Preoperative Predictors for Complications after Pancreaticoduodenectomy: Impact of BMI and Body Fat Distribution

Background The purpose of this study was to examine the preoperative patient and radiographic factors that are associated with operative morbidity after pancreaticoduodenectomy. Material and Methods Patient characteristics and preoperative radiographic findings and their association with postoperative complications after pancreaticoduodenectomy were analyzed for 356 patients with pancreatic adenocarcinoma who underwent resection between 2000 and 2005. Results Postoperative complications developed in 135 patients (38%). The most common complications were pancreatic fistula/abscess (15%), wound infection (14%), and delayed gastric emptying (4%). On multivariate analysis, the only preoperative radiographic factors associated with having any postoperative complication were the absence of pancreatic atrophy and the extent of central obesity determined by the thickness of retrorenal visceral fat (VF). Complications occurred in 51% of patients with VF ≥ 2 cm, compared to 31% of patients with VF < 2 cm, p < 0.001. Postoperatively, pancreatic fistula developed in 24% of patients with VF ≥ 2 cm and in only 10% of patients with VF < 2 cm, p = 0.01. Wound infections occurred in 21% of the patients with body mass index greater than or equal to 30 kg/m² compared to 12% of the nonobese patients, p = 0.03. Conclusions Generalized obesity is associated with postoperative wound infections after pancreaticoduodenectomy. The degree of visceral fat on preoperative cross-sectional imaging is associated with significantly higher rates of overall complications and pancreatic fistula. Presented in part at the 48th Annual Meeting of the Society for Surgery of the Alimentary Tract, May 21, 2007, Washington, DC.     

Perioperative Treatment with Infliximab in Patients with Crohn’s Disease and Ulcerative Colitis is Not Associated with an Increased Rate of Postoperative Complications

Purpose  The impact of infliximab (IFX) on postoperative complications in surgical patients with Crohn’s disease (CD) and ulcerative colitis (UC) is unclear. We examined a large patient cohort to clarify whether a relationship exists between IFX and postoperative complications. Methods  A total of 413 consecutive patients—188 (45.5%) with suspected CD, 156 (37.8%) with UC, and 69 (16.7%) with indeterminate colitis—underwent abdominal surgery at the Massachusetts General Hospital between January 1993 and June 2007. One hundred one (24.5%) had received preoperative IFX ≤ 12 weeks before surgery. These patients were compared to those who did not receive IFX with respect to demographics, comorbidities, presence of preoperative infections, steroid use, and nutritional status. We then compared the cumulative rate of complications for each group, which included deaths, anastomotic leak, infection, thrombotic complications, prolonged ileus/small bowel obstruction, cardiac, and hepatorenal complications. Potential risk factors for infectious complications including preexisting infection, pathological diagnosis, and steroid or IFX exposure were further evaluated using logistic regression analysis. Results  Patients were similar with respect to gender (IFX = 40.6% men vs. non-IFX = 51.9%, p = 0.06), age (36.1 years vs.37.8, p = 0.43), Charlson Comorbidity Index (5.3 vs. 5.7, p = 0.25), concomitant steroids (75.3% vs. 76.9%, p = 0.79), preoperative albumin level (3.3 vs. 3.2, p = 0.36), and rate of emergent surgery (3.0% vs. 3.5%, p = 1.00). IFX patients had higher rates of CD (56.4% vs. 41.9%, p = 0.02), concomitant azathioprine/6-mercaptopurine use (34.6% vs. 16.6%, p < 0.0001), and lower rates of intra-abdominal abscess (3.9% vs. 11%, p < 0.05). After surgery, the two groups had similar rates of death (2% vs. 0.3% p = 0.09), anastomotic leak (3.0% vs. 2.9%, p = 0.97), cumulative infections (5.97% vs. 10.1%, p = 1), thrombotic complications (3.6% vs. 3.0%, p = 0.06), prolonged ileus/small bowel obstructions (3.9 vs. 2.8, p = 0.59), cardiac complications (1% vs. 0.6%, p = 0.42), and hepatic or renal complications (1.0 vs. 0.6% p = 0.72). A logistic regression model was then created to assess the impact of IFX, as well as other potential risk factors, on the rates of cumulative postoperative infections. We found that steroids (odds ratio [OR] = 1.2, p = 0.74), IFX (OR 2.5, p = 0.14), preoperative diagnosis of CD (OR = 0.7, p = 0.63) or UC (OR = 0.6, p = 0.48), and preoperative infection (OR = 1.2, p = 0.76) did not affect rates of clinically important postoperative infections. Conclusions  Preoperative IFX was not associated with an increased rate of cumulative postoperative complications. Dr. Sands has received research grants and honoraria for lecturing and consulting from Centocor.     

Safety of Conservative Management of Bile Leakage after Hepatectomy with Biliary Reconstruction

Background  The risks associated with the conservative management of bile leakage after hepatectomy and associated cholangiojejunostomy are not well defined. Aim  The aim of this study was to evaluate incidence and severity of complications associated with bile leakages after liver resection with biliary reconstruction. Patients and methods  Clinical data from 1,034 consecutive patients who underwent liver resection were prospectively collected and reviewed. Bile leakage occurred in 25 out of 119 patients (21.0%) who underwent hepatectomy with biliary reconstruction (group 1) and in 42 out of 915 patients (4.6%) without biliary anastomosis (group 2; p < 0.001). Serum albumin and bilirubin levels were the only preoperative factors significantly different between the two groups. Lymphadenectomy was more frequently performed in patients of group 1 (88% vs 16.7, p < 0.001). Results  Mortality rates were similar in the two groups (8% in group 1 vs 2.3% in group 2, p = 0.28). One or more postoperative complications occurred in 68% in group 1 and in 40.4% in group 2 (p = 0.02). The incidence of sepsis (32% vs 7.1%, p = 0.01), intra-abdominal abscess (12% vs 0, p = 0.04), and abdominal bleeding (28% vs 0, p = 0.006) was significantly higher in group 1. Bile leaks spontaneously healed in 52% of patients in group 1 vs 76.2% in group 2 (p = 0.04). In order to identify independent predictive factors for abdominal bleeding, we compared clinical data of patients with abdominal bleeding (seven patients) and without abdominal bleeding (18 patients) after hepatectomy and biliary reconstruction. Stepwise logistic regression analysis identified the number of reconstructed bile ducts as an independent predictive factor of abdominal bleeding (p = 0.038). Conclusions  Conservative management of bile leakage after liver resection with biliary reconstruction is associated with higher rates of morbidity. The most severe complication is abdominal bleeding, which is related to the number of bile ducts requiring reconstruction.     

Mechanisms of Primary Operative Failure and Results of Remedial Operation in Patients with Chronic Pancreatitis

Introduction  Resection and drainage operations achieve long-term pain relief in approximately 85% of patients with chronic pancreatitis (CP). In patients who develop recurrent pain, a few data exist on the long-term results of remedial operations. Materials and methods  Over an 18-year period (1988–2006), 316 patients with CP had primary resection or drainage operations at our institution. Thirty-nine developed recurrent pain and were treated by a remedial resection or drainage operation. Patient demographics, time to symptom recurrence, radiographic anatomic abnormalities, type of remedial operation, postoperative morbidity, and long-term outcomes were analyzed. Results  Thirty-nine patients, 56% female with a mean age of 41 years (range 16–61 years) had either remedial resection: total pancreatectomy (TP; N = 8), pancreaticoduodenectomy (PD; N = 6), distal pancreatectomy (DP; N = 5), or drainage operation: duodenal preserving pancreatic head resection (DPPHR; N = 8), revision of pancreaticojejunostomy (N = 12). TP achieved pain relief in 88% with postoperative complications greater than or equal to grade III in 38% and diabetes in 100%. Drainage operations achieved pain relief in 67% of patients with postoperative complications greater than or equal to grade III in only 8%. Partial parenchymal resections (DPPHR, PD, DP) as a remedial procedure achieved pain relief <50% of the time. Conclusion  Drainage procedures, when anatomically feasible, are the preferred reoperation to treat patients with recurrent pain after failed primary operation for chronic pancreatitis. Presented at the 49th annual meeting of the Society for Surgery of the Alimentary Tract, May 20, 2008, San Diego, California.     

Distal Pancreatectomy for Chronic Pancreatitis: Risk Factors for Postoperative Pancreatic Fistula

One of the most common complications after distal pancreatectomy is a fistula from the pancreatic remnant. Factors influencing the development of a pancreatic fistula after distal pancreatectomy have not been clearly elucidated. The records of 91 patients who underwent distal pancreatectomy for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Average daily volume and amylase concentration between postoperative days 2 and 20 from drains located at the pancreatic resection site were compared to clinical variables. Out of 137 pre- and intraoperative clinical variables, multivariate analysis showed serum creatinine (t = 3.05, p = 0.004), history of intraabdominal operation (t = −2.68, p = 0.01), right-sided pancreatic duct dilation (t = 2.65, p = 0.01), synchronous cholecystectomy (t = 2.53, p = 0.02), and serum albumin (t = −2.19, p = 0.04) to be independently associated with drain volume. Drain amylase concentration was linked to serum creatinine (t = 8.55, p < 0.001), blood urea nitrogen (t = −3.43, p = .001), preoperative parenteral nutrition (t = 2.56, p = .01), and serum alkaline phosphatase (t = 2.51, p = 0.01). There was no correlation between the degree of fibrosis and drain output. Technique of pancreatic transection and presence of suture closure of the pancreatic duct did not affect drain output. In conclusion, the amount and amylase concentration of postsurgical drainage after distal pancreatectomy for chronic pancreatitis is dependent on markers of renal dysfunction, malnutrition, biliary disease, and possibly inflammation. These factors, if medically reversible, should be addressed in patients who are candidates for distal pancreatectomy for chronic pancreatitis. This paper was presented, in part, at the 46th Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, IL, USA, May 14–18, 2005.     

Liver metastasis as an initial recurrence has no impact on the survival of patients with resectable pancreatic adenocarcinoma

Background  Prognosis of the patients with pancreatic adenocarcinoma is still poor due to a recurrence, and liver metastasis is a distant metastasis that is foreboded the short survival period. Methods  Between 1999 and 2005, 68 patients for pancreatic adenocarcinoma underwent a pancreaticoduodenectomy (n = 17), a pylorus-preserving pancreaticoduodenectomy (n = 27), distal pancreatectomy (n = 22), or total pancreatectomy (n = 2) with an extensive lymph node dissection. Results  A tumor recurrence occurred to 55 patients (13 of the liver, 21 of the local recurrence, 16 of peritoneal dissemination, three of the lymph node, and two of lung). The low tumor grade and female demonstrated a risk factor for a liver metastasis (P = 0.043, P = 0.031). A logistic regression analysis demonstrated female (P = 0.02) and low tumor grade (P = 0.04) as independent risk factors for recurrence with liver metastasis. The median survival time (MST) was 13.6 months, and MST of patients with a liver metastasis as an initial recurrent site was 13.7 months; the liver metastasis as an initial recurrent site has no impact on the MST after pancreatic resection. Conclusions  We concluded potentially supporting the hypothesis that even patients thought to be at higher risk of liver metastasis may still be given the chance of resection, considering the satisfying survival.     

Preoperative Biliary Drainage Increases Infectious Complications after Hepatectomy for Proximal Bile Duct Tumor Obstruction

Background  The role of preoperative biliary drainage before liver resection in jaundiced patients remains controversial. The objective of this study is to compare the perioperative outcome of liver resection for carcinoma involving the proximal bile duct in jaundiced patients with and without preoperative biliary drainage. Methods  Seventy-four consecutive jaundiced patients underwent hepatectomy for carcinoma involving the proximal bile duct from January 1989 to June 2006 and their data were retrospectively analyzed. Fourteen patients underwent biliary drainage before portal vein embolization and were excluded from the study. Thirty patients underwent biliary drainage before hepatectomy and 30 underwent liver resection without preoperative biliary drainage. All patients underwent resection of the extrahepatic bile duct. Results  Overall mortality and operative morbidity were similar in the two groups (3% vs. 10%, p = 0.612 and 70% vs. 63%, p = 0.583, respectively). The incidence of noninfectious complications was similar in the two groups. There was no difference in hospital stay between the two groups. Patients with preoperative biliary drainage had a significantly higher rate of infectious complications (40% vs. 17%, p = 0.044). At multivariate analysis, preoperative biliary drainage was the only independent risk factor for infectious complication in the postoperative course (RR = 4.411, 95%CI = 1.216-16.002, p = 0.024). Even considering patients with preoperative biliary drainage in whom the bilirubin level went below 5 mg/dl, the risk of infectious complications was higher compared with patients without biliary drainage (47.6% vs. 16.6%, p = 0.017). Conclusions  Overall mortality and morbidity after liver resection are not improved by preoperative biliary drainage in jaundiced patients. Prehepatectomy biliary drainage increases the incidence of infectious complications.     

Prospective 6 Weeks Follow-up Post-cholecystectomy: The Predictive Value of Pre-Operative Symptoms

Objective  Many patients with symptomatic cholelithiasis report persisting symptoms after elective cholecystectomy. The current prospective follow-up study aims at the identification and valuation of risk factors for negative symptomatic outcome at 6 weeks. Methods  Consecutive patients (n = 183), age 18–65 years, indicated for elective cholecystectomy due to symptomatic cholelithiasis, completed a self-report questionnaire. At 6 weeks post-operatively, the same self-report questionnaires were completed (n = 129). Predictors of the persistence and emergence of biliary and dyspeptic symptoms at 6 weeks post-cholecystectomy were investigated using univariate and multivariate logistic regression. Results  At 6 weeks post-operatively, the report of post-operative biliary symptoms was independently predicted by pre-operative dyspeptic symptoms (OR = 6.60) and bad taste (OR = 3.55). Pre-operative flatulence was an independent predictor of the report of biliary and dyspeptic symptoms ((OR = 3.33) and (OR = 3.27), respectively) and persisting biliary symptoms (OR = 4.21). Predictors of symptomatic outcome were only identified in women, not in men. Conclusion  Patients with pre-operative dyspeptic symptoms, notably bad taste and flatulence, have an increased risk of negative post-cholecystectomy outcomes at 6 weeks. A symptom-specific approach should lead to optimalization of the indication of cholecystectomy and information of patients. Known risk factors for long-term outcomes might be valuable in female patients only.     

Is Liver Resection Justified in Advanced Hepatocellular Carcinoma? Results of an Observational Study in 464 Patients

Background and Objective  The role of liver resection in advanced hepatocellular carcinoma (multinodular or with macroscopic vascular involvement) is still controversial. The aim of this study is to evaluate the role of surgical resection compared to other therapeutic modalities in patients with advanced hepatocellular carcinoma (HCC). Methods  Four hundred sixty four patients with HCC observed from 1991 to 2007 were included in the study. All the patients were evaluated for the treatment of HCC in relation to the severity of liver impairment and tumor stage. All the patients included in the study had no evidence of distant metastases. Results  Median follow up time for surviving patients was 25 months (range 1–155). Two-hundred and eighty-three patients were in Child–Pugh class A, 161 in class B, and 20 in class C. Two-hundred and seventy-one patients had single HCC, 121 patients had two or three HCCs, and 72 more than three HCCs. One-hundred and thirty-six patients (29.3%) were submitted to liver resection (LR), 232 (50.0%) to local ablative therapies (LAT) (ethanol injection, radiofrequency ablation, chemoembolization), eight (1.7%) to liver transplantation (LT), and 88 (19%) to supportive therapy (ST). Median survival time for all patients was 36 months (95% CI 24–36). Median survival time was 57 months for LR, 30 months for LAT, and 8 months for ST, with a 5-year survival of 47%, 20%, and 2.5%, respectively (p = 0.001). Actuarial 5-year survival for patients submitted to LT was 75%. Overall survival was significantly shorter in patients with multiple HCCs compared to single HCC, with median survival times of 39, 16, and 11 months for patients with a single HCC, with two to three HCCs, and with more than three HCCs, respectively (p = 0.01). Survival for patients with single HCC was significantly longer in patients submitted to LR compared to LAT and ST with median survival times of 57, 37, and 14 months, respectively (p = 0.02). Also, in patients with multinodular HCCs (2–3 HCCs) LR showed the best results with a median survival time of 58 months compared to 22 and 8 months for LAT and ST (p = 0.01). In patients with more than three HCCs, LR did not show different results compared to LAT and ST. Seventy-three patients had evidence of macroscopic vascular involvement; median survival in this subgroup of patients was significantly shorter compared to patients without vascular involvement, 10 and 36 months, respectively. Survival for patients with macroscopic vascular involvement submitted to LR or LAT was significant longer compared to ST, with mean survivals of 27, 30, and 12 months, respectively (p = 0.01). Conclusions  The present study shows that the surgery can achieve good results in patients with single HCC and good liver function. Also, patients with multinodular HCCs (two to three nodules) could benefit from LR where survival is longer than after LAT or ST. In patients with more than three HCCs, LR have similar results of LAT. Macroscopic vascular invasion is a major prognostic factor, and the LR is justified in selected patients, where it can allow good long-term results compared to ST. This study was presented as Quick Shot oral presentation of the Surgical Society Alimentary Tract at Digestive Disease Week, May 20, 2008, San Diego Convention Center, San Diego, CA, USA and as oral presentation at 23rd Annual SSAT Residents & Fellows Research Conference, May 17, 2008, Omni San Diego, San Diego, CA.     

Gastrectomy and Lymphadenectomy for Gastric Cancer: is the Pancreas Safe?

Introduction  Resection of the capsule of the pancreas is part of the radical operation proposed by oriental authors for the treatment of gastric cancer. It is unclear; however, if resection of the capsule is a safe procedure or even if it is necessary. This study aims to assess in patients treated for gastric cancer the occurrence of: (a) pancreatic fistula and (b) metastasis to the pancreatic capsule. Methods  We studied 80 patients (mean age 61 years, 42 males) submitted to gastrectomy with resection of the pancreatic capsule by hydrodissection. Patients with pancreatic disease, tumoral invasion of the pancreas, submitted to concomitant splenectomy, or anastomotic leakage were excluded. The tumor was located in the distal third of the stomach in 60% of the patients, in the middle third in 27%, and proximally in 12%. Total gastrectomy was performed in 27% of the cases and partial gastrectomy in 73%. In all patients, amylase activity in the drainage fluid was measured on day 2. If initial measurement was abnormal, subsequent measurements were performed in alternated days until normalization. Pancreatic fistula was defined as amylase levels greater than 600. In 25 of these patients (mean age 53 years, 16 males), the pancreatic capsule was histologically analyzed for metastasis. Results  Pancreatic fistula was diagnosed in eight (10%) patients. The mean amylase level was 5,863. Normalization of amylase levels was achieved within 7 days in all patients. No patient developed clinical signs of fistula besides abnormal amylase levels in the drainage fluid, such as intra-abdominal abscesses. Pancreatic fistula was associated to younger age (p = 0.03) but not to gender (p = 0.1), tumor location (p = 0.6), and type of gastrectomy (p = 0.8). Metastasis to the pancreatic capsule was not identified. Conclusion  In conclusion, resection of the pancreatic capsule must be discouraged due to subclinical pancreatic fistula in a significant number of the cases and absence of metastasis. Presented as poster at the Digestive Disease Week, May 17–22, 2008, San Diego, CA, USA.     

A Central Pancreatectomy for Benign or Low-Grade Malignant Neoplasms

Inctroduction  A central pancreatectomy is a parenchyma-sparing procedure that is performed to reduce long-term endocrine and exocrine insufficiency. Method  In this study, we analyzed the perioperative course, the frequency of postoperative onset of diabetes mellitus, and long-term change of body weight in patients undergoing a central pancreatectomy, in comparison to the patients undergoing a distal pancreatectomy for low-grade neoplasms including cystic neoplasms and neuroendocrine tumors. Results and Discussion  The rate of postoperative complications including grade B/C pancreatic fistula was no different between both groups. Only one patient undergoing a central pancreatectomy (4.7%) developed new onset of mild diabetes, whereas 35% in the distal pancreatectomy group developed new onset or worsening diabetes (p = 0.0129). The body weight in the distal pancreatectomy group was significant lower than that in the central pancreatectomy group at 1 and 2 years after surgery (1 year; P < 0.0001, 2 years; P = 0.0055), and the body weight in the patients undergoing a central pancreatectomy improved to preoperative values within 2 years after surgery. Conclusion  A central pancreatectomy is a safe procedure for the treatment of low-grade malignant neoplasms in the pancreatic body; the rate of onset of diabetes is minimal, and the body weight improves early in the postoperative course.     

Utilization of Preoperative Patient Factors to Predict Postoperative Vitamin D Deficiency for Patients Undergoing Gastric Bypass

Introduction  Vitamin D deficiency occurring after gastric bypass procedures can predispose patients to calcium and parathyroid hormone (PTH) level abnormalities. The aim of the study is to identify preoperative patient risk factors for postoperative vitamin D deficiency. Methods  We retrospectively reviewed patients who underwent Roux-en-Y gastric bypass procedures between 2005 and 2006. Patient demographics, laboratory values of calcium, vitamin D, and PTH were followed at quarterly intervals for 1 year. Results  One hundred forty-five patients were included in the study. The mean age for the group was 44 years with an average body mass index of 49.5 kg/m². Eighty-six percent of patients were female and 23% was African–American. Forty-two percent of the patients had vitamin D deficiency (<20 ng/mL) either preoperatively or at year 1. The mean calcium levels decreased from 9.39 to 9.16 mg/dL (p < 0.001) while the mean PTH levels increased from 25.7 to 43.9 ng/mL (p < 0.001). A logistic regression model recognized preoperative vitamin D levels, race, and bypass limb length to be the only significant factors (p < 0.05) for postoperative vitamin D deficiency. Conclusion  It is important to recognize patients who are at risk for vitamin D deficiency before surgery so that early intervention could be in place to minimize further postoperative deficiency. This paper had been presented as a poster at the DDW meeting May 2008, San Diego, CA, USA.     

Prospective Nonrandomized Comparison Between Pylorus-Preserving and Subtotal Stomach-Preserving Pancreaticoduodenectomy from the Perspectives of DGE Occurrence and Postoperative Digestive Functions

Background  To determine the influence of pylorus preservation after pancreaticoduodenectomy, we compared the postoperative course of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) and pylorus-preserving pancreaticoduodenectomy (PPPD). Methods  A prospective, nonrandomized comparison of 77 consecutive patients undergoing PPPD (n = 37) or SSPPD (n = 40) between January 2003 and March 2007 was planned. The early postoperative course, dietary intake, and the incidence of delayed gastric emptying (DGE) were evaluated. Results  SSPPD included significantly more cases of regional lymph node dissection (D2, PPPD 53% vs. SSPPD 80%) and portal vein resection. The median duration of surgery (457 vs. 520 min) was significantly shorter, and blood loss (619 vs. 1,235 ml) was significantly less in PPPD. Regarding postoperative clinical factors, the duration of nasogastric tube intubation (1 vs.1 day), days until solid diet (7 vs. 7 days), and the incidence of DGE (9% vs.10%) were similar in PPPD and SSPPD. However, the postoperative/preoperative body weight ratio (95% vs. 93%) was significantly higher, and the postoperative hospital stay (31 vs. 38 days) was significantly shorter in PPPD (p < 0.05). Conclusions  Despite the bias of the operative factors, the incidence of DGE and postoperative dietary intake after SSPPD was comparable with PPPD, and therefore, pylorus preservation seemed to have no impact on postoperative dietary intake or DGE.     

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy: A Meta-Analysis

Background   The role of prophylactic antibiotics in laparoscopic cholecystectomy in low-risk patients is controversial. We conducted a meta-analysis to evaluate the efficacy of prophylactic antibiotics in low-risk patients (those without cholelithiasis or cholangitis) undergoing laparoscopic cholecystectomy. Methods   Multiple databases and abstracts were searched. Randomized controlled trials (RCTs) comparing prophylactic antibiotics to placebo or no antibiotics in low-risk laparoscopic cholecystectomy were included. The effects of prophylactic antibiotics were analyzed by calculating pooled estimates of overall infections, superficial wound infections, major infections, distant infections, and length of hospital stay. Separate analyses were performed for each outcome by using odds ratio or weighted mean difference. Both random and fixed effects models were used. Publication bias was assessed by funnel plot. Heterogeneity among studies was assessed by calculating I ² measure of inconsistency. Results   Nine RCTs (N = 1,437) met the inclusion criteria. No statistically significant reduction was noted for those receiving prophylactic antibiotics and those who did not for overall infectious complications (p = 0.20), superficial wound infections (p = 0.36), major infections (p = 0.97), distant infections (p = 0.28), or length of hospital stay (p = 0.77). No statistically significant publication bias or heterogeneity were noted. Conclusions   Prophylactic antibiotics do not prevent infections in low-risk patients undergoing laparoscopic cholecystectomy. Scientific Meeting: Data presented at Digestive Disease Week on 19 May 2008 at San Diego, CA.     

Reduced Postoperative Pancreatic Fistula Rate After Pancreatogastrostomy Versus Pancreaticojejunostomy

Introduction  Metaanalysis of retrospective studies employing various definitions of pancreatic fistulas demonstrated a reduced postoperative pancreatic fistula rate after pancreatogastrostomy versus pancreaticojejunostomy. Prospective trials failed to do so, which causes an ongoing debate on the superiority of one or the other procedure. The aim of this study was to compare the two types of anastomosis at our institution with regard to postoperative pancreatic fistula and other complications. Materials and Methods  From 2001 to 2007, 114 pancreatogastrostomies and 115 pancreaticojejunostomies were performed. For retrospective analysis, the ISGPS definitions were employed. Primary endpoint was the occurrence of postoperative pancreatic fistula grade B or C. Secondary endpoints were postpancreatectomy hemorrhage, delayed gastric emptying, intraabdominal fluid collection, reoperation, and mortality. Operative time, intensive care unit stay, and overall hospital stay were also compared. Results  With pancreatogastrostomy, there were significantly less postoperative pancreatic fistulae grade B and C (pancreatogastrostomy (PG) versus pancreaticojejunostomy (PJ), 11.4% versus 22.6%, p = 0.03), more intraluminal hemorrhage (PG versus PJ, 10.5% versus 0%, p < 0.001) and more delayed gastric emptying grade B and C (PG versus PJ, 18.3% versus 7.9%, p = 0.03). Operative time was shorter (PG versus PJ, median 420 versus 450 min, p < 0.01), and intensive care unit stay was longer (PG versus PJ, median 4 days versus 5 days, p < 0.01), with a tendency toward reduced overall hospital stay (PG versus PJ, median 17 versus 19 days, p = 0.08). Conclusion  Surgeons should be aware of a higher rate of delayed gastric emptying and perform meticulous hemostasis to prevent intraluminal bleeding with pancreatogastrostomy. Pancreatogastrostomy is superior to pancreaticojejunostomy in terms of relevant postoperative pancreatic fistula.     

High Volume and Outcome After Liver Resection: Surgeon or Center?

Introduction  In a case controlled analysis, we attempted to determine if the volume–survival benefit persists in liver resection (LR) after eliminating differences in background characteristics. Methods  Using the Nationwide Inpatient Sample (NIS), we identified all LR (n = 2,949) with available surgeon/hospital identifiers performed from 1998–2005. Propensity scoring adjusted for background characteristics. Volume cut-points were selected to create equal groups. A logistic regression for mortality was then performed with these matched groups. Results  At high volume (HV) hospitals, patients (n = 1423) were more often older, white, private insurance holders, elective admissions, carriers of a malignant diagnosis, and high income residents (p < 0.05). Propensity matching eliminated differences in background characteristics. Adjusted in-hospital mortality was significantly lower in the HV group (2.6% vs. 4.8%, p = 0.02). Logistic regression found that private insurance and elective admission type decreased mortality; preoperative comorbidity increased mortality. Only LR performed by HV surgeons at HV centers was independently associated with improved in-hospital mortality (HR, 0.43; 95% CI, 0.22–0.83). Conclusions  A socioeconomic bias may exist at HV centers. When these factors are accounted for and adjusted, center volume does not appear to influence in-hospital mortality unless LR is performed by HV surgeons at HV centers. Presented at the 49th Annual Meeting of the Society for Surgeons of the Alimentary Tract at Digestive Disease Week, May 17–21, 2008, San Diego, CA, USA     

Pancreatic Fistula Rates After 462 Distal Pancreatectomies: Staplers Do Not Decrease Fistula Rates

Introduction  Pancreatic fistula is a major source of morbidity after distal pancreatectomy (DP). We reviewed 462 consecutive patients undergoing DP to determine if the method of stump closure impacted fistula rates. Methods  A retrospective review of clinicopatologic variables of patients who underwent DP between February 1994 and February 2008 was performed. The International Study Group classification for pancreatic fistula was utilized (Bassi et al., Surgery, 138(1):8–13, 2005). Results  The overall pancreatic fistula rate was 29% (133/462). DP with splenectomy was performed in 321 (69%) patients. Additional organs were resected in 116 (25%) patients. The pancreatic stump was closed with a fish-mouth suture closure in 227, of whom 67 (30%) developed a fistula. Pancreatic duct ligation did not decrease the fistula rate (29% vs. 30%). A free falciform patch was used in 108 patients, with a fistula rate of 28% (30/108). Stapled compared to stapled with staple line reinforcement had a fistula rate of 24% (10/41) vs. 33% (15/45). There is no significant difference in the rate of fistula formation between the different stump closures (p = 0.73). On multivariate analysis, BMI > 30 kg/m², male gender, and an additional procedure were significant predictors of pancreatic fistula. Conclusions  The pancreatic fistula rate was 29%. Staplers with or without staple line reinforcement do not significantly reduce fistula rates after DP. Reduction of pancreatic fistulas after DP remains an unsolved challenge. Presented at the DDW in San Diego, CA, USA, May 21, 2008.     

Leukocyte Depletion in Allogeneic Blood Transfusion Does Not Change the Negative Influence on Survival Following Transthoracic Resection for Esophageal Cancer

Background  Perioperative transfusion of allogeneic blood has been hypothesized to have an immunomodulatory effect and influence survival in several cancer types. This study evaluates the association between receipt of leucocyte-depleted and non-depleted allogeneic blood and survival following esophagectomy for cancer. Methods  A retrospective analysis was performed including 291 patients with esophageal cancers who underwent transthoracic en bloc esophagectomy and extended mediastinal lymphadenectomy. Neoadjuvant chemoradiation was administered in 152 (52.2%) patients. Perioperative blood transfusions were quantified and the potential prognostic cutoff for transfused units was calculated according to LeBlanc. Results  The median number of perioperative blood transfusions was 2 (0–24), and 106 patients (36.4%) received no transfusions. Patients with one or less blood transfusion showed a significantly improved survival compared to patients receiving more than one unit (p < 0.009). In multivariate analysis, blood transfusion categories showed significance (p < 0.015) next to pT, pN, pM category, and residual tumor categories (R-categories). Separate analysis of 183 patients treated after the mandatory introduction of leukocyte-depleted blood transfusions detected a strong tendency, but no significant difference in survival for patients getting one or less or more than one transfusion (p = 0.056). Receipt of leukocyte-depleted versus non-depleted units, however, had no influence on survival (p = 0.766). Conclusions  The need for perioperative allogeneic blood transfusions is significantly associated with poorer survival following resection for esophageal cancer by univariate and multivariate analysis. Our data suggest that the reduction of leukocytes in allogeneic transfusions is not sufficient to overcome the negative influence on survival. This paper was presented at DDW 2008 in the San Diego Convention Center, San Diego, CA, May 17–22, 2008.     

Preoperative Resolution of Jaundice Following Biliary Stenting Predicts More Favourable Early Survival in Resected Pancreatic Ductal Adenocarcinoma

Introduction  Despite the widespread use of endoscopic biliary stenting in patients presenting with potentially resectable pancreatic cancer, there is no general consensus regarding whether this represents a superior management approach over expeditious surgical intervention. The objective of this study was to investigate the influence of preoperative biliary stenting and resolution of jaundice on subsequent postoperative survival following resection for pancreatic cancer. Methods  155 patients undergoing partial pancreatoduodenectomy for pancreatic ductal adenocarcinoma between January 1997 and August 2007 were identified from a prospectively maintained database. Results  There was no survival difference when comparing patients undergoing preoperative biliary drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When analysing individual prognostic factors as continuous variables in univariate Cox analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels (P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer overall survival. Multivariable Cox regression demonstrated that both albumin (P = 0.008) and CRP (P = 0.038) remained significant independent predictors of overall survival alongside lymph node ratio (P = 0.018). Although preoperative bilirubin levels were not associated with overall survival when analysed as a continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin >35 μmol/l) at the time of surgery was a significant adverse predictor of early survival in patients undergoing preoperative biliary drainage (Breslow–Gehan–Wilcoxon, P = 0.013) and remained a significant predictor of early survival when included in a further Cox analysis with censoring of cases who survived beyond 6 months (Cox, P = 0.017). Conclusion  These results suggest that the presence of jaundice at the time of resection has an adverse impact on early, but not overall, postoperative survival in pancreatic cancer patients undergoing preoperative biliary drainage.