84.05 Health Disparities Impact the Expected Treatment of Pancreatic Ductal Adenocarcinoma Nationally

Posted on January 18, 2018

W. Lutfi1, M. S. Zenati1, A. H. Zureikat1, H. J. Zeh1, M. E. Hogg1  1University Of Pittsburg,Pittsburgh, PA, USA

Introduction:

National adherence to guidelines recommended for treatment of resectable pancreatic ductal adenocarcinoma (PDAC) is a concern. We recently sought to address failure to treat for all PDAC stages using institutional data and found that demographic factors including age and gender were associated with treatment adherence disparities. This study aims to evaluate national expected treatment (ET) adherence for all PDAC stages. We hypothesized that both patient and hospital demographics are associated with national ET disparities for PDAC.

 

Methods:

We evaluated PDAC patients from the National Cancer Data Base (NCDB) from 2004 to 2013 who underwent treatment for clinical stages I through IV. ET was defined as surgery with or without chemotherapy or radiation therapy for stage I and II, chemotherapy or radiation for stage III, and chemotherapy for stage IV. Unexpected treatment (UT) was defined as no surgery for stage I and II, surgery for stage III, and radiation or surgery for stage IV. Patients without any therapy are no treatment (NT).

 

Results:

171,351 patients were identified. 56,589 (33.0%) were stage I and II, 23,459 (13.7%) were stage III, and 91,0303 (53.3%) were stage IV.  48.4% of patients received ET, 14.7% received UT, and 36.9% received no treatment (stage I and II – ET=41.1%, UT=30.0%, NT=28.9%; stage III – ET=65.4%, UT=6.8%, NT=27.8%; stage IV – ET=48.5%, UT=7.3%, NT=44.2%). On multivariable logistic regression analysis, older age, non-white race, lower socioeconomic status (SES), being uninsured or having Medicare, higher comorbidity index, being treated at a non-academic center, and being treated at a low volume hospital were all independent negative predictors of receiving ET; gender was not a predictor of ET. Subgroup analysis revealed that high volume academic centers had higher ET adherence for stage I/II and stage IV patients (P<0.001), however there were similar demographic predictors of poor adherence to ET. In terms of survival for stage I and II patients, ET had the best overall survival followed by UT and then NT (P<0.001). For locally advanced stage III, UT had the best overall survival followed by ET and NT (P<0.001).  Of the stage III patients that received UT (surgery), 53% received neoadjuvant therapy and 51% had vascular abutment based on NCDB coding. For metastatic stage IV patients, UT had the best overall survival followed by ET and NT (P<0.001).  Of the stage IV patients that received UT, 22% underwent surgical resection.

 

Conclusions:

Treatment, especially surgery, improves survival for patients with PDAC. Several patient and hospital factors impacted the ET of pancreas cancer on a national level. These national treatment disparities for PDAC are cause for concern, even at high-volume academic centers where ET adherence is highest.  Future studies are needed to identify the causes of treatment disparities for PDAC with intervention measures aimed to relieve treatment disparities.

84.04 The Role of a Multidisciplinary Tumor Board in Management of Patients with Pancreatic Cystic Lesions

Posted on January 18, 2018

K. Rawlins1, C. McQuinn2, E. B. Schneider2, P. Muscarella3, M. Dillhoff2, C. R. Schmidt2, L. A. Shirley2  1Ohio State University,College Of Medicine,Columbus, OH, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA 3Albert Einstein College Of Medicine,Department Of Surgery,Bronx, NY, USA

Introduction: Pancreatic cystic lesions are being increasingly discovered due to use of axial imaging. Since risk of malignancy varies greatly based upon lesion type, we sought to examine whether case presentation to a multidisciplinary tumor board was associated with changes in working diagnosis and treatment plan.

Methods: We reviewed all patients who were presented to our institution’s tumor board with a pancreatic cystic lesion from 2012-2015. Patients were divided into six categories based upon lesion type. Pre-discussion diagnosis and treatment plan were compared to post-discussion diagnosis and plan. Corresponding change in diagnosis and plan were examined according to lesion type. Changes in plan were assessed by whether the change was from a less aggressive to a more aggressive treatment option or vice versa. The implementation of treatment plans was also noted.

Results: A total of 208 cases were presented to the tumor board representing 169 individuals who met study criteria. Types of disease included branch-duct Intraductal papillary mucinous neoplasm (BD-IPMN) (32.7%), serous cystadenoma (14.4%), main-duct IPMN (MD-IPMN) (13.9%), pseudocyst (5.8%), mucinous cystic neoplasm (MCN) (3.8%), and other/unknown cystic lesions (29.3%). Overall, post-tumor board diagnosis differed from preliminary 9.6% of the time, varying from other/unknown cystic lesion (23.0%), MCN (12.5%), BD-IPMN (5.9%), and serous cystadenoma (3.3%) (P=0.002). Tumor board recommendations differed from the proposed treatment plan for 44.2% of presented cases; where board recommendations differed from prior planning, tumor board recommended treatment was implemented for 66.3% of patients. Treatment change occurred most frequently with patients who presented with a preliminary diagnosis of serous cystadenoma (60%) followed by other cyst (55.7%), MD-IPMN (41.4%), MCN (37.5%), pseudocyst (33.3%) and BD-IPMN (30.9%) (P=0.034). Of those with a change in plan, 64.8% were from a less aggressive to more aggressive treatment option.

Conclusion: Presentation to a multidisciplinary tumor board is associated with a 9.6% change in diagnosis. A change in treatment recommendations was seen over 40% of the time, with a plan that is considered more aggressive being made in nearly 65% of these cases. Presenting patients with pancreatic cystic lesions to a tumor board may be useful when attempting to accurately diagnose and care for this patient population.

 

84.03 The Effects of Morbid Obesity on Outcomes Following Pancreaticoduodenectomy for Pancreatic Cancer

Posted on January 18, 2018

E. H. Chang1, P. L. Rosen1, D. J. Gross1, V. Roudnitsky2, M. Muthusamy4, G. F. Coppa3, G. Sugiyama3, P. J. Chung4  1State University Of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 4Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction: An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for pancreatic cancer. Obese patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer have reduced long-term survival compared to non-obese patients, however the effects of increasing BMI on short-term postoperative outcomes are mixed. Therefore our goal is to elucidate the effects that morbid obesity has on outcomes after PD for pancreatic head cancer using a national, prospectively maintained clinical database.

Methods: Using the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database we identified cases of PD (CPT 48150) for pancreatic head cancer (ICD 9 157.0), excluding cases that were emergent, had contaminated/dirty wound class, and missing outcomes data. Multiple imputation was performed for missing risk variables. Morbid obesity was defined as a BMI ≥35 kg/m2. Propensity score analysis was used to match morbidly obese patients to control. Outcomes of interest included 30-day postoperative mortality and complications (infectious, wound, pulmonary, renal, cardiovascular, and septic), and return to operating room, which were evaluated using conditional logistic regression.

Results: A total of 4,387 patients were identified and 390 (8. 9%) were morbidly obese. These patients were younger (mean 62.2 vs 66.4 years, p<0.0001), more likely to be female (60.0%, p<0.0001), have insulin-dependent diabetes (27.2% vs 15.1%, p<0.0001), dyspnea with moderate exertion (11.0% vs 5.8%, p=0.0007), hypertension (75.8% vs 55.3%, p=0.0001), and had higher proportions of patients who were African American (11.8% vs 8.8%, p=0.001), ASA class 3 (76.7% vs 69.8%, p=0.005), and had longer operative times (mean 421.7 vs 388.3 minutes, p<0.0001). Propensity score matching identified 381 morbidly obese to 1,102 control cases that were well balanced along all covariates. Morbid obesity was associated with higher risk of organ space surgical site infection (OR 1.54, 95%CI [1.09, 2.18], p=0.014), unplanned reintubation (OR 1.77, 95% CI [1.08, 2.89], p=0.023), pulmonary embolism (OR 2.92, 95%CI [1.02, 8.32], p=0.046), failure to wean from ventilator (OR 2.40, 95%CI [1.46, 3.94], p=0.00059), renal insufficiency (OR 2.87, 95%CI [1.14, 7.24], p=0.026), septic shock (OR 2.31, 95%CI [1.35, 3.93], p=0.0021), return to operating room (OR 1.81, 95%CI [1.14, 2.89], p=0.013), and mortality (OR 2.31, 95%CI [1.09, 4.89], p=0.029).

Conclusion: In this large observational study, morbid obesity in patients undergoing pancreaticoduodenectomy for head of pancreas cancer was associated with increased risk of postoperative complications and mortality. Clinicians should be aware of these increased risks and prospective studies to identify preoperative and perioperative factors that will mitigate these adverse outcomes are warranted.

84.02 Tumor Biology Impacts Survival in Surgically Managed Primary Hepatic Vascular Malignancies

Posted on January 18, 2018

E. Dogeas1, A. E. Mokdad1, M. Porembka1, S. Wang1, A. Yopp1, P. Polanco1, J. Mansour1, R. Minter1, M. A. Choti1, M. M. Augustine1  1University Of Texas Southwestern Medical Center,Surgical Oncology,Dallas, TX, USA

Introduction: Hepatic angiosarcoma (AS) and hepatic epithelioid hemangioendothelioma (HEHE) are rare primary liver vascular malignancies that remain poorly understood. We sought to identify factors predicting survival after surgical intervention using a large national database in an effort to guide management.

Methods: In a retrospective analysis of the National Cancer Database (2004-2013) patients with a diagnosis of AS and HEHE were identified. Clinicopathologic factors were extracted. The Mann-Whitney U and chi-squared tests were used to compare the two disease groups. Overall survival (OS) was estimated with the Kaplan-Meier method and the Cox proportional hazards model was used to identify predictors of survival. 

Results: 137,051 primary liver malignancies were captured in the NCDB. AS was diagnosed in 390 (0.3%) and HEHE in 216 (0.1%) patients. AS patients were older (59 vs 46 years, p<0.001), male (64% vs 43%, p<0.001) and presented with larger tumors (7.9 vs 3.8 cm, p<0.001) that more commonly exhibited poor differentiation (25% vs 2%, p<0.001). Only 16% of AS and 36% of HEHE patients underwent surgery(p<0.001). The median OS in the entire cohort was 5 months, with AS patients exhibiting worse prognosis (5-year OS: 5% vs 51%, p<0.001).

Within the surgically-managed cohort (n=142), AS patients tended to be older (59 vs 46 years. p<0.001) and exhibited larger (6.5 vs 3.8 cm, p<0.001) and more poorly differentiated tumors (34% vs 5%, p<0.001). Surgical interventions, including ablation, minor and major hepatectomy, and liver transplantation were similar between the two histologic groups (p=0.128). Negative-margin resection was achieved in ~70% of both groups. The median OS for surgically-managed patients was 97 months, with 5-year OS of 30% for AS versus 69% for HEHE patients (p<0.001). Tumor biology strongly impacted OS, with AS histology conferring a Hazard Ratio (HR) of 3.61 (1.55-8.42), moderate/poor tumor differentiation a HR of 3.86 (1.03-14.46) and tumor size a HR of 1.01 (1.00-1.01). The presence of metastatic disease in the surgically managed cohort, HR: 5.22 (2.01-13.57), and involved surgical margins, HR: 3.87 (1.59-9.42), were independently associated with worse survival. Finally, patient age was negatively associated with OS, HR: 1.04 (1.01-1.07), while the type of operation was not (p=0.894).

Conclusion: In this national cohort, we identified factors that influence patient outcomes in surgically managed, primary hepatic vascular malignancies. AS histology, tumor differentiation and tumor size were strongly associated with survival. Residual tumor burden after surgical resection, in the form of positive surgical margins and the presence of metastasis, were negatively associated with survival. Despite attempts at curative-intent surgery for hepatic vascular malignancies, tumor biology impacts survival, emphasizing the need for effective forms of adjunctive systemic therapies for this group of malignancies.

84.01 Surgical Resection in Stage IV Pancreatic Cancer: A Review of the SEER Database (2004-2013)

Posted on January 18, 2018

K. M. Turner1, C. J. Joyce1, A. R. Dhanarajan1, J. L. Gnerlich2  1Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA 2Louisiana State University Health Sciences Center,Surgery,New Orleans, LA, USA

Introduction: Over half of the patients diagnosed with pancreatic cancer have metastatic disease at presentation. Pancreatic resection is not considered an option for management of Stage IV pancreatic cancer; however, small institutional studies have shown a questionable survival benefit in select metastatic patients who underwent a pancreatectomy. For patients with low-volume metastatic disease and a good response to systemic therapy, questions regarding further management including surgery need to be addressed. Our aim is to determine if there is a survival advantage with surgical resection of the primary tumor in a large subset of patients with metastatic disease.

Methods:  We conducted a retrospective, population-based cohort study of Stage IV pancreatic adenocarcinoma patients using the 2004-2013 Surveillance, Epidemiology, and End Results (SEER) database to compare patients who underwent surgical resection with patients who did not. Associations between patient characteristics and surgery were assessed for statistical significance with chi-square tests. Median survival time was calculated using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazards models were used to determine the hazard ratios for patient and treatment characteristics associated with mortality. 

Results: Of the 35,767 SEER patients with Stage IV pancreatic adenocarcinoma, 814 (2.3%) underwent pancreatic surgery and 34,953 (97.7%) did not receive surgery. Over the study time period, rates of pancreatic resection were similar. Overall, 6.0% of patients received radiation, 13.0% surgery group vs. 5.8% no surgery group (p<0.001). Patients who were younger, married, had lower grade, smaller tumors (<4cm), pancreatic head tumors, and those who received radiation were significantly more likely to undergo surgery (p<0.05 for each). On univariable Cox proportional hazards modeling, both radiation (HR: 0.68, 95% CI: 0.65-0.71) and surgery (HR: 0.47, 95% CI: 0.44-0.51) conferred a survival advantage. Median survival was longer for those who underwent surgery compared with those who did not undergo surgery (9 vs. 3 months, p<0.001). After adjustment for age, gender, race, tumor size, location, and radiation, surgery was associated with improved survival (aHR: 0.51, 95% CI: 0.47-0.56). Results were similar and remained significant in a sensitivity analysis considering cause-specific mortality.

Conclusion: Analysis of the 2004-2013 SEER data suggests that a subset of patients with Stage IV pancreatic cancer are undergoing surgery with improved survival. With increased survival times and response rates to multi-agent systemic therapy, future studies are needed to determine which metastatic patients will benefit from surgical resection.  

 

71.05 Arterial, but Not Venous, Reconstruction Increases Morbidity and Mortality in Pancreaticoduodenectomy

Posted on January 18, 2018

S. L. Zettervall1, J. Holzmacher1, T. Ju1, G. Werba1, B. Huysman1, P. Lin1, A. Sidawy1, K. Vaziri1  1George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA

Introduction:  Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, very few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous resection with reconstruction during this procedure.

Methods:  A retrospective analysis of prospectively collected data was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Program (NSQIP) for patients undergoing pancreaticoduodenectomy from 2012-2014. Demographics, comorbidities, and 30-day outcomes were compared among patients who underwent venous or arterial reconstruction and no vascular reconstruction. Multivariate analysis was utilized to adjust for differences in demographic and operative characteristics.

Results: 3002 patients were included in NSQIP in the time period studied: 384 with venous reconstruction, 52 with arterial reconstruction, and 2566 without. Patients who underwent both venous and arterial reconstruction were excluded (N=81). Compared to patients without reconstruction, those with venous reconstruction had more congestive heart failure (0.2% vs. 1.8%, P <.01), and those with arterial reconstruction had higher rates of pulmonary disease (11.5 vs. 4.5%, P =0.02). Pre-operative chemotherapy was more common in both venous (34% vs 12%, P < .01), and arterial reconstruction (21% vs 12%, P < .04). On multivariate analysis, there was also no increase in morbidity or mortality following venous reconstruction, compared to those without reconstruction. In contrast, using multivariate analysis, arterial reconstruction was associated with increased 30-day mortality with an Odds Ratio (OR): 6.7, 95%; Confidence Interval (CI): 1.8-25. Also morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5-15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7-11), and reintubation (OR: 3.9, 95%; CI: 1.1-14).

Conclusion: These findings suggest that venous reconstruction, may be considered to improve survival in patients previously thought of as unresectable due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30-day from operative procedure.

 

71.04 Significance of repeat hepatectomy for intrahepatic recurrence of HCC within Milan criteria

Posted on January 18, 2018

T. Gocho1, Y. Saito1, M. Tsunematsu1, R. Maruguchi1, R. Iwase1, J. Yasuda1, F. Suzuki1, S. Onda1, T. Hata1, S. Wakiyama1, Y. Ishida1, K. Yanaga1  1Jikei University School Of Medicine,Department Of Surgery,Minato-ku, TOKYO, Japan

Introduction: Standard treatment strategy for intrahepatic recurrence (IHR) of hepatocellular carcinoma (HCC) within Milan criteria (MC) after primary hepatic resection is different between Western countries and Japan. In Western countries, salvage liver transplantation (ST) is reported to have good results, while repeat hepatectomy in Japan is usually a treatment of choice for patients with good hepatic reserves in Japan. The aim of this study is to evaluate the prognostic impact of IHR of HCC within MC and to identify factors related to IHR within MC.

Methods: Between April 2003 and December 2015, 218 patients were treated with primary resection for HCC at Jikei University Hospital. Of those, 118 patients who developed IHR were retrospectively reviewed, and the significance of the following clinicopathological factors were assessed: patient factors (age, sex, viral status, background liver), primary and recurrent tumor factors (size, number, macroscopic portal vein invasion), treatment modality and 5-year overall survival after recurrence (5-y OS).

Results: Median age was 68 years (29 – 90) and 107 patients (91%) were male. Sixty-eight patients (58%) developed IHR within MC, and 37 patients (54%) were treated with repeat hepatectomy. With the median follow-up period of 64.6 months, IHR within MC showed significantly better 5-y OS (74%) as compared with IHR beyond MC (22%) (p < 0.001?. 5-y OS of the patients with IHR within MC treated with repeat hepatectomy was 85%, which was better than reported 5-y OS of ST. By univariate analysis, the patients with IHR within MC had higher rate of HBV+?p = 0.034?, tumor size more than 5 cm ?p < 0.001? and macroscopic PV invasion ?p = 0.041?. By multivariate analysis, independent prognostic factors consisted of tumor size more than 5 cm ?p = 0.041?, macroscopic PV invasion (p = 0.027? and repeat hepatectomy ?p < 0.001?.

Conclusion: IHR within MC after primary liver resection in selected patients for HCC could be treated with repeat hepatectomy with good outcome as compared with ST.

71.03 So Many Pancreatic Cystic Neoplasms, So Little Known About Their Natural History

Posted on January 18, 2018

F. F. Yang1, M. M. Dua2, P. J. Worth2, G. A. Poultsides3, J. A. Norton3, W. G. Park4, B. C. Visser2  1Stanford University,School Of Medicine,Palo Alto, CA, USA 2Stanford University,Hepatobiliary & Pancreatic Surgery,Palo Alto, CA, USA 3Stanford University,Surgical Oncology,Palo Alto, CA, USA 4Stanford University,Gastroenterology & Hepatology,Palo Alto, CA, USA

Introduction: Pancreatic cystic neoplasms (PCNs) are a frequent incidental finding on imaging performed for indications unrelated to the pancreas. Guidelines for management of PCNs are largely based on surgical series; important aspects of their natural history are still unknown. The purpose of this study was to characterize which PCNs can be safely observed.

Methods: A retrospective study of patients who either underwent immediate resection of a PCN (within 6 weeks of presentation) or observation with at least two imaging studies between 2004-2014 was performed. Descriptive statistics and multiple logistic regression analyses were performed to determine predictors of premalignancy and malignancy.

Results:  Of the 1151 patients in this study, 66 (5.7%) underwent immediate surgery while 1085 patients had surveillance with a median follow-up of 15.5 months, mean of 24.7 (SD 25.6). Of the observed patients, 183 (16.9%) demonstrated radiographic progression, while the majority (83.1%) did not progress. Eighty-four (7.6%) of the observed patients eventually underwent surgery for concerning features with a median of 8.0 months until resection, mean of 18.1 (SD 26.1). The risk of malignancy among patients undergoing immediate surgery was 65%. The risk of developing malignancy during the first 12 months of surveillance was 5.3%, while the risk for malignancy decreases with surveillance time (TABLE).

Multiple logistic regression demonstrated that amongst all patients, jaundice (OR=36.3, CI 95%=5.96-221, p<0.0001), initial cyst size>3.0cm (OR=5.14, CI 95%=1.13-23.5, p=0.035), solid component (OR=2.96, CI 95%=1.04-8.42, p=0.042), and main pancreatic duct dilation (MPD)>5mm (OR=4.18, CI 95%=1.18-14.9, p=0.27) were independent predictors of premalignancy or malignancy. Among observed patients, jaundice (OR=13.9, CI 95%=1.48-130.3, p=0.021), unintentional weight loss (OR=8.03, CI 95%=1.59-40.5, p=0.012), radiographic progression (OR=3.42, CI 95%=1.28-7.91, p=0.004), and MPD>5mm (OR=4.99, CI 95%=1.24-20.0, p=0.023) were independent predictors of premalignancy or malignancy.

Conclusion: Relatively few pancreatic cystic lesions progress to malignancy during surveillance, especially beyond a time frame of one year. However, the risk of transformation does persist after 5 years of follow-up. This understanding of the natural history, predictors of malignancy, and especially the timeframe of transformation of PCN to either carcinoma-in-situ or invasive adenocarcinoma is important for counseling of patients undergoing surveillance.

71.02 Raid Growth Speed of Cyst was a Predictive Factor for Malignant Intraductal Mucinous Papillary Neoplasms

Posted on January 18, 2018

K. Akahoshi1, N. Chiyonobu1, H. Ono1, Y. Mitsunori1, T. Ogura1, K. Ogawa1, D. Ban1, A. Kudo1, M. Tanabe1  1Tokyo Medical And Dental University,Hepato-Biliary-Pancreatic Surgery,Bunkyo-ku, Tokyo, Japan

Introduction:
Intraductal mucinous papillary neoplasms (IPMN) are cystic tumors of the pancreas with the ability to progress to invasive cancer, and being discovered with increasing frequency. Currently, the timing of surgical treatment is determined based on the international consensus guideline. However, pre-operative risk stratification for malignant IPMN is sill difficult. Novel predictors for malignant potential of IPMN are expected to be identified.

Methods:
This is a retrospective, single-center study of IPMN patients who underwent surgical resection between 2005 and 2015, and 81 patients were enrolled. Clinical and pathological data were collected and analyzed. The differences between benign IPMN and malignant IPMN were compared. Malignant IPMN was defined as presence of high-grade dysplasia or invasive cancer based on pathological diagnosis of resected specimen.

Results:
Of the 81 patients, 46 showed benign (low to intermediate dysplasia) and 35 showed malignant IPMN. Malignant IPMN were present in 28% of patients with branch duct type (10/36), 55% with combined duct type (17/31) and 57% with main duct type (8/14). Fifty-nine percent (24/41) of patients with high-risk stigmata and 27% (10/37) with worrisome features exhibited malignant IPMN. High-risk stigmata significantly correlated with malignant potential (p=0.006). Next, cyst growth speed of branch duct type and combined type patients with at least 2 contrast-enhanced imaging studies was measured. Average cyst growth speed of benign IPMN and malignant IPMN patients was 0.979±1.796mm/year and 6.933±2.958mm/year, respectively (p<0.001).

Conclusion:
Rapid cyst growth speed was a predictive factor for malignant IPMN as well as high-risk stigmata. Evaluation of cyst growth speed would contribute to optimize treatment strategy of IPMN patients.
 

71.01 Damage Control Pancreatic Débridement: Salvaging the Most Severely Ill

Posted on January 18, 2018

T. K. Maatman1, A. Roch1, M. House1, A. Nakeeb1, E. Ceppa1, C. Schmidt1, K. Wehlage1, R. Cournoyer1, N. Zyromski1  1Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:  Damage Control Laparotomy is a widely accepted practice in trauma surgery. We have applied this approach selectively to severely ill patients requiring open pancreatic débridement. Damage Control Débridement (DCD) is a novel, staged approach to pancreatic débridement; we sought to evaluate outcomes associated with this technique.

Methods:  Retrospective review evaluating 75 consecutive patients undergoing open pancreatic débridement between 2006 and 2016. Data were prospectively collected in our institutional Necrotizing Pancreatitis Database. 12 patients undergoing DCD were compared to 63 undergoing single stage débridement (SSD). Two independent groups T-tests and Pearson’s correlations or Fisher’s exact tests were performed to analyze the bivariate relationships between DCD and suspected factors defined pre- and post-operatively. P-values of <0.05 were accepted as statistically significant.

Results: Patients treated by DCD were more severely ill globally. DCD patients had higher incidence of preoperative organ failure, need for ICU admission, APACHE II scores (table), and more profound malnutrition (albumin DCD=1.9 g/dL, SSD=2.5 g/dL; p=0.03). Indications for DCD included: hemodynamic compromise (n=4), medical coagulopathy (n=4), or a combination (n=4). 6 of 12 DCD patients required more than one subsequent débridement prior to definitive abdominal closure (mean number of total débridements=2.6; range 2-4). Length of stay (DCD=43.8, SSD=17.1, p<0.01) and ICU stay (DCD=20.8, SSD=5.9, p<0.01) was longer in DCD patients. However, no difference was seen in the rate of readmission (DCD=42%, SSD=41%, p=0.90) or repeat intervention (any: DCD=58%, SSD=33%, p=0.10; endoscopic: DCD=17%, SSD=11%, p=0.59; percutaneous drain: DCD=42%, SSD=19%, p=0.09; return to OR after abdominal closure: DCD=0%, SSD=13%, p=0.20). The DCD group had a decreased rate of pancreatic fistula (DCD=33%, SSD=65%, p=0.04). Overall mortality was 2.7%; no significant difference in mortality was observed between DCD (8%) and SSD (2%), p=0.19.

Conclusion: Despite having substantially more severe acute illness, necrotizing pancreatitis patients treated with damage control débridement had equivalent morbidity and mortality as those undergoing elective single stage pancreatic débridement. Damage control débridement is an effective technique with which to salvage severely ill necrotizing pancreatitis patients.

 

64.10 Preoperative Frailty Assessment Predicts Short-Term Outcomes After Hepatopancreatobiliary Surgery

Posted on January 18, 2018

P. Bou-Samra1, D. Van Der Windt1, P. Varley1, X. Chen1, A. Tsung1  1University Of Pittsburg,Hepatobiliary & Pancreatic Surgery,Pittsburgh, PA, USA

Introduction: Given the aging of our population, increasing numbers of elderly patients are evaluated for surgery. Preoperative assessment of frailty, defined as the lack of physiological reserve, is a novel concept that has recently gained interest to predict postoperative complications. The comprehensive Risk Analysis Index (RAI) for frailty has been shown to predict mortality in a large cohort of surgical patients. RAI is now measured in all patients presenting to surgical clinics in our institution. Initial analysis showed that patients with hepatopancreatobiliary disease have the highest frailty scores, only second to patients presenting for cardiovascular surgery. Therefore, the aim of this study was to specifically evaluate the performance of RAI in predicting short-term post-operative outcomes in patients undergoing hepatopancreatobiliary surgery, a significantly frail patient population.

Methods: From June-December 2016, the RAI was determined in 162 patients prior to surgery. RAI includes 12 variables to evaluate e.g. age, kidney disease, congestive heart failure, cognitive functioning, independence in daily activities, and weight loss. Data on 30-day post-operative outcomes were prospectively collected. Complications were scored according to the Clavien-Dindo classification and summarized in the Comprehensive Complication Index (CCI). Other assessed post-operative outcomes included ICU admission, length of stay, and rates of readmissions. Logistic and linear regressions were done to assess for correlation of RAI score and each measured outcome. A multivariate analysis was done to control for the magnitude of the operation, coronary artery disease, cancer stage, and intraoperative blood loss.

Results: Our cohort of 162 patients (79 M; 83 F, median age 67, range 19-95), included 55 undergoing minor operation, 56 undergoing intermediate operation, and 51 undergoing major surgery. Their RAI scores ranged from 0 to 25, with a median of 7. With every unit increase in RAI score, length of stay increased by 5% (IRR 1.05; 95%CI 1.04-1.07, P<0.01), the odds of discharging the patient to a special facility increased by 10% (OR 1.10; 95%CI 1.02-1.17, P<0.01), the odds of admission to the ICU increased by 11% (OR 1.11; 95%CI 1.02-1.20, P=0.01), the expected ICU length of stay increased by 17% (IRR=1.17; CI 1.06-1.30), the odds of readmission increased by 8% (OR=1.08; CI 0.99-1.17, P=0.054), the CCI increased by 1.6 units (coefficient=1.60; CI 0.61-2.58, p<0.01). In multivariate analysis, frailty remained positively associated with CCI (p=0.01)

Conclusion: The RAI score is predictive of short-term post-operative outcomes after hepatopancreatobiliary surgery. Pre-operative risk assessment with RAI could aid in decision-making for treatment allocation to surgery versus less morbid locoregional treatment options in frail patients. 

 

64.09 Role of the patient-provider relationship in Hepato-pancreato-biliary diseases

Posted on January 18, 2018

E. J. Cerier1, Q. Chen1, E. Beal1, A. Paredes1, S. Sun1, G. Olsen1, J. Cloyd1, M. Dillhoff1, C. Schmidt1, T. Pawlik1  1Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction: An optimal patient-provider relationship (PPR) may improve medication / appointment adherence, healthcare resource utilization, as well as reduce healthcare costs.  The objective of the current study was to define the impact of PPR on healthcare outcomes among a cohort of patients with hepato-pancreato-biliary (HPB) diseases.

Methods: Utilizing the Medical Expenditure Panel Survey Database from 2008-2014, patients with an HPB disease diagnosis were identified. PPR was determined using a weighted score based on survey items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Specifically, patient responses to questions concerning access to healthcare providers, responsiveness of healthcare providers, patient-provider communication, and shared decision-making were obtained. Patient provider communication was stratified into three categories using a composite score that ranged from 4 to 12 (score 4-7: "poor," 8-11: "average," and 12 "optimal"). The relationship between PPR and health care outcomes was analyzed using regression analyses and generalized linear modeling.

Results: Among 594 adult-patients, representing 6 million HPB patients, reported PPR was "optimal" (n=210, 35.4%), "average" (n=270, 45.5%), and "poor" (n=114, 19.2%). Uninsured (uninsured: 36.3% vs. Medicaid: 28.8% vs. Medicare: 15.4% vs. Private: 14.0%; p=0.03) and poor-income (high: 14.0% vs. middle: 12.8% vs. low: 21.5% vs. poor: 24.3%; p=0.03) patients were more likely to report "poor" PPR. In contrast, other factors such as race, sex, education, and age were not associated with PPR. In addition, there was no association between PPR and overall annual healthcare expenditures ("poor" PPR: $19,405, CI $15,207-23,602 vs. "average" PPR: $20,148, CI $15,538-24,714 vs. "optimal" PPR: $19,064, CI $15,344-22,784; p=0.89) or out-of-pocket expenditures ("poor" PPR: $1,341, CI $618-2,065 vs. "average" PPR: $1,374, CI $1,079-1,668 vs. "optimal" PPR: $1,475, CI $1,150-1,800; p=0.77). Patients who reported "poor" PPR were also more likely to self-report poor mental health scores (OR 5.0, CI 1.3-16.7), as well as have high emergency room utilization (≥ 2 visits: OR 2.4, CI 1.2-5.0)(both p<0.05). Patients with reported "poor" PPR did not, however, have worse physical health scores or more previous inpatient hospital stays (both p>0.05)(Figure).

Conclusion: Patient self-reported PPR was associated with insurance and socioeconomic status.  In addition, patients with perceived "poor" PPR were more likely to have poor mental health and be high utilizers of the emergency room.  Efforts to improve PPR should focus on these high-risk populations.

64.08 Cost burden of overtreating low grade pancreatic cystic neoplasms

Posted on January 18, 2018

J. M. Sharib1, K. Wimmer1, A. L. Fonseca3, S. Hatcher1, L. Esserman1, A. Maitra2, Y. Shen4, E. Ozanne5, K. S. Kirkwood1  1University Of California – San Francisco,Surgery,San Francisco, CA, USA 2University Of Texas MD Anderson Cancer Center,Pathology,Houston, TX, USA 3University Of Texas MD Anderson Cancer Center,Surgery,Houston, TX, USA 4University Of Texas MD Anderson Cancer Center,Biostatistics,Houston, TX, USA 5University Of Utah,Population Health Sciences,Salt Lake City, UT, USA

Introduction: Consensus guidelines recommend resection of intraductal papillary mucinous neoplasms (IPMN) with high risk stigmata, and laborious surveillance for cysts with worrisome features. In practice, resections are performed at higher rates due to fear of malignancy. As a result, many cysts harboring no or low grade dysplasia (LGD) are removed unnecessarily, with undue risk to patients. This study compares the costs and effectiveness of practice patterns at UCSF and MD Anderson to alternative management strategies for pancreatic cysts. Potential cost savings that would be realized if diagnostic accuracy were improved and prevented resection of LGD are also estimated.

Methods: We developed a decision analytic model to compare costs and effectiveness of three treatment strategies for a newly diagnosed pancreatic cyst: 1) Immediate surgery, 2) Do nothing, and 3) “Surveillance” based on consensus guidelines. Model estimates were derived from published literature and retrospective data for pancreatic cyst resections at UCSF and MD Anderson from 2005-2016. Costs and effectiveness (quality adjusted life years, QALYs) were predicted and used to develop incremental cost effectiveness ratios (ICERs). To estimate the cost burden of resecting LGD, the “Surveillance” strategy was adjusted to remove the possibility of resecting LGD, “Precision Surveillance”, and these costs were compared with the original model.

Results: The “Immediate surgery” strategy was the costliest and most effective, while the “Do nothing” strategy was least costly and least effective (Fig 1a). The “Surveillance” strategy was the preferred strategy, however, it increased costs by $129,372 per quality adjusted life year gained (ICER) compared to “Do nothing”; above the commonly accepted $100,000/QALY willingness to pay threshold. When resection of LGD was eliminated, the cost of “Precision Surveillance” decreased by $21,295, while the effectiveness increased by 0.6 QALY, making it the preferred strategy (Fig 1b). The resulting incremental cost discount of “Precision Surgery” was $35,905 per QALY compared to “Surveillance” with current diagnostic accuracy. This cost reduction brought the “Precision Surveillance” strategy below the $100,000/QALY threshold compared to the “Do Nothing” strategy.

Conclusion: Surveillance under current consensus guidelines for IPMN is the preferred strategy compared to the ”Immediate surgery” and “Do nothing” strategies. Our present inability to distinguish LGD from high grade/invasive lesions adds significant costs to the treatment of IPMN. Improved diagnostics that accurately grade cystic pancreatic neoplasms and empower clinicians to reduce the resection of LGD would decrease overall costs and improve effectiveness of surveillance.

64.07 Cost-Effectiveness of Rescuing Patients from Major Complications after Hepatectomy

Posted on January 18, 2018

J. J. Idrees1, C. Schmidt1, M. Dillhoff1, J. Cloyd1, E. Ellison1, T. M. Pawlik1  1The Ohio State University, Wexner Medical Center,Department Of Surgery,Columbus, OH, USA

Introduction:  Major complications after liver resection can increase costs, as well as be associated with higher mortality. Failure to rescue (FTR) has been inversely correlated with hospital volume.  We sought to determine whether high or medium volume centers were more cost-effective at rescuing patients from major complications relative to low volume centers following hepatic resection. 

Methods:  The Nationwide Inpatient Sample (NIS) was used to identify 96,107 liver resections that occurred between 2011-2011. Hospitals were categorized into high (HV) (150+ cases/year), medium (MV)(51-149 cases/year), and low (LV) (1-49 cases/year) volume centers. Cost-effectiveness analyses were performed using propensity score matched cohorts adjusted for patient co-morbidities among HV vs. LV (8,924 pairs), as well as MV vs. LV (18,158 pairs) centers. Incremental cost effectiveness ratio (ICER) was calculated to assess cost-effectiveness of HV and MV centers relative to LV centers. ICER was calculated at the willingness to pay threshold of $50,000. Sensitivity analyses were performed using the bootstrap method with 10,000 replications.

Results: The overall incidence of complications following hepatectomy was 14.9% (n=14,313), which was roughly comparable among centers regardless of volume (HV 14.2 % vs. MV 14.3% vs. LV 15.4%; p<0.001).  In contrast, while overall FTR was 11.2%, the FTR rate was substantially lower among HV centers (HV: 7.7%, MV: 11.2%, LV: 12.3%, p<0.001).  Both HV and MV centers were more cost-effective at rescuing patients from a major complication relative to LV centers.  Specifically, the incremental cost per year of life gained was $3,296 at HV versus $4,182 at MV centers compared with LV hospitals. HV were particularly cost-effective at managing certain complications.  For example, compared to LV centers, HV hospitals had lower costs with a higher survival benefit in managing bile duct complications (ICER: -$1,580) and sepsis (ICER: -$2,760). 

Conclusion: Morbidity following liver resection was relatively common as 1 in 7 patients experienced a complication. Not only was FTR lower at HV hospitals, but the management of most major complications was also more cost-effective at HV centers. 
 

64.06 Epidural-related events are associated with ASA class, but not ketamine infusion following pancreatectomy

Posted on January 18, 2018

V. Ly1, J. Sharib1, L. Chen2, K. Kirkwood1  2University Of California – San Francisco,Anesthesia,San Francisco, CA, USA 1University Of California – San Francisco,Surgical Oncology,San Francisco, CA, USA

Introduction:

Epidural analgesia following pancreatectomy has become widely adopted; however, high epidural rates are often associated with early hypotensive events that require rate reduction and fluid resuscitation. It is unclear which patients are most at risk for such events. Continuous subanesthetic ketamine infusion reduces opioid consumption after major abdominal surgery. The effects of ketamine added to epidural analgesia have not been well studied in patients undergoing pancreatectomy. This study evaluates the safety and postoperative analgesic requirements in patients who received continuous ketamine infusion as an adjunct to epidural analgesia following pancreatectomy.

Methods:

A retrospective data analysis was conducted on 234 patients undergoing pancreaticoduodenectomy (n=165) or distal pancreatectomy (n=69) at UCSF Medical Center between January 2014 and January 2017. Patient demographics, including history of prior opiate use, along with perioperative fentanyl-ropivacaine epidural and continuous intravenous ketamine rates were collected. Oral morphine equivalents (OME) and visual analogue pain scales (VAS) were recorded at post op day 0, 1, 2, 3, and 4. To assess for safety, epidural rate decreases due to hypotension within the first 24 hours post op and ketamine-related adverse events were recorded.

Results:

Epidural (n=197) and other opiate analgesia (n=234) were administered perioperatively per surgeon preferences and institutional standards. Continuous ketamine infusion was given intraoperatively, postoperatively, or both in 71 patients, with a trend toward preferential use in patients with prior opiate exposure. Ketamine infusion was not associated with hypotensive events, daily maximum epidural rates, or significant epidural rate changes on postoperative days 0-4. OMEs and VAS were similar between groups, regardless of prior opiate use. Patients with American Society of Anesthesia (ASA) class 3 or 4 (n=111) were more likely to require epidural rate decreases (OR 2.37, 95%CI 1.3-4.2, p = 0.003) and associated interventions in the first 24 hours post op. Three patients reported ketamine-related adverse events such as unpleasant dreams and hallucinations.

Conclusion:

Subanesthetic ketamine infusion as an adjunct to epidural analgesia for pancreatic surgery patients is safe. Patients with ASA classification 3 or 4 experience more hypotensive events which require epidural rate decreases in the first postoperative day following pancreatectomy. Further study is required to assess whether ketamine infusion allows for use of lower epidural rates, reduces post op opioid consumption, or improves pain score in the early postoperative period.

64.05 Prognostic Value of Hepatocellular Carcinoma Staging Systems: A Comparison

Posted on January 18, 2018

S. Bergstresser2, P. Li2, K. Vines2, B. Comeaux1, D. DuBay3, S. Gray1,2, D. Eckhoff1,2, J. White1,2  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Transplantation,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 3Medical University Of South Carolina,Department Of Surgery, Division Of Transplantation,Charleston, Sc, USA

Introduction:  Hepatocellular carcinoma (HCC) is the third most common cause of cancer related deaths worldwide. As the incidence of HCC continues to trend upwards, it is imperative to have validated staging systems to guide clinicians when choosing treatment options.  Seven HCC staging systems have been validated to varying degrees, however, there is currently inadequate evidence in the literature regarding which system is the best predictor of survival. The purpose of this investigation was to determine predictors of survival and compare the 7 staging systems in their ability to predict survival in a cohort of patients diagnosed with HCC. 

Methods:  This is a prospectively controlled chart review study of 782 patients diagnosed with HCC between January 2007 and April 2015 at a large, single-center hospital. Lab values, patient demographics, and tumor characteristics were used to stage patients and calculate Model for End Stage Liver Disease (MELD) and Child-Pugh scores. Kaplan-Meier method and log-rank test were used to identify the risk factors of overall survival. Cox regression model was used to calculate linear trend χ 2 and likelihood ratio χ 2 to determine linear trend and homogeneity of the staging systems, respectively. 

Results: Univariate analyses suggested that tumor number (P < .0001), diameter of largest lesion (P < .0001), tumor taking up > 50% of liver mass (P < .0001), tumor major vessel involvement (P = .0025), alpha fetoprotein level (AFP) 21-200 vs > 200 (P < .0001), and Child Pugh score (P <.0001) were significant predictors of overall survival; while portal hypertension (P= .520) and pre-intervention bilirubin (P= .0904) were not. In all patients, the Cancer of Liver Italian Program (CLIP) provided the largest linear trend χ 2 and likelihood ratio χ 2 in the Cox model when compared to other staging systems, indicating the best predictive power for survival. 

Conclusion:Based on our statistical analysis, Child Pugh score, tumor size, number, presence of vascular invasion, and AFP level play a significant role in determining survival. In all patients and in patients receiving treatment other than transplantation (ablation, chemoembolization), CLIP appears to be the best predictor of survival. The CLIP staging system takes into account Child Pugh score, tumor morphology, AFP level, and portal vein thrombosis, which may explain its significant ability to predict survival. 

 

64.04 Comparing Frailty Scales to Guide Creation of a Multidimensional Assessment for Surgical Patients

Posted on January 18, 2018

J. McDonnell1, P. R. Varley1, D. E. Hall1,2, J. W. Marsh1, D. A. Geller1, A. Tsung1  1University Of Pittsburgh,General Surgery,Pittsburgh, PA, USA 2VA Pittsburgh Healthcare System,General Surgery,Pittsburgh, PA, USA

Introduction:  Frailty defines a phenotype of functional decline that places patients at risk for death and disability, and the American College of Surgeons and American Geriatric Society have joint guidelines which recommend implementation of a frailty assessment for aging patients. Though various instruments for measuring patient frailty have been described in the literature, it is unclear which is the most appropriate for routine screening of surgical patients. The goal of this project was to compare assessments from three separate frailty instruments in a cohort of surgical patients in order to inform the development of a robust, clinically feasible frailty assessment for surgical patients.

Methods:  Demographic and medical history for all new patients evaluated at the Liver Cancer Center of UPMC was collected by patient-completed questionnaire and verified by a research associate (RA). Patients were then assessed for functional measures of frailty including extended timed up-and-go (eTUG), walking speed, grip strength, and Mini-Cog. Information from this assessment was then used to calculate scores for the Fried Frailty Phenotype (FF), Edmonton Frail Scale (EFS), and Risk Analysis Index (RAI). Frailty was defined as FF ≥ 3, EFS ≥ 8, or RAI ≥ 21.

Results: As part of a pilot project, 127 patients were evaluated. 64 (52.0%) of the patients were male. The cohort had a mean age of 62.9±15.0 years, and mean BMI of 29.4±6.4. Median scores for the RAI were 10 [IQR 7-17], 3 [IQR 2-5] for the EFS, and 1 [IQR 0-2] for FF. With respect to frailty, 36 (28.4%) of the patients were frail with respect to any of the three measures of frailty. 12 (9.5%) of patients were rated frail by the EFS, while 21 (16.5%) of patients were rated frail by the FF and 23 (18.1%) by the RAI. 20 patients (15.8%) were classified frail by only one measure, 12 (9.5%) by two measures, and only 4 (2.2%) by all 3 scales. Inter-rater agreement between the three scales was fair (κ = 0.33, p <0.001). Figure 1 demonstrates the concordance of measures among all three instruments, and demonstrates that choosing only one of the EFS, RAI or FF would have failed to recognize 16 (44.4%), 10 (27.8%), and 12 (33.3%) of the potentially frail patients respectively. 

Conclusion: The results of this pilot project suggest that it is feasible to implement a routine frailty screening process in a busy surgical clinic. Utilizing only single frailty instrument to evaluate patients may lead to an underestimate of frailty in surgical populations. Future work should focus on creation of a frailty screening process developed specifically for surgical patients and linked to surgical outcomes.

 

64.03 National Trends and Predictors of Adequate Nodal Sampling for Resectable Gallbladder Adenocarcinoma

Posted on January 18, 2018

A. J. Lee1, Y. Chiang1, C. Conrad1, Y. Chun-Segraves1, J. Lee1, T. Aloia1, J. Vauthey1, C. Tzeng1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction: For gallbladder cancer (GBC), the new American Joint Committee on Cancer 8th edition (AJCC8) staging system classifies lymph node (LN) stage by the number of metastatic LN, rather than their anatomic location as in AJCC6 and AJCC7.  Additionally, AJCC8 now recommends resection of ≥6 LNs for adequate nodal staging.  In the context of this new staging system and recommendation for GBC surgery, we evaluated current national trends in LN staging and sought to identify factors associated with any and/or adequate LN staging according to this new guideline.

Methods: Utilizing the National Cancer Data Base (NCDB), we identified all gallbladder adenocarcinoma patients treated with surgical resection with complete tumor staging information between 2004-2014.  We excluded patients with T1a and lower pathologic T-stage, as nodal staging is not indicated in these patients.  Nodal staging and nodal positivity rates were compared over the study period.  Univariate and multivariate logistic regression modeling were performed to identify factors associated with any and/or adequate nodal staging.

Results: We identified 11,525 patients with T-stage ≥T1b, for whom lymphadenectomy is recommended.  Only 49.6% (n=5,719) of patients had any LN removed for staging.  On multivariate analysis, treatment at academic centers (OR=2.33, p<0.001), more recent year of diagnosis (OR=2.29, p<0.001), clinical node-positive status (OR=3.46, p<0.001), pathologic T2 stage (OR=1.25, p<0.001), and radical surgical resection (OR=4.85, p<0.001) were associated with higher likelihood of having any nodal staging.  Age ≥80 (OR=0.57, p <0.001), and higher co-morbidity index (OR=0.70, p<0.001) were associated with lower likelihood of having any nodal staging.  However, of the 5,719 patients who underwent any nodal staging, only 21.8% (n=1,244) met the AJCC8 recommendation of adequate LN staging.  On multivariate analysis, female sex (OR=1.18, p=0.02), treatment at academic centers (OR=1.52, p<0.001), radical surgical resection (OR=2.53, p<0.001), and pathologic T4 stage (OR=2.14, p<0.001) were associated with having ≥6 LN resected concomitantly with their oncologic operation.  Patients over 80 years old (OR=0.60, p<0.001) and in South region (OR=0.79, p=0.002) were less likely to have adequate LN sampling according to the new recommendation.

Conclusion: National trends in the overall GBC LN staging rate of 49.6% do not live up to the new AJCC8 recommendations.  Furthermore, the finding that only 21.8% of patients met the 6 LN threshold highlights the gap between the new AJCC8 recommendations and reality.  We have identified demographic and clinicopathologic factors associated with any and/or adequate LN staging, which can be incorporated into future targeted quality improvement initiatives.

64.02 Isolated Pancreatic Tail Remnants After Transgastric Necrosectomy Can Be Observed

Posted on January 18, 2018

C. W. Jensen1, S. Friedland2, P. J. Worth1, G. A. Poultsides1, J. A. Norton1, W. G. Park2, B. C. Visser1, M. M. Dua1  1Stanford University,Surgery,Palo Alto, CA, USA 2Stanford University,Gastroenterology,Palo Alto, CA, USA

Introduction:  Severe necrotizing pancreatitis may result in mid-body necrosis and ductal disruption. When a significant portion of the tail remains viable but cannot drain into the proximal pancreas, the “unstable anatomy” that results is often deemed an indication for distal pancreatectomy. The transgastric approach to pancreatic drainage/debridement has been shown to be effective for retrogastric walled-off collections. A subset of these cases are performed in patients with an isolated viable tail. The purpose of this study was to characterize the outcomes among patients with an isolated pancreatic tail remnant who underwent trangastric drainage or necrosectomy (endoscopic or surgical) and determine how often they required subsequent operative management.

Methods:  Patients with necrotizing pancreatitis and retrogastric walled-off collections that were treated by either surgical transgastric necrosectomy or endoscopic cystgastrostomy +/- necrosectomy between 2009-2017 were identified by retrospective chart review. Clinical and operative details were obtained through the medical record. All available pre- and post-procedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants. 

Results: A total of 75 patients were included in this study (41 surgical and 34 endoscopic). All of the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 27 patients that underwent pseudocyst drainage and 7 that underwent necrosectomy. Median follow-up for the entire cohort was 13 months and there was one death. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and 9 endoscopic). After the surgical or endoscopic creation of an internal fistula (“cystgastrostomy”), there were no external fistulas despite the viable tail. Of the 22 patients, there were 5 (23%) patients that developed symptoms at a median of 23 months from the index procedure (3-recurrent episodic pancreatitis and 2-intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 6 and 24 months after index procedure. 

Conclusion: Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly “unstable anatomy,” the creation of an internal fistula via surgical or endoscopic “cystgastrostomy” avoids external fistulas/drains and the short term (near to initial pancreatitis) necessity of surgical distal pancretectomy. A very small subset require intervention for late symptoms. In our series, the patients that ultimately required distal pancreatectomy had initially undergone an endoscopic rather than a surgical approach; however, whether there is a difference between the two approaches in the outcome of the isolated pancreatic remnant is difficult to conclude due to small sample size.                                              

 

43.17 Perioperative Considerations for Bloodless Pancreatic Surgery- A Systematic Review

Posted on January 18, 2018

M. Khalili1, W. F. Morano1, L. Marconcini3, M. Sheikh1, M. Styler3, M. Zebrower2, W. Bowne1  1Drexel University College Of Medicine,Division Of Surgical Oncology/Department Of Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Division Of Anesthesia/Perioperative Medicine,Philadelphia, PA, USA 3Drexel University College Of Medicine,Division Of Hematology & Oncology/Department Of Medicine,Philadelphia, PA, USA

Introduction: Bloodless surgery is a multidisciplinary field that seeks to minimize blood
transfusions in surgical patients through a variety of perioperative hemoglobin optimizing
management strategies. Multidisciplinary techniques have been applied to various surgical
subspecialties with favorable outcomes. Bloodless pancreatic surgery (BPS) is a rarely
performed and understudied application of these protocols.

Methods: Literature search was performed on MEDLINE using MeSH terms "bloodless surgery"
or “Jehovah’s witness” and “pancreatectomy” or “pancreaticoduodenectomy,” published
between 2000 and 2017. We reviewed articles focused on BPS and searched references of
relevant articles. We examined implementation of reported preoperative, intraoperative and
postoperative transfusion reduction strategies. We report data regarding categorical variables as
proportions and data regarding quantitative continuous variables as medians with ranges.

Results: Fifteen patients requiring BPS are reported in the literature. We report an additional
three here (N=18). Surgical procedures involved distal pancreatectomy (n=5), radical antegrade
modular pancreaticosplenectomy (n=1), and pancreaticoduodenectomy (n=12). Specifically,
reported strategies fell into three categories: preoperative, intraoperative, and postoperative.
Preoperative strategies include treatment with erythropoietin (n=4), iron (n=4), vitamin B12
(n=1), and vitamin K (n=1). Intraoperative strategies include acute normovolemic hemodilution
(n=8) and cell saver (n=5). Postoperative strategies include treatment with erythropoietin (n=6)
and iron (n=6). Complications for the study cohort include bleeding (n=2), intra-abdominal
abscess (n=1), pancreatic leak (n=2), gastrojejunostomy stricture (n=1) and cardiopulmonary
issues (n=3). No mortalities were reported.

Conclusion: BPS is rarely performed, but feasible. Consultation requires a multidisciplinary
approach. Review of the literature reveals that no single bloodless strategy is used, while
combinations of strategies are employed based upon patient characteristics, multidisciplinary
practice, and surgeon/anesthesiologist preference. With careful patient blood management, BPS
can be performed with good outcomes.

 

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