Introduction Many factors increase the complexity of abdominal wall reconstruction including attenuated fascia, loss-of-domain, prior hernia surgeries, multiple fascial defects, enterocutaneous fistulas, and mesh infections. We describe our experience of using a suture-less mesh fixation underlay ventral herniorrhaphy technique to combat such issues in high-risk ventral hernia repair. Methods This is a prospective-observational study. Patients from 2019 onward undergoing emergent or elective cases were included. The technique: A large porcine acellular-dermal-matrix (ADM) alone or sutured to a light-weight, macroporous polypropylene mesh is created and placed with ADM facing the bowel. Fibrin glue is sprayed over the mesh, fascia and skin closed. An abdominal binder is placed pre-extubation and left undisturbed for 5 postoperative days. Results Of 34 included patients, the average demographic was a Caucasian (62.9%) female (65.7%), with class-I or greater obesity (76.5%), hypertension (74.3%), dyslipidemia (48.6%), non-skin malignancy (40.0%), type II diabetes mellitus (34.3%), a ventral hernia working group class of III-IV (55.9%), a mean of 3 ± 2.2 prior surgeries, and mean fascial defect size of 12.3 x 13.5cm. Five were prior solid-organ transplant recipients. Four patients underwent simultaneous tumor extirpations and herniorrhaphy. Five cases (14.7%) were emergent. Removal of prior mesh was performed in 48.5% of cases—seven had infected mesh. Median length of stay was 7 days, with 141 days median follow-up time. Fifteen patients (44.1%) developed a complication. Hernia-specific complications were limited to healing problems. There were no recurrences. Conclusion This technique is easy and safe to employ in patients requiring high-risk complex abdominal reconstructions with minimal hernia-specific complications.

Background: Tendon injuries of the upper extremity remain a common surgical condition requiring prompt intervention. The authors review their initialexperience with the PONTiS flexor tendon repair system, a knotless, multifilament,stainless steel crimp system. Methods: Consecutive patients undergoing repair by plastic and orthopedicsurgeons with the PONTiS system were reviewed for the period from 2015 to2017. Multivariate risk and Kaplan-Meier survival analyses were performed toassess risk factors associated with complications. Results: Eighty-one patients, with a mean follow-up of 75 days (range, 0 to 33months), were identified. The most common demographics showed patientswere right-handed (82.9 percent), male (71.4 percent), and laborers (35.7 percent) and sustained laceration injuries (77.1 percent) at zone 2 (27.2 percent).There were, on average, 3.7 tendon injuries per patient. Associated injuriesincluded fractures (21.4 percent), arterial injuries (24.3 percent), and nerve injuries (61.4 percent). Thirteen patients (16.0 percent) developed complications, including adhesions/contracture (n = 4), rupture (n = 2), flap ischemia (n = 2), arterial thrombosis (n = 1), wound dehiscence (n = 1), tendon lag (n = 1), and erosion of the PONTiS system through soft-tissue grafts (n = 2). Multivariate analysis identified poor soft-tissue coverage (OR, 9.990; p = 0.043) and zone 2 involvement (OR, 7.936; p = 0.016) as risk factors, while epitendinous repairs (OR, 0.096; p = 0.010) were protective against complications. Conclusions: The PONTiS flexor tendon repair system is rapid, simple to deploy, and advantageous, especially in multiple traumatic tendon injuries. In comparison to traditional suture repair, it has a comparable overall complication profile but superior rupture and tenolysis rates. The authors advise using it with caution in cases with poor soft-tissue coverage to minimize risks of extrusion, and they strongly recommend the use of epitendinous sutures concurrently to limit complications.

BACKGROUND:The use of neoadjuvant chemotherapy (NAC) for pancreatic ductal adenocarcinoma (PDAC) has increased in recent years. Limited data exists on the impact of NAC on biliary microbiome.METHODS:Patients who underwent pancreaticoduodenectomy (PD) for PDAC between 2014 and 2017 were reviewed. Patients were stratified into two groups based on their NAC status for comparison.RESULTS:Of 168 patients included, 63 (37.5%) received NAC. Patients who received NAC exhibited significantly increased growth of Gram-negative anaerobic bacteria (p = 0.043). Patients in the non-NAC group were more likely to grow pathogens resistant to ampicillin-sulbactam (47% vs 21%, p = 0.007), cefazolin (49% vs 28%, p = 0.040), cefoxitin (42% vs 11%, p = 0.009) and cefuroxime (26% vs 4%, p = 0.019). NAC status did not impact infectious postoperative outcomes, including SSIs.CONCLUSION:Patients who did not receive NAC were more likely to grow pathogens resistant to cephalosporins. Perioperative antibiotic prophylaxis should be tailored to cover Gram-negative organisms and enterococci.

Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH). Seventy-five patients who underwent MIRH during 2007–2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis. Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7 cm (±3.6), mean operative time was 196 min (±74), and mean EBL was 220 mL (±170). Average transection diameter was 10.1 cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index. This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.

Background: Aortic aneurysms occur concomitantly with malignancy in approximately 1.0-17.0% of patients. There is little published information regarding the effects of subsequent oncological therapies on aortic aneurysm growth. The aim of this study was to determine the effects of chemoradiation therapies on the natural progression of small abdominal aortic aneurysm (AAA), thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm. Methods: Patients with aortic aneurysms with and without malignancy between 2005 and 2017 were identified within institutional databases using Current Procedural Terminology and International Classification of Disease codes. Inclusion criteria included complete chemotherapy documentation, a minimum of 3 multiplanar axial/coronal imaging or ultrasonography before, during, and after receiving therapy or 2 studies for patients without malignancy. Propensity matching, Cox and linear regression, and Kaplan-Meier survival analyses were performed. Results: A total of 159 (172 aneurysms) patients with malignancy and 127 (149 aneurysms) patients without malignancy were included. Average patient demographics were 74.4 +/- 9.8-years-old, Caucasian (66.8%), male (70.3%), with hypertension (71.1%), current smoking (24.5%), coronary atherosclerotic disease (26.2%), and AAA (71.0%). The most common malignancy was lung cancer (48.4%) with most chemotherapy regimens including a platinum-based alkylating agent and concurrent antimetabolite (56.0%). The overall median follow-up time was 28.2 (range 3.1-174.4) months. Aortic aneurysms in patients without malignancy grew to larger sizes (4.43 +/- 0.96 vs. 4.14 +/- 1.00, P = 0.008) with similar median growth rates (0.12 vs. 0.12 cm/year, P = 0.090), had more atypical morphologic features (14.1% vs. 0.6%, P < 0.001), more frequently underwent repair (22.1% vs. 8.7%, P = 0.001), and more frequently required emergency repair for rupture (5.4% vs. 0.0%, P = 0.087). Cox regression identified initial aortic size >= 4.0 cm (hazard ratio [HR] 3.028), AAA (HR 2.146), chronic aortic findings (3.589), and the use of topoisomerase inhibitors (HR 2.694). Linear regression demonstrated increased growth rates predicted by antimetabolite chemotherapy ((3 0.170), initial aortic size ((3 0.086), and abdominal aortic location (beta 0.139, all P < 0.002). Conclusions: Small aortic aneurysms with concomitant malignancies are discovered at smaller initial sizes, grow at similar rates, require fewer interventions, and have fewer ruptures and acute dissections than patients without malignancy. Antimetabolite therapies modestly accelerate aneurysmal growth, and patients receiving topoisomerase inhibitors may require earlier repair. Patients with concomitant disease can be confidently treated according to standard institutional aneurysm surveillance protocols. Overall, we recommend treatment of the malignancy before small aortic aneurysm repair as these aneurysms behave similarly to those in patients without malignancy.

Presenter: Syed Omair Nadeem MBBS | Emory University Background: Postoperative infectious complications constitute a major source of morbidity in pancreatic surgery. For patients with pancreatic ductal adenocarcinoma (PDAC), the use of neoadjuvant chemotherapy is becoming more commonly adopted. Yet data is limited regarding its impact on the biliary microbiome. It has been hypothesized that the currently recommended peri-operative antibiotic coverages may be inadequate prophylaxis for patients undergoing pancreatic resection. The aim of this study was to determine the effect of neoadjuvant therapy on the biliary microbiome in patients with and without preoperative stenting as a surrogate for overall patient microbiome status Methods: Demographic, operative, post-operative, and biliary pathogen morphology and antibiotic sensitivity data was reviewed from consecutive patients with pathologically confirmed PDAC from January 2014 to December 2017. Data was expressed as percentages. Chi square and ANOVA testing was performed for comparison between groups. Results: A total of 263 patients with PDAC were identified. 258 cases with complete stent data were included in the analysis. Of them 199 (77.1%) had received preoperative stenting, amongst whom 71 (35.7%) had received neoadjuvant chemotherapy. Ancef/Flagyl (n=167, 84%) was the most common antibiotic combination for perioperative prophylaxis followed by Clindamycin/Aztreonam (n=16, 8%). There were no significant differences in baseline characteristics between the people who did and did not receive neoadjuvant chemotherapy. The most common pathogens isolated from biliary cultures were Klebsiella Pneumoniae (n=31, 18.5%), Enterobacter Clocae (n=20, 11.9%) and E.Coli (n=16, 9.5%). Patients who did not receive neoadjuvant chemotherapy were more likely to grow, fungi (5.5% vs 0% p=0.039), E.Coli and Enterobacter (25% vs 12.7%, p=0.039). However, growth of Gram-negative anaerobes (32.4% vs 18.8%, p= 0.030) and unspecified bacterial species (31% compared to 14.8%, p=0.007) was higher in the patients who received neoadjuvant chemotherapy. Patients who did not receive neoadjuvant therapy were more likely to grow gram-negative pathogens resistant to Ampicillin-Sulbactam (47% vs 21%, p=0.007), Cefazolin (49% vs 28%, p=0.040), Cefoxitin (42% vs 11%, p=0.009) and Cefuroxime (26% vs 4%, p=0.019) than the patients who did receive neoadjuvant chemotherapy. No differences were seen in resistance to Ampicillin (p=0.376), Aztreonam (p=0.977), Cefepime (p=0.172), Ceftriaxone (p=0.183) and Piperacillin-Tazobactam (p=0.36) (figure 1). Stratified by stent status, there were no differences in resistance patterns among patients who did and did not receive neoadjuvant chemotherapy. Conclusion: Neoadjuvant chemotherapy significantly alters the biliary microbiome in patients with PDAC undergoing pancreaticoduodenectomy. Patients who did not receive neoadjuvant chemotherapy were more likely to grow pathogens resistant to cephalosporin antibiotics and have fungal colonization of their bile compared to patients who did receive neoadjuvant chemotherapy. Perioperative antibiotic coverage should be tailored to cover enterococci and gram negative organisms, especially for the subset of patients who had a biliary stent placed

Synthetic mesh and acellular dermal matrix reinforcement during complex abdominal wall reconstruction (CAWR) have significantly improved outcomes. In an attempt to further improve outcomes, we combined both into a single biosynthetic by suturing a synthetic mesh on top of porcine acellular dermal matrix. Our aim was to review our experience with this new technique. Patients undergoing CAWR with the biosynthetic mesh were reviewed from a prospective database from 2015 to 2018. A total of 39 patients were 56.3 ± 10.9 years old, white (59.0%), and female (74.4%), with 31.9 ± 7.4 kg/m of body mass index. Eight repairs were performed on patients classified as greater than or equal to modified Ventral Hernia Working Group (mVHWG) class 3a, and 41.0% followed a concurrent resection of previously placed mesh. The biosynthetic mesh was placed as an underlay (51.3%) or inlay (46.2%) with primary closure in 51.3% and component separation in 12.8%. Recurrence at 3 years of follow-up occurred in 3 patients (7.7%). Complications within 60 days occurred in 6 patients (15.4%), including 4 soft tissue infections-one requiring explantation, with a total of 2 patients (5.1%) requiring explantation overall. Type 2 diabetes, previous mesh removal, component separation, and mVHWG class 3b independently predicted noninfectious complications. Male sex and mVHWG class 3b independently predicted surgical site infection. No predictors were found for recurrence. Biosynthetic mesh does not seem to increase the risk of early complications and may reduce recurrences and improve long-term outcomes after CAWR.

Background Pre-operative neoadjuvant chemotherapy (NAC) is routinely used for pancreatic ductal adenocarcinoma (PDAC), however there are no validated tools for evaluating pathologic response in these patients. This study compared changes in imaging characteristics to determine if pathologic response after NAC can be predicted. Methods 36 patients with histologically confirmed PDAC, who underwent pancreaticoduodenectomy, with pre-operative NAC and pre and post therapy diffusion weighted MRI (DW-MRI) between 2016 and 2018 were included. Response to NAC was determined using tumor size changes, RECIST criteria and DW-MRI (changes in apparent diffusion coefficient (ADC)). Pathologic response on final histology was used as reference. Results 25 (69%) patients demonstrated pathologic response to NAC. Reduction in size was noted in 31 patients. ADC values increased on restaging MRI in 15 cases. Reduction in size alone predicted pathologic response with 92% sensitivity and 27% specificity compared to increased ADCs, 48% sensitivity and 73% specificity. Discussion Reduction in tumor size alone correlated with pathologic response to NAC. DW sequences alone had poor sensitivity but better specificity of predicting response. Caution is urged in using ADC values from DW-MRI to determine responses after NAC. Traditional size criteria should continue to be used for predicting pathologic response after NAC.

Background: The amount of IV fluids sufficient to prevent post -operative acute kidney injury (AKI) during pancreaticoduodenectomy (PD) is unknown. We assessed the restrictive IOIVF use in PD on the rate of post -operative AKI, delayed gastric emptying and ileus, and pancreatic fistulas (POPF). Methods: Patients who underwent PD between 2012 and 2017 were reviewed. Univariate and multi-variate analyses looked for association between pre-and intra-operative factors on AKI, ileus and POPF. Results: Of 395 included patients, 97,172, and 126 patients received less than 1000 mL (ultra -restrictive), 1000 mL to less than 2000 mL (restrictive), and 2000 mL and greater (nonrestrictive) normalized total IOIVF respectively. Of these 23 (24.2%), 34(20.4%), and 21(17.4%) developed AKI respectively, most of them mild. There was no difference in odds of developing AKI, ileus, or pancreatic fistula among fluid groups. While there was no difference in Clavien-Dindo III -IV complications, the incidence of Clavien-Dindo type I -II complications was lower in the restricted fluid groups. Discussion: Restricted fluids did not lead to higher AKI rates but were associated with fewer low-grade complications. (C) 2020 Elsevier Inc. All rights reserved.

Background: Existing research suggests patients with blood group O are less likely to develop pancreatic ductal adenocarcinoma (PDAC) compared to those with non-O blood groups, and that survival from PDAC may be affected by ABO blood type. This study assessed survival outcomes in PDAC patients who underwent pancreatoduodenectomy (PD) in one health system. Methods: From 2010 to 2017, demographic, operative, chemotherapy and survival data for patients undergoing PD at Emory Healthcare were reviewed. Patients with blood type AB were excluded due to small sample size. The relationship between ABO blood group and survival was analyzed using Kaplan-Meier survival curves and multivariate cox proportional regression analysis. Results: Of 449 PDAC patients assessed, 204 (45.4%), 60 (13.4%) and 185 (41.2%) were blood groups A, B and O, respectively. Patients were well matched in clinicopathologic characteristics. Median survival did not differ by blood group (p = 0.82), and this relationship remained insignificant on cox regression analysis (p = 0.15). On multivariate analysis, lymph node positivity (p < 0.001) and increasing age (p = 0.001) were associated with reduced survival. Conclusion: In contrast to recent reports, this larger study found that blood group did not impact overall survival among patients undergoing PD for PDAC.

Background: Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy. Methods: Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic rightsided hepatectomies(LRH) were reviewed from 2008 to 2018. Results: Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p <0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR3.558), BMI >= 30 kg/m(2) (RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p <0.030). Conclusion: Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed. (C) 2019 Elsevier Inc. All rights reserved.

prospectively identified as low risk for POPF is predicted to be both cost-ineffective and unnecessary.We sought to evaluate the effect of prophylactic pasireotide on POPF in this high-risk population.Methods: Consecutive patients treated 2011e2014 and retrospectively stratified based on preoperative risk factors for B/C POPF were compared to consecutive patients treated 2016-2018 using newly-implemented and previously-described risk stratified pancreatectomy care pathways.In the latter cohort, only patients prospectively calculated to be at high risk for grade B/C POPF were assigned, per pathway, to receive perioperative pasireotide for 7 days or until day of discharge (if earlier).Results: Three hundred fifteen historic patients (142 [45%] low risk for B/C POPF, 173 [55%] high risk) who did not receive prophylactic pasireotide were compared to 212 patients subsequently assigned to a perioperative care pathway on the basis of their calculated risk for POPF.Among the 107 [50%] high risk patients assigned to receive prophylactic pasireotide per pathway, only 77 (72%) completed the entire treatment course (14 did not complete due to nausea, 5 due to prolonged QT interval, 1 hyperglycemia).The rate of B/C fistula among patients calculated to be at low risk for POPF and treated without pasireotide both before and after pathway implementation was similar (5.6% vs. 2.9%, p = 0.363).Among high risk patients, those assigned to prophylaxis with pasireotide per pathway had a rate of B/C POPF statistically identical to that of patients previously treated without pasireotide, both overall (32.7% vs 32.4%, p = 0.99), and among subsets who underwent pancreatoduodenectomy (38.9% vs 41.7%, p = 0.849) and distal pancreatectomy (26.4% vs 27.4%, p = 1.00).Amongst the high-risk patients assigned to receive pasireotide, those who completed therapy had a higher rate of B/C POPF than those who did not (40% vs 13.3%, p = 0.011).Conclusion: Preoperative variables can be used to prospectively identify patients at low risk for grade B/C POPF without pharmacologic prophylaxis.Among patients at high risk for POPF, pasireotide is poorly tolerated and does not appear to reduce the POPF rate.These data do not support the routine administration of perioperative pasireotide to patients undergoing pancreatectomy, even to a high-risk subgroup. 53

Maxwell, Daniel DO; Jajja, Mohammad Raheel MD; Sarmiento, Juan MD, FACS Author Information

Maxwell, Daniel DO; Jajja, Mohammad Raheel MD; Tariq, Marvi MD; Galindo, Rodolfo MD; Sarmiento, Juan MD, FACS Author Information

Background There is a growing literature of evidence that the use of acellular dermal matrices (ADMs) in abdominal wall reconstruction (AWR) for high-risk patients provides superior complication profiles when compared with standard synthetic mesh. Here we compare Fortiva, Strattice, and Alloderm ADMs in AWR. Methods In a prospectively maintained database, all patients undergoing AWR between January 2003 and November 2016 were reviewed. Hernia recurrence and surgical site occurrence (SSO) were our primary and secondary endpoints. Kaplan-Meier survival curves and logistic regression models were used to evaluate risks for hernia recurrence and SSO. Results A total of 229 patients underwent AWR with 1 of 3 ADMs. Median follow-up time was 20.9 months (1-60 months). Cumulative recurrence rates for each mesh were 6.9%, 11.2%, and 22.0% (P = 0.04), for Fortiva, Strattice, and Alloderm groups. Surgical site occurrence for each mesh was 56.9%, 49.0%, and 49.2%, respectively. Seroma was significantly lower in the Fortiva group (1.4%; P = 0.02). Independent risk factors hernia recurrence included body mass index of 30 kg/m(2) or higher and hypertension. Adjusted risk factors included oncologic resection for hernia recurrence (odds ratio, 5.3; confidence interval, 1.1-97.7; P = 0.11) and a wound class of contaminated or dirty/infected for SSO (odds ratio, 3.6; confidence interval, 1.0-16.6; P = 0.07). Conclusions Acellular dermal matrices provide a durable repair with low overall rate of recurrence and complications in AWR. The recurrence and complication profiles differ between brands. With proper patient selection and consideration, ADMs can be used confidently for a variety of indications and wound classifications.

BACKGROUND:Limited literature is available on the postoperative development of impaired glucose tolerance (IGT) and new-onset diabetes mellitus (NODM) following Distal Pancreatectomy (DP). We aimed to study the post-surgical clinical evolution of IGT/DM and its association with preoperative glycemic profiles of patients undergoing DP. METHODS:Pre- and postoperative glycemic laboratories were measured in patients undergoing DP by the senior author from 2007-2017. Multivariate risk factor analysis was performed to determine risk factors for new-onset IGT/DM after DP. Kaplan-Meier curves were constructed for development of NODM postoperatively. RESULTS:Of 216 included patients, n = 63, n = 68 and n = 85 were preoperatively diagnosed with no-diabetes (No-DM), pre-diabetes (Pre-DM), and diabetes (DM), respectively. At 2-year follow-up, n = 37, n = 80 and n = 99 were classified as No-DM, Pre-DM or DM, respectively. Pre-diabetics had a higher risk of developing postoperative dysglycemia (RR 2.230, 95% CI 1.732-2.870, p = 0.001). Preoperative OGTT>130, HbA1c >6.0, and chronic pancreatitis were risk factors for postoperative DM. CONCLUSION:40% of patients undergoing DP were unaware of their dysglycemic status (pre-DM or DM) pre-operatively. At 2-year follow-up, 36% non-diabetic and 57% pre-diabetic patients had developed NODM. Appropriate pre-operative diabetic assessment is warranted for all patients undergoing pancreatic resections.

Background: Distal pancreatectomy (DP) is a commonly utilized procedure by hepatopancreatobiliary surgeons for the management of pancreatic body and tail lesions. While associated with low mortality rates, the development of postoperative diabetes represents a challenge to both patient and physician. Limited literature is available regarding the development or reversibility of impaired glucose tolerance and/or type-II diabetes mellitus (IGT/DM) in this patient population. The primary aim was to define the post-surgical clinical evolution of IGT/DM and the association with the pre-operative glycemic profile of patients following DP. Methods: In this prospective study, pre and postoperative fasting and 2-hour postprandial oral glucose challenge testing (OGTT) laboratories including plasma glucose, glycated hemoglobin (A1c), insulin, and c-peptide were measured in consecutive non-diabetic patients undergoing DP by the senior author from 2007 to 2017. Benign, pre-malignant, and malignant indications were included. Differences in postprandial chemistries from fasting values are denoted with delta (Δ) prefix. American Diabetes Association definitions were used for glycemic classifications. Univariate and multivariate risk factor analysis was performed overall and for individual diabetic classes in determining the development of IGT/DM. Kaplan-Meier survival curves were constructed for onset to endocrine and exocrine dysfunctions, and patient survival. Results: Among 216 patients included (mean age 63 ± 13.7 years, 71.3% Caucasians, 56% female, mean BMI 28.5 m/kg2); 29.6% (n = 64), 31% (n = 67), 39.5% (n = 85) were pre-operatively diagnosed with no-diabetes (No-DM), with pre-diabetes (Pre-DM), or diabetes (DM), respectively. At 120-months of follow-up, 17 (13.5%), 86 (39.0%), and 115 (53.2%) patients were classified as No-DM, Pre-DM or DM, respectively. Based on preoperative laboratories, patients with Pre-DM had 85% increased risk of developing post-op dysglycemia (RR = 1.85, CI 1.126-3.041, p = 0.021), compared to those with no-DM, while 80% (68/85) patients with preoperative DM retained there IGT/DM status postoperatively. Patients developing post-operative IGT/DM demonstrated higher preoperative fasting glucose, OGTT-glucose, and A1c (all p ≤ 0.010), and a greater Δglucose compared to those classified as Pre-DM and No-DM, respectively (Δ64.5±38.0 vs Δ32.5±37.9 vs Δ4.33 ± 6.03; p 130, Δglucose >30, A1c >6.0, HOMA-IR ≥2, and surgical pathology of chronic pancreatitis as risk factors for developing IGT/DM. In patients with No-DM preoperatively, a HOMA-IR >1 was identified as a risk factor for development of postoperative IGT/DM after adjusting for multiple co-variates. For patients classified with DM preoperatively by fasting or OGTT chemistries but whom still retained an A1c ≤ 6.4, multivariate analysis identified an A1c ≤ 6.1 and the absence of a history of smoking as predictors of these diabetics returning to euglycemia postoperatively. There was no association between advancing age, BMI, race, or pancreatic ductal adenocarcinoma and post-operative IGT/DM development. Conclusion: Approximately 40% and 53% of patients undergoing distal pancreatectomy develop post-operative IGT and DM, respectively over 10-years. Higher pre-op fasting glucose, OGTT glucose, A1c, HOMA-IR, and chronic pancreatitis are significant risk factors for development of diabetes. Alternatively, diabetics diagnosed by fasting or OGTT glucose values but non-diabetic A1c values, a preoperative A1c ≤ 6.1 and absence of a history of smoking may indicate postoperative conversion to a euglycemic state. The development of new-onset IGT/DM or persistent diabetes diagnosis following distal pancreatectomy is multifactorial and assessment of pre-operative glycemic status is paramount when counseling patients on their risk of developing postoperative IGT/DM.

Aortic aneurysms occur concomitantly with malignant neoplasms in approximately 4% to 14% of patients. However, there is little information about the effects of malignant neoplasms, chemotherapeutics, and radiation treatment on the natural progression of abdominal aortic aneurysms (AAAs), thoracic aortic aneurysms, and thoracoabdominal aortic aneurysms. The aims of this study were to determine the effects that malignant neoplasms and their associated chemoradiation therapies impart on the progression and outcomes of aortic aneurysms. Patients diagnosed with malignant disease with concomitant AAAs or thoracic aortic aneurysms from 2005 to 2017 were reviewed. Inclusion criteria included complete neoadjuvant or adjuvant therapy documentation with multiplanar axial and coronal imaging or ultrasound before, during, and after therapy. Patients with repairs before malignant diagnosis and therapies were excluded. Multivariate risk factor and survival analysis were performed. Of 340 included aneurysms from 288 patients, 193 aortic aneurysms coexisted with malignant neoplasms necessitating chemoradiation (MAA), and 147 were aneurysms alone (AA). Average demographics were as follows: 75.4 ± 8.2 years old, white (60.8%), male (57.6%), hypertension (81.5%), history of smoking (77.9%), coronary atherosclerotic disease (62.6%), and AAA (73.8%). The most common malignant neoplasm was lung cancer (47.9%), with an initial chemotherapy regimen including a platinum-based alkylating agent and concurrent antimetabolite (67.5%). The overall median follow-up time and MAA group chemotherapy durations were 20.9 and 7.5 months, respectively. The AA group had a significantly older mean age of aneurysm discovery (78.0 vs 73.3 years; P < .001) and demonstrated overall increased comorbid states (hypertension, coronary artery disease, chronic kidney disease; P < .020), but with significantly decreased smoking and chronic obstructive pulmonary disease incidence (both P < .001) compared with the MAA group. Overall, the MAA group presented with smaller aneurysms (Fig 1; P = .044) and a slower median growth in the anteroposterior axis compared with the AA group (0.11 vs 0.17 cm/y; P = .070), which approached significance. Multivariate analysis demonstrated aneurysm size ≥4.0 cm on presentation as an independent predictor for requiring repair for any reason (odds ratio, 3.861; confidence interval, 2.261-6.591; P < .001; Fig 2). There were no associations with chemotherapy, radiation, duration of chemotherapeutic treatment, and growth rates or need for repair on analysis. There were no differences in complications between groups. Aortic aneurysms with concomitant malignant neoplasms necessitating chemotherapeutics are discovered earlier and at smaller sizes, and they exhibit decreased rates of growth compared with aortic aneurysms alone. Patients with coexisting malignant neoplasms do not appear to be at increased risk of aneurysm-associated adverse events compared with patients without malignant disease and should subscribe to standard institutional surveillance protocols.Fig 2Proportion of aneurysms not meeting repair criteria. AA, Aneurysm alone; MAA, aortic aneurysm with malignant neoplasm necessitating chemoradiation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Background: Minimally invasive surgery (MIS) for hepatic resections have been increasing in popularity over the last decade. While MIS approach has been demonstrated to lead to better perioperative outcomes, there are limited data on long term oncologic outcomes. Specifically, local recurrences and overall survival have not been reported extensively after minimally invasive hepatectomies (MIH) for malignant indications. Our group has previously published some of the largest single center series on minimally invasive liver resections from North America, we elected to review our database to fill this gap in literature specifically homing in on long-term oncologic outcomes. Methods: Data for all patients undergoing minimally invasive hepatectomy between January 2008 and December 2017 at Emory University were reviewed retrospectively. Inclusion criteria was hepatic resection for colorectal liver metastasis (CRCLM). We identified 175 patients who met our inclusion criteria. 131 patients underwent open hepatectomy (OH) and 44 underwent minimally invasive hepatectomy (MIH) with curative intent. Demographic data was collected, pathology reports and clinical notes were reviewed for data acquisition. Univariate and multivariate cox regression analysis of patient and pathologic factors were performed to determine factors affecting long term oncologic outcomes. Kaplan-Meir survival curves were constructed for survival and recurrence by operative approach. Results: The MIH patients had a higher BMI and higher ASA class preoperatively while primary tumor pathology was similar between the two groups (Figure A). In OH group 58 (44.3%) patients had a hemi-hepatectomy, 24 (18.3%) had sectionectomy and 49 (37.4%) had a segmentectomy or bisegmentectomy compared to 27 (61.4%), 6 (13.6%) and 11 (25%) for the MIH group. Perioperative outcomes were significantly better with MIH, OH had 48 (36.6%) ICU admissions compared to 9 (20.5%) for MIH (p = 0.034). Length of stay (LOS) was longer with OH (median 6 days) compared to MIH (median LOS 4 days) (p = 0.007). OH group had 8 (6.1%) microscopic R1 resections compared to 7 (15.9%) for MIH (p = 0.022). Both groups had equal proportion of recurrences (32 (72.7%) for MIH and 93 (71.0%) for OH) on follow-up (p = 0.99). Local recurrence as first event was observed in 60 (45.8%) of OH patients compared to 17 (38.6%) MIH patients (p = 0.614). Median time to first local recurrence was 12.4 months (0.3–61.4) for OH patients and 17.7 months (1.07–60.0) for MIH patients (p = 0.197). On multivariate analysis tumor <2mm from margin (OR 3.460 (1.1–11.2), p = 0.039) and male gender (OR 2.990 (1.1–7.9), p = 0.029) were the only factors predictive of developing local recurrences. Overall survival was no different between MIH (38 months ±3.4) and OH (43 months ±4.2) (p = 0.53) (Figure B). No difference in survival was observed for R0 (44.7 months ±5.7) compared to R1 (27 months ±1.8) resections in this cohort of patients (p = 0.291). On univariate analysis no factors predicted overall survival, however on multivariate cox regression analysis an elevated total bilirubin predicted lower survival (HR 3.333 (1.053–10.551) p = 0.041) in this dataset. Conclusion: We demonstrate comparable oncologic outcomes after MIH and OH for the most common malignancy requiring hepatic resection in North America. It is important to note that patients undergoing MIH in our cohort had worse ASA and BMIs, though overall perioperative outcomes were still better with MIH. Our data demonstrates no difference in overall survival when comparing OH to MIH (Figure 1B). While our data is limited in numbers we do find slightly higher rates of R1 resection. Though more significantly this difference in R1 resection had no bearing on overall recurrences, number or timing of distant recurrences, or on overall survival. The drastically improved perioperative outcomes combined with comparable oncologic outcomes should continue to drive hepatobiliary surgeons to undertake MIS approaches to oncologic liver resections.

BACKGROUND: Limited literature is available on the development of impaired glucose tolerance and diabetes mellitus after pancreaticoduodenectomy. The primary aim was to define the diabetic phenotype and correlate preoperative glycemic laboratory results to new-onset diabetes after pancreaticoduodenectomy. STUDY DESIGN: In this prospective study, perioperative fasting and postprandial (oral glucose tolerance test) plasma glucose, glycated hemoglobin, insulin, and c-peptide were measured in consecutive patients undergoing pancreaticoduodenectomy by the senior author from 2006 to 2017. American Diabetes Association definitions were used for glycemic classifications. Multivariate risk factor analysis was performed. RESULTS: Of 774 identified patients, 371 diabetics were excluded and 403 patients were included: 167 and 236 were preoperatively classified as nondiabetic and prediabetic, respectively. The incidence rates of diabetes at 120 months post pancreaticoduodenectomy were 9.0%(nondiabetics), 22.0%(pre-diabetics), and 16.6%(overall). Patients in whom diabetes developed demonstrated a 3-fold larger difference between oral glucose tolerance test and fasting glucose (Delta), and 2-fold larger Delta insulin and Delta c-peptide values. Tiered multivariate analysis identified glycated hemoglobin > 5.4% with a relative risk (RR) of 2.944 (p = 0.047) as an independent predictor of impaired glucose tolerance and diabetes mellitus. Analysis of patients stratified by preoperative classification identified fasting glucose > 95 mg/dL (nondiabetics, RR 1.925; p = 0.002), and glycated hemoglobin >= 5.4% (prediabetics, RR 3.125; p = 0.040) as independent risk factors for diabetes. Compared with nondiabetics, prediabetics classified by any laboratory results demonstrated an RR of 2.471 (p = 0.001) for diabetes developing postoperatively. There was no association between primary pathology, advancing age, or BMI and increased risk of diabetes development. CONCLUSIONS: Diabetes will develop after pancreaticoduodenectomy in approximately 16.6% of patients. A preoperative glycated hemoglobin > 5.4% independently predicts new-onset diabetes. Pre- and postoperative endocrine analysis remains paramount for proper patient risk stratification. (C) 2019 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.