Foregut Surgery in the Modern Era: A National Survey

Background: Foregut surgery is technically complex. In recent years, increasing attention has been paid to high-stakes surgery outcomes, including mortality and complications. In addition, the use of advanced technology including minimally invasive approaches has been introduced. The current study aims to determine national trends in utilization and outcomes of potentially curative cancer resections of the foregut, including esophagus, stomach, liver, and pancreas. Methods: The Nationwide Inpatient Sample was queried to identify all esophageal, gastric, liver and pancreas resections performed for cancer during 1998-2009. Annual incidence, major in-hospital postoperative complications, length of stay and in-hospital mortality were evaluated. Univariate and multivariate analysis performed by chi square and logistic regression. For all comparisons, p-values Results: 298,871 patients (nationally-weighted) underwent cancer directed foregut surgery 1998-2009. Of those 19,002 (6%) were esophagectomies, 123,198 (41%) were gastrectomies, 62,313 (21%) were hepatectomies and 94,358 (32%) were pancreatectomies. From early years (1998-2000) to late years (2007-2009) use of laparoscopy in foregut surgery increased from 3% to 5%. Laparoscopy in esophagectomy increased the most from 1% to 5%, while its use in hepatectomy remained unchanged at 4%. Gastrectomy and pancreatectomy involving minimally invasive techniques increased from 2% to 5% and 5% to 6%, respectively. For all four foregut surgery types, patient comorbidities increased over time; patients with ≥2 major comorbidities increased from 53% to 64%. Conversely, patient mortality and length of stay (LOS) decreased over time. However, we observed an increase in complications for all sites combined from 22.8% to 24.4%. Laparoscopy was not significantly associated with decreased complications, but was associated with lower mortality when compared to open resection alone 3.1% vs. 5%. Independent predictors of increased complications included older age, gender, higher comorbidity, hospital volume. Older age, male sex, higher comorbidity, low volume center and non-use of laparoscopy were independent predictors of in-hospital mortality. Conclusion: Foregut surgery in the modern era is being increasingly deployed on sicker patients. While decreased in-hospital mortality and LOS are commendable, complication rates remain substantial and nondecreasing. Minimally invasive techniques have minor but increasing penetrance in foregut surgery. Our results suggest comparable advances and potential pitfalls among major types of foregut surgery in the current era

Endemic Gallbladder Cancer: Is There a Role for Prophylactic Cholecystectomy?

Background: Gallbladder cancer (GBC) is an often lethal malignancy with variable distribution. Incidence in the United States is low. However, in areas of Central/South America, Central Europe, Japan, and the Indian subcontinent, GBC is a major cause of cancer death. Cholecystectomy is safe and commonly performed worldwide. Thus, prophylactic cholecystectomy (PCCY) has been proposed in regions with endemic GBC. We developed a simple decision model to assist caregivers in determining the optimal strategy for managing GBC based on local incidence and technological capabilities. Methods: Rates of disease and outcomes were derived from a review of the literature. Using TreeAge-Pro software, a decision model was created to simulate expected health outcomes for populations with high GBC incidence, following 3 treatment strategies: no early intervention, one-time screening ultrasound (US), or PCCY. Lifetime cancer-specific survival was the outcome of interest. Sensitivity analyses were performed to determine threshold values. Results: Based on our model, populations where lifetime risk of GBC exceeds 0.4% may benefit from early intervention by US or PCCY. Two-way sensitivity analysis shows that over a relatively narrow range of disease incidence, US may be favored if sensitivity exceeds 50%. In many cases where lifetime risk exceeds 1%, PCCY may improve survival. Conclusions: GBC varies in incidence, but affects many individuals in some populations in the Americas. The lethality of GBC may justify aggressive public health intervention including screening or prophylactic cholecystectomy. Decision analysis models using best-available evidence may help determine the optimal treatment of individuals at risk for GBC

Impact of Pre-Injury Warfarin Use Among Medicare Beneficiaries With Head Trauma

Introduction: The effect of warfarin on outcomes of head injured patients remains controversial. Yet more than 2 million Americans, many of them elderly, are started on warfarin annually. Meanwhile, with the aging US population, elderly Americans are becoming an increasingly large proportion of head injured patients. We studied a national cohort of Medicare beneficiaries with head injuries to determine the effects of pre-injury warfarin on outcomes. Methods: A retrospective review of a 5% random sample of Medicare claims data (2009-2010) was performed for enrollees with at least 1 year of Medicare eligibility. Head injury cases were identified using ICD-9 codes for intracranial hemorrhage with or without accompanying skull fractures. Using Part D prescription drug claims, warfarin exposure was defined as \u3e2 warfarin prescriptions filled within 60 days prior to injury. Characteristics and outcomes (mortality, length of stay (LOS), ICU LOS) between warfarin users and patients not on warfarin (non-users) were compared using univariate tests of association. Multivariable models adjusting for patient characteristics, concomitant torso injuries/long-bone fractures, and need for ICU care were conducted to measure the independent effect of warfarin on in-hospital mortality. Results: We identified 3,420 head injured patients,6.6% of whom were treated with warfarin. Warfarin users were more likely to be female (74.2%vs.65.6%, p Conclusion: Anticoagulation with warfarin increases risk of mortality after head injury nearly two fold in Medicare beneficiaries even after adjusting for other risk factors. As new, more difficult to reverse, agents are introduced for chronic anticoagulation this problem may be exacerbated. Physicians should exercise caution when initiating chronic anticoagulation in patients over the age of 65

Is pancreatic cancer palliatable? A national study

Background: Pancreatic cancer is frequently diagnosed at advanced stages where potentially curative resection is no longer possible. Palliative procedures can be performed; however, results on a national level are unknown. This study examines pancreatic cancer patients who underwent potentially palliative procedures including gastric bypass, biliary bypass surgery, celiac block, biliary stent, gastrostomy or jejunostomy, and examines post-intervention complications and 30-day mortality. Methods: SEER-Medicare 1991-2005 was used to identify patients with Stage 3-4 pancreatic cancer. Complication rates were calculated including post-op infection, myocardial infarction, aspiration pneumonia, DVT/PE, pulmonary compromise, gastric bleed, acute renal failure, and reoperation. Kaplan-Meier survival analysis was performed. Finally, Cox proportional hazards modeling was used to control for the effects of age, sex, race, stage, and resection. Results: Of 22,314 pancreatic cancer patients, 858 (3.9%) patients were Stage 3, and 11,149 (50.0%) stage 4. Post-procedure median survival for all patients is approximately two months, with longest survival for biliary bypass patients (3.2mo, 95% CI(2.9-3.7), and lowest survival for jejunostomy 1.3 mo (1.2-1.5) and gastrostomy 1.5 mo (1.4-1.8). Post-procedure 30-day mortality was highest for gastrostomy patients at 41.5%; followed by jejunostomy (39.1%), celiac plexus block (30.0%), gastric bypass (23.8%), biliary bypass (17.8%), and biliary stent (21.2%). The rate of complications averaged 40%, with highest rate for gastrostomy (47.4%) and gastric bypass (45.3%) and lowest for celiac plexus block (29.3%). Stage 4 disease was an independent predictor of death for patients undergoing five out of six procedures. Conclusion: We found that morbidity and mortality of palliative procedures in unresectable pancreatic cancer is high, especially in stage 4 patients. Further studies need to be conducted to identify patients who will have sufficient expected post-procedure survival to benefit from these palliative interventions

SAGES consensus recommendations on surgical video data use, structure, and exploration (for research in artificial intelligence, clinical quality improvement, and surgical education)

BACKGROUND: Surgery generates a vast amount of data from each procedure. Particularly video data provides significant value for surgical research, clinical outcome assessment, quality control, and education. The data lifecycle is influenced by various factors, including data structure, acquisition, storage, and sharing; data use and exploration, and finally data governance, which encompasses all ethical and legal regulations associated with the data. There is a universal need among stakeholders in surgical data science to establish standardized frameworks that address all aspects of this lifecycle to ensure data quality and purpose. METHODS: Working groups were formed, among 48 representatives from academia and industry, including clinicians, computer scientists and industry representatives. These working groups focused on: Data Use, Data Structure, Data Exploration, and Data Governance. After working group and panel discussions, a modified Delphi process was conducted. RESULTS: The resulting Delphi consensus provides conceptualized and structured recommendations for each domain related to surgical video data. We identified the key stakeholders within the data lifecycle and formulated comprehensive, easily understandable, and widely applicable guidelines for data utilization. Standardization of data structure should encompass format and quality, data sources, documentation, metadata, and account for biases within the data. To foster scientific data exploration, datasets should reflect diversity and remain adaptable to future applications. Data governance must be transparent to all stakeholders, addressing legal and ethical considerations surrounding the data. CONCLUSION: This consensus presents essential recommendations around the generation of standardized and diverse surgical video databanks, accounting for multiple stakeholders involved in data generation and use throughout its lifecycle. Following the SAGES annotation framework, we lay the foundation for standardization of data use, structure, and exploration. A detailed exploration of requirements for adequate data governance will follow

Outcomes following resection of pancreatic cancer

Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long-term survival after resection

Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries

BACKGROUND: Elderly Americans are at increased risk of head trauma, particularly fall related. The effect of warfarin on head trauma outcomes remains controversial. METHODS: Medicare beneficiaries with head injuries from 2009 to 2011 were identified by International Classification of Diseases (ICD)-9 code. Preinjury warfarin use was determined using Part D claims. Multiple logistic regression models determined the association of preinjury warfarin on need for hospitalization, intensive care unit care, and occurrence of intracranial hemorrhage. Association between warfarin and in-hospital mortality was assessed using a Cox proportional hazard model. RESULTS: Of 11,078 head injured patients, 5.2% were injured while on warfarin. Preinjury warfarin increased the odds of intracranial hemorrhage by 40% and doubled the risk of 30-day in-hospital mortality after adjusting for demographic and clinical factors. CONCLUSIONS: Warfarin at the time of head injury increases the risk of adverse outcomes in Medicare beneficiaries with head injuries. Caution should be used when initiating anticoagulation in elderly Americans at risk for trauma

Is it worth looking? Abdominal imaging after pancreatic cancer resection: a national study

INTRODUCTION: Abdominal imaging is often performed after pancreatic cancer resection. We attempted to quantify the volume and estimate the cost of complex imaging after pancreatectomy nationwide, and to determine whether their frequent use confers benefit. METHODS: Patients with pancreatic adenocarcinoma who underwent resection were identified in Surveillance, Epidemiology and End Results-Medicare (1991-2005). Claims for abdominal imaging RESULTS: Eleven thousand eight hundred fifty studies were performed on 2,217 patients. Ten thousand five hundred forty-two (89%) were CT scans. The median number of scans doubled from three in 1991 to six in 2005 (p \u3c 0.0001). Among patients with sufficient survival to allow for analysis, 51.3% received annual CT scans, while only 32.4% of top-performing patients received annual scans. Univariate analysis of the 10% of patients with superior survival did not reveal any significant benefit associated with annual imaging. CONCLUSION: Utilization of complex imaging after pancreatic cancer resection has increased substantially among Medicare beneficiaries, driven primarily by an increasing number of CT scans. Our study demonstrated no significant survival benefit among patients who received scans on a routine basis

National trends in pancreaticoduodenal trauma: interventions and outcomes

OBJECTIVES: Pancreaticoduodenal trauma (PDT) is associated with substantial mortality and morbidity. In this study, contemporary trends were analysed using national data. METHODS: The Nationwide Inpatient Sample for 1998-2009 was queried for patients with PDT. Interventions including any operation (Any-Op) and pancreas-specific surgery (PSURG) were identified. Trends in treatment and outcomes were determined [complications, length of stay (LoS), mortality] for the Any-Op, PSURG and non-operative (Non-Op) groups. Analyses included chi-squared tests, Cochran-Armitage trend tests and logistic regression. RESULTS: A total of 27 216 patients (nationally weighted) with PDT were identified. Over time, the frequency of PDT increased by 8.3%, whereas the proportion of patients submitted to PSURG declined (from 21.7% to 19.8%; P = 0.0004) and the percentage of patients submitted to non-operative management increased (from 56.7% to 59.1%; P = 0.01). In the Non-Op group, mortality decreased from 9.7% to 8.6% (P \u3c 0.001); morbidity and LoS remained unchanged at approximately 40% and approximately 12 days, respectively. In the PSURG group, mortality remained stable at approximately 15%, complications increased from 50.2% to 71.8% (P \u3c 0.0001) and LoS remained stable at approximately 21 days. For all PDT patients, significant independent predictors of mortality included: the presence of combined pancreatic and duodenal injuries; penetrating trauma, and age over 50 years. Having any operation (Any-Op) was associated with mortality, but PSURG was not a predictor of death. CONCLUSIONS: The utilization of operations for PDT has declined without affecting mortality, but operative morbidity increased significantly over the 12 years to 2009. The development of an evidence-based approach to invasive manoeuvres and an early multidisciplinary approach involving pancreatic surgeons may improve outcomes in patients with these morbid injuries

Colectomy performance improvement within NSQIP 2005-2008

BACKGROUND: All open and laparoscopic colectomies submitted to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were evaluated for trends and improvements in operative outcomes. METHODS: 48,247 adults (\u3e/=18 y old) underwent colectomy in ACS NSQIP, as grouped by surgical approach (laparoscopic versus open), urgency (emergent versus elective), and operative year (2005 to 2008). Primary outcomes measured morbidity, mortality, perioperative, and postoperative complications. RESULTS: The proportion of laparoscopic colectomies performed increased annually (26.3% to 34.0%), while open colectomies decreased (73.7% to 66.0%; P \u3c 0.0001). Most emergent colectomies were open procedures (93.5%) representing 24.3% of all open cases. The overall risk-adjusted morbidity and mortality for all colectomy procedures did not show a statistically significant change over time, however, morbidity and mortality increased among open colectomies (r = 0.03) and decreased among laparoscopic colectomies (r = -0.04; P \u3c 0.0001). Postoperative complications reduced significantly including superficial surgical site infections (9.17% to 8.20%, P \u3c 0.004), pneumonia (4.60% to 3.97%, P \u3c 0.0001), and sepsis (4.72%, 2005; 6.81%, 2006; 5.62%, 2007; 5.09%, 2008; P \u3c 0.0002). Perioperative improvements included operative time (169.2 to 160.0 min), PRBC transfusions (0.27 to 0.25 units) and length of stay (10.5 to 6.61 d; P \u3c 0.0001). CONCLUSION: It appears that laparoscopic colectomies are growing in popularity over open colectomies, but the need for emergent open procedures remains unchanged. Across all colectomies, however, key postoperative and perioperative complications have improved over time. Participation in ACS NSQIP demonstrates quality improvement and may encourage greater enrollment