INTRODUCTION:Post-hepatectomy liver insufficiency (PHLI) is a significant cause of morbidity and mortality after liver resection. Quantitative imaging analysis using CT scans measures variations in pixel intensity related to perfusion. The objective of this study was to create a predictive model for PHLI using quantitative imaging features of the future liver remnant (FLR) from preoperative CT scans. METHODS:From 5 high-volume academic centers, patients were retrospectively identified who developed PHLI after major hepatectomy and were matched to control patients without PHLI (by extent of resection, chemotherapy, age [AE5 years], and sex). Quantitative imaging features were extracted from the FLR in the preoperative CT scan, and the most discriminatory features were included in naïve-Bayes classifier to predict PHLI. The study cohort was split into 70-30 training and test sets. RESULTS:From 2000 to 2015, 74 patients with PHLI and 74 matched controls were identified. The most common indications for surgery were colorectal liver metastases (79/148, 53%), hepatocellular carcinoma (54/148, 37%), and cholangiocarcinoma (13/148, 9%). The most frequently performed resections were right hemihepatectomy (108/148, 73%) and right trisectionectomy (25/148, 24%). The median percentage remnant liver volume (%RLV) of patients with PHLI was 38.0% (interquartile range [IQR] 30.1% to 43.2%), compared with 41.6% (IQR 33.9% to 49.9%) in control patients (p ¼ 0.036). The quantitative imaging prediction model for PHLI had an area under the curve (AUC) of 0.709 and 0.746 in the training and test sets, respectively. The combination model of imaging features and %RLV achieved the highest AUC (Table). Table. Model AUC Training Test Imaging features 0.709 0.746 %RLV 0.616 0.569 Imaging features and %RLV 0.727 0.746 CONCLUSIONS:Quantitative imaging features can independently predict PHLI and are a promising preoperative risk stratification tool.

Drains can be safely omitted for one-quarter of PDs. Drain amylase analysis identifies which moderate/high risk patients benefit from early drain removal. This data-driven, risk-stratified approach significantly decreases the occurrence of clinically relevant pancreatic fistula.

The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.

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.

To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

The findings of this large-scale, multi-institutional study indicate that intraoperative bile cultures should be routinely obtained in patients who underwent preoperative endoscopic retrograde cholangiopancreatography since the isolated microorganisms closely correlate with those identified on postoperative wound cultures. Institution-specific internal reviews should amend current protocols for antibiotic prophylaxis to reduce the incidence of wound infections following PD.

BACKGROUND:The role of adjuvant chemotherapy (AC) in the treatment of small bowel adenocarcinoma is poorly defined. Previous analyses have been limited by small sample sizes and have failed to demonstrate a survival advantage. METHODS: Patients with resected small bowel adenocarcinoma (American Joint Committee on Cancer [AJCC] pathologic stage I-III) who were receiving AC (n 5 1674) or surgery alone (SA; n 5 3072) were identified in the NCDB (1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011). Cox regression identified covariates associated with overall survival (OS). AC and SA cohorts were matched (1:1) by propensity scores based on the likelihood of receiving AC or the survival hazard from Cox modeling. OS was compared with Kaplan-Meier estimates. RESULTS: The omission of AC conferred an increased risk of death (hazard ratio, 1.36; 95% confidence interval, 1.24-1.50; P <.001). After propensity score matching, there was a nonsignificant trend toward improved OS with AC in AJCC stage I patients (158.8 vs 110.7 months; P 5.226) and AJCC stage II patients (104.0 vs 79.6 months; P 5.185), including the subset with a T4 tumor classification (64.0 vs 47.4 months; P 5.130) or a positive resection margin (44.4 vs 31.0 months; P 5.333). Median OS was superior for patients with AJCC stage III disease who were receiving AC versus SA (42.4 vs 26.1 months; P <.001). CONCLUSIONS: These data support the use of AC for resected stage III small bowel adenocarcinoma. The trend toward improved OS for patients without nodal metastasis, including those who have T4 tumors or have undergone positive-margin resection, may justify the use of AC in select patients with earlier stage disease. Cancer 2016;122:693-701.

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.