Surgery residency training programmes have greater impact on outcomes after pancreaticoduodenectomy than hospital volume or surgeon frequency

Background:

Hospital volume of pancreaticoduodenectomy (PD) and surgeon frequency of PD have been shown to impact outcomes. The impact of surgery residency training programmes after PD is unknown. This study was undertaken to determine the impact of surgery training programmes on outcomes after PD, as well as their importance relative to hospital volume and surgeon frequency of PD.

Methods:

The State of Florida Agency for Healthcare Administration Database was queried for patients undergoing PD during 2002–2007. Measures of outcome were compared for patients undergoing PD at centres with vs. without surgery residency training programmes.

Results:

A total of 2345 PDs were identified, of which 1478 (63%) were undertaken at training centres and 867 (37%) were performed at non-training centres. Patients undergoing PD at training centres had shorter lengths of stay, lower hospital charges and lower in-hospital mortality. Relative to surgeon frequency of PD, training centres had a greater favourable impact on hospital length of stay, hospital charges and in-hospital mortality (P < 0.001 for each, ancova). Relative to hospital volume of PDs undertaken, training centres had a greater impact on hospital charges (P < 0.001, ancova).

Conclusions:

Surgery residency training programmes have a favourable effect on outcomes following PD and their impact on outcome is greater than the impact of hospital volume or surgeon frequency of PD.     

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Background:

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

Materials and Methods:

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

Results:

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).

Conclusions:

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.     

Is isolated Roux loop pancreaticojejunostomy superior to conventional reconstruction in pancreaticoduodenectomy?

Objectives:

Pancreatic fistula (PF) predicts mortality and morbidity in patients undergoing pancreaticoduodenectomy (PD). This study aimed to assess whether isolated Roux loop pancreaticojejunostomy (IPJ) is superior to conventional pancreaticojejunostomy (CPJ).

Methods:

Between September 2003 and July 2007, we performed 108 PDs. All patients underwent classical Kausch–Whipple PD with pancreaticojejunostomy (PJ). Patients were divided into two groups based on the type of PJ. Patients in group 1 underwent IPJ and those in group 2 underwent CPJ. A retrospective analysis of prospectively maintained data was performed to compare outcomes in the two groups.

Results:

There were 53 patients in group 1 and 55 in group 2. The two groups were comparable in both pre- and intraoperative parameters. The overall incidence of PF was 10.1% (five cases in group 1 vs. six in group 2). The course of clinically significant PF was similar in both groups in terms of fistula behaviour, management and the duration of spontaneous closure. Two patients in each group died. Overall complications, mortality and length of hospital stay were also similar; however, duration of surgery was significantly higher in group 1 vs. group 2 (442 min and 370 min, respectively; P= 0.005).

Conclusions:

Isolated Roux loop pancreaticojejunostomy is not superior to conventional PJ; instead, it increases the duration of surgery.     

Combined pancreaticoduodenectomy and extended right hemicolectomy: outcomes and indications

Background:

Pancreaticoduodenectomy (PD) combined with an en bloc extended right hemicolectomy is required to achieve complete oncological resection of various malignancies. Information regarding the indications and outcomes of this procedure is limited.

Study design:

Patients requiring PD combined with extended right hemicolectomy for primary tumours from 2002 to 2008 were identified.

Results:

PD combined with an en bloc extended right hemicolectomy was required in 14 patients, constituting 8% of pancreaticoduodenal resections. Pancreatic adenocarcinoma (8), retroperitoneal sarcoma (2) and colon cancer (2) were the main primary tumours resected. The indication for an extended right hemicolectomy was extensive tumour involvement of the transverse mesentery in seven patients. Clear tumour margins were achieved in 11 individuals. The median operating time was 10 h with intra-operative transfusions required in three patients. One or more complications were noted in eight, with delayed gastric emptying and pancreatic fistula the most common. The median length of hospital stay was 8 days. The overall 2-year survival in this series was 37%, with a median survival of 20 months in pancreatic cancer patients.

Conclusions:

This series suggests that PD combined with an en bloc extended right hemicolectomy is feasible and can achieve complete tumour clearance with acceptable morbidity.     

Preoperative computed tomography measurements of pancreatic steatosis and visceral fat: prognostic markers for dissemination and lethality of pancreatic adenocarcinoma

Background

Increased visceral fat and pancreatic steatosis promote lymphatic metastases and decreased survival in patients with pancreatic adenocarcinoma after pancreatoduodenectomy (PD).

Objectives

We aim to determine the utility of preoperative computed tomography (CT) measurements of pancreatic steatosis and visceral fat as prognostic indicators in patients with pancreatic adenocarcinoma.

Methods

High-resolution CT scans of 42 patients undergoing PD for pancreatic adenocarcinoma were reviewed. Attenuation in CT of the pancreas, liver and spleen were measured in Hounsfield units and scored by two blinded investigators. Perirenal adipose tissue was measured in mm.

Results

Lymphatic metastases were present in 57% of patients. Age, gender, tumour size and margin status were similar in patients with and without nodal metastases. Node-positive patients had increased visceral but not subcutaneous fat pads compared with node-negative patients and decreased CT attenuation of the pancreatic body and tail and liver. Node-positive patients stratified by visceral adiposity (≥10 mm vs. <10 mm) demonstrated poorer survival (7 ± 1 months vs. 16 ± 2 months; P < 0.01).

Conclusions

In resected pancreatic adenocarcinoma, increased pancreatic steatosis and increased visceral fat stores are associated with lymphatic metastases. Furthermore, increased visceral fat is associated with abbreviated survival in patients with lymphatic metastases. Hence, increased visceral fat may be a causative factor of abbreviated survival and serves a prognostic role in patients with pancreatic malignancies.     

Effect of dialysis modality on survival of hepatitis C-infected ESRF patients

Summary

Background and objectives

Hepatitis C virus (HCV) infection is associated with increased mortality and morbidity in end-stage renal failure (ESRF) patients. Despite a lower incidence and risk of transmission of HCV infection with peritoneal dialysis (PD), the optimal dialysis modality for HCV-infected ESRF patients is not known. The aim of this study was to evaluate the impact of dialysis modality on the survival of HCV-infected ESRF patients.

Design, setting, participants, & measurements

The study included all adult incident ESRF patients in Australia and New Zealand who commenced dialysis between January 1, 1994, and December 31, 2008, and were HCV antibody-positive at the time of dialysis commencement. Time to all-cause mortality was compared between hemodialysis (HD) and PD according to modality assignment at day 90, using Cox proportional hazards model analysis.

Results

A total of 424 HCV-infected ESRF patients commenced dialysis during the study period and survived for at least 90 days (PD n = 134; HD n = 290). Mortality rates were comparable between PD and HD in the first year (10.7 versus 13.8 deaths per 100 patient-years, respectively; adjusted hazard ratio [HR] 0.65, 95% CI 0.34 to 1.26) and thereafter (20 versus 15.9 deaths per 100 patient-years, respectively; HR 1.27, 95% CI 0.86 to 1.88).

Conclusions

The survival of HCV-infected ESRF patients is comparable between PD and HD.     

Prediction of post-operative pancreatic fistula in pancreaticoduodenectomy patients using pre-operative MRI: a pilot study

Background:

Post-operative pancreatic fistula (POPF) is one of the most fearful complications which may occur after pancreaticoduodenectomy (PD). The methods used to predict POPF pre-operatively have not been studied in great detail. We analyzed correlation between various parameters related to PD including pre-operative magnetic resonance imaging (MRI) signal intensity (SI), pathology of pancreatic fibrosis and occurrence rates of POPF, and verified that MRI SI results could be the determining values for pre-operative prediction of POPF.

Methods:

From January 2005 to August 2006, we retrospectively examined 43 cases of PDs by reviewing abdominal MRI findings, degree of fibrosis of remnant pancreatic stump, and other surgery-related parameters.

Results:

POPF encountered in PD were 11 cases (25.6%). Operation time and degree of fibrosis of remnant pancreatic cut surface were related to POPF (P= 0.030, P= 0.010). The pancreas–liver SI ratio (PLSI) between fistula group and no fistula group was −0.0009 ± 0.2 and −0.1297 ± 0.2, respectively (P= 0.0004). The pancreas–spleen SI ratio (PSSI) in each group was 0.423 ± 0.25 and 0.288 ± 0.32, respectively (P= 0.014). Using quantitative analysis, the SI ratios were 1.27 and 0.66 in each group (P= 0.013).

Conclusions:

When analyzing the results of POPF in 43 patients who underwent PD, PLSI, PSSI and qualitative analysis, fistula group differed significantly from no fistula group. Using these results, it will be helpful for us to predict the occurrence of POPF pre-operatively using MRI in PD patients.     

Modified Cattell's pancreaticojejunostomy,buttressing for soft pancreases and an isolated biliopancreatic loop are safety measurements that improve outcome after pancreaticoduodenectomy: a pilot study

Background:

Pancreatic anastomotic leak is one of the most serious complications following pancreaticoduodenectomy (PD). Various factors have been implicated as contributors to pancreatic anastomotic leaks, the incidence of which has been as high as 28% in some series.

Objectives:

We describe technical modifications to Cattell''s technique for pancreaticojejunostomy (PJ), with buttressing of ‘soft’ pancreases and use of an isolated biliopancreatic loop for reconstruction following a PD.

Methods:

We report our early experience using this technique in 50 patients who underwent PD between May 2002 and June 2006.

Results:

There was no mortality in our series. The postoperative morbidity rate was 32% (16/50), with major complications occurring in seven (14%) patients. Pancreatic leak occurred in one patient (2%) and bile leak in one patient (2%). Both patients were managed conservatively.

Conclusions:

Reconstruction after PD using an isolated biliopancreatic loop and modifications to Cattell''s technique for PJ, with buttressing of the soft pancreas, can be performed with a low risk of pancreatic anastomotic leakage.     

A diagnostic paradigm for resectable liver lesions: to biopsy or not to biopsy?

Background:

Despite a growing body of evidence reporting the deleterious mechanical and oncological complications of biopsy of hepatic malignancy, a small but significant number of patients undergo the procedure prior to specialist surgical referral. Biopsy has been shown to result in poorer longterm survival following resection and advances in modern imaging modalities provide equivalent, or better, diagnostic accuracy.

Methods:

The literature relating to needle-tract seeding of primary and secondary liver cancers was reviewed. MEDLINE, EMBASE and the Cochrane Library were searched for case reports and series relating to the oncological complications of biopsy of liver malignancies. Current non-invasive diagnostic modalities are reviewed and their diagnostic accuracy presented.

Results:

Biopsy of malignant liver lesions has been shown to result in poorer longterm survival following resection and does not confer any diagnostic advantage over a combination of non-invasive imaging techniques and serum tumour markers.

Conclusions:

Given that chemotherapeutic advances now often permit downstaging and subsequent resection of ‘unresectable’ disease, the time has come to abandon biopsy of solid lesions outside the setting of a specialist multi-disciplinary team meeting (MDT).     

Identification of risk categories for in pancreaticoduodenectomy based on diagnosis

Background

Studies of pancreaticoduodenectomy (PD) frequently overlook diagnosis as a variable when evaluating postoperative outcomes or generically group patients according to whether they have ‘benign’ or ‘malignant’ disease. Large multicentre studies comparing postoperative outcomes in PD stratified by diagnosis are lacking. The present study was conducted to verify the hypothesis that postoperative morbidity and length of stay (LoS) following PD vary by diagnosis and that patients may be grouped into low- and high-risk categories.

Methods

The database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was reviewed for all PDs performed during 2005–2011. Diagnoses were identified using ICD-9 codes and grouped based on the incidence of major morbidity. Univariate and multivariate analyses were utilized to assess the impact of diagnosis on PD outcomes.

Results

Of 5537 patients, those with pancreas cancer (n = 3173) and chronic pancreatitis (n = 485) experienced similar incidences of major morbidity (P = 0.95) and were grouped as having low-risk diagnoses. Patients with bile duct and ampullary (n = 1181), duodenal (n = 558) and neuroendocrine (n = 140) disease experienced similar levels of major morbidity (P = 0.78) and were grouped as having high-risk diagnoses. A high-risk diagnosis was identified as an independent risk factor for a prolonged LoS [odds ratio (OR) 1.67], organ space infection (OR 2.57), sepsis or septic shock (OR 1.83), and major morbidity (OR 1.70). Diagnosis did not predict readmission.

Conclusions

The high-risk diagnosis is independently associated with postoperative morbidity and prolonged LoS. Patients with PD should be stratified by diagnosis to more accurately reflect their risk for postoperative complications and the complexity of care they will require.     

The role of interventional radiology in the management of surgical complications after pancreatoduodenectomy

Objectives

This study evaluates the role of interventional radiology (IR) in the management of postoperative complications after pancreatoduodenectomy (PD).

Methods

A total of 120 consecutive patients were reviewed to identify IR procedures performed for early complications after PD.

Results

Findings showed that 24 patients (20.0%) required urgent radiological or surgical re-intervention for early complications, including 11 instances of post-pancreatectomy haemorrhage (PPH), six intra-abdominal abscesses, two bile leaks, one pancreatic fistula and one bowel ischaemia. Three of 24 complications were managed by surgery and 21 were managed by IR. Two of 11 PPHs involved intraluminal haemorrhage (ILH) and nine involved intra-abdominal haemorrhage (IAH). One ILH was managed conservatively and one required surgical intervention. In eight of nine patients with IAH, the bleeding site was identified on computed tomography angiography, and endovascular stenting or coil embolization were performed. No patient required a re-look laparotomy following IR for haemorrhage or intra-abdominal abscess. Overall, three of 120 patients required an urgent re-look laparotomy for early complications.

Conclusions

Rates of major morbidity after PD remain high. However, many significant complications (PPH, pancreatic fistula, intra-abdominal abscess) can be managed by IR, reducing the need for reoperation. Re-look surgery is still required in a small percentage (2.5%) of patients.     

Transcatheter arterial chemoembolization for hepatic recurrence after curative resection of pancreatic adenocarcinoma

Background/Aims

Despite curative resection, hepatic recurrences cause a significant reduction in survival in patients with primary pancreatic adenocarcinoma. Transcatheter arterial chemoembolization (TACE) has recently been used successfully to treat primary and secondary hepatic malignancy.

Methods

Between 2003 and 2008, 15 patients underwent TACE because of hepatic recurrence after curative resection of a pancreatic adenocarcinoma. The tumor response was evaluated based on computed tomography scans after TACE. The overall duration of patient survival was measured.

Results

After TACE, a radiographically evident response occurred in six patients whose tumors demonstrated a tumor blush on angiography. Four patients demonstrated stabilization of a hypovascular mass. The remaining five patients demonstrated continued progression of hypovascular hepatic lesions. The median survival periods from the time of diagnosis and from the time of initial TACE were 9.6 and 7.5 months, respectively.

Conclusions

TACE may represent a viable therapeutic modality in patients with hepatic recurrence after curative resection of pancreatic adenocarcinoma.     

Changes in the management of benign liver tumours: an analysis of 285 patients

Objectives

Benign liver tumours (BLTs) are common and their management remains controversial. This study assesses the safety of a selective management approach.

Methods

Patients with BLT were identified from an institutional database. Patients with simple cysts or an incidental BLT in the setting of metastasis or concomitant malignancy were excluded.

Results

A total of 285 patients presenting during the period from January 1992 to December 2009 with haemangioma (53.0%), focal nodular hyperplasia (23.9%), adenoma (10.2%) or indeterminate/other lesions (13.0%) were evaluated. Of these, 117 patients (41.1%) underwent immediate resection and 168 patients (58.9%) were followed with serial imaging (median follow-up: 30 months). During observation, eight patients (4.8%) underwent resection for tumour growth, inability to exclude malignancy or symptoms; no patients demonstrated malignant transformation or tumour-related complications. During the study period, the number of BLTs evaluated and the proportion of patients observed increased from 129 BLTs of which 36.4% were observed in 1992–2002 to 156 BLTs of which 71.2% were observed in 2003–2009 (P < 0.001). Diagnostic uncertainty led to resection in 29.5% of patients during the earlier period, but in only 13.4% during the more recent 7 years (P < 0.05).

Conclusions

Asymptomatic BLTs without concern for malignancy or adenoma can be safely observed with minimal risk for misdiagnosis. Patients selected for observation rarely require resection or develop tumour-related complications.     

Complications following liver resection for colorectal metastases do not impact on longterm outcome

Background

It has been suggested that adverse postoperative outcomes may have a negative impact on longterm survival in patients with colorectal liver metastases.

Objectives

This study was conducted to evaluate the prognostic impact of postoperative complications in patients submitted to a potentially curative resection of colorectal liver metastases.

Methods

A retrospective analysis of outcomes in 199 patients submitted to hepatic resection with curative intent for metastatic colorectal cancer during 1999–2008 was conducted.

Results

The overall complication rate was 38% (n = 75). Of all complications, 79% were minor (Grades I or II). There were five deaths (3%). The median length of follow-up was 39 months. Rates of 5-year overall and disease-free survival were 44% and 27%, respectively. Univariate analysis demonstrated that an elevated preoperative level of carcinoembryonic antigen (CEA), intraoperative blood loss of >300 ml, multiple metastases, large (≥35 mm) metastases and resection margins of <1 mm were associated with poor overall and disease-free survival. In addition, male sex and synchronous metastases were associated with poor disease-free survival. Postoperative complications did not have an impact on either survival measure. The multivariate model did not include complications as a predictive factor.

Conclusions

Postoperative complications were not found to influence overall or disease-free survival in the present series. The number and size of liver metastases were confirmed as significant prognostic factors.     

Safety and efficacy of LigaSure usage in pancreaticoduodenectomy

Background

Over recent years, use of the LigaSure™ vessel sealing device has increased in major abdominal surgery to include pancreaticoduodenectomy (PD). LigaSure™ use during PD has expanded to include all steps of the procedure, including the division of the uncinate margin. This introduces the potential for thermal major vascular injury or margin positivity. The aim of the present study was to evaluate the safety and efficacy of LigaSure™ usage in PD in comparison to established dissection techniques.

Methods

One hundred and forty-eight patients who underwent PD from 2007 to 2012 at Robert Wood Johnson University Hospital were identified from a retrospective database. Two groups were recognized: those in which the LigaSure™ device was used (N = 114), and in those it was not (N = 34). Peri-operative outcomes were compared.

Results

Vascular intra-operative complications directly caused by thermal injury from LigaSure™ use occurred in 1.8% of patients. Overall vascular intra-operative complications, uncinate margin positivity, blood loss, length of stay, and complication severity were not significantly different between groups. The mean operative time was 77 min less (P < 0.010) in the LigaSure™ group. Savings per case where the LigaSure™ was used amounted to $1776.73.

Conclusion

LigaSure™ usage during PD is safe and effective. It is associated with decreased operative times, which may decrease operative costs in PD.     

Icodextrin Increases Technique Survival Rate in Peritoneal Dialysis Patients with Diabetic Nephropathy by Improving Body Fluid Management: A Randomized Controlled Trial

Summary

Background and objectives

There are still controversies whether peritoneal dialysis (PD) with icodextrin preserves residual renal and peritoneal membrane functions in patients with diabetes. However, there are no randomized controlled and long-term clinical trials in newly started PD patients with diabetic nephropathy.

Design, setting, participants, & measurements

Forty-one patients with diabetic nephropathy with ESRD were enrolled and randomly assigned to the glucose group (GLU) treated with 8 L of 1.5% or 2.5% glucose or an icodextrin group (ICO) treated with 1.5 or 2.0 L of 7.5% icodextrin-containing solutions. Technique failure, body fluid management, glucose and lipid metabolism, and residual renal and peritoneal functions and were evaluated over 2 years.

Results

The technique survival rate was 71.4% in ICO and 45.0% in GLU, with most of the technique failure due to volume overload. ICO showed significantly better cumulative technique survival. Net ultrafiltration volume was significantly higher in ICO throughout the study period. There were no beneficial effects of icodextrin on hemoglobin A1c, glycoalbumin, and lipid profile at 24 months. Urine volume and residual renal function declined faster in ICO, but there were no significant differences between the two groups. For peritoneal function, no differences were observed in dialysis-to-plasma creatinine ratios during the observation.

Conclusions

In PD therapy for diabetic nephropathy, the use of icodextrin-containing solutions has a beneficial effect on technique survival, but there are no apparent benefits or disadvantages in residual renal and peritoneal functions compared with conventional PD with glucose solution.     

Hepatectomy after hepatic arterial therapy with either yttrium-90 or drug-eluting bead chemotherapy: is it safe?

Background

The use of hepatic arterial therapy (HAT) with either yttrium-90 or drug-eluting bead therapy for initially unresectable hepatic malignancies has risen significantly. The safety of hepatic resection after hepatic arterial therapy (HAT) is not established.

Objective

The present study evaluates the safety profile for hepatic resection after HAT.

Methods

We identified 840 patients undergoing hepatectomy for primary or metastatic lesions. Forty patients underwent HAT before hepatectomy (pre-HAT). A 1 : 4 case-matched analysis compared three groups: (i) pre-HAT and pre-operative chemotherapy (n = 40); (ii) pre-operative chemotherapy (n = 160); and (iii) no pre-operative therapy (n = 640). Controls were matched for age, resection type, maximal tumour size and magnitude of resection. Morbidity and mortality among groups were compared using a graded complication scale.

Results

There were no differences in post-operative complications, grade of complication or liver-specific complications among the groups. A proportional hazards model for all patients did not demonstrate any association between increased complications and either pre-HAT or pre-operative chemotherapy when compared with patients without pre-operative therapy (P = 0.7).

Conclusions

Pre-HAT demonstrated similar morbidity, liver-specific morbidity and intra-operative complications when compared with patients undergoing pre-operative chemotherapy alone or without pre-operative chemotherapy. These results suggest that pre-HAT is safe and should not preclude hepatectomy in carefully selected patients.     

The impact of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction on pancreatic fistula after pancreaticoduodenectomy: meta-analysis of randomized controlled trials

Background

Pancreatic fistula (PF) remains a common source of morbidity following pancreaticoduodenectomy (PD). Despite numerous studies, the optimal method of pancreatic remnant reconstruction is controversial. This study examines the hypothesis that pancreaticogastrostomy (PG) is associated with a lower risk for PF after PD compared with pancreaticojejunostomy (PJ).

Methods

Five electronic databases and the grey literature were searched for randomized controlled trials (RCTs) comparing PJ and PG after PD. Two reviewers independently selected studies, extracted data and assessed methodology. The primary outcome was the occurrence of PF of International Study Group on Pancreatic Fistula (ISGPF) Grade B or C.

Results

Four RCTs including 676 patients were included. Pancreaticogastrostomy reduced the risk for PF [relative risk (RR) 0.41, 95% confidence interval (CI) 0.21–0.62] without any difference between high- and low-risk patients. Absolute risk reduction for PF was 4% (95% CI 2.4–5.6) in low-risk patients compared with 10% (95% CI 6.5–14.8) in high-risk patients undergoing PG rather than PJ. The strength of evidence for PF outcome was moderate according to the GRADE classification.

Conclusions

Reconstruction by PG decreases the rate of PF in comparison with PJ. Surgeons should consider reconstructing the pancreatic remnant following PD with PG, particularly in patients at high risk for PF.     

Longterm survival after pancreaticoduodenectomy for periampullary adenocarcinomas

Objectives

The aim of this study was to identify predictors for longterm survival following pancreaticoduodenectomy (PD) for pancreatic and other periampullary adenocarcinomas.

Methods

Clinicopathological factors were compared between short-term (<5 years) and longterm (≥5 years) survival groups. Rates of actual 5-year and actuarial 10-year survival were determined.

Results

There were 109 (21.8%) longterm survivors among a sample of 501 patients. Patients with ampullary adenocarcinoma represented 76.1% of the longterm survivors. Favourable factors for longterm survival included female gender, lack of jaundice, lower blood loss, classical PD, absence of postoperative bleeding or intra-abdominal abscess, non-pancreatic primary cancer, earlier tumour stage, smaller tumour size (≤2 cm), curative resection, negative lymph node involvement, well-differentiated tumours, and absence of perineural invasion. Independent factors associated with longterm survival were diagnosis of primary tumour, jaundice, intra-abdominal abscess, tumour stage, tumour size, radicality, lymph node status and cell differentiation. The prognosis was best for ampullary adenocarcinoma, for which the rate of actual 5-year survival was 32.8%, and poorest for pancreatic head adenocarcinoma, for which actual 5-year survival was only 6.5%.

Conclusions

The majority of longterm survivors after PD for periampullary adenocarcinomas are patients with ampullary adenocarcinoma. The longterm prognosis in pancreatic head adenocarcinoma remains dismal.     

National trends in discharge disposition after hepatic resection for malignancy

Background

There is a paucity of data on the trends in discharge disposition for patients undergoing hepatic resection for malignancy.

Aim

To analyse the national trends in discharge disposition after hepatic resection for malignancy.

Methods

The National Inpatient Sample (NIS) database was queried (1993 to 2005) to identify patients that underwent hepatic resection for malignancy and analyse the discharge status (home, home health or rehabilitation/skilled facility).

Results

A weighted total of 74 520 patients underwent hepatic resection of whom, 53 770 patients had a principal diagnosis of malignancy. The overall mortality improved from 6.3% to 3.4%. After excluding patients that died in the post-operative period and those with incomplete discharge status, 45 583 patients were included. The proportion of patients that had acute care needs preventing them from being discharged home without assistance increased from 10.9% in 1993 to 19.5% in 2005. While there was an increase in the number of patients discharged to home health care during this time (8.9% to 13.8%), there was a larger increase in the proportion of patients that were discharged to a rehabilitation or skilled nursing facility (2% to 5.7%). Despite a decrease in the mortality rates, there was no improvement in rate of patients discharged home without assistance over the period of the study.

Conclusions

The results of the present study demonstrate that after hepatic resection, a significant proportion of patients will need assistance upon discharge. This information needs to be included in patient counselling during pre-operative risk and benefit assessment.