95.19 USING COGNITIVE TASK ANALYSIS TO DEFINE HEPATO-PANCREATICO-BILIARY INTRAOPERATIVE ULTRASOUND

Posted on January 18, 2018

N. J. Zyromski1, M. G. House1, A. Nakeeb1, M. Boehler1, G. L. Dunnington1  1Indiana University School Of Medicine,SURGERY,Indianapolis, IN, USA

Introduction:
Intraoperative ultrasound (IOUS) is an indispensable asset in contemporary hepato-pancreatico-biliary (HPB) surgery.  However, few formal instructional objectives exist with which to teach this complex task.  The educational construct of cognitive task analysis (CTA) provides ideal methodology with which to deconstruct complex cognitive strategies and goal structures underlying the automated procedural skills of experts. We sought to define specific tasks associated with IOUS by means of CTA.

Methods:
One analyst broadly experienced in CTA evaluated three expert HPB surgeons (mean IOUS experience 15 years).  Evaluation included direct observation of IOUS as well as focused interviews with each expert during which action and decision steps of specific tasks were interrogated.  The results of these interviews were aggregated into a document defining the task, including a stepwise protocol as well as action and cognitive decision points involved with the procedure.

Results:
CTA defined the objective, prerequisite skills and knowledge, conditions and equipment required for HPB IOUS.  The task list included: 1) initial scan and exposure; 2) equipment preparation (orientation, image refinement); and 3) systematic scanning and interpretation.  Systematic scanning steps were defined for the liver, pancreas, and biliary tree.

Conclusion:
Defining concrete measurable procedural steps by cognitive task analysis will facilitate achieving expertise in the complex cognitive technical skill of hepato-pancreatico-biliary intraoperative ultrasound.
 

95.13 New Surgery Residency and Timing of Cholecystectomy for Biliary Pancreatitis

Posted on January 18, 2018

A. D. Kalani1, L. Gomez1, J. R. Popovich1, K. Lee1, S. Cassaro1,2  1Kaweah Delta Medical Center,General Surgery,Visalia, CA, USA 2University Of California – Irvine,Surgery,Orange, CA, USA

Introduction:  Biliary pancreatitis (BP) is a frequent cause of emergency surgical admissions. In most cases BP is clinically mild and resolves rapidly. Current evidence indicates that a cholecystectomy should be carried out before discharge to avoid a frequent recurrence. The implementation of acute care surgery (ACS) services has been reported to positively affect adherence to cholecystectomy during the initial admission for BP, and to decrease average length of stay (ALOS). The presence of surgical residents has been reported to increase operative times. We report our experience with BP before and after the implementation of a dedicated ACS service at our institution to assess the impact of the service and the effects of a newly established Accreditation Council for Graduate Medical Education (ACGME) residency program in General Surgery.

Methods:  We reviewed 420 BP admissions between January 1, 2010 and June 30, 2016 and abstracted demographics, ALOS, time from admission to surgery, time from surgery to discharge, and operative time, then compared them for periods before and after the creation of dedicated ACS service, as well as before and after the first class of surgery residents began its training.

Results: 373 (88%) patients were managed operatively and 47 (12%) non-operatively. A cholecystectomy was performed during the same admission in 352 (83%) patients. After the implementation of the ACS service, both overall and post-procedural ALOS decreased significantly (p<0.05) from 5.4 to 4.4 and from 3.4 to 2.1 days, respectively. There were no significant demographic or management differences between any of the periods reviewed.

Conclusion: Post-procedural ALOS decreased after the ACS started and operative time did not increase after a surgery residency was established. 

 

92.13 The effects of BMI on patients undergoing total neoadjuvant therapy for pancreatic cancer

Posted on January 18, 2018

K. Ang1, N. Goel1, M. Kilcoyne1, A. Nadler1, W. H. Ward1, J. Farma1, A. Karachristos1, N. Esnaola1, J. P. Hoffman1, S. Reddy1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA

Introduction: Increased BMI in patients with pancreatic cancer undergoing pancreatic resection who has been associated with increased intra-operative and post-operative complications. However, the effects of BMI on patients that have undergone total neoadjuvant therapy (TNT) have yet to be investigated. All of the patients in this study have undergone TNT, an institutional practice where patients receive systemic chemotherapy and chemoradiation, followed by definitive surgical resection if there is no evidence of metastatic disease.  The objective of this study is to evaluate the association of BMI with response and postoperative complications in patients who underwent TNT.

Methods: A retrospective review of an institutional database at a tertiary care cancer center was undertaken to evaluate patients undergoing pancreatic resection from 2000 to 2017 who completed TNT and had pretreatment documented BMI. Clinical and pathologic data were collected including: overall survival, CA19-9 response, and R0 resection. Comparative analysis was performed with chi-square and survival outcomes were assessed using Kaplan-Meier.

Results: The analytic cohort consisted of 57 patients. Patients with normal BMI (NBMI) (18.5 – 24.9; n=26) and overweight/obese (OBMI) (BMI > 25; n=30) at the time of diagnosis were included in the final analysis. The median age at diagnosis was 67 years old (range 38 – 82). Twenty-nine (50.9%) of the patients were female. Fifty-two (91%) were Caucasian, 4 (7%) patients were African American, and 1 patient (1.8%) was Asian.

The median initial CA19-9 prior TNT was 254 (0-35 U/mL) for the NBMI cohort, and 127 for the OBMI cohort (p=0.880). For the NBMI cohort, 63% (n=17) achieved a >50% decrease in CA19-9 levels, 19% (n=5) achieved <50% decrease, 4%% (n=1) had no change or an increase. For the OBMI cohort, 47% (n=14) achieved >50% decrease, 20% (n=6) achieved <50% decrease, 10% (n=3) had no change or an increase. Complications from TNT occurred in a higher proportion of OBMI patients (43%; n=13) than in NBMI patients (41%; n=11), (p=0.023). A breakdown of incidences of each particular adverse effect is illustrated in Table 1. Surgical site infections occurred in 29.6% of NBMI patients (n=8) and in 20% (n=6) of OBMI patients (p=0.541). Length of hospital stay following surgery was 8 days for the NBMI patients compared to 10 days for OBMI patients (p=0.88). The median overall survival for the NBMI cohort was 41.2 months with a 5-year survival rate of 21.2%, while the median overall survival for patients in the OBMI cohort was 37.4 months with a 5-year survival rate of 6.5% (p=0.096).

Conclusions: NBMI patients experienced less complications from TNT than OBMI patients. The borderline significant difference in overall survival between the NBMI cohort and the OBMI warrants further investigation with a larger sample size.

89.20 Implementation of Enhanced Recovery to Improve Perioperative Outcomes at a Community Hospital

Posted on January 18, 2018

D. N. Maurente1, A. Ardeljan1, A. Johns1, S. Willis1, H. Abdul1, M. Bustos1, S. Sennhauser1, M. Ghali1, A. Rashid1, M. Perez1, O. M. Rashid1  1Holy Cross Hospital,Michael And Dianne Bienes Comprehensive Cancer Center,Fort Lauderdale, FL, USA 2Massachusetts General Hospital,Boston, MA, USA 3University Of Miami Miller School Of Medicine,Miami, FL, USA 4Charles E. Schmidt College Of Medicine At Florida Atlantic University,Boca Raton, FL, USA

Introduction:
To improve postoperative length of stay (LOS) and readmissions (RA) in bowel surgery, enhanced recovery protocols (ERP) were developed promoting a multidisciplinary approach with minimal anesthesia, early ambulation and enteral alimentation, and multimodality analgesia. This study evaluated ERP at a community Hospital (HCH) for improved patient outcomes.

Methods:
Patient charts for DRG 329, 330, and 330 were retrospectively reviewed at HCH in 2017 to compare outcomes in ERP versus non-ERP cases. The Medicare claims database (CMS) was also retrospectively reviewed by the same DRG codes to determine LOS and RA. Standard statistical comparisons were used to determine significance.

Results:

At HCH: DRG 329 mean LOS for non ERP was 13.0833 days (n = 12) versus 3.375 (n = 8), p = < 0.001; DRG 330 mean LOS for non ERP was 10.861 days (n = 36) versus 4.583 (n = 24), p = < 0.001; and DRG 331 mean LOS for non ERP was 7.272 days (n = 11) versus 3.348 (n = 23), p = 0.004. 

Based on comparable CMS data, HCH DRG 329 LOS improved from 90th to top 10th percentile (n = 238,907); DRG 330 from 90th to 28th percentile for DRG 330 (n = 285,423); and DRG 331 from 90th to 46th percentile for (n = 126,941), p < 0.001. HCH RA in ERP and non-ERP cases was 3% at 30 and 90 days. CMS RA for DRG 329 was 25.1% at 90 days and 9.9% at 30 days; DRG 330 RA was 18.3% at 90 days and 6.6% at 30 days; and DRG 331 RA was 11% at 90 days and 3.9% at 30 days. 

Conclusion:
Implementation of ERP for bowel surgery at HCH improved outcomes, and future ERP research in non-bowel surgery is recommended.

89.14 The impact of thrombocytopenia on pure laparoscopic hepatectomy for hepatocellular carcinoma

Posted on January 18, 2018

T. Cheung1, C. Lo1  1The University Of Hong Kong,Hong Kong, HONG KONG, Hong Kong

Introduction:
 Bleeding in the presence of thrombocytopenia has been a major issue in liver resection even in open procedures. Although laparoscopic liver resection has been reported to be a safe and effective treatment even in patients with liver cirrhosis, there is very little evidence in patients with thrombocytopenia.

Methods:

Between October 2002 and February 2016, 132 patients had undergone pure laparoscopic liver resection for hepatocellular carcinoma (HCC). Thrombocytopenia was defined as platelet counts <100x 109/L. Amongst 132 patients received laparoscopic liver resection, 17 patients who had thrombocytopenia (Group 1) and 111 patients who did not have thrombocytopenia (Group 2) with the same solitary tumor and clear resection margin characteristics were chosen for comparison. 

The immediate operation outcome and survival including operation morbidity were compared. The disease free survival and overall survival were also compared.

Results:

Comparing Group1 to Group 2, the median operation time was 184 minutes vs 175 minutes p=0.817, the median blood loss was 200ml vs 100ml (P=0.347). Hospital stay was 4 days vs 4 days (P<0.888), postoperative complication was 3(17.6%) vs 8(7.2%) (p=0.334), median disease free survival was 20 months vs 71 months (P<0.001) and the median overall survival was >120 months vs 136 months (P=0.298). The median disease free survival for stage II HCC was 12 months vs 71 months (p=0.001).

 

Conclusion:

Thrombocytopenia does not have an adverse effect immediately on laparoscopic liver resection. Long term outcome has to be evaluated further in future. 

89.13 Carcinoma of the Ampulla of Vater: Biologic and Surgical Factors Predicting Recurrence and Survival

Posted on January 18, 2018

E. C. Poli1,2, S. J. Stocker2, C. Wang2, V. Parini4, R. Marsh3, R. Prinz2, C. R. Hall2, M. S. Talamonti2  1University Of Chicago,Department Of General Surgery,Chicago, IL, USA 2Northshore University Health System,Department Of Surgery,Evanston, IL, USA 3Northshore University Health System,Section Of Gastrointestinal Oncology,Evanston, IL, USA 4Northwestern University,Comprehensive Cancer Center,Chicago, IL, USA

Introduction: Carcinoma of the ampulla of Vater accounts for 6.8-20% of all periampullary tumors. The purpose of this study was to determine prognostic factors affecting disease-free and overall survival following pancreaticoduodenectomy for localized, non-metastatic disease.

Methods: This was an IRB approved retrospective review of a prospectively maintained database of patients operated on for ampullary carcinoma from 1997-2014 at Northwestern Memorial and NorthShore University HealthSystem hospitals.  Regression analyses were performed on clinical and pathologic data to determine significant predictors of recurrence and mortality.

Results: A total of 104 patients were included in the study: 52 (50%) were female; mean age of all patients was 64, and 90 (87%) were Caucasian. Eighty-one patients (78%) had a biliary stent placed prior to surgery. Tumor characteristics are as follows: T0/Tis 4 (4%), T1 10 (10%), T2 32 (31%), T3 39 (38%), T4 19 (18%); N0 51 (49%), N1 53 (51%).  Lymphovascular invasion was present in 49 (49%) and perineural invasion in 31 (57%) patients. There was a positive resection margin in 3 (3%) patients. The median number of positive nodes was 2 and the median LN ratio was 0.13. Eighteen patients (34%) had a LN ratio >20%. Pathologic data with IHC staining was gathered for 63 patients; 20 (32%) had intestinal type, 37 (59%) had biliary type, and 4 (6%) had mixed tumors. Median follow-up was 39 months and 57 (56%) patients died during follow-up. The 5-year disease-free survival rate was 42% and the 5-year overall survival rate was 50%. On univariate analysis, factors that were significant predictors of recurrence included elevated serum bilirubin level (p=0.005, HR=1.1), AJCC Stage 3 (p=0.007, HR=3.1), tumor size > 20mm (p=0.029, HR= 2.1), positive node status (p=0.048, HR=1.9), perineural invasion (p=0.05, HR=2.5), and positive resection margin (p=0.003, HR=5.4).  On multivariate analysis, elevated serum bilirubin and positive resection margin were significant for recurrence.  Factors that were significant predictors of mortality on univariate analysis included tumor size >20mm (p=0.005, HR=2.3), positive node status (p=0.034, HR=1.8), major vessel involvement (p=0.014, HR=3.5), and AJCC stage (p=0.13, HR= 2.4). When controlling for T category, tumor size, major vessel involvement, and positive resection margin were significant on multivariate analysis and positive node status approached significance.

Conclusion: In this cohort of patients with ampullary cancers treated by surgical resection, the predominant determinants of recurrence and overall-survival included biologic and pathologic factors that reflect the extent of local and regional disease. The effectiveness of surgical intervention was driven by the ability to achieve a complete margin-negative extirpation of localized disease. These findings may help guide treatment recommendations for patients with poor prognostic factors as delineated in this series.

 

89.12 Outcomes of Extended Hepatectomy for Hepatobiliary Tumors. Who is More Important Than Where

Posted on January 18, 2018

A. M. Attili1,2, I. Sucandy1, N. Patel1, J. Spence1, K. Luberice1, T. Bourdeau1, S. Ross1, A. Rosemurgy1  1Florida Hospital Tampa,General Surgery,Tampa`, FL, USA 2University Of Central Florida,General Surgery,Orlanda, FL, USA

Introduction:  Hepatectomy is the gold standard curative treatment for hepatic neoplasms in patients with preserved liver function. Many large tumors involving central liver segments require extended hepatectomy (EH) to gain complete resection with negative margins,however some patients with impaired liver function are offered non surgical options due to high morbidity and mortality following this major operation. Outcome data is relatively limited with the majority of extended hepatectomies offered only at major hepatobiliary centers. We aim to describe outcomes of EH at our hepatobiliary center.

Methods:  With institutional review board approval, all patients undergoing hepatectomy between 2012-2017 were prospectively followed. Patient demographic data, perioperative outcomes, and short/long-term survival data were collected and analyzed. Data are presented as median (mean ± SD).

Results: A total of 91 patients underwent hepatectomy (open and robotic approach) within the study period with 10 patients undergoing EH. The majority of patients who underwent EH were women (70%), age of 63 (60.3 ± 16.5) years, body mass index of 24 (24.7 ± 3.8) kg/m2, and MELD score of 11 (10.9 ± 1.6). Six patients underwent an extended right hepatectomy (resecting segment IV-VIII), while 4 patients underwent extended left hepatectomy (resecting segment II-V and VIII). Indications were Klatskin tumor (30%), hepatocellular carcinoma (30%), intrahepatic cholangiocarcinoma (20%), and metastatic neuroendocrine tumor (20%). Operative time was 224 (253.1 ± 111.7) minutes with estimated blood loss of 500 (845 ± 1002.9) ml. No intraoperative complications were seen. One patient had blood transfusion. Negative resection margins (R0) were achieved in 9 patients. One patient with R1 resection margin had hepatocellular carcinoma involving a deep intrahepatic portion of the right hepatic duct, where bile duct resection followed by hepaticojejunostomy was unsafe to perform. Two patients experienced postoperative complications (pleural effusion requiring thoracentesis in one patient and respiratory failure leading to multisystem organ failure and death in another). Length of intensive care unit stay was 2(2.1 ± 1.5) days, and hospital stay was 5(5.6 ± 2.6) days. Readmissions to the hospital were seen in 3 patients (failure to thrive in 2 patients and development of postoperative ascites with pulmonary embolism in 1 patient). 80% of the patients are currently alive with median follow up of 41.2 months. 

Conclusion: Despite major concerns of postoperative complications and liver failure for patients with a component of liver dysfunction who has otherwise resectable tumors, EH can be a feasible curative option for these patients. Clinical success mainly depends on preoperative planning, experience of hepatobiliary team, and optimum postoperative care.

84.17 Improving Care of Patients with Pancreatic Cancer: An Analysis of the SEER Database

Posted on January 18, 2018

A. Salami1, A. Joshi1  1Albert Einstein Medical Center,Surgery,Philadelphia, PA, USA

Introduction:  Pancreatic cancer remains the 4th leading cause of cancer deaths in the United States. Despite improvements in overall survival for most cancers, survival for patients with pancreatic cancer has remained persistently low. We sought to compare recent trends in clinical presentation, treatment, and survival for pancreatic adenocarcinoma. 

Methods:  A retrospective cohort study using data from the SEER program (2014 – 2014). All patients with a histologic diagnosis of pancreatic adenocarcinoma were included. The exposure of interest was the era of diagnosis, 2004 – 2009 (Era-A) vs. 2010 – 2014 (Era-B). Outcomes of interest were the: (1) incidence of metastatic disease (2) utilization of resection and (3) overall survival. Multivariable logistic and Cox regression analyses were performed to elucidate associations. 

Results: A total of 62,201 patients were included in this study [Era-B – 31,998 (51.4%)]. A significant higher proportion of patients diagnosed in Era-B were older (68.8 vs. 68.1 years), non-Caucasian (20.2 vs. 19.6%) and insured (95.3 vs. 51.4%); p<0.05 for all. No significant gender differences were observed between the study groups. On univariate analysis, patients diagnosed in Era-B were less likely to present with metastatic disease (OR: 0.95, CI: 0.92-0.98, p=0.002), undergo resection (OR: 0.87, CI: 0.83-0.92; p<0.001) or suffer mortality (HR: 0.91, CI: 0.90-0.93; p<0.001). Following multivariable adjustment, having a diagnosis of pancreatic cancer in Era-B was independently associated with a decreased incidence of metastatic disease (OR: 0.91, CI: 0.88-0.96; p<0.001), and mortality (HR: 0.88, CI: 0.86-0.89; p<0.001). Similarly, for patients with non-metastatic disease, having a diagnosis in Era-B was an independent predictor of resection (OR: 1.11, CI: 1.04-1.20; p=0.002). The association between era of diagnosis and mortality was independent of resection status (resected patients – HR: 0.80, CI: 0.76-0.85; p<0.001 and unresected patients – HR: 0.89, CI: 0.87-0.91; p<0.001). 

Conclusion: There has been significant improvement in pancreatic cancer care over the last decade, as evidenced by earlier diagnosis, increased utilization of surgery, and improvement in overall survival for both resected and unresected patients. Patients with pancreatic cancer should be encouraged to undergo evidence-based and guideline-driven treatment, in order to optimize outcomes. 

84.18 Long term results of cholecystectomy for biliary dyskinesia: patient outcomes and resource utilization

Posted on January 18, 2018

S. B. Cairo1, G. Ventro1, E. Sandoval3, D. H. Rothstein1,2  1Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NEW YORK, USA 2University At Buffalo Jacobs School Of Medicine And Biomedical Sciences,Division Of Surgery,Buffalo, NY, USA 3Jacobs School Of Medicine And Biomedical Sciences,Buffalo, NEW YORK, USA

Introduction:  Rates of cholecystectomy in pediatric patients have risen dramatically in the past decade, driven in part by an increased acceptance of biliary dyskinesia as a principle indication. Symptom improvement after cholecystectomy in this group, however, is disappointingly inconsistent. We seek to characterize post-operative resource utilization in patients with persistent symptoms after cholecystectomy for biliary dyskinesia.

Methods:  Single-institution, retrospective chart review of patients less than 18 years old who underwent cholecystectomy for an ICD9 diagnostic code of biliary dyskinesia between December 1, 2010 and July 2, 2016. Patient demographics, symptoms, pre-operative workups, operative details and post-operative interventions were abstracted. Telephone follow-up was performed to identify patients with persistent symptoms, characterize the patient experience, and quantify post-operative resource utilization. 

Results: Forty-nine patients underwent cholecystectomy for biliary dyskinesia.  All of the procedures were performed laparoscopically without intraoperative cholangiogram. Nearly half (22, 45%) were seen post-operatively by a gastroenterologist, 32% of whom were known to a gastroenterologist prior to cholecystectomy, as well. Post-operative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, 5 ERCPs, 1 endoscopic ultrasound, 1 MRCP, and 5 colonoscopies.  Only 2 patients had undergone ERCP pre-operatively in this cohort.  Of the patients with additional diagnostic testing post-operatively, one was found to have mild esophagitis, 3 were diagnosed with Sphincter of Oddi dysfunction, and 1 was diagnosed with suspected inflammatory bowel disease.  Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea or vomiting at an average of 26 months after operation. Of note, all patients who underwent post-operative ERCP with sphincterotomy reported symptom relief following this procedure. 

Conclusion: Relief of symptoms after cholecystectomy for biliary dyskinesia in the pediatric population is inconsistent. Post-operative studies are myriad, and have no consistent diagnostic yield and generate high costs. The volume and inconclusive nature of post-operative work up for patients with ongoing symptoms suggests that the initial diagnostic criteria and treatment algorithm may require revision.  

 

84.16 Sites of Distant Metastases in Patients with Positive Peritoneal Cytology for Pancreatic Cancer

Posted on January 18, 2018

M. Kilcoyne1, N. Goel1, K. Ang1, A. Nadler1, W. H. Ward1, J. M. Farma1, N. F. Esnaola1, A. Karachristos1, J. P. Hoffman1, S. Reddy1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA

Introduction:  Although positive peritoneal cytology (PPC) in patients with potentially resectable pancreatic adenocarcinoma is known to be associated with poor outcome, there is limited data regarding the location and prognostic significance of subsequent intra/extraperitoneal distant metastases. The objective of this study was to describe common sites of subsequent distant metastases in patients with potentially resectable pancreatic adenocarcinoma and PPC, and compare their respective impact on overall survival (OS). 

Methods:  We retrospectively analyzed patients with potentially resectable pancreatic adenocarcinoma treated at our institution from 2000-2017 who underwent peritoneal washings prior to surgical resection. Clinical and pathologic data was directly abstracted from the clinical record. Survival curves were constructed by the Kaplan-Meier product limit method.

Results: Eleven out of 287 patients with potentially resectable pancreatic adenocarcinoma (4%) were found to have PPC on final cytology. Nine out of these 11 patients (82%) subsequently developed distant metastatic disease: 5/9 (56%) subsequently developed radiologically evident peritoneal carcinomatosis, 2/9 patients (22%) developed liver metastases, 1/9 (11%) developed bony metastases, and 1/9 (11%) developed lung metastases. Two patients were lost to follow-up before evidence of distant metastasis. Among the 11 patients with PPC, the median OS was 16.3 months. The median OS of patients with subsequent liver metastases and peritoneal carcinomatosis were 12.3 months and 16.3 months, respectively. In contrast, the median OS of patients with subsequent bony metastases and lung metastases were 27.3 months and 64.9 months, respectively. 

Conclusion: PPC is associated with poor prognosis in patients with (otherwise) potentially resectable pancreatic adenocarcinoma. The peritoneal cavity is the most common site for subsequent distant disease progression, followed by the liver. Longer than expected OS was observed in a limited number of patients with subsequent bony metastases and lung metastases. Additional studies are needed to validate these findings and determine whether surgical resection and potential bone/lung directed therapies may be of therapeutic value in these patients.  
 

84.15 Where There’s Smoke, There’s Fistula: Smoking Linked to Higher Fistula Rate After Pancreas Resection

Posted on January 18, 2018

N. Rozich1, A. Landmann1, M. Bonds1, L. Fischer1, R. Postier1, K. Morris1  1University Of Oklahoma College Of Medicine,General Surgery,Oklahoma City, OK, USA

Introduction: Cigarette smoking is an established risk factor for the development of pancreatic adenocarcinoma, however, there is little data regarding its effects on postoperative morbidity after pancreaticoduodenectomy. While most surgeons encourage smoking cessation, there is limited evidence to support the argument that smoking increases post-operative complications. We hypothesize that cigarette smoking is associated with higher morbidity rates following pancreatic head resection. 

Methods: A retrospective review of all patients undergoing pancreaticoduodenectomy from 2011-2016 at a single institution was performed. Demographic data, including co-morbidities and post-operative complications were recorded and analyzed based on smoking history (never-smoker versus any history of smoking). Univariate and multivariable analyses were performed using SPSS version 24 (IBM Corp., Armonk, NY). P-values of less than 0.05 were considered significant.

Results: 220 patients met inclusion criteria. On univariate analysis, there was a significant difference in younger age at diagnosis (65.3 versus 68.4 years, p=0.019), male gender (63.4% versus 43.3%, p=0.004), and fistula rate (37% versus 18%, p=0.040) between smokers and never-smokers. There were trends towards higher rates of postoperative intra-abdominal abscesses, pneumonia, and cardiac complications. There was no significant difference in terms of BMI, diabetes, neoadjuvant therapy, delayed gastric emptying, readmission, or hospital length of stay between smokers and never-smokers. On multivariable analysis, fistula rate had an OR of 0.510 for women (p=0.046) and OR 0.557 for never-smokers (p=0.085). In analysis of gender differences, we found that male sex was significantly associated with fistula rate (31% vs 17%, p=0.019) and that smoking history was significantly related to fistula formation only in the male cohort (37% versus 19%, p=0.040 in men and 18% versus 16%, p=0.851 in women).

Conclusion: Smoking status was associated with a significant increase in postoperative pancreatic fistula rate following pancreaticoduodenectomy in men. Further studies are needed to determine if smoking cessation before surgery decreases this risk, and if so, the duration of cessation optimal to minimize morbidities.

 

84.14 Outcomes of alternative preoperative total neoadjuvant therapy regimens in pancreatic cancer

Posted on January 18, 2018

K. Ang1, N. Goel1, M. Kilcoyne1, A. Nadler1, W. H. Ward1, J. Farma1, A. Karachristos1, N. Esnaola1, J. P. Hoffman1, S. Reddy1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PENNSYLVANIA, USA

Introduction: While there is growing interest in the role of neoadjuvant therapy (including chemotherapy and chemoradiation) in patients with localized, borderline resectable (BR), and locally advanced (LA) pancreatic adenocarcinoma, the relative value of alternative chemotherapeutic regimens remains to be defined. The objective of this study was to evaluate biochemical and oncologic outcomes (serum CA19-9 response, R0 resection rate, overall survival [OS]) associated with alternative preoperative chemotherapeutic regimens (FOLFIRINOX versus Gemcitabine [Gem]-based chemotherapy) in patients with localized/BR/LA pancreatic adenocarcinoma treated with total neoadjuvant therapy (defined as neoadjuvant systemic chemotherapy followed by chemoradiation).

Methods: We retrospectively analyzed patients with localized/BR/LA pancreatic adenocarcinoma treated with total neoadjuvant therapy and subsequent surgical resection treated at our institution from 2000-2017. Clinical and pathologic data was directly abstracted from the clinical record.

Comparative analyses were performed with chi-square tests; survival outcomes were assessed using the Kaplan-Meier product limit method and compared using log rank tests.

Results: Sixty-nine patients completed TNT prior to surgical resection: 15 patients received FOLFIRINOX, while 54 patients received Gem-based chemotherapy. 20 of patients had localized disease; 49 had BR or LA disease at presentation, respectively. Overall, the median age was 64 years old (range 38 – 82); 50.7% of patients were male, 88.4% were Caucasian, 8.7% were Black/African American, and 2.9% were Asian. The median serum CA19-9 level at presentation was 173.5 (normal range, 0-35 U/mL) for the group that received FOLFIRINOX vs. 127 for the group that received Gem-based chemotherapy (p=0.352). Among patients who received FOLFIRINOX, 53% experienced a >50% decrease in serum CA19-9 after TNT, 13.3% experienced a <50% decrease, and 6.6% experienced no change (or an increase).  Among patients who received Gem-based chemotherapy, 50% experienced a >50% decrease in serum CA19-9 after TNT, 14.8% experienced a <50% decrease, and 9.3% experienced no change (or an increase).   93% vs. 83% percent of patients who received FOLFIRINOX vs. Gem-based chemotherapy subsequently underwent an R0 resection (p=0.33). Median OS and 3-year survival of patients who received FOLFIRINOX were 47.6 months and 48%, respectively; in comparison, median OS and 3-year survival of patients who received Gem-based chemotherapy respectively (p=0.173).

Conclusions: Among patients with localized/BR/LA pancreatic adenocarcinoma, treatment with FOLFIRINOX vs. Gem-based chemotherapy within the context of TNT results in comparable biochemical and oncologic outcomes. Our data suggests that (at the current time) the choice of neoadjuvant chemotherapeutic regimens (as part of TNT) should ideally be based on performance status at presentation and potential toxicity. 

84.13 Feasibility of Early Postoperative Exercise Therapy After Major Gastrointestinal Surgery

Posted on January 18, 2018

L. Willcox1, J. Swinarska1, C. J. Clark1  1Wake Forest Baptist Health,Division Of Surgical Oncology,Winston Salem, NC, USA

Introduction:
Early mobilization after surgery has been shown to improve outcomes including decreased length of stay, lower postoperative morbidity, and increased patient satisfaction. However, adherence rates to Enchanced Recovery After Surgery protocols and frequency of patient ambulation during the postoperative period remain highly variable. The current study aimed to identify patient-reported barriers and facilitators for successful implementation of an inpatient exercise program after major gastrointestinal (GI) surgery. 

Methods:
In this IRB-approved prospective cohort study at a large, academic, comprehensive cancer center, patients who underwent major GI surgery were identified using the electronic medical record. Eligible patients were followed postoperatively and barriers to mobilization and physical activity preferences were evaluated using a survey instrument. Additional data captured included daily ambulation frequency, clinicopathologic information, and postoperative outcomes. 

Results:
40 patients (53% female, mean age 62 yrs) underwent major GI surgery with a mean length of stay of nine days. 78% of patients presented with a cancer diagnosis, the most common being upper GI malignancy. The majority of operations utilized an open approach (70%) with a mean operation time of 293 minutes and mean EBL of 341mL. Complications occurred in 48% of patients. Prior to surgery patients had a mean karnofsky performance index of 86, and the most common comorbidities included diabetes (25%), ulcer disease (17.5%), and cerebrovascular disease (7.5%). 53% of patients had a prior abdominal operation and 12.5% of patients were current smokers at the time of surgery. Eight (20%) of patients reported no regular exercise before surgery. During hospitalization, patients reported that their physical activity level was determined more by nursing (47.5%) and family encouragement (55%) and less due to the incision site (27.5%), foley catheter (24%), intravenous lines (45%), or pain level (30%). Over half (53.3%) of patients reported interest in completing a walking exercise program over a biking exercise program (26.7%) during the postoperative recovery period.  Patients indicated a preference to ambulate around the hospital ward (83.3%) as opposed to walking on a treadmill (8.3%). Nearly all patients reported they could exercise more than once daily (67%), at light intensity (80%), for short time intervals (40%) preferably in the morning (80%). The majority of patients would be more compelled to exercise if it was personalized to fit their needs (93%) and recommended by their doctor (87%). Nearly all patients (93%) reported experiencing fatigue after surgery, yet no patients reported receiving education on fatigue management strategies. 

Conclusion:
Family member and nursing staff encouragement are key determinates of postoperative activity for major GI surgery patients.  The current study indicates patients are receptive to a postoperative exercise program that includes high frequency, short-duration, low-intensity ambulation.  High-intensive treadmill or biking exercise programs are less likely to be successful. 
 

84.12 Vital Signs Predict Post-Operative Complications in Patients Undergoing Pancreaticoduodenectomy

Posted on January 18, 2018

K. Dukleska1, A. Felix1, S. Iyer1, G. Medina1, H. Lavu1, C. J. Yeo1, J. M. Winter1  1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA

Introduction: Major complications remain common after pancreaticoduodenectomy (PD), and are associated with increased length of stay, cost, and hospital readmissions. We hypothesized that abnormal vital signs in the early postoperative period could predict postoperative complications.

Methods: A retrospective analysis was performed of patients undergoing PD from 2009-2014 at a single high-volume academic center. Vital sign values were collected over the first seven postoperative days and assessed as predictors of postoperative complications. A subgroup analysis was performed in patients who developed complications after postoperative day number four. Vital signs obtained prior to the complication were analyzed using univariate and multivariable regression analyses to identify abnormal values that were associated with these complications.

Results: Vital signs were available for 720 patients after PD. At least one documented complication occurred in 414 (57.7%) patients, and an infectious complication occurred in 267 (37%) patients. Complications with a Clavien score ≥ 3 occurred in 136 (19%) patients. A total of 563 patients were included in the subgroup analysis. Cutoff values for temperature and heart rate (HR) greater than 100 degrees Fahrenheit (median value, Odds Ratio (OR) 17, p<0.001) and 110 beats per minute (mean value, OR 6.3, p=0.002), respectively, proved to be the most informative predictors of infection. On multivariable regression analysis, after adjusting for other vital sign values, these thresholds remained independently associated with infectious complications (median temperature, OR 12.8, p=0.002; mean HR, OR 4.1, p=0.02) (Table 1). Moreover, mean diastolic blood pressure <58 was associated with an increased 90-day mortality (OR 21.6, p=0.006).

Conclusion: Routinely collected vital signs can be used as predictors for postoperative complications in patients after PD, and ultimately may be used to select patients for early workup and intervention for occult infection. This line of investigation may lead to improved patient outcomes and reduce cost of care.

 

84.11 Comparing Oncologic and Short-Term Outcomes of Minimally Invasive vs Open Pancreaticoduodenectomy

Posted on January 18, 2018

R. J. Torphy1, C. Friedman1, B. C. Chapman1, M. D. McCarter1, R. D. Schulick1, B. H. Edil1, A. Gleisner1  1University Of Colorado,Department Of Surgery,Aurora, CO, USA

Introduction:

Minimally invasive pancreaticoduodenectomy (MIPD) has been slow to gain acceptance given its complexity and concern for oncologic equivalency when compared with an open approach. The National Cancer Database (NCDB) began documenting surgical approach in 2010. Our objective was to compare oncologic and short-term outcomes of patients with cancer who underwent open vs MIPD (laparoscopic and robotic) from 2010 to 2013 using the NCDB.

Methods:

Adults who underwent pancreaticoduodenectomy from 2010-2013 for cancer were identified after exclusion of patients with metastatic disease, pathologic T0, in-situ disease, or an unknown operating facility. Laparoscopic and robotic approaches were defined as minimally invasive. Multivariable logistic regression that accounted for clustering of patients at facilities was performed to examine the relationship between patient and facility characteristics and the use of MIPD, oncologic outcomes (margin status and lymph node harvest) and short-term outcomes (days to discharge, unplanned 30-day readmission, and 30- and 90-day mortality). The multivariable analyses controlled for demographics, insurance, institutional classification, distance to treating institution, year, Charlson comorbidity score, pathologic tumor stage (pT), nodal stage (pN) and overall stage, grade, histologic diagnosis, and hospital volume of open and MIPD.

Results:

Of the 11,066 patients who underwent pancreaticoduodenectomy for cancer from 2010-2013, 85% (9,406) were performed open and 15% (1,660) were performed minimally invasively. The percentage of minimally invasive cases increased from 11.8% in 2010 to 15.9% in 2013 (P<0.001). Factors independently associated with MIPD included age >80 (OR 1.30, P=0.021), pT2 (OR 0.80, P=0.020), and histologic diagnosis of neuroendocrine tumor (NET) (OR 1.45, P<0.001). Patients undergoing MIPD had decreased odds of a prolonged hospitalization (≥10 days) (OR 0.82, P=0.008). There was no difference in short-term outcomes of unplanned 30-day readmission and 30- or 90-day mortality. Patients undergoing MIPD had decreased odds of positive margins (OR 0.79, P=0.004), and no difference in number of lymph nodes resected. Using our multivariable model, increased hospital volume of open and MIPD was a significant predictor of improved 30- and 90-day mortality, decreased length of stay, and greater number of lymph nodes harvested, with centers in the highest quartile for volume (>21.5 cases per year) performing best.

Conclusion:

MIPD has increased in prevalence in the United States from 2010 to 2013. Patients selected for MIPD were more likely to have a diagnosis of NET and have smaller tumors, demonstrating a selection bias between approaches. After controlling for these differences, short-term and oncologic outcomes are equivalent between open and MIPD. These results also demonstrate an association between improved outcomes with higher hospital volume of pancreaticoduodenectomies for cancer.

84.10 Postoperative Outcomes After Preoperative Chemotherapy vs Chemoradiation in Resected Pancreas Cancer

Posted on January 18, 2018

A. A. Mokdad1, C. A. Hester1, S. C. Wang1, M. R. Porembka1, M. M. Augustine1, A. C. Yopp1, J. C. Mansour1, R. M. Minter1, M. A. Choti1, P. M. Polanco1  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA

Introduction: Preoperative therapy is being increasingly used in the management of resectable and borderline resectable pancreatic cancer. Some data suggest that long-term outcomes are comparable between preoperative chemotherapy and preoperative chemoradiation; however, chemoradiation may be associated with worse early postoperative outcomes. In this study, we compared early postoperative morbidity and mortality between preoperative chemotherapy and chemoradiation in resected pancreatic adenocarcinoma.

Methods: We used the National Surgical Quality Improvement Program (NSQIP) complemented by the NSQIP procedure targeted pancreatectomy variables for 2014 and 2015. We included patients with non-metastatic adenocarcinoma of the pancreas who received preoperative chemotherapy (preopCT) or chemoradiation (preopCRT) followed by resection. Patients undergoing enucleation or emergent resection were excluded. We abstracted patient demographic and comorbidity data as well as perioperative information. We compared early postoperative outcomes between the preopCT and preopCRT groups. We used inverse probability of treatment weighting (IPTW)–estimated using a propensity score–to adjust for preoperative and intraoperative variables.

 

Results: A total of 1,133 patients were included; 609 (54%) in the preopCT group and 524 (46%) in the preopCRT group. Most patients underwent a pancreaticoduodenectomy (77%). Preoperative stent placement was comparable between preopCT and preopCRT (54% vs 55%, P=0.86) and 34% vs 39% (P=0.07) had a vascular resection, respectively. PreopCT was associated with higher pathological stages (stages 2 or 3: 89% vs 78%, P<0.01) and firmer pancreatic tissue (58% vs 69%, P<0.01). After adjusting using IPTW, organ space surgical site infections (8% vs 8%, adjusted P (aP)=0.79), pancreatic fistula (10% vs 11%, aP=0.42), delayed gastric emptying (13% vs 13%, aP=0.66), intraoperative and immediate postoperative blood transfusions (27% vs 27%, aP=0.71), reoperation within 30 days (6% vs 6%, aP=1.00), length of stay (9.5 days vs 9.5 days, aP=0.88), discharge to home (88% vs 87%, aP=0.12), and 30-day mortality (2% vs 1%, aP=0.78) were comparable between preopCT and preopCRT. Mean operative time was longer in preopCRT (376 minutes vs 415 minutes, aP<0.01) and unplanned 30-day readmissions were more common in preopCRT (14% vs 21%, aP<0.01).

Conclusion: Early postoperative morbidity and mortality after pancreatic resection are largely comparable between preoperative chemotherapy and preoperative chemoradiation. Our findings support equipoise between preoperative chemotherapy and chemoradiation and highlight the need to evaluate further the role of these regimens in ongoing and future preoperative clinical trials for pancreatic adenocarcinoma.

84.09 Mortality After Pancreaticoduodenectomy: Determining Early and Late Causes of Patient Specific Death

Posted on January 18, 2018

S. Narayanan1, A. N. Martin1, F. E. Turrentine1, T. W. Bauer1, R. B. Adams1, V. M. Zaydfudim1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA

Introduction:
Safety of pancreaticoduodenectomy has improved significantly in the past two decades. Current inpatient and 30-day mortality rates are low. However, incidence and causes of 90-day and 1-year 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 postoperative pancreatectomy-specific morbidity and cause-specific mortality were compared between early (within 90-days) and late (91-365 days) post-operative recovery period.   

Results:
A total of 552 pancreaticoduodenectomies were performed during the study period. Clinically significant pancreatic leak (11.8% versus 0%) and intra-abdominal abscess not related to pancreatic leak (4.0% versus 0.4%) were more common during early rather than late post-operative period (both p<0.001). Proportion of re-operations were higher in early compared to late post-operative period (6.5% versus 3.8%, respectively, p=0.041). Mortality at 30, 90, 180, and 365 days following pancreaticoduodenectomy was 6 (1.1%), 20 (3.6%), 45 (8.2%), and 90 (16.3%) patients, respectively. Causes of early and late mortality varied significantly (p<0.001). The most common cause of death within 90 days was due to intra-abdominal infection, sepsis and multiple system organ failure in 10 (50%) patients, followed by post-pancreatectomy hemorrhage in 4 patients (20%), 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 45 (64%) patients during the late post-operative period between 91 and 365 days. Mortality from failure to thrive and debility, which was most frequently associated with delayed gastric emptying and failure of nutritional recovery, was similar between early (within 90-days) and late (91-365 days) post-operative periods (15% versus 16%, p=0.856). 

Conclusion:
A majority of quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early post-operative mortality. Further reduction in post-operative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating post-operative malnutrition, and optimizing preoperative cancer staging and management strategies.  
 

84.08 Management of Biliary Stent-Induced Cholecystitis in Patients with Pancreatic Adenocarcinoma

Posted on January 18, 2018

N. R. Jariwalla1, M. Aburajab2, A. H. Khan2, K. Dua2, M. Aldakkak1, K. K. Christians1, B. George3, P. S. Ritch3, B. A. Erickson4, W. A. Hall4, M. Griffin5, D. B. Evans1, S. Tsai1  1Medical College Of Wisconsin,Surgical Oncology/Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Gastroenterology/Medicine,Milwaukee, WI, USA 3Medical College Of Wisconsin,Hematology Oncology/Medicine,Milwaukee, WI, USA 4Medical College Of Wisconsin,Radiation Oncology,Milwaukee, WI, USA 5Medical College Of Wisconsin,Radiology,Milwaukee, WI, USA

Introduction:
Patients with localized pancreatic cancer (PC) often have a biliary stent placed to relieve obstructive jaundice. During neoadjuvant therapy, they are at risk of developing acute cholecystitis. The potential for treatment of cholecystitis to cause a delay in pancreatic cancer therapy is not well understood.

Methods:
Treatment details were abstracted on consecutive patients with localized PC who had a biliary stent placed at the time of diagnosis. Stent-related complications were noted and the time from stent placement to the development of a stent-related complication during the neoadjuvant treatment period was calculated. Patients were categorized as having surgical versus non-surgical management of the cholecystitis.  Time to surgery was defined as the time from the start of treatment to surgery.

Results:
Data was available for 283 patients, 121 (43%) with resectable and 162 (57%) with borderline resectable PC. Of the 283 patients, acute cholecystitis occurred in 17 (6%) patients. There was no association between the development of cholecystitis with clinical disease stage (p = 0.80) or type of neoadjuvant therapy (p =0.50). The median time to cholecystitis from date of stent placement was 2.3 months; 2 patients developed cholecystitis within the first week while the remaining 15 patients developed cholecystitis at a median of 2.6 months from stent placement. Acute cholecystitis was managed with cholecystostomy tube placement in 15 (88%) patients and cholecystectomy in 2 (12%). In total, 189 (67%) of the 283 patients completed all intended neoadjuvant therapy and surgery; 10 (59%) of the 17 patients with cholecystitis and 179 (67%) of the 266 patients without cholecystitis (p =0.47). Of the 15 patients with a cholecystostomy tube 5 (33%) did not complete neoadjuvant therapy and surgery. Both patients who had a cholecystectomy did not complete all neoadjuvant therapy and surgery. Of the 189 patients who completed all neoadjuvant therapy and surgery, the median time to surgery was 3.2 months for the 179 patients without cholecystitis and 3.6 months for the 10 patients with cholecystitis (p = 1.00). 

Conclusion:
The development of acute cholecystitis during neoadjuvant therapy occurred in 6% of patients who had an endobiliary stent. The placement of a cholecystostomy tube for the management of acute cholecystitis does not significantly delay the completion of neoadjuvant therapy and surgery and should be considered the optimal management of this complication. 
 

84.07 Two Enhanced Recovery After Pancreatectomy Protocols Do Not Offer Similar Results

Posted on January 18, 2018

A. McQuaid1, K. Subramaniam2, M. Boisen2, S. Esper2, K. Meister2, J. Gealey2, J. Holder-Murray3, A. Hamad3, M. Hogg3, H. Zeh3, A. Zureikat3  1University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,Department Of Anesthesia,Pittsburgh, PA, USA 3University Of Pittsburgh Medical Center,Department Of GI Surgical Oncology,Pittsburgh, PA, USA

Introduction: Enhanced recovery protocols in pancreatic surgery have been shown to reduce length of hospital stay without compromising outcomes. Assessing the relative contribution of individual interventions, however, is difficult when multiple practice changes are implemented simultaneously. We implemented similar pancreatectomy pathways that differ in anesthesia management at 2 hospitals with the same group of surgeons. We aimed to compare pain management and outcomes in these 2 groups with the purpose of implementing the best practice system-wide.

Methods: Patients who underwent pancreatic surgery between July 2015 and May 2017 on an enhanced recovery pathway were included. Hospital A patients received intrathecal morphine, whereas Hospital B patients received quadratus lumborum/transversus abdominal plane blocks. Data were retrospectively extracted from the electronic medical record and from a prospectively collected institutional database. Patients were analyzed according to the hospital where they received care (Hospital A, n=226, Hospital B, n=45) by univariate analysis. We also performed 2:1 propensity matched analysis (45 Hospital B patients were matched to 90 Hospital A patients) to account for potential confounding factors including comorbidities and at-home prior medications that could affect post-operative experience of pain. Primary outcomes were opioid consumption and average visual analog pain scores. Secondary outcomes were length of hospital and PACU stay, ICU admission, extubation location, ondansetron requirement, time to first bowel movement, local and systemic complications, readmission, and mortality. SPSS version 24 was used for analysis.

Results: Postoperative analgesia was superior on postoperative day 0 in patients who received intrathecal morphine (Hospital A) by both univariate and propensity matched analysis. Among matched groups, Hospital A had a significantly reduced median intravenous morphine equivalent consumption on day 0 [(Hospital A 2.6 mg (0.0-8.5), Hospital B 8.0 mg (0.0-24.4), p=0.002] and median visual analog pain score on days 0 and 5 [Hospital A 4.2 (2.0-5.6) and 4.0 (3.0-5.15), Hospital B 5.7 (2.9-6.9) and 5.7 (3.7-6.2), p=0.01, 0.029]. Although opioid consumption and pain scales did not reach statistical significance on other postoperative days, there was a consistent trend towards superior pain relief for Hospital A patients. Hospital B patients were also significantly less likely to undergo extubation in the operating room (Hospital A 94.4%, Hospital B 62.2%, p=0.006). Wound infection was higher in Hospital B (p=0.02), whereas pancreatic leak was higher in Hospital A (p=0.011). All other variables did not differ significantly.

Conclusion: Intrathecal morphine based enhanced recovery protocols improved postoperative pain relief over nerve block based. The relation between pain management protocols and incidence of wound infection and pancreatic leaks requires further evaluation.

 

84.06 A Prognostic Nomogram for Patients with Fibrolamellar Hepatocellular Carcinoma After Resection

Posted on January 18, 2018

O. S. Eng1, M. Raoof1, P. Ituarte1, S. G. Warner1, G. Singh1, Y. Fong1, L. G. Melstrom1  1City Of Hope National Medical Center,Duarte, CA, USA

Introduction:
Fibrolamellar hepatocellular carcinoma (FLHC) is a unique entity compared to conventional hepatocellular carcinoma.  The aim of this study was to examine post-resection outcomes and prognostic indicators for survival in this group of FLHC patients.

Methods:
A retrospective analysis of the National Cancer Database (NCDB) for patients with FLHC who had undergone resection from 2004-2014 was performed.  Univariate and multivariate Cox proportional hazard models were used to identify factors associated with overall survival, and a prognostic nomogram was generated.

Results:
There were 197 patients identified, 171 (87%) of whom had long-term follow-up data. The mean age was 34 years (IQR 22-39), median tumor size was 9.2 cm (IQR 6.2-13.1), and 22% of patients had regional node-positive disease on final pathology. Univariate and multivariate analyses were performed using patient and tumor demographics with the outcome variable of overall survival. On multivariate analysis, age (HR 1.03, p=0.004), vascular invasion (HR 1.77, p=0.046), tumor size >7cm (HR 2.27, p=0.036), multifocal disease (HR 3.28, p=0.002), adjuvant chemotherapy (HR 2.27, p=0.020), and pN+ disease (HR 2.36, p=0.013) were all negative predictors of overall survival. A prognostic nomogram was generated (Figure 1). The c-statistic for the nomogram (0.710) was superior to that of AJCC staging (0.654).

Conclusion:

Independent predictors of decreased overall survival in patients with fibrolamellar hepatocellular carcinoma include age, vascular invasion, tumor size >7cm, multifocal disease, adjuvant chemotherapy, and pN+ disease. This is the first study to develop a nomogram for FLHC that may be a strong predictor of survival in future studies.

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