Background: This study investigates textbook oncologic outcomes (TOO), a measurement operationally defined to produce a holistic measure of surgical success, with respect to patients diagnosed with pancreatic adenocarcinoma undergoing distal (left) pancreatectomy for pancreatic adenocarcinoma. This study aims to identify factors associated with achieving TOO, emphasizing the role of hospital type. Methods: The NCDB (2010-2022) was queried for patients with clinical stage I-III pancreatic adenocarcinoma. Inclusion criteria consisted of patients > 18 who underwent curative partial or total pancreatectomy. The primary outcome was the achievement of TOO-operationally defined as R0 resection, ≥12 lymph nodes examined, no prolonged hospital stay, absence of 30-day mortality, and no readmissions. Logistic regression analyses were conducted to identify predictors of TOO. Results: Analysis of 11,194 patients showed that 38.9% achieved TOO. Achievement of TOO was associated with a median increase in one year in overall survival. Factors associated with TOO achievements in the adjusted model include female sex, private insurance, a lower Charlson/Deyo score, minimally invasive surgery (MIS), and high-volume centers. Notably, MIS emerged as a significant factor associated with 26% higher TOO (OR 1.26, 95% CI: 1.14-1.40) while treatment at high-volume hospitals was associated with 28-112% increased TOO (OR 1.28, 95% CI: 1.08-1.54 for Q3 volume and OR 2.12, 95% CI: 1.76-2.55 for Q4 volume). Conclusions: Achieving TOO is significantly influenced by patient demographics, clinical characteristics, and notably, the case volume of the treatment facility. These findings underscore the importance of considering centers experienced in surgical planning and patient counseling to optimize outcomes in distal pancreatectomies.

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive human tumor that is typically diagnosed at a later stage when surgery is not possible. Case Presentation: We report the case of a 62-year-old woman who presented to the emergency department with abdominal pain. Computed tomography (CT) revealed a solitary hepatic lesion and a pancreatic body lesion. The pancreatic body lesion was biopsied endoscopically, and a tissue diagnosis was obtained to confirm the diagnosis of PDAC. She was then treated with 12 cycles of FOLFIRINOX with stable disease on CT. Due to the history of a hepatic lesion, she received 11 cycles of gemcitabine/Abraxane and a combination of a MEK inhibitor, Mekinist, and a BRAF inhibitor, BRAFTOVI. Subsequently, the patient underwent a liver biopsy. The biopsy result was negative, and the tumor was deemed resectable. The patient underwent a distal pancreatectomy. Surgical pathology demonstrated a 1.1-cm low-grade papillary mucinous neoplasm with negative margins and lymph nodes, staged T0N0. Adjuvant chemotherapy was not administered. Conclusion: To our knowledge, this is the first report of a patient with metastatic pancreatic adenocarcinoma who received prolonged IV and oral chemotherapy. At the time of the operation, the pathological stage was T0N0. The patient has recently been seen 9 months after surgery with no evidence cancer recurrence. Additionally, ctDNA remains negative.

e16330 Background: Pancreatic cancer is the only human cancer in which most of the tumors are KRAS mutated. A majority of the mutations occur in codon 12. Mutations percentages are as follows: G12D (50%), G12V (35%) and G12R(12%). We are reporting on a pilot study in patients with advanced pancreatic cancer who have failed, or have become resistant to FOLFIRINOX. Thereafter the patients were placed on Nab-paclitaxel and Gemcitabine in combination with oral Cobimetinib and encorafenib. Methods: Patients with advanced pancreatic cancers are typically offered modified FOLFIRINOX followed by Nab-paclitaxel and Gemcitabine. After obtaining a written informed consent, we conducted a single arm study of patients with pathologic proven unresectable metastatic pancreatic cancer. Patients who had failed FOLFRINOX were placed on a modified regimen of Gemcitabine (1000mg/m2) and Nab-paclitaxel (125 mg/M2) on days 1 and 15 every 28-day cycle. Oral medications, Cobimetinib 20 mg bid and encorafenib of 150 mg bid were given. The oral chemotherapies were administered weekdays only during the 28-day cycle. The primary end point was to determine the response rate from the time the patients were placed on Nab-paclitaxel and Gemcitabine and the oral medication. The secondary endpoint was to assess the overall survivorship from the beginning of the therapy, and overall toxicities of the combination therapy. Twelve patients with advanced metastatic pancreatic cancer were enrolled on this pilot study. Six patients were male, and the median age was 67 years. Liver metastases were present in eight patients. Treatment was continued as long as there was no disease progression. CBC, CMP, CA19-9 was performed every other week. CT and PET scan was ordered every eight weeks. Results: Overall follow up is from 5 to 19 months (median 14 months). Segmental median survival from the start of oral therapy in conjunction with Nab-paclitaxel and Gemcitabine is 5 months (2-9 months). As from now,all patients are alive and 10 of 12 patients are on therapy. One patient who achieved pathologic response in the liver was deemed operable, and pathologically the distal pancreatectomy demonstrated NO disease. The other patient has progressed and is not on treatment. Grade 3 non-hematological toxicities included nausea, vomiting and fatigue in 3 of 12 patients. Hematological toxicities included neutropenia and neutrophil support was needed in 6 out of 12 patients. Median survivorship has NOT been reached. In this small study, we have observed a rapid and dramatic reduction in tumor volume. Conclusions: The combination of MEK and BRAF inhibitors with chemotherapy may be potentially active in pancreatic tumors (G12D and G12V). Based on the data presented, Nab-paclitaxel and Gemcitabine in combination with oral Cobimetinib and encorafenib needs to be further explored in a larger cohort of patients.

This case report describes a 73 -year -old male with pancreatic adenocarcinoma expressing a KRAS G12R mutational variant among KRAS-mutated PDACs. The patient demonstrated a response to treatment with a combination of gemcitabine, nab-paclitaxel, and the MEK inhibitor, Cobimetinib. Imaging revealed resolution of abdominal distention and the CA 19-9 laboratory marker regressed into a normal range. Molecular profiling revealed distinct differences between G12R PDAC tumors, including lower PD -L1 expression, immune infiltration, and metabolic markers in G12R tumors, suggesting reduced immunogenicity. However, the G12R population showed the highest overall survival among codon 12 variants. This case highlights the potential vulnerability of G12R PDAC to targeted MEK inhibition alongside standard chemotherapy, leading to clinical benefits. Further investigation into the unique biology of G12R tumors may uncover novel therapeutic strategies.

OBJECTIVE: Critically ill and injured patients are rou-tinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Envi-ronment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty -spe-cific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, super-vised handoffs by trauma attendings, and surgical educa-tion. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed.RESULTS: The study task was completed by 147 post-graduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees uti-lized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance sur-gical knowledge. As TC continue to be a focus of certify-ing bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education. ( J Surg Ed 80:1687-1692. (c) 2023 Association of Program Direc-tors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background Complex surgeries such as pancreaticoduodenectomies (PD) have been shown to have better outcomes when performed at high-volume centers (HVCs) compared to low-volume centers (LVCs). Few studies have compared these factors on a national level. The purpose of this study was to analyze nationwide outcomes for patients undergoing PD across hospital centers with different surgical volumes. Methods The Nationwide Readmissions Database (2010-2014) was queried for all patients who underwent open PD for pancreatic carcinoma. High-volume centers were defined as hospitals where 20 or more PDs were performed per year. Sociodemographic factors, readmission rates, and perioperative outcomes were compared before and after propensity score-matched analysis (PSMA) for 76 covariates including demographics, hospital factors, comorbidities, and additional diagnoses. Results were weighted for national estimates. Results A total of 19,810 patients were identified with age 66 ± 11 years. There were 6,840 (35%) cases performed at LVCs, and 12,970 (65%) at HVCs. Patient comorbidities were greater in the LVC cohort, and more PDs were performed at teaching hospitals in the HVC cohort. These discrepancies were controlled for with PSMA. Length of stay (LOS), mortality, invasive procedures, and perioperative complications were greater in LVCs when compared to HVCs before and after PSMA. Additionally, readmission rates at one year (38% vs 34%, P < .001) and readmission complications were greater in the LVC cohort. Conclusions Pancreaticoduodenectomy is more commonly performed at HVCs, which is associated with less complications and improved outcomes compared to LVCs.

Pancreatic adenocarcinoma has increasingly become one of the leading causes of death in western countries. However, presentation with colonic metastases is far less frequently reported in the literature and may be misdiagnosed as colonic adenocarcinoma. This is a case of a female patient with metastatic pancreatic adenocarcinoma that presented with a sigmoid obstruction.

Kronenfeld, Joshua P. MD; Collier, Amber L. MD; Khalafi, Shayan MD; Sleeman, Danny MD, FACS; Franceschi, Dido MD, FACS; Livingstone, Alan S. MD, FACS; Thorson, Chad M. MD, FACS Author Information

BACKGROUND: Professionalism is a core competency that is difficult to assess. We examined the incidence of publication inaccuracies in Electronic Residency Application Service applications to our training program as potential indicators of unprofessional behavior. STUDY DESIGN: We reviewed all 2019-2020 National Resident Matching Program applicants being considered for interview. Applicant demographic characteristics recorded included standard-ized examination scores, gender, medical school, and medical school ranking (2019 US News & World Report). Publication verification by a medical librarian was performed for peer-reviewed journal articles/abstracts, peer-reviewed book chapters, and peer-reviewed online publications. Inaccuracies were classified as "nonserious" (eg incorrect author order without author rank promotion) or "serious" (eg miscategorization, non-peer-reviewed journal, incorrect author order with author rank promotion, nonauthorship of cited exist-ing publication, and unverifiable publication). Multivariate logistic regression analysis was performed for demographic characteristics to identify predictors of overall inaccuracy and serious inaccuracy. RESULTS: Of 319 applicants, 48 (15%) had a total of 98 inaccuracies; after removing nonserious inac-curacies, 37 (12%) with serious inaccuracies remained. Seven publications were reported in predatory open access journals. In the regression model, none of the variables (US vs non -US medical school, gender, or medical school ranking) were significantly associated with overall inaccuracy or serious inaccuracy. CONCLUSIONS: One in 8 applicants (12%) interviewing at a general surgery residency program were found to have a serious inaccuracy in publication reporting on their Electronic Residency Application Service application. These inaccuracies might represent inattention to detail or professional-ism transgressions. (C) 2021 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

4642 Background: he KRAS proto-oncogene is involved in the RAS/MAPK pathway. Various G12X mutations have been examined with the most common mutations being G12D (40%), G12V (30%), and G12R (15-20%) in pancreatic cancer patients. Throughout the course of studying the G12X mutations, we have observed that not all KRAS mutations are equal. Preclinical data shows G12R is impaired in pI3Kα signaling, as compared to KRAS G12V/D. This mechanism is important in PDAC as it allows tumor growth to be sustained. In preclinical studies, PDX derived tumors were transplanted in mice and were treated with a MEK inhibitor plus chemotherapy, which demonstrated a greater tumor regression than either agent alone. Therefore, we have decided to treat patients with Gemcitabine alongside a 2nd generation MEK inhibitor (Cobimetinib). Methods: In our single arm study, 13 KRAS mutated pancreatic patients (KRAS G12D, G12V, and G12R) received the combination of Cobimetinib 20mg BID weekly for three weeks alongside Gemcitabine at 1000mg/m2 weekly, followed by one week of rest. The above constitutes one cycle. Results: Patients were divided into two groups; Group 1 consists of seven patients that were KRAS G12D/G12V mutated, and Group 2 included six KRAS G12R mutated patients. In Group 1, seven patients on treatment progressed and died within two months on the study. In Group 2, one achieved PR and others stable disease. Median progression-free survival was 6.0 months (95% CI 3-9.3 months) and median OS has not been reached. All patients are alive at 8 months. Common adverse reactions include rash, fatigue, nausea, and vomiting. Cancer antigen 19-9 decreased in ≥ 50 of all patients in the latter group. We would like to report our positive study to the society. Moreover, we intend to confirm the study in a larger patient cohort. Conclusions: Pancreatic cancer patients that demonstrate KRAS G12R mutations are treatable with a new active combination chemotherapy.

Dante Yeh, Daniel MD, MHPE, FACS, FCCM; Daniel Pust, Gerd MD, FACS; Sleeman, Danny MD, FACS; Lineberry, Matthew PhD; Yudkowsky, Rachel MD, MHPE; Soo Park, Yoon PhD Author Information

Background: In the era of subspecialization and duty-hour restrictions, many General Surgery residents desire additional training in their future subspecialty areas. This study examines the relationship between case distributions performed by General Surgery residents and their chosen future subspecialty. Methods: A retrospective review of Accreditation Council for Graduate Medical Education case logs of 101 graduated General Surgery residents at a single academic institution (2002-2018) was performed. The total number of operative cases performed during General Surgery residency overall and in Accreditation Council for Graduate Medical Education-defined categories were compared between residents with differing areas of future subspecialization. Results: Residents pursuing surgical fellowships in Endocrine, Cardiothoracic, Vascular, and Trauma/Critical Care Surgery logged respectively more endocrine (63 [11] vs 32 [13]; P < .001), thoracic (61 [15] vs 41 [13]; P < .001), vascular (225 [38] vs 162 [38]; P < .001), and operative trauma (83 [29] vs 71 [25]; P = .045) cases, compared with program average. Residents pursuing General Surgery (no fellowship) performed significantly more endoscopies (131 [47] vs 105 [28]; P = .029) than peers. Residents pursuing Breast, Oncology, Colorectal, and Pediatric Surgery fellowships performed numerically (non-significantly) more breast (94 [16] vs 78 [20]; P = .180), liver/pancreas (39 [3.1] vs 33 [8.0]; P = .173), large intestinal (132 [30] vs 125 [24]; P = .507), and pediatric (173 [27] vs 155 [37]; P = .832) cases, respectively, compared with peers. The majority of these additional cases were performed in postgraduate years 3 to 5. Conclusion: In this single-institution study, many General Surgery residents perform more cases than peers in respective areas of future subspecialization. This may reflect residents at the reporting institution, and similar large, university-based programs seeking focused training in preparation for fellowship while still meeting case-volume minimums in all Accreditation Council for Graduate Medical Education-defined categories. (C) 2019 Elsevier Inc. All rights reserved.

Background: Preoperative chemotherapy in pancreatic adenocarcinoma (PDAC) provides early treatment of micrometastatic disease, reduces positive surgical margin rates, identifies patients with rapidly progressive disease and assures that surgical candidates will receive chemotherapy even in case of postoperative complications.However, limited data is available on the impact of neoadjuvant chemotherapy on very early PDAC (Stage IA).Material and Methods: Pancreaticoduodenectomy patients for PDAC between 2010 and 2014 were identified in the National Cancer Data Base (NCDB).Early-stage patients (IA-IB) with complete oncologic and clinical information and more than 30-day survival were included.The effect of neoadjuvant therapy on margin status was assessed with binary logistic regression.The effect of therapy sequencing and comparison of preoperative (NCT), postoperative (ACT), perioperative (pre and post-OP, PCT) chemotherapy and surgery only (SURG) was analyzed using Cox regression, correcting for age, sex, grade, margin status, hospital volume and hospital setting (community, academic center, NCI designated cancer center).Results: Of 4,231 patients, 602 (14.2%) were Stage IA, and 3629 (85.8%)IB.The rate of NCT was only 8.1%.Rate of margin positivity was 19.1% for the entire cohort and lower for NCT (12.3 vs 19.7%).After correcting for confounders, the risk of a positive margin was lower in NCT (OR 0.703, 95% CI 0.500-0.988,p=0.042).Cox regression showed a significant overall survival advantage for NCT (p=0.003,HR 0.799), ACT (p=0.001,HR 0.749) and PCT (p<0.001,HR 0.706) compared to SURG.There was no difference in survival between chemotherapy groups with a trend towards optimal survival for PCT.Conclusion: Neoadjuvant Chemotherapy results in lower risk of a positive surgical margin and improved survival compared to surgery alone even in stage IA PDAC.These results suggest that PCT should be strongly considered in all patients with resectable PDAC, including very early PDAC cases.

Introduction: Postoperative pancreatic fistula (POPF) is a major complication after pancreaticoduodenectomy (PD).The aim of this study was to assess the value of C-reactive protein (CRP) preoperatively and postoperatively as early predictor of POPF.Method: 51 patients undergoing PD for various hepatobiliary and pancreatic diseases from November 2016 to November 2018 were included.Clinical, pathological, biochemical and intraoperative characteristics were recorded along with preoperative, post operative day 1 (POD1) and post operative day 3 (POD3) CRP values.Patients developing POPF were analyzed and were grouped into 2 categories -clinically relevant (Grade B+C) and clinically non relevant POPF (No POPF+Grade A/ Biochemical leak) according to the International Study Group on Pancreatic Surgery classification (2016).High CRP values were classified using cut off values based on ROC curve analysis.Result: Out of the 51 patients, 13 developed clinically relevant POPF.POD1 and POD3 CRP values were found to be significantly correlated with clinically relevant POPF (p=0.025 and P=0.006, respectively).The development of clinically relevant POPFs could be predicted with 69.2% sensitivity and 60.5% specificity by POD1 CRP cut off value of 106.5 and with 76.9% sensitivity and 71.1% specificity by POD3 CRP cut off level of 199.5.Conclusion: POD1 and POD3 CRP values can be used as early predictors of clinically relevant POPF after PD.

Hepatocellular carcinoma (HCC) has a recurrence rate of up to 70% in 5 years after resection, detrimentally lowering survival. The role of adjuvant therapy remains controversial; therefore, the aim of this study was to evaluate the disease‐free and overall survival of patients with HCC, not candidates for transplantation, undergoing resection and adjuvant hepatic artery infusion therapy vs resection alone. Our meta‐analysis showed that adjuvant HAIC improves overall and disease‐free survival after resection, especially in tumors ≥7 cm.