Publications by authors named "Victor M Zaydfudim"

44 Publications

The impact of obesity and severe obesity on postoperative outcomes after pancreatoduodenectomy.

Surgery 2021 May 28. Epub 2021 May 28.

Department of Surgery, University of Virginia, Charlottesville, VA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, USA. Electronic address:

Background: The impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied.

Methods: All pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5-29.9), class 1/2 obesity (body mass index 30-39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures.

Results: A total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤ .001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33-1.67, P < .001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05-1.28, P = .004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18-1.38, P < .001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36-2.36, P < .001).

Conclusion: Obesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population.
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http://dx.doi.org/10.1016/j.surg.2021.04.028DOI Listing
May 2021

Donor Morbidity Is Equivalent Between Right and Left Hepatectomy For Living Liver Donation: A meta-analysis.

Liver Transpl 2021 May 30. Epub 2021 May 30.

Department of Surgery, Division of Transplant Surgery, University of Virginia Health System, Charlottesville, VA, USA.

Rationale: Maximizing liver graft volume benefits the living donor liver recipient. Whether maximizing graft volume negatively impacts living donor recovery and outcomes remains controversial. Patient randomization between right and left hepatectomy has not been possible due to anatomic constraints; however, a number of published, non-randomized observational studies summarize donor outcomes between two anatomic living donor hepatectomies. This meta-analysis compares donor-specific outcomes after right vs. left living donor hepatectomy.

Methods: Systematic searches were performed via PubMed, Cochrane, ResearchGate and Google Scholar databases to identify relevant studies between January 2005 and November 2019. The primary outcomes compared overall morbidity and incidence of severe complications (Clavien-Dindo >III) between right and left hepatectomy in donors after liver donation. Random effects meta-analysis was performed to derive summary risk estimates of outcomes.

Results: A total of 33 studies (3 prospective and 30 retrospective cohort) were used to identify 7,649 pooled patients included in the study (5993 right hepatectomy and 1027 left hepatectomy). Proportion of donors who developed postoperative complications did not significantly differ after right hepatectomy (0.33, 95% CI: 0.27-0.40) and left hepatectomy (0.23, 95% CI: 0.17-0.29), p=0.19. The overall risk ratio did not differ between right vs. left hepatectomy (RR=1.16 95% CI: 0.83-1.63, p=0.36). The relative risk for a donor to develop severe complications showed no differences by hepatectomy side (IRR=0.97 (95% CI: 0.67, 1.40) p=0.86.

Conclusion: There is no evidence that the overall morbidity differs between right and left lobe donors. Publication bias reflects institutional and surgeon variation. A prospective, standardized, multi-institutional study would help quantify the burden of donor complications after liver donation.
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http://dx.doi.org/10.1002/lt.26183DOI Listing
May 2021

Specialty-Specific Readmission Risk Models Outperform General Models in Estimating Hepatopancreatobiliary Surgery Readmission Risk.

J Gastrointest Surg 2021 May 4. Epub 2021 May 4.

Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.

Background: Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population.

Methods: Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC).

Results: A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58).

Conclusion: HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.
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http://dx.doi.org/10.1007/s11605-021-05023-zDOI Listing
May 2021

Combined portal vein and hepatic vein embolization to augment hepatic lobar hypertrophy.

Surgery 2021 04 21;169(4):986. Epub 2020 Oct 21.

Department of Surgery, University of Virginia, Charlottesville, VA.

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http://dx.doi.org/10.1016/j.surg.2020.09.025DOI Listing
April 2021

Clinical-Radiomic Analysis for Pretreatment Prediction of Objective Response to First Transarterial Chemoembolization in Hepatocellular Carcinoma.

Liver Cancer 2021 Feb 7;10(1):38-51. Epub 2021 Jan 7.

Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China.

Background: The preoperative selection of patients with intermediate-stage hepatocellular carcinoma (HCC) who are likely to have an objective response to first transarterial chemoembolization (TACE) remains challenging.

Objective: To develop and validate a clinical-radiomic model (CR model) for preoperatively predicting treatment response to first TACE in patients with intermediate-stage HCC.

Methods: A total of 595 patients with intermediate-stage HCC were included in this retrospective study. A tumoral and peritumoral (10 mm) radiomic signature (TPR-signature) was constructed based on 3,404 radiomic features from 4 regions of interest. A predictive CR model based on TPR-signature and clinical factors was developed using multivariate logistic regression. Calibration curves and area under the receiver operating characteristic curves (AUCs) were used to evaluate the model's performance.

Results: The final CR model consisted of 5 independent predictors, including TPR-signature ( < 0.001), AFP ( = 0.004), Barcelona Clinic Liver Cancer System Stage B (BCLC B) subclassification ( = 0.01), tumor location ( = 0.039), and arterial hyperenhancement ( = 0.050). The internal and external validation results demonstrated the high-performance level of this model, with internal and external AUCs of 0.94 and 0.90, respectively. In addition, the predicted objective response via the CR model was associated with improved survival in the external validation cohort (hazard ratio: 2.43; 95% confidence interval: 1.60-3.69; < 0.001). The predicted treatment response also allowed for significant discrimination between the Kaplan-Meier curves of each BCLC B subclassification.

Conclusions: The CR model had an excellent performance in predicting the first TACE response in patients with intermediate-stage HCC and could provide a robust predictive tool to assist with the selection of patients for TACE.
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http://dx.doi.org/10.1159/000512028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923935PMC
February 2021

Increasing aggressiveness of resection in patients with perihilar cholangiocarcinoma.

Surgery 2021 Jun 13;169(6):1279. Epub 2020 Nov 13.

Department of Surgery, University of Virginia, Charlottesville, VA. Electronic address:

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http://dx.doi.org/10.1016/j.surg.2020.10.013DOI Listing
June 2021

Postoperative complications after major abdominal operations.

Surgery 2021 May 12;169(5):1017. Epub 2020 Nov 12.

Department of Surgery, University of Virginia, Charlottesville, VA. Electronic address:

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http://dx.doi.org/10.1016/j.surg.2020.10.006DOI Listing
May 2021

Is there a role for a wound protector during pancreatoduodenectomy?

Surgery 2021 May 12;169(5):1016. Epub 2020 Nov 12.

Department of Surgery, University of Virginia, Charlottesville, VA. Electronic address:

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http://dx.doi.org/10.1016/j.surg.2020.10.007DOI Listing
May 2021

Early Patient Discharge in Selected Patients is Not Associated with Higher Readmission After Major Abdominal Operations.

Ann Surg 2020 Nov 4. Epub 2020 Nov 4.

Department of Surgery.

Objective: Our objective was to examine the associations between early discharge and readmission after major abdominal operations.

Background: Advances in patient care resulted in earlier patient discharge after complex abdominal operations. Whether early discharge is associated with patient readmissions remains controversial.

Methods: Patients who had colorectal, liver, and pancreas operations abstracted in 2011-2017 ACS NSQIP Participant Use Data Files were included. Patient readmission was stratified by 6 operative groups. Patients who were discharged prior to median discharge date within each operative group were categorized as an early discharge. Analyses tested associations between early discharge and likelihood of 30-day postoperative unplanned readmission.

Results: 364,609 patients with major abdominal operations were included. Individual patient groups and corresponding median day of discharge were: laparoscopic colectomy (n = 152,575; median = 4), open colectomy (n = 137,462; median = 7), laparoscopic proctectomy (n = 12,238; median = 5), open proctectomy (n = 24,925; median = 6), major hepatectomy (n = 9,805; median = 6), pancreatoduodenectomy (n = 27,604; median = 8). Early discharge was not associated with an increase in proportion of readmissions in any operative group. Early discharge was associated with a decrease in average proportion of patient readmissions compared to patients discharged on median date in each of the operative groups: laparoscopic colectomy 6% versus 8%, open colectomy 11% versus 14%, laparoscopic proctectomy 13% versus 16%, open proctectomy 13% vs 17%, major hepatectomy 8% versus 12%, pancreatoduodenectomy 16% versus 20% (all p ≤ 0.02). Serious morbidity composite was significantly lower in patients who were discharged early than those who were not in each operative group (all p < 0.001).

Conclusions: Early discharge in selected patients after major abdominal operations is associated with lower, and not higher, rate of 30-day unplanned readmission.
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http://dx.doi.org/10.1097/SLA.0000000000004582DOI Listing
November 2020

Postoperative complications and long-term health-related quality of life (HRQOL) after esophagectomy.

Surgery 2021 04 31;169(4):988. Epub 2020 Oct 31.

Department of Surgery, University of Virginia, Charlottesville, VA.

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http://dx.doi.org/10.1016/j.surg.2020.09.023DOI Listing
April 2021

Long-term outcomes in mesh versus no mesh laparoscopic repair of hiatal hernia.

Surgery 2021 04 31;169(4):987. Epub 2020 Oct 31.

Department of Surgery, University of Virginia, Charlottesville, VA.

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http://dx.doi.org/10.1016/j.surg.2020.09.024DOI Listing
April 2021

Clinical and Economic Outcomes of Patients Undergoing Guideline-Directed Management of Pancreatic Cysts.

Am J Gastroenterol 2020 10;115(10):1689-1697

Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA.

Introduction: Numerous guidelines exist for the management of pancreatic cysts. We sought to compare the guideline-directed management strategies for pancreatic cysts by comparing 2 approaches (2017 International Consensus Guidelines and 2015 American Gastroenterological Association Guidelines) that differ significantly in their thresholds for imaging, surveillance, and surgery.

Methods: We developed a Monte Carlo model to evaluate the outcomes for a cohort of 10,000 patients managed per each guideline. The primary outcome was mortality related to pancreatic cyst management. Secondary outcomes included all-cause mortality, missed cancers, number of surgeries, number of imaging studies, cumulative cost, and quality-adjusted life years.

Results: Deaths because of pancreatic cyst management and quality-adjusted life years were similar in both guidelines at a significantly higher cost of $3.6 million per additional cancer detected in the Consensus Guidelines. Deaths from "unrelated" causes (1,422) vastly outnumbered deaths related to pancreatic cysts (125). Secondary outcomes included more missed cancers in the American Gastroenterological Association guideline (71 vs 49), more surgeries and imaging studies in the Consensus guideline (711 vs 163; 116,997 vs 68,912), and higher cost in the Consensus guideline ($168.3 million vs $89.4 million). As the rate of malignant transformation increases, a more-intensive guideline resulted in fewer deaths related to pancreatic cyst management.

Discussion: Our study demonstrates trade-offs between more- and less-intensive management strategies for pancreatic cysts. Although deaths related to pancreatic cyst management were similar in each strategy, fewer missed cancers in the more-intensive surveillance strategy is offset by a greater number of surgical deaths and higher cost. In conclusion, our study identifies that if the rate malignant transformation of pancreatic cysts is low (0.12% annually), a less-intensive guideline will result in similar deaths to a more-intensive guideline at a much lower cost.
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http://dx.doi.org/10.14309/ajg.0000000000000730DOI Listing
October 2020

Enhanced Recovery in Patients Selected for Pancreatoduodenectomy: Standardization of Care Improves Patient Outcomes.

World J Surg 2020 07;44(7):2085-2086

Department of Surgery, Section of Hepatobiliary and Pancreatic Surgery, Division of Surgical Oncology, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.

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http://dx.doi.org/10.1007/s00268-020-05558-3DOI Listing
July 2020

Safety of Major Abdominal Operations in the Elderly: A Study of Geriatric-Specific Determinants of Health.

World J Surg 2020 08;44(8):2592-2600

Department of Surgery, University of Virginia, Charlottesville, VA, USA.

Background: Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations.

Methods: Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination.

Results: A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p < 0.001). After adjustment for ACS NSQIP-estimated probabilities of morbidity or mortality, no geriatric-specific preoperative risk factors were significantly associated with increased risk of death or complications in any age group (all p > 0.055). Patients 75-84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p < 0.001) compared to patients 65-74 years. All geriatric-specific variables: use of mobility aid, living alone, consent signed by a surrogate, and fall history, were significantly associated with discharge to a facility (all p ≤ 0.001).

Conclusions: After adjusting for comorbid conditions, geriatric-specific variables are not associated with postoperative mortality and morbidity among elderly patients; however, geriatric-specific variables are significantly associated with discharge to a facility.
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http://dx.doi.org/10.1007/s00268-020-05515-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223877PMC
August 2020

Quality of Life After Curative Resection for Gastric Cancer: Survey Metrics and Implications of Surgical Technique.

J Surg Res 2020 07 7;251:168-179. Epub 2020 Mar 7.

Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia; Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia. Electronic address:

Gastric cancer is one of the most common cancers worldwide, and radical gastrectomy is an integral component of curative therapy. With improvements in perioperative morbidity and mortality, attention has turned to short- and long-term post-gastrectomy quality of life (QoL). This article reviews the common psychometric surveys and preference-based measures used among patients following gastrectomy. It also provides an overview of studies that address associations between surgical decision-making and postoperative health-related QoL. Further attention is focused on reported associations between technical aspects of the operation, such as extent of gastric resection, minimally-invasive approach, pouch-based conduits, enteric reconstruction, and postoperative QoL. While there are several randomized studies that include QoL outcomes, much remains to be explored. The relationship between symptom profiles and preference-based measures of health state utility is an area in need of further research.
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http://dx.doi.org/10.1016/j.jss.2020.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7247930PMC
July 2020

Association of Geriatric-Specific Variables with 30-Day Hospital Readmission Risk of Elderly Surgical Patients: A NSQIP Analysis.

J Am Coll Surg 2020 04 18;230(4):527-533.e1. Epub 2020 Feb 18.

Department of Surgery, University of Virginia, Charlottesville, VA.

Background: Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients.

Methods: The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression.

Results: The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p < 0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p < 0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p = 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p = 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p = 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p = 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p = 0.04) were associated with readmission.

Conclusions: Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.12.032DOI Listing
April 2020

The impact of cirrhosis and MELD score on postoperative morbidity and mortality among patients selected for liver resection.

Am J Surg 2020 09 20;220(3):682-686. Epub 2020 Jan 20.

Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.

Background: Independent associations between chronic liver disease, MELD, and postoperative outcomes among patients selected for liver resection have not been completely established. We hypothesized independent associations between MELD, cirrhosis, and postoperative mortality.

Methods: Patient-level data from the targeted hepatectomy module and ACS NSQIP PUF during 2014-2015 were merged. Multivariable regression models with interaction effect between MELD and liver texture (normal, congested/fatty, cirrhotic) tested the independent effects of covariates on mortality and morbidity.

Results: 3,530 patients were included, of whom 668 patients (19%) had cirrhosis. ACS NSQIP defined mortality (3.9%vs1.1%) and morbidity (23.5%vs15.8%) were higher in patients with cirrhosis (both p < 0.001). In multivariable models, cirrhosis (OR = 2.24; 95%CI:1.16-4.34, p = 0.016) and MELD (OR = 1.10; 95%CI:1.03-1.18, p = 0.007) were independently associated with mortality. MELD (OR = 1.04; 95%CI:1.002-1.08, p = 0.038) was associated with postoperative morbidity.

Conclusions: Higher MELD and presence of cirrhosis have an independent negative effect on mortality after liver resection. MELD could be used to estimate postoperative risk in patients with and without cirrhosis.
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http://dx.doi.org/10.1016/j.amjsurg.2020.01.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369232PMC
September 2020

Development, Growth, and Maturation of Pancreatoduodenectomy Program: Future Directions.

World J Surg 2020 08;44(8):2795-2796

Department of Surgery, Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.

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http://dx.doi.org/10.1007/s00268-019-05356-6DOI Listing
August 2020

Liver resection versus chemoembolization for patients with multifocal hepatocellular carcinoma.

Hepatobiliary Surg Nutr 2019 Oct;8(5):543-545

Department of Surgery, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA.

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http://dx.doi.org/10.21037/hbsn.2019.04.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791989PMC
October 2019

Comparative Effectiveness of Lymphadenectomy Strategies During Curative Resection for Gastric Adenocarcinoma.

J Gastrointest Surg 2020 10 12;24(10):2212-2218. Epub 2019 Sep 12.

Department of Surgery, Division of Surgical Oncology, University of Virginia School of Medicine, PO Box 800709, Charlottesville, VA, 22908-0679, USA.

Background: The purpose of this study was to compare the long-term effectiveness of three lymphadenectomy strategies in patients with gastric cancer. We hypothesized that, compared with the traditional standard (D2) lymph node dissection strategy, the less aggressive modified standard (mD2) lymphadenectomy may offer superior effectiveness due to reduced operative morbidity and comparable long-term recurrence-free survival.

Methods: A Markov decision analysis model was created to simulate 5-year outcomes across three lymphadenectomy approaches for gastric cancer: limited regional (D1), traditional standard (D2), and modified standard (mD2). The primary outcome was discounted quality-adjusted life-years (dQALY). Model variable estimates were derived from outcomes data and quality of life estimates published in Europe and America within the last 15 years. One-way and probabilistic sensitivity analyses were performed for clinically relevant variables.

Results: The mD2 lymphadenectomy offered 3.03 dQALY over 5 years, outperforming D2 (2.62 dQALY) and D1 (2.37 dQALY). Monte Carlo simulations indicated that both mD2 and D2 lymph node dissection strategies outperformed D1 in 94.9% of simulations. Sensitivity analyses demonstrated that the mD2 approach would be less effective than D2 if the perioperative mortality rate of mD2 was greater than 6.9% (3.2% baseline).

Conclusions: Across modern series, the modified standard mD2 lymphadenectomy is an effective alternative to the traditional D2 lymphadenectomy for patients with gastric cancer. A D1-limited regional lymphadenectomy is not recommended during gastric cancer resection.
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http://dx.doi.org/10.1007/s11605-019-04393-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065947PMC
October 2020

Efficacy of Radiofrequency Ablation Transarterial Chemoembolization for Patients with Solitary Hepatocellular Carcinoma ≤3 cm.

Am Surg 2019 Feb;85(2):150-155

Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (±9.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23% 27% 36%, respectively, = 0.445) and similar 5-year OS (21% 24% 33%, respectively, = 0.287). Thirty-five (24%) patients were bridged to transplantation with TACE and/or RFA. The 5-year OS was significantly improved in patients bridged to transplantation ( < 0.001). Survival does not differ between patients with solitary HCC ≤ 3 cm treated with TACE or RFA. Patients who were bridged to transplantation had significantly greater OS compared with patients who were not transplanted.
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February 2019

Mortality after pancreaticoduodenectomy: assessing early and late causes of patient death.

J Surg Res 2018 11 27;231:304-308. Epub 2018 Jun 27.

Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgery Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored.

Methods: All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods.

Results: A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76).

Conclusions: Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.
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http://dx.doi.org/10.1016/j.jss.2018.05.075DOI Listing
November 2018

Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy.

PLoS One 2018 13;13(9):e0203841. Epub 2018 Sep 13.

Department of Surgery, University of Virginia, Charlottesville, VA, United States of America.

Background: Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy.

Methods: All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy.

Results: A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001).

Conclusions: Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0203841PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6136772PMC
March 2019

The negative effect of perioperative red blood cell transfusion on morbidity and mortality after major abdominal operations.

Am J Surg 2018 09 17;216(3):487-491. Epub 2018 Feb 17.

Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgery Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Division of Surgical Oncology, University of Virginia, Charlottesville, VA, USA. Electronic address:

Background: This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations.

Methods: The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality.

Results: Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p < 0.001), pancreatectomy (OR = 1.88/3.01, p < 0.001), hepatectomy (OR = 2.82/5.78, p < 0.001), colectomy (OR = 2.15/3.17, p < 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p < 0.001).

Conclusions: Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations.
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http://dx.doi.org/10.1016/j.amjsurg.2018.02.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6097952PMC
September 2018

Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection.

J Gastrointest Surg 2018 04 15;22(4):661-667. Epub 2017 Dec 15.

Department of Surgery, University of Virginia, Charlottesville, VA, USA.

Background: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.

Methods: Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.

Results: Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262).

Conclusion: Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.
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http://dx.doi.org/10.1007/s11605-017-3650-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871550PMC
April 2018

Immunotherapy for hepatocellular carcinoma patients: is it ready for prime time?

Cancer Immunol Immunother 2018 02 20;67(2):161-174. Epub 2017 Oct 20.

Department of Medical Oncology, Dana-Farber Cancer Institute Harvard Medical School, 450 Brookline Avenue, M1B13, Boston, MA, 02215, USA.

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second most common cause of cancer death worldwide. Current treatment options for patients with intermediate and advanced HCC are limited, and there is an unmet need for novel therapeutic approaches. HCC is an attractive target for immunomodulation therapy, since it arises in an inflammatory milieu due to hepatitis B and C infections and cirrhosis. However, a major barrier to the development and success of immunotherapy in patients with HCC is the liver's inherent immunosuppressive function. Recent advances in the field of cancer immunology allowed further characterization of immune cell subsets and function, and created new opportunities for therapeutic modulation of the immune system. In this review, we present the different immune cell subsets involved in potential immune modulation of HCC, discuss their function and clinical relevance, review the variety of immune therapeutic agents currently under investigation in clinical trials, and outline future research directions.
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http://dx.doi.org/10.1007/s00262-017-2082-zDOI Listing
February 2018

Challenges in patient selection for liver resection or transplantation in patients with hepatocellular carcinoma beyond Milan criteria.

Hepatobiliary Surg Nutr 2017 Aug;6(4):287-289

Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.

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http://dx.doi.org/10.21037/hbsn.2017.07.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5554769PMC
August 2017

Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy.

J Surg Res 2016 11 15;206(1):106-112. Epub 2016 Jul 15.

Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy.

Materials And Methods: Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality.

Results: Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870).

Conclusions: Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.
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http://dx.doi.org/10.1016/j.jss.2016.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5142215PMC
November 2016

The impact of bacterial colonization on graft success after total pancreatectomy with autologous islet transplantation: considerations for early definitive surgical intervention.

Clin Transplant 2016 11 17;30(11):1473-1479. Epub 2016 Oct 17.

Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA.

Objective: The purpose of this study was to determine whether bacterial contamination of islets affects graft success after total pancreatectomy with islet autotransplantation (TPIAT).

Background: Factors associated with insulin independence after TPIAT are inconclusive. Although bacterial contamination does not preclude transplantation, the impact of bacterial contamination on graft success is unknown.

Methods: Patients who received TPIAT at the University of Virginia between January 2007 and January 2016 were reviewed. Patient charts were reviewed for bacterial contamination and patients were prospectively contacted to assess rates of insulin independence.

Results: There was no significant difference in demographic or perioperative data between patients who achieved insulin independence and those who did not. However, six of 27 patients analyzed (22.2%) grew bacterial contaminants from culture of the final islet preparations. These patients had significantly lower islet yield and C-peptide at most recent follow-up (P<.05), and none of these patients achieved insulin independence.

Conclusions: Islet transplant solutions are often culture positive, likely secondary to preprocurement pancreatic manipulation and introduction of enteric flora. Although autotransplantation of culture-positive islets is safe, it is associated with higher rates of graft failure and poor islet yield. Consideration should be given to identify patients who may develop refractory chronic pancreatitis and offer early operative management to prevent bacterial colonization.
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http://dx.doi.org/10.1111/ctr.12842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5183974PMC
November 2016