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IntroductionAssessment of regional lymph nodes (LN) is essential for determining prognosis among patients with gallbladder cancer (GBC). The impact of surgical technique on LN yield has not been well explored. We investigated the impact of minimally invasive surgery (MIS; robotic or laparoscopic) on the evaluation and retrieval of regional LN for patients with GBC.MethodsWe queried the National Cancer Database (NCDB) to identify patients with GBC who underwent curative-intent surgery between 2010 and 2015. Patients with metastatic disease or those with missing data on surgical resection or LN evaluation were excluded.ResultsWe identified 2014 patients who underwent an open (n = 1141, 56.6%) or MIS approach (n = 873, 43.4%) for GBC and met the inclusion criteria. Patients who underwent MIS were older (open: 68 years, IQR: 60, 75 vs. MIS: 70 years, IQR (61, 77); P = 0.02), and were more commonly treated at a comprehensive community cancer program (P < 0.001). Approximately 3 out of 4 patients (n = 1468, 72.9%) underwent an evaluation of regional LN, with nearly half of these patients (n = 607, 41.7%) having LN metastasis. Among patients who underwent a regional lymphadenectomy, average lymph node yield was 3 (IQR: 1, 6) and was similar between the two groups (P = 0.04). After controlling for all factors, operative approach was not associated with likelihood of receiving a lymphadenectomy during curative-intent resection (OR 0.81, 95% CI 0.63–1.04; P = 0.11).ConclusionIn conclusion, patients undergoing curative-intent resection for GBC had similar rates of lymph node evaluation and yield regardless of operative approach. Over one-quarter of patients did not undergo a lymphadenectomy at the time of surgery. Further studies are needed to identify barriers to lymph node evaluation and yield among patients undergoing surgery for gallbladder cancer. Presented at the 2019 2nd World Congress of the International Laparoscopic Liver Society, Tokyo, Japan

Background Better outcomes at high-volume surgical centers have driven regionalization of complex surgical care. In turn, access to high-volume centers often requires travel over longer distances. We sought to characterize travel patterns among patients who underwent a hepatectomy. Methods The California Office of Statewide Health Planning database was used to identify patients who underwent hepatectomy between 2005 and 2016. Total distance traveled and whether a patient bypassed the nearest hospital that performed hepatectomy to get to a higher-volume center were assessed. Multivariate analyses were used to identify factors associated with bypassing a local hospital for a higher-volume center. Results Overall, 13,379 adults underwent a hepatectomy in 229 hospitals; only 26 hospitals were high volume ( >  15 cases/year). Median travel time to a hospital that performed hepatectomy was 25.2 min (IQR: 13.1–52.0). The overwhelming majority of patients (91.6%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, 75.5% went to a high-volume hospital. Outcomes at destination hospitals were improved compared with nearest hospitals (incidence of complications: 20.4% vs. 22.9% %; failure-to-rescue: 7.1% vs 10.9%; mortality 1.5% vs. 2.6%). Medicaid beneficiaries (OR 0.69, 95%CI 0.56–0.85) were less likely to bypass the nearest hospital to go to a high-volume hospital; additionally, Medicaid patients were less likely to undergo hepatectomy at a high-volume hospital independent of bypassing the nearest hospital (OR 0.60, 95%CI 0.48–0.76). Among the 3703 patients who underwent hepatectomy at a low-volume center, 2126 patients had actually bypassed a high-volume hospital. Among the remaining 1577 patients, 95% of individuals would have needed to travel less than 1 additional hour to reach a high-volume center. Conclusion Roughly, one-quarter of patients undergoing hepatectomy received care at a low-volume center; nearly all of these patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center. Travel distance needs to be considered in policies and healthcare delivery design to improve care of patients undergoing hepatic resection.

Background Pancreatic diseases have long been associated with impaired glucose control. This study sought to identify the incidence of new insulin-dependent diabetes mellitus (IDDM) after pancreatectomy and the predictive accuracy of hemoglobin A1c (HbA1c) or blood glucose. Methods Patients who underwent partial pancreatectomy and had preoperative HbA1c available at two academic institutions were assessed for new IDDM on discharge in relation to complication rates and survival. Results Of the 267 patients analyzed, 67% had abnormal HbA1c levels prior to surgery (mean 6.8%, glucose 135 mg/dL). Two hundred eight (77.9%) were not insulin-dependent prior to surgery, and 35 (16.8%) developed new IDDM after resection. On multivariable regression, increasing HbA1c and preoperative glucose were the only significant predictors for new IDDM. Optimal predictive cutoffs (HbA1c of 6.25% and glucose of 121 mg/dL) were determined in a discovery group ( n = 143) and confirmed in a validation group ( n = 124) with a diagnostic sensitivity of 72.7% and specificity of 84.8%. Patients with new IDDM after resection had higher rates of severe complications (OR 3.39), increased TPN at discharge (OR 4.32), and increased rates of discharge to nursing facilities (OR 2.57) (all P < 0.05). New IDDM was also associated with a decreased cancer-specific survival. Conclusion Preoperative HbA1c ≥ 6.25% and blood glucose ≥ 121 mg/dL can accurately identify patients at increased risk of IDDM. These diagnostics may help identify patients in a preoperative setting that may benefit from interventions such as diabetes education or enhanced glucose control preoperatively.

Background Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias. Methods After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student’s t test, the Mann–Whitney U test, chi-square, and Fisher’s exact test as appropriate. Results The review showed that 172 patients had undergone either open mesh repair ( n  = 61) or laparoscopic mesh repair ( n  = 111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group ( p  = 0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias ( p  = 0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation ( p  = 0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group ( p  = 0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias ( p  = 0.59). Conclusions This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.

A 60-year-old man was found to have an incidental pancreatic cystic lesion (PCL) during surveillance magnetic resonance imaging (MRI) for a known left renal lesion. Endoscopic ultrasound (EUS) revealed a 2.6 x 2.0 cm cystic lesion with a single thick septation in the pancreatic tail (Video 1). Needle-based confocal laser endomicroscopy (nCLE) was performed with an AQ-Flex-19 miniprobe (Cellvizio; Mauna Kea Technologies Inc, Paris, France). This demonstrating nests of cells surrounded by fibrous septae and vascularity, suggestive of a cystic pancreatic neuroendocrine tumor (PNET) [Figure 1, Video 1]. A pattern of vacuolization was also observed (Figure 2, Video 1). Fine needle aspiration (FNA) with immunostaining confirmed the diagnosis of a well-differentiated PNET. The patient underwent distal pancreatectomy and splenectomy. Histopathology of the surgical specimen showed a well-circumscribed mixed solid-cystic lesion. Synaptophysin immunostaining was reactive and chromatin demonstrated a salt-and-pepper pattern, consistent with a well-differentiated PNET (Video 1). Additionally, the tumor cells contained hyaline globules of varying sizes within the cytoplasm (Figure 3), which correlated with the vacuolization image pattern seen on nCLE. The presence of these globules has been described in PNETs and solid pseudopapillary tumors, with the descriptive appearance of cytoplasmic vacuolization.1 A similar pattern has been attributed to the presence of cytoplasmic lipid, more common in cystic NETs.2 EUS-nCLE findings thus far described in cystic PNETs include a trabecular network of dark cells with surrounding fibrosis and vascularity.3 This case presents a unique recurring feature of vacuolization that correlated with a comparable histopathological pattern. This spectrum of nCLE image patterns of cystic-NET can further assist in differentiation of PCLs.

Introduction: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a nationally recognized, publicly reported, standardized instrument used to measure patients' perceptions of their hospital experience. The aim of this study is to determine which survey instrument questions are associated with high HCAHPS scores in patients (pts) hospitalized with acute pancreatitis (AP). Methods: HCAHPS surveys were randomly administered to discharged pts with AP (n=318). The primary outcome, \"patients' satisfaction\", was judged by overall hospital rating(1-10 scale): A score of 9 or 10 was considered SATISFIED while scores less than 9 are considered NOT SATSIFIED. For the secondary outcome, \"willingness to recommend the hospital\", choosing that they would \"definitely\" recommend the hospital was considered a positive response. Binary variables were derived to represent each criteria of interest. A univariate analysis and subsequent adjustments for confounders using fitted logistic regression models were used for this analysis. Significance was determined using Holm's method with a family-wise p value =.05 Results: 299 responders [NOT SATISFIED, n=96; SATISFIED, n=203] were included in the final analyses. Groups were similar with the exception that SATISFIED responders were older (57 vs 53yr; p=.006, Table 1). Perception of adequate pain control did not impact patients' satisfaction [adjusted odd ratio (aOR)=1.07 p=.874] or willingness to recommend the hospital (aOR=1.46 p=.326). However, courtesy/respect (aOR=10.18 p=.001, 5.16 p=.007), and effective communication with nurses and doctors (aOR=4.01 p< .0002, 3.97 p< .0002), and positive facilities rating (aOR=4.01 p < .0002, 3.97 p < .002) were all positively associated with patients' satisfaction and willingness to recommend the hospital (Table 2). Conclusion: In hospitalized AP pts, perceived courtesy/respect, effective communication, facility cleanliness and quietness impacted HCAHPS score. Perception of adequate pain control had no impact on HCAHPS scores. Facility-based interventions intended to improve patients' experience should be directed to these domains to be effective. Additional studies involving larger sample size are needed to validate these findings.

Introduction: Prior studies have validated EUS-guided needle-based confocal laser endomicroscopy (nCLE) diagnosis of IPMNs by detection of characteristic papillae. We sought to further assess the performance and interobserver agreement (IOA) of EUS-nCLE for differentiating IPMNs with high grade dysplasia (HGD) or adenocarcinoma (HGD-Ca) from those with low or intermediate-grade dysplasia (LGD). Methods: In a prospective single center study evaluating EUS-nCLE for the evaluation of pancreatic cysts, 26 patients with a definitive diagnosis of IPMNs (surgery=24; confirmatory cytology/metastatic adenocarcinoma=2) were identified. EUS-nCLE imaging variables predictive (Table 1) of advanced neoplasia were internally derived amongst 3 EUS-MDs with experience in nCLE (Fig. 1). Six external endosonographers (nCLE experience>30 cases) blinded to all clinical data, reviewed all nCLE videos (Fig. 2). After 2 weeks, the assessors reviewed the same images in a different sequence. A self-study tutorial of nCLE variables predictive of HGD-Ca was provided before each review. Prior to the second review, an interactive web-based discussion was also conducted. The IOAs (к statistic) of diagnostic nCLE image patterns to detect HGD-Ca were calculated. Results: Among the subjects with IPMNs (16 mixed, 10 branch-duct; mean size 3.4±1.7 cm), there were 9 with LGD and 17 with advanced neoplasia (12 HGD, 2 non-invasive and 3 invasive adenocarcinoma). The six observers identified papillary structures diagnostic of IPMN in all videos. The overall sensitivity, speci-ficity, accuracy, and IOA of EUS-nCLE to diagnose HGD-Ca was 90%, 73%, 84%, and к=0.54 (moderate), respectively (Table 1). Correlating with histopathological progression of dysplasia in IPMNs, nCLE imag-ing characteristics of papillary \"thickness\" (indicative of cellular and nuclear stratification) and \"darkness\" (increased nuclear/cytoplasmic ratio) were the most sensitive (90% and 91%) and accurate (86% and 84%) with substantial (к=0.61) and moderate (к=0.55) IOAs for detecting HGD-Ca, respectively (Table 1). Conclusion: In this derivation study, blinded expert endosonographers identified several EUS-nCLE imaging features of IPMNs that are associated with advanced neoplasia. Further studies are needed to refine and validate these features for applying EUS-nCLE to identify advanced dysplasia.