Major Hepatopancreatobiliary Research Articles

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.

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.

Acute postoperative pain management techniques, their efficacy and complications after major gastrointestinal and hepato-pancreato-biliary cancer surgeries: An observational study.

Patients undergoing major gastrointestinal (GI) surgery including hepato-pancreato-biliary (HPB) surgeries have large incisions, which cause severe acute postoperative pain that, if untreated, is associated with a higher incidence of postoperative morbidity and delayed recovery. Our study included all patients who underwent elective major upper GI and HPB surgeries from 1 January 2018 to 31 December 2018. The patients were divided into two groups: the epidural and the non-epidural group. The average and worst pain scores at rest and movement were compared between both groups. We also studied the effect of pain relief in the two groups and associated postoperative outcomes, resumption of feeding, ambulation, hospital stay and intensive care unit stay. A total of 566 patients were included in the study, out of which 490 received epidurals, and the rest, 76, belonged to the non-epidural group (transversus abdominis plane, rectus sheath block or no regional analgesia technique). The median average pain score at rest and movement was 2.0 and 3.0, respectively, in the epidural and non-epidural groups. The postoperative outcomes showed no statistical difference. The epidural group and the non-epidural group had similar pain scores, and the postoperative outcomes were also comparable.

HPB P08 Exploring Carbon-13 breath delta value and other biomarkers of infection following Liver Transplantation and Hepatopancreatobiliary Surgery

Abstract Background Sepsis and infection are the leading cause of morbidity and mortality after surgery, but the inflammatory response to the trauma of surgery can make diagnosis challenging. Carbon-13 breath delta value (13C BDV) has been shown to be discriminant as a novel diagnostic marker for sepsis and infection. We aim to assess biomarkers including BDV following major hepatopancreatobiliary (HPB) surgery to diagnose postoperative infection/sepsis. Methods 20 participants undergoing HPB surgery were recruited prospectively. Breath samples were collected from baseline preoperatively, and on postoperative days (POD) 1–9, with plasma and peripheral blood mononuclear cell (PBMC) samples preoperatively, POD1, 4 and 8. Breath samples were analysed using infrared laser spectroscopy to generate BDV (per mil). Plasma was analysed for cytokines using MesoScale Discovery immunoassay, Procalcitonin (PCT) using ELISA, and Cell surface marker expression on monocytes was phenotyped using flow cytometry. Differences between groups who did and did not develop infective complications was analysed using two-way ANOVA and Mann Whitney U test. Results 5/20 participants developed infective complications, with a mean day of diagnosis POD5. There was no difference between BDV in patients with or without infection. Monocyte count was increased in infected participants at all timepoints, and monocyte expression of PD-L1 on POD1, and CD155 and HLA-DR on POD4 was upregulated, +13.09% (95%CI 1.59 to 24.61, p&amp;lt;0.05), +422.5 MFI (95% CI -770.9 to -73.68, p&amp;lt;0.05), and +19.02% (95% CI 37.58 to 0.45, p&amp;lt;0.05) respectively. Conclusions Monocyte expression of PD-L1, HLA-DR and CD155 is associated with infection, +13.09% (p&amp;lt;0.05), +422.5 MFI (p&amp;lt;0.05), and +19.02% (p&amp;lt;0.05) respectively. The innate immune system is dysregulated in infection following major HPB surgery. In this cohort BDV did not predict infection. Further investigation of novel biomarkers including BDV and soluble monocyte markers is required.

HPB P54 General surgery telemedicine clinics: here to stay post-pandemic?

Abstract Background The telemedicine clinic in general surgery has become widespread since the onset of the COVID-19 pandemic and has remained so following relaxation of restrictions on conventional face-to-face appointments. However, there has been significant scepticism regarding its continued utility. In particular, there is a concern that patients cannot be adequately assessed and counselled for invasive procedures, which may result in high cancellation rates on the day of procedure. The aim of this study was to assess the cancellation rate on the day of surgery for procedures booked in telemedicine clinics. Methods We conducted a retrospective analysis of surgical procedures booked via hepatopancreatobiliary (HPB) and general surgery telemedicine clinics from March 2020 to November 2021. From September 2020 onwards, telemedicine clinics were only run for laparoscopic cholecystectomies for benign gallbladder disease. The primary outcome was the cancellation rate of surgical cases booked from telemedicine clinics. Statistical analysis was done using JASP 0.16.2 software. Results We identified 240 cases booked for surgery from telemedicine clinic. 162 patients (68%) were female; the median age of the study population was 51 (16–81). 186 (78%) patients had gallstones, 19 (8%) gallbladder polyps, 13 (5%) secondary liver tumour, 5 (2%) liver cyst, 5 (2%) pancreatic tumour, 4 (1.7%) primary liver tumour, 2 (0.8%) gallbladder tumour and 6 (2.5%) other pathologies. 225 patients (94%) underwent surgery on their first admission. Procedures included 192 cholecystectomies, 10 open segmental liver resections, 6 laparoscopic segmental liver resections, 4 distal pancreatectomies, 3 open right hepatectomies, 2 Whipple procedures, 2 laparoscopic deroofing of the liver cyst, 2 laparoscopic lymph node biopsy, 1 extended right hepatectomy, 1 left hepatectomy, 1 small bowel resection and 1 exploratory laparotomy. 15 (6%) patients had surgery cancelled on the day of surgery, 14 of those were for laparoscopic cholecystectomy, 1 for laparoscopic liver resection. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. The majority 212 (88%) of patients were ASA class 1–2; only 28 (12%) were ASA class 3. There was no significant association between high ASA (3) and cancellation rate (Chi square test 5% vs 14% p=0.062). Conclusions Telemedicine clinic in general surgery was often the only option to assess and plan operative management for newly referred patients during the COVID-19 pandemic. Our series showed that it was feasible to assess and counsel patients on the phone even for major HPB procedures with a minimal cancellation rate on the day of operation.

Enhanced Recovery After Surgery® (ERAS) in Octogenarians Undergoing HPB Surgery

Background: Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80 years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Methods: Patients ≥ 80 years old in a single HPB ERAS program (September 2015 – July 2018) were prospectively tracked in the Electronic Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Results: Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, p=0.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. Conclusions: ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions.

Pre-operative 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 outcome remains controversial. The aim of this study was to investigate the impact of the CONUT score on postoperative outcomes in patients with major hepatopancreatobiliary (HPB) cancers.

Enhanced Recovery After Surgery® in Octogenarians Undergoing Hepatopancreatobiliary Surgery.

Advances in perioperative care have increased the frequency of surgical intervention performed on the very elderly (≥80years). This study aims to investigate the impact of Enhanced Recovery After Surgery (ERAS) on outcomes for octogenarians after major hepatopancreatobiliary (HPB) surgery. Patients ≥80 years old in a single HPB ERAS program (September 2015-July 2018) were prospectively tracked in the ERAS Interactive Audit System (EIAS). Postoperative length of stay (LOS) as well as 30-day major complications, readmissions, and mortality were compared to a pre-ERAS octogenarian control. Since ERAS implementation, octogenarians comprised 7.3% (27 of 370) of patients who underwent pancreaticoduodenectomy (n=17), distal pancreatectomy (n=7), or hepatectomy (n=3). Thirty-day readmissions decreased after ERAS implementation (50% to 15%, P=.037). Thirty-day major complications, mortality, and LOS were similar with 64% median protocol compliance. ERAS for octogenarians in HPB surgery is safe and may contribute to more sustainable recovery resulting in reduced readmissions.

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study.

BackgroundThe Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult.ObjectiveWe report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic.MethodsWe divided our study into 4 phases—phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post–CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post–CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%.ResultsA total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre–CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%).ConclusionsThis follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.

Weight Loss Following Hepatopancreatobiliary Surgery. How Much is Too Much? A Retrospective Cohort Study.

Background & Aims. Postoperative weight loss is common following hepato-pancreato-biliary (HPB) surgical resections; however, the extent of weight loss and the association with poor outcomes have not been well described. We assessed the average percentage of weight loss and risk factors associated with sustained postoperative weight loss. Materials and Methods. We enrolled patients undergoing major HPB surgical resections from 2011–2016 at a single institution. We evaluated percent change in weight postoperatively, incidence of complications, and nutritional clinical markers at 1, 3, and 6 months postoperatively compared to preoperative baseline. We used multiple logistic regression to evaluate factors associated with significant weight loss (>10% from baseline) at 3 months from surgery. Results. Among 262 patients undergoing HPB surgery, liver surgery patients lost 2.5% of baseline weight at 3 months postoperatively but regained baseline weight by 6 months. Pancreatic surgery patients lost 7.7% at 3 months and were unable to recover their baseline weights at 6 months. Forty-three (16%) patients had major postoperative complications including abdominal abscess (5.3%) and anastomotic leak (3.8%). Patients who experienced major postoperative complications had a greater percentage weight loss at 3 months compared to those without major complications: median 11% (interquartile range (IQR): 7%–15%) vs 4% (IQR: 0%–8%), P < .001. In the multivariable analysis, major postoperative complications were associated with significant weight loss at 3 months (OR 3.39, 95% CI 1.38–8.33). Conclusions. Due to the association of weight loss and major postoperative complications, patients who experience significant weight loss (>10% from baseline) may benefit from nutritional assessment for dietary intervention.

Improving postoperative mobilisation rates in patients undergoing elective major hepatopancreatobiliary surgery

BackgroundEarly mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery...

Importance of "muscle" and "intestine" training before major HPB surgery: A review.

Major hepato-pancreato-biliary (HPB) surgery is one of the most invasive abdominal surgeries. Through the experiences of several clinical trials, including those involving patients undergoing major HPB surgery, we have recognized the importance of "muscle" and "intestine" training before surgery. This review article summarizes the results of our clinical trials, specifically focusing on the importance of "muscle" and "intestine". The patients with low skeletal muscle mass or those with low functional exercise capacity showed a significantly worse postoperative course and poor long-term survival after surgery for HPB malignancy. The introduction of prehabilitation (preoperative physical and nutritional support) improved nutritional status and functional exercise capacity, even in patients with malignancy. Daily physical activity was correlated with nutritional status before surgery. These results indicated the usefulness of prehabilitation. The intestinal microenvironment, which is extrapolated from the fecal concentrations of short-chain fatty acids (SCFAs), showed a significant association with the incidence of surgery-induced bacterial translocation and postoperative infectious complications (POICs). The use of perioperative synbiotics not only increased the fecal levels of SCFAs but also prevented the incidence of POICs. A recent study also indicated that there are correlations between muscle mass and the intestinal microenvironment. Further investigation is required to determine the best "muscle" and "intestine" training protocol to improve the outcomes of major HPB surgeries.

Risk factors and outcomes of postoperative delirum after major hepatobiliary-pancreatic surgery; single center, prospective cohort study.

Introduction: Post-operative delirium(POD) is one of the most common complication of major abdominal surgery. Although it is temporary and reversible, it is known to be related with the increased incidence of post-operative complications. The aim of this study was to figure out the incidence of POD in patients undergoing a major hepato-pancreato-biliary(HPB) surgery and to determine the risk factors of its development. Method: Patients over 20 years undergoing elective major HPB operations at the Center for Liver Cancer, National Cancer Center were prospectively enrolled. All patients were screened for delirium using the Korean Nursing Delirium Scale (Nu-DESC) and an independent psychiatrist assessed referred patients thereafter. Univariate and multivariate analysis were performed. Result: 119 patients were enrolled with a median age of 63 years. The overall incidence of POD was 30.3% (36/119). The median onset was on the second post-operative day. Older age and lower mini-mental status exam(MMSE) score were predictive of an increased risk of POD. Patients who developed POD showed a tendency of an increased length of stay (19.7 vs 15.2), and an increased risk of developing grade 3 or higher complication (Clavien-Dindo classification). Conclusion: In this study, we demonstrated that POD is associated with older age and low cognitive function test score.

Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted?

IntroductionThe Center for Medicare and Medicaid Services (CMS) has identified readmission as an important quality metric. With an increased emphasis on regionalization of complex hepato-pancreato-biliary (HPB) surgery to high-volume centers, care of readmitted HPB patients may be fragmented if readmission occurs at a non-index hospital. We sought to define the proportion of HPB readmissions, as well as evaluate outcomes, that occur at an index versus non-index hospitals and to identify factors associated with non-index hospital readmission. MethodsThe National Readmissions Database (NRD) was used to identify patients who underwent major HPB surgery between 2010 and 2015. Factors associated with readmission at 30 and 90 days at index versus non-index hospitals were analyzed. Differences in mortality and complications were analyzed among patients readmitted to index versus non-index hospitals. ResultsA total of 49,080 patients underwent HPB surgery (liver n = 27,081, 55%; pancreas n = 14,787, 30%; biliary n = 7212, 15%). Overall, 6643 (14%) and 11,709 (24%) patients were readmitted within 30 and 90 days, respectively. Among all first readmissions, 18 and 21% were to a non-index hospital within the first 30 and 90 days, respectively. On multivariable analysis, factors associated with readmission to a non-index hospital included age (OR 1.19, 95% CI 1.05, 1.34), pancreatic cancer (OR 1.40, 95% CI 1.14, 1.34) and ≥ 3 comorbidities (OR 1.34, 95% CI 1.10, 1.63), while procedures on the pancreas (OR 0.69, 95% CI 0.61, 0.80), private insurance (OR 0.77, 95% CI 0.68, 0.87), initial admission at a large hospital (OR 0.77, 95% CI 0.65, 0.91), and initial admission length of stay > 7 days (OR 0.77, 95% CI 0.69, 0.86) were associated with decreased odds of a non-index hospital readmission (all p < 0.05). Patients readmitted to a non-index hospital had higher inpatient mortality (3.7 vs. 2.7%, p = 0.010). ConclusionsRoughly 1 in 5 patients were readmitted to a non-index hospital where the initial HPB operation had not taken place. Readmission to a non-index hospital was associated with higher overall in-hospital mortality. The impact of regionalization of HPB care relative to site of subsequent readmission may have important implications for patients.

Experience with a simplified feeding jejunostomy technique for enteral nutrition following major visceral operations

Background: Perioperative nutrition support has been shown to impact on outcomes for patients with gastrointestinal cancer. Postoperative benefits of feeding tubes must be weighed against morbidity related to placement and use. A simplified jejunostomy tube technique was evaluated for outcomes. A 16-Fr rubber tube is secured at the jejunal entry site without Witzel tunnel, followed by a continuous, circumferential and alternating suture between jejunal wall and parietal peritoneum. Prospectively collected data were analyzed. The technique was performed in 343 of 803 major hepatopancreatobiliary and upper gastrointestinal (GI) resections (43%). Of these patients (male =57%, median age: 65.8 years, range, 24.0-98.0 years), 89% had a cancer diagnosis. The procedures included pancreatectomy (n=189, 55%), gastrectomy (n=109, 32%), esophagectomy (n=19, 6%) and others (n=26, 7%). The operative intent was curative in 78%, palliative in 10%, or combined in 12% of patients. Postoperative morbidity rate was 40%, with 19 lethal events (5.5%), and a median length of stay of 10 days (range, 4-111 days). Tube feeds were administered in 139 patients (41%), and in 17% continued beyond discharge. Use of the feeding tube was linked to treatment interval, length of stay, major complication grade (all at P<0.0001), metastatic stage (P=0.0007) and noncurative intent (P=0.001). Tube feeds beyond discharge were associated with time interval (P<0.0001), length of stay (P=0.0006) and noncurative intent (P=0.014). Tube-specific events in 38 patients (11%) were all minor, without any intraabdominal leak, infection or obstruction. The technique described is safe and expedient, and the overall tube-related morbidity is low. This procedure can be recommended in cases at risk for major morbidity and nutrition support needs.

Effect of polylactic film (Surgi-Wrap) on preventing postoperative ileus after major hepato-pancreato-biliary surgery

Backgrounds/AimsMajor hepato-pancreato-biliary (HPB) surgery is usually performed via an open method rather than a laparoscopic method. Postoperative ileus (POI) is a classic complication after open surgery. The purpose of this study was to determine whether polylactic film is useful in the prevention of POI.MethodsA total of 179 patients who underwent major HPB surgery between 2005 and 2014, were retrospectively reviewed. A diagnosis of POI was made by a physical examination, laboratory, and radiological findings. Surgi-Wrap® polylactic film was preferentially used intraperitoneally by surgeons, just before wound closure.ResultsMajor HPB surgery included pancreatoduodenectomy (n=48), distal or subtotal pancreatectomy (n=24), hepatectomy (n=67), other bile duct or gallbladder operations (n=35), and others (n=5). Although patients with polylactic film showed a significantly lower incidence of POI (n=3, 4.1% vs. n=14, 13.3%, p=0.041), they showed a significantly higher complication rate (n=20, 27.0% vs. n=19, 18.1%, p=0.004), particularly intra-abdominal fluid collection (n=7, 9.4% vs. n=2, 1.9%), and wound infections (n=6, 8.1% vs. n=3, 2.9%), than those who did not receive the film, respectively.ConclusionsAlthough the polylactic film prevented POI, more complications other than POI were observed. Well-designed randomized controlled trials, using this anti-adhesive product, are needed to evaluate its effect on POI after major HPB surgery.

Training in Hepatopancreatobiliary Surgery: Assessment of the Hepatopancreatobiliary Surgery Workforce in North America.

Evaluate the current status of Hepatopancreatobiliary (HPB) Surgery workforce in North America. HPB fellowships have proliferated, with HPB surgeons entering the field through 3 pathways: transplant surgery, surgical oncology, or HPB surgery training. Impact of this growth is unknown. An anonymous survey was distributed to 654 is used as HPB surgeons from October 2012 to January 2013. Questions evaluated satisfaction with job availability after training and description of current practice. Nationwide Inpatient Sample (NIS) data from 2003 to 2010 was queried to describe the growth of HPB cases in the United States; these data were compared to prior HPB workforce projections performed using 2003 NIS data. A total of 416 HPB surgeons responded (66%). HPB surgeons are concentrated in a small number of states/provinces with a lack of HPB surgeon workforce in central United States. HPB graduates from 2008 to 2012 report increased difficulty in identifying an HPB-focused practice versus prior to 2008. Mature HPB surgery practices report a composition of 25% to 50% non-HPB operative cases. Fifty-one percent of respondents reported an opinion that current HPB Surgeon production was excessive; however, 2010 NIS data demonstrate that major HPB surgery cases have grown significantly more than was previously projected using 2003 NIS data. A cohesive strategy for responsibly responding to the HPB surgical workforce requirements of North America is needed. Elevation of training standards, standardization of requirements for certification, and careful modeling that accounts for regionalization of care should be pursued to prevent overtraining and decentralization of HPB surgical care in the future.

ACS-NSQIP has the potential to create an HPB-NSQIP option

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was started in 2004. Presently, 58% of the 198 hospitals participating in ACS-NSQIP are academic or teaching hospitals. In 2008, ACS-NSQIP initiated a number of changes and made risk-adjusted data available for use by participating hospitals. This analysis explores the ACS-NSQIP database for utility in developing hepato-pancreato-biliary (HPB) surgery-specific outcomes (HPB-NSQIP). MethodsThe ACS-NSQIP Participant Use File was queried for patient demographics and outcomes for 49 HPB operations from 1 January 2005 through 31 December 2007. The procedures included six hepatic, 16 pancreatic and 23 complex biliary operations. Four laparoscopic or open cholecystectomy operations were also studied. Risk-adjusted probabilities for morbidity and mortality were compared with observed rates for each operation. ResultsDuring this 36-month period, data were accumulated on 9723 patients who underwent major HPB surgery, as well as on 44189 who received cholecystectomies. The major HPB operations included 2847 hepatic (29%), 5074 pancreatic (52%) and 1802 complex biliary (19%) procedures. Patients undergoing hepatic resections were more likely to have metastatic disease (42%) and recent chemotherapy (7%), whereas those undergoing complex biliary procedures were more likely to have significant weight loss (20%), diabetes (13%) and ascites (5%). Morbidity was high for hepatic, pancreatic and complex biliary operations (20.1%, 32.4% and 21.2%, respectively), whereas mortality was low (2.3%, 2.7% and 2.7%, respectively). Compared with laparoscopic cholecystectomy, the open operation was associated with higher rates of morbidity (19.2% vs. 6.0%) and mortality (2.5% vs. 0.3%). The ratios between observed and expected morbidity and mortality rates were <1.0 for hepatic, pancreatic and biliary operations. ConclusionsThese data suggest that HPB operations performed at ACS-NSQIP hospitals have acceptable outcomes. However, the creation of an HPB-NSQIP has the potential to improve quality, provide risk-adjusted registries with HPB-specific data and facilitate multi-institutional clinical trials.

A Change in Practice from Epidural to Intrathecal Morphine Analgesia for Hepato‐Pancreato‐Biliary Surgery

This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3-11) liters vs. 5 (3-11) liters, P < 0.05) and in total (15.5 (5-48.5) liters vs. 9 (3-70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3-36) days vs. 7 (3-55) days, P < 0.01). In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.