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Americas Hepato-Pancreato-Biliary Association (AHPBA): Annual Meeting
No postop phosphorus dip worrisome for hepatectomy patients
MIAMI BEACH – A failure to develop hypophosphatemia during the first few days after major hepatectomy was associated with up to a threefold increase in the risk of major complications, hepatic insufficiency, and 30-day mortality.
Contrary to a widely held belief, hypophosphatemia may not be a problem requiring treatment, but rather a normal physiologic response to liver resection – a sign that hepatocytes are working hard to regenerate and recover their function, Dr. Malcolm Squires said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The process of liver regeneration is metabolically demanding," said Dr. Squires of Emory University, Atlanta. "Immediately after hepatectomy, the [adenosine triphosphate] content decreases by 35%. The level starts to recover by day 6, to about preoperative levels by day 14. But during that process, the hepatocytes are rapidly consuming ATP; there is a significant concurrent phosphate uptake by the liver remnant, and we see that decrease in serum phosphorus."
These are all signs of normal liver remnant recovery, Dr. Squires said. Consequently, the failure to follow this pathway suggests that the remnant is not on a good recovery trajectory, but instead, a path that could lead to big problems.
To examine this idea, he and his colleagues looked at 719 patients who had undergone major hepatectomy from 2000 to 2012 and who had serum phosphorus evaluated after surgery.
Measures included daily phosphorus levels for the first week after surgery, as well as the day of the phosphorus nadir. Mean age of the patients was 57 years. The most common type of resection was a right hepatectomy (39%), followed by a left (23%), extended right (20%), and extended left (6%). Ten percent of patients had a nonanatomic resection, and 20% a concurrent bile duct resection.
The most common pathology was metastatic colorectal cancer (32%), followed by cholangiocarcinoma (12%), hepatocellular carcinoma (9%), and metastatic neuroendocrine tumor (5%). Other pathologies made up the remainder.
Most patients (69%) got phosphorus repletion in the first 72 hours after surgery, although this intervention was not protocol driven, Dr. Squires noted.
Postoperative hepatic insufficiency developed in 63 patients (9%). About a fourth (169) had major complications. Mortality was 4% within 30 days and 5% within 90 days.
The median preoperative serum phosphorus level was 3.7 mg/dL. This fell precipitously to a median nadir of 2.4 mg/dL (the lower limit of normal), which occurred on postoperative day 2 or 3 for the majority of patients. Recovery was linear, with a near-complete postoperative recovery by day 14. Patients followed the same trajectory regardless of the type of hepatectomy.
The researchers dichotomized the patients into those with a postoperative day 2 phosphorus of 2.4 mg/dL or higher (72%), or below 2.4 mg/dL (28%).
Patients with the higher levels were significantly more likely to develop hepatic insufficiency (12% vs. 7%) and major complications (27% vs. 20%), and to die within 30 days (4% vs. 2%) and 90 days (8% vs. 4%).
A multivariate analysis found that phosphorus of more than 2.4 mg/dL increased the risk of hepatic insufficiency by 78% and major complications by 60%. It nearly tripled the risk of 30-day mortality (HR 2.7) and more than doubled the risk of 90-day mortality (HR 2.5).
The team also looked at the timing of phosphorus nadir. Most patients (80%) achieved this by postoperative day 3, so the researchers divided the group into those who had that level within 3 days and those who had it later. Patients with the delayed nadir were twice as likely to have hepatic insufficiency and major complications, and to die within 30 days. The trend was to increased death within 90 days as well, but Dr. Squires said the difference was not statistically significant.
Early postoperative phosphorus administration did not affect these findings, he added.
Dr. Squires reported having no financial disclosures.
MIAMI BEACH – A failure to develop hypophosphatemia during the first few days after major hepatectomy was associated with up to a threefold increase in the risk of major complications, hepatic insufficiency, and 30-day mortality.
Contrary to a widely held belief, hypophosphatemia may not be a problem requiring treatment, but rather a normal physiologic response to liver resection – a sign that hepatocytes are working hard to regenerate and recover their function, Dr. Malcolm Squires said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The process of liver regeneration is metabolically demanding," said Dr. Squires of Emory University, Atlanta. "Immediately after hepatectomy, the [adenosine triphosphate] content decreases by 35%. The level starts to recover by day 6, to about preoperative levels by day 14. But during that process, the hepatocytes are rapidly consuming ATP; there is a significant concurrent phosphate uptake by the liver remnant, and we see that decrease in serum phosphorus."
These are all signs of normal liver remnant recovery, Dr. Squires said. Consequently, the failure to follow this pathway suggests that the remnant is not on a good recovery trajectory, but instead, a path that could lead to big problems.
To examine this idea, he and his colleagues looked at 719 patients who had undergone major hepatectomy from 2000 to 2012 and who had serum phosphorus evaluated after surgery.
Measures included daily phosphorus levels for the first week after surgery, as well as the day of the phosphorus nadir. Mean age of the patients was 57 years. The most common type of resection was a right hepatectomy (39%), followed by a left (23%), extended right (20%), and extended left (6%). Ten percent of patients had a nonanatomic resection, and 20% a concurrent bile duct resection.
The most common pathology was metastatic colorectal cancer (32%), followed by cholangiocarcinoma (12%), hepatocellular carcinoma (9%), and metastatic neuroendocrine tumor (5%). Other pathologies made up the remainder.
Most patients (69%) got phosphorus repletion in the first 72 hours after surgery, although this intervention was not protocol driven, Dr. Squires noted.
Postoperative hepatic insufficiency developed in 63 patients (9%). About a fourth (169) had major complications. Mortality was 4% within 30 days and 5% within 90 days.
The median preoperative serum phosphorus level was 3.7 mg/dL. This fell precipitously to a median nadir of 2.4 mg/dL (the lower limit of normal), which occurred on postoperative day 2 or 3 for the majority of patients. Recovery was linear, with a near-complete postoperative recovery by day 14. Patients followed the same trajectory regardless of the type of hepatectomy.
The researchers dichotomized the patients into those with a postoperative day 2 phosphorus of 2.4 mg/dL or higher (72%), or below 2.4 mg/dL (28%).
Patients with the higher levels were significantly more likely to develop hepatic insufficiency (12% vs. 7%) and major complications (27% vs. 20%), and to die within 30 days (4% vs. 2%) and 90 days (8% vs. 4%).
A multivariate analysis found that phosphorus of more than 2.4 mg/dL increased the risk of hepatic insufficiency by 78% and major complications by 60%. It nearly tripled the risk of 30-day mortality (HR 2.7) and more than doubled the risk of 90-day mortality (HR 2.5).
The team also looked at the timing of phosphorus nadir. Most patients (80%) achieved this by postoperative day 3, so the researchers divided the group into those who had that level within 3 days and those who had it later. Patients with the delayed nadir were twice as likely to have hepatic insufficiency and major complications, and to die within 30 days. The trend was to increased death within 90 days as well, but Dr. Squires said the difference was not statistically significant.
Early postoperative phosphorus administration did not affect these findings, he added.
Dr. Squires reported having no financial disclosures.
MIAMI BEACH – A failure to develop hypophosphatemia during the first few days after major hepatectomy was associated with up to a threefold increase in the risk of major complications, hepatic insufficiency, and 30-day mortality.
Contrary to a widely held belief, hypophosphatemia may not be a problem requiring treatment, but rather a normal physiologic response to liver resection – a sign that hepatocytes are working hard to regenerate and recover their function, Dr. Malcolm Squires said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The process of liver regeneration is metabolically demanding," said Dr. Squires of Emory University, Atlanta. "Immediately after hepatectomy, the [adenosine triphosphate] content decreases by 35%. The level starts to recover by day 6, to about preoperative levels by day 14. But during that process, the hepatocytes are rapidly consuming ATP; there is a significant concurrent phosphate uptake by the liver remnant, and we see that decrease in serum phosphorus."
These are all signs of normal liver remnant recovery, Dr. Squires said. Consequently, the failure to follow this pathway suggests that the remnant is not on a good recovery trajectory, but instead, a path that could lead to big problems.
To examine this idea, he and his colleagues looked at 719 patients who had undergone major hepatectomy from 2000 to 2012 and who had serum phosphorus evaluated after surgery.
Measures included daily phosphorus levels for the first week after surgery, as well as the day of the phosphorus nadir. Mean age of the patients was 57 years. The most common type of resection was a right hepatectomy (39%), followed by a left (23%), extended right (20%), and extended left (6%). Ten percent of patients had a nonanatomic resection, and 20% a concurrent bile duct resection.
The most common pathology was metastatic colorectal cancer (32%), followed by cholangiocarcinoma (12%), hepatocellular carcinoma (9%), and metastatic neuroendocrine tumor (5%). Other pathologies made up the remainder.
Most patients (69%) got phosphorus repletion in the first 72 hours after surgery, although this intervention was not protocol driven, Dr. Squires noted.
Postoperative hepatic insufficiency developed in 63 patients (9%). About a fourth (169) had major complications. Mortality was 4% within 30 days and 5% within 90 days.
The median preoperative serum phosphorus level was 3.7 mg/dL. This fell precipitously to a median nadir of 2.4 mg/dL (the lower limit of normal), which occurred on postoperative day 2 or 3 for the majority of patients. Recovery was linear, with a near-complete postoperative recovery by day 14. Patients followed the same trajectory regardless of the type of hepatectomy.
The researchers dichotomized the patients into those with a postoperative day 2 phosphorus of 2.4 mg/dL or higher (72%), or below 2.4 mg/dL (28%).
Patients with the higher levels were significantly more likely to develop hepatic insufficiency (12% vs. 7%) and major complications (27% vs. 20%), and to die within 30 days (4% vs. 2%) and 90 days (8% vs. 4%).
A multivariate analysis found that phosphorus of more than 2.4 mg/dL increased the risk of hepatic insufficiency by 78% and major complications by 60%. It nearly tripled the risk of 30-day mortality (HR 2.7) and more than doubled the risk of 90-day mortality (HR 2.5).
The team also looked at the timing of phosphorus nadir. Most patients (80%) achieved this by postoperative day 3, so the researchers divided the group into those who had that level within 3 days and those who had it later. Patients with the delayed nadir were twice as likely to have hepatic insufficiency and major complications, and to die within 30 days. The trend was to increased death within 90 days as well, but Dr. Squires said the difference was not statistically significant.
Early postoperative phosphorus administration did not affect these findings, he added.
Dr. Squires reported having no financial disclosures.
AT AHPBA 2014
Major finding: A posthepatectomy phosphorus of more than 2.4 mg/dL increased the risk of hepatic insufficiency by 78% and nearly tripled the risk of 30- and 90-day mortality
Data source: A retrospective study of 719 patients.
Disclosures: Dr. Malcolm Squires had no financial disclosures.
Simultaneous colorectal/liver mets resection saves time and money
MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."
Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."
Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."
Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
AT AHPBA 2014
Major finding: Compared to a staged surgery, simultaneously resecting colorectal cancer and liver metastases saved about 6 days of hospital stay, with a 55% cost savings in total hospital charges.
Data source: A retrospective study of 224 patients.
Disclosures: Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
Fluorescent cholangiography as effective as standard, but cheaper
MIAMI BEACH – Intraoperative fluorescent cholangiography is just as effective as traditional cholangiography but costs hundreds of dollars less and is significantly faster to perform.
It’s also a great teaching tool, Dr. Fernando Dip said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. In just one session, all of the third- and fourth-year surgical residents were able to correctly identify 100% of the biliary structures.
"It appears to be an additional tool for the laparoscopic surgeon," said Dr. Dip, chief of surgical research at the Cleveland Clinic in Weston, Fla. "It’s quick, inexpensive, real-time, there are no adverse events, and it’s an inciscionless procedure."
Common bile duct injury is the most frequent injury seen in laparoscopic cholecystectomy, he said, and although the overall incidence is low, the number of injuries each year is not inconsiderable, since more than 750,000 laparoscopic cholecystectomies are performed in the United States annually.
"Only 3% of these injuries are due to problems with technical skill," Dr. Dip said. "The other 97% are problems of visual perception – illusions of where the ducts are."
Intraoperative cholangiography helps surgeons visualize this anatomy, but its true usefulness is somewhat controversial. Dr. Dip cited a recent study of almost 93,000 patients – 40% of whom underwent the procedure. It showed that intraoperative cholangiography is not effective as a preventive strategy against common duct injury during cholecystectomy.
Intraoperative fluorescent cholangiography is sometimes used to identify biliary anatomy in extrahepatic surgery. Dr. Dip and his colleagues examined its usefulness in 45 patients undergoing laparoscopic cholecystectomy. Senior residents performed all of the procedures under the supervision of experienced laparoscopic surgeons. All patients underwent the investigational procedure, followed by standard cholangiography.
The patients had a mean age of 49 years and were evenly split between men and women. The mean body mass index was 28 kg/m2. Surgical indications were cholelithiasis (22), acute cholecystitis (17), chronic cholecystitis (5), and polyp (1). About 1 hour before surgery, patients received an infusion of indocyanine green 0.5 mg/kg. During the laparoscopic exploration, surgeons used near-infrared light to make the marker fluoresce as it was excreted by the liver.
In a picture review before surgery, all residents correctly identified 100% of the anatomic structures visualized by the fluorescent procedure. They were able to complete the fluorescent procedure in all of the patients. The completion rate for cholangiography was 93% (42 patients). In three patients, cholangiography failed because the cystic duct could not be cannulated.
The residents identified the cystic duct in 44 of the patients (98%), the common bile duct in 36 (80%), and the common hepatic ducts in 27 (60%). Neither technique identified any aberrant or accessory ducts.
Because fluorescent cholangiography is a real-time surgical procedure, it allowed checking of the transection and resection of the gallbladder pedicle before smooth dissection in all of the patients.
The procedure was significantly quicker than standard cholangiography (0.71 minutes vs. 7.15 minutes). It was also significantly cheaper, costing a mean of $14 vs. $778. There were no adverse surgical events, and no adverse reactions to the dye or at the infusion site, Dr. Dip said. Additionally, he noted, fluorescent cholangiography does not rely on x-rays, and so spared the patients any radiation exposure.
He added that the Cleveland Clinic, in conjunction with the University of Tokyo, will soon launch a randomized clinical trial comparing the two methods. An ongoing trial from another institution is evaluating fluorescent cholangiography compared with critical view technique in visualizing anatomy during laparoscopic cholecystectomy. It was set to wrap up in January, but according to the trial record on clinicaltrials.gov, is still recruiting patients.
Dr. Dip had no financial disclosures.
On Twitter @alz_gal
MIAMI BEACH – Intraoperative fluorescent cholangiography is just as effective as traditional cholangiography but costs hundreds of dollars less and is significantly faster to perform.
It’s also a great teaching tool, Dr. Fernando Dip said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. In just one session, all of the third- and fourth-year surgical residents were able to correctly identify 100% of the biliary structures.
"It appears to be an additional tool for the laparoscopic surgeon," said Dr. Dip, chief of surgical research at the Cleveland Clinic in Weston, Fla. "It’s quick, inexpensive, real-time, there are no adverse events, and it’s an inciscionless procedure."
Common bile duct injury is the most frequent injury seen in laparoscopic cholecystectomy, he said, and although the overall incidence is low, the number of injuries each year is not inconsiderable, since more than 750,000 laparoscopic cholecystectomies are performed in the United States annually.
"Only 3% of these injuries are due to problems with technical skill," Dr. Dip said. "The other 97% are problems of visual perception – illusions of where the ducts are."
Intraoperative cholangiography helps surgeons visualize this anatomy, but its true usefulness is somewhat controversial. Dr. Dip cited a recent study of almost 93,000 patients – 40% of whom underwent the procedure. It showed that intraoperative cholangiography is not effective as a preventive strategy against common duct injury during cholecystectomy.
Intraoperative fluorescent cholangiography is sometimes used to identify biliary anatomy in extrahepatic surgery. Dr. Dip and his colleagues examined its usefulness in 45 patients undergoing laparoscopic cholecystectomy. Senior residents performed all of the procedures under the supervision of experienced laparoscopic surgeons. All patients underwent the investigational procedure, followed by standard cholangiography.
The patients had a mean age of 49 years and were evenly split between men and women. The mean body mass index was 28 kg/m2. Surgical indications were cholelithiasis (22), acute cholecystitis (17), chronic cholecystitis (5), and polyp (1). About 1 hour before surgery, patients received an infusion of indocyanine green 0.5 mg/kg. During the laparoscopic exploration, surgeons used near-infrared light to make the marker fluoresce as it was excreted by the liver.
In a picture review before surgery, all residents correctly identified 100% of the anatomic structures visualized by the fluorescent procedure. They were able to complete the fluorescent procedure in all of the patients. The completion rate for cholangiography was 93% (42 patients). In three patients, cholangiography failed because the cystic duct could not be cannulated.
The residents identified the cystic duct in 44 of the patients (98%), the common bile duct in 36 (80%), and the common hepatic ducts in 27 (60%). Neither technique identified any aberrant or accessory ducts.
Because fluorescent cholangiography is a real-time surgical procedure, it allowed checking of the transection and resection of the gallbladder pedicle before smooth dissection in all of the patients.
The procedure was significantly quicker than standard cholangiography (0.71 minutes vs. 7.15 minutes). It was also significantly cheaper, costing a mean of $14 vs. $778. There were no adverse surgical events, and no adverse reactions to the dye or at the infusion site, Dr. Dip said. Additionally, he noted, fluorescent cholangiography does not rely on x-rays, and so spared the patients any radiation exposure.
He added that the Cleveland Clinic, in conjunction with the University of Tokyo, will soon launch a randomized clinical trial comparing the two methods. An ongoing trial from another institution is evaluating fluorescent cholangiography compared with critical view technique in visualizing anatomy during laparoscopic cholecystectomy. It was set to wrap up in January, but according to the trial record on clinicaltrials.gov, is still recruiting patients.
Dr. Dip had no financial disclosures.
On Twitter @alz_gal
MIAMI BEACH – Intraoperative fluorescent cholangiography is just as effective as traditional cholangiography but costs hundreds of dollars less and is significantly faster to perform.
It’s also a great teaching tool, Dr. Fernando Dip said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. In just one session, all of the third- and fourth-year surgical residents were able to correctly identify 100% of the biliary structures.
"It appears to be an additional tool for the laparoscopic surgeon," said Dr. Dip, chief of surgical research at the Cleveland Clinic in Weston, Fla. "It’s quick, inexpensive, real-time, there are no adverse events, and it’s an inciscionless procedure."
Common bile duct injury is the most frequent injury seen in laparoscopic cholecystectomy, he said, and although the overall incidence is low, the number of injuries each year is not inconsiderable, since more than 750,000 laparoscopic cholecystectomies are performed in the United States annually.
"Only 3% of these injuries are due to problems with technical skill," Dr. Dip said. "The other 97% are problems of visual perception – illusions of where the ducts are."
Intraoperative cholangiography helps surgeons visualize this anatomy, but its true usefulness is somewhat controversial. Dr. Dip cited a recent study of almost 93,000 patients – 40% of whom underwent the procedure. It showed that intraoperative cholangiography is not effective as a preventive strategy against common duct injury during cholecystectomy.
Intraoperative fluorescent cholangiography is sometimes used to identify biliary anatomy in extrahepatic surgery. Dr. Dip and his colleagues examined its usefulness in 45 patients undergoing laparoscopic cholecystectomy. Senior residents performed all of the procedures under the supervision of experienced laparoscopic surgeons. All patients underwent the investigational procedure, followed by standard cholangiography.
The patients had a mean age of 49 years and were evenly split between men and women. The mean body mass index was 28 kg/m2. Surgical indications were cholelithiasis (22), acute cholecystitis (17), chronic cholecystitis (5), and polyp (1). About 1 hour before surgery, patients received an infusion of indocyanine green 0.5 mg/kg. During the laparoscopic exploration, surgeons used near-infrared light to make the marker fluoresce as it was excreted by the liver.
In a picture review before surgery, all residents correctly identified 100% of the anatomic structures visualized by the fluorescent procedure. They were able to complete the fluorescent procedure in all of the patients. The completion rate for cholangiography was 93% (42 patients). In three patients, cholangiography failed because the cystic duct could not be cannulated.
The residents identified the cystic duct in 44 of the patients (98%), the common bile duct in 36 (80%), and the common hepatic ducts in 27 (60%). Neither technique identified any aberrant or accessory ducts.
Because fluorescent cholangiography is a real-time surgical procedure, it allowed checking of the transection and resection of the gallbladder pedicle before smooth dissection in all of the patients.
The procedure was significantly quicker than standard cholangiography (0.71 minutes vs. 7.15 minutes). It was also significantly cheaper, costing a mean of $14 vs. $778. There were no adverse surgical events, and no adverse reactions to the dye or at the infusion site, Dr. Dip said. Additionally, he noted, fluorescent cholangiography does not rely on x-rays, and so spared the patients any radiation exposure.
He added that the Cleveland Clinic, in conjunction with the University of Tokyo, will soon launch a randomized clinical trial comparing the two methods. An ongoing trial from another institution is evaluating fluorescent cholangiography compared with critical view technique in visualizing anatomy during laparoscopic cholecystectomy. It was set to wrap up in January, but according to the trial record on clinicaltrials.gov, is still recruiting patients.
Dr. Dip had no financial disclosures.
On Twitter @alz_gal
AT AHPBA 2014
Major finding: Fluorescent cholangiography identified 100% of relevant anatomy during laparoscopic cholecystectomy, while costing less than standard cholangiography ($14 vs. $778).
Data source: Prospective study of 45 patients.
Disclosures: Dr. Dip had no financial disclosures.
High posthepatectomy bilirubin bodes ill for patients
MIAMI BEACH – An elevated bilirubin level on postoperative day 3 after major hepatectomy may be a harbinger of hepatic insufficiency that leads to poor outcomes – including an increased risk of death.
Compared with patients who had lower bilirubin levels, a level of 3 mg/dL or higher was associated with an eightfold increase in the risk of both a major complication and of dying within 90 days of surgery, Dr. Joanna W. Etra said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
Unfortunately, said Dr. Etra of the Winship Cancer Institute of Emory University, Atlanta, there seems to be no way to predict before surgery who will develop the elevated levels, and no preemptive treatment. Still, she said, the finding could be a good way to be alert to the possibility of a problem.
She presented a retrospective study of 535 patients who underwent a major hepatectomy at the center from 2000 to 2012. Their mean age was 55 years. Most (73%) had cancer; 39% had undergone preoperative chemotherapy. About a third (38%) had colorectal metastases in the liver. The average preoperative bilirubin level was 0.7 mg/dL. Most of the procedures (83%) were open, with a right hepatectomy most common (44%)
Postoperatively, 10% of the group developed hepatic insufficiency. Postoperative complications developed in 58%; of these, of which 22% were major. Death within 90 days occurred in 4.5% of the entire group.
Dr. Etra and her colleagues divided the group by postoperative day 3 bilirubin levels: lower than 3 mg/dL and 3 mg/dL or higher. They examined outcomes among the two groups.
Postoperative complications were significantly more common among those with the higher bilirubin levels (76% vs. 54%), as were major complications (46% vs. 18%), and 90-day mortality (16% vs. 2%).
A multivariate analysis found that the higher level doubled the risk of any complication, and tripled the risk of both a major complication and 90-day mortality,
"Having identified this association with outcomes, we refocused on the dichotomized bilirubin groups to see if we could also identify any pre- or intraoperative factors that might predict this elevated bilirubin," she said. "But in a multifactorial analysis, we found that no single factor – age, gender, cancer, preoperative platelets, MELD [model for end-stage liver disease] score, blood loss or transfusion – was a significant predictor."
Dr. Etra had no financial disclosures.
MIAMI BEACH – An elevated bilirubin level on postoperative day 3 after major hepatectomy may be a harbinger of hepatic insufficiency that leads to poor outcomes – including an increased risk of death.
Compared with patients who had lower bilirubin levels, a level of 3 mg/dL or higher was associated with an eightfold increase in the risk of both a major complication and of dying within 90 days of surgery, Dr. Joanna W. Etra said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
Unfortunately, said Dr. Etra of the Winship Cancer Institute of Emory University, Atlanta, there seems to be no way to predict before surgery who will develop the elevated levels, and no preemptive treatment. Still, she said, the finding could be a good way to be alert to the possibility of a problem.
She presented a retrospective study of 535 patients who underwent a major hepatectomy at the center from 2000 to 2012. Their mean age was 55 years. Most (73%) had cancer; 39% had undergone preoperative chemotherapy. About a third (38%) had colorectal metastases in the liver. The average preoperative bilirubin level was 0.7 mg/dL. Most of the procedures (83%) were open, with a right hepatectomy most common (44%)
Postoperatively, 10% of the group developed hepatic insufficiency. Postoperative complications developed in 58%; of these, of which 22% were major. Death within 90 days occurred in 4.5% of the entire group.
Dr. Etra and her colleagues divided the group by postoperative day 3 bilirubin levels: lower than 3 mg/dL and 3 mg/dL or higher. They examined outcomes among the two groups.
Postoperative complications were significantly more common among those with the higher bilirubin levels (76% vs. 54%), as were major complications (46% vs. 18%), and 90-day mortality (16% vs. 2%).
A multivariate analysis found that the higher level doubled the risk of any complication, and tripled the risk of both a major complication and 90-day mortality,
"Having identified this association with outcomes, we refocused on the dichotomized bilirubin groups to see if we could also identify any pre- or intraoperative factors that might predict this elevated bilirubin," she said. "But in a multifactorial analysis, we found that no single factor – age, gender, cancer, preoperative platelets, MELD [model for end-stage liver disease] score, blood loss or transfusion – was a significant predictor."
Dr. Etra had no financial disclosures.
MIAMI BEACH – An elevated bilirubin level on postoperative day 3 after major hepatectomy may be a harbinger of hepatic insufficiency that leads to poor outcomes – including an increased risk of death.
Compared with patients who had lower bilirubin levels, a level of 3 mg/dL or higher was associated with an eightfold increase in the risk of both a major complication and of dying within 90 days of surgery, Dr. Joanna W. Etra said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
Unfortunately, said Dr. Etra of the Winship Cancer Institute of Emory University, Atlanta, there seems to be no way to predict before surgery who will develop the elevated levels, and no preemptive treatment. Still, she said, the finding could be a good way to be alert to the possibility of a problem.
She presented a retrospective study of 535 patients who underwent a major hepatectomy at the center from 2000 to 2012. Their mean age was 55 years. Most (73%) had cancer; 39% had undergone preoperative chemotherapy. About a third (38%) had colorectal metastases in the liver. The average preoperative bilirubin level was 0.7 mg/dL. Most of the procedures (83%) were open, with a right hepatectomy most common (44%)
Postoperatively, 10% of the group developed hepatic insufficiency. Postoperative complications developed in 58%; of these, of which 22% were major. Death within 90 days occurred in 4.5% of the entire group.
Dr. Etra and her colleagues divided the group by postoperative day 3 bilirubin levels: lower than 3 mg/dL and 3 mg/dL or higher. They examined outcomes among the two groups.
Postoperative complications were significantly more common among those with the higher bilirubin levels (76% vs. 54%), as were major complications (46% vs. 18%), and 90-day mortality (16% vs. 2%).
A multivariate analysis found that the higher level doubled the risk of any complication, and tripled the risk of both a major complication and 90-day mortality,
"Having identified this association with outcomes, we refocused on the dichotomized bilirubin groups to see if we could also identify any pre- or intraoperative factors that might predict this elevated bilirubin," she said. "But in a multifactorial analysis, we found that no single factor – age, gender, cancer, preoperative platelets, MELD [model for end-stage liver disease] score, blood loss or transfusion – was a significant predictor."
Dr. Etra had no financial disclosures.
AT AHPBA 2014
Major finding: A high posthepatectomy bilirubin level was associated with an 8-fold increase in the risk of postoperative complications and 90-day mortality.
Data source: A retrospective study of 535 patients.
Disclosures: Dr. Joanna Etra had no financial disclosures.
Team planning cuts pancreatectomy readmissions
MIAMI BEACH – A combination of teamwork and leadership led to a 50% reduction in readmission after pancreatectomy in a large academic facility.
The readmission rate at Indiana University Hospital fell from a high of 23% to just over 11% over 5 years – even though length of stay and mortality remained stable, Dr. Eugene Ceppa reported at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
The multifaceted project made some progress during the first few years of implementation, said Dr. Ceppa of Indiana University Hospital, Indianapolis. But the biggest changes really came in years 4 and 5, after the team adopted its own version of a national readmission prevention plan, and created a "discharge coach" – a staff member dedicated to ensuring that patients were ready to leave the hospital, with plenty of support at home.
Studies generally show that pancreatectomy has a very high readmission rate, hovering around 18%. The situation was tolerated over the years, according to Dr. Henry Pitt, who coauthored the paper. But in 2008, the Centers for Medicare & Medicaid Services introduced the idea that hospital readmissions were eating away at health care dollars.
In a landmark paper, Dr. Brian Jack and colleagues noted that only 13% of discharged patients needed repeat hospitalizations, but these patients used up to 60% of the $753 billion spent on discharge in 2003.
Project RED (ReEngineering Discharge), originating from Boston University Medical Center, suggested that reducing readmissions could save $5 billion each year. Originally focused on reducing readmissions for heart failure, Project RED has been successfully adapted to multiple models – including surgery.
Changes have not come about overnight, said Dr. Pitt, now chief quality officer for Temple University Health System in Philadelphia. "There was denial at first that readmission was a problem," he said in an interview. "Then there was a period of time when there was acceptance but no idea of how to fix it. Now we are beginning to do so."
As pay-for-performance became ever more important, pancreatic surgeons at Indiana University Hospital decided to attack the problem of readmission for their pancreatectomy patients. Over a 5-year period, from 2007 to 2012, they implemented a number of reforms, beginning with renewed efforts to decrease surgical morbidity – especially their 24% rate of surgical site infections after pancreatectomy. Dr. Pitt and his colleagues had already shown that these infections were a leading cause of surgical morbidity, and reducing them was a logical first step toward reducing readmission.
The next step was to create a discharge team that would work cooperatively to make sure patients were in optimal condition to leave the hospital. The Readmission Quality Improvement Team consisted of physicians, nurses, physical and occupational therapists, case managers, pharmacists, and dietitians. Because of their efforts, the number of pancreatectomy patients discharged with some kind of home health care support increased from 20% to 50%.
At the same time, the surgeons made a policy change: There would be no readmissions without the approval of the attending surgeon. Because patients often traveled far to the university hospital, they would frequently go to their local hospitals when problems arose after they went home.
"A lot of the calls to us from patients would go to residents," Dr. Pitt said. "The default was to send them to their local emergency department, because the patients were so far away. And then we would get calls for transfers. We said that house staff would no longer have the authority to make those admissions. If they thought readmission was necessary, they had to call the attending surgeon. Just improving that decision-making process made a big difference, with fewer people going to the ED in the first place. Often it was just a matter of reassuring the patient."
By 2010, readmissions had dropped from 24% to 16%. In 2011, the team employed its own adaptation of Project RED. Each discharge included an 11-point checklist of things that had to be completed before a patient could leave. Those tasks include the following:
• Reconcile medications.
• Reconcile discharge plan with national guidelines.
• Make follow-up appointments.
• Follow up on any outstanding tests.
• Arrange for postdischarge services.
• Explain to the patient what do if a problem arises.
• Conduct patient education.
• Communicate discharge information to primary care physician.
• Make a follow-up call within 3 days of discharge.
The final puzzle piece was the discharge coach, Dr. Pitt said. The coach is a highly experienced nurse whose job it is to make sure each patient receives consistent discharge care and follow-through.
Last year, the team reviewed the project’s results, which Dr. Ceppa presented during the meeting. From 2007 to 2012, 1,147 patients underwent pancreatectomy at the facility. The mean age was 58 years. Pancreatic adenocarcinoma was the most common indication for surgery.
During the study period, neither mortality (2.7%) nor mean length of stay (10 days) changed. But readmission steadily decreased from the 2007 high of 23%. From 2008 through 2011, the readmission ranged from 18% to 15%. But after the changes implemented in 2011, the rate dropped to 11% – a significant decrease from baseline. Dr. Ceppa and Dr. Pitt attributed this to a combination of factors: stepped up discharge planning, attending-only readmission, and the discharge coach.
"I think the major thing we learned is that improving something like this isn’t simple or quick," Dr Pitt said. "You have to be persistent and really work on all the puzzle pieces until they fit into place."
Neither Dr. Pitt nor Dr. Ceppa had any financial disclosures.
MIAMI BEACH – A combination of teamwork and leadership led to a 50% reduction in readmission after pancreatectomy in a large academic facility.
The readmission rate at Indiana University Hospital fell from a high of 23% to just over 11% over 5 years – even though length of stay and mortality remained stable, Dr. Eugene Ceppa reported at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
The multifaceted project made some progress during the first few years of implementation, said Dr. Ceppa of Indiana University Hospital, Indianapolis. But the biggest changes really came in years 4 and 5, after the team adopted its own version of a national readmission prevention plan, and created a "discharge coach" – a staff member dedicated to ensuring that patients were ready to leave the hospital, with plenty of support at home.
Studies generally show that pancreatectomy has a very high readmission rate, hovering around 18%. The situation was tolerated over the years, according to Dr. Henry Pitt, who coauthored the paper. But in 2008, the Centers for Medicare & Medicaid Services introduced the idea that hospital readmissions were eating away at health care dollars.
In a landmark paper, Dr. Brian Jack and colleagues noted that only 13% of discharged patients needed repeat hospitalizations, but these patients used up to 60% of the $753 billion spent on discharge in 2003.
Project RED (ReEngineering Discharge), originating from Boston University Medical Center, suggested that reducing readmissions could save $5 billion each year. Originally focused on reducing readmissions for heart failure, Project RED has been successfully adapted to multiple models – including surgery.
Changes have not come about overnight, said Dr. Pitt, now chief quality officer for Temple University Health System in Philadelphia. "There was denial at first that readmission was a problem," he said in an interview. "Then there was a period of time when there was acceptance but no idea of how to fix it. Now we are beginning to do so."
As pay-for-performance became ever more important, pancreatic surgeons at Indiana University Hospital decided to attack the problem of readmission for their pancreatectomy patients. Over a 5-year period, from 2007 to 2012, they implemented a number of reforms, beginning with renewed efforts to decrease surgical morbidity – especially their 24% rate of surgical site infections after pancreatectomy. Dr. Pitt and his colleagues had already shown that these infections were a leading cause of surgical morbidity, and reducing them was a logical first step toward reducing readmission.
The next step was to create a discharge team that would work cooperatively to make sure patients were in optimal condition to leave the hospital. The Readmission Quality Improvement Team consisted of physicians, nurses, physical and occupational therapists, case managers, pharmacists, and dietitians. Because of their efforts, the number of pancreatectomy patients discharged with some kind of home health care support increased from 20% to 50%.
At the same time, the surgeons made a policy change: There would be no readmissions without the approval of the attending surgeon. Because patients often traveled far to the university hospital, they would frequently go to their local hospitals when problems arose after they went home.
"A lot of the calls to us from patients would go to residents," Dr. Pitt said. "The default was to send them to their local emergency department, because the patients were so far away. And then we would get calls for transfers. We said that house staff would no longer have the authority to make those admissions. If they thought readmission was necessary, they had to call the attending surgeon. Just improving that decision-making process made a big difference, with fewer people going to the ED in the first place. Often it was just a matter of reassuring the patient."
By 2010, readmissions had dropped from 24% to 16%. In 2011, the team employed its own adaptation of Project RED. Each discharge included an 11-point checklist of things that had to be completed before a patient could leave. Those tasks include the following:
• Reconcile medications.
• Reconcile discharge plan with national guidelines.
• Make follow-up appointments.
• Follow up on any outstanding tests.
• Arrange for postdischarge services.
• Explain to the patient what do if a problem arises.
• Conduct patient education.
• Communicate discharge information to primary care physician.
• Make a follow-up call within 3 days of discharge.
The final puzzle piece was the discharge coach, Dr. Pitt said. The coach is a highly experienced nurse whose job it is to make sure each patient receives consistent discharge care and follow-through.
Last year, the team reviewed the project’s results, which Dr. Ceppa presented during the meeting. From 2007 to 2012, 1,147 patients underwent pancreatectomy at the facility. The mean age was 58 years. Pancreatic adenocarcinoma was the most common indication for surgery.
During the study period, neither mortality (2.7%) nor mean length of stay (10 days) changed. But readmission steadily decreased from the 2007 high of 23%. From 2008 through 2011, the readmission ranged from 18% to 15%. But after the changes implemented in 2011, the rate dropped to 11% – a significant decrease from baseline. Dr. Ceppa and Dr. Pitt attributed this to a combination of factors: stepped up discharge planning, attending-only readmission, and the discharge coach.
"I think the major thing we learned is that improving something like this isn’t simple or quick," Dr Pitt said. "You have to be persistent and really work on all the puzzle pieces until they fit into place."
Neither Dr. Pitt nor Dr. Ceppa had any financial disclosures.
MIAMI BEACH – A combination of teamwork and leadership led to a 50% reduction in readmission after pancreatectomy in a large academic facility.
The readmission rate at Indiana University Hospital fell from a high of 23% to just over 11% over 5 years – even though length of stay and mortality remained stable, Dr. Eugene Ceppa reported at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
The multifaceted project made some progress during the first few years of implementation, said Dr. Ceppa of Indiana University Hospital, Indianapolis. But the biggest changes really came in years 4 and 5, after the team adopted its own version of a national readmission prevention plan, and created a "discharge coach" – a staff member dedicated to ensuring that patients were ready to leave the hospital, with plenty of support at home.
Studies generally show that pancreatectomy has a very high readmission rate, hovering around 18%. The situation was tolerated over the years, according to Dr. Henry Pitt, who coauthored the paper. But in 2008, the Centers for Medicare & Medicaid Services introduced the idea that hospital readmissions were eating away at health care dollars.
In a landmark paper, Dr. Brian Jack and colleagues noted that only 13% of discharged patients needed repeat hospitalizations, but these patients used up to 60% of the $753 billion spent on discharge in 2003.
Project RED (ReEngineering Discharge), originating from Boston University Medical Center, suggested that reducing readmissions could save $5 billion each year. Originally focused on reducing readmissions for heart failure, Project RED has been successfully adapted to multiple models – including surgery.
Changes have not come about overnight, said Dr. Pitt, now chief quality officer for Temple University Health System in Philadelphia. "There was denial at first that readmission was a problem," he said in an interview. "Then there was a period of time when there was acceptance but no idea of how to fix it. Now we are beginning to do so."
As pay-for-performance became ever more important, pancreatic surgeons at Indiana University Hospital decided to attack the problem of readmission for their pancreatectomy patients. Over a 5-year period, from 2007 to 2012, they implemented a number of reforms, beginning with renewed efforts to decrease surgical morbidity – especially their 24% rate of surgical site infections after pancreatectomy. Dr. Pitt and his colleagues had already shown that these infections were a leading cause of surgical morbidity, and reducing them was a logical first step toward reducing readmission.
The next step was to create a discharge team that would work cooperatively to make sure patients were in optimal condition to leave the hospital. The Readmission Quality Improvement Team consisted of physicians, nurses, physical and occupational therapists, case managers, pharmacists, and dietitians. Because of their efforts, the number of pancreatectomy patients discharged with some kind of home health care support increased from 20% to 50%.
At the same time, the surgeons made a policy change: There would be no readmissions without the approval of the attending surgeon. Because patients often traveled far to the university hospital, they would frequently go to their local hospitals when problems arose after they went home.
"A lot of the calls to us from patients would go to residents," Dr. Pitt said. "The default was to send them to their local emergency department, because the patients were so far away. And then we would get calls for transfers. We said that house staff would no longer have the authority to make those admissions. If they thought readmission was necessary, they had to call the attending surgeon. Just improving that decision-making process made a big difference, with fewer people going to the ED in the first place. Often it was just a matter of reassuring the patient."
By 2010, readmissions had dropped from 24% to 16%. In 2011, the team employed its own adaptation of Project RED. Each discharge included an 11-point checklist of things that had to be completed before a patient could leave. Those tasks include the following:
• Reconcile medications.
• Reconcile discharge plan with national guidelines.
• Make follow-up appointments.
• Follow up on any outstanding tests.
• Arrange for postdischarge services.
• Explain to the patient what do if a problem arises.
• Conduct patient education.
• Communicate discharge information to primary care physician.
• Make a follow-up call within 3 days of discharge.
The final puzzle piece was the discharge coach, Dr. Pitt said. The coach is a highly experienced nurse whose job it is to make sure each patient receives consistent discharge care and follow-through.
Last year, the team reviewed the project’s results, which Dr. Ceppa presented during the meeting. From 2007 to 2012, 1,147 patients underwent pancreatectomy at the facility. The mean age was 58 years. Pancreatic adenocarcinoma was the most common indication for surgery.
During the study period, neither mortality (2.7%) nor mean length of stay (10 days) changed. But readmission steadily decreased from the 2007 high of 23%. From 2008 through 2011, the readmission ranged from 18% to 15%. But after the changes implemented in 2011, the rate dropped to 11% – a significant decrease from baseline. Dr. Ceppa and Dr. Pitt attributed this to a combination of factors: stepped up discharge planning, attending-only readmission, and the discharge coach.
"I think the major thing we learned is that improving something like this isn’t simple or quick," Dr Pitt said. "You have to be persistent and really work on all the puzzle pieces until they fit into place."
Neither Dr. Pitt nor Dr. Ceppa had any financial disclosures.
AT AHPBA 2014
Major finding: Readmission after pancreatectomy dropped from 24% to 11% after implementation of a multifaceted effort to reduce infections and improve discharge planning,
Data source: A retrospective study of 1,147 patients.
Disclosures: Neither Dr. Ceppa nor Dr. Pitt had any financial disclosures.
Intraoperative ultrasound can change approach to liver resection
MIAMI BEACH – Intraoperative ultrasound during resection of colorectal liver metastases changed operative management in 43% of cases, according to a retrospective study.
Ultrasound employed during surgery identified new lesions not seen on preoperative imaging, and gave additional details about known lesions, said Dr. Sarah Knowles, a surgical resident at the University of Western Ontario, London (Canada).
"Intraoperative ultrasound provided new information about the number, size, location, and appearance of the lesions," she said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. The procedure was associated with significantly more blood loss, however, and there were no differences in negative surgical margins between patients who had ultrasound during surgery and those who did not.
Dr. Knowles presented a retrospective study of 103 patients who, from 2009 to 2012, underwent liver resection of colorectal cancer metastases. Mean age of the patients was 62 years. Most (94%) had undergone preoperative computerized tomography; the rest had undergone magnetic resonance imaging. The mean time from preoperative imaging to surgery was 66 days. Most of the patients (72) had intraoperative ultrasound imaging.
There were 45 anatomic resections and 27 nonanatomic resections in the group that had intraoperative ultrasound. This was significantly different from the nonultrasound group, which had 25 anatomic and 6 nonanatomic resections.
Ultrasound changed surgical strategy in 43% (31) of those who had it. Surgical strategy changed in 10% of those who had no intraoperative imaging – a significant difference (P = less than .001). Blood loss was significantly greater in the ultrasound group (650 mL vs. 350 mL).
The bulk of the strategic changes in the ultrasound group (17) were due to additional information about the location of lesions – either deeper or more superficial than preoperative imaging suggested. Other reasons for a shift in strategy were the discovery of new lesions (13), a disappearing lesion (1), larger-than-expected lesions (5), smaller-than-expected lesions (2), or a difference in the lesions’ appearance (3).
Resection margins were similar in the two groups. In the ultrasound group, 85% had R0 margins and 15% had R1 margins. In the group without ultrasound, 87% had R0 margins and 13% had R1 margins. There was no significant difference in disease-free 5-year survival.
Dr. Knowles had no financial disclosures.
MIAMI BEACH – Intraoperative ultrasound during resection of colorectal liver metastases changed operative management in 43% of cases, according to a retrospective study.
Ultrasound employed during surgery identified new lesions not seen on preoperative imaging, and gave additional details about known lesions, said Dr. Sarah Knowles, a surgical resident at the University of Western Ontario, London (Canada).
"Intraoperative ultrasound provided new information about the number, size, location, and appearance of the lesions," she said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. The procedure was associated with significantly more blood loss, however, and there were no differences in negative surgical margins between patients who had ultrasound during surgery and those who did not.
Dr. Knowles presented a retrospective study of 103 patients who, from 2009 to 2012, underwent liver resection of colorectal cancer metastases. Mean age of the patients was 62 years. Most (94%) had undergone preoperative computerized tomography; the rest had undergone magnetic resonance imaging. The mean time from preoperative imaging to surgery was 66 days. Most of the patients (72) had intraoperative ultrasound imaging.
There were 45 anatomic resections and 27 nonanatomic resections in the group that had intraoperative ultrasound. This was significantly different from the nonultrasound group, which had 25 anatomic and 6 nonanatomic resections.
Ultrasound changed surgical strategy in 43% (31) of those who had it. Surgical strategy changed in 10% of those who had no intraoperative imaging – a significant difference (P = less than .001). Blood loss was significantly greater in the ultrasound group (650 mL vs. 350 mL).
The bulk of the strategic changes in the ultrasound group (17) were due to additional information about the location of lesions – either deeper or more superficial than preoperative imaging suggested. Other reasons for a shift in strategy were the discovery of new lesions (13), a disappearing lesion (1), larger-than-expected lesions (5), smaller-than-expected lesions (2), or a difference in the lesions’ appearance (3).
Resection margins were similar in the two groups. In the ultrasound group, 85% had R0 margins and 15% had R1 margins. In the group without ultrasound, 87% had R0 margins and 13% had R1 margins. There was no significant difference in disease-free 5-year survival.
Dr. Knowles had no financial disclosures.
MIAMI BEACH – Intraoperative ultrasound during resection of colorectal liver metastases changed operative management in 43% of cases, according to a retrospective study.
Ultrasound employed during surgery identified new lesions not seen on preoperative imaging, and gave additional details about known lesions, said Dr. Sarah Knowles, a surgical resident at the University of Western Ontario, London (Canada).
"Intraoperative ultrasound provided new information about the number, size, location, and appearance of the lesions," she said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. The procedure was associated with significantly more blood loss, however, and there were no differences in negative surgical margins between patients who had ultrasound during surgery and those who did not.
Dr. Knowles presented a retrospective study of 103 patients who, from 2009 to 2012, underwent liver resection of colorectal cancer metastases. Mean age of the patients was 62 years. Most (94%) had undergone preoperative computerized tomography; the rest had undergone magnetic resonance imaging. The mean time from preoperative imaging to surgery was 66 days. Most of the patients (72) had intraoperative ultrasound imaging.
There were 45 anatomic resections and 27 nonanatomic resections in the group that had intraoperative ultrasound. This was significantly different from the nonultrasound group, which had 25 anatomic and 6 nonanatomic resections.
Ultrasound changed surgical strategy in 43% (31) of those who had it. Surgical strategy changed in 10% of those who had no intraoperative imaging – a significant difference (P = less than .001). Blood loss was significantly greater in the ultrasound group (650 mL vs. 350 mL).
The bulk of the strategic changes in the ultrasound group (17) were due to additional information about the location of lesions – either deeper or more superficial than preoperative imaging suggested. Other reasons for a shift in strategy were the discovery of new lesions (13), a disappearing lesion (1), larger-than-expected lesions (5), smaller-than-expected lesions (2), or a difference in the lesions’ appearance (3).
Resection margins were similar in the two groups. In the ultrasound group, 85% had R0 margins and 15% had R1 margins. In the group without ultrasound, 87% had R0 margins and 13% had R1 margins. There was no significant difference in disease-free 5-year survival.
Dr. Knowles had no financial disclosures.
AT AHPBA 2014
Major finding: Intraoperative ultrasound changed surgical strategy in 43% of patients undergoing liver resections of colorectal cancer metastases.
Data source: A retrospective study of 103 patients.
Disclosures: Dr. Knowles had no financial disclosures.
Volume matters: Whipple success hinges on surgeon experience
MIAMI BEACH – Studies continue to confirm it: When it comes to complex surgical procedures, higher volume equals better outcomes. But like the chicken-or-egg conundrum, researchers are asking which factor comes first – surgeon or facility.
Data presented at the annual meeting of the Americas Hepato-Pancreato-Biliary Association suggest that personal experience makes the biggest difference, at least for the difficult Whipple procedure. Surgeons who performed the highest number of pancreaticoduodenectomies each year had the best outcomes; when they transferred to low-volume hospitals with historically poor results, these surgeons improved perioperative complications, mortality, and readmissions, and lowered costs.
"The salutary effects of being a high-volume hospital for pancreaticoduodenectomy are transferred when high-volume surgeons relocate," said Dr. Paul Toomey. "It seems that the benefits of a high-volume hospital are more due to who does the surgery rather than where it’s undertaken."
Dr. Toomey, a surgical fellow at the Florida Hospital, Tampa, had a unique opportunity to study what happens when two surgeons highly experienced in the Whipple procedure transferred from a busy hospital to low-volume facilities. The surgeons, who together performed more than 100 of the procedures each year, moved for personal reasons, Dr. Toomey said in an interview.
The study focused on perioperative outcomes, mortality, and readmissions in two groups of Whipple patients: the last 50 undertaken at the high-volume hospital (more than 12 pancreaticoduodenectomies per year), and the first 50 at the low-volume hospital where they worked afterward.
The patient groups were similar. Their mean age was 78 years, a little more than half were men, and the average American Society of Anesthesiologists class was 3. The rates of malignancy were similar in the high- and low-volume centers (88% vs. 82%, respectively).
Overall, the average operative time was 252 minutes, with an estimated blood loss of 300 mL. Patients were in intensive care for 2 days, with an average hospital stay of 9 days. The readmission rate was 19% and 30-day mortality, 5%.
But when Dr. Toomey compared the two time periods, he found significant differences in outcomes, which appeared to be associated with the transfer of the highly experienced surgeons. In fact, he said, outcomes were actually much better at the low- than the high-volume centers after the transfer.
The mean operative time at the low-volume centers was 205 minutes, compared with 305 minutes at the high-volume centers. Estimated blood loss was also less at the low-volume centers (350 vs. 255 mL). ICU stays were significantly shorter (1 vs. 3 days), as was total length of stay (7 vs. 12 days). Readmission rates over 30 days were similar (20% vs. 18%), as was 30-day mortality (4% vs. 6%).
"The salutary benefits of being a high-volume hospital for pancreaticoduodenectomy seem to be transferred when high-volume surgeons relocate," Dr. Toomey said. "The benefits of a high-volume hospital may be more due to who does the pancreaticoduodenectomy rather than where the pancreaticoduodenectomy is undertaken."
Dr. Thomas Wood, also of the Florida Hospital, found a similar trend in his study, which examined Whipple outcomes statewide over 20 years. He related the outcomes to concentration, rather decentralization, of care.
For his study, Dr. Wood examined data from the Florida Agency for Health Care Administration, collected over three 3-year epochs: 1992-1994, 2001-2003, and 2010-2012. The data were sorted by surgeon volume of pancreaticoduodenectomy during these periods and correlated to length of stay, in-hospital mortality, and hospital charges, which were adjusted to 2012 dollars.
Over the 9 years, 893 surgeons performed 3,531 pancreaticoduodenectomies. During each epoch, the number of surgeons went down as the number of operations increased.
In the first epoch, 363 surgeons performed 729 operations. In the second, 334 surgeons performed 1,233 surgeries, and in the third, 196 performed 1,569 operations.
"By 2010-2012, 46% fewer surgeons undertook 115% more surgeries compared to the first period," Dr. Wood said. "In 1992-1994, 62% of pancreaticoduodenectomies were undertaken by surgeons who performed one or fewer per year. This fell to 13% by 2010-2012."
At the same time, the number of surgeons who performed more than 36 procedures in each 3-year period (12 per year) grew significantly. In the first epoch, one surgeon alone performed 45 procedures. In the second, six surgeons performed a total of 361. And in the third epoch, 11 surgeons performed 806 Whipples.
"From [the first through third periods,] there was an 11-fold increase in the number of high-volume surgeons and a corresponding 18-fold increase in the number of pancreaticoduodenectomies by surgeons who were performing at least 12 each year. They were performing more than 50% of these operations."
A separate analysis of just the 2010-2012 data evaluated outcomes by surgeons’ operation volume.
In the first epoch, in-hospital mortality was about 12%. In the second, it fell to 8%, and by the third, to 4%. Patients whose surgeons performed one to nine procedures (up to three per year) were hospitalized an average of about 14 days. Those whose surgeons performed 19 to 36 procedures (up to 12 per year) stayed an average of 8 days – a significant difference.
Mortality followed the same pattern. About 9% of patients whose surgeons performed one to three procedures per year died after surgery, compared with 2% of those whose doctors performed 12 procedures per year.
These more experienced surgeons also discharged more patients to home rather than nursing facilities (88% vs. 82%, a significant difference).
Both hospital and surgeon volume also affected costs. Overall, hospital costs increased significantly, even after adjustment for inflation, jumping from $93,000 to $133,000. But surgeons who performed at least 12 Whipples per year did so at a half the cost of those who performed 1-3 per year ($100,000 vs. $200,000).
"Suffice it to say, the busiest surgeons got the best results," Dr. Wood said.
Despite advances in centralizing this kind of specialized care, though, many low-volume centers are still performing the operations, said Dr. Jeffrey Sutton of the University of Cincinnati. "Research continues to show that high-volume centers have better outcomes," he said. "And yet a significant number of cases are still being done at hospitals that do less than one per year."
If research data aren’t enough to persuade hospitals to send patients to regional centers, Dr. Sutton wondered, could money be a motivating factor? He examined the records of almost 10,000 Whipple operations performed at 419 centers that are part of the University Health Systems Consortium clinical database. Of these, 120 were academic centers and 299 were affiliated hospitals. The procedures were performed from 2009 to 2011. Clinical outcomes included length of stay, mortality, and readmissions. He also assessed the cost of both the index admission and readmissions.
Hospitals were divided into volume quintiles of lowest, low, middle, high, and highest. The lowest-volume centers performed up to 21 cases/year in 2009 to up to 23 in 2011. The highest-volume centers performed up to 180 cases/year in 2009 and up to 216 in 2011.
Intraoperative mortality hovered around 2% at the middle-, high-, and highest-volume centers. At the low-volume centers, it reached 2.5% – not significantly different. But at the lowest-volume centers, 30-day mortality was significantly higher – nearly 4%.
Length of stay was similarly associated with volume. In low-, middle-, and high-volume centers, it was about 9 days. But in the lowest-volume centers, the average length of stay was 11 days – significantly longer than any of the others.
Readmission rates over the first postoperative month were also lowest in the highest-volume centers (16.5%). In the low-volume centers, 30-day readmission was just under 19%. But in the middle-, low-, and lowest-volume centers, it was significantly greater, hovering at nearly 20%.
"It’s not only that lower-volume centers are holding on to patients longer, they also are readmitting those same patients significantly more often," Dr. Sutton noted.
The cost analysis looked at Medicare charge data. "When both index and readmission costs were considered, the median per-patient cost at the lowest-volume centers was $23,005 – 11% more than at the highest-volume center."
But there was no significant difference in the cost of readmissions. "That means that the difference of about $2,263 extra per case was based solely on the index admission," Dr. Sutton said. "Essentially what we saw was that the more cases that are performed, the cheaper each individual case becomes."
"To put it bluntly, some low-volume centers are currently reimbursed higher sums of money for delivering suboptimal care to patients," Dr. Sutton said in an interview. In our current health care climate, which emphasizes improved outcomes at lower costs, this is a travesty. As health service researchers, it is our obligation to our patients to analyze and disseminate these data in an effort to urge policymakers to limit the financial reimbursements for poorer-performing providers."
None of the researchers quoted in this article reported any financial disclosures.
MIAMI BEACH – Studies continue to confirm it: When it comes to complex surgical procedures, higher volume equals better outcomes. But like the chicken-or-egg conundrum, researchers are asking which factor comes first – surgeon or facility.
Data presented at the annual meeting of the Americas Hepato-Pancreato-Biliary Association suggest that personal experience makes the biggest difference, at least for the difficult Whipple procedure. Surgeons who performed the highest number of pancreaticoduodenectomies each year had the best outcomes; when they transferred to low-volume hospitals with historically poor results, these surgeons improved perioperative complications, mortality, and readmissions, and lowered costs.
"The salutary effects of being a high-volume hospital for pancreaticoduodenectomy are transferred when high-volume surgeons relocate," said Dr. Paul Toomey. "It seems that the benefits of a high-volume hospital are more due to who does the surgery rather than where it’s undertaken."
Dr. Toomey, a surgical fellow at the Florida Hospital, Tampa, had a unique opportunity to study what happens when two surgeons highly experienced in the Whipple procedure transferred from a busy hospital to low-volume facilities. The surgeons, who together performed more than 100 of the procedures each year, moved for personal reasons, Dr. Toomey said in an interview.
The study focused on perioperative outcomes, mortality, and readmissions in two groups of Whipple patients: the last 50 undertaken at the high-volume hospital (more than 12 pancreaticoduodenectomies per year), and the first 50 at the low-volume hospital where they worked afterward.
The patient groups were similar. Their mean age was 78 years, a little more than half were men, and the average American Society of Anesthesiologists class was 3. The rates of malignancy were similar in the high- and low-volume centers (88% vs. 82%, respectively).
Overall, the average operative time was 252 minutes, with an estimated blood loss of 300 mL. Patients were in intensive care for 2 days, with an average hospital stay of 9 days. The readmission rate was 19% and 30-day mortality, 5%.
But when Dr. Toomey compared the two time periods, he found significant differences in outcomes, which appeared to be associated with the transfer of the highly experienced surgeons. In fact, he said, outcomes were actually much better at the low- than the high-volume centers after the transfer.
The mean operative time at the low-volume centers was 205 minutes, compared with 305 minutes at the high-volume centers. Estimated blood loss was also less at the low-volume centers (350 vs. 255 mL). ICU stays were significantly shorter (1 vs. 3 days), as was total length of stay (7 vs. 12 days). Readmission rates over 30 days were similar (20% vs. 18%), as was 30-day mortality (4% vs. 6%).
"The salutary benefits of being a high-volume hospital for pancreaticoduodenectomy seem to be transferred when high-volume surgeons relocate," Dr. Toomey said. "The benefits of a high-volume hospital may be more due to who does the pancreaticoduodenectomy rather than where the pancreaticoduodenectomy is undertaken."
Dr. Thomas Wood, also of the Florida Hospital, found a similar trend in his study, which examined Whipple outcomes statewide over 20 years. He related the outcomes to concentration, rather decentralization, of care.
For his study, Dr. Wood examined data from the Florida Agency for Health Care Administration, collected over three 3-year epochs: 1992-1994, 2001-2003, and 2010-2012. The data were sorted by surgeon volume of pancreaticoduodenectomy during these periods and correlated to length of stay, in-hospital mortality, and hospital charges, which were adjusted to 2012 dollars.
Over the 9 years, 893 surgeons performed 3,531 pancreaticoduodenectomies. During each epoch, the number of surgeons went down as the number of operations increased.
In the first epoch, 363 surgeons performed 729 operations. In the second, 334 surgeons performed 1,233 surgeries, and in the third, 196 performed 1,569 operations.
"By 2010-2012, 46% fewer surgeons undertook 115% more surgeries compared to the first period," Dr. Wood said. "In 1992-1994, 62% of pancreaticoduodenectomies were undertaken by surgeons who performed one or fewer per year. This fell to 13% by 2010-2012."
At the same time, the number of surgeons who performed more than 36 procedures in each 3-year period (12 per year) grew significantly. In the first epoch, one surgeon alone performed 45 procedures. In the second, six surgeons performed a total of 361. And in the third epoch, 11 surgeons performed 806 Whipples.
"From [the first through third periods,] there was an 11-fold increase in the number of high-volume surgeons and a corresponding 18-fold increase in the number of pancreaticoduodenectomies by surgeons who were performing at least 12 each year. They were performing more than 50% of these operations."
A separate analysis of just the 2010-2012 data evaluated outcomes by surgeons’ operation volume.
In the first epoch, in-hospital mortality was about 12%. In the second, it fell to 8%, and by the third, to 4%. Patients whose surgeons performed one to nine procedures (up to three per year) were hospitalized an average of about 14 days. Those whose surgeons performed 19 to 36 procedures (up to 12 per year) stayed an average of 8 days – a significant difference.
Mortality followed the same pattern. About 9% of patients whose surgeons performed one to three procedures per year died after surgery, compared with 2% of those whose doctors performed 12 procedures per year.
These more experienced surgeons also discharged more patients to home rather than nursing facilities (88% vs. 82%, a significant difference).
Both hospital and surgeon volume also affected costs. Overall, hospital costs increased significantly, even after adjustment for inflation, jumping from $93,000 to $133,000. But surgeons who performed at least 12 Whipples per year did so at a half the cost of those who performed 1-3 per year ($100,000 vs. $200,000).
"Suffice it to say, the busiest surgeons got the best results," Dr. Wood said.
Despite advances in centralizing this kind of specialized care, though, many low-volume centers are still performing the operations, said Dr. Jeffrey Sutton of the University of Cincinnati. "Research continues to show that high-volume centers have better outcomes," he said. "And yet a significant number of cases are still being done at hospitals that do less than one per year."
If research data aren’t enough to persuade hospitals to send patients to regional centers, Dr. Sutton wondered, could money be a motivating factor? He examined the records of almost 10,000 Whipple operations performed at 419 centers that are part of the University Health Systems Consortium clinical database. Of these, 120 were academic centers and 299 were affiliated hospitals. The procedures were performed from 2009 to 2011. Clinical outcomes included length of stay, mortality, and readmissions. He also assessed the cost of both the index admission and readmissions.
Hospitals were divided into volume quintiles of lowest, low, middle, high, and highest. The lowest-volume centers performed up to 21 cases/year in 2009 to up to 23 in 2011. The highest-volume centers performed up to 180 cases/year in 2009 and up to 216 in 2011.
Intraoperative mortality hovered around 2% at the middle-, high-, and highest-volume centers. At the low-volume centers, it reached 2.5% – not significantly different. But at the lowest-volume centers, 30-day mortality was significantly higher – nearly 4%.
Length of stay was similarly associated with volume. In low-, middle-, and high-volume centers, it was about 9 days. But in the lowest-volume centers, the average length of stay was 11 days – significantly longer than any of the others.
Readmission rates over the first postoperative month were also lowest in the highest-volume centers (16.5%). In the low-volume centers, 30-day readmission was just under 19%. But in the middle-, low-, and lowest-volume centers, it was significantly greater, hovering at nearly 20%.
"It’s not only that lower-volume centers are holding on to patients longer, they also are readmitting those same patients significantly more often," Dr. Sutton noted.
The cost analysis looked at Medicare charge data. "When both index and readmission costs were considered, the median per-patient cost at the lowest-volume centers was $23,005 – 11% more than at the highest-volume center."
But there was no significant difference in the cost of readmissions. "That means that the difference of about $2,263 extra per case was based solely on the index admission," Dr. Sutton said. "Essentially what we saw was that the more cases that are performed, the cheaper each individual case becomes."
"To put it bluntly, some low-volume centers are currently reimbursed higher sums of money for delivering suboptimal care to patients," Dr. Sutton said in an interview. In our current health care climate, which emphasizes improved outcomes at lower costs, this is a travesty. As health service researchers, it is our obligation to our patients to analyze and disseminate these data in an effort to urge policymakers to limit the financial reimbursements for poorer-performing providers."
None of the researchers quoted in this article reported any financial disclosures.
MIAMI BEACH – Studies continue to confirm it: When it comes to complex surgical procedures, higher volume equals better outcomes. But like the chicken-or-egg conundrum, researchers are asking which factor comes first – surgeon or facility.
Data presented at the annual meeting of the Americas Hepato-Pancreato-Biliary Association suggest that personal experience makes the biggest difference, at least for the difficult Whipple procedure. Surgeons who performed the highest number of pancreaticoduodenectomies each year had the best outcomes; when they transferred to low-volume hospitals with historically poor results, these surgeons improved perioperative complications, mortality, and readmissions, and lowered costs.
"The salutary effects of being a high-volume hospital for pancreaticoduodenectomy are transferred when high-volume surgeons relocate," said Dr. Paul Toomey. "It seems that the benefits of a high-volume hospital are more due to who does the surgery rather than where it’s undertaken."
Dr. Toomey, a surgical fellow at the Florida Hospital, Tampa, had a unique opportunity to study what happens when two surgeons highly experienced in the Whipple procedure transferred from a busy hospital to low-volume facilities. The surgeons, who together performed more than 100 of the procedures each year, moved for personal reasons, Dr. Toomey said in an interview.
The study focused on perioperative outcomes, mortality, and readmissions in two groups of Whipple patients: the last 50 undertaken at the high-volume hospital (more than 12 pancreaticoduodenectomies per year), and the first 50 at the low-volume hospital where they worked afterward.
The patient groups were similar. Their mean age was 78 years, a little more than half were men, and the average American Society of Anesthesiologists class was 3. The rates of malignancy were similar in the high- and low-volume centers (88% vs. 82%, respectively).
Overall, the average operative time was 252 minutes, with an estimated blood loss of 300 mL. Patients were in intensive care for 2 days, with an average hospital stay of 9 days. The readmission rate was 19% and 30-day mortality, 5%.
But when Dr. Toomey compared the two time periods, he found significant differences in outcomes, which appeared to be associated with the transfer of the highly experienced surgeons. In fact, he said, outcomes were actually much better at the low- than the high-volume centers after the transfer.
The mean operative time at the low-volume centers was 205 minutes, compared with 305 minutes at the high-volume centers. Estimated blood loss was also less at the low-volume centers (350 vs. 255 mL). ICU stays were significantly shorter (1 vs. 3 days), as was total length of stay (7 vs. 12 days). Readmission rates over 30 days were similar (20% vs. 18%), as was 30-day mortality (4% vs. 6%).
"The salutary benefits of being a high-volume hospital for pancreaticoduodenectomy seem to be transferred when high-volume surgeons relocate," Dr. Toomey said. "The benefits of a high-volume hospital may be more due to who does the pancreaticoduodenectomy rather than where the pancreaticoduodenectomy is undertaken."
Dr. Thomas Wood, also of the Florida Hospital, found a similar trend in his study, which examined Whipple outcomes statewide over 20 years. He related the outcomes to concentration, rather decentralization, of care.
For his study, Dr. Wood examined data from the Florida Agency for Health Care Administration, collected over three 3-year epochs: 1992-1994, 2001-2003, and 2010-2012. The data were sorted by surgeon volume of pancreaticoduodenectomy during these periods and correlated to length of stay, in-hospital mortality, and hospital charges, which were adjusted to 2012 dollars.
Over the 9 years, 893 surgeons performed 3,531 pancreaticoduodenectomies. During each epoch, the number of surgeons went down as the number of operations increased.
In the first epoch, 363 surgeons performed 729 operations. In the second, 334 surgeons performed 1,233 surgeries, and in the third, 196 performed 1,569 operations.
"By 2010-2012, 46% fewer surgeons undertook 115% more surgeries compared to the first period," Dr. Wood said. "In 1992-1994, 62% of pancreaticoduodenectomies were undertaken by surgeons who performed one or fewer per year. This fell to 13% by 2010-2012."
At the same time, the number of surgeons who performed more than 36 procedures in each 3-year period (12 per year) grew significantly. In the first epoch, one surgeon alone performed 45 procedures. In the second, six surgeons performed a total of 361. And in the third epoch, 11 surgeons performed 806 Whipples.
"From [the first through third periods,] there was an 11-fold increase in the number of high-volume surgeons and a corresponding 18-fold increase in the number of pancreaticoduodenectomies by surgeons who were performing at least 12 each year. They were performing more than 50% of these operations."
A separate analysis of just the 2010-2012 data evaluated outcomes by surgeons’ operation volume.
In the first epoch, in-hospital mortality was about 12%. In the second, it fell to 8%, and by the third, to 4%. Patients whose surgeons performed one to nine procedures (up to three per year) were hospitalized an average of about 14 days. Those whose surgeons performed 19 to 36 procedures (up to 12 per year) stayed an average of 8 days – a significant difference.
Mortality followed the same pattern. About 9% of patients whose surgeons performed one to three procedures per year died after surgery, compared with 2% of those whose doctors performed 12 procedures per year.
These more experienced surgeons also discharged more patients to home rather than nursing facilities (88% vs. 82%, a significant difference).
Both hospital and surgeon volume also affected costs. Overall, hospital costs increased significantly, even after adjustment for inflation, jumping from $93,000 to $133,000. But surgeons who performed at least 12 Whipples per year did so at a half the cost of those who performed 1-3 per year ($100,000 vs. $200,000).
"Suffice it to say, the busiest surgeons got the best results," Dr. Wood said.
Despite advances in centralizing this kind of specialized care, though, many low-volume centers are still performing the operations, said Dr. Jeffrey Sutton of the University of Cincinnati. "Research continues to show that high-volume centers have better outcomes," he said. "And yet a significant number of cases are still being done at hospitals that do less than one per year."
If research data aren’t enough to persuade hospitals to send patients to regional centers, Dr. Sutton wondered, could money be a motivating factor? He examined the records of almost 10,000 Whipple operations performed at 419 centers that are part of the University Health Systems Consortium clinical database. Of these, 120 were academic centers and 299 were affiliated hospitals. The procedures were performed from 2009 to 2011. Clinical outcomes included length of stay, mortality, and readmissions. He also assessed the cost of both the index admission and readmissions.
Hospitals were divided into volume quintiles of lowest, low, middle, high, and highest. The lowest-volume centers performed up to 21 cases/year in 2009 to up to 23 in 2011. The highest-volume centers performed up to 180 cases/year in 2009 and up to 216 in 2011.
Intraoperative mortality hovered around 2% at the middle-, high-, and highest-volume centers. At the low-volume centers, it reached 2.5% – not significantly different. But at the lowest-volume centers, 30-day mortality was significantly higher – nearly 4%.
Length of stay was similarly associated with volume. In low-, middle-, and high-volume centers, it was about 9 days. But in the lowest-volume centers, the average length of stay was 11 days – significantly longer than any of the others.
Readmission rates over the first postoperative month were also lowest in the highest-volume centers (16.5%). In the low-volume centers, 30-day readmission was just under 19%. But in the middle-, low-, and lowest-volume centers, it was significantly greater, hovering at nearly 20%.
"It’s not only that lower-volume centers are holding on to patients longer, they also are readmitting those same patients significantly more often," Dr. Sutton noted.
The cost analysis looked at Medicare charge data. "When both index and readmission costs were considered, the median per-patient cost at the lowest-volume centers was $23,005 – 11% more than at the highest-volume center."
But there was no significant difference in the cost of readmissions. "That means that the difference of about $2,263 extra per case was based solely on the index admission," Dr. Sutton said. "Essentially what we saw was that the more cases that are performed, the cheaper each individual case becomes."
"To put it bluntly, some low-volume centers are currently reimbursed higher sums of money for delivering suboptimal care to patients," Dr. Sutton said in an interview. In our current health care climate, which emphasizes improved outcomes at lower costs, this is a travesty. As health service researchers, it is our obligation to our patients to analyze and disseminate these data in an effort to urge policymakers to limit the financial reimbursements for poorer-performing providers."
None of the researchers quoted in this article reported any financial disclosures.
AT AHPBA 2014
Major finding: When high-volume surgeons transferred to low-volume institutions, these surgeons improved perioperative complications, mortality, and readmissions, and lowered costs in the low-volume institutions. The mean operative time at the low-volume centers was 205 minutes, compared with 305 minutes at the high-volume centers. Estimated blood loss was also less at the low-volume centers (350 vs. 255 mL), as was total length of stay (7 vs. 12 days).
Data source: Data from more than 100 Whipple procedures performed by two experienced surgeons who transferred to low-volume institutions.
Disclosures: None of the researchers quoted in this article reported any financial disclosures.
Outcomes similar for two reconstruction techniques, except for risk of severe complications
MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.
"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."
Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.
Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.
All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.
The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).
Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.
There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).
In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).
Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).
"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"
Dr. Grendar said he had no relevant financial disclosures.
*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.
MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.
"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."
Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.
Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.
All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.
The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).
Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.
There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).
In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).
Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).
"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"
Dr. Grendar said he had no relevant financial disclosures.
*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.
MIAMI BEACH* – There appears to be no difference in the rate of anastomotic leak in pancreaticogastrostomy compared with pancreaticojejunostomy reconstruction after a Whipple procedure, but pancreaticogastrostomy does appear to increase the risk of some serious postoperative complications, a study found.
"We didn’t show any significant differences in terms of leaks, severity of leaks, or even overall complications," Dr. Jan Grendar said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association. "But we did show a significant difference in complications of Clavien grades III-V severity. This anastomosis just did a little bit worse in terms of severe complications."
Grade III Clavien complications are those that require a second invasive procedure, like reoperation or drainage, with local or general anesthesia. Grade IV complications are more serious – they include organ failures such as renal failure requiring hemodialysis, heart failure, and liver failure, and intubation. The Grade V complication is patient death.
Dr. Grendar, a surgical resident at the University of Calgary (Alta.), and his colleagues randomized 98 patients with benign or malignant pancreatic disease to either of the two reconstruction techniques after a Whipple procedure. Pancreaticojejunostomy (PJ) is the procedure typically performed in North America. Pancreaticogastrostomy (PG) is typically performed in Europe. The hepatobiliary pancreatic surgeons and residents at the university, however, have become adept at this second procedure and employ it as an alternative reconstruction, depending on the characteristics of the pancreas discovered during surgery. They most often use it on patients who have a soft pancreas or small pancreatic duct.
All of the patients in the study had a pancreatic or periampullary neoplasm that appeared resectable on preoperative imaging. There were no differences in baseline patient characteristics. The mean age was 64 in the PG group and 68 in the PJ group. The median Charlson comorbidity index score was 2.
The intraoperative outcomes were mostly similar. Gland mobilization occurred significantly more often in the PG group (31 vs. 18 mm). Significantly fewer PG patients had a two-layer anastomosis (77% vs. 94%). The mean pancreatic duct size was smaller in the PG patients (3.8 vs. 4.3 mm), but this wasn’t statistically significant. Significantly fewer PG patients had a pancreatic duct stent placed (22% vs. 83%).
Postoperative outcomes included pancreatic fistula, any postoperative complications, severe complications, and length of stay.
There was no difference between the groups in Clavien grade complications separately, but significantly more PG patients had severe, Clavien grade III-V complications (31% vs. 12%). But these didn’t affect the mean length of stay, which was similar between the groups (17 vs. 14 days).
In a multivariate analysis, only having a soft pancreas significantly increased the risk of developing a pancreatic fistula (odds ratio, 5.87). Female gender significantly decreased the risk (OR, 0.31). This most likely represents a correlation between pancreatic texture and patient sex rather than a true protective property of being female. Having a soft pancreas also significantly increased the risk of any postoperative complications (OR, 3.08).
Several factors significantly increased the risk of a severe complication. These included a baseline American Society of Anesthesiologists grade of 2 or 3 (OR, 12.75 and 29.56, respectively). Being randomized to the PJ procedure significantly decreased the risk of a severe complication (OR, 0.11).
"Unlike the European centers that report different outcomes, these results are coming from a center that wasn’t very enthusiastic about this type of reconstruction prior to this study," Dr. Grendar said in an interview. "Despite the initial preference, high-risk patients in Calgary, those with soft pancreatic glands and small pancreatic ducts, are now likely to be offered a pancreaticogastrostomy"
Dr. Grendar said he had no relevant financial disclosures.
*Correction, 3/11/2014: An earlier version of the article misstated the name of the city where the AHPBA meeting took place.
AT AHPBA 2014
Major finding: Severe complications occurred in significantly more Whipple patients who had a pancreaticogastrostomy reconstruction than a pancreaticojejunostomy (31% vs. 12%).
Data source: A randomized study involving 98 patients.
Disclosures: Dr. Grendar said he had no relevant financial disclosures.
Renal insufficiency tied to risk of post–liver surgery problems
MIAMI BEACH – Renal insufficiency significantly increased the risk of major complications after liver surgery.
However, it wasn’t associated with an increased risk of 90-day mortality, suggesting that patients with poor renal function shouldn’t be ruled out as surgical candidates, Dr. Malcolm Squires III said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"While they may be at a potential risk of major complications – renal failure and respiratory failure – we are ultimately able to get these patients through the postoperative period without any significant increase in mortality," said Dr. Squires of Emory University, Atlanta.
He presented a large retrospective study that examined postoperative outcomes in 1,170 patients (mean age, 57 years) who underwent major hepatectomy at three national academic hospitals from 2000 to 2012. The study determined the link between major complications and preoperative serum creatinine levels. These levels were dichotomized as normal (1.8 mg/dL or less) and elevated (greater than 1.8 mg/dL).
Most patients (1,148) had normal levels; only 22 had elevated serum creatinine, considered to be reflective of chronic renal insufficiency.
Pathology included cholangiocarcinoma, hepatocellular carcinoma, metastatic colorectal cancer, other cancers, and benign lesions. Cirrhosis was present in 4% and steatosis in 39%.
Most (83%) had open surgery; 17% had a laparoscopic procedure. The mean blood loss was 510 cc; 25% needed an intraoperative blood transfusion.
Postoperative complications arose in 56% of the group. A quarter (24%) had a major complication, including renal failure (3%) and respiratory failure (5%). Three-month mortality in the entire group was 5%.
In a multivariate model, preoperative renal insufficiency conferred a fourfold increased risk of developing a major postoperative complication. Other significant predictors were a high American Society of Anesthesiologists classification score (odds ratio, 1.6), having a bile duct resection (OR, 1.7), and a low preoperative albumin level (OR, 1.6).
Renal insufficiency also significantly predicted postoperative respiratory failure (OR, 4.4). Other predictors of respiratory failure were older age (OR, 1.06) and cirrhosis (OR, 6.6).
Renal insufficiency was also a significant risk factor for renal failure, increasing the odds by 4.6.
The biggest predictor of 90-day mortality was hepatitis C, which conferred a ninefold increased risk. Cardiac disease also significantly increased the risk (OR, 2), as did bile duct resection (OR, 2.3), intraoperative transfusion (OR, 2) and cirrhosis (OR, 4.7).
Preoperative renal insufficiency did not significantly increase the risk of death, Dr. Squires noted.
"These findings should be taken into consideration when evaluating patients with preoperative renal insufficiency for hepatic resection," he said. "Careful patient selection and appropriate preoperative counseling are critical."
Dr. Squires had no financial disclosures.
MIAMI BEACH – Renal insufficiency significantly increased the risk of major complications after liver surgery.
However, it wasn’t associated with an increased risk of 90-day mortality, suggesting that patients with poor renal function shouldn’t be ruled out as surgical candidates, Dr. Malcolm Squires III said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"While they may be at a potential risk of major complications – renal failure and respiratory failure – we are ultimately able to get these patients through the postoperative period without any significant increase in mortality," said Dr. Squires of Emory University, Atlanta.
He presented a large retrospective study that examined postoperative outcomes in 1,170 patients (mean age, 57 years) who underwent major hepatectomy at three national academic hospitals from 2000 to 2012. The study determined the link between major complications and preoperative serum creatinine levels. These levels were dichotomized as normal (1.8 mg/dL or less) and elevated (greater than 1.8 mg/dL).
Most patients (1,148) had normal levels; only 22 had elevated serum creatinine, considered to be reflective of chronic renal insufficiency.
Pathology included cholangiocarcinoma, hepatocellular carcinoma, metastatic colorectal cancer, other cancers, and benign lesions. Cirrhosis was present in 4% and steatosis in 39%.
Most (83%) had open surgery; 17% had a laparoscopic procedure. The mean blood loss was 510 cc; 25% needed an intraoperative blood transfusion.
Postoperative complications arose in 56% of the group. A quarter (24%) had a major complication, including renal failure (3%) and respiratory failure (5%). Three-month mortality in the entire group was 5%.
In a multivariate model, preoperative renal insufficiency conferred a fourfold increased risk of developing a major postoperative complication. Other significant predictors were a high American Society of Anesthesiologists classification score (odds ratio, 1.6), having a bile duct resection (OR, 1.7), and a low preoperative albumin level (OR, 1.6).
Renal insufficiency also significantly predicted postoperative respiratory failure (OR, 4.4). Other predictors of respiratory failure were older age (OR, 1.06) and cirrhosis (OR, 6.6).
Renal insufficiency was also a significant risk factor for renal failure, increasing the odds by 4.6.
The biggest predictor of 90-day mortality was hepatitis C, which conferred a ninefold increased risk. Cardiac disease also significantly increased the risk (OR, 2), as did bile duct resection (OR, 2.3), intraoperative transfusion (OR, 2) and cirrhosis (OR, 4.7).
Preoperative renal insufficiency did not significantly increase the risk of death, Dr. Squires noted.
"These findings should be taken into consideration when evaluating patients with preoperative renal insufficiency for hepatic resection," he said. "Careful patient selection and appropriate preoperative counseling are critical."
Dr. Squires had no financial disclosures.
MIAMI BEACH – Renal insufficiency significantly increased the risk of major complications after liver surgery.
However, it wasn’t associated with an increased risk of 90-day mortality, suggesting that patients with poor renal function shouldn’t be ruled out as surgical candidates, Dr. Malcolm Squires III said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"While they may be at a potential risk of major complications – renal failure and respiratory failure – we are ultimately able to get these patients through the postoperative period without any significant increase in mortality," said Dr. Squires of Emory University, Atlanta.
He presented a large retrospective study that examined postoperative outcomes in 1,170 patients (mean age, 57 years) who underwent major hepatectomy at three national academic hospitals from 2000 to 2012. The study determined the link between major complications and preoperative serum creatinine levels. These levels were dichotomized as normal (1.8 mg/dL or less) and elevated (greater than 1.8 mg/dL).
Most patients (1,148) had normal levels; only 22 had elevated serum creatinine, considered to be reflective of chronic renal insufficiency.
Pathology included cholangiocarcinoma, hepatocellular carcinoma, metastatic colorectal cancer, other cancers, and benign lesions. Cirrhosis was present in 4% and steatosis in 39%.
Most (83%) had open surgery; 17% had a laparoscopic procedure. The mean blood loss was 510 cc; 25% needed an intraoperative blood transfusion.
Postoperative complications arose in 56% of the group. A quarter (24%) had a major complication, including renal failure (3%) and respiratory failure (5%). Three-month mortality in the entire group was 5%.
In a multivariate model, preoperative renal insufficiency conferred a fourfold increased risk of developing a major postoperative complication. Other significant predictors were a high American Society of Anesthesiologists classification score (odds ratio, 1.6), having a bile duct resection (OR, 1.7), and a low preoperative albumin level (OR, 1.6).
Renal insufficiency also significantly predicted postoperative respiratory failure (OR, 4.4). Other predictors of respiratory failure were older age (OR, 1.06) and cirrhosis (OR, 6.6).
Renal insufficiency was also a significant risk factor for renal failure, increasing the odds by 4.6.
The biggest predictor of 90-day mortality was hepatitis C, which conferred a ninefold increased risk. Cardiac disease also significantly increased the risk (OR, 2), as did bile duct resection (OR, 2.3), intraoperative transfusion (OR, 2) and cirrhosis (OR, 4.7).
Preoperative renal insufficiency did not significantly increase the risk of death, Dr. Squires noted.
"These findings should be taken into consideration when evaluating patients with preoperative renal insufficiency for hepatic resection," he said. "Careful patient selection and appropriate preoperative counseling are critical."
Dr. Squires had no financial disclosures.
AT AHPBA 2014
Major finding: Chronic preoperative renal insufficiency confers a fourfold increase in the risk of major complications after hepatic resection, although it did not increase the risk of 90-day mortality.
Data source: The retrospective study looked at postoperative outcomes in 1,170 patients.
Disclosures: Dr. Squires had no financial disclosures.