Hepatopancreatobiliary Research Articles

HPB SO26 - Evaluation of Theatre Database Accuracy in a Tertiary HPB Center According to NCIP Standards in the UK

Abstract Background The goal of creating the NCIP (National Clinical Improvement Programme) theatre data set discovery information system is to allow NHS Improvement to evaluate how theatre data can improve the attribution of surgical activities, as documented in Hospital Episode Statistics (HES) Admitted Patient Care (APC) data, to individual consultants. The success of NCIP is at risk due to the inaccurate attribution of existing activity data to consultants. Method The NCIP theatre database for the Hepato-Pancreato-Biliary (HPB) surgery department was compiled over a 12-month period (from April 2022 to April 2023) and analyzed based on the operating consultant recorded in the operative notes, clinical letters, and the Carfelow system (admitting office records). Results In Nottingham University Hospitals (NUH), 143 major liver and pancreatic resections were performed, including 38 Whipple’s procedures (both classic and Pylorus-preserving Pancreatico-Duodenectomy), 19 Distal Pancreatectomies, and 86 Liver resections. Of these, only 58 patients (40.6%) had correct entries in the NCIP database regarding the operating surgeon. The NCIP data inaccuracies for the operating consultant were 65.8% (25/38) for Whipple’s procedures, 57.9% (11/19) for Distal Pancreatectomies, and 56.97% (49/86) for Liver resections. Conversely, the NCIP data was 100% accurate concerning the assigned consultant on Careflow, which matches the clinical letters from the outpatient clinic. Conclusion The gap between the NCIP database and the admitting office database leads to inaccurate attributions of surgical activity. This hinders learning and improvement efforts essential for achieving program benefits and prevents providers from complying with license conditions and delivering efficient healthcare services. To ensure accurate HES data, admitting officers should request proper communication and accurate consultant codes from consultant secretaries to ensure accurate data across the different hospital systems

HPB SO38 - Assessing current pancreatic cancer reporting practice against the PACT-UK Synoptic Reporting Template: An initial clinical audit

Abstract Background In the last decade, the incidence of pancreatic cancer has increased by 9% in the UK. The gold standard for initial assessment of pancreatic cancer (or even peri-ampullary cancer) resectability is pancreatic-protocol CT scan. The PACT-UK project introduced a synoptic template for pancreatic cancer to standardise CT reporting practice across UK and enable consistent reporting of pertinent aspects of resectability status such as vascular involvement of the tumour. The aim of this audit is to assess the quality of current CT reports received by a tertiary hepato-pancreato-biliary (HPB) unit against the standards set out by PACT-UK. Method A retrospective analysis of 66 patients who underwent pancreatic resection between September 2023 and May 2024 at a tertiary HPB centre was undertaken. Patients were excluded from the analysis if they underwent resection for benign pancreatic pathology, were diagnosed with pathology other than peri-ampullary cancer or did not have a formal report of their CT scan. Initial CT scans performed at presentation and if available, subsequent up-to-date staging scan prior to surgery were assessed against the PACT-UK reporting template, in accordance with their guidance. The audit was registered with our clinical audit team (no. 11643). Results In total, 42 patients with peri-ampullary cancers were included in this audit. All patients had a reported CT scan on presentation. Additionally, 24 patients had a reported staging CT scan. The compliance (i.e. more than 90% information available) with PACT-UK reporting standards was 0% for initial presentation scans and 4.2% (n=1) for staging scans. The only staging scan with >90% compliance was reported using the PACT-UK template. Majority (more than 80%) of CT scan reports lacked information on aspects such as pancreatic duct size, predicted tumour type and radiological stage, variant vascular anomalies, and arterial/venous involvement. Conclusion This audit highlights the substandard quality of current CT reporting for peri-ampullary cancer. There is an urgent need to adopt a structured and dedicated reporting template to address the issue. Utilising a template such as the one developed by PACT-UK will help ensure that relevant information is formally reported to facilitate optimal decision-making at MDT meetings, and assist surgeons in operative planning and oncologists in assessing treatment response.

HPB SO63 - A Closed-Loop Audit on Surgical Ward Round Documentation in a Tertiary Hospital

Abstract Background Surgical ward rounds play a pivotal role in overall patient outcome during surgical and perioperative care. Clear and comprehensive documentations are crucial in providing an accurate account of ward round activities. We aimed to assess the quality of hepatopancreatobiliary (HPB) ward round documentation and the impact of a HPB surgical ward round proforma on the quality of documentation. Method 50 medical notes were reviewed in a tertiary centre to determine if key components of ward round documentation such as the date, time, diagnosis, procedure, consultant, person documenting, information communicated to patient, observations, investigations and management plan were documented. A proforma for ward round documentation was introduced. A re-audit was performed to review the impact of a proforma on ward-round documentation. Results The time of ward round, relevant history, NEWS and management plan were recorded in more than 50% of medical notes. However, the diagnosis, consultant, person documenting, information communicated to patient, wound review, medication review, fluid balance, investigations, follow up and discharge plans were documented in less than 50% of medical notes. After the introduction of a proforma, the date and time of the surgical ward round were documented in 94% of medical notes. 84% had initials of the consultants leading ward-rounds and the person documenting. More than 80% notes included relevant examination, information communicated to patient, wound and medications review. Conclusion Surgical ward round proformas have a role in improving ward round documentation. Good record keeping is essential for continuity of care, optimising quality of care and ensuring patient safety.

Rates of Textbook Outcome Achieved in Patients Undergoing Liver and Pancreatic Surgery.

Backgorund: Textbook outcome (TO) is a composite measure that reflects the most desirable surgical results as a single indicator. The aim of this study was to assess the achievement of TO at a hepatopancreatobiliary (HPB) surgery unit in a Spanish tertiary hospital. Methods: We performed a retrospective observational study of all consecutive patients who underwent HPB surgery over a 4-year period. Morbidity according to the Clavien-Dindo classification at 30 days, hospital stay, risk of morbidity and mortality according to the POSSUM, and mortality and readmissions at 90 days were recorded. TO was considered when a patient presented no major complications (≥IIIA), no mortality, no readmission, and no prolonged length of stay (≤75th). Results: 283 patients were included. Morbidity >IIIA was reported in 21.6%, and 5.7% died; the median postoperative stay was 4 days. TO was achieved in 56.2% of patients. Comparing patients who presented TO with those who did not, significant differences were recorded for the type of procedure and the expected risk of morbidity and mortality calculated according to the POSSUM scale. There were significant differences between patients with major resections (TO rates: major hepatectomy (46.3%) and major pancreatectomy (52.5%)) and those with minor resections (TO rates minor hepatectomy (67.7%) and minor pancreatectomy (40.4%)). Conclusions: TO is a useful management tool for assessing postoperative results.

The Role of a Community Surgeon in the Care of Hepatopancreatobiliary Patients: Short-Term Outcomes and Learning Curve.

Background Owing to the well-established volume-outcome relationship, hepatopancreatobiliary (HPB) surgery is commonly regionalized to academic, teaching hospitals. However, regionalization is associated with decreased access for some populations in need, as well as geographic and financial barriers for patients. If high surgeon and institutional volumes can be achieved, the community, non-teaching HPB surgical practice could help alleviate some issues associated with regionalization. The HPB experience of a community surgeon immediately after surgical oncology training was reviewed, hypothesizing that high volumes with acceptable short-term outcomes could be achieved, although a learning curve may be observed. Materials and methods Electronic medical records from 2013 to 2023 were reviewed. Data included patient demographics, perioperative details, pathology, complications, and deaths over 90 postoperative days. Perioperative quality metrics were assessed for trends over time in pancreaticoduodenectomy (PD) and liver resection subgroups. Results A total of 295 patients underwent 176 (59.7%) pancreatic and 119 (40.3%) hepatobiliary operations. The most common operations were PD (n=87; 49.4%) and partial hepatic lobectomy (n=56; 41.1%). In the pancreas group, morbidity was 25% (n=44), and mortality was 4.5% (n=8). In the hepatobiliary group, morbidity and mortality were 19.3% (n=23) and 5.0% (n=6), respectively. Within the PD and liver resection subgroups, operative time, estimated blood loss, and hospital length of stay (LOS) trended downward over time, with LOS decreasing significantly. Conclusion High HPB volumes with acceptable short-term outcomes can be achieved by a solo practitioner in the community, non-teaching setting. For PDs and liver resections, perioperative metrics trended downward over time, illustrating the learning curve encountered after training.

Essential Elements in Synoptic Operative Reports for Hepato-Pancreato-Biliary Cancer Surgery: An HPB/CGSO Training Program Survey.

Synoptic operative reports (SORs) are checklists or templates that contain standardized elements of an operation. These elements are associated with standardized inclusion of critical elements of the operative report that translate into numerous potential benefits. Whereas SORs for melanoma, breast, and colorectal cancer surgery have already been widely implemented, similar templates for hepato-pancreato-biliary (HPB) cancer surgery are currently lacking. An anonymous voluntary online survey was distributed to HPB attendings and fellows at HPB and complex general surgical oncology (CGSO) fellowship programs. The 54 participants in this study comprised 31 (57%) HPB surgery attendings, 15 (28%) HPB surgery fellows, and 8 (15%) CGSO fellows. Notably, only six (11%) participants reported consistent use of an HPB SOR. The most commonly reported barriers to SOR uptake were the "lack of a readily available template" (55%) and the "lack of consensus/guidelines" (49%). Despite these limiting factors, a majority of respondents indicated a strong willingness to use a standardized and readily available HPB SOR (mean, 4.13/5 ± 1.23). This interest did not differ between attendings and fellows (p = 0.52) or between the participants stratified by surgical experience (p = 0.58).Finally, the participants were provided a comprehensive list of possible elements to incorporate into a standardized pancreatic and hepatobiliary SOR. After the exclusion of elements with less than 75% agreement, the pancreatic SORs included 17 (57%) of 30 possible elements, and the hepatobiliary SORs included 19 (76%) of 25 possible elements. Broad consensus on several elements of the HPB SOR suggests that uptake should be accelerated in HPB surgery.

ThP4.9 - The role of preoperative nutritional assessment in postoperative outcomes of hepato-pancreato-biliary patients: A bicenter prospective observational study

Abstract Aims Preoperative nutritional status of patients who undergo surgery due to hepato-pancreato-biliary (HPB) cancer has been considered as a prognostic factor of their postoperative course. The aim of the present study was to investigate the association of preoperative nutritional assessment with the postoperative morbidity and mortality in such patients. Methods Patients undergoing surgery due to HPB cancer from March 2022 until March 2023 at two university surgical departments were included in the present study. Patients’ demographics and postoperative parameters, such as complications’ severity according to Clavien-Dindo classification and mortality, along with malignancy stage were reported. Preoperative nutritional assessment was conducted according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and the Controlling Nutritional Status (CONUT) score. The present study was registered in ClinicalTrials.gov (NCT05795374). Results The present study included 66 patients with a mean age of 63 ± 12 years old. The high risk of malnutrition according to the GLIM criteria was associated with major (Clavien-Dindo≥3) postoperative complications (74% vs 32%, p=0.026) and increased 30-day mortality (80% vs 23%, p=0.021). Moreover, malnutrition according to the CONUT tool was correlated to increased 30-day mortality (66% vs 45%, p=0.016). Conclusions Preoperative malnutrition seems to be associated with higher rates of postoperative mortality and major morbidity in patients undergoing surgery due to HPB cancer.

Not just a BLiP: early experience with a novel multidisciplinary case conference for benign hepatopancreatobiliary disease at a tertiary Canadian healthcare center.

Benign Liver and Pancreas (BLiPs) rounds, implemented in 2022 at our Canadian tertiary care center, are a novel concept of a multidisciplinary case conference (MCC) for discussion of benign hepatopancreatobiliary (HPB) disease. BLiPs Rounds are a monthly virtual meeting of surgeons, gastroenterologists, and interventional radiologists experienced in biliary and pancreatic disease. This case series was completed to review the patient cases discussed over the first year of BLiPs rounds, and to evaluate the effect of the multidisciplinary discussion on patient management plans. Meeting minutes were reviewed for BLiPs rounds between May 2022 and July 2023. Data were collected retrospectively on all discussed patients by review of the electronic medical record, and analyzed using frequencies and means with standard deviations. Between May 2022 and July 2023, 56 cases were discussed at 12 case conferences. 68% of cases concerned pancreatic pathology, 25% concerned biliary pathology, the remainder liver or duodenal pathology. 49 cases (88%) were presented to discuss therapeutic options, and 7 presented as diagnostic challenges. Cases were usually presented once, but 7 patients were discussed at multiple conferences due to complex issues or ongoing symptomatology. 40 patients (71%) had undergone previous endoscopic, percutaneous, or surgical interventions prior to discussion. Endoscopic intervention was recommended in 32% of cases, percutaneous interventional approach in 13%, a combined endoscopic and percutaneous approach in 9%, and surgery in 18%. Repeat imaging or observation was recommended in 29% of cases. Discussion at rounds led to a change or adjustment in the proposed management in 46 cases (82%). The plan recommended by the MCC was carried out in 71% of cases. BLiPs case conference provides a valuable venue to discuss cases, encourage interdisciplinary collaboration, and refine treatment approaches, leading to a change in proposed management plan in over three-quarters of cases presented.

A critical analysis of surgical outcomes indicators in hepato-pancreato-biliary surgery: From crude mortality to composite outcomes.

Indicators of surgical outcomes are designed to objectively evaluate surgical performance, enabling comparisons among surgeons and institutions. In recent years, there has been a surge in complex indicators of perioperative short-term and long-term outcomes. The aim of this narrative review is to provide an overview and a critical analysis of surgical outcomes indicators, with a special emphasis on hepato-pancreato-biliary (HPB) surgery. A narrative review of outcome measures was conducted using a combined text and MeSH search strategy to identify relevant articles focused on perioperative outcomes, specifically within HPB surgery. The literature search yielded 624 records, and 94 studies were included in the analysis. Included papers were classified depending on whether they assessed intraoperative or postoperative specific or composite outcomes, and whether they assessed purely clinical or combined clinical and socio-economic indicators. Specific indicators included in composite outcomes were categorized into three main domains: intraoperative metrics, postoperative outcomes, and oncological outcomes. While postoperative mortality, complications, hospital stay and readmission were the indicators most frequently included in composite outcomes, oncological outcomes were rarely considered. The evolution of surgical outcomes has shifted from the simplistic assessment of crude mortality rates to complex composite outcomes. Whether the recent explosion of publications on these topics has a clinical impact in real life is questionable. Outcomes from the patient perspective, integrating social and financial indicators, are not yet integrated into most of these composite analytical tools but should not be underestimated.

Advancing minimally invasive hepato-pancreato-biliary surgery: barriers to adoption and equitable access.

Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption. A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results. Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training. This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.

Safety of robotic cholecystectomy as index training procedure: the UK experience.

To evaluate the safety profile of robotic cholecystectomy performed within the United Kingdom (UK) Robotic Hepatopancreatobiliary (HPB) training programme. A retrospective evaluation of prospectively collected data from eleven centres participating in the UK Robotic HPB training programme was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. A total of 600 patients were included. The median age was 53 (IQR 65-41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600), and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). The current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low bile leak rate, low conversion to open surgery, and low need for subtotal cholecystectomy.

Association of surgeon's sex, and surgeon-patient dyad with financial outcomes among patients undergoing cancer surgery.

Surgeon sex has been associated with perioperative clinical outcomes among patients undergoing oncologic surgery. There may be variations in financial outcomes relative to the surgeon-patient dyad. We sought to define the association of surgeon's sex with perioperative financial outcomes following cancer surgery. Patients who underwent resection of lung, breast, hepato-pancreato-biliary (HPB), or colorectal cancer between 2014 and 2021 were identified from the Medicare Standard Analytic Files. A generalized linear model with gamma regression was utilized to characterize the association between sex concordance and expenditures. Among 207,935 Medicare beneficiaries (breast: n = 14,753, 7.1%, lung: n = 59,644, 28.7%, HPB: n = 23,400, 11.3%, colorectal: n = 110,118, 53.0%), 87.8% (n = 182,643) and 12.2% (n = 25,292) of patients were treated by male and female surgeons, respectively. On multivariable analysis, female surgeon sex was associated with slightly reduced index expenditures (mean difference -$353, 95%CI -$580, -$126; p = 0.003). However, there were no differences in 90-day post-discharge inpatient (mean difference -$-225, 95%CI -$570, -$121; p = 0.205) and total expenditures (mean difference $133, 95%CI -$279, $545; p = 0.525). There was minor risk-adjusted variation in perioperative expenditures relative to surgeon sex. To improve perioperative financial outcomes, a diverse surgical workforce with respect to patient and surgeon sex is warranted.

Resident and Fellow Performance and Supervision in Surgical Oncology Procedures.

Previous research has highlighted concerns among trainees and attendings that general surgery training and fellowship are inadequately preparing trainees for practice. Providing trainees with supervision that matches their proficiency may help bridge this gap. We sought to benchmark operative performance and supervision levels among senior surgery residents (post-graduate year 4 or 5) and fellows performing general surgical oncology procedures. Observational data were obtained from the Society for Improving Medical Procedural Learning (SIMPL) OR application for core general surgical oncology procedures performed at 103 unique residency and fellowship programs. Procedures were divided into breast and soft tissue, endocrine, and hepatopancreatobiliary (HPB). Case evaluations completed by trainees and attendings were analyzed to benchmark trainee operative performance and level of supervision. There were 4,907 resident cases and 425 fellow cases. Practice-ready performance, as assessed by trainees and faculty, was achieved by relatively low proportions of residents and fellows for breast and soft tissue cases (residents: 38%, fellows: 48%), endocrine cases (residents: 22%, fellows: 41%), and HPB cases (residents: 10%, fellows: 40%). Among cases in which trainees did achieve practice-ready performance, supervision only was provided for low proportions of cases as rated by trainees (residents: 17%, fellows: 18%) and attendings (residents: 21%, fellows 25%). In a sample of 103 residency and fellowship programs, attending surgeons rarely provided senior residents and fellows with levels of supervision commensurate to performance for surgical oncology procedures, even for high performing trainees. These findings suggest a critical need for surgical training programs to prioritize providing greater levels of independence to trainees that have demonstrated excellent performance.

Implementing a robotic hepatopancreatobiliary program for new faculty: safety, feasibility and lessons learned.

Robotic surgery is increasingly utilized in hepatopancreatobiliary (HPB) surgery, but the learning curve is a substantial obstacle hindering implementation. Comprehensive robotic training can help to surmount this obstacle; however, despite the expansion of robotic training into residency and fellowship programs, limited data are available about how this translates into successful incorporation in faculty practice. All operations performed during the first three years of practice of a surgical oncologist at a tertiary care academic institution were retrospectively reviewed. The surgeon underwent comprehensive robotic training during residency and fellowship. 137 HPB operations were performed during the initial three years of practice. Over 80% were performed robotically each year across a spectrum of HPB procedures with a 6% conversion rate. Median operative time, a metric for operative proficiency and evaluation for a learning curve, was similar throughout the study period for each major operation and below several reported optimized operative time benchmarks. The major complications, defined as a Clavien-Dindo of 3 or more, were similar across the experience and comparable to published series. Comprehensive robotic training in residency and fellowship as well as a dedicated, well-trained operative team allows for early attainment of optimized outcomes in a new HPB robotic practice.

Postoperative Outcomes Among Patients Undergoing Cancer Surgery: United States versus International Medical Graduates.

We sought to characterize postoperative outcomes among patients who underwent an oncologic operation relative to whether the treating surgeon was an international medical graduate (IMG) versus a United States medical graduate (USMG). IMGs comprise approximately one quarter of the physician workforce in the United States. The 100% Medicare Standard Analytic Files were utilized to extract data on patients with breast, lung, hepato-pancreato-biliary (HPB), and colorectal cancer who underwent surgical resection between 2014 and 2020. Entropy balancing and multivariable regression analysis were performed to evaluate the association between postoperative outcomes among USMG and IMG surgeons. Among 285,930 beneficiaries, 242,914 (85.0%) and 43,016 (15.0%) underwent surgery by a USMG or IMG surgeon, respectively. Overall, 129,576 (45.3%) individuals were male, and 168,848 (59.1%) patients had a Charlson Comorbidity Index score >2. Notably, IMG surgeons were more likely to care for racial/ethnic minority patients (14.7% vs 12.5%) and individuals with a high social vulnerability index (33.3% vs 32.1%) (all P <0.001). On multivariable analysis after entropy balancing, patients treated by an IMG surgeon were less likely to experience adverse postoperative outcomes, including 90-day readmission [odds ratio (OR) 0.89, 95% CI: 0.80-0.99] and index complications (OR: 0.84, 95% CI: 0.74-0.95) versus USMG surgeons (all P <0.05). Patients treated by IMG versus USMG surgeons had no difference in likelihood to achieve a textbook outcome (OR: 1.10, 95% CI: 0.99-1.21; P =0.077). Postoperative outcomes among patients treated by IMG surgeons were roughly equivalent to those of USMG surgeons. In addition, IMG surgeons were more likely to care for patients with multiple comorbidities and individuals from vulnerable communities.

An Age-Stratified Analysis of Early Postoperative Mortality Among Medicare-Eligible Patients With Common Gastrointestinal and Hepato-pancreato-biliary Malignancies.

Background: The frequency of major cancer surgery in the elderly (≥80years) has increased concomitantly with the rise in average age of the population. We assessed early postoperative mortality following hepato-pancreato-biliary (HPB) and gastrointestinal (GI) procedures for common malignancies stratified by age. Methods: The National Cancer Database (2004-2017) was queried for patients who underwent resection for GI (gastroesophageal and colorectal) or HPB (pancreatic adenocarcinoma, biliary tract, and primary liver) cancers. We compared early postoperative mortality (30d and 90d) stratified by age (65-79 vs ≥80years) and procedure, and compared survival outcomes by age and operative vs nonoperative management. Results: A total of 709,358 patients were included. The 30-day mortality ranged from 1.8% to 5.8% among patients 65-79years and from 3.2% to 12.4% among patients ≥80years depending on procedure. The 90-day mortality ranged from 3.6% to 10.6% in patients 65-79years compared to 8.4%-21.0% among patients ≥80years. The overall 90-day mortality was 5.2% for patients 65-79years and 12.0% for patients ≥80years (P < .001). Age ≥80 was associated with worse survival among operatively managed patients with each upper GI, HPB, and lower GI malignancy relative to younger patients on multivariable analysis. However, operative management of patients ≥80years was associated with improved survival relative to nonoperative management. Discussion: Elderly patients suffer higher postoperative mortality after major GI and HPB cancer surgery, but operative management is associated with improved survival among patients ≥80years as compared to nonoperative management. These data are important to contextualize when counseling elderly patients on their treatment options for localized GI and HPB cancers.

Evaluating postoperative outcome assessment tools in hepato-pancreato-biliary surgery: A comparative analysis of the comprehensive complication index and Clavien-Dindo classification in a cohort of 1240 patients at a tertiary care center.

The comprehensive complication index (CCI) has emerged as a new tool for reporting postoperative complications. The aim of this study is to evaluate and compare the efficacy of CCI and Clavien-Dindo Classification (CDC) in measuring postoperative outcomes in patients undergoing hepato-pancreato-biliary (HPB) surgery. In this single-centered, prospective, comparative study conducted between January 2022 and March 2023, 1240 patients underwent HPB surgery, including laparoscopic cholecystectomies and complex HPB surgery. Postoperative complications were evaluated utilizing the CCI and CDC indices, and their relationships with length of ICU stay, hospital stay, and return to activity were compared. A total of 117 patients (9.44%) experienced complications of varying grades. There was a strong correlation between CCI and CDC (r=0.982, P <0.001). Both CCI and CDC demonstrated a strong correlation with the length of hospital stay, ICU stay, and return to normal activity. While CCI showed a better correlation with the length of hospital stay (r=0.706 vs. 0.695) and return to normal activity (r=0.620 vs. 0.611) than CDC, the difference was not statistically significant. CCI exhibited a stronger correlation with the length of stay and return to activity; however, no statistically significant advantage was observed over CDC.

Hepato-pancreato-biliary surgery in West Africa: a timely capacity assessment

BackgroundWest Africa has among the highest rates of hepato-pancreato-biliary (HPB) malignancies in the world. Although surgery is critical for treatment, the availability of HPB surgery in Africa is unknown. This cross-sectional study investigated the current HPB surgical capacity of West African hospitals. MethodThe Surgeons OverSeas Personnel, Infrastructure, Procedure, Equipment, and Supplies (PIPES) survey was modified to include HPB-specific parameters and quantify capacity. The survey was completed by consultant surgeons from West Africa. A PIPES index was calculated, and a higher score corresponded to greater HPB surgical capacity. ResultsThe HPB PIPES survey was completed by 35 institutions from The Gambia, Ghana, Ivory Coast, and Nigeria. Most institutions (94.2%) were tertiary referral centres; five had an HPB-trained surgeon. The most commonly available procedure was an open cholecystectomy (91.4%), followed by gastric bypass (88.6%). Major hepatic resections (14.3%) and the Whipple procedure (17.1%) were rare. ICU capabilities were present at 88.6% of facilities while interventional radiology was present in 25.7%. ConclusionsThis is the first HPB capacity assessment in Africa. This study showed the limited availability of HPB surgery in West Africa. These results can be used for regional quality improvement initiatives and as a baseline for future capacity assessments.

Assessing quality of hepato-pancreato-biliary surgery: nationwide benchmarking.

Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of individual hospitals using national averages. This study aimed to evaluate the use of quality indicators for benchmarking hepato-pancreato-biliary (HPB) surgery and when outlier hospitals could be identified. A population-based study used data from two nationwide Dutch HPB audits (DHBA and DPCA) from 2014 to 2021. Sample size calculations determined the threshold (in percentage points) to identify centres as statistical outliers, based on current volume requirements (annual minimum of 20 resections) on a two-year period (2020-2021), covering mortality rate, failure to rescue (FTR), major morbidity rate and textbook/ideal outcome (TO) for minor liver resection (LR), major LR, pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). In total, 10 963 and 7365 patients who underwent liver and pancreatic resection respectively were included. Benchmark and corresponding range of mortality rates were 0.6% (0 -3.2%) and 3.3% (0-16.7%) for minor and major LR, and 2.7% (0-7.0%) and 0.6% (0-4.2%) for PD and DP respectively. FTR rates were 5.4% (0-33.3%), 14.2% (0-100%), 7.5% (1.6%-28.5%) and 3.1% (0-14.9%). For major morbidity rate, corresponding rates were 9.8% (0-20.5%), 28.1% (0-47.1%), 36% (15.8%-58.3%) and 22.3% (5.2%-46.1%). For TO, corresponding rates were 73.6% (61.3%-94.4%), 54.1% (35.3-100), 46.8% (25.3%-59.4%) and 63.3% (30.7%-84.6%). Mortality rate thresholds indicating a significant outlier were 8.6% and 15.4% for minor and major LR and 14.2% and 8.6% for PD and DP. For FTR, these thresholds were 17.9%, 31.6%, 22.9% and 15.0%. For major morbidity rate, these thresholds were 26.1%, 49.7%, 57.9% and 52.9% respectively. For TO, lower thresholds were 52.5%, 32.5%, 25.8% and 41.4% respectively. Higher hospital volumes decrease thresholds to detect outliers. Current event rates and minimum volume requirements per hospital are too low to detect any meaningful between hospital differences in mortality rate and FTR. Major morbidity rate and TO are better candidates to use for benchmarking.

Preoperative Controlling Nutritional Status Score on Predicting the Postoperative Complications Following Major Hepatopancreatobiliary Surgery.

Introduction The prognostic significance of the controlling nutritional status (CONUT) score in hepatopancreatobiliary (HPB) surgery has been shown by many studies but the clinical significance of the CONUT score for postoperative short-term outcomes remains controversial. This study aimed to investigate the impact of the CONUT score on early postoperative outcomes in patients following major HPBsurgery. Method This was a prospective study of 57 patients who underwent major HPB surgery from November 2019 to January 2021 at the Department of Surgical Gastroenterology, Tribhuvan University Teaching Hospital, Nepal. Result A total of 57 patients, 25 males and 32 females, were operated on. The number of patients assigned to the normal, mild, and moderate malnutrition groups was 13, 41, and 3, respectively. The high CONUT group (CONUT ³ 2) consisted of 44 patients (77%) and the low CONUT group (CONUT <2) consisted of 13 patients (33%). The overall complications (Clavien-Dindo classification ³1) and major complications (Clavien-Dindo classification ³3) were present in 37 patients (64.9%) and 14 patients (24.6%), respectively. Increased operative time and intraoperative blood loss were associated with an increased incidence of major (OR: 1.01, p: 0.018) and overall (OR: 1.006, p: 0.039) postoperative complications, respectively, in univariate analysis. A high CONUT score was not associated with a higher incidence of overall and major postoperative complications. Conclusion In our study, the preoperative CONUT score did not predict the postoperative morbidity following hepatopancreatobiliary surgery.