Kevin Verhoeff

Evaluation of arterial resection (AR) during pancreatoduodenectomy (PD) remains limited. This study compares PD with AR to PD with venous resection (VR) and no vascular resection (NVR). Patient demographics, outcomes, and changes over 5 years are evaluated. In this study, NSQIP data was analyzed comparing patients undergoing PD with AR to NVR and VR. Demographics and 30‐day post‐operative outcomes were compared, and multivariable modeling evaluated factors associated with serious complications and mortality. Propensity score matched (PSM) analysis compared AR to NVR, AR to VR, and VR to NVR. We evaluated 28,083 patients with 4.1% having AR and 10.9% having VR. After demographic adjustment, both AR (1.40; p < 0.001) and VR (OR 1.32; p < 0.001) were independently associated with serious complications and mortality (AR: OR 2.03; p = 0.002; VR: OR 1.43; p = 0.043). PSM supported increased serious complications (+4.9% VR, p < 0.001; +5.40% AR, p = 0.008) but not mortality (+0.4% VR, p = 0.323; +1.4% AR, p = 0.067) compared to NVR. AR did not increase the risk of complications or mortality compared to VR following PSM. Evaluating AR/VR from 2017 to 2021 shows consistent demographics but increasing neoadjuvant treatment (40.2%–48.9%; p < 0.001). Length of stay has decreased (12.3–9.6 days; p < 0.001), while serious complications (19.7%–22.1%) and mortality (1.7%–3.1%) remained similar. Results demonstrate that arterial (and venous) resection during PD is independently associated with 30‐day serious complications compared to without vascular resection. However, absolute morbidity rates during vascular resection may be acceptable in selected patients and appear to be similar with arterial and venous resection. Future studies evaluating long‐term outcomes are needed.

Introduction: Advances in neoadjuvant therapy and surgical techniques have led to more total pancreatectomies (TP) with vascular resection for pancreatic cancer. This study assesses contemporary outcomes of TP with venous (VR) and arterial (AR) resections compared to non‐vascular resection (NVR). Methods: A multicenter, retrospective cohort study was performed using ACS NSQIP data from 2017 to 2021. Patients were divided into three cohorts: NVR, VR only, and AR. Demographics, comorbidities, 30‐day post‐operative morbidity, and year‐to‐year trends were analyzed. Multivariable models and propensity score matching evaluated the impact of vascular resection on complications. Results: Of 1101 TP patients, 78.0% had NVR, 15.5% VR, and 6.4% AR. VR and AR patients were older. AR had significantly higher major complication rates (40.9%) than VR (25.2%) and NVR (20.6%). Multivariable analysis identified VR (OR 1.75; p = 0.020) and AR as independent predictors of major complications (OR 3.66; p < 0.001). Year‐to‐year analysis showed increasing rates of AR, more than doubling from 4.0% in 2017 to 9.3% in 2021, while patient demographics and outcomes remained stable. Conclusions: Rates of vascular resection in TP are increasing, emphasizing the need to reassess patient outcomes following these complex surgeries. Both VR and especially AR are independently associated with major post‐operative complications and should remain reserved for optimally fit patients with ideal biologic disease.

Introduction Bariatric surgery is primarily performed using minimally invasive techniques. Intraoperative conversion to open is associated with increased complications. This study aimed to provide a contemporary overview of frequency of conversion to open, compare complication rates and determine factors associated with conversion. Methods The MBSAQIP database from 2020 to 2022 was analyzed to identify two cohorts; those who underwent a minimally invasive approach and those who required conversion to open. Patients undergoing primary sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS) and single anastomosis duodenal-ileal bypass (SADI) were included. Univariate analysis was performed to characterize differences and assess for rate of complications between cohorts. Multivariate logistic regression was performed to determine factors associated with conversion and 30-day serious complications. Results A total of 524 224 patients were identified of which 181 (0.03%) required conversion to open. Factors associated with increased risk of conversion to open included age, BMI, lower albumin, sleep apnea, undergoing RYBG or BPD-DS (vs. SG) and previous foregut surgery. Patients converted were more likely to have 30-day reoperation, reintervention, or readmission on bivariate analysis. Conversion to open was also an independent predictor of serious complications on multivariate analysis. Conclusion Conversion to open in bariatric surgery is rare but associated with significant increased risk of postoperative complications. Patients at increased risk may benefit from preoperative risk mitigation, such as those undergoing BPD-DS or RYGB, with sleep apnea, or with a history of previous foregut surgery.

Background: Surgical resection is the standard treatment for phaeochromocytoma (PCC). Current guidelines recommend an open approach for large tumours due to the increased risk of complications. This study aimed to characterize surgical outcomes for large (≥ 6 cm) and small (< 6 cm) PCCs and to identify factors that may improve postoperative outcomes. Methods: This retrospective cohort study of patients undergoing adrenalectomy for PCC in 49 international centres between 2012 and 2022 compared patients with tumours < 6 cm in diameter and those with tumours ≥ 6 cm in diameter. Univariate, bivariate (dichotomous), and multivariate (multiple logistic and linear) analyses were used to evaluate outcomes and risk factors for complications. A secondary multivariable analysis evaluated factors, including operative approach, influencing outcomes for patients with tumours ≥ 6 cm. A 1:1 propensity score-matched (PSM) analysis was completed to control for age, sex, body mass index, and the Charlson Co-morbidity Index. Results: Of the 2301 patients included in the analysis, 598 (26.0%) had PCCs with a diameter ≥ 6 cm. Patients with tumours ≥ 6 cm had a higher incidence of severe (Clavien–Dindo grade ≥ IIIa) postoperative complications (11.2% versus 4.8%; P < 0.001). Multivariable analysis revealed that tumour size ≥ 6 cm was an independent predictor of any complications (odds ratio (OR) 1.93; P < 0.001). Subanalysis of patients with tumours ≥ 6 cm demonstrated that laparoscopic (OR 0.33; P < 0.001) and robotic (OR 0.40; P = 0.038) adrenalectomy were independently associated with less morbidity than an open approach. PSM analysis revealed a mean 276.0-ml higher blood loss (95% confidence interval (c.i.) 138.9 to 413.0 ml; P < 0.001) and 2.9-point higher Comprehensive Complication Index (95% c.i. 0.6 to 5.3; P = 0.015) for patients with tumours ≥ 6 cm compared with patients with PCCs < 6 cm in diameter. Optimal cut-off analysis revealed that a tumour diameter of ≥ 5.8 cm was associated with increased complications. Conclusion: Patients undergoing adrenalectomy for PCCs ≥ 6 cm have a higher risk of severe complications than patients with smaller tumours. Despite this increased risk in patients with large (≥ 6 cm) tumours, minimally invasive surgery was independently associated with a reduced likelihood of complications. This study supports a minimally invasive approach in patients with large PCCs.

Background: The National Surgical Quality Improvement Program (NSQIP) database provides one of the largest repositories of surgical outcome data—guiding local, national, and international quality improvement and research. We aim to describe a model to estimate Clavien–Dindo complication (CDC) rates from NSQIP data to enable comprehensive outcome measurement, allowing an NSQIP-based surrogate measure for longer-term outcomes. Methods: This is a validation study of a model to estimate CDCs from NSQIP data for pancreaticoduodenectomy (PD) and hepatic resection (HR). The primary objective of this study is to evaluate whether our method to estimate CDCs ≥ 3 outcomes from NSQIP data results in similar serious complication rates to large benchmark studies on outcomes following PD and HR. Secondary outcomes evaluate whether specific NSQIP outcomes provide adequate information to estimate CDC grades I-V following PD and HR. Results: We evaluated 20,575 patients undergoing PD, with 71.3% having pancreatic ductal adenocarcinoma. Comparing CDCs ≥ 3 complications for NSQIP and benchmark PD patients, we estimated a 23.2% rate with our model, which was significantly lower than the reported 27.6% in the benchmark study (p < 0.001). Additionally, the benchmark reported higher complication rates for every CDC grade compared to our estimates using NSQIP PD patients (p < 0.001). Further, we evaluated 29,809 patients within NSQIP undergoing HR, where most patients with a diagnosis listed had colorectal cancer metastases (30.8%). Compared to the benchmark HR study (n = 2159), the NSQIP patients were less likely to have hepatic resection for malignancy (57.7% vs. 84.0%; p < 0.001). Comparing CDCs ≥ 3 complications following HR demonstrated that rates were clinically similar (13.0% vs. 15.8%) but statistically different between the benchmark study and NSQIP data (p < 0.001). Additionally, the NSQIP patients had lower rates of estimated complications for nearly all CDC grades (p < 0.001). Conclusions: This is the first reported method to estimate aggregate morbidity from NSQIP data. Results demonstrate that despite differences in this and comparator cohorts, this model may underestimate CDC grade 1–2 complications but provide similar rates of CDCs ≥ 3 complications compared to benchmark studies. Future studies to validate or modify this estimation method are warranted and may allow extrapolation of short-term NSQIP measures to oncologic, quality of life, and long-term outcomes.

Background: Primary sclerosing cholangitis (PSC) accounts for 10–15% of liver transplants but is the leading cause of retransplant. This study evaluates whether PSC patients have different survival and graft outcomes when receiving grafts from donors after brain death (DBD) versus circulatory (DCD) death. Methods: Using the SRTR database (2004–2024), we compared PSC patients receiving DCD vs. DBD grafts. Demographics and outcomes including graft loss, mortality, and retransplant were analyzed using multivariable logistic and Cox regression, along with propensity-matched analysis. Results: Among 5762 PSC patients, 391 (6.8%) received DCD grafts. Patients receiving DCD grafts were older but had lower MELD scores (19 vs. 22; p < 0.001) and were less often functionally dependent (11.3% vs. 24.4%; p < 0.001). Multivariable Cox regression demonstrated that receipt of a DCD graft was independently associated with time to graft loss (HR 1.59; CI 1.10–2.31; p = 0.013. Similarly, DCD graft receipt significantly increased the likelihood of requiring retransplant (HR 3.25; CI: 1.93–5.46; p < 0.001) but did not increase the likelihood of mortality. Propensity matched analysis further supported these finding with significantly higher graft loss with DCD grafts at one and two years and higher retransplant rates at all time points including 5-years (+7.9%, CI 4.4 to 11.4%; p < 0.001). Conclusions: DCD grafts in PSC patients are linked to worse graft survival and higher retransplant rates. They may be best suited for older, lower-MELD patients, but further studies on perfusion strategies are needed.

Background: Wound protectors (WPs) have been shown to decrease postoperative wound complications, yet limited data exist supporting WP for pancreaticoduodenectomies, with limited uptake in practice. We evaluated the effect of WP in pancreaticoduodenectomies on surgical site infections (SSIs) and serious complications.Methods: Utilizing the National Surgical Quality Improvement Program database, we included patients undergoing pancreaticoduodenectomy between 2017 and 2021. Baseline demographics and complications were compared between WP and no WP cohorts. Multivariate logistic regression was performed to identify the effect of WP use on 30‐day complications and factors associated with WP use.Results: Of 20 960 patients, 6167 (29.4%) used a WP. WPs were more commonly used in lower ASA classes, more comorbid patients, and preoperative weight loss. WP use was associated with increased operative time but decreased length of stay, SSIs, organ space infection, pancreatic fistula, reoperation, and serious complication. WP was independently associated with decreased serious complication (aOR 0.80, p < 0.001) and SSI (aOR 0.57, p < 0.001). Factors associated with increased likelihood of WP use include preoperative weight loss, broad‐spectrum antibiotic use, absence of bleeding disorder and firmer pancreatic texture.Conclusion: WP use during pancreaticoduodenectomy is associated with decreased number of postoperative complications and SSI. Future prospective randomized studies should assess cost–benefit and barriers to use to increase uptake of WP use.