visual Science database and gray literature. Main outcome was the mean difference between the visual acuity measured at baseline and at six months expressed in the logMAR scale. Secondary outcome was a composite of any adverse ocular outcome including: worsening of visual acuity, visual fields or fluorescein angiography, or development of iris neovascularization, any neovascularization or neovascular glaucoma. Subgroup analyses for branch versus central retinal vein occlusion were conducted. We identified 1,084 references of which 3 studies comparing low molecular weight heparin with aspirin (229 evaluable patients) were included. Overall, the pooled mean visual acuity difference was -0.23 logMAR (95% CI -0.38, -0.09; P=0.002) in favor of low molecular weight heparin. Low molecular weight heparin was associated with a 78% risk reduction for developing any adverse ocular outcome (pooled RR 0.22; 95% CI 0.10, 0.46; P<0.001). In subgroup analyses benefits seemed lower in branch retinal vein occlusion. No increased vitreous hemorrhages were observed. In patients with retinal vein occlusion treatment with low molecular weight heparin seems to be associated with improvement in the visual acuity and less adverse ocular outcomes. These benefits might differ in patients with central as opposed to branch retinal vein occlusion. Further studies are required to confirm these findings and clarify its benefits in specific subgroups of patients before definitive recommendations can be made.
Benign Liver and Pancreas (BLiPs) rounds, implemented in 2022 at our Canadian tertiary care center, are a novel concept of a multidisciplinary case conference (MCC) for discussion of benign ...hepatopancreatobiliary (HPB) disease. BLiPs Rounds are a monthly virtual meeting of surgeons, gastroenterologists, and interventional radiologists experienced in biliary and pancreatic disease.BACKGROUNDBenign Liver and Pancreas (BLiPs) rounds, implemented in 2022 at our Canadian tertiary care center, are a novel concept of a multidisciplinary case conference (MCC) for discussion of benign hepatopancreatobiliary (HPB) disease. BLiPs Rounds are a monthly virtual meeting of surgeons, gastroenterologists, and interventional radiologists experienced in biliary and pancreatic disease.This case series was completed to review the patient cases discussed over the first year of BLiPs rounds, and to evaluate the effect of the multidisciplinary discussion on patient management plans. Meeting minutes were reviewed for BLiPs rounds between May 2022 and July 2023. Data were collected retrospectively on all discussed patients by review of the electronic medical record, and analyzed using frequencies and means with standard deviations.METHODSThis case series was completed to review the patient cases discussed over the first year of BLiPs rounds, and to evaluate the effect of the multidisciplinary discussion on patient management plans. Meeting minutes were reviewed for BLiPs rounds between May 2022 and July 2023. Data were collected retrospectively on all discussed patients by review of the electronic medical record, and analyzed using frequencies and means with standard deviations.Between May 2022 and July 2023, 56 cases were discussed at 12 case conferences. 68% of cases concerned pancreatic pathology, 25% concerned biliary pathology, the remainder liver or duodenal pathology. 49 cases (88%) were presented to discuss therapeutic options, and 7 presented as diagnostic challenges. Cases were usually presented once, but 7 patients were discussed at multiple conferences due to complex issues or ongoing symptomatology. 40 patients (71%) had undergone previous endoscopic, percutaneous, or surgical interventions prior to discussion. Endoscopic intervention was recommended in 32% of cases, percutaneous interventional approach in 13%, a combined endoscopic and percutaneous approach in 9%, and surgery in 18%. Repeat imaging or observation was recommended in 29% of cases. Discussion at rounds led to a change or adjustment in the proposed management in 46 cases (82%). The plan recommended by the MCC was carried out in 71% of cases.RESULTSBetween May 2022 and July 2023, 56 cases were discussed at 12 case conferences. 68% of cases concerned pancreatic pathology, 25% concerned biliary pathology, the remainder liver or duodenal pathology. 49 cases (88%) were presented to discuss therapeutic options, and 7 presented as diagnostic challenges. Cases were usually presented once, but 7 patients were discussed at multiple conferences due to complex issues or ongoing symptomatology. 40 patients (71%) had undergone previous endoscopic, percutaneous, or surgical interventions prior to discussion. Endoscopic intervention was recommended in 32% of cases, percutaneous interventional approach in 13%, a combined endoscopic and percutaneous approach in 9%, and surgery in 18%. Repeat imaging or observation was recommended in 29% of cases. Discussion at rounds led to a change or adjustment in the proposed management in 46 cases (82%). The plan recommended by the MCC was carried out in 71% of cases.BLiPs case conference provides a valuable venue to discuss cases, encourage interdisciplinary collaboration, and refine treatment approaches, leading to a change in proposed management plan in over three-quarters of cases presented.CONCLUSIONBLiPs case conference provides a valuable venue to discuss cases, encourage interdisciplinary collaboration, and refine treatment approaches, leading to a change in proposed management plan in over three-quarters of cases presented.
Background: Postoperative pulmonary complications (PPCs) are common following surgery. Preoperative pulmonary physiotherapy can decrease the risk of PPCs. Oscillating positive expiratory pressure ...(OPEP) is a novel respiratory therapy that uses positive pressure and oscillatory vibrations to exercise pulmonary muscles and promote mucus clearance. Evidence is lacking regarding the use of OPEP devices in the preoperative setting to reduce PPCs. Methods: We conducted a systematic review to identify all available literature regarding the usage of OPEP or similar respiratory modalities in the preoperative setting for reducing PPCs. We conducted a literature search within CINAHL Complete, Cochrane Central Register of Controlled Trials, Ovid AMED, Ovid Embase Classic+Embase, Ovid MEDLINE, and PubMed. Title, background, and full-text screening were performed independently by 2 investigators. We included studies that were trial based, involved a comparison of therapeutic interventions, and where patients received OPEP therapy, or a similar device-based respiratory therapy, preoperatively. Included studies examined the effect of the intervention on the incidence of PPCs. We excluded studies that were not trial based, used postoperative or intraoperative interventions, and all other studies using respiratory therapies unrelated to OPEP. Results: We identified 598 studies; 43 were selected for detailed evaluation, and 4 met our inclusion criteria. Only 1 study used an OPEP device in the preoperative setting, which demonstrated a reduction in PPCs from 20.5% to 2.9%. The remaining studies used respiratory therapy modalities such as intermittent positive pressure breathing, bottle blowing, and inspiratory muscle training, without demonstrating a reduction in PPCs. Conclusion: This systematic review demonstrates a paucity of data regarding the potential impact of OPEP therapy in the preoperative setting for PPC reduction. Most studies identified in the literature were performed in the postoperative setting. Only 1 study used an OPEP device exclusively in the preoperative setting. Further trials are needed to address this knowledge gap.
With a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop ...reliable benchmarking targets.
To investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients.
This is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016.
A multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery.
Among a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR odds ratio .85, 95% CI confidence interval .70-1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26-4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02-1.62), and previously higher health care users (OR 1.30, 95% CI 1.15-1.46) were most significantly associated with reoperations.
Reoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.
Periampullary cancer (PC) is a term encompassing malignancies that originate near the ampulla of Vater. It includes cancers of the head and neck of the pancreas, distal common bile duct, second part ...of the duodenum, and the ampulla itself. Differentiating between these entities, even with biopsy, is often not possible. Therefore, PC is managed identically to pancreatic adenocarcinoma, the fourth leading cause of cancer death in the United States despite representing only 3.1% of new cancer diagnoses. Surgical resection by pancreaticoduodenectomy is the only potentially curative measure. Unfortunately, as PC frequently presents at an advanced stage (particularly pancreatic adenocarcinoma), it is often inoperable at the time of diagnosis. The 2016 National Comprehensive Cancer Network (NCCN) Guidelines for Pancreatic Adenocarcinoma define criteria to determine resectability. Nonetheless, a subset of patients undergo noncurative laparotomy (NCL) either because the resection is 1) margin positive (termed an R1 resection) or 2) the disease is found to be unresectable due to local invasion or unexpected metastases. Although it is not the preferred outcome, NCL can benefit patients via definitive staging in borderline resectable cases, surgical bypass of obstructed bowel or bile ducts, placement of fiducial markers for radiation therapy, and tumour debulking. One reason NCLs occur is the failure to detect any of the following: vascular invasion, lymph node involvement, and distant metastases via preoperative computed tomography (CT). The Society of Abdominal Radiology and American Pancreatic Association have published a structured reporting template containing the significant criteria for resectability. This is intended primarily for pancreatic adenocarcinoma, but its components are salient for staging other PCs, as differentiating between them preoperatively is not always possible. There is growing evidence that structured reports more effectively communicate disease extent than do nonstructured reports, and may better inform surgical decision making. For example, Brook et al obtained feedback of structured and nonstructured reports for pancreatic cancer from three pancreatic surgeons. All surgeons found that the structured reports contained sufficient information for surgical planning significantly more often than did nonstructured reports. Two of three surgeons found that information pertinent to surgical planning was more easily accessible in structured reports significantly more often than in nonstructured reports. In our study, using the aforementioned structured reporting template, we retrospectively examined CT scans of patients with PC who had an NCL. To the best of our knowledge, this subgroup has not received focused study in the literature. Our aim was to improve identification of borderline resectable or unresectable PC. This would potentially allow for the application of neoadjuvant treatment or minimally invasive palliative procedures, avoiding the morbidity of NCL. Specifically, we analysed preoperative CT in these patients to 1) identify evidence of unresectable disease, 2) correlate imaging with surgical and pathological findings, and 3) compare retrospectively performed structured reviews—blinded to the original CT reports and other findings—to the original nonstructured reports in terms of predicted resectability.
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