There is a substantial learning curve associated with minimally invasive pancreaticoduodenectomy (MIPD). We sought to determine if national MIPD pancreatic fistula rates are decreasing with time. All patients undergoing elective MIPD and accrued into the pancreatectomy-targeted NSQIP database between 2014 and 2017 were included in the study. Trends in MIPD outcomes by year were examined using Cochran-Armitage and Mann-Kendall tests for trend. Multivariable logistic regression was used to assess for an independent association between increasing year of operation and pancreatic fistula. There were 1,096 patients who underwent MIPD between 2014 and 2017. There was a significant trend toward decreasing pancreatic fistula rates (23.6% vs 19.2% vs 14.9% vs 12.7%, p < 0.01) and clinically relevant pancreatic fistula rates (18.3% vs 15.4% vs 11.1% vs 9.1%, p < 0.01) by increasing year. In multivariable analysis, increasing year of operation was independently protective against pancreatic fistula (odds ratio [OR] 0.76 per year, p < 0.01) and clinically relevant pancreatic fistula (OR 0.73 per year, p < 0.01). Patients without pancreas ducts < 3 mm or soft pancreas gland texture experienced a significant decreasing trend in pancreatic fistula rates (23.7% vs 13.2% vs 10.3% vs 8.0%, p < 0.01) and clinically relevant pancreatic fistula rates (18.3% vs 9.1% vs 5.2% vs 6.0%, p < 0.01), respectively, by increasing year. However, there was not a significant trend in pancreatic fistula rate or clinically relevant fistula rate among patients having either pancreas ducts < 3 mm or soft gland texture. National MIPD pancreatic fistula rates are improving with time. A major contributing factor for this finding is better outcomes in patients who are at lower risk of pancreatic fistula, which could be a reflection of evolving minimally invasive anastomotic techniques.

The objective of our study was to delineate CT findings and anatomic areas of involvement of surgically proven Fournier gangrene (FG) and determine interobserver reliability. This study was a single-center retrospective study of patients with FG who underwent CT before surgical débridement of FG during a 9-year period. Thirty-eight patients with FG, 17 male and 21 female patients, underwent preoperative CT. Two radiologists reviewed the CT studies and recorded findings and anatomic areas of involvement. CT findings were categorized according to a previously described CT scoring system for necrotizing fasciitis and included the presence or absence of fascial air, muscle or fascial edema, fluid tracking, lymphadenopathy, and subcutaneous edema. Cohen kappa was calculated for interobserver reliability. Mean body mass index (BMI [weight in kilograms divided by height in meters squared]) was 42, and 22 of 38 (58%) patients had diabetes. Mean BMI and proportion of patients with diabetes were significantly higher in female patients (mean BMI = 46; 16/21 with diabetes) than male patients (mean BMI = 36; 6/17 with diabetes). CT studies of most patients showed fascial air (36/38 [95%], both readers 1 and 2). Interobserver reliability was substantial to almost perfect for all CT findings except lymphadenopathy, for which it was fair (κ = 0.37). Genital, perineal, and ischiorectal involvement were seen in 87% (33/38), 87% (33/38), and 32% (12/38) of patients for reader 1 and 84% (32/38), 84% (32/38), and 26% (10/38) of patients for reader 2 (κ = 0.29, penis; κ = 0.65, scrotum; κ = 0.91, vulva and labia; κ = 0.68, perineal involvement; κ = 0.80, ischiorectal involvement). Most CT findings of FG and anatomic areas of involvement showed good interobserver reliability. A high proportion of female patients with FG were observed in this study compared with prior series.

Background: Previous studies have suggested that percutaneous drainage and interval appendectomy is an effective treatment for appendicitis with associated abscess. Few studies to date have analyzed risk factors for failed drain management. We hypothesized that older patients with more co-morbidities would be at higher risk for failing conservative treatment. Methods: The 2010–2014 editions of the National Inpatient Sample (NIS) were queried for patients with diagnoses of peri-appendiceal abscesses. Minors and elective admissions were excluded. We identified patients who underwent percutaneous drainage and defined drain failure as undergoing a surgical operation after drainage but during the same inpatient visit to assess for factors associated with failure of drainage alone as a treatment. After univariable analysis, binomial logistic regression was used to assess for independent risk factors. Frequencies were analyzed by χ² and continuous variables by Student's t-test. Results: A total of 2,209 patients with appendiceal abscesses received drains; 561 patients (25.4%) failed conservative management and underwent operative intervention. On univariable analysis, patients who failed conservative management were younger, more likely to be Hispanic, have more inpatient diagnoses, and to have undergone drainage earlier in the hospital course. Multivariable regression demonstrated that the number of diagnoses, female sex, and Hispanic race were predictive of failure of drainage alone. Older age, West and Midwest census regions, and later drain placement were predictive of successful treatment with drainage alone. Failure was associated with more charges and longer hospital stay but not with a higher mortality rate. Conclusion: Approximately a quarter of patients will fail management of appendiceal abscess with percutaneous drain placement alone. Risk factors for failure are patient complexity, female sex, earlier drainage, and Hispanic race. Failure of drainage is associated with higher total charges and longer hospital stay; however, no change in the mortality rate was noted.

Intrahepatic cholangiocarcinoma (iCCA) is a rare and complex malignancy of the biliary epithelium. Due to its silent presentation, patients are frequently diagnosed late in their disease course, resulting in poor overall survival. Advances in molecular profiling and targeted therapies have improved medical management, but long-term survival is rarely seen with medical therapy alone. Surgical resection offers a survival advantage, but negative oncologic margins are difficult to achieve, recurrence rates are high, and the need for adequate future liver remnant limits the extent of resection. Advances in neoadjuvant and adjuvant treatments have broadened patient treatment options, and these agents are undergoing active investigation, especially in the setting of advanced, initially unresectable disease. For those who are not able to undergo resection, liver transplantation is emerging as a potential curative therapy in certain cases. Patient selection, favorable tumor biology, and a protocolized, multidisciplinary approach are ultimately necessary for best patient outcomes. This review will discuss the current surgical management of locally advanced, liver-limited intrahepatic cholangiocarcinoma as well as the role of liver transplantation for select patients with background liver disease.

Laparotomy incisions with contamination have a high incidence of surgical site infection (SSI). One strategy to reduce SSI has been to allow these wounds to heal by secondary intention; however, this results in an ongoing need for wound care after discharge. A prospectively maintained Acute and Critical Care Surgery database was queried for patients who underwent exploratory laparotomy during 2008-2018. Patients were stratified into two groups: 2008-2015 (no protocol [NP]) and 2016-2018 (closure protocol [CP]). CP patients were operated on by a single surgeon utilizing a multi-modal high-risk incisional closure protocol, which included dilute chlorhexidine lavage, closed suction drains for incisions deeper than 3 centimeters, and incisional negative-pressure wound therapy (iNPWT). The CDC (Centers for Disease Control and Prevention) guidelines were used to determine wound classification and SSI based on chart review. Groups were compared using univariate and multivariate analysis. A total of 139 patients met the study criteria. The overall SSI rate, including superficial and deep space infections, was no different in NP versus CP (21.6 vs. 24.1%; p=0.74). The rate of superficial SSI was similar between NP and CP (11.8 vs. 8.4%; p=0.53). Rates of wound closure at discharge were higher in the CP group than the NP group across wound classes, with the greatest difference among dirty wounds (50.0% NP vs. 94.9% CP; p<0.01). CP significantly increased the likelihood of wound closure (OR=179.2; p<0.001) even after controlling for body mass index, wound classification, ASA (American Society of Anesthesiologists) status, and initially open abdomen. By addressing both tissue factors and bacterial burden through the use of a multi-modal high-risk incisional closure protocol involving iNPWT, all wounds can be considered for closure without increasing the risk of SSI.

Hyperglycemia associated with critical illness, also called “stress hyperglycemia” or “stress diabetes”, is a consequence of many pathophysiologic hormonal responses including increased catecholamines, cortisol, glucagon, and growth hormone. Alterations in multiple biochemical pathways result in increased hepatic and peripheral insulin resistance with an uncontrolled activation of gluconeogenesis and glycogenolysis. Hyperglycemia has a negative impact on the function of the immune system, on the host response to illness or injury, and on infectious and overall outcomes. The degree of glucose elevation is associated with increased disease severity. Large randomized controlled trials including the Van den Berghe study, the NICE-SUGAR trial, VISEP and GLUCONTROL have shown that the control of glucose levels in critically ill patients has implications on outcome and that both hyperglycemia and hypoglycemia are detrimental and should be avoided. Glucose variability has also been shown to be detrimental. Aggressive glucose control strategies have changed due to the concerns of hypoglycemia and therefore intermediate target glucose control strategies are most often adopted. Different patient populations may vary with regards to optimal glucose targets, timing and approach for glucose control, and with regards to the prognostic significance of glucose excursions and variability. Medical, surgical, and trauma patients may benefit at different rates from glucose control and the approach may need to be adapted to various medical settings and to correspond to the workflow of health providers. Effect modifiers for the success of insulin therapy for hyperglycemia include the methods of nutritional supplementation and exogenous glucose administration. Further research is required to improve insulin protocols for glucose control, to further define glucose targets, and to enhance the accuracy of glucose measuring technologies.