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  • 1
    Language: English
    In: HPB, September 2015, Vol.17(9), pp.804-810
    Description: Surgical intervention is uncommon in chronic pancreatitis. Literature largely describes single institution or international experiences. This study describes US‐based chronic pancreatitis surgical management. Retrospective analysis of chronic pancreatitis patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007–2011. Patients with malignancy or congenital abnormalities were excluded. Univariate analysis using the chi‐square test. The number of readmissions, inpatient length of stay and cost using Wilcoxon's signed‐rank test. Multivariate analysis of surgery by logistic regression. Twenty‐one thousand four hundred and forty‐five patients with chronic pancreatitis. 10.8% (2 307) underwent surgery including 1652 cholecystectomies, 564 drainage procedures and 498 pancreatectomies. Procedures decreased from 12.1% to 8.3% over time ( 〈 0.001), but intervention within 3 months increased (7.2% to 8.4%; = 0.017). 15.3% (3 278) had pancreatic cysts/pseudocysts and 43.4% (9 312) had diabetes. The median numbers of admissions were 2 [interquartile range (IQR) 1,5] and 3 (IQR 2,7) among non‐surgical and surgical patients, respectively ( 〈 0.001). Predictors of surgery were fewer co‐morbidities, private insurance, and either diabetes mellitus or pancreatic cyst/pseudocyst. Chronic pancreatitis leads to numerous inpatient readmissions, but surgical intervention only occurs in a minority of cases. Complicated patients are more likely to undergo surgery. The complexities of chronic pancreatitis management warrant early multidisciplinary evaluation and ongoing consideration of surgical and non‐surgical options.
    Keywords: Medicine
    ISSN: 1365-182X
    E-ISSN: 1477-2574
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  • 2
    Language: English
    In: Gastroenterology, April 2015, Vol.148(4), pp.S-1107-S-1107
    Description: To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0016-5085(15)33771-9 Byline: Susanna W. deGeus, Lindsay A. Bliss, Mariam F. Eskander, Alexander Vahrmeijer, Tara S. Kent, A. James Moser, Mark P. Callery, Bert A. Bonsing, Jennifer F. Tseng
    Keywords: Medicine
    ISSN: 0016-5085
    E-ISSN: 1528-0012
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  • 3
    Language: English
    In: HPB, September 2015, Vol.17(9), pp.753-762
    Description: Bile duct reconstruction (BDR) is used to manage benign and malignant neoplasms, congenital anomalies, bile duct injuries and other non-malignant diseases. BDR outcomes overall, by year, and by indication were compared. Retrospective analysis of Nationwide Inpatient Sample discharges (2004–2011) including ICD-9 codes for BDR. All statistical testing was performed using survey weighting. Univariate analysis of admission characteristics by chi square testing. Multivariate modelling for inpatient complications and inpatient death by logistic regression. Identified 67 160 weighted patient admissions: 2.5% congenital anomaly, 37.4% malignant neoplasm, 2.3% benign neoplasm, 9.9% biliary injury, 47.9% other non-malignant disease. Most BDRs were performed in teaching hospitals (69.6%) but only 25% at centres with a BDR volume more than 35/year. 32.3% involved ≥ 1 complication, and 84.7% were discharges home. There was a 4.2% inpatient death rate. The complication rate increased but the inpatient death rate decreased over time. The rates of acute renal failure increased. Significant multivariate predictors of inpatient death include indication of biliary injury or malignancy, and predictors of any complication include public insurance and non-elective admission. This is the first national description of BDRs using a large database. In this diverse sampling, both procedure indication and patient characteristics influence morbidity and mortality.
    Keywords: Medicine
    ISSN: 1365-182X
    E-ISSN: 1477-2574
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  • 4
    Language: English
    In: HPB, October 2014, Vol.16(10), pp.899-906
    Description: The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown. Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004–2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low 〈5, medium 5–18, high 〉18). Multivariable regression model evaluated predictors of resection at a high-volume centre. In total, 129 609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality ( 〈 0.001), fewer complications ( 〈 0.001) and a shorter median length of stay ( 〈 0.001). Patients at non-high-volume centres had more comorbidities ( = 0.001), lower rates of private insurance ( 〈 0.001) and more non-elective admissions ( 〈 0.001). In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.
    Keywords: Medicine
    ISSN: 1365-182X
    E-ISSN: 1477-2574
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  • 5
    Language: English
    In: HPB, August 2016, Vol.18(8), pp.671-677
    Description: The optimal treatment for biliary obstruction in pancreatic cancer remains controversial between surgical bypass and endoscopic stenting. Retrospective analysis of unresected pancreatic cancer patients in the Healthcare Cost and Utilization Project Florida State Inpatient and Ambulatory Surgery databases (2007–2011). Propensity score matching by procedure. Primary outcome was reintervention, and secondary outcomes were readmission, overall length of stay (LOS), discharge home, death and cost. Multivariate analyses performed by logistic regression. In a matched cohort of 622, 20.3% (63) of endoscopic and 4.5% (14) of surgical patients underwent reintervention (p 〈 0.0001) and 56.0% (174) vs. 60.1% (187) were readmitted (p = 0.2909). Endoscopic patients had lower median LOS (10 vs. 19 days, p 〈 0.0001) and cost ($21,648 vs. $38,106, p 〈 0.0001) as well as increased discharge home (p = 0.0029). No difference in mortality on index admission. On multivariate analysis, initial procedure not predictive of readmission (p = 0.1406), but early surgical bypass associated with lower odds of reintervention (OR = 0.233, 95% CI 0.119, 0.434). Among propensity score-matched patients receiving bypass vs. stenting, readmission and mortality rates are similar. However, candidates for both techniques may experience fewer subsequent procedures if offered early biliary bypass with the caveats of decreased discharge home and increased cost/LOS.
    Keywords: Medicine
    ISSN: 1365-182X
    E-ISSN: 1477-2574
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  • 6
    Language: English
    In: Journal of Gastrointestinal Surgery, 2016, Vol.20(1), pp.85-92
    Description: Adjuvant chemotherapy plays a critical role in the treatment of resected pancreatic cancer patients. However, the role of adjuvant radiation remains controversial. This study compares survival between resected pancreatic cancer patients who received adjuvant radiation and no adjuvant radiation. Medical records of patients with pancreatic ductal adenocarcinoma who underwent surgical resection from January 2003 through 2013 at medical centers in Boston and Leiden were retrospectively reviewed. Propensity score matching was used to correct for potential selection bias in the allocation of adjuvant chemoradiation versus chemotherapy alone. Three hundred fifty total patients were identified, of whom 138 (39.4 %) received adjuvant radiation. On pathological staging, 245 (70.0 %) had positive lymph nodes, and these patients gained a significant survival benefit from adjuvant radiation (hazard ratio (HR) 0.74; 95 % confidence interval (CI) 0.56–0.99) in the complete cohort. After propensity score matching, adjuvant radiation lost its prognostic significance in the complete cohort. However, after matching, patients who survived longer than 12 months and had positive lymph nodes ( n  = 108) demonstrated a significant (log-rank p  = 0.04) survival benefit from adjuvant radiation. This study, while non-randomized, suggests that adjuvant radiation may be associated with a survival benefit for resected pancreatic cancer patients in specific situations.
    Keywords: Pancreatic neoplasm ; Adjuvant chemoradiotherapy ; Adjuvant radiotherapy ; Survival
    ISSN: 1091-255X
    E-ISSN: 1873-4626
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