John Christein - Academia.edu (original) (raw)

Papers by John Christein

Research paper thumbnail of Preoperative Detection of Malignant Transformation in a Choledochal Cyst

Clinical Gastroenterology and Hepatology the Official Clinical Practice Journal of the American Gastroenterological Association, Dec 1, 2010

A 27-year-old female patient presented with jaundice and upper abdominal pain. Physical examinati... more A 27-year-old female patient presented with jaundice and upper abdominal pain. Physical examination revealed scleral icterus and right upper quadrant abdominal tenderness. Laboratory investigations were significant for total bilirubin of 6.7 mg/dL (normal, 0.2–1.3 mg/dL) and alkaline ...

Research paper thumbnail of Prospective Randomized Trial Comparing Endoscopic Ultrasound (EUS) and Gastroscopy (EGD) for Trans-Mural Drainage of Pancreatic Pseudocysts

Gastrointest Endoscop, 2008

Research paper thumbnail of Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy

Annals of Surgery, 2015

To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative... more To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator. Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk. This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance. There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment. This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

Research paper thumbnail of Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy

Surgery, Jan 6, 2015

Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after... more Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C). ACB values were derived from fistula severity scores based on the Modified Accordion Severity Grading. The ACB of POPFs was compared between PD and DP. POPFs were more common after DP compared with PD (34.5 vs 27.2%; P < .001); however, the incidence of any complication was greater after PD (64.9 vs 53.2%; P < .001). When POPFs occurred, they were more likely to be the highest-graded complication after DP compared with PD (65.1 vs...

Research paper thumbnail of 298 Endoscopic Transmural Drainage of Pancreatic Fluid Collections (PFCs) in 200 Consecutive Patients: An Assessment of Outcomes

Data Revues 00165107 V73i4ss S0016510711002586, Apr 1, 2011

Research paper thumbnail of Durability of portal venous reconstruction following resection during pancreaticoduodenectomy

Journal of Gastrointestinal Surgery, Dec 31, 2006

Venous resection and reconstruction is becoming more common during pancreaticoduodenectomy (PD). ... more Venous resection and reconstruction is becoming more common during pancreaticoduodenectomy (PD). There are multiple options for reconstruction of the mesenteric venous system ranging from primary repair to grafting with autologous or synthetic material. Few studies report on the patency rates and long-term morbidity of these repairs. We sought to describe our experience with venous reconstruction during PD with specific attention to patency and long-term morbidity and mortality. Thrombosis rates of mesenteric venous reconstruction during PD are low, with low associated morbidity. In this retrospective cohort, clinical, operative, and pathologic data were collected from consecutive patients for 1988 through 2003. Graft patency on follow-up imaging studies was determined, and short- as well as long-term morbidity and mortality were recorded. Sixty-four patients underwent PD with venous resection/reconstruction from 1988 through 2003. Mean patient age was 63 years, with pancreatic ductal adenocarcinoma as the pathology in 88%. Reconstruction consisted of primary lateral venorrhaphy in 29 (45%), PTFE graft in 18 (28%), primary end-to-end repair in 13 (20%), and autologous vein graft in 4 (6%). There was one perioperative death (2%). Follow-up imaging to assess patency was available for a mean of 12.2 months postoperatively. Eleven thromboses were diagnosed at a mean of 11.9 months. Three thromboses (5%) were noted within 30 days and full anticoagulation was chosen. Fifty-three percent of patients received anticoagulation with aspirin, warfarin, or clopidogrel based upon surgeon preference. There was no difference in thrombosis rates between those receiving anticoagulation and those who did not (P = 0.65). In those patients with thrombosis outside the acute time period, morbidity was limited to ascites in three patients and splenic vein thrombosis with uncomplicated esophageal varices in another patient. Mesenteric venous resection and reconstruction during PD has a high patency rate, and those reconstructions that do thrombose are associated with a low morbidity. The majority of reconstruction thromboses that occurred late were associated with recurrence.

Research paper thumbnail of 559 Applying Proteomics Based Biomarker Tools for the Accurate Diagnosis of Pancreatic Cancer

Research paper thumbnail of Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes/DISCUSSION

The American Surgeon, Aug 1, 2009

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 19... more Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01), blood loss (157 vs 719 mL, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01), and length of stay (5.9 vs 8.6 days, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

Research paper thumbnail of Argo JL, Contreras JL, Wesley MM, et al. Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis

The American surgeon

ABSTRACT

Research paper thumbnail of Argo JL, Contreras JL, Wesley MM, et al. Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis

The American surgeon

ABSTRACT

Research paper thumbnail of The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy

Journal of Gastrointestinal Surgery, 2015

International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas... more International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas (POPF) are the greatest contributor to major morbidity and mortality following pancreatoduodenectomy (PD); however, their infrequent occurrence has hindered deeper analysis. This study sought to develop a predictive algorithm, which could facilitate effective management of this challenging complication. Data were accrued from 4301 PDs worldwide. Demographics, postoperative management, and microbiological characteristics of grade C POPFs were evaluated. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) preoperative and intraoperative variables were compared between grade C POPFs and a 639-case sample of non-grade C POPFs. Risk factors for grade C POPF formation were identified using regression analysis. Grade C POPFs developed in 79 patients (1.8 %). Deaths (90 days) occurred in 2.0 % (N = 88) of the overall series, with 35 % (N = 25) occurring in the presence of a grade C POPF. Reoperations occurred 72.2 % of the time. The rates of single- and multi-system organ failure were 28.2 and 39.7 %, respectively. Mortality rates escalated with pulmonary, renal, and neurologic organ failure, but they were unaffected by reoperation(s). The median number of complications incurred was four (IQR: 2-5), and the median duration of hospital stay was 32 (IQR: 21-54) days. Warning signs for impending grade C POPFs most often presented on postoperative day (POD) 6. Adjuvant chemotherapy might have benefited 55.7 % of grade C POPF patients, yet it was delayed in 25.6 % and never delivered in 67.4 % of these patients. Predictive models for grade C POPF occurrence based on preoperative factors alone and preoperative and intraoperative factors yielded areas under the receiver operating characteristic curve of 0.73 and 0.84 (both P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.000001), respectively. This global study represents the largest analysis of grade C POPFs following PD. It describes the severe burden that grade C POPFs incur on patients, with high rates of reoperation and infection, while also potentially worsening overall survival by causing death and delay/omission of adjuvant therapy. Additionally, aggressive clinical management for these POPFs did not improve or worsen 90-day mortality. Predictive tools developed through these data may provide value in managing this difficult complication.

Research paper thumbnail of Biliary metal stents are superior to plastic stents for preoperative biliary decompression in pancreatic cancer

Surgical Endoscopy, 2011

Background It is unclear whether plastic or metal stents are more suitable for preoperative bilia... more Background It is unclear whether plastic or metal stents are more suitable for preoperative biliary decompression in pancreatic cancer. The objective of this study was to compare the rate of endoscopic reinterventions in patients with pancreatic cancer undergoing plastic or self-expandable metal stent (SEMS) placements for preoperative biliary decompression. Methods This was a retrospective study of all patients with obstructive jaundice secondary to pancreatic head cancer who underwent their index endoscopic retrograde cholangiopancreatography (ERCP) and all follow-up biliary stent placements at our center before undergoing pancreaticoduodenectomy. Plastic or SEMS were placed at ERCP for biliary decompression. The main outcome measure was to compare the rate of endoscopic reinterventions between the plastic and SEMS cohorts. Results 29 patients who underwent pancreaticoduodenectomy had preoperative biliary stent placement (18 plastic, 11 SEMS) at our center. Whereas none of the 11 patients who Electronic supplementary material The online version of this article (

Research paper thumbnail of Progress in the management of necrotizing pancreatitis

Expert review of gastroenterology & hepatology

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in sig... more Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was si...

Research paper thumbnail of Stenting versus gastrojejunostomy for management of malignant gastric outlet obstruction: comparison of clinical outcomes and costs

Surgical Endoscopy, 2012

Background Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ... more Background Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ) is still considered the gold standard for relief of malignant gastric outlet obstruction (GOO). The aim of this study is to compare clinical outcomes and hospital costs between patients undergoing GJ or stenting for management of malignant GOO. Methods A retrospective claims analysis of the Medicare (MedPAR) database was conducted to identify all inpatient hospitalizations for GJ or endoscopic stenting for malignant GOO during 2007-2008. The main outcome measure evaluated using the MedPAR database was a comparison of the total length of hospital stay (LOS) and costs associated with both techniques. As MedPAR is a claims database that does not provide outcomes at patient level, a single-institution retrospective study was conducted to compare the rates of technical and treatment success, post-procedure LOS, and delayed complications per patient between the two techniques. Results The MedPAR claims data evaluated 425 stenting and 339 GJ hospitalizations. Compared with GJ, median LOS (8 vs. 16 days; p \ 0.0001) and median cost (US 15,366vs.US15,366 vs. US 15,366vs.US27,391; p \ 0.0001) per claim were both significantly lower for stenting. Stenting was more commonly performed at urban versus rural hospitals (89 % vs. 11 %; p \ 0.0001), teaching versus non-teaching hospitals (59 % vs. 41 %, p = 0.0005), and academic institutions (56 % vs. 44 %; p = 0.0157). The institutional patient data analysis included 29 patients who underwent stenting and 75 who underwent surgical GJ. While both modalities were technically successful and relieved gastric outlet obstruction in all cases, compared with surgical GJ, the median post-procedure LOS was significantly lower for enteral stenting (1.5 vs. 10.7 days, p \ 0.0001). There was no difference in rates of delayed complications between stenting and surgical GJ (13.8 % vs. 6.7 %; p = 0.26). Conclusions While the technical and clinical outcomes of surgical GJ and endoscopic stenting appear comparable, stent placement is less costly and is associated with shorter length of hospital stay. Dissemination of endoscopic stenting beyond teaching, academic hospitals located in urban areas as a treatment for malignant GOO is important given its implications for patient care and resource utilization. Keywords Duodenal stenting Á Gastrojejunostomy Á Costs Á Health resource use Gastric outlet obstruction (GOO) is a common symptom, occurring in 15-20 % of patients with locally advanced gastrointestinal cancer [1-3]. Clinical manifestations of Podium presentation: Digestive Disease Week

Research paper thumbnail of Abstract 4612: JQ1 suppresses tumor growth in tumorgraft models of pancreatic ductal adenocarcinoma

Research paper thumbnail of Preliminary General Surgery Residents: Indentured Servitude or Golden Opportunity?

Current Surgery, 2006

One-year, preliminary general surgery (GS) positions are viewed by medical student applicants as ... more One-year, preliminary general surgery (GS) positions are viewed by medical student applicants as among the least desirable positions offered through the match. Hundreds of preliminary GS positions go unfilled each year, and international medical graduates (IMGs) fill a substantial portion of the spots filled. &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Prelims&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; foster diversity and add manpower to surgical training programs, but do trainees eventually benefit from this 1-year effort? Nondesignated (ND) preliminary GS residents at the Mayo Clinic, Rochester, Minnesota, were identified from 1993 to 2003. Trainees were followed (telephone, e-mail, Internet registries) looking at subsequent training, specialty choice, and eventual practice location. From 118 ND preliminary GS residents, the current data of 105 (46 U.S. medical graduates, 59 IMGs) trainees are known. Thirteen trainees (11%) progressed on to a second year of training (location: United States=10, international=3), but they could not be located thereafter. Two additional prelims chose another profession. Seventy one of the remaining 103 prelims (70%) advanced to other non-Mayo residency programs to continue or finish their training in general surgery (n=22), a surgical subspecialty (n=26), or some other field (n=23). Thirty-two prelims remained at Mayo Clinic-Rochester in GS (n=16), a surgical subspecialty (n=12), or a nonsurgical field (n=4). From the 59 IMGs, 52 remained in the United States, whereas 7 left for another country to practice medicine. Most of our ND preliminary GS residents progress toward completion of surgical or medicine residencies. Although initially described as a finite period of training, the 1-year preliminary GS residency offers both U.S. and international students opportunity for career advancement.

Research paper thumbnail of Intraductal papillary carcinoma of common bile duct diagnosed by endoscopic ultrasound-guided fine-needle aspiration

Research paper thumbnail of Endoscopic Transmural Drainage of Peripancreatic Fluid Collections: Outcomes and Predictors of Treatment Success in 211 Consecutive Patients

Journal of Gastrointestinal Surgery, 2011

Objectives Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid c... more Objectives Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections. Methods This is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7 years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively. Results A total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6 mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356 days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, p<0.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, p=0.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted OR=7.6, 95% CI [2.9, 20.1], p<0.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection. Conclusions Endoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

Research paper thumbnail of Patterns of Failure for Lymph Node-Positive Resected Pancreatic Adenocarcinoma After Adjuvant Radiotherapy or Gemcitabine-based Chemotherapy Alone

Journal of Gastrointestinal Cancer, 2015

The purpose of this study was to investigate the effect of radiotherapy on local control and mord... more The purpose of this study was to investigate the effect of radiotherapy on local control and mordibity for patients with resected lymph node-positive pancreatic cancer as compared to gemcitabine-based chemotherapy alone. Sixty-nine patients received adjuvant therapy for pancreatic adenocarcinoma with lymph node involvement after surgical resection and met the inclusion criteria for this analysis. Forty (58 %) patients received postoperative radiotherapy (PORT) to a median dose of 50.4 Gy with capecitabine or 5-fluorouracil concurrently in all but one case; 15 patients also received gemcitabine prior to PORT. Twenty-nine (42 %) patients received gemcitabine-based chemotherapy without PORT for a median of 6 cycles. The median overall survival for patients receiving PORT was 24.4 months compared to 25.6 months for patients not receiving PORT (p = 0.943). At 2 years, the rate of local control was 57 % for patients receiving PORT compared to 37 % for those who did not (p = 0.034). At 2 years, the rate of palliative local interventions was 16 % for patients receiving PORT compared to 18 % for patients who did not (p = 0.821). The use of PORT was associated with improved local control in the gemcitabine era for patients with resected, node-positive, pancreatic adenocarcinoma. The rates of overall survival and palliative interventions did not differ between the two groups.

Research paper thumbnail of Applying Proteomic-Based Biomarker Tools for the Accurate Diagnosis of Pancreatic Cancer

Journal of Gastrointestinal Surgery, 2008

Background The proteome varies with physiologic and disease states. Few studies have been reporte... more Background The proteome varies with physiologic and disease states. Few studies have been reported that differentiate the proteome of those with pancreatic cancer. Aim To apply proteomic-based technologies to body fluids. To differentiate pancreatic neoplasia from nonneoplastic pancreatic disease. Methods Samples from 50 patients (15 healthy (H), 24 cancer (Ca), 11 chronic pancreatitis (CP)) were prospectively collected and underwent analysis. A high-throughput method, using high-affinity solid lipophilic extraction resins, enriched low molecular weight proteins for extraction with a high-speed 200-Hz matrix-assisted laser desorption/ionization time-offlight mass spectrometer (MALDI-MS; Bruker Ultraflex III). Samples underwent software processing with FlexAnalysis, Clinprot, MatLab, and Statistica (baseline, align, and normalize spectra). Nonparametric pairwise statistics, multidimensional scaling, hierarchical analysis, and leave-one-out cross validation completed the analysis. Sensitivity (sn) and specificity (sp) of group comparisons were determined. Two top-down-directed protein identification approaches were combined with MALDI-MS and tandem mass spectrometry to fully characterize the most significant protein biomarker. Results Using eight serum features, we differentiated Ca from H (sn 88%, sp 93%), Ca from CP (sn 88%, sp 30%), and Ca from both H and CP combined (sn 88%, sp 66%). In addition, nine features obtained from urine differentiated Ca from both H and CP combined with high efficiency (sn 90%, sp 90%). Interestingly, the plasma samples (considered by the Human Proteome Organization to be the preferred biological fluid) did not show significant differences. Multidimensional scaling indicated that markers from both serum and urine led to a highly effective clinical indicator of each specific disease state. Conclusions The proteomic analysis of noninvasively acquired biological fluids provided a high level of predictability for diagnosing pancreatic cancer. While the proteomic analysis of serum was capable of screening individuals for pancreatic disease (i.e., CP and Ca vs. H), specific urine biomarkers further distinguished malignancy (Ca) from chronic inflammation (CP).

Research paper thumbnail of Preoperative Detection of Malignant Transformation in a Choledochal Cyst

Clinical Gastroenterology and Hepatology the Official Clinical Practice Journal of the American Gastroenterological Association, Dec 1, 2010

A 27-year-old female patient presented with jaundice and upper abdominal pain. Physical examinati... more A 27-year-old female patient presented with jaundice and upper abdominal pain. Physical examination revealed scleral icterus and right upper quadrant abdominal tenderness. Laboratory investigations were significant for total bilirubin of 6.7 mg/dL (normal, 0.2–1.3 mg/dL) and alkaline ...

Research paper thumbnail of Prospective Randomized Trial Comparing Endoscopic Ultrasound (EUS) and Gastroscopy (EGD) for Trans-Mural Drainage of Pancreatic Pseudocysts

Gastrointest Endoscop, 2008

Research paper thumbnail of Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy

Annals of Surgery, 2015

To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative... more To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator. Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk. This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance. There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.00001) and octreotide (odds ratio 3.30, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment. This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

Research paper thumbnail of Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy

Surgery, Jan 6, 2015

Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after... more Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C). ACB values were derived from fistula severity scores based on the Modified Accordion Severity Grading. The ACB of POPFs was compared between PD and DP. POPFs were more common after DP compared with PD (34.5 vs 27.2%; P < .001); however, the incidence of any complication was greater after PD (64.9 vs 53.2%; P < .001). When POPFs occurred, they were more likely to be the highest-graded complication after DP compared with PD (65.1 vs...

Research paper thumbnail of 298 Endoscopic Transmural Drainage of Pancreatic Fluid Collections (PFCs) in 200 Consecutive Patients: An Assessment of Outcomes

Data Revues 00165107 V73i4ss S0016510711002586, Apr 1, 2011

Research paper thumbnail of Durability of portal venous reconstruction following resection during pancreaticoduodenectomy

Journal of Gastrointestinal Surgery, Dec 31, 2006

Venous resection and reconstruction is becoming more common during pancreaticoduodenectomy (PD). ... more Venous resection and reconstruction is becoming more common during pancreaticoduodenectomy (PD). There are multiple options for reconstruction of the mesenteric venous system ranging from primary repair to grafting with autologous or synthetic material. Few studies report on the patency rates and long-term morbidity of these repairs. We sought to describe our experience with venous reconstruction during PD with specific attention to patency and long-term morbidity and mortality. Thrombosis rates of mesenteric venous reconstruction during PD are low, with low associated morbidity. In this retrospective cohort, clinical, operative, and pathologic data were collected from consecutive patients for 1988 through 2003. Graft patency on follow-up imaging studies was determined, and short- as well as long-term morbidity and mortality were recorded. Sixty-four patients underwent PD with venous resection/reconstruction from 1988 through 2003. Mean patient age was 63 years, with pancreatic ductal adenocarcinoma as the pathology in 88%. Reconstruction consisted of primary lateral venorrhaphy in 29 (45%), PTFE graft in 18 (28%), primary end-to-end repair in 13 (20%), and autologous vein graft in 4 (6%). There was one perioperative death (2%). Follow-up imaging to assess patency was available for a mean of 12.2 months postoperatively. Eleven thromboses were diagnosed at a mean of 11.9 months. Three thromboses (5%) were noted within 30 days and full anticoagulation was chosen. Fifty-three percent of patients received anticoagulation with aspirin, warfarin, or clopidogrel based upon surgeon preference. There was no difference in thrombosis rates between those receiving anticoagulation and those who did not (P = 0.65). In those patients with thrombosis outside the acute time period, morbidity was limited to ascites in three patients and splenic vein thrombosis with uncomplicated esophageal varices in another patient. Mesenteric venous resection and reconstruction during PD has a high patency rate, and those reconstructions that do thrombose are associated with a low morbidity. The majority of reconstruction thromboses that occurred late were associated with recurrence.

Research paper thumbnail of 559 Applying Proteomics Based Biomarker Tools for the Accurate Diagnosis of Pancreatic Cancer

Research paper thumbnail of Laparoscopic and Open Distal Pancreatectomy: A Comparison of Outcomes/DISCUSSION

The American Surgeon, Aug 1, 2009

Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 19... more Laparoscopic (lap) pancreatic surgery has been increasingly reported since its introduction in 1992. A retrospective analysis of consecutive patients undergoing elective lap and open distal pancreatectomy from 2002 to 2007 was performed. Univariate analysis was completed to evaluate perioperative variables. Logistic regression analysis was used to model predictors of postoperative pancreatic fistula. One hundred forty-eight subjects underwent distal pancreatectomy; 98 completed open, 44 lap, and six converted to open. There was no significant difference in the incidence of postoperative morbidity or mortality between the surgical approaches. Decreased operative time (156 vs 200 minutes, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01), blood loss (157 vs 719 mL, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01), and length of stay (5.9 vs 8.6 days, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) were seen in the lap group. There was no significant difference in the rate of all pancreatic fistula formation (50 vs 46%, P = 0.94) or clinically significant leaks (18 vs 19%, P = 0.97) between techniques. A preoperative biopsy-proven cancer, increasing body mass index, history of pancreatitis, and male gender were significant predictors of having a pancreatic fistula. Lap and open distal pancreatectomy are performed safely at high-volume pancreatic surgery centers. This report provides ongoing support of the feasibility and safety of the lap approach with improved perioperative outcomes and equivalent pancreatic fistula rate.

Research paper thumbnail of Argo JL, Contreras JL, Wesley MM, et al. Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis

The American surgeon

ABSTRACT

Research paper thumbnail of Argo JL, Contreras JL, Wesley MM, et al. Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis

The American surgeon

ABSTRACT

Research paper thumbnail of The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy

Journal of Gastrointestinal Surgery, 2015

International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas... more International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas (POPF) are the greatest contributor to major morbidity and mortality following pancreatoduodenectomy (PD); however, their infrequent occurrence has hindered deeper analysis. This study sought to develop a predictive algorithm, which could facilitate effective management of this challenging complication. Data were accrued from 4301 PDs worldwide. Demographics, postoperative management, and microbiological characteristics of grade C POPFs were evaluated. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) preoperative and intraoperative variables were compared between grade C POPFs and a 639-case sample of non-grade C POPFs. Risk factors for grade C POPF formation were identified using regression analysis. Grade C POPFs developed in 79 patients (1.8 %). Deaths (90 days) occurred in 2.0 % (N = 88) of the overall series, with 35 % (N = 25) occurring in the presence of a grade C POPF. Reoperations occurred 72.2 % of the time. The rates of single- and multi-system organ failure were 28.2 and 39.7 %, respectively. Mortality rates escalated with pulmonary, renal, and neurologic organ failure, but they were unaffected by reoperation(s). The median number of complications incurred was four (IQR: 2-5), and the median duration of hospital stay was 32 (IQR: 21-54) days. Warning signs for impending grade C POPFs most often presented on postoperative day (POD) 6. Adjuvant chemotherapy might have benefited 55.7 % of grade C POPF patients, yet it was delayed in 25.6 % and never delivered in 67.4 % of these patients. Predictive models for grade C POPF occurrence based on preoperative factors alone and preoperative and intraoperative factors yielded areas under the receiver operating characteristic curve of 0.73 and 0.84 (both P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.000001), respectively. This global study represents the largest analysis of grade C POPFs following PD. It describes the severe burden that grade C POPFs incur on patients, with high rates of reoperation and infection, while also potentially worsening overall survival by causing death and delay/omission of adjuvant therapy. Additionally, aggressive clinical management for these POPFs did not improve or worsen 90-day mortality. Predictive tools developed through these data may provide value in managing this difficult complication.

Research paper thumbnail of Biliary metal stents are superior to plastic stents for preoperative biliary decompression in pancreatic cancer

Surgical Endoscopy, 2011

Background It is unclear whether plastic or metal stents are more suitable for preoperative bilia... more Background It is unclear whether plastic or metal stents are more suitable for preoperative biliary decompression in pancreatic cancer. The objective of this study was to compare the rate of endoscopic reinterventions in patients with pancreatic cancer undergoing plastic or self-expandable metal stent (SEMS) placements for preoperative biliary decompression. Methods This was a retrospective study of all patients with obstructive jaundice secondary to pancreatic head cancer who underwent their index endoscopic retrograde cholangiopancreatography (ERCP) and all follow-up biliary stent placements at our center before undergoing pancreaticoduodenectomy. Plastic or SEMS were placed at ERCP for biliary decompression. The main outcome measure was to compare the rate of endoscopic reinterventions between the plastic and SEMS cohorts. Results 29 patients who underwent pancreaticoduodenectomy had preoperative biliary stent placement (18 plastic, 11 SEMS) at our center. Whereas none of the 11 patients who Electronic supplementary material The online version of this article (

Research paper thumbnail of Progress in the management of necrotizing pancreatitis

Expert review of gastroenterology & hepatology

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in sig... more Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was si...

Research paper thumbnail of Stenting versus gastrojejunostomy for management of malignant gastric outlet obstruction: comparison of clinical outcomes and costs

Surgical Endoscopy, 2012

Background Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ... more Background Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ) is still considered the gold standard for relief of malignant gastric outlet obstruction (GOO). The aim of this study is to compare clinical outcomes and hospital costs between patients undergoing GJ or stenting for management of malignant GOO. Methods A retrospective claims analysis of the Medicare (MedPAR) database was conducted to identify all inpatient hospitalizations for GJ or endoscopic stenting for malignant GOO during 2007-2008. The main outcome measure evaluated using the MedPAR database was a comparison of the total length of hospital stay (LOS) and costs associated with both techniques. As MedPAR is a claims database that does not provide outcomes at patient level, a single-institution retrospective study was conducted to compare the rates of technical and treatment success, post-procedure LOS, and delayed complications per patient between the two techniques. Results The MedPAR claims data evaluated 425 stenting and 339 GJ hospitalizations. Compared with GJ, median LOS (8 vs. 16 days; p \ 0.0001) and median cost (US 15,366vs.US15,366 vs. US 15,366vs.US27,391; p \ 0.0001) per claim were both significantly lower for stenting. Stenting was more commonly performed at urban versus rural hospitals (89 % vs. 11 %; p \ 0.0001), teaching versus non-teaching hospitals (59 % vs. 41 %, p = 0.0005), and academic institutions (56 % vs. 44 %; p = 0.0157). The institutional patient data analysis included 29 patients who underwent stenting and 75 who underwent surgical GJ. While both modalities were technically successful and relieved gastric outlet obstruction in all cases, compared with surgical GJ, the median post-procedure LOS was significantly lower for enteral stenting (1.5 vs. 10.7 days, p \ 0.0001). There was no difference in rates of delayed complications between stenting and surgical GJ (13.8 % vs. 6.7 %; p = 0.26). Conclusions While the technical and clinical outcomes of surgical GJ and endoscopic stenting appear comparable, stent placement is less costly and is associated with shorter length of hospital stay. Dissemination of endoscopic stenting beyond teaching, academic hospitals located in urban areas as a treatment for malignant GOO is important given its implications for patient care and resource utilization. Keywords Duodenal stenting Á Gastrojejunostomy Á Costs Á Health resource use Gastric outlet obstruction (GOO) is a common symptom, occurring in 15-20 % of patients with locally advanced gastrointestinal cancer [1-3]. Clinical manifestations of Podium presentation: Digestive Disease Week

Research paper thumbnail of Abstract 4612: JQ1 suppresses tumor growth in tumorgraft models of pancreatic ductal adenocarcinoma

Research paper thumbnail of Preliminary General Surgery Residents: Indentured Servitude or Golden Opportunity?

Current Surgery, 2006

One-year, preliminary general surgery (GS) positions are viewed by medical student applicants as ... more One-year, preliminary general surgery (GS) positions are viewed by medical student applicants as among the least desirable positions offered through the match. Hundreds of preliminary GS positions go unfilled each year, and international medical graduates (IMGs) fill a substantial portion of the spots filled. &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Prelims&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; foster diversity and add manpower to surgical training programs, but do trainees eventually benefit from this 1-year effort? Nondesignated (ND) preliminary GS residents at the Mayo Clinic, Rochester, Minnesota, were identified from 1993 to 2003. Trainees were followed (telephone, e-mail, Internet registries) looking at subsequent training, specialty choice, and eventual practice location. From 118 ND preliminary GS residents, the current data of 105 (46 U.S. medical graduates, 59 IMGs) trainees are known. Thirteen trainees (11%) progressed on to a second year of training (location: United States=10, international=3), but they could not be located thereafter. Two additional prelims chose another profession. Seventy one of the remaining 103 prelims (70%) advanced to other non-Mayo residency programs to continue or finish their training in general surgery (n=22), a surgical subspecialty (n=26), or some other field (n=23). Thirty-two prelims remained at Mayo Clinic-Rochester in GS (n=16), a surgical subspecialty (n=12), or a nonsurgical field (n=4). From the 59 IMGs, 52 remained in the United States, whereas 7 left for another country to practice medicine. Most of our ND preliminary GS residents progress toward completion of surgical or medicine residencies. Although initially described as a finite period of training, the 1-year preliminary GS residency offers both U.S. and international students opportunity for career advancement.

Research paper thumbnail of Intraductal papillary carcinoma of common bile duct diagnosed by endoscopic ultrasound-guided fine-needle aspiration

Research paper thumbnail of Endoscopic Transmural Drainage of Peripancreatic Fluid Collections: Outcomes and Predictors of Treatment Success in 211 Consecutive Patients

Journal of Gastrointestinal Surgery, 2011

Objectives Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid c... more Objectives Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections. Methods This is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7 years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively. Results A total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6 mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356 days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, p<0.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, p=0.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted OR=7.6, 95% CI [2.9, 20.1], p<0.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection. Conclusions Endoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

Research paper thumbnail of Patterns of Failure for Lymph Node-Positive Resected Pancreatic Adenocarcinoma After Adjuvant Radiotherapy or Gemcitabine-based Chemotherapy Alone

Journal of Gastrointestinal Cancer, 2015

The purpose of this study was to investigate the effect of radiotherapy on local control and mord... more The purpose of this study was to investigate the effect of radiotherapy on local control and mordibity for patients with resected lymph node-positive pancreatic cancer as compared to gemcitabine-based chemotherapy alone. Sixty-nine patients received adjuvant therapy for pancreatic adenocarcinoma with lymph node involvement after surgical resection and met the inclusion criteria for this analysis. Forty (58 %) patients received postoperative radiotherapy (PORT) to a median dose of 50.4 Gy with capecitabine or 5-fluorouracil concurrently in all but one case; 15 patients also received gemcitabine prior to PORT. Twenty-nine (42 %) patients received gemcitabine-based chemotherapy without PORT for a median of 6 cycles. The median overall survival for patients receiving PORT was 24.4 months compared to 25.6 months for patients not receiving PORT (p = 0.943). At 2 years, the rate of local control was 57 % for patients receiving PORT compared to 37 % for those who did not (p = 0.034). At 2 years, the rate of palliative local interventions was 16 % for patients receiving PORT compared to 18 % for patients who did not (p = 0.821). The use of PORT was associated with improved local control in the gemcitabine era for patients with resected, node-positive, pancreatic adenocarcinoma. The rates of overall survival and palliative interventions did not differ between the two groups.

Research paper thumbnail of Applying Proteomic-Based Biomarker Tools for the Accurate Diagnosis of Pancreatic Cancer

Journal of Gastrointestinal Surgery, 2008

Background The proteome varies with physiologic and disease states. Few studies have been reporte... more Background The proteome varies with physiologic and disease states. Few studies have been reported that differentiate the proteome of those with pancreatic cancer. Aim To apply proteomic-based technologies to body fluids. To differentiate pancreatic neoplasia from nonneoplastic pancreatic disease. Methods Samples from 50 patients (15 healthy (H), 24 cancer (Ca), 11 chronic pancreatitis (CP)) were prospectively collected and underwent analysis. A high-throughput method, using high-affinity solid lipophilic extraction resins, enriched low molecular weight proteins for extraction with a high-speed 200-Hz matrix-assisted laser desorption/ionization time-offlight mass spectrometer (MALDI-MS; Bruker Ultraflex III). Samples underwent software processing with FlexAnalysis, Clinprot, MatLab, and Statistica (baseline, align, and normalize spectra). Nonparametric pairwise statistics, multidimensional scaling, hierarchical analysis, and leave-one-out cross validation completed the analysis. Sensitivity (sn) and specificity (sp) of group comparisons were determined. Two top-down-directed protein identification approaches were combined with MALDI-MS and tandem mass spectrometry to fully characterize the most significant protein biomarker. Results Using eight serum features, we differentiated Ca from H (sn 88%, sp 93%), Ca from CP (sn 88%, sp 30%), and Ca from both H and CP combined (sn 88%, sp 66%). In addition, nine features obtained from urine differentiated Ca from both H and CP combined with high efficiency (sn 90%, sp 90%). Interestingly, the plasma samples (considered by the Human Proteome Organization to be the preferred biological fluid) did not show significant differences. Multidimensional scaling indicated that markers from both serum and urine led to a highly effective clinical indicator of each specific disease state. Conclusions The proteomic analysis of noninvasively acquired biological fluids provided a high level of predictability for diagnosing pancreatic cancer. While the proteomic analysis of serum was capable of screening individuals for pancreatic disease (i.e., CP and Ca vs. H), specific urine biomarkers further distinguished malignancy (Ca) from chronic inflammation (CP).