RESUMEN

BACKGROUND: Improvements in outcomes after pancreatoduodenectomy (PD) have permitted more complex resections. Complete extirpation at PD may require multivisceral resection (MVR-PD); however, descriptions of morbidity of MVR-PD are limited to small, single-institution series. METHODS: The National Surgical Quality Improvement Project database (2005-2011) was used to compare 30-day postoperative morbidity of PD with MVR-PD. Concurrent resection of colon, small bowel, stomach, kidney, or adrenal gland defined MVR-PD. RESULTS: Of 9,927 PDs, MVR-PD was performed in 273 patients (3%). MVR included colon (58%), small bowel (30%), and gastric (12%) resections. Preoperative comorbidities were similar between groups. Pancreatic, duodenal, or periampullary cancer was present in 75% of patients. Mortality (8.8% vs 2.9%) and major morbidity (56.8% vs 30.8%) were much greater for MVR-PD versus PD alone (P < .001). MVR-PD patients also experienced greater rates of wound, pulmonary, cardiac, thromboembolic, renal, and septic complications. On multivariable regression, MVR was an independent predictor of death (odds ratio [OR], 3.4; P < .001), overall morbidity (OR, 3.01; P < .001), major morbidity (OR, 3.21; P < .001), and minor morbidity (OR, 1.65; P = .03). Among patients undergoing PD+MVR, colectomy was an independent predictor of increased overall morbidity (OR, 1.96; P = .03) and major morbidity (OR, 1.90; P = .02). CONCLUSION: Margin-negative resection may require MVRs at the time of PD. MVR at is associated with 3-fold mortality and substantial morbidity after adjusting for comorbidities. Colectomy independently predicted major morbidity. At PD, the morbidity of MVR should be approached with caution when attempting margin-negative resection.

Asunto(s)

Neoplasias Duodenales/cirugía , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Complicaciones Posoperatorias/etiología , Adrenalectomía/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Colectomía/mortalidad , Bases de Datos Factuales , Neoplasias Duodenales/mortalidad , Femenino , Gastrectomía/mortalidad , Humanos , Intestino Delgado/cirugía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Nefrectomía/mortalidad , Oportunidad Relativa , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/mortalidad , Complicaciones Posoperatorias/epidemiología , Resultado del Tratamiento , Estados Unidos

RESUMEN

INTRODUCTION: Hepatectomy is an advanced technique learned during surgical fellowship. Outcomes have not been described for hepatectomies involving fellows. METHODS: We analyzed hepatectomies from the 2005-2011 National Surgical Quality Improvement Program database. We compared cases with a fellow (FELLOW group) and those without a fellow (ATTENDING group). RESULTS: FELLOW cases (n = 1,562; 54%) included more major hepatectomies and more metastasectomies (P < .002). Mortality was 3.2% versus 2.7% (P = .5) and morbidity was 30.7% vs 26.2% (P = .008) for FELLOW versus ATTENDING cases. On multivariate analysis, mortality was similar, but morbidity was greater in FELLOW cases (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.02-1.4; P = .03), with increased superficial surgical site infections (OR, 1.72; 95% CI, 1.2-2.4; P = .001). There were no differences in rates of sepsis, cardiac, pulmonary, or thromboembolic complications. Compared with ATTENDING cases, FELLOW cases during the first half of training, carried greater morbidity (OR, 1.43; 95% CI, 1.1-1.8; P = .006); however, this difference disappears by the second half of the academic year. CONCLUSION: Hepatectomy involving a fellow may be associated with an increased risk of surgical site infections. FELLOW cases were more complex. Mortality, cardiac, pulmonary, and other serious morbidities were similar. Despite slightly greater rates of surgical site infections, training in hepatic surgery maintains excellent patient outcomes.

Asunto(s)

Hepatectomía/educación , Infección de la Herida Quirúrgica/cirugía , Becas , Femenino , Hepatectomía/mortalidad , Hepatectomía/normas , Humanos , Internado y Residencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiología

RESUMEN

Improvements in the understanding of molecular oncogenesis and mechanisms of drug resistance have presented new opportunities for the treatment of gastrointestinal stromal tumors (GIST). In particular, the discovery of c-kit genomic mutations in GIST and the development of targeted therapy with imatinib mesylate and sunitinib have heralded a new era in the treatment of this disease. Due to its high activity in GIST, imatinib has become the standard of care in treating both advanced disease and localized disease with high-risk features. On the other hand, these developments have provided new challenges in optimizing the use of our drug armamentarium in conjunction with surgery. This review focuses on the molecular oncogenesis of GIST and provides a summary of recent approaches in the management of this disease.