Attila Nakeeb

Massachusetts General Hospital, Boston, Massachusetts, United States

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Publications (119)649.17 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Pancreatic fistula remains the primary source of morbidity following distal pancreatectomy. Previous studies have reported specific methods of parenchymal transection/stump sealing in an effort to decrease the pancreatic fistula rate with highly variable results. The aim of this study was to determine postoperative outcomes following various pancreatic stump-sealing methods. All cases of distal pancreatectomy were reviewed at a single institution between January 2008 and June 2011 and were monitored with complete 30-day outcomes through ACS-NSQIP. Pancreatic stump-sealing method was used to create three operation groups (suture, staple, or saline-linked radiofrequency). Two- and three-way statistical analyses were performed among the operation groups. Two hundred three patients underwent distal pancreatectomy. The most common diagnoses included chronic pancreatitis, adenocarcinoma, and IPMN. The suture, staple, and SLRF groups included 90 (44 %), 61 (30 %), and 52 (26 %) patients, respectively. Overall complications (range 31-38 %) and pancreatic fistula (range 25-26 %) were similar with each pancreatic closure technique. Operative technique was not associated with an increased need for postoperative interventions or hospital readmission. Postoperative outcomes after distal pancreatectomy are unaffected by the use of SLRF sealing of the pancreatic stump when compared to traditional suture or reinforced stapling techniques.
    Journal of Gastrointestinal Surgery 04/2015; DOI:10.1007/s11605-015-2825-0 · 2.39 Impact Factor
  • Journal of the American College of Surgeons 04/2015; DOI:10.1016/j.jamcollsurg.2015.04.020 · 4.45 Impact Factor
  • Gastroenterology 04/2015; 148(4):S-1121. DOI:10.1016/S0016-5085(15)33820-8 · 13.93 Impact Factor
  • Gastroenterology 04/2015; 148(4):S-1119-S-1120. DOI:10.1016/S0016-5085(15)33817-8 · 13.93 Impact Factor
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    ABSTRACT: Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons. the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons. After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5 % (confidence interval (CI) 1.8-3.2 %) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0 % (CI 1.0-2.9 %), while "classic" PD procedures report an overall rate of 2.6 % (CI 1.6-3.6 %). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4 % (CI 0.1-1.7 %). One hundred forty-four of 200 (72 %) surveys were returned, from which it was determined that 92 % of pancreatic surgeons have dealt with this complication, and 86 % routinely prescribe prophylactic antisecretory medication after PD. The incidence of MU after PD is 2.5 % with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86 %) routinely prescribe prophylactic gastric antisecretory medication.
    Journal of Gastrointestinal Surgery 02/2015; 19(4). DOI:10.1007/s11605-015-2765-8 · 2.39 Impact Factor
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    ABSTRACT: Patients with adenocarcinoma of the pancreatic body/tail and associated vascular thrombosis or adjacent organ invasion are suboptimal candidates for resection. We hypothesized that extended distal pancreatectomy (EDP) for locally advanced adenocarcinoma is associated with a survival benefit. We retrospectively reviewed a prospectively collected database of patients who underwent distal pancreatectomy (DP) for adenocarcinoma at a single academic institution (1996 to 2011) with greater than or equal to 2 years of follow-up. Among 680 DP patients, 93 were indicated for pancreatic adenocarcinoma. Splenic vein thrombosis (n = 26) did not significantly affect morbidity, mortality, or survival. Standard DP was performed in 70 patients and 23 underwent EDP with no difference in morbidity/mortality. Patients with EDP had a survival comparable with patients with standard DP (disease-free survival 18 vs 12 months = .8; overall survival 23 vs 17 months, P =.6). There was no difference in survival between EDP patients with versus without pathologic invasion of adjacent organs, but a trend favored those without. EDP is safe and should be considered in fit patients with locally advanced adenocarcinoma. Copyright © 2015 Elsevier Inc. All rights reserved.
    The American Journal of Surgery 12/2014; 209(3). DOI:10.1016/j.amjsurg.2014.10.017 · 2.41 Impact Factor
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    ABSTRACT: Introduction Pancreatitis is associated with intraductal papillary mucinous neoplasm (IPMN). This association is in part due to inflammation from pancreatic ductal obstruction. Although the correlation between pancreatitis and the malignant potential of IPMN is unclear, the 2012 International Consensus Guidelines (ICG) consider pancreatitis a “worrisome feature.” We hypothesized that serum pancreatic enzymes, markers of inflammation, are a better predictor of malignancy than pancreatitis in patients with IPMN. Methods Between 1992 and 2012, 364 patients underwent resection for IPMN at a single university hospital. In the past decade, serum amylase and lipase were collected prospectively as an inflammatory marker in 203 patients with IPMN at initial surveillance and “cyst clinic” visits. The latest serum pancreatic enzyme values within 3 months preoperatively were studied. Pancreatitis was defined according to the 2012 revision of the Atlanta Consensus. Results Of the 203 eligible patients, there were 76 with pancreatitis. Pancreatitis was not associated with an increased rate of malignancy (P = .51) or invasiveness (P = .08). Serum pancreatic enzymes categorically outside of normal range (high or low) were also not associated with malignancy or invasiveness. In contrast, as a continuous variable, the higher the serum pancreatic enzymes were, the greater the rate of invasive IPMN. Of the 127 remaining patients without pancreatitis, serum pancreatic enzymes outside of normal range (low and high) were each associated with a greater rate of malignancy (P < .0001 and P = .0009, respectively). Serum pancreatic enzyme levels above normal range (high) were associated with a greater rate of invasiveness (P = .02). Conclusion In patients with IPMN without a history of pancreatitis, serum pancreatic enzymes outside of the normal range are associated with a greater risk of malignancy. In patients with a history of pancreatitis, there is a positive correlation between the levels of serum pancreatic enzymes and the presence of invasive IPMN. These data suggest serum pancreatic enzymes may be useful markers in stratification of pancreatic cancer risk in patients with IPMN.
    Surgery 10/2014; 156(4):923–930. DOI:10.1016/j.surg.2014.07.010 · 3.11 Impact Factor
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    ABSTRACT: As such, the natural history of MPD-involved IPMN is poorly understood.
    Annals of Surgery 10/2014; 260(4):680-690. DOI:10.1097/SLA.0000000000000927 · 7.19 Impact Factor
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    ABSTRACT: Purpose. The aim of this study was to determine if early recognition and treatment of delayed gastric emptying (DGE) can augment postoperative outcomes in patients undergoing pancreatectomy. Methods. The International Study Group of Pancreatic Surgery definition of DGE was used to identify patients at Indiana University Hospital who required supplemental nutrition for DGE after pancreatectomy. Outcomes were compared between those without DGE, those with DGE who received supplemental nutrition within 10 days after pancreatectomy (early intervention), and those treated after 10 days (late intervention). Results. Between 2007 and 2012, the incidence of DGE was 15% (n = 163/1,089), 45% (n = 73) required supplemental nutrition, including 60% (n = 44/73) in the early intervention and 40% (n = 29/73) in the late intervention groups. Postoperative morbidity (62% vs 41%; P < .01), duration of stay (16 vs 7 days; P < .01), and readmissions (41% vs 17%; P < .01) were greater among those with DGE. The early intervention group resumed a regular diet sooner (day 24 vs 36; P = .05) and were readmitted less often (25% vs 65%; P < .01) than those in the late intervention group. Treatment-related complications occurred in 14% of patients. Conclusion. Patients with DGE can be managed with acceptable treatment-related morbidity. Outcomes are best when supplemental nutrition is started within 10 days of operation.
    Surgery 08/2014; DOI:10.1016/j.surg.2014.06.024 · 3.11 Impact Factor
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    ABSTRACT: Objectives: Adjuvant therapy after surgical resection is the current standard for pancreatic adenocarcinoma; however, the role of chemoradiotherapy (CRT) remains unclear. This study was conducted to compare the efficacy outcomes with adjuvant gemcitabine and gemcitabine-based CRT (CT-CRT) versus gemcitabine chemotherapy (CT) alone after pancreaticoduodenectomy. Methods: Among 165 patients who underwent surgical resection for pancreatic cancer at Indiana University Medical Center between 2004 and 2008, we retrospectively identified 53 consecutive patients who received adjuvant therapy (CT-CRT=34 patients; CT=19 patients) and had adequate follow-up medical records. The median follow-up was 19.1 months. Median disease-free (DFS) and overall survival (OS) were determined using Kaplan-Meier method, and a Cox-regression model was used to compare survival outcomes after adjusting for age, status of resection margins, and lymph node involvement. Results: The OS for the CT-CRT group was significantly higher compared with the CT group (median, 20.4 vs. 16.6 mo; hazard ratio, 2.42; 95% CI, 1.17-5.01). The median DFS for the CT-CRT group was 13.7 versus 11.1 months for the CT group (hazard ratio, 2.88; 95% CI, 1.37-6.06). On subgroup analyses, significantly superior OS and DFS were observed among patients younger than 65 years, T3/T4 tumor stage, negative resection margins, and positive lymph node involvement. Conclusion: Gemcitabine plus gemcitabine-based CRT compared with gemcitabine alone leads to superior DFS and OS for patients with resected pancreatic cancer.
    American Journal of Clinical Oncology 08/2014; DOI:10.1097/COC.0000000000000115 · 2.61 Impact Factor
  • Gastroenterology 05/2014; 146(5):S-1068. DOI:10.1016/S0016-5085(14)63895-6 · 13.93 Impact Factor
  • Gastroenterology 05/2014; 146(5):S-1069. DOI:10.1016/S0016-5085(14)63898-1 · 13.93 Impact Factor
  • Gastroenterology 05/2014; 146(5):S-1044-S-1045. DOI:10.1016/S0016-5085(14)63807-5 · 13.93 Impact Factor
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    ABSTRACT: Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated.
    Journal of the American College of Surgeons 03/2014; 219(1). DOI:10.1016/j.jamcollsurg.2014.03.021 · 4.45 Impact Factor
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    ABSTRACT: Pancreaticoduodenectomy (PD) remains a challenging operation with a 40 % postoperative complication rate. Pyogenic liver abscess (PLA) is an uncommon complication following PD with little information on its incidence or treatment. This study was done to examine the incidence, risk factors, treatment, and long-term outcome of PLA after PD. We retrospectively reviewed 1,189 patients undergoing PD (N = 839) or distal pancreatectomy (DP) (N = 350) at a single institution over a 14-year period (January 1, 1994-January 1, 2008). Pancreatic databases (PD and DP) were queried for postoperative complications and cross-checked through a hospital-wide database using ICD-9 codes 572.0 (PLA) and 006.3 (amebic liver abscess) as primary or secondary diagnoses. No PLA occurred following DP. Twenty-two patients (2.6 %) developed PLA following PD. These 22 patients were matched (1:3) for age, gender, year of operation, and indication for surgery with 66 patients without PLA following PD. PLA occurred in 2.6 % (22/839) of patients following PD, with 13 patients (59.1 %) having a solitary abscess and 9 (40.9 %) multiple abscesses. Treatment involved antibiotics and percutaneous drainage (N = 15, 68.2 %) or antibiotics alone (N = 7, 31.8 %) with a mean hospital stay of 12 days. No patient required surgical drainage, two abscesses recurred, and all subsequently resolved. Three patients (14 %) died related to PLA. Postoperatively, patients with biliary fistula (13.6 vs. 0 %, p = 0.014) or who required reoperation (18.2 vs. 1.5 %, p = 0.013) had a significantly higher rate of PLA than matched controls. Long-term follow-up showed equivalent 1-year (79 vs.74 %), 2-year (50 vs. 57 %), and 3-year (38 vs. 33 %) survival rates and hepatic function between patients with PLA and matched controls. Postoperative biliary fistula and need for reoperation are risk factors for PLA following PD. Antibiotics and selective percutaneous drainage was effective in 86 % of patients with no adverse effects on long-term hepatic function or survival.
    Journal of Gastrointestinal Surgery 02/2014; 18(5). DOI:10.1007/s11605-014-2466-8 · 2.39 Impact Factor
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    ABSTRACT: Main pancreatic duct (MPD) involvement is a well-demonstrated risk factor for malignancy in intraductal papillary mucinous neoplasm (IPMN). Preoperative radiographic determination of IPMN type is heavily relied upon in oncologic risk stratification. We hypothesized that radiographic assessment of MPD involvement in IPMN is an accurate predictor of pathological MPD involvement. Data regarding all patients undergoing resection for IPMN at a single academic institution between 1992 and 2012 were gathered prospectively. Retrospective analysis of imaging and pathologic data was undertaken. Preoperative classification of IPMN type was based on cross-sectional imaging (MRI/magnetic resonance cholangiopancreatography (MRCP) and/or CT). Three hundred sixty-two patients underwent resection for IPMN. Of these, 334 had complete data for analysis. Of 164 suspected branch duct (BD) IPMN, 34 (20.7 %) demonstrated MPD involvement on final pathology. Of 170 patients with suspicion of MPD involvement, 50 (29.4 %) demonstrated no MPD involvement. Of 34 patients with suspected BD-IPMN who were found to have MPD involvement on pathology, 10 (29.4 %) had invasive carcinoma. Alternatively, 2/50 (4 %) of the patients with suspected MPD involvement who ultimately had isolated BD-IPMN demonstrated invasive carcinoma. Preoperative radiographic IPMN type did not correlate with final pathology in 25 % of the patients. In addition, risk of invasive carcinoma correlates with pathologic presence of MPD involvement.
    Journal of Gastrointestinal Surgery 01/2014; 18(3). DOI:10.1007/s11605-013-2444-6 · 2.39 Impact Factor
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    ABSTRACT: Background Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)–involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. Study Design From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter ≥5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. Results Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). Conclusions Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.
    Journal of the American College of Surgeons 01/2014; 219(1):122–129. · 4.45 Impact Factor
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    ABSTRACT: To test by randomized prospective multicenter trial the hypothesis that pancreaticoduodenectomy (PD) without the use of intraperitoneal drainage does not increase the frequency or severity of complications. Some surgeons have abandoned the use of drains placed during pancreas resection. We randomized 137 patients to PD with (n = 68, drain group) and without (n = 69, no-drain group) the use of intraperitoneal drainage and compared the safety of this approach and spectrum of complications between the 2 groups. There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage. This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.
    Annals of surgery 12/2013; DOI:10.1097/SLA.0000000000000460 · 7.19 Impact Factor
  • Attila Nakeeb
    Journal of Gastrointestinal Surgery 07/2013; 17(9). DOI:10.1007/s11605-013-2280-8 · 2.39 Impact Factor
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    ABSTRACT: Patients undergoing complex hepatopancreatobiliary (HPB) operations are at high risk for surgical site infection (SSI). Factors such as biliary obstruction, operative time and pancreatic or biliary fistulae contribute to the high SSI rate. The purpose of this study was to analyse whether a multifactorial approach would reduce the incidence and cost of SSI after HPB surgery. From January 2007 to December 2009, 895 complex HPB operations were monitored for SSI through the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). In 2008, surgeon-specific SSI rates were provided to HPB surgeons, and guidelines for the management of perioperative factors were established. Observed SSI rates were monitored before and after these interventions. Hospital cost data were analysed and cost savings were calculated. Observed SSI for hepatic, pancreatic and complex biliary operations decreased by 9.6% over a 2-year period (P < 0.03). The excess cost per SSI was US$11 462 and was driven by increased length of stay and hospital readmission for infection. Surgeons rated surgeon-specific feedback on SSI rate as the most important factor in improvement. High SSI rates following complex HPB operations can be improved by a multifactorial approach that features process improvements, individual surgeon feedback and reduced variation in patient management.
    HPB 05/2013; 15(5):384-91. DOI:10.1111/j.1477-2574.2012.00604.x · 2.05 Impact Factor

Publication Stats

3k Citations
649.17 Total Impact Points

Institutions

  • 2014
    • Massachusetts General Hospital
      • Department of Surgery
      Boston, Massachusetts, United States
    • Indiana University-Purdue University School of Medicine
      • Surgery
      Indianapolis, Indiana, United States
  • 2004–2014
    • Indiana University-Purdue University Indianapolis
      • Department of Surgery
      Indianapolis, Indiana, United States
  • 2011
    • Universidade Federal de São Paulo
      San Paulo, São Paulo, Brazil
  • 2010
    • Virginia Commonwealth University
      Ричмонд, Virginia, United States
    • University of Miami Miller School of Medicine
      Miami, Florida, United States
  • 2001–2009
    • Medical College of Wisconsin
      • Department of Surgery
      Milwaukee, WI, United States
  • 1995–2001
    • Johns Hopkins Medicine
      • Department of Surgery
      Baltimore, MD, United States
  • 2000
    • University of Wisconsin - Milwaukee
      Milwaukee, Wisconsin, United States
  • 1996
    • University of Maryland, Baltimore
      • Department of Surgery
      Baltimore, Maryland, United States