BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tail...BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.展开更多
Intraductal papillary mucinous neoplasm(IPMN) is a disease in evolution.Since its first description almost 30 years ago,a better understanding of the disease has steadily accrued.Yet,there are numerous challenges stil...Intraductal papillary mucinous neoplasm(IPMN) is a disease in evolution.Since its first description almost 30 years ago,a better understanding of the disease has steadily accrued.Yet,there are numerous challenges still for clinicians who treat this fascinating disease.A group of leading content experts on IPMN was assembled and charged with presenting cutting-edge knowledge on various topics for which they have considerable experience.This manuscript provides an historical perspective of both clinical and biological quandaries that have been resolved to date.Furthermore,it poses new avenues for investigation while highlighting the contributions of the various authors to this collective review.展开更多
Background: The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We...Background: The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We sought to better understand surgeon viewpoints on optimal referral patterns and the delivery of simultaneous resections. Methods: A 40 question on-line survey was offered to members of the Canadian surgical community. Statistical analysis was descriptive. Results: A total of 52 surgeons responded. Most colorectal surgeons (CRS) had access to and a good working relationship with regional hepatobiliary (HPB) surgeons (86%) and medical oncologists (100%). The majority (92%) believed there was a role for simultaneous resection of sCRLM, with 69% having first hand experience. Many CRS (62%) discussed all cases of known hepatic metastases with HPB prior to any resection. When a lesion was asymptomatic/minimally symptomatic, most CRS (92%) discussed them with medical oncology/HPB prior to resection (8%). Bilobar metastases (58%), patient comorbidities (35%), portal lymphadenopathy (35%), and patient age (15%) restricted CRS from obtaining HPB consultations. Many CRS (46%) did not believe that resecting hepatic metastases prior to the primary lesion might be beneficial. Most CRS (60%) reported they could not accurately predict hepatic resectability, with only 27%familiarity with evidence-based guidelines. Despite working in smaller hospitals with less access to HPB and less experience with simultaneous resections, non-CR general surgeons more commonly supported a 'liver-first' approach. Conclusions: There was general agreement between CRS and general surgeons on numerous topics, but additional education is required with regard to HPB surgical capabilities and to provide truly individualized patient-centered care.展开更多
Colorectal liver metastases (CRLM) were traditionally associated with a very poor prognosis after resection, with some historical series reporting 5-year survival rates as low as 14% for completely resected multiple m...Colorectal liver metastases (CRLM) were traditionally associated with a very poor prognosis after resection, with some historical series reporting 5-year survival rates as low as 14% for completely resected multiple metastases (1). However, as modern chemotherapy and surgical techniques have evolved, there has been much progress made in improving survival for this unique group of patients, with 5-year survival approaching 55% with R0 resection (2). However, not all CRLM are the same, with very different biological behaviour and ultimately oncologic outcomes in different patients. There have been many attempts to create a scoring system defining factors which will predict this behaviour, with the system created by Fong et al. in 1999 being the most commonly employed (3). These scoring systems are important because they help the selection of patients who are likely to benefit from surgical treatment of their metastases. Patients who are unlikely to benefit from surgical resection may be better treated by alternative and potentially less morbid therapies, such as the various forms of ablation, or with systemic treatments. It is apparent that the accuracy of this prediction is essential to allow patients to benefit either by having appropriate surgical therapy or by avoiding potentially unnecessary surgical morbidity.展开更多
基金This study was approved by the Campus Research Ethics Committee,St.Augustine.
文摘BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.
基金Supported by Summer studentships(2010,2011,and 2012)by Alberta Innovates-Health Solutions.Alexandra Frolkis is funded by an Alberta Innovates-Health Solutions studentship to Samuel QuanA New Investigator Award from the Canadian Institute of Health Research and a Clinical Investigator Award from Alberta Innovates-Health Solutions to Dr.MyersA New Investigator Award from the Canadian Institute of Health Research and a Population Health Investigator Award from Alberta Innovates-Health Solutions to Dr.Kaplan
文摘AIM: To evaluate the incidence, surgery, mortality, and readmission of upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).
文摘Intraductal papillary mucinous neoplasm(IPMN) is a disease in evolution.Since its first description almost 30 years ago,a better understanding of the disease has steadily accrued.Yet,there are numerous challenges still for clinicians who treat this fascinating disease.A group of leading content experts on IPMN was assembled and charged with presenting cutting-edge knowledge on various topics for which they have considerable experience.This manuscript provides an historical perspective of both clinical and biological quandaries that have been resolved to date.Furthermore,it poses new avenues for investigation while highlighting the contributions of the various authors to this collective review.
基金approved by the University of Calgary Conjoint Research Ethics Board (HREBA. CC-14-0170).
文摘Background: The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We sought to better understand surgeon viewpoints on optimal referral patterns and the delivery of simultaneous resections. Methods: A 40 question on-line survey was offered to members of the Canadian surgical community. Statistical analysis was descriptive. Results: A total of 52 surgeons responded. Most colorectal surgeons (CRS) had access to and a good working relationship with regional hepatobiliary (HPB) surgeons (86%) and medical oncologists (100%). The majority (92%) believed there was a role for simultaneous resection of sCRLM, with 69% having first hand experience. Many CRS (62%) discussed all cases of known hepatic metastases with HPB prior to any resection. When a lesion was asymptomatic/minimally symptomatic, most CRS (92%) discussed them with medical oncology/HPB prior to resection (8%). Bilobar metastases (58%), patient comorbidities (35%), portal lymphadenopathy (35%), and patient age (15%) restricted CRS from obtaining HPB consultations. Many CRS (46%) did not believe that resecting hepatic metastases prior to the primary lesion might be beneficial. Most CRS (60%) reported they could not accurately predict hepatic resectability, with only 27%familiarity with evidence-based guidelines. Despite working in smaller hospitals with less access to HPB and less experience with simultaneous resections, non-CR general surgeons more commonly supported a 'liver-first' approach. Conclusions: There was general agreement between CRS and general surgeons on numerous topics, but additional education is required with regard to HPB surgical capabilities and to provide truly individualized patient-centered care.
文摘Colorectal liver metastases (CRLM) were traditionally associated with a very poor prognosis after resection, with some historical series reporting 5-year survival rates as low as 14% for completely resected multiple metastases (1). However, as modern chemotherapy and surgical techniques have evolved, there has been much progress made in improving survival for this unique group of patients, with 5-year survival approaching 55% with R0 resection (2). However, not all CRLM are the same, with very different biological behaviour and ultimately oncologic outcomes in different patients. There have been many attempts to create a scoring system defining factors which will predict this behaviour, with the system created by Fong et al. in 1999 being the most commonly employed (3). These scoring systems are important because they help the selection of patients who are likely to benefit from surgical treatment of their metastases. Patients who are unlikely to benefit from surgical resection may be better treated by alternative and potentially less morbid therapies, such as the various forms of ablation, or with systemic treatments. It is apparent that the accuracy of this prediction is essential to allow patients to benefit either by having appropriate surgical therapy or by avoiding potentially unnecessary surgical morbidity.
