Publications by authors named "Mathew Chung"

49 Publications

A Prospective Observational Study Comparing Effects of Call Schedules on Surgical Resident Sleep and Physical Activity Using the Fitbit.

J Grad Med Educ 2021 Feb 31;13(1):113-118. Epub 2020 Dec 31.

Background: Surgical residency training has an extended tradition of long hours. Residency programs use a variety of call schedules to combat resident fatigue and sleep deprivation while maintaining adherence to duty hour restrictions. Nonetheless, there is a paucity of data regarding objective measurements of sleep during the different call schedules included in general surgery training.

Objective: The primary objective of this study was to compare the quantity of sleep in 24-hour time frames across all types of shifts worked by general surgery residents at our institution. The secondary objective was to measure activity level in total steps during various time frames.

Methods: This prospective observational study was performed between April 4 and August 26, 2018, with general surgery residents. Each resident was assigned a Fitbit Charge 2 to wear during all rotations, including general surgery and subspecialty services.

Results: Twenty-six out of 31 residents voluntarily participated in the study (84%). In-house call (IHC) had significantly less sleep in a 24-hour time frame than home call and night float (144 vs 283 vs 246 minutes, < .001 and < .028). IHC had significantly more steps than home call (11 245 vs 8756 steps, = .039). The smallest number of steps was obtained when residents were not working (7904 steps).

Conclusions: Our data demonstrate that surgical residents on IHC have significantly less sleep compared to all other types of on-call time frames. Residents on IHC have the most steps across all time frames.
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http://dx.doi.org/10.4300/JGME-D-20-00304.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901626PMC
February 2021

Recurrence patterns and postrecurrence survival after curative intent resection for pancreatic ductal adenocarcinoma.

Surgery 2021 03 15;169(3):649-654. Epub 2020 Aug 15.

Spectrum Health General Surgery Residency, Grand Rapids, MI; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI; Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI.

Background: Pancreatic ductal adenocarcinoma has a high rate of recurrence after resection. We aimed to investigate patterns of recurrence of pancreatic ductal adenocarcinoma to identify opportunities for targeted intervention toward improving survival.

Methods: This was a retrospective analysis of consecutive patients that underwent curative-intent resection for pancreatic ductal adenocarcinoma between 2007 and 2015. Recurrence and survival were analyzed based on site of recurrence. Multiple clinicopathologic factors were calculated for likelihood of site-specific recurrence.

Results: The study included 221 patients with median follow-up of 83 months. Median overall and recurrence-free survival was 19 and 13 months, respectively. Recurrence was observed in 71.9% patients. Local recurrence occurred in 16.4%, distant recurrence in 67.3%, and combined in 15.9%. The most common site of distant recurrence was the liver (49.7%) followed by lung (31.8%) and peritoneum (16.6%). Median time to liver recurrence was shortest (5 months, 95% confidence interval 1.7-8.3) and post recurrence survival was poor (4 months, 95% confidence interval 1.9-6.1). Patients with poorly differentiated tumors on pathology were 4.8 times more likely to recur in the liver (odds ratio 4.83, 95% confidence interval 1.7-13.9).

Conclusion: Liver metastasis after resection of pancreatic ductal adenocarcinoma occurs most frequently, earliest after surgery, and is rapidly fatal. Liver-directed therapies represent a target for future study.
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http://dx.doi.org/10.1016/j.surg.2020.06.042DOI Listing
March 2021

Preoperative tranexamic acid does not reduce transfusion rates in major oncologic surgery: Results of a randomized, double-blind, and placebo-controlled trial.

J Surg Oncol 2020 Nov 31;122(6):1037-1042. Epub 2020 Jul 31.

Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, Michigan.

Background And Objectives: Allogeneic blood transfusions are associated with worse postoperative outcomes in oncologic surgery. The aim of this study was to introduce a preoperative intervention to reduce transfusion rates in this population.

Methods: Adult patients undergoing major oncologic surgery in five categories with similar transfusion rates were recruited. Enrollees received a single preoperative intravenous dose of placebo or tranexamic acid (1000 mg). The primary outcome measure was perioperative transfusion rate. Secondary outcome measures included: estimated blood loss, thromboembolic events, morbidity, hospital length of stay, and readmission rate.

Results: Seventy-six patients were enrolled, 39 in the tranexamic acid group and 37 in the placebo group, respectively. Demographics and surgery type were equivalent between groups. The transfusion rates were 8 out of 39 (20.5%) in the tranexamic acid group and 5 out of 37 (13.5%) in the placebo group, respectively (P = .418). Median estimated blood loss was 400 mL (interquartile range [IQR] = 150-600) in the tranexamic acid group compared with 300 mL (IQR = 150-800) in the placebo group (P = .983). There was one pulmonary embolism in each arm and no deep venous thrombosis (P > .999).

Conclusion: Preoperative administration of tranexamic acid at a 1000 mg intravenous dose does not decrease transfusion rates or estimated blood loss in patients undergoing major oncologic surgery.
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http://dx.doi.org/10.1002/jso.26142DOI Listing
November 2020

Impact of Neoadjuvant Versus Adjuvant Chemotherapy on the Extent of Axillary Surgery for Clinically Node-Negative Breast Cancers of Triple-Negative and HER2-Overexpressing Phenotypes.

Clin Breast Cancer 2020 10 21;20(5):390-394. Epub 2020 Apr 21.

Spectrum Health General Surgery Residency Program, Grand Rapids, MI; Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI.

Background: Breast cancer patients with triple-negative or human epidermal growth factor receptor 2 (HER2)-overexpressing phenotypes are recommended to receive chemotherapy for primary tumors greater than 1 cm regardless of nodal status. Neoadjuvant chemotherapy may eradicate subclinical nodal metastases and reduce the extent of axillary surgery performed.

Patients And Methods: A query of the National Cancer Database Participant User File was performed for new cases of female breast cancer from 2012 to 2015. Inclusion criteria were clinical N0 status, receipt of chemotherapy, and receipt of axillary surgery. Exclusions included hormone-positive/HER2-negative tumors and/or distant metastatic disease. Subjects were divided into groups by receipt of neoadjuvant or adjuvant chemotherapy. The primary end point was the extent of axillary surgery, defined as sentinel lymph node biopsy alone or axillary lymph node dissection (ALND). Subgroup analyses were performed on the basis of tumor phenotype and surgery of the primary site.

Results: A total of 66,771 female patients were included, 15,967 of whom underwent neoadjuvant chemotherapy. ALND rates were higher in patients who received adjuvant chemotherapy (30.6% vs. 28.8%, P < .001). Among tumor phenotypes, the extent of axillary surgery was reduced most significantly for hormone-negative, HER2-positive disease (30.0% vs. 25.8%, P < .001). ALND rates were more substantially reduced for patients who underwent mastectomy (41.3% vs. 36.1%, P < .001) compared to partial mastectomy (21.8% vs. 20.1%, P = .002). Adjuvant chemotherapy was an independent predictor of ALND (odds ratio, 1.26; 95% confidence interval, 1.19-1.33).

Conclusion: Neoadjuvant chemotherapy reduces the extent of axillary surgery in clinically node-negative, nonluminal breast cancers.
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http://dx.doi.org/10.1016/j.clbc.2020.04.007DOI Listing
October 2020

Implementation of a Weekly Administrative Hour and the Impact on Case Logging and Duty Hour Reporting in Surgical Residents.

J Surg Educ 2020 Jul - Aug;77(4):765-771. Epub 2020 Mar 5.

Spectrum Health General Surgery Residency, Grand Rapids, Michigan; Spectrum Health Medical Group, Grand Rapids, Michigan.

Objective: To investigate the impact of a dedicated weekly administrative hour on case logging, duty hour reporting, and duty hour violations.

Design: Retrospective analyses of 2 timeframes pre-implementation and post-implementation of a dedicated weekly administrative hour in a surgical residency were assessed for changes in duty hour reporting, case logging, and duty hour violations. The preimplementation period spanned from July 2011 to June 2014 and the postimplementation period from July 2014 to June 2017.

Setting: Community-based, university-affiliated hospital.

Participants: A total of 79 surgical residents were included over a 6-year period. The subjects worked before and after the implementation of a weekly dedicated administrative time.

Results: Seven and 30-day procedure logging rates improved from 28.7% to 37.2% and 52.7% to 69.9%, respectively (p < 0.001). PGY 1 residents showed a significant increase in procedures logged within 7 days during the postimplementation period. PGY 1, PGY 2 and PGY 3 all showed a significant increase in procedures logged within 30 days during the postimplementation period. Seven and 30-day duty hour completion rates increased postimplementation from 7.8% to 9.2% (p < 0.001) and 64.7% to 67.3% (p < 0.001), respectively. Duty hour violations decreased in the postimplementation time frame (40.6% vs 29.2%, p < 0.001). Duty hour violations were more common in earlier years of training. PGY 1 were 15.6 times more likely to have an 80 hours. per week violation than a PGY5 (OR: 15.1; 95% CI: 2.1-118.0).

Conclusions: Procedural logging and duty hour compliance improved after implementation of a dedicated weekly time for administrative duties. The year of a resident in training is related to compliance with logging and may impact the incidence of duty hour violations. Residents reported significantly fewer duty hour violations, however this may be multifactorial.
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http://dx.doi.org/10.1016/j.jsurg.2020.02.007DOI Listing
June 2021

The impact of obesity on treatment choices and outcomes in operable breast cancer.

Am J Surg 2019 03 14;217(3):474-477. Epub 2018 Nov 14.

Spectrum Health General Surgery Residency Program, Grand Rapids, MI, USA; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI, USA; Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI, USA.

Introduction: Obesity has been associated with negative oncologic outcomes in breast cancer.

Methods: Retrospective review of patients with operable breast cancer at a single institution from 2009 to 2012. Patients with carcinoma in situ or metastatic disease were excluded. Variables included utilization of MRI, surgical treatment, perioperative, and long-term oncologic outcomes. Primary outcome was rate of breast conserving surgery. Secondary outcomes included MRI utilization, contralateral prophylactic mastectomy, and perioperative outcomes.

Results: There were 1566 patients included for the study, 596 (38%) of whom were obese. MRI was utilized less in obese patients (62.4% vs 51.2%, p < 0.001). Breast conserving surgery was more common in obese patients (53.1% vs 59.7%, p 0.010). There was no difference in performance of contralateral prophylactic mastectomy or post-mastectomy reconstruction. Perioperative outcomes were inferior in obese patients including increased surgical site infections (5.7% vs 11.7%, p < 0.001), return to the emergency department (2.5% vs 5.2%, p 0.004), and hospital readmissions (1.8% vs 3.7%, p 0.017). No difference in survival was observed.

Conclusion: Obese patients with operable breast cancer receive different treatment than non-obese patients, however survival and recurrence outcomes were similar among the two groups.
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http://dx.doi.org/10.1016/j.amjsurg.2018.10.048DOI Listing
March 2019

Is there a role for Ytrrium-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma?

Am J Surg 2018 Mar 2;215(3):467-470. Epub 2018 Feb 2.

Spectrum Health, General Surgery Residency Program, Grand Rapids, MI, USA; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI, USA; Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI, USA. Electronic address:

Background: Selective internal radiation therapy (SIRT) with Ytrrium-90 (Y-90) has been used to treat hepatic malignancies with success. This study focuses on the efficacy and safety of Y-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma (ICC).

Methods: A single-institution retrospective case review was performed for patients with unresectable and metastatic ICC treated with Y-90 between 2006 and 2016.

Results: Seventeen patients with ICC underwent 21 Y-90 treatments. Four patients had undergone prior liver resection, and six patients had extrahepatic disease at the time of treatment. Five year overall survival was 26.8%, with a median survival of 33.6 months. One patient underwent margin negative liver resection after a single treatment. Complications were appreciated in two cases. Ninety-day mortality was 0%.

Conclusion: Treatment of ICC using Y-90 is a safe and promising procedure. Further research is needed to clarify its role in the treatment of unresectable and metastatic ICC.
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http://dx.doi.org/10.1016/j.amjsurg.2017.11.022DOI Listing
March 2018

Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial.

Am J Surg 2018 Mar 16;215(3):498-501. Epub 2017 Nov 16.

Spectrum Health General Surgery Residency Program, Grand Rapids, MI, United States; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI, United States; Section of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI, United States. Electronic address:

Background: The purpose of this study was to compare patient outcomes for thoracic epidural anesthesia (TEA) with transversus abdominis plane (TAP) blocks.

Methods: A prospective, randomized trial was performed for patients undergoing abdominal oncologic surgeries.

Results: There were 32 TAP and 35 TEA subjects. The TEA group demonstrated increased episodes of hypotension in the first 24 h (3 v 0.6, p = 0.02). There was no difference in 24-48 h fluid balance between the groups. Overall parenteral morphine equivalents of opioids administered for the TEA group were higher for each postoperative day (p < 0.05). The post-operative survey did not demonstrate any difference in subjective pain between the TAP and TEA groups (6 v 6 p = 0.35). There was no attributable morbidity associated with either technique.

Conclusions: TAP block use was associated with lower parenteral morphine equivalent usage and decreased incidence of hypotension in the early post-operative period compared to TEA.
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http://dx.doi.org/10.1016/j.amjsurg.2017.10.055DOI Listing
March 2018

Locally Recurrent Well-Differentiated Nonfunctioning Pancreatic Neuroendocrine Tumor Requiring Re-excision Including Portal Vein Resection.

J Gastrointest Cancer 2019 Jun;50(2):324-327

Spectrum Health Hospital, Surgical Oncology, Michigan State University College of Human Medicine, 221 Michigan NE, Suite 402, Grand Rapids, MI, 49503, USA.

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http://dx.doi.org/10.1007/s12029-017-0010-2DOI Listing
June 2019

Liver Resection After Selective Internal Radiation Therapy with Yttrium-90 is Safe and Feasible: A Bi-institutional Analysis.

Ann Surg Oncol 2017 Apr 22;24(4):906-913. Epub 2016 Nov 22.

Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI, USA.

Background: Treatment with yttrium-90 (Y90) microspheres has emerged as a viable liver-directed therapy for patients with unresectable tumors and those outside transplantation criteria. A select number of patients demonstrate a favorable response and become candidates for surgical resection.

Methods: Patients who underwent selective internal radiation therapy (SIRT) with Y90 microspheres at two institutions were reviewed. Patients who underwent liver resection were included in the study. The data gathered included demographics, tumor characteristics, response to Y90, surgical details, perioperative outcomes, and survival.

Results: The inclusion criteria were met by 12 patients. The diagnoses included metastatic disease from colorectal adenocarcinoma (n = 6), neuroendocrine tumor (n = 1), and ocular melanoma (n = 1) in addition to hepatocellular carcinoma (n = 4). The median time from liver disease diagnosis to Y90 treatment was 5.5 months (range 2-92 months). The median time from Y90 treatment to surgery was 9.5 months (range 3-20 months). The surgical approach included right hepatectomy (n = 3), extended right hepatectomy (n = 5), extended left hepatectomy (n = 1), segmentectomy with ablation (n = 2), and segmentectomy with isolated liver perfusion (n = 1). The hospital stay was 7 days (range 4-31 days), and 67% of the patients were discharged home. The readmission rate was 42%. The 90-day morbidity and mortality rates were respectively 42 and 8%. At this writing, the median overall survival has not been reached at 25 months.

Conclusion: Liver resection after Y90 SIRT is a challenging surgical procedure with high rates of perioperative morbidity and hospital readmission. However, for properly selected patients, potential exists for extending disease-free and overall survival in the current era of multimodal therapy for malignant liver disease.
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http://dx.doi.org/10.1245/s10434-016-5697-yDOI Listing
April 2017

Utility of feeding jejunostomy tubes in pancreaticoduodenectomy.

Am J Surg 2017 Mar 8;213(3):530-533. Epub 2016 Nov 8.

Grand Rapids Medical Education Partners, General Surgery Residency Program, Grand Rapids, MI, United States; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI, United States; Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI, United States. Electronic address:

Background: Routine placement of jejunostomy tubes (JT) during pancreaticoduodenectomy (PD) is controversial.

Methods: A retrospective chart review of patients undergoing PD from 1/1/08 through 12/31/14 was performed. The patients were divided into groups by placement of JT. Outcome measures were 90-day morbidity, 90-day mortality, length of stay, rate of delayed gastric emptying (DGE), and JT-specific complications.

Results: 256 patients were included. There were no significant differences in 90-day morbidity (39.9% vs. 37.9%, p = 0.747), 90-day mortality (3.9% vs. 1.0%, p = 0.247) or TPN use (24.8 vs. 25.2%, p = 0.941) between those with and without JT, respectively. Patients with a JT had a higher rate of DGE (p < 0.001), longer hospital stay (14.3 vs. 11.6, p < 0.001), and longer time to solid intake (9.4 vs. 7.3, p < 0.001). Eleven patients (7.2%) with JT had tube-related morbidity.

Conclusions: Routine placement of JT at the time of PD should be abandoned with efforts focused on preoperative nutrition optimization and early oral diet trials.
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http://dx.doi.org/10.1016/j.amjsurg.2016.11.005DOI Listing
March 2017

Intraoperative Fluid Resuscitation Strategies in Pancreatectomy: Results from 38 Hospitals in Michigan.

Ann Surg Oncol 2016 09 26;23(9):3047-55. Epub 2016 Apr 26.

Department of Surgery, Henry Ford Health System, Detroit, MI, USA.

Background: Fluid administration practices may affect complication rates in some abdominal surgeries, but effects in patients undergoing pancreatectomy are not understood well. We sought to determine whether amount of intraoperative fluid administered to patients undergoing pancreatectomy is associated with postoperative complication rates and to determine whether hospitals vary in their fluid administration practices.

Methods: Data for 504 patients undergoing pancreatectomy at 38 hospitals between 2012 and 2015 were evaluated. The main exposure was intraoperative fluid administration (≤10, 10-15, >15 mL/kg/h). Mortality, complications, and length of stay were the main outcomes of interest. Patient-level associations between exposure and outcome were tested, with adjustment for potentially confounding patient and surgical factors, using random intercept, mixed-effects linear or logistic regression models. Hospitals were then categorized as having a restrictive, intermediate, or liberal resuscitation practice, and adjusted outcomes were compared.

Results: A total of 167 (33.1 %), 185 (36.7 %) and 152 (30.2 %) patients received restrictive, intermediate, or liberal fluid administration, respectively. Hospitals with more restrictive practices had significantly lower adjusted 30-day mortality than those with more liberal practices (2.7 vs. 6.6 %; P < 0.001). Hospitals with more restrictive practices had the lowest rates of severe (Grade 2 and 3) complications (15.4 % restrictive vs. 25.3 % intermediate vs. 44.3 % liberal; P < 0.001). More restrictive hospitals had decreased adjusted mean length of stay (9.5 days vs. 12.7 days intermediate vs. 11.6 days liberal; P < 0.001).

Conclusions: More restrictive intraoperative resuscitation practices in pancreatectomy are associated with decreased hospital-level mortality, severe complications, and length of stay.
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http://dx.doi.org/10.1245/s10434-016-5235-yDOI Listing
September 2016

Sarcopenia and survival in patients undergoing pancreatic resection.

Pancreatology 2016 Mar-Apr;16(2):284-9. Epub 2016 Feb 3.

MSU Department of Surgery, USA; Department of Surgical Oncology, Spectrum Health Medical Group, USA.

Background: Recent studies have suggested that lean core muscle area may predict outcomes from major abdominal surgeries. Pancreatic resections have been independently analyzed less frequently.

Methods: Pancreatic resections from 2005 to 2012 were reviewed. Sarcopenia was defined as the lowest tertile for lean psoas muscle area (LPMA). Preoperative risk factors, including comorbidities, albumin, weight loss, age and gender, were analyzed with a primary endpoint of overall survival. Secondary endpoints included complications, discharge destination and readmission.

Results: The study sample of 270 patients had complications in 42% of patients, with 26% developing serious complication. The majority (80%) were discharged home, and 1.9% died in the peri-operative period. The mean length of follow up was 31.2 months (range 0-94), and 37% required at least one readmission. LPMA was predictive of discharge destination for females (p = 0.038). Sarcopenia was predictive of readmission in males, compared to subjects in the second LPMA tertile (HR 0.3; 95% CI: 0.1-0.9). In all male subjects, including a subset with adenocarcinoma, patients with sarcopenia were more likely to die than males in the highest LPMA tertile (HR: 2.6; 95% CI: 1.4-4.8 and HR: 2.4; 95% CI: 1.2-4.9, respectively). In all patients with pancreatic ductal adenocarcinoma, transfusion (HR: 1.9; 95% CI: 1.1-3.4) and positive margins (HR: 2.0; 95% CI: 1.2-3.3) were the only factors predictive of overall survival.

Conclusions: Sarcopenia appears to be a predictor of overall survival in male patients undergoing pancreatic resections, but not specifically for patients with pancreatic ductal adenocarcinoma. As prospective data in future studies are identified, sarcopenia may become a useful tool in predicting outcomes.
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http://dx.doi.org/10.1016/j.pan.2016.01.009DOI Listing
December 2016

Using next-generation sequencing to determine potential molecularly guided therapy options for patients with resectable pancreatic adenocarcinoma.

Am J Surg 2016 Mar 20;211(3):506-11. Epub 2015 Dec 20.

General Surgery Residency Program, Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency Program, 221 Michigan St, Suite 200A, Grand Rapids, 49503, MI, USA; Department of Surgery, Michigan State University College of Human Medicine, 221 Michigan St, Suite 200A, Grand Rapids, MI, 49503, USA; Division of Surgical Oncology, Spectrum Health Medical Group, Grand Rapids, MI, USA.

Background: Genomic sequencing technology may identify personalized treatment options for patients with pancreatic adenocarcinoma.

Methods: The study was conducted using tissue specimens obtained from 2012 to 2014. Patients with resected pancreatic adenocarcinoma were identified. Next-generation sequencing was performed from paraffin-tumor blocks. Mutational profiles were reviewed to determine available targeted therapies and clinical trial eligibility.

Results: Thirty patients were identified. The incidence of mutations was: Kirsten rat sarcoma viral oncogene homolong (KRAS) = 87%, tumor protein 53 (TP53) = 63%, cyclin-dependent kinase inhibitor 2A (CDKN2A) = 20%, Mothers Against Decapentaplegic Homolog 4 (SMAD4) = 20%, epidermal growth factor receptor (EGFR) = 7%. Multiple mutations were found in 73%. All CDKN2A mutations occurred in male patients (P = .06), and there was a trend toward younger patient age in this group (P = .13). Potential for Federal Drug Administration (FDA)-approved targeted therapies was identified in 8 of 30 (27%). In addition, 29 of 30 (97%) had mutations applicable for ongoing phase I or II clinical trials.

Conclusions: Next-generation sequencing of resected pancreatic adenocarcinoma specimens can determine common genetic mutations and identify patients who may be eligible for off-label use of targeted therapies or clinical trial enrollment.
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http://dx.doi.org/10.1016/j.amjsurg.2015.11.002DOI Listing
March 2016

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis.

Am J Surg 2016 Jun 11;211(6):1035-40. Epub 2015 Dec 11.

Grand Rapids Medical Education Partners/Michigan State University, General Surgery Residency Program, 221 Michigan St, Suite 200A, Grand Rapids, MI 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 221 Michigan St, Suite 200A, Grand Rapids, MI 49503, USA; Spectrum Health Medical Group, Division of Surgical Specialties, 145 Michigan St NE, Suite 5500, Grand Rapids, MI 49503, USA.

Background: The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention.

Methods: A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS).

Results: One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis.

Conclusions: Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.
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http://dx.doi.org/10.1016/j.amjsurg.2015.10.010DOI Listing
June 2016

Left-Sided Breast Irradiation does not Result in Increased Long-Term Cardiac-Related Mortality Among Women Treated with Breast-Conserving Surgery.

Ann Surg Oncol 2016 Apr 3;23(4):1117-22. Epub 2015 Nov 3.

Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency Program, Grand Rapids, MI, USA.

Background: Standard therapy following lumpectomy for breast cancer has included adjuvant whole-breast radiotherapy. Recent, long-term studies have suggested a possible association between left-sided whole breast radiotherapy and long-term cardiac-related mortality. We sought to determine whether left-sided breast cancers treated with breast-conserving treatment have worse cardiac-related outcomes.

Methods: The surveillance, epidemiology, and end results database was queried for female breast cancer cases diagnosed from 1990 to 1999. Subjects who underwent lumpectomy and adjuvant radiotherapy were included for study and grouped according to laterality. The primary outcome measure was the rate of cardiac-related mortality. Secondary outcome measures were overall and cancer-specific survival. A Cox proportional hazards model was constructed to analyze the primary outcome measure and included age, race, grade, stage, hormone receptor status, and histologic subtype.

Results: A total of 66,687 subjects were identified. These were divided equally by laterality groups: 33,866 left (50.8 %) and 32,801 right (49.2 %). Median follow-up was 15.5 years, and the groups were otherwise well-matched. Left-sided cancer was not associated with poorer survival for any of the metrics. Fifteen-year overall survival and disease-specific survival were 62.8 and 87.0 % for left-sided and 63.0 and 87.1 % for right-sided breast cancers, respectively (p = 0.260, p = 0.702). Rate of cardiac-related mortality at 5-, 10-, and 15-year follow-up were 1.5, 4.3, and 7.7 % for left-sided cancers and 1.6, 4.4, and 8.0 % for right-sided cancers, respectively (p = 0.435).

Conclusions: In this large population-based study, women receiving left-sided external beam radiation for breast cancer did not have an increase in cardiac-related mortality.
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http://dx.doi.org/10.1245/s10434-015-4949-6DOI Listing
April 2016

Predicting length of stay and conversion to open cholecystectomy for acute cholecystitis using the 2013 Tokyo Guidelines in a US population.

J Hepatobiliary Pancreat Sci 2015 Nov 15;22(11):795-801. Epub 2015 Sep 15.

General Surgery Residency Program, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA.

Background: The 2013 Tokyo Guidelines (TG13) for acute cholecystitis have not been studied extensively in US populations.

Methods: A retrospective review of patients with acute cholecystitis within a single system from 2009 to 2013 was performed. The diagnosis and severity of acute cholecystitis were assigned by the TG13. The primary outcome measures were length of stay and conversion to open cholecystectomy.

Results: Four hundred and forty-five patients with acute cholecystitis were studied. For all patients, length of stay (P < 0.001), disposition to home (P < 0.001), and morbidity (P = 0.003) were related to increasing TG13 grade. For surgical patients (n = 256), worsened outcomes with increasing TG13 grade were seen for conversion to open (P = 0.001), operative duration (P < 0.001), length of stay (P < 0.001), disposition to home (P < 0.001), and readmission (P = 0.037). On multivariate analysis, TG13 grade was an independent predictor of increasing length of stay (P = 0.009) and conversion to open surgery (grade 2: OR 7.63 (2.25-25.90), grade 3: OR 24.2 (5.0-116.37)).

Conclusions: Wide adoption of the TG13 in the US can better inform patients, hospital systems, and payers of the expected outcomes of acute cholecystitis.
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http://dx.doi.org/10.1002/jhbp.284DOI Listing
November 2015

A multidisciplinary approach for abdominal venous involvement in oncologic resections.

Ann Vasc Surg 2015 Jul 7;29(5):1007-14. Epub 2015 Mar 7.

Grand Rapids Medical Education Partners, General Surgery Residency Program, Grand Rapids, MI; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI; Department of Surgical Specialties, Spectrum Health Medical Group, Grand Rapids, MI. Electronic address:

Background: An aggressive surgical approach to locally advanced malignancy is being increasingly used in the absence of distant metastatic disease. This includes resection and reconstruction of major venous structures. We investigated the results of using a multidisciplinary surgical approach in these instances.

Methods: The study data were obtained from a university-affiliated hospital from January 1, 2006, to December 31, 2012. All patients who underwent an oncologic resection using a multidisciplinary approach with vascular surgery consultation were included in the analysis. Primary outcomes analyzed included rate of margin positivity, postoperative venous patency, and survival. Secondary outcome measures included operative time, estimated blood loss, and length of hospital stay.

Results: A total of 23 patients met criteria for study. Venous involvement included the portal and/or superior mesenteric vein and inferior vena cava in 14 and 9 patients, respectively. Nine patients had clear vascular involvement before surgery and received preoperative consultation. Overall margins were positive in 56.5%, whereas the rate of vascular margin positivity was 30.4%. The postoperative venous patency rate was 65.0%. There were no perioperative mortalities, and median survival was 10 months (range, 4-80).

Conclusions: Major venous resections and reconstructions in oncologic surgery are safe but associated with a high rate of positive margins. Future efforts should focus on identifying patients in the preoperative phase to provide opportunity for optimal multidisciplinary planning.
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http://dx.doi.org/10.1016/j.avsg.2015.01.012DOI Listing
July 2015

Surgical Referral for Colorectal Liver Metastases: A Population-Based Survey.

Ann Surg Oncol 2015 Jul 13;22(7):2179-94. Epub 2015 Jan 13.

Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.

Background: Surgical resection is underutilized for patients with colorectal liver metastases (CLM). Although the causes of underutilization are poorly understood, provider attitudes towards surgical referral may be contributory. We sought to understand medical oncologists' perspectives on referral for CLM.

Methods: Medical oncologists who treat colorectal cancer in the US state of Michigan were surveyed. We characterized respondents' attitudes regarding clinical and tumor-related contraindications to liver resection for CLM, as well as referral and treatment preferences using case-based scenarios. We then evaluated practice characteristics and treatment preferences between physicians.

Results: A total of 112 eligible responses were received (46 % response rate). Nearly 40 % of respondents reported having no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic disease (80.3 %), poor performance status (77.7 %), the presence of >4 metastases (62.5 %), bilobar metastases (43.8 %), and metastasis size >5 cm (40.2 %). Compared with high-referring physicians, low-referring physicians were just as likely to refer a patient with very low recurrence risk (89.3 vs. 98.3 %; p = 0.099), but much less likely to refer a patient with moderate risk (0 vs. 82.8 %; p < 0.001). High-referring physicians were more likely to consider resection for scenarios consistent with higher recurrence risk (31.0 vs. 10.7 %; p = 0.05).

Conclusions: We found wide variation in surgical referral patterns for CLM. Many felt that bilobar disease and tumor size were contraindications to liver-directed therapy despite a lack of supporting data. These findings suggest an urgent need to increase dissemination of evidence and guidance regarding management for CLM, perhaps through increased specialist participation in tumor boards.
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http://dx.doi.org/10.1245/s10434-014-4318-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4631547PMC
July 2015

Is there truly an oncologic indication for interval appendectomy?

Am J Surg 2015 Mar 11;209(3):442-6. Epub 2014 Dec 11.

Grand Rapids Medical Education Partners, General Surgery Residency Program, Grand Rapids, MI, USA; Michigan State University College of Human Medicine, Department of Surgery, Grand Rapids, MI, USA; Spectrum Health Medical Group, Division of Surgical Specialties, Grand Rapids, MI, USA.

Background: The rate of recurrent appendicitis is low following nonoperative management of complicated appendicitis. However, recent data suggest an increased rate of neoplasms in these cases.

Methods: The study was a retrospective review of patients with acute appendicitis at 2 university-affiliated community hospitals over a 12-year period. The primary outcome measure was the incidence of appendiceal neoplasm following interval appendectomy.

Results: Six thousand thirty-eight patients presented with acute appendicitis. Appendectomy was performed in 5,851 (97%) patients at the index admission. Of the 188 patients treated with initial nonoperative management, 89 (47%) underwent interval appendectomy. Appendiceal neoplasms were identified in 11 of the 89 (12%) patients. These included mucinous neoplasms (n = 6), carcinoid tumors (n = 4), and adenocarcinoma (n = 1). The rate of neoplasm in patients over age 40 was 16%.

Conclusions: There is a significant rate of neoplasms identified in patient over age 40 undergoing interval appendectomy. This should be considered following nonoperative management of complicated appendicitis.
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http://dx.doi.org/10.1016/j.amjsurg.2014.09.020DOI Listing
March 2015

Measuring the impact of the American College of Surgeons Oncology Group Z0011 trial on breast cancer surgery in a community health system.

Am J Surg 2015 Feb 20;209(2):240-5. Epub 2014 Aug 20.

Grand Rapids Medical Education Partners, General Surgery Residency Program, Grand Rapids, MI, USA; Michigan State University College of Human Medicine, Grand Rapids, MI, USA; Spectrum Health Medical Group, Division of Surgical Specialties, Grand Rapids, MI, USA.

Background: The American College of Surgeons Oncology Group Z0011 trial has been lauded as practice changing. We sought to identify its impact on breast cancer surgery in the community hospital setting.

Methods: A retrospective review was performed from 8 community hospitals identifying patients with invasive breast cancer meeting the Z0011 criteria. The primary outcome measures were the rate of completion axillary lymph node dissection (ALND) and performance of intraoperative sentinel lymph node (SLN) analysis over time.

Results: A total of 1,125 lumpectomies with SLN biopsies were performed with 180 subjects meeting inclusion criteria. Performance of ALND (P < .0001) and intraoperative SLN analysis (P < .0001) declined during each time period. Patients more likely to undergo ALND included those with extracapsular extension (odds ratio [OR] 12.8, 95% confidence interval [CI] 2.5 to 67.1) and those who underwent reoperative surgery (OR 10.8, 95% CI 2.6 to 44.4) or intraoperative SLN analysis (OR 5.1, 95% CI 1.2 to 21.9).

Conclusion: American College of Surgeons Oncology Group Z0011 trial has been rapidly practice changing in the community hospital setting.
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http://dx.doi.org/10.1016/j.amjsurg.2014.07.001DOI Listing
February 2015

Is a routine colonoscopy before esophagectomy necessary?

Am Surg 2014 May;80(5):515-7

Spectrum Health, Michigan State University, Department of Medico-Surgical Sciences and Biotechnologies Sapienza University, Rome, Italy.

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May 2014

The drowning whipple: perioperative fluid balance and outcomes following pancreaticoduodenectomy.

J Surg Oncol 2014 Sep 26;110(4):407-11. Epub 2014 May 26.

Grand Rapids Medical Education Partners, General Surgery Residency Program, Grand Rapids, Michigan; Michigan State University College of Human Medicine, Department of Surgery, Grand Rapids, Michigan.

Background And Objectives: Given the high incidence of postoperative morbidity following pancreaticoduodenectomy (PD), efforts at improving patient outcomes are vital. We sought to determine the impact of perioperative fluid balance on outcomes following PD in order to identify a targeted strategy for reducing morbidity.

Methods: A retrospective review of consecutive PDs from 2008 to 2012 was completed. Cumulative fluid balances were recorded at 0, 24, 48, and 72 hr postoperatively and patients were divided into quartiles. Multivariate analyses were performed accounting for age, gender, diagnosis, ASA class, estimated blood loss, colloid and blood product use, and hemoglobin nadir. The predefined primary outcome measures were 90-day morbidity (Clavien grade ≥ III), mortality, and hospital readmission.

Results: One hundred sixty-nine PDs were performed during the study period. The 90-day morbidity and mortality rates for the cohort were 40.2% and 3.0%, respectively, while hospital length of stay was 13.6 ± 6.7 days (mean ± SD). Higher fluid balance at 48 and 72 hr postoperatively was an independent predictor of morbidity and length of stay on multivariate analysis.

Conclusions: Higher postoperative fluid balance is associated with increased postoperative morbidity and longer hospital stay following PD. Efforts at maintaining a fluid-restrictive strategy should be emphasized in this population.
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http://dx.doi.org/10.1002/jso.23662DOI Listing
September 2014

Hormone receptor status does not affect prognosis in metaplastic breast cancer: a population-based analysis with comparison to infiltrating ductal and lobular carcinomas.

Ann Surg Oncol 2014 Oct 17;21(11):3497-503. Epub 2014 May 17.

GRMEP/MSU General Surgery Residency Program, Grand Rapids, MI, USA,

Background: Metaplastic breast cancer is a rare histologic variant among breast cancers. We sought to investigate the impact of hormone receptor status in metaplastic breast cancer and compare outcomes with common histologic variants of breast cancer.

Methods: The study was performed utilizing the Surveillance, Epidemiology, and End Results database. A query was made for patients with metaplastic breast cancer from 2000 to 2010. A separate query identified all patients with infiltrating ductal (IDC) or lobular (ILC) carcinoma during the same period. Effect of hormone receptor status was evaluated using Cox regression analysis. Significance was assessed for p < 0.05.

Results: A total of 2,338 patients with metaplastic breast cancer were available for study. Most tumors were hormone receptor negative (79.0 %) and greater than or equal to grade 3 (82.9 %). For comparison, 382,667 and 44,813 patients with IDC and ILC, respectively, were obtained. Overall 5-year survival for metaplastic breast cancer was 62.2 % compared with 81.2 % for IDC (p < 0.001) and 80.2 % for ILC (p < 0.001). For metaplastic cases, no difference in 5-year survival was found between hormone-positive and hormone-negative tumors (65.7 vs. 63.5 %; p = 0.70). Multivariate analysis demonstrated metaplastic histology as an independent risk factor for cancer-related mortality both among hormone-positive (hazard ratio [HR] 2.4; 95 % confidence interval [CI] 1.8-3.0; p < 0.001) and hormone-negative (HR 1.7; 95 % CI 1.5-1.9; p < 0.001) breast cancers.

Conclusion: Metaplastic breast cancer is an aggressive histologic variant that portends a poor prognosis compared with common breast cancer subtypes. Contrary to other breast cancers, hormone receptor positivity does not improve prognosis in metaplastic breast cancer.
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http://dx.doi.org/10.1245/s10434-014-3782-7DOI Listing
October 2014

Comparison of stapling techniques and management of the mesoappendix in laparoscopic appendectomy.

Surg Laparosc Endosc Percutan Tech 2015 Feb;25(1):e11-e15

Grand Rapids Medical Education Partners General Surgery Residency Program Michigan State University College of Human Medicine Spectrum Health Medical Group, Department of Surgical Specialties, Grand Rapids, MI.

Many techniques for laparoscopic appendectomy have been proposed with few comparative studies. We performed a retrospective review of all patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from 2006 to 2011. Techniques were: (1) transection of the mesoappendix and appendix with a single staple line (SSL); (2) transection of the mesoappendix and appendix with multiple staple lines (MSL); and (3) transection of the mesoappendix with ultrasonic shears and the appendix with a single staple line (USSL). A total of 565 cases were reviewed (149 SSL, 259 MSL, and 157 USSL). Patients treated with the SSL technique had decreased operative duration (P<0.001) and length of stay (P=0.003) despite equivalent disease presentations. Multivariate analysis demonstrated decreased operative duration with the SSL technique (P=0.001). Use of a SSL for transection of the mesoappendix and appendix is both a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes.
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http://dx.doi.org/10.1097/SLE.0000000000000040DOI Listing
February 2015

Accuracy of endoscopic ultrasound in the evaluation of cystic pancreatic neoplasms: a community hospital experience.

Pancreas 2014 Apr;43(3):465-9

From the *Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency Program; †Michigan State University College of Human Medicine; ‡Grand River Gastroenterology; §Mercy Health Saint Mary's Hospital; and ∥Spectrum Health Medical Group, Grand Rapids, MI.

Objectives: Reports on the use of endoscopic ultrasound (EUS) in differentiating benign, premalignant, and malignant pancreatic lesions have been widely variable, particularly with cystic neoplasms. We evaluated the use of EUS for cystic pancreatic lesions in a community hospital setting.

Methods: All patients who underwent EUS for cystic pancreatic neoplasms from 2007 to 2010 were reviewed. A final EUS diagnosis was determined based on the examiner's impression and fine-needle aspiration results if available. Lesions were stratified as benign, premalignant, or malignant. Patients underwent surgical resection, serial imaging studies, or medical oncology/palliative care consultation as indicated.

Results: One hundred eighteen patients with cystic pancreatic lesions underwent EUS during the study period. Endoscopic ultrasound diagnoses included 75 benign (63.6%), 35 premalignant (29.7%), and 8 malignant (4.2%) lesions. Thirty-eight patients (32.2%) underwent surgery, 77 (65.3%) were monitored with imaging, and 3 (2.5%) had unresectable malignancies. Elevated carcinoembryonic antigen levels showed a trend toward predicting mucinous cysts (P = 0.062). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for cystic lesions were 87.3%, 86.8%, 87.5%, 76.7%, and 93.3%, respectively.

Conclusions: Endoscopic ultrasound is a valuable diagnostic modality in the evaluation of cystic pancreatic neoplasms in a community hospital setting.
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http://dx.doi.org/10.1097/MPA.0000000000000057DOI Listing
April 2014

Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement.

Am J Surg 2014 Mar 19;207(3):361-5; discussion 364-5. Epub 2013 Dec 19.

Grand Rapids Medical Educations Partners, General Surgery Residency Program, Grand Rapids, MI, USA; Michigan State University College of Human Medicine, Department of Surgery, Grand Rapids, MI, USA; Spectrum Health Medical Group, Division of Surgical Oncology, Grand Rapids, MI, USA.

Background: The impact of preoperative percutaneous endoscopic gastrostomy (PEG) tube placement in patients undergoing esophagectomy is uncertain.

Methods: A retrospective review was performed in consecutive patients who underwent esophagectomy. Patients were divided into groups based on whether or not they had preoperative PEG placement.

Results: One hundred seventeen patients were studied, 102 without (PEG-) and 15 with PEG+ before PEG tube placement. The overall morbidity and mortality rates were 38% and 3%, respectively. The use of a gastric conduit was similar between groups (94% PEG- vs 87% PEG+, P = .27), and the presence of a PEG before PEG tube placement was not prohibitive in any case. Anastomotic leak rates were similar between groups (11% PEG- vs 15% PEG+, P = .65), and there were no leaks from previous PEG sites.

Conclusion: It appears that preoperative PEG tube placement has no adverse effect on the performance of esophagectomy and may be considered in highly selected patients with poor nutritional status.
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http://dx.doi.org/10.1016/j.amjsurg.2013.10.012DOI Listing
March 2014

Selective laparoscopic approach in suspected gallbladder malignancy.

JSLS 2013 Oct-Dec;17(4):596-601

Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency Program, Grand Rapids, MI, USA; Michigan State University College of Human Medicine, Grand Rapids, MI, USA, Spectrum Health Medical Group, Grand Rapids, MI, USA.

Background And Objectives: We examined patients with clinical findings that are concerning for gallbladder malignancy to determine the incidence of pathology-confirmed malignancy and to discover factors that may be used to determine which patients may be initially treated with a laparoscopic approach.

Methods: All patients referred to a surgical oncologist with preoperative findings that are concerning for gallbladder malignancy who had not undergone previous surgical resection from 2005 to 2011 were reviewed. Variables collected included demographics, imaging, operative findings, and final pathology. Patients were grouped into 3 categories based on preoperative findings: gallbladder mass, irregular wall thickening, and abnormal intraoperative findings on previous diagnostic laparoscopy.

Results: Twenty-nine of 4474 patients evaluated for gallbladder pathology during the study period met the inclusion criteria. Preoperative imaging included computed tomography, ultrasonography, and magnetic resonance imaging. Twelve patients had multiple imaging studies. Eight patients were initially treated with a laparoscopic approach with 3 conversions to an open procedure. Forty-eight percent of patients had pathology-confirmed malignancy. Patients without a discrete mass on imaging were more likely to have benign disease (P = .04).

Conclusions: Our results demonstrate that >50% of patients with suspicious preoperative findings had benign pathology, suggesting that the initial laparoscopic approach in selected patients may be appropriate.
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http://dx.doi.org/10.4293/108680813X13693422519352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3866064PMC
September 2014

A review of splenic pathology in distal pancreatectomies.

Pancreatology 2013 Nov-Dec;13(6):625-8. Epub 2013 Oct 23.

Grand Rapids Medical Education Partners/Michigan State University General Surgery Residency, Grand Rapids, MI, USA. Electronic address:

Objectives: Splenectomy is often performed during distal pancreatectomy for malignancy, yet little data exist demonstrating splenic involvement in distal pancreatic pathology.

Methods: We retrospectively reviewed 81 distal pancreatectomies performed for suspected or known pancreatic malignancies from 6/1/05 to 7/6/11. Exclusion criteria included metastatic disease, previous splenic preserving distal pancreatectomy, or planned en-bloc resection, leaving 47 cases. Data collected included spleen, hilar lymph node, or splenic vessel involvement by malignancy as confirmed by final pathology report. This was correlated with preoperative computed tomography (CT).

Results: Final pathology showed adenocarcinoma in 10 (21%) patients. Three patients with adenocarcinoma had invasion of the spleen, splenic vessels or nodes on pathology. The first involved the splenic flexure, necessitating en-bloc colon resection. The second had splenic artery involvement as identified by CT, but no malignancy within the spleen. The third had direct extension to one of 11 peri-splenic nodes with significant inflammatory reaction noted intraoperatively.

Conclusions: Splenectomy is not mandated for all distal pancreatic tumors, and the spleen can be preserved in an overwhelming majority of cases. Pre- and intraoperative factors can adequately identify the necessity of splenectomy, and the approach should be tailored to individual patients.
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http://dx.doi.org/10.1016/j.pan.2013.10.006DOI Listing
July 2014
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