Surgical Advances for Pancreas Cancer and Related Diseases

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The Effects of Total Intravenous Versus Inhalational Anesthesia on Fluid Balance for Patients Undergoing Pancreaticoduodenectomy

Introduction: Pancreaticoduodenectomy (PD), the most common surgical treatment for pancreatic cancer, is a complex procedure with a morbidity of 45-60%. Recent studies indicate that intraoperative use of total intravenous anesthesia (TIVA) may reduce post-operative complications for PD patients, when compared to inhalational anesthesia (INHA). We hypothesized that patients who receive TIVA may have a more favorable fluid balance, which is known to reduce postoperative complications in PD patients. Methods: We carried out a retrospective analysis of patients who underwent PD at Thomas Jefferson University Hospital and were administered TIVA or INHA during surgery between April 2017 and January 2019. We analyzed intraoperative net fluid balance, complication rates, length of stay (LOS), and readmission rates. Statistical significance was determined using Fisher’s exact test or t-test as appropriate. Results: In the study period we found 50 patients who underwent PD (34 TIVA, 16 INHA). Intraoperative net fluid balance was not significantly different (ns) between groups (TIVA=4127mL, INHA=3458.5mL). Complication rates (TIVA=52.9%, INHA=56.3%, ns) and median LOS (TIVA=5.5, INHA=6.0, ns) were comparable between groups. Readmission rates were similar (TIVA=44.1%, INHA=37.5%, ns). Discussion: In the study comparing TIVA to INHA we found no differences in fluid balance, complication rates, LOS, or readmission rates. Given the ease of using an alternative surgical anesthetic, determining whether PD patients who receive TIVA have reduced morbidity, as compared to INHA, is an important potential avenue to improve patient outcomes. While we did not find significant differences, we were limited by a small sample size at the time of analysis

Emil Theodor Kocher, M.D., and his Nobel Prize (1841-1917).

Major contributions to the advancement of surgery occurred at the turn of the 20th century. Theodor Billroth was in the midst of revolutionizing abdominal surgery, whereas Louis Pasteur and Joseph Lister were making landmark strides in antisepsis, forever changing the foundations of surgical thinking. Undoubtedly, Theodor Kocher’s (Fig. 1) exposure to these and other giants had a major influence on his career and contributed to his success and ascent as the first, and one of only 10, surgeons ever to be awarded the Nobel Prize in Medicine

Edoardo Bassini (1844-1924): father of modern-day hernia surgery.

According to Roman scripture, it was Celsus who attempted the first inguinal hernia repair in history during the first century A.D. His attempts were unsuccessful and resulted in an early recurrence of the hernia, which eventually led to the patient’s death.1 Over the next two millennia, little understanding was gained regarding the anatomy of the inguinal canal. It was only in the last 100 years that major advancements in herniorrhaphy were established, thanks in large part to the work of Edoardo Bassini, who revolutionized the surgical treatment of the inguinal hernia with a technique which has become the basis of modern-day herniorrhaphy

Christian Albert Theodor Billroth, M.D., founding father of abdominal surgery (1829-1894).

In the 1800s, the field of surgery was in its infancy, somewhat primitive and embryonic. The technical nature of surgery was the basis for the dividing line between the disciplines of surgery and internal medicine. Sterilization was not a common practice. Radical surgical resections and experimentation in medicine were shunned. With his boldness equaled only by his innovation and resourcefulness, Theodor Billroth would become a pioneer not only in the development of modern surgery, but also in the advancement of its cultural and historical significance

Patient Attitudes Toward a Physician Led Radiology Review: Improved Understanding of Medical Conditions and a Potential New Quality Metric

Objectives: We were interested in understanding patient perspectives regarding the importance of reviewing their imaging studies with a surgeon. Specific Aims: 1. What value do patients place on viewing their imaging? 2. Do patients have a better understanding of their disease and planned operation after a surgeon led review of imaging studies? 3. Do patients find viewing images an accessible educational tool?https://jdc.jefferson.edu/patientsafetyposters/1022/thumbnail.jp

Early Perioperative Fluid Benchmarking to Predict Pancreaticoduodenectomy (PD) Outcomes

Introduction: PD is a complex operation associated with a marked systemic inflammatory response and significant fluid shifts. Establishing a benchmark for ideal perioperative fluid management is critical to optimising PD patient recovery. Methods: In this retrospective study, we evaluated perioperative fluid data for patients undergoing PD. We compared an optimal benchmark group who were discharged home by postoperative day five (≤5day) to a group of patients with an in hospital recovery greater than ten days (≥10day). Results: Seventy-six patients who underwent PD between June 2015 and November 2016 were evaluated. The ≤5day group had a significantly lower intraoperative fluid administration (5.4 vs. 6.6 L, p= 0.012), despite similar operative times (447 mins and 476 mins, respectively). POD1 cumulative fluid balance was lower in the ≤5day group compared to the ≥10day group, 7.8L (97 mL/kg) vs. 9.7L (148 mL/kg) (p= 0.002), respectively. As expected, the postoperative complication rate was reduced in the ≤5day group (5% vs. 95%). Complications included pancreatic fistula (40%), delayed gastric emptying (53%), and intra-abdominal infection (16%). The median weight change from baseline to POD5 was -0.2 Kg for the ≤5day group compared to +2.9 Kg for ≥10day group (p= 0.000006). Conclusions: Patients in the benchmark PD group received less fluid intraoperatively, had a lower cumulative fluid balance by POD1, and were able to return to their preoperative weight by POD5 when compared to ≥10day group. These data offer insights into optimal fluid administration for PD patients

Total Parenteral Nutrition in Patients Following Pancreaticoduodenectomy: Lessons from 1184 Patients

Poster presented at Sigma XI Student Research Day at Thomas Jefferson University. Background: Total parenteral nutrition (TPN) has historically been used conservatively in the management of patients after pancreaticoduodenectomy (PD). In this study, we evaluate the indications for and outcomes associated with TPN use in a high-volume pancreatic surgery center.https://jdc.jefferson.edu/surgeryposters/1007/thumbnail.jp

Prognostic Properties of KRAS Gene Mutation Subtypes in Resected Pancreatic Cancer

Introduction Pancreatic ductal adenocarcinoma (PDAC) is an aggressive and therapy-resistant cancer with an overall 5-year survival rate of almost 12%, making it among the most lethal of all major cancers.1 PDAC has a distinct genomic profile, with somatic KRAS protooncogene mutations in ~90% of cases.2,3 Current literature has not reached a consensus on disease prognosis based on KRAS mutation subtype.2-5https://jdc.jefferson.edu/aoa_research_symposium_posters/1005/thumbnail.jp

Postoperative Aspiration Pneumonia (PoPNA) Prevention Protocol

Postoperative pneumonia increases morbidity, mortality, length of stay, and hospital costs up to $12,000-$40,000 per patient TJUH Center City ranked in the top 3rd - 4th quartile of pulmonary complications on the 2020 National Surgical Quality Improvement Program perioperative review ICOUGH protocol: widely accepted, standardized set of post-operative interventions to reduce pneumonia incidence Survey design: measure ICOUGH compliance before and after implementation of resident note checklist in EPI