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Background Pancreaticoduodenectomy (PD) has long been associated with high rates of morbidity and mortality. The objective of this study was to identify preoperative risk factors for serious complications and mortality after PD and to construct a prediction tool to facilitate risk stratification prior to surgery. Materials and Methods Patients who underwent elective PD from 2005 to 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Multivariate logistic regression identified predictors of 30-day serious complications and mortality. A prediction tool was created and validated in a sample of 1254 patients. Results Of 4945 patients who underwent PD, 1342 (27.1%) suffered a serious complication and 127 (2.6%) died within 30 days. The most frequent complications were sepsis (15.3%), surgical site infection (13.1%), and respiratory complications (9.5%). After adjusting for potential confounders, the significant predictors of morbidity included older age, male gender, overweight and obesity, dependent functional status, chronic obstructive pulmonary disease (COPD), steroid use, bleeding disorder, leukocytosis, elevated serum creatinine, and hypoalbuminemia. Significant predictors of 30-day mortality included COPD, hypertension, neoadjuvant radiation therapy, elevated serum creatinine, and hypoalbuminemia. Multivariable models were used to construct a preoperative risk stratification tool. Conclusions Preoperative factors are associated with perioperative outcomes after PD. The prediction tool estimates the probability of early morbidity and mortality for patients undergoing PD. The tool may be used to provide information for patient counseling during the informed consent process and to identify high-risk patients for the purpose of tailoring perioperative care.

Background While pancreatic ductal adenocarcinoma is the most common form of pancreatic cancer, many other histologic forms of pancreatic cancer are also recognized. These histologic variants portray unique characteristics in terms of patient demographics, tumor behavior, survival, and responsiveness to treatments. Materials and Methods Patients who underwent surgical resection of the pancreas for non-metastatic, invasive pancreatic cancer between 2004 and 2014 were selected from the National Cancer Data Base and categorized by histologic variant according to WHO classification guidelines. Patient demographics, tumor variables, treatment characteristics, and survival were compared between histologic groups and subgroups. Results A total of 57,804 patients met inclusion and exclusion criteria and were grouped into eight major histologic categories. Survival analysis by the histologic group showed median overall survival of 20.2 months for ductal adenocarcinoma, 20.5 months for squamous cell carcinoma, 26.8 months for mixed acinar-neuroendocrine carcinomas, 52.6 months for cystic mucinous neoplasms with an associated invasive carcinoma, 67.5 months for acinar cell carcinoma, and 69.3 months for mesenchymal tumors. Median survival was not reached for neuroendocrine tumors and solid-pseudopapillary neoplasms, with 5-year overall survival rates of 84% and 97% respectively. Conclusions Rare subtypes of pancreatic cancer present unique clinicopathologic characteristics and display distinct tumor biologies. This study presents data on demographic, prognostic, treatment, and survival outcomes between rare forms of pancreatic neoplasms in order to aid understanding of the natural history and behavior of these neoplasms, with the hope of serving as a reference in clinical decision-making and ability to provide accurate prognostic information to patients.

Background The potential for malignant transformation varies among pancreatic cystic neoplasms (PCN) subtypes. Imaging and cyst fluid analysis are used to identify premalignant or malignant cases that should undergo operative resection, but the accuracy of operative decision-making process is unclear. The objective of this study was to characterize misdiagnoses of PCN and determine how often operations are undertaken for benign, non-premalignant disease. Methods A retrospective analysis of patients undergoing pancreatic resection for the preoperative diagnosis of PCN was undertaken. Preoperative and pathological diagnoses were compared to measure diagnostic accuracy. Results Between 1999 and 2011, 74 patients underwent pancreatic resection for the preoperative diagnosis of PCN. Preoperative classification of mucinous vs. non-mucinous PCN was correct in 74 %. The specific preoperative PCN diagnosis was correct in 47 %, but half of incorrect preoperative diagnoses were clinically equivalent to the pathological diagnoses. The likelihood that the pathological diagnosis was of higher malignant potential than the preoperative diagnosis was 7 %. In 20 % of cases, the preoperative diagnosis was premalignant or malignant, but the pathological diagnosis was benign. Diagnostic accuracy and the rate of undercall diagnoses and overcall operations did not change with the use of EUS or during the time period of this analysis. Conclusions Precise, preoperative classification of PCN is frequently incorrect but results in appropriate clinical decision-making in three-quarters of cases. However, one in five pancreatic resections performed for PCN was for benign disease with no malignant potential. An appreciation for the rate of diagnostic inaccuracies should inform our operative management of PCN.

Patient satisfaction is often measured using the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Our aim was to examine the structural and clinical determinants of satisfaction among inpatients with prolonged lengths of stays (LOS). Adult patients who were admitted between 2009 and 2012, had a LOS of 21 days or more, and completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey, were included. Univariate analyses assessed the relationship between satisfaction and patient/system variables. Recursive partitioning was used to examine the relative importance of the identified variables. One hundred one patients met inclusion criteria. The average LOS was 35 days and 58% were admitted to a surgical service. Satisfaction with physician communication was significantly associated with fewer consultations (P < .01), nonoperative admission (P < .001), no intensive care unit stay (P < .01), nonsurgical service (P < .01), and non-emergency room admissions (P = .03). Among these, having fewer consultations had the highest relative importance. In long stay patients, having fewer inpatient consultations was the strongest predictor of patient satisfaction with physician communication. This suggests that examination of patient-level data in clinically relevant subgroups may be a useful way to identify targets for quality improvement.

Abstract Currently, serum carcinoembryonic agent (CEA) along with contrast-enhanced imaging and colonoscopy are used for evaluation of recurrence of colorectal cancer. However, CEA is an unreliable and nonspecific biomarker that may fail to rise and signal relapse. Analysis of circulating tumor DNA (ctDNA) in patients offers a minimally invasive method to assess risk of relapse several months ahead of conventional clinical means. Here, we report the case of a colon adenocarcinoma with postoperative liver metastasis diagnosed early by ctDNA measurement, using a personalized NGS-mPCR assay. While ctDNA levels continued to rise, CEA levels tested negative. Metastatic relapse to the liver was promptly confirmed by PET/CT scan. The patient underwent a successful metastasectomy with curative intent. Following surgery, the patient exhibited no evidence of disease and ctDNA levels remained negative. Our case report suggests that the early detection of postoperative molecular residual disease by means of ctDNA measurement can accurately predict mCRC relapse in cases where CEA levels fail to increase. Close monitoring of ctDNA levels during the postoperative period can allow for earlier intervention and more favorable outcomes in relapsing mCRC patients.

Background: Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective. Objective: To assess patient-rated complication severity and determine concordance with existing grading systems. Methods: A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked. Results: One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest. Conclusion: Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

Background The effect of routine drainage after abdominal surgery with enteric anastomoses is controversial. In particular, the role of peritoneal drain (PD) placement after total gastrectomy for adenocarcinoma is not well established. Methods Patients who underwent total gastrectomy for gastric adenocarcinoma (GAC) at seven institutions from the US Gastric Cancer Collaborative, from 2000 to 2012, were identified. The association of PD placement with postoperative outcomes was analyzed. Results Overall, 344 patients were identified and 253 (74 %) patients received a PD. The anastomotic leak rate was 9 %. Those with PD placement had similar American Society of Anesthesiologists score, tumor size, TNM stage, and the need for additional organ resection when compared with their counterparts. No difference was observed in the rate of any complication (54 vs. 48 %; p   =  0.45), major complication (25 vs. 24 %; p   =  0.90), or 30-day mortality (7 vs. 4 %; p   =  0.51) between the two groups. In addition, no difference in anastomotic leak (9 vs. 10 %; p   =  0.90), the need for secondary drainage (10 vs. 9 %; p   =  0.92), or reoperation (13 vs. 8 %; p   =  0.28) was identified. On multivariate analysis, PD placement was not associated with decreased postoperative complications. Subset analysis, stratified by patients who did not undergo concomitant pancreatectomy ( n   =  319) or those who experienced anastomotic leak ( n   =  31), similarly demonstrated no association of PD placement with reduced complications or mortality. Conclusions PD placement after total gastrectomy for GAC is associated with neither a decrease in the frequency and severity of adverse postoperative outcomes, including anastomotic leak and mortality, nor a decrease in the need for secondary drainage procedures or reoperation. Routine use of PDs is not warranted.

For patients with small bowel obstruction (SBO), surgical care has been associated with improved outcomes; however, it remains unknown how it impacts satisfaction. Patients admitted for SBO who completed the hospital satisfaction survey were eligible. Only those with adhesions or hernias were included. Chart review extracted structural characteristics and outcomes. Forty-seven patients were included; 74% (n = 35) were admitted to a surgical service. Twenty-six percent of the patients (n = 12) were admitted to medicine, and 50% of those (n = 6) had surgical consultation. Patients with surgical involvement as the consulting or primary service (SURG) had higher satisfaction with the hospital than those cared for by the medical service (MED) (80% SURG, 33% MED, P = .015). SURG patients also had higher satisfaction with physicians (74% SURG, 44% MED, P = .015). Surgical involvement during SBO admissions is associated with increased patient satisfaction, and adds further weight to the recommendation that these patients be cared for by surgeons.

Background In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes. Study Design Patients undergoing PR from 2005–2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR. Results The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % ( p  < 0.001) and 4.5 vs. 2.0 % ( p  < 0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % ( p  < 0.001) and 8.6 vs. 2.2 % ( p  < 0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality. Conclusions In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.

Video-based surgical coaching is gaining traction within the surgical community. It has an increasing adoption rate and growing recognition of its utility, especially an advanced continuous professional growth tool, for continued educational purposes. This method offers instructional flexibility in real-time remote settings and asynchronous feedback scenarios. In our first paper, we delineated fundamental principles for video-based coaching, emphasizing the customization of feedback to suit individual surgeon’s needs. In this second part of the series, we review into practical applications of video-based coaching, focusing on quality improvements in a team-based setting, such as the trauma bay. Additionally, we address the potential risks associated with surgical video recording, storage, and distribution, particularly regarding medicolegal aspects. We propose a comprehensive framework to facilitate the implementation of video coaching within individual healthcare institutions. Our paper examines the legal and ethical framework and explores the potential benefits and challenges, offering insights into the real-world implications of this educational approach. This paper contributes to the discourse on integrating video-based coaching into continuous professional development. It aims to facilitate informed decision-making in healthcare institutions, considering the adoption of this innovative educational quality tool.