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ABSTRACT: BACKGROUND: Minimally invasive surgical techniques for pancreatic cancer are being applied with increasing frequency. With support of the literature, the location of the tumor within the pancreas is the factor which determines if these techniques can be safely used routinely by pancreatic surgeons. METHODS: Literature supporting minimally invasive techniques for all types of resections for pancreatic cancer was reviewed. RESULTS: Multiple meta-analysis regarding laparoscopic distal pancreatectomy all support the routine use of laparoscopy for these lesions. There are several case series describing the safety and efficacious use of laparoscopy in pancreaticoduodenectomy, and results have been promising in these highly specialized centers. CONCLUSIONS: The location of the tumor within the pancreas remains the most critical factor in the use of laparoscopy as the standard of care. Lesions in the body and tail, which are readily resected with a distal or subtotal pancreatectomy should be performed laparoscopically unless there is a clear reason why not to do so. Lesions in the head of the pancreas have been shown to be removed safely and effectively with laparoscopy. However, the technical skills necessary and the ability to teach these to trainees are the limiting factors to widespread use. Further series are necessary to assess if the laparoscopic approach to pancreaticoduodenectomy will play a similar role as the one it plays in the surgical treatment for distal lesions.
Journal of hepato-biliary-pancreatic sciences. 04/2013;
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ABSTRACT: Many studies have shown laparoscopic distal pancreatectomy (LDP) to have benefits over open distal pancreatectomy (ODP). This institution made a unique abrupt transition from an exclusively open approach to a preference for the laparoscopic technique. This study aimed to compare outcomes in patients undergoing LDP and ODP, respectively, over the period of transition.
A retrospective review of all patients undergoing LDP (n = 82) or ODP (n = 90) was performed. Surrogate oncologic markers for the subgroup of patients with malignant disease were also studied.
The ODP and LDP groups were well matched with regard to demographics, comorbidities and tumour characteristics. Significant differences were noted in favour of the LDP group in which decreases were seen in estimated blood loss (<0.001), need for packed red blood cell transfusions (<0.001), length of hospital stay (<0.001) and intensive care unit stay (<0.001). No other significant differences in the occurrence of complications or oncologic outcomes were seen. Rates of Grade B and C fistulae were 10% and 6% in the ODP and LDP groups, respectively. Grade III-V complications occurred in 20% and 13% of the ODP and LDP groups, respectively.
Laparoscopic distal pancreatectomy continues to compare favourably with ODP when well-matched patient series are reviewed. The results show a decreased need for blood transfusions and hospital resources in LDP. Additionally, there may be oncologic advantages associated with LDP compared with ODP in pancreatic malignancies.
HPB 02/2013; 15(2):149-55. · 1.60 Impact Factor
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ABSTRACT: BACKGROUND: Recent national attention has focused on improving upon the surgical quality of hospitals across the United States. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database includes expected morbidity probability for each surgical patient. We sought to investigate the accuracy of this probability across the spectrum of general surgical operations and assess the variability based on the age and disease process. MATERIALS AND METHODS: Using the 2008 ACS-NSQIP database, we identified 190,929 operations that would be in the scope of practice of a modern general surgeon; the four most common included breast resection (n = 22,175; 11.6%), colon resection (n = 21,363; 11.2%), cholecystectomy (n = 20,889; 10.9%), and inguinal hernia repair (n = 11,709; 6.1%). We calculated the surgical observed versus expected morbidity rates (O/E) of each operation type and compared them by decile of patient age. We then determined the effect of case mix and patient age on theoretical hospitals performing at the NSQIP average. RESULTS: There is substantial variability in O/E ratios when comparing these disease processes across deciles of age. For patients undergoing breast resections, 67.2% of morbidities were solely attributed to 30-d reoperations; colon resections had an O/E ratio greater than 1 for all age deciles except over 90 y old. For cholecystectomies and the majority of patients undergoing inguinal hernia repairs, there was a lower morbidity rate than expected. Case mix and patient age were found to independently affect assessment of hospital quality. CONCLUSIONS: It is conceivable that general surgery case mix and patient age could independently affect the quality assessment of a hospital. This variability may have implications for overall quality measures.
Journal of Surgical Research 11/2012; · 2.25 Impact Factor
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ABSTRACT: BACKGROUND: Minimally invasive esophagectomy (MIE) is performed through various approaches, including using video-assisted thoracoscopic surgery for mediastinal esophageal dissection. The prone technique allows for gravity-aided retraction of the lung. The aim of this study was to examine perioperative outcomes after prone MIE in relation to patient preoperative comorbidities. METHODS: A retrospective cohort study from our single tertiary-care center is presented. Between January 2007 and August 2010, a total of 42 patients underwent three-field prone MIE. The majority of patients were male (37 vs. 5 female), with an average age of 68 years (range = 37-87). The diagnoses for patients who underwent MIE were 35 adenocarcinoma, four Barrett's esophagus with high-grade dysplasia, two achalasia, and one squamous cell carcinoma. Neoadjuvant chemotherapy with or without radiotherapy was administered to 16 (38 %) patients. Preoperative comorbidities were quantified using the Modified Charlson Comorbidity Index; low risk was defined as a score of 0-2 (23 patients), moderate risk 3-4 (14 patients), and high risk 5 or higher (five patients). Postoperative complications were stratified using the Clavien Classification Scale; minor complications were grades 1 and 2 and major complications were grades 3-5. RESULTS: Median length of hospital stay was 8 days (range = 6-51) and median ICU stay was 2 days (range = 1-26). Average prone surgical time was 108 min (range = 67-198). Thirty-seven of 42 patients (88 %) were extubated on the day of operation. Postoperatively, all five high-risk patients had a complication, three of which were major. Eight of the 14 moderate-risk patients had a complication and three were major, and 17 of the 23 low-risk group had a complication with nine being major. There was a total of 15 major complications. Predominant complications were arrhythmias (15) and pneumonia (five), with four anastomotic leaks and two postoperative 30-day mortalities. CONCLUSIONS: This series supports using prone MIE. Despite a clinical pathway, including immediate extubation postoperatively, there is still a risk of pulmonary complications that appears to correlate with higher preoperative comorbidity scores.
Surgical Endoscopy 08/2012; · 4.01 Impact Factor
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ABSTRACT: To investigate national trends in distal pancreatectomy (DP) through query of three national patient care databases.
From the Nationwide Inpatient Sample (NIS, 2003-2009), the National Surgical Quality Improvement Project (NSQIP, 2005-2010), and the Surveillance Epidemiology and End Results (SEER, 2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy. Utilization of laparoscopy was defined in NIS by the International Classification of Diseases, Ninth Revision correspondent procedure code; and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes. In SEER, patients were identified by the International Classification of Diseases for Oncology, Third Edition diagnosis codes and the SEER Program Code Manual, third edition procedure codes. We analyzed the databases with respect to trends of inpatient outcome metrics, oncologic outcomes, and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection.
NIS, NSQIP and SEER identified 4242, 2681 and 11 082 DP resections, respectively. Overall, laparoscopy was utilized in 15% (NIS) and 27% (NSQIP). No significant increase was seen over the course of the study. Resection was performed for malignancy in 59% (NIS) and 66% (NSQIP). Neither patient Body mass index nor comorbidities were associated with operative approach (P = 0.95 and P = 0.96, respectively). Mortality (3% vs 2%, P = 0.05) and reoperation (4% vs 4%, P = 1.0) was not different between laparoscopy and open groups. Overall complications (10% vs 15%, P < 0.001), hospital costs [44 741 dollars, interquartile range (IQR) 28 347-74 114 dollars vs 49 792 dollars, IQR 13 299-73 463, P = 0.02] and hospital length of stay (7 d, IQR 4-11 d vs 7 d, IQR 6-10, P < 0.001) were less when laparoscopy was utilized. One and two year survival after resection for malignancy were unchanged over the course of the study (ductal adenocarinoma 1-year 63.6% and 2-year 35.1%, P = 0.53; intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%, P = 0.25). The majority of resections were performed in teaching hospitals (77% NIS and 85% NSQIP), but minimally invasive surgery (MIS) was not more likely to be used in teaching hospitals (15% vs 14%, P = 0.26). Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%, P < 0.001), but were no more likely to utilize MIS at resection. Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching (15% vs 14%, P = 0.72) and lower volume hospitals (14% vs 15%, P = 0.99). No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year (P = 0.17 and P = 0.96, respectively).
There appears to be an overall underutilization of laparoscopy for DP. Centralization does not appear to be occurring. Survival and lymph node harvest have not changed.
World Journal of Gastroenterology 08/2012; 18(32):4342-9. · 2.47 Impact Factor
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The American Journal of Gastroenterology 08/2012; 107(8):1265-6. · 7.28 Impact Factor
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ABSTRACT: Ampullary and extensive periampullary lesions can be difficult to treat and often require pancreaticoduodenectomy (PD) for complete removal, even if benign. However, PD may be overtreatment for noninvasive lesions, and pancreas-sparing total duodenectomy (PSTD) is an emerging valid surgical option for selected cases.
We reviewed patients undergoing PSTD at our institution over 16 months and a comparison group who had undergone PD for benign duodenal disease over the past 15 years. We also reviewed cases in the English-language literature and performed a meta-analysis of those patients who had undergone PSTD.
PSTD had been performed in four patients, who had an average hospital length of stay (LOS) of 13 days; two of them experienced complications. None required conversion to PD, experienced a postoperative fistula or endocrine or exocrine insufficiency, or required intensive care. Two of the PSTDs were performed laparoscopically. Open PD for benign duodenal disease was performed in 22 patients, with overall morbidity and pancreas fistula rates of 82 and 27 %, respectively. The meta-analysis found 128 unique cases of PSTD with morbidity and mortality rates of 46.4 and 2.3 %, respectively. Pancreaticobiliary leak was seen in 20 %, with an average LOS of 17 days.
Although PSTD can be used to avoid PD and can be performed laparoscopically, it is technically challenging and still associated with morbidity.
World Journal of Surgery 06/2012; 36(10):2461-72. · 2.36 Impact Factor
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John A Stauffer
Journal of Laparoendoscopic & Advanced Surgical Techniques 05/2012; 22(4):403. · 1.40 Impact Factor
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ABSTRACT: The objective of this study was to examine whether preoperative recommendation for specific reductions in body mass index (BMI) influenced weight loss in obese surgical patients. We retrospectively reviewed the electronic medical records of 48 patients who enrolled between January 2007 to June 2010 in an 800-calorie per day liquid meal replacement (LMR) weight loss program. Of these, 9 patients (surgical group) enrolled as a result of general surgeon-directed weight loss to enable nonbariatric surgery and 39 enrolled seeking weight loss (medical group). Patients enrolled in the LMR program before bariatric surgery were excluded from analysis. All patients were seen in the setting of a comprehensive weight loss program supervised by a medical bariatrician and followed for a period of 4 months. There were no significant differences in mean initial BMI between surgical and medical patients (41.7 ± 4.55 and 41.6 ± 8.54 kg/m(2), respectively) or participation time in the weight loss program (120 days vs 133 days). Of the nine surgical patients, only five (56%) reached their weight goal and underwent the planned surgical procedure. Weight loss was significantly less in the surgical compared with medical patients (BMI reduction 4.03 ± 3.99 vs 7.75 ± 4.90 kg/m(2), respectively; P < 0.05). Weight loss was significantly lower in patients directed to undergo BMI reduction to enable a general surgical procedure. Future studies are needed to assess factors influencing weight loss (metabolism, exercise capacity, motivation) in patients requiring weight loss to enable a surgical procedure.
The American surgeon 03/2012; 78(3):325-8. · 1.28 Impact Factor
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ABSTRACT: The surgical management of pancreatic endocrine tumors in patients with multiple endocrine neoplasia type 1 (MEN-1) is controversial and complicated by the fact that these tumors are frequently multifocal. The degree of tumor resection is determined by weighing the risk of malignancy or tumor recurrence against the risks of endocrine/exocrine insufficiency with complete gland removal.
A retrospective review was performed identifying 4 patients with MEN-1 and pancreatic endocrine tumors treated with pancreatic resection over a 2-year period at our institution.
Mean age at operation was 35 years. Surgical approach was determined by size of tumor(s) and presence of multifocality. MRI and EUS were performed in all patients. While EUS identified a greater number of tumors when compared to MRI (median 5 versus 1), both studies grossly underestimated the total number of tumors found on final pathology. Three patients underwent laparoscopic total pancreatectomy for multifocal disease with diffuse pancreatic involvement, finding a median of 12 tumors. One patient underwent laparoscopic subtotal pancreatectomy for a presumed single pancreatic tail mass, but was found to have multifocal disease on final pathology consisting of 7 tumors. The average number of tumors found on final pathology was 13.5 with an average size of 2.6 cm. The median number of lymph nodes analyzed was 14. Diffuse, multifocal disease was present in all 4 patients. No major postoperative complications were observed.
In patients with MEN-1 and pancreatic endocrine tumors, preoperative workup underestimates extent of disease and total pancreatectomy should be considered for complete tumor removal.
JOP: Journal of the pancreas 01/2012; 13(4):402-8.
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Laith H Jamil,
Ana M Chindris,
Kanwar R S Gill,
Daniela Scimeca, John A Stauffer,
Michael G Heckman,
Shon E Meek,
Justin H Nguyen,
Horacio J Asbun,
Massimo Raimondo,
Timothy A Woodward,
Michael B Wallace
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ABSTRACT: Background. Glycemic control following total pancreatectomy (TP) has been thought to be difficult to manage. Diffuse intraductal papillary mucinous neoplasm (IPMN) is a potentially curable precursor to pancreatic adenocarcinoma, best treated by TP. Objective. Compare glycemic control in patients undergoing TP for IPMN to patients with type 1 diabetes mellitus (DM). Design/Setting. Retrospective cohort. Outcome Measure. Hemoglobin A1C(HbA1C) at 6, 12, 18, and 24 months after TP. In the control group, baseline was defined as 6 months prior to the first HbA1c measure. Results. Mean HgbA1C at each point of interest was similar between TP and type I DM patients (6 months (7.5% versus 7.7%, P = 0.52), 12 months (7.3% versus 8.0%, P = 0.081), 18 months (7.7% and 7.6%, P = 0.64), and at 24 months (7.3% versus 7.8%, P = 0.10)). Seven TP patients (50%) experienced a hypoglycemic event compared to 65 type 1 DM patients (65%, P = 0.38). Limitations. Small number of TP patients, retrospective design, lack of long-termfollowup. Conclusion. This suggests that glycemic control following TP for IPMNcan be well managed, similar to type 1 DM patients. Fear of DM following TP for IPMN should not preclude surgery when TP is indicated.
HPB Surgery 01/2012; 2012:381328.
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Archives of surgery (Chicago, Ill.: 1960) 09/2011; 146(9):1099-100. · 4.32 Impact Factor
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ABSTRACT: Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim is to demonstrate feasibility of two-field MIE with TVED and improve recovery in high-risk patients.
We performed a retrospective cohort study of eight patients who underwent two-field MIE with TVED over 10 months. The majority were male (N = 6) with mean age of 63 ± 12 years. Mean body mass index (BMI) was 30.2 ± 5.1 kg/m(2). Indications for operation were: high-grade dysplasia (N = 2), adenocarcinoma (N = 6) with one receiving neoadjuvant chemoradiation. Using the Charlson comorbidity index, three patients were low risk and five were high risk. TVED was performed with a modified single-incision access device across the left neck. The mediastinal esophagus was dissected distally and circumferentially with simultaneous transabdominal laparoscopy for gastric conduit creation and distal esophageal dissection.
Mean operative time was 292 min (range 194-375 min). Three obese patients required temporary abdominal desufflation to avoid extrinsic mediastinal compression. Mean estimated blood loss was 119 mL (range 25-400 mL). A median of 23 lymph nodes (range 13-29) was harvested. Median intensive care unit (ICU) stay was 1 day (range 1-5 days), and median overall stay was 7 days (range 5-16 days). The three low-risk patients had no major complications. Three of five high-risk patients had major complications, including two cervical anastomotic leaks. Major complications were seen in three of four obese patients (BMI >30 kg/m(2)). There were no mortalities.
The TVED approach may avoid the morbidity of transthoracic esophageal dissection by improving esophageal visualization. Complications with TVED appear to correlate with obesity and comorbidities. Although TVED appears feasible, a larger experience is required.
Surgical Endoscopy 06/2011; 25(12):3865-9. · 4.01 Impact Factor
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ABSTRACT: Laparoscopic surgery is becoming a more widely used approach for benign and malignant lesions in the neck, body, and tail of the pancreas. Recent literature reports appear to demonstrate that laparoscopic distal pancreatectomy (LDP) has clear benefits compared with open distal pancreatectomy (ODP). However, the procedure is relatively new and in some patients may remain a technically demanding operation.
Twenty-nine LDPs were performed by a single surgeon during the course of 12 months by using a multistep clockwise technique described in detail below. The technique appears to simplify and standardize the approach for both the simpler and the more difficult procedure. Retrospective analysis was performed regarding perioperative outcomes.
Twenty-three procedures were performed for a neoplastic process with five patients having pancreatic adenocarcinoma. There was no conversion to ODP, but one patient required a hand-assist method. Splenectomy was performed in 26 patients. Median operative time, estimated blood loss, and length of stay was 182 min, 50 ml, and 4 days respectively. Overall morbidity and pancreatic fistula rate was 17.2% and 10.3%, respectively. Median number of lymph nodes was 14, concomitant left adrenalectomy was performed in 3 patients, and margins were negative in 28 patients.
LDP has been shown to be an acceptable approach to both benign and malignant disease of the distal pancreas. The technique used in this manuscript appears to facilitate a reliable and safe five-step method to perform this procedure and ensures that appropriate oncologic principles are followed through each step. Even though this is a small feasibility series focused on surgical technique, our results appear to demonstrate an acceptable pancreatic leak rate.
Surgical Endoscopy 04/2011; 25(8):2643-9. · 4.01 Impact Factor
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Journal of the American Geriatrics Society 01/2011; 59(1):184-6. · 3.74 Impact Factor
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Journal of the American College of Surgeons 10/2010; 212(1):113-8. · 4.55 Impact Factor
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ABSTRACT: Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. We examined outcomes in patients who underwent vein reconstruction using polytetrafluoroethylene (PTFE).
Review of prospectively maintained databases at 3 centers identified all patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique.
Thirty-three patients underwent segmental vein resection with interposition PTFE graft reconstruction. Median age was 67 years; median Eastern Cooperative Oncology Group score was 1. Most operations were performed for pancreatic adenocarcinoma (n = 28, 85%); 96% were T3 lesions or greater. Standard PD was performed in 12 (36%) patients, pylorus-preservation in 17 (52%), and total pancreatectomy in 4 (12%). Combined resection of portal and superior mesenteric veins (SMV) was required in 49%, with resection isolated to PV in 12% and SMV in 39%. Splenic vein ligation was necessary in 30%. Median graft diameter was 12 mm (range 8 to 20 mm), with the majority being ring-enforced (73%). Median operative and vascular clamp times were 463 and 41 minutes, respectively, with median blood loss of 1,500 mL. The negative margin rate was 64%. Overall morbidity rate was 46%, and 30-day mortality was 6%. No patients developed irreversible hepatic necrosis or graft infection. Pancreatic fistulas occurred in 3 (9.1%). With mean follow-up of 14 months, overall graft patency was 76%. Estimated median duration of graft patency was 21 months. Median survival was 12 months for pancreatic adenocarcinoma.
With careful patient selection, PTFE graft reconstruction of resected PV/SMV during pancreaticoduodenectomy is possible with minimal risk of hepatic necrosis or graft infection. Comparison studies to primary anastomosis and autologous vein reconstruction are necessary.
Journal of the American College of Surgeons 09/2010; 211(3):316-24. · 4.55 Impact Factor
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Colorectal Disease 03/2010; 13(4):e65-6. · 2.93 Impact Factor
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ABSTRACT: Liver transplantation may occasionally be indicated in patients with unique clinical scenarios. Little is known regarding the outcomes of patients who have had a pancreatic resection prior to, in combination with, or after liver transplantation. A retrospective review of all patients undergoing liver transplantation from March 1998 to March 2008 identified 17 patients who also underwent pancreatic resection. An additional literature review was performed. Five underwent pancreatic resection prior to liver transplantation (1.7, 3.6, 3.8, 6.8, and 8.1 years), another 9 underwent pancreatic resection together with liver transplantation, and 3 underwent pancreatic resection after liver transplantation (2.2, 2.6, and 3.8 years). Indications for pancreatic resection included cholangiocarcinoma (n = 6), neuroendocrine tumor (n = 5), pancreatic cancer (n = 2), gastrointestinal stromal tumor (n = 1), periampullary adenocarcinoma (n = 1), duodenal adenomas (n = 1), and benign pancreatic mass (n = 1). Indications for liver transplantation were metastatic neuroendocrine tumor disease (n = 5), primary sclerosing cholangitis (n = 5), hepatitis C virus (n = 2), metastatic gastrointestinal stromal tumor (n = 1), Klatskin tumor (n = 1), alcohol cirrhosis (n = 1), alpha-1 antitrypsin deficiency (n = 1), and chemotherapy-induced cirrhosis (n = 1). One patient died intraoperatively, 7 patients died of tumor recurrence, 2 patients died from transplant complications, and 7 patients are still alive. Pancreatic resection-related complications included 4 pancreatic fistulas. A literature review confirmed liver transplantation/pancreatic resection-related complications. In conclusion, liver transplantation and pancreatic resection remain uncommon, and a good outcome can be achieved. Recurrence of malignant disease is the main factor limiting survival, and specific morbidity may be related to pancreatic resection and liver transplantation.
Liver Transplantation 12/2009; 15(12):1728-37. · 3.39 Impact Factor
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ABSTRACT: Aberrant arterial anatomy is a common finding during foregut surgery. Anomalies to the right hepatic lobe are especially relevant during pancreaticoduodenectomy (PD) and their recognition serves to protect the blood supply to the liver and bile ducts. We report our experience with aberrant right hepatic arterial anatomy (ARHAA) found during PD.
All patients who underwent PD between February 2003 and June 2007 were retrospectively reviewed and those with ARHAA were identified. Preoperative imaging studies were assessed by one radiologist, graded according to the presence of ARHAA and compared with the original interpretations.
We found ARHAA in 31 of 191 patients (16.2%). Operative management included dissection and preservation in 24, transection and reconstruction in four, and transection and primary anastomosis in three patients. Reconstruction of ARHAA was carried out through interposition grafts in two patients and implantation into the gastroduodenal stump in two patients. No cases of arterial thrombosis, liver infarction, abscess formation or biliary fistula were demonstrated in the immediate postoperative period. Review of preoperative imaging interpretations found that only nine of 23 reports indicated the presence of ARHAA; however, the retrospective review of the images found that ARHAA was readily apparent in 24 patients.
Recognition of aberrant vasculature to the liver before PD is important. Preoperative imaging studies will often be adequate to identify these anomalies, but interpreting radiologists may not be aware of its clinical significance. Surgeons performing PD must be adept at managing ARHAA safely.
HPB 02/2009; 11(2):161-5. · 1.60 Impact Factor
