Steven C Cunningham - Academia.edu (original) (raw)
Papers by Steven C Cunningham
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jul 16, 2017
World Journal of Gastrointestinal Pathophysiology, 2015
There are several common causes of acute pancreatitis, principally excessive alcohol intake and g... more There are several common causes of acute pancreatitis, principally excessive alcohol intake and gallstones, and there are many rare causes. However, cases of pancreatitis still occur in the absence of any recognizable factors, and these cases of idiopathic pancreatitis suggest the presence of unrecognized etiologies. Five cases of acute pancreatitis in four patients came to attention due to a strong temporal association with exposure to nerve stimulators and energy drinks. Given that these cases of pancreatitis were otherwise unexplained, and given that these exposures were not clearly known to be associated with pancreatitis, we performed a search for precedent cases and for mechanistic bases. No clear precedent cases were found in PubMed and only scant, weak precedent cases were found in public-health databases. However, there was a coherent body of intriguing literature in support of a mechanistic basis for these exposures playing a role in the etiology of pancreatitis.
Journal of Gastrointestinal Surgery, 2006
It is estimated that by 2050, there will be a 300% increase in the elderly population (>65 years)... more It is estimated that by 2050, there will be a 300% increase in the elderly population (>65 years) and a corresponding increase in elderly patients presenting for surgical evaluation. Surgical decision-making in this population can be difficult because outcomes in the elderly are poorly defined. We reviewed 2698 consecutive pancreaticoduodenectomies (PDs) at our institution over a 35-year period (April 1970 through March 2005), with the last 1000 resections being done in the last 4 years. Data collected included surgical indication, mortality (defined as 30-day or in-hospital mortality), complications, and survival. Patients were divided by age into three groups (!80, 80289, and >90 years) and evaluated using multiple logistic regression. Two hundred seven patients >80 years old underwent a PD (7.7% of 2698). Patients 80289 years of age had a mortality rate of 4.1% (8 of 197) and a complication rate of 52.8% (99 of 197), whereas patients <79 years of age had a mortality of 1.7% and a complication rate of 41.6% (P ! 0.05). There were no perioperative deaths among the 10 patients >90 years of age, and their complication rate was 50% (5 of 10). One-year survival for patients 80289 years of age was 59.1%, and that for patients >90 years was 60%. Age was not an independent risk factor for perioperative mortality and morbidity following PD after adjusting for preoperative comorbidities. We demonstrate that PD can be safely performed in patients over 80 years of age and conclude that age alone should not be a contraindication to pancreatic resection. The advent of improved surgical outcomes and an aging population will likely result in a significant increase in the number of PDs performed in the next few decades.
Journal of Gastrointestinal Surgery, 2006
Paragangliomas are rare tumors arising from extra-adrenal chromaffin cells. We examined the clini... more Paragangliomas are rare tumors arising from extra-adrenal chromaffin cells. We examined the clinical characteristics of all patients at our institution having paragangliomas resected from 1984 through 2005. Of 253 resections, 22 (9%) were retroperitoneal and were selected for further study. The ratio of males to females was 1.3:1, and the median age was 39 years. The average size, rate of metastasis (i.e., malignancy), and rate of function was 7.4 cm, 9.5%, and 57.1%, respectively. Tumors larger than 7 cm were more likely to require adjacent organ resection (P 5 0.01). The overall 5-year survival was 73%. Survival was significantly worse after metastasis (P 5 0.0023) but did not depend on the tumor diameter, the secreting function of the tumor, the status of surgical margins of resection, or status of the resected lymph nodes.
Journal of Gastrointestinal Surgery, 2008
Background The surgical management of hepatocellular carcinoma in patients with well-compensated ... more Background The surgical management of hepatocellular carcinoma in patients with well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of patients with well-compensated cirrhosis and early stage hepatocellular carcinoma treated with initial hepatic resection versus transplantation. Methods Between 1985 and 2008, 245 patients underwent hepatic resection, and 134 patients underwent liver transplantation for early stage hepatocellular carcinoma. All patients had well-compensated cirrhosis. Prognostic factors were evaluated using univariate and multivariate analyses; survival was calculated using the Kaplan-Meier method. Results Compared with transplantation, patients undergoing resection had larger tumors and a higher incidence of microscopic vascular invasion. Transplantation was associated with better 5-year disease-free and overall survival compared with resection. Hepatitis status, presence of microscopic vascular invasion, and tumor size were predictors for recurrence,
Gastroenterology, 2008
R2 in 9.0%. Patients underwent resection at NCI centers 12.3%, other academic hospitals 34.2%, VA... more R2 in 9.0%. Patients underwent resection at NCI centers 12.3%, other academic hospitals 34.2%, VA facilities 1.2%, and community hospitals 52.2%. Patients were more likely to have ACC if male, white, larger tumor size, no nodal involvement, or pancreatic tail tumors. Five-year survival in resected patients was significantly better than in patients who did not undergo resection: 36.2%vs.10.4%. Stage-specific survival was significantly better for resected ACC vs. adenocarcinoma: I: 52.4%vs.28.4%, II: 40.2%vs.9.8%, III: 22.8%vs.6.8%, and IV: 17.2%vs.2.8%. On univariate analysis, age <65 yrs, well-differentiated tumors, R0 status, and adjuvant chemoradiation were associated with better long-term survival. On multivariate analysis, age <65, well-differentiated tumors, and negative margins (R0 vs. R1/R2) were the only independent prognostic factors. Conclusions: ACC accounts for~1% of resected pancreatic cancers; however, it carries a considerably better prognosis than pancreatic adenocarcinoma. Tumors are typically larger, but size is not associated with survival and should not preclude resection. Thus, surgical resection with negative margins and consideration of adjuvant therapy is the best chance for long-term survival in these favorable pancreatic cancers.
Carcinogenesis, 2005
Norethindrone is a commonly used drug for contraception and hormone replacement therapy, whose ca... more Norethindrone is a commonly used drug for contraception and hormone replacement therapy, whose carcinogenic potential is still controversial. We applied a novel and particularly sensitive method to screen for DNA damage with special attention to double-strand breaks (DSBs) and identified norethindrone to be likely genotoxic and therefore potentially mutagenic: a p53-reporter assay served as a first, high-throughput screening method and was followed by the immunofluorescent detection of phosphorylated H2AX as a sensitive assay for the presence of DSBs. Norethindrone at concentrations of 2-100 mg/ml activated p53 and phosphorylated H2AX specifically and in a dose-dependent manner. No p53 activation or H2AX phosphorylation was detected using a panel of structurally/ functionally related drugs. The overall amount of DNA damage induced by norethindrone was low as compared with etoposide and ionizing radiation. Consistently, norethindrone treatment did not cause a cell cycle arrest. DSBs were not detected with the neutral comet assay, a less sensitive method for DSB assessment than H2AX phosphorylation. Our findings in the p53-reporter and g-H2AX assays could not be ascribed to common DSBcausing artifacts in standard genotoxicity screening, including drug precipitation, high cytotoxicity levels and increased apoptosis. Therefore, our study suggests that norethindrone induces DSBs in our experimental setting, both complementing and adding a new aspect to the existing literature on the genotoxic potential of norethindrone. As the effective concentrations of norethindrone used in our assays were $100to 1000-fold higher than therapeutical doses, the significance of these findings with regard to human exposure still remains to be determined.
Annals of Surgical Oncology, 2009
Background. Liver cell adenoma (LCA) is a benign hepatic tumor with poorly characterized risk for... more Background. Liver cell adenoma (LCA) is a benign hepatic tumor with poorly characterized risk for spontaneous rupture and malignant transformation. Methods. Records from five tertiary hepatobiliary centers were reviewed for all patients treated for LCA from 1997 to 2006. Clinicopathological data were collected and analyzed, and factors that were associated with rupture and/or malignant transformation were assessed by using multivariable logistic regression. Results. A total of 124 patients were analyzed, of which 8 (6.5%) were men; 119 patients underwent resection, and 5 patients had embolic therapy only. Mean patient age was 39 ± 11 years, and 55% had history of hormone use. Rupture occurred in 31 (25%) cases. Ruptured tumors were larger (10.5 ± 4.5 cm vs. 7.2 ± 4.8 cm; p = 0.001), and no tumor \5 cm ruptured. Patients with ruptured LCAs were more likely to require preoperative blood transfusion (32% vs. 9%, p = 0.006), preoperative embolization (16% vs. 1%, p = 0.021), and major (C3 segments) hepatic resection (65% vs. 32%, p = 0.003). By multivariate analysis, increasing tumor size (odds ratio (OR), 7.8; 95% confidence interval (CI), 2.2-26.3; p \ 0.01) and recent (within 6 months) hormone use (OR, 4.5; 95% CI, 1.5-13.3; p \ 0.01) remained independently associated with risk of rupture. Five cases (4%) had evidence of underlying malignancy, but none had LCA \8 cm in diameter. Conclusion. In this multicenter analysis of patients with LCAs, risk of rupture correlated with increasing tumor size and recent hormone use. Rupture is associated with greater need for preoperative blood transfusion and major hepatic resection. These data suggest that patients with asymptomatic LCAs approaching 4 cm and those requiring hormonal therapy should undergo surgical therapy.
Annals of Surgery, 2006
Objective: To define a simple and reproducible classification of complications following pancreat... more Objective: To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system. Background: While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center. Methods: The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival. Results: A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P Ͻ 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula. Conclusion: This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.
Annals of Surgery, 2007
Objective: To assess long-term survival and prognostic factors in a large series of patients with... more Objective: To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer. Summary Background Data: The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most series. Methods: We studied 564 consecutive patients with bile duct cancer operated upon between 1973 and 2004. Patients were divided into intrahepatic, perihilar, and distal groups. Principle outcome measures were complications, 30-day mortality, and survival. Results: Of the 564 patients, 44 (8%) had intrahepatic, 281 (50%) had perihilar, and 239 (42%) had distal tumors. Approximately half (294, 52%) were treated before 1995, while 270 (48%) were treated thereafter. The perioperative mortality rate was 4%. In log-rank analyses, survival was higher in the later time period (P ϭ 0.002), in patients with intrahepatic disease (P ϭ 0.001), with negative resection margins (P Ͻ 0.001), with well/moderately differentiated tumors (P Ͻ 0.001), and those with negative lymph nodal status (P Ͻ 0.001). In multivariate analysis, negative margins (P Ͻ 0.001), tumor differentiation (P Ͻ 0.001), and negative nodal status (P Ͻ 0.001), but not tumor diameter, were significant independent prognostic factors. In R0-resected patients, lymph node status (P Ͻ 0.001), but not tumor diameter, histology, or differentiation, further predicted survival. The median survivals for R0-resected intrahepatic, perihilar, and distal tumors were 80, 30, and 25 months, respectively, and the 5-year survivals were 63%, 30%, and 27%, respectively. Conclusion: R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.
Hepatobiliary & pancreatic diseases international : HBPD INT, Jan 7, 2018
After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical er... more After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. We used Nationwide Inpatient Sample (NIS) data (2000-2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is ...
Best practice & research. Clinical gastroenterology, 2016
As the number, diversity, and complexity of endoscopic complications has increased, so too has th... more As the number, diversity, and complexity of endoscopic complications has increased, so too has the number, diversity, and complexity of operative interventions required to treat them. The most common complications of endoscopy in general are bleeding and perforation, but each endoscopic modality has specific nuances of these and other complications. Accordingly, this review considers the surgical complications of endoscopy by location within the gastrointestinal tract, as opposed to by complication types, since there are many complication types that are specific for only one or few locations, such as buried-bumper syndrome after percutaneous endoscopic gastrostomy and pancreatitis after endoscopic retrograde cholangiopancreatography, and since the management of a given complication, such as perforation, may be vastly different in one area than in another area, such as perforations of the esophagus versus the retroperitoneal duodenum versus the intraperitoneal duodenum. It is hoped t...
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract, Jul 16, 2017
World Journal of Gastrointestinal Pathophysiology, 2015
There are several common causes of acute pancreatitis, principally excessive alcohol intake and g... more There are several common causes of acute pancreatitis, principally excessive alcohol intake and gallstones, and there are many rare causes. However, cases of pancreatitis still occur in the absence of any recognizable factors, and these cases of idiopathic pancreatitis suggest the presence of unrecognized etiologies. Five cases of acute pancreatitis in four patients came to attention due to a strong temporal association with exposure to nerve stimulators and energy drinks. Given that these cases of pancreatitis were otherwise unexplained, and given that these exposures were not clearly known to be associated with pancreatitis, we performed a search for precedent cases and for mechanistic bases. No clear precedent cases were found in PubMed and only scant, weak precedent cases were found in public-health databases. However, there was a coherent body of intriguing literature in support of a mechanistic basis for these exposures playing a role in the etiology of pancreatitis.
Journal of Gastrointestinal Surgery, 2006
It is estimated that by 2050, there will be a 300% increase in the elderly population (>65 years)... more It is estimated that by 2050, there will be a 300% increase in the elderly population (>65 years) and a corresponding increase in elderly patients presenting for surgical evaluation. Surgical decision-making in this population can be difficult because outcomes in the elderly are poorly defined. We reviewed 2698 consecutive pancreaticoduodenectomies (PDs) at our institution over a 35-year period (April 1970 through March 2005), with the last 1000 resections being done in the last 4 years. Data collected included surgical indication, mortality (defined as 30-day or in-hospital mortality), complications, and survival. Patients were divided by age into three groups (!80, 80289, and >90 years) and evaluated using multiple logistic regression. Two hundred seven patients >80 years old underwent a PD (7.7% of 2698). Patients 80289 years of age had a mortality rate of 4.1% (8 of 197) and a complication rate of 52.8% (99 of 197), whereas patients <79 years of age had a mortality of 1.7% and a complication rate of 41.6% (P ! 0.05). There were no perioperative deaths among the 10 patients >90 years of age, and their complication rate was 50% (5 of 10). One-year survival for patients 80289 years of age was 59.1%, and that for patients >90 years was 60%. Age was not an independent risk factor for perioperative mortality and morbidity following PD after adjusting for preoperative comorbidities. We demonstrate that PD can be safely performed in patients over 80 years of age and conclude that age alone should not be a contraindication to pancreatic resection. The advent of improved surgical outcomes and an aging population will likely result in a significant increase in the number of PDs performed in the next few decades.
Journal of Gastrointestinal Surgery, 2006
Paragangliomas are rare tumors arising from extra-adrenal chromaffin cells. We examined the clini... more Paragangliomas are rare tumors arising from extra-adrenal chromaffin cells. We examined the clinical characteristics of all patients at our institution having paragangliomas resected from 1984 through 2005. Of 253 resections, 22 (9%) were retroperitoneal and were selected for further study. The ratio of males to females was 1.3:1, and the median age was 39 years. The average size, rate of metastasis (i.e., malignancy), and rate of function was 7.4 cm, 9.5%, and 57.1%, respectively. Tumors larger than 7 cm were more likely to require adjacent organ resection (P 5 0.01). The overall 5-year survival was 73%. Survival was significantly worse after metastasis (P 5 0.0023) but did not depend on the tumor diameter, the secreting function of the tumor, the status of surgical margins of resection, or status of the resected lymph nodes.
Journal of Gastrointestinal Surgery, 2008
Background The surgical management of hepatocellular carcinoma in patients with well-compensated ... more Background The surgical management of hepatocellular carcinoma in patients with well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of patients with well-compensated cirrhosis and early stage hepatocellular carcinoma treated with initial hepatic resection versus transplantation. Methods Between 1985 and 2008, 245 patients underwent hepatic resection, and 134 patients underwent liver transplantation for early stage hepatocellular carcinoma. All patients had well-compensated cirrhosis. Prognostic factors were evaluated using univariate and multivariate analyses; survival was calculated using the Kaplan-Meier method. Results Compared with transplantation, patients undergoing resection had larger tumors and a higher incidence of microscopic vascular invasion. Transplantation was associated with better 5-year disease-free and overall survival compared with resection. Hepatitis status, presence of microscopic vascular invasion, and tumor size were predictors for recurrence,
Gastroenterology, 2008
R2 in 9.0%. Patients underwent resection at NCI centers 12.3%, other academic hospitals 34.2%, VA... more R2 in 9.0%. Patients underwent resection at NCI centers 12.3%, other academic hospitals 34.2%, VA facilities 1.2%, and community hospitals 52.2%. Patients were more likely to have ACC if male, white, larger tumor size, no nodal involvement, or pancreatic tail tumors. Five-year survival in resected patients was significantly better than in patients who did not undergo resection: 36.2%vs.10.4%. Stage-specific survival was significantly better for resected ACC vs. adenocarcinoma: I: 52.4%vs.28.4%, II: 40.2%vs.9.8%, III: 22.8%vs.6.8%, and IV: 17.2%vs.2.8%. On univariate analysis, age <65 yrs, well-differentiated tumors, R0 status, and adjuvant chemoradiation were associated with better long-term survival. On multivariate analysis, age <65, well-differentiated tumors, and negative margins (R0 vs. R1/R2) were the only independent prognostic factors. Conclusions: ACC accounts for~1% of resected pancreatic cancers; however, it carries a considerably better prognosis than pancreatic adenocarcinoma. Tumors are typically larger, but size is not associated with survival and should not preclude resection. Thus, surgical resection with negative margins and consideration of adjuvant therapy is the best chance for long-term survival in these favorable pancreatic cancers.
Carcinogenesis, 2005
Norethindrone is a commonly used drug for contraception and hormone replacement therapy, whose ca... more Norethindrone is a commonly used drug for contraception and hormone replacement therapy, whose carcinogenic potential is still controversial. We applied a novel and particularly sensitive method to screen for DNA damage with special attention to double-strand breaks (DSBs) and identified norethindrone to be likely genotoxic and therefore potentially mutagenic: a p53-reporter assay served as a first, high-throughput screening method and was followed by the immunofluorescent detection of phosphorylated H2AX as a sensitive assay for the presence of DSBs. Norethindrone at concentrations of 2-100 mg/ml activated p53 and phosphorylated H2AX specifically and in a dose-dependent manner. No p53 activation or H2AX phosphorylation was detected using a panel of structurally/ functionally related drugs. The overall amount of DNA damage induced by norethindrone was low as compared with etoposide and ionizing radiation. Consistently, norethindrone treatment did not cause a cell cycle arrest. DSBs were not detected with the neutral comet assay, a less sensitive method for DSB assessment than H2AX phosphorylation. Our findings in the p53-reporter and g-H2AX assays could not be ascribed to common DSBcausing artifacts in standard genotoxicity screening, including drug precipitation, high cytotoxicity levels and increased apoptosis. Therefore, our study suggests that norethindrone induces DSBs in our experimental setting, both complementing and adding a new aspect to the existing literature on the genotoxic potential of norethindrone. As the effective concentrations of norethindrone used in our assays were $100to 1000-fold higher than therapeutical doses, the significance of these findings with regard to human exposure still remains to be determined.
Annals of Surgical Oncology, 2009
Background. Liver cell adenoma (LCA) is a benign hepatic tumor with poorly characterized risk for... more Background. Liver cell adenoma (LCA) is a benign hepatic tumor with poorly characterized risk for spontaneous rupture and malignant transformation. Methods. Records from five tertiary hepatobiliary centers were reviewed for all patients treated for LCA from 1997 to 2006. Clinicopathological data were collected and analyzed, and factors that were associated with rupture and/or malignant transformation were assessed by using multivariable logistic regression. Results. A total of 124 patients were analyzed, of which 8 (6.5%) were men; 119 patients underwent resection, and 5 patients had embolic therapy only. Mean patient age was 39 ± 11 years, and 55% had history of hormone use. Rupture occurred in 31 (25%) cases. Ruptured tumors were larger (10.5 ± 4.5 cm vs. 7.2 ± 4.8 cm; p = 0.001), and no tumor \5 cm ruptured. Patients with ruptured LCAs were more likely to require preoperative blood transfusion (32% vs. 9%, p = 0.006), preoperative embolization (16% vs. 1%, p = 0.021), and major (C3 segments) hepatic resection (65% vs. 32%, p = 0.003). By multivariate analysis, increasing tumor size (odds ratio (OR), 7.8; 95% confidence interval (CI), 2.2-26.3; p \ 0.01) and recent (within 6 months) hormone use (OR, 4.5; 95% CI, 1.5-13.3; p \ 0.01) remained independently associated with risk of rupture. Five cases (4%) had evidence of underlying malignancy, but none had LCA \8 cm in diameter. Conclusion. In this multicenter analysis of patients with LCAs, risk of rupture correlated with increasing tumor size and recent hormone use. Rupture is associated with greater need for preoperative blood transfusion and major hepatic resection. These data suggest that patients with asymptomatic LCAs approaching 4 cm and those requiring hormonal therapy should undergo surgical therapy.
Annals of Surgery, 2006
Objective: To define a simple and reproducible classification of complications following pancreat... more Objective: To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system. Background: While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center. Methods: The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival. Results: A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P Ͻ 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula. Conclusion: This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.
Annals of Surgery, 2007
Objective: To assess long-term survival and prognostic factors in a large series of patients with... more Objective: To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer. Summary Background Data: The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most series. Methods: We studied 564 consecutive patients with bile duct cancer operated upon between 1973 and 2004. Patients were divided into intrahepatic, perihilar, and distal groups. Principle outcome measures were complications, 30-day mortality, and survival. Results: Of the 564 patients, 44 (8%) had intrahepatic, 281 (50%) had perihilar, and 239 (42%) had distal tumors. Approximately half (294, 52%) were treated before 1995, while 270 (48%) were treated thereafter. The perioperative mortality rate was 4%. In log-rank analyses, survival was higher in the later time period (P ϭ 0.002), in patients with intrahepatic disease (P ϭ 0.001), with negative resection margins (P Ͻ 0.001), with well/moderately differentiated tumors (P Ͻ 0.001), and those with negative lymph nodal status (P Ͻ 0.001). In multivariate analysis, negative margins (P Ͻ 0.001), tumor differentiation (P Ͻ 0.001), and negative nodal status (P Ͻ 0.001), but not tumor diameter, were significant independent prognostic factors. In R0-resected patients, lymph node status (P Ͻ 0.001), but not tumor diameter, histology, or differentiation, further predicted survival. The median survivals for R0-resected intrahepatic, perihilar, and distal tumors were 80, 30, and 25 months, respectively, and the 5-year survivals were 63%, 30%, and 27%, respectively. Conclusion: R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.
Hepatobiliary & pancreatic diseases international : HBPD INT, Jan 7, 2018
After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical er... more After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. We used Nationwide Inpatient Sample (NIS) data (2000-2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is ...
Best practice & research. Clinical gastroenterology, 2016
As the number, diversity, and complexity of endoscopic complications has increased, so too has th... more As the number, diversity, and complexity of endoscopic complications has increased, so too has the number, diversity, and complexity of operative interventions required to treat them. The most common complications of endoscopy in general are bleeding and perforation, but each endoscopic modality has specific nuances of these and other complications. Accordingly, this review considers the surgical complications of endoscopy by location within the gastrointestinal tract, as opposed to by complication types, since there are many complication types that are specific for only one or few locations, such as buried-bumper syndrome after percutaneous endoscopic gastrostomy and pancreatitis after endoscopic retrograde cholangiopancreatography, and since the management of a given complication, such as perforation, may be vastly different in one area than in another area, such as perforations of the esophagus versus the retroperitoneal duodenum versus the intraperitoneal duodenum. It is hoped t...