Distinct predictors of pre‐ versus post‐discharge venous thromboembolism after hepatectomy: analysis of 7621 NSQIP patients

AbstractObjectivesHepatectomy patients are known to be at significant risk for venous thromboembolism (VTE), but previous studies have not differentiated pre‐ versus post‐discharge events. This study was designed to evaluate the timing, rate and predictors of pre‐ (‘early’) versus post‐discharge (‘late’) VTE.MethodsAll patients undergoing elective hepatectomy during 2005–2010 and recorded in the American College of Surgeons National Surgical Quality Improvement Program participant use file were identified. Perioperative factors associated with 30‐day rates of early and late VTE were analysed.ResultsA total of 7621 patients underwent 4553 (59.7%) partial, 802 (10.5%) left, 1494 (19.6%) right and 772 (10.1%) extended hepatectomies. Event rates were 1.9% for deep venous thrombosis, 1.2% for pulmonary embolus and 2.8% for VTE. Of instances of VTE, 28.6% occurred post‐discharge. The median time of presentation of late VTE was postoperative day 14. Multivariate analysis determined that early VTE was associated with age ≥75 years [odds ratio (OR) 1.92, P = 0.007], male gender (OR 1.87, P = 0.002), intraoperative transfusion (OR 2.49, P < 0.001), operative time of >240 min (OR 2.28, P < 0.001), organ space infection (OSI) (OR 2.60, P < 0.001), and return to operating room (ROR) (OR 3.25, P < 0.001). Late VTE was associated with operative time of >240 min (OR 2.35, P = 0.008), OSI (OR 3.78, P < 0.001) and ROR (OR 2.84, P = 0.011).ConclusionsLate VTE events occur in patients with clearly identifiable intraoperative and postoperative risk factors. This provides a rationale for the selective use of post‐discharge VTE chemoprophylaxis in high‐risk patients

Long-term outcome of patients undergoing liver transplantation for mixed hepatocellular carcinoma and cholangiocarcinoma: an analysis of the UNOS database

AbstractBackgroundMixed hepatocellular and cholangiocarcinoma (HCC-CC) have been associated with a poor prognosis after liver transplantation (LT). We aimed to evaluate long-term outcomes in patients undergoing LT for HCC-CC versus patients with hepatocellular carcinoma (HCC) or cholangiocarcinoma (CC).MethodsRetrospective analysis of the United Network for Organ Sharing (UNOS) database from 1994–2013. Overall survival (OS) in patients with HCC-CC, HCC, and CC, were compared.ResultsWe identified 4049 patients transplanted for primary malignancy (94 HCC-CC; 3515 HCC; 440 CC). Mean age of patients with HCC-CC was 57 ± 10 years, and 77% were male. MELD score did not differ among the groups (p = 0.637). Hepatitis C virus was the most common secondary diagnosis within the HCC-CC (44%) and HCC (36%) cohorts, with primary sclerosing cholangitis in the CC (16%) cohort. OS rates at 1, 3 and 5 years for HCC-CC (82%, 47%, 40%) were similar to CC (79%, 58%, 47%), but significantly worse than HCC (86%, 72%, and 62% p = 0.002).DiscussionPatients undergoing LT for HCC had significantly better survival compared to those transplanted for HCC-CC and CC. LT for mixed HCC-CC confers a survival rate similar to selected patients with CC. Efforts should be made to identify HCC-CC patients preoperatively

Yield of clinical and radiographic surveillance in patients with resected pancreatic adenocarcinoma following multimodal therapy

AbstractBackgroundFollowing potentially curative resection at this centre, patients with pancreatic adenocarcinoma (PAC) are routinely enrolled in a programme of clinical and radiographic surveillance. This study sought to evaluate its diagnostic yield.MethodsAll patients who underwent pancreaticoduodenectomy for PAC at this institution during 1998–2008 were identified. Patients with asymptomatic recurrence were compared with those with symptomatic recurrence. Factors associated with survival following the detection of recurrence were compared.ResultsA total of 216 of 327 (66.1%) resected patients developed recurrence. Asymptomatic recurrence was detected in 118 (54.6%) patients. Symptomatic recurrence was associated with multifocal disease or carcinomatosis, poor performance status and less frequent subsequent therapy. Median time to recurrence did not differ between groups, but survival after detection was shorter in symptomatic patients (5.1months vs. 13.0months; P < 0.001). Treatment was administered more frequently to asymptomatic patients (91.2% vs. 61.4%; P < 0.001). At recurrence, a preserved performance status score of ≤1, further therapy, low CA 19-9, and an isolated site of recurrence were independently associated with longer post-recurrence survival (P < 0.001).ConclusionsOverall, 54.6% of cases of recurrent PAC were detected prior to the onset of symptoms using a standardized clinical and radiographic surveillance strategy. Although this retrospective analysis limits definitive conclusions associating this strategy with survival, these results suggest the need for further studies of postoperative surveillance

Impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX:Trans-Atlantic Pancreatic Surgery (TAPS) Consortium study

Background: Surgery in selected patients with locally advanced pancreatic cancer after induction chemotherapy may have drawbacks related to surgical risks and breaks or delays in oncological treatment, in particular when curative intent resection is not possible (that is non-therapeutic laparotomy). The aim of this study was to assess the incidence and oncological impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX chemotherapy. Methods : This was a retrospective international multicentre study including patients diagnosed with pathology-proven locally advanced pancreatic cancer treated with at least one cycle of (m)FOLFIRINOX (2012–2019). Patients undergoing a non-therapeutic laparotomy (group A) were compared with those not undergoing surgery (group B) and those undergoing resection (group C). Results : Overall, 663 patients with locally advanced pancreatic cancer were included (67 patients (10.1%) in group A, 425 patients (64.1%) in group B, and 171 patients (25.8%) in group C). A non-therapeutic laparotomy occurred in 28.2% of all explorations (67 of 238), with occult metastases in 30 patients (30 of 67, 44.8%) and a 90-day mortality rate of 3.0% (2 of 67). Administration of palliative therapy (65.9% versus 73.1%; P = 0.307) and median overall survival (20.4 [95% c.i. 15.9 to 27.3] versus 20.2 [95% c.i. 19.1 to 22.7] months; P = 0.752) did not differ between group A and group B respectively. The median overall survival in group C was 36.1 (95% c.i. 30.5 to 41.2) months. The 5-year overall survival rates were 11.4%, 8.7%, and 24.7% in group A, group B, and group C, respectively. Compared with group B, non-therapeutic laparotomy (group A) was not associated with reduced overall survival (HR = 0.88 [95% c.i. 0.61 to 1.27]). Conclusion: More than a quarter of surgically explored patients with locally advanced pancreatic cancer after induction (m) FOLFIRINOX did not undergo a resection. Such non-therapeutic laparotomy does not appear to substantially impact oncological outcomes.</p

Impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX:Trans-Atlantic Pancreatic Surgery (TAPS) Consortium study

Background: Surgery in selected patients with locally advanced pancreatic cancer after induction chemotherapy may have drawbacks related to surgical risks and breaks or delays in oncological treatment, in particular when curative intent resection is not possible (that is non-therapeutic laparotomy). The aim of this study was to assess the incidence and oncological impact of a non-therapeutic laparotomy in patients with locally advanced pancreatic cancer treated with induction (m)FOLFIRINOX chemotherapy. Methods : This was a retrospective international multicentre study including patients diagnosed with pathology-proven locally advanced pancreatic cancer treated with at least one cycle of (m)FOLFIRINOX (2012–2019). Patients undergoing a non-therapeutic laparotomy (group A) were compared with those not undergoing surgery (group B) and those undergoing resection (group C). Results : Overall, 663 patients with locally advanced pancreatic cancer were included (67 patients (10.1%) in group A, 425 patients (64.1%) in group B, and 171 patients (25.8%) in group C). A non-therapeutic laparotomy occurred in 28.2% of all explorations (67 of 238), with occult metastases in 30 patients (30 of 67, 44.8%) and a 90-day mortality rate of 3.0% (2 of 67). Administration of palliative therapy (65.9% versus 73.1%; P = 0.307) and median overall survival (20.4 [95% c.i. 15.9 to 27.3] versus 20.2 [95% c.i. 19.1 to 22.7] months; P = 0.752) did not differ between group A and group B respectively. The median overall survival in group C was 36.1 (95% c.i. 30.5 to 41.2) months. The 5-year overall survival rates were 11.4%, 8.7%, and 24.7% in group A, group B, and group C, respectively. Compared with group B, non-therapeutic laparotomy (group A) was not associated with reduced overall survival (HR = 0.88 [95% c.i. 0.61 to 1.27]). Conclusion: More than a quarter of surgically explored patients with locally advanced pancreatic cancer after induction (m) FOLFIRINOX did not undergo a resection. Such non-therapeutic laparotomy does not appear to substantially impact oncological outcomes.</p

Prognostic Significance of Preoperative and Postoperative Ca 19–9 Normalization in Pancreatic Adenocarcinoma Treated With Neoadjuvant Therapy or Surgery First

BACKGROUND: Normal(ization) of serum carbohydrate 19-9 (CA19-9) before/after surgery has not been compared in patients with pancreatic adenocarcinoma (PDAC) treated with neoadjuvant therapy (NT) versus surgery-first (SF). METHODS: Characteristics for patients with PDAC who underwent resection from July 2011 to October 2018 were collected. Patients with pre-/postoperative CA19-9, bilirubin/dL, and initial CA19-9 \u3e 1 U/ml were included. Overall survival (OS) and recurrence-free survival (RFS) were compared by pre-/postoperative CA19-9. RESULTS: In patients receiving NT, normal pre/postoperative CA19-9 ( NT CONCLUSIONS: While a normal(ized) postoperative CA19-9 may result in similar survival as preoperative normal(ization), postoperative normalization failed to occur in nearly 30% of SF patients. NT should be considered in patients presenting with elevated CA19-9. If considering SF, ideal patients may include those with normal CA19-9 at presentation

Comparative Analyses of the Clinicopathologic Features of Short-Term and Long-Term Survivors of Patients with Pancreatic Ductal Adenocarcinoma Who Received Neoadjuvant Therapy and Pancreatoduodenectomy

Neoadjuvant therapy (NAT) is increasingly used to treat patients with pancreatic ductal adenocarcinoma (PDAC). Patients with PDAC often show heterogenous responses to NAT with variable clinical outcomes, and the clinicopathologic parameters associated with these variable outcomes remain unclear. In this study, we systematically examined the clinicopathologic characteristics of 60 short-term survivors (overall survival \u3c 15 months) and 149 long-term survivors (overall survival \u3e 60 months) and compared them to 352 intermediate-term survivors (overall survival: 15-60 months) of PDAC who received NAT and pancreatoduodenectomy. We found that the short-term survivor group was associated with male gender (p = 0.03), tumor resectability prior to NAT (p = 0.04), poorly differentiated tumor histology (p = 0.006), more positive lymph nodes (p = 0.04), higher ypN stage (p = 0.002), and higher positive lymph node ratio (p = 0.03). The long-term survivor group had smaller tumor size (p = 0.001), lower ypT stage (p = 0.001), fewer positive lymph nodes (p \u3c 0.001), lower ypN stage (p \u3c 0.001), lower positive lymph node ratio (p \u3c 0.001), lower rate of lymphovascular invasion (p = 0.001) and perineural invasion (p \u3c 0.001), better tumor response grading (p \u3c 0.001), and less frequent recurrence/metastasis (p \u3c 0.001). The ypN stage is an independent predictor of both short-term and long-term survivors by multivariate logistic regression analyses. In addition, tumor differentiation was also an independent predictor for short-term survivors, and tumor response grading and perineural invasion were independent predictors for long-term survivors. Our results may help to plan and select post-operative adjuvant therapy for patients with PDAC who received NAT and pancreatoduodenectomy based on the pathologic data

Comparative Analysis of Opioid Use Between Robotic and Open Pancreatoduodenectomy

BACKGROUND/PURPOSE: Risk-stratified pancreatectomy clinical pathways using regional anesthesia and multimodality analgesia have decreased overall opioid use, but the additional benefits of robotic surgery in opioid reduction for pancreatoduodenectomy (PD) are unknown. We compared the inpatient opioid use between robotic PD and open PD. METHODS: Patients undergoing open PD within a protocol evaluating preincisional regional anesthetic block bundles were compared to consecutively-treated patients undergoing robotic PD identified from a prospectively maintained single-institutional database. Clinical characteristics, operative outcomes, pain scores and inpatient oral morphine equivalent (OME) use were compared between patients treated with robotic or open PD. Patients with a history of continuous-release opioid dependence were excluded. RESULTS: Of 114 total patients, 25 underwent robotic PD and 89 underwent open PD. Intraoperative opioid use was not different (P = .87), nor were cumulative pain scores. Robotic PD patients used significantly fewer OMEs per day on postoperative days 1-4 (P = .039), used fewer total OMEs during hospitalization (robotic: median = 79, IQR 42.5-141; open: median = 126, IQR 61.3-203.8; P = .0036) and were discharged with fewer OMEs (robotic: median = 0, IQR 0-43.8; open: median = 25, IQR 0-75; P = .009) despite a shorter length of stay (robotic: median = 4, open: median = 5, P = .002). CONCLUSIONS: Robotic PD patients required fewer inpatient OMEs than open PD while maintaining similar pain scores. A higher percentage of robotic PD patients tapered off of opioids prior to discharge than open surgery patients treated with a standardized opioid reduction protocol despite a shorter length of stay. These results provide a rationale for choosing robotic PD when feasible to minimize opioid use