Deborah McGrath

Massachusetts General Hospital, Boston, MA, United States

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Publications (9)43.62 Total impact

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    ABSTRACT: Since Allen O. Whipple published his seminal paper in 1935, the procedure that bears his name has been performed widely throughout the world and is now a common operation in major medical centers. The goal of this study was to investigate the evolution of pancreatoduodenectomy at the Massachusetts General Hospital (MGH). We sought to identify all pancreatoduodenectomies performed at the MGH since 1935. Cases were obtained from a computerized database, hospital medical records, and the MGH historical archive. Demographics, diagnosis, intraoperative variables and short-term surgical outcomes were recorded. The first pancreatoduodenectomy at the MGH was carried out in 1941; since then, 2,050 Whipple procedures have been performed. Pancreatic ductal adenocarcinoma was the most frequent indication (36%). Pylorus preservation has been the most important variation in technique, accounting for 45% of Whipple procedures in the 1980s; observation of frequent delayed gastric emptying after this procedure led to decline in its use. Pancreatic fistula was the most frequent complication (13%). Operative blood replacement and reoperation rates have decreased markedly over time; the most frequent indication for reoperation was intra-abdominal bleeding. Mortality has decreased from 45% to 0.8%, with sepsis and hypovolemic shock being the most frequent causes of death. Mean duration of hospital stay has decreased from >30 to 9.5 days, along with an increasing readmission rate (currently 19%). The Whipple procedure in the 21st century is a well-established operation. Improvements in operative technique and perioperative care have contributed in making it a safe operation that continues evolving.
    Surgery 07/2012; 152(3 Suppl 1):S56-63. · 3.37 Impact Factor
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    ABSTRACT: Invasive cancers arising from intraductal papillary mucinous neoplasm (IPMN) are recognised as a morphologically and biologically heterogeneous group of neoplasms. Less is known about the epithelial subtypes of the precursor IPMN from which these lesions arise. The authors investigate the clinicopathological characteristics and the impact on survival of both the invasive component and its background IPMN. The study cohort comprised 61 patients with invasive IPMN (study group) and 570 patients with pancreatic ductal adenocarcinoma (PDAC, control group) resected at a single institution. Multivariate analyses were performed using a stage-matched Cox proportional hazard model. The histology of invasive components of the IPMN cohort was tubular in 38 (62%), colloid in 16 (26%), and oncocytic in seven (12%). Compared with PDAC, invasive IPMNs were associated with a lower incidence of adverse pathological features and improved mortality by multivariate analysis (HR 0.58; 95% CI 0.39 to 0.86). In subtype analysis, this favourable outcome remained only for colloid and oncocytic carcinomas, while tubular adenocarcinoma was associated with worse overall survival, not significantly different from that of PDAC (HR 0.85; 95% CI 0.53 to 1.36). Colloid and oncocytic carcinomas arose only from intestinal- and oncocytic-type IPMNs, respectively, and were mostly of the main-duct type, whereas tubular adenocarcinomas primarily originated in the gastric background, which was often associated with branch-duct IPMN. Overall survival of patients with invasive adenocarcinomas arising from gastric-type IPMN was significantly worse than that of patients with non-gastric-type IPMN (p=0.016). Tubular, colloid and oncocytic invasive IPMNs have varying prognosis, and arise from different epithelial subtypes. Colloid and oncocytic types have markedly improved biology, whereas the tubular type has a course that resembles PDAC. Analysis of these subtypes indicates that the background epithelium plays an equally, if not more, important role in defining the biology and prognosis of invasive IPMNs.
    Gut 06/2011; 60(12):1712-20. · 10.73 Impact Factor
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    ABSTRACT: Management of uncomplicated common bile duct stone (CBDS) and gallstone pancreatitis (GP) presumably varies based on whether a patient is admitted to medicine or surgery. This study evaluates the impact of admitting team on outcome and cost. Three hundred seventy patients admitted to the Massachusetts General Hospital for CBDS or GP were retrospectively analyzed for demographics, insurance status, procedures, complications, length of stay, readmission, and cost. A multivariable analysis was conducted for outcome and cost measures. Patients admitted to a surgical service were younger than those admitted to a medical service. Gender, race, tobacco use, and the presence of chronic obstructive pulmonary disease and chronic renal insufficiency were not significantly different between groups. Patients admitted to a medical service had a higher incidence of coronary artery disease and diabetes. Despite lower readmission rates for surgical patients, there was no difference in total hospital days between groups. Though total cost of an initial surgical admission was greater than a medical admission, total cost attributable to the index admission diminished over time and ultimately was not significant in follow-up. Despite variations in uncomplicated management of CBDS and GP, there is no difference, in long-term follow-up, in the total number of hospital days or cost for the management of CBDS or GP based on admitting team practices.
    Journal of Gastrointestinal Surgery 08/2008; 12(9):1554-60. · 2.36 Impact Factor
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    ABSTRACT: To describe the management and impact of pancreatic fistulas in a high-volume center. Retrospective case series. Tertiary academic center. Five hundred eighty-one consecutive patients who underwent pancreaticoduodenectomy from January 2001 through June 2006. Development of a pancreatic fistula (defined as > 30 mL of amylase-rich fluid from drains on or after postoperative day 7, or discharge with surgical drains in place, regardless of amount); the need for additional interventions or total parenteral nutrition; other morbidity; and mortality. Seventy-five patients (12.9%) developed a pancreatic fistula. Fistulas were managed with gradual withdrawal of surgical drains. This allowed for patient discharge and eventual closure at a mean of 18 days in 38.7% of cases; these were classified as low-impact fistulas. The remaining 46 patients (61.3%) had an associated abscess, required percutaneous drainage or total parenteral nutrition, or developed bleeding; these were classified as high-impact fistulas and closed a mean of 35 days after surgery. Standard 30-day in-hospital mortality was 1.9% for all pancreaticoduodenectomies and 6.7% for those who developed a pancreatic fistula. The overall fistula-related mortality was 9.3% (7 patients), all but 1 of which was related to major hemorrhage. More than one-third of pancreatic fistulas are clinically insignificant (low impact). The remaining 60% of fistulas have a high clinical impact and nearly an 8-fold increase in overall mortality.
    Archives of surgery (Chicago, Ill.: 1960) 05/2008; 143(5):476-81. · 4.32 Impact Factor
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    ABSTRACT: Objective: To describe the management and impact of pancreatic fistulas in a high-volume center. Design: Retrospective case series. Setting: Tertiary academic center. Patients: Five hundred eighty-one consecutive pa-tients who underwent pancreaticoduodenectomy from January 2001 through June 2006. Main Outcome Measures: Development of a pancre-atic fistula (defined as Ͼ30 mL of amylase-rich fluid from drains on or after postoperative day 7, or discharge with surgical drains in place, regardless of amount); the need for additional interventions or total parenteral nutri-tion; other morbidity; and mortality. Results: Seventy-five patients (12.9%) developed a pan-creatic fistula. Fistulas were managed with gradual with-drawal of surgical drains. This allowed for patient dis-charge and eventual closure at a mean of 18 days in 38.7% of cases; these were classified as low-impact fistulas. The remaining 46 patients (61.3%) had an associated ab-scess, required percutaneous drainage or total paren-teral nutrition, or developed bleeding; these were clas-sified as high-impact fistulas and closed a mean of 35 days after surgery. Standard 30-day in-hospital mortality was 1.9% for all pancreaticoduodenectomies and 6.7% for those who developed a pancreatic fistula. The overall fis-tula-related mortality was 9.3% (7 patients), all but 1 of which was related to major hemorrhage. Conclusions: More than one-third of pancreatic fistu-las are clinically insignificant (low impact). The remain-ing 60% of fistulas have a high clinical impact and nearly an 8-fold increase in overall mortality.
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    ABSTRACT: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas arising in branch ducts are thought to be less aggressive than their main-duct counterparts, and guidelines for their conservative management were recently proposed. This study describes the combined experience of 2 tertiary centers with branch-duct IPMNs aiming to validate these recommendations. A review of 145 patients with resected, pathologically confirmed, branch-duct IPMNs between 1990 and 2005 was conducted. Sixty-six patients (45.5%) had adenoma, 47 (32%) borderline tumors, 16 (11%) carcinoma in situ, and 16 (11%) invasive carcinoma. Median age was similar between benign and malignant subgroups (66 vs 67.5 years, respectively). Jaundice was more frequent in patients with cancer (12.5% vs 1.8%, respectively, P = .022) and abdominal pain in patients with benign tumors (45% vs 25%, respectively, P = .025). Forty percent of tumors were discovered incidentally. Findings associated with malignancy were the presence of a thick wall (P < .001), nodules (P < .001), and tumor diameter >or=30 mm (P < .001). All neoplasms with cancer were larger than 30 mm in size or had nodules or caused symptoms. After a mean follow-up of 45 months, the 5-year disease-specific survival for branch-duct IPMNs with noninvasive neoplasms was 100% and, for invasive cancer, was 63%. This large cohort of resected branch-duct IPMNs shows that cancer is present in 22% of cases and validates the recent guidelines that indicate absence of malignancy in tumors <30 mm, without symptoms or mural nodules.
    Gastroenterology 08/2007; 133(1):72-9; quiz 309-10. · 12.82 Impact Factor
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    ABSTRACT: To assess changing patterns in the detection and outcomes of pancreatic neuroendocrine neoplasms (PNENs). Retrospective review from May 21, 1977, through September 16, 2005. Massachusetts General Hospital, a tertiary care center. We evaluated 168 patients (51% male; mean age, 56 years) who underwent surgery for histologically confirmed PNENs. Surgical outcomes, survival, and changes in presentation of PNENs in 2 time groups: 1977-1999 (77 patients) and 2000-2005 (91 patients). Ninety-eight patients (58.3%) had nonfunctioning PNENs, 86 of which were incidental. Insulinomas were the most common type of functional neoplasm (33.3%), followed by gastrinomas and glucagonomas; 12 patients (7.1%) had multiple endocrine neoplasia type 1. Of the neoplasms, 107 (63.7%) were located in the pancreatic body or tail. A pancreaticoduodenectomy was performed in 37 patients (22.0%), distal pancreatectomy was done in 88 (52.4%), and the rest had either middle segment pancreatectomy or enucleation. There were no operative deaths. We classified 76.8% of neoplasms as benign; of those classified as malignant, 25.6% had liver metastases. Of the patients, 10.1% received adjuvant therapy. Complete follow up was available in 90.5% of patients (mean, 63.3 months). Five- and 10-year actuarial survival rates were 77% and 62%, respectively. Incidentally discovered nonfunctioning neoplasms were significantly more frequent in the last 5 years (60.4% vs 40.3%; P = .007), with a trend toward smaller neoplasms (mean, 4.2 cm vs 5.6 cm; P = .19) and lesser likelihood of malignancy (21.8% vs 40.0%; P = .08). We report a large single-center experience with PNENs. Increasing numbers of PNENs are being resected, largely owing to the incidental detection of nonfunctioning neoplasms. This may lead to the treatment of smaller and less malignant neoplasms.
    Archives of Surgery 05/2007; 142(4):347-54. · 4.10 Impact Factor
  • Pancreas 01/2006; 33(4). · 2.95 Impact Factor
  • Pancreas 01/2006; 33(4). · 2.95 Impact Factor