86.06 Recurrence of pilonidal disease: our best is not good enough

Posted on January 18, 2018

D. R. Halleran1,2, J. J. Lopez1,2, A. E. Lawrence1,2, K. L. Leonhart2, Y. V. Sebastião2, B. A. Fischer2, J. N. Cooper2, P. C. Minneci1,2, K. J. Deans1,2  1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA 2Nationwide Children’s Hospital,The Center For Surgical Outcomes Research,Columbus, OH, USA

Introduction:  Pilonidal disease is a common and painful disorder among adolescents and young adults, affecting males at a rate of 2 to 4 times that of females. Approximately 1% of the population will be diagnosed with pilonidal disease between the ages of 15-30 years. Patients with recurrent pilonidal disease can develop chronic wounds and draining sinuses that incur long term morbidity, disability, and decreased quality of life. Recurrence rates have been conservatively reported at 16% and as high as 30%. The aim of this study was to characterize rates of recurrence in patients with pilonidal disease treated by pediatric surgeons.

Methods:  We conducted a retrospective review of patients at our institution diagnosed with pilonidal disease and evaluated by surgery from 2010-2015. Demographic and clinical characteristics were collected from the electronic medical record. Summary measures were used to examine patient demographics and clinical outcomes. This study was approved by our institutional review board. 

Results: In 360 patients with pilonidal disease treated at our institution over the study period, 51% were male with a median age at initial evaluation of 16 years (IQR 14-17) and a median BMI of 28.3 kg/m2 (23.5-34.0). Recurrent pilonidal disease was seen in 34.4% of the patients in our cohort with approximately 22% of patients having a recurrence within the first year of initial evaluation (Table). In patients treated after their first episode of disease, recurrence rates were 21.3% after treatment with antibiotics only, 26.8% after treatment with incision and drainage, and 30.4 % after surgical excision. Approximately 66% of patients underwent surgical excision of their pilonidal disease in our cohort.

Conclusion: Pilonidal disease has a substantial recurrence rate even after surgical excision.  Future studies investigating treatments that can prevent disease recurrence are needed.

86.08 Suspected Appendicitis Pathway Continues to Lower CT Rates in Children Two Years After Implementation

Posted on January 18, 2018

L. A. Gurien1,2, M. S. Dassinger1, M. Crandall2, J. J. Tepas2, S. D. Smith1  1Arkansas Children’s Hospital,Pediatric Surgery,Little Rock, AR, USA 2University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA

Introduction:
A protocol to evaluate pediatric patients with suspected appendicitis was implemented at our institution in July 2012. Ultrasound (US) was chosen as the initial imaging modality to decrease radiation exposure in our pediatric population.  A computerized tomography scan (CT) was obtained only after surgical consultation. We sought to evaluate rates of CT utilization as well as the diagnostic accuracy of the pathway two years after pathway implementation.

Methods:
After receiving exemption from the Institutional Review Board, all charts of patients who underwent abdominal imaging with CT or US in the Emergency Department of a freestanding children’s hospital were reviewed.  Subjects were excluded if they were 18 years of age or older, arrived with imaging from an outside source, or underwent imaging for a suspected disease process other than appendicitis.  CT rates were compared before (July 2011 – June 2012) and after (January 2013 – June 2014) implementation of the protocol using Chi-square test, and monthly CT rates during the post-pathway period were calculated to assess trends in CT utilization.  Criteria to confirm adherence to the pathway included: (1) US only was performed; (2) US and surgical evaluation were obtained prior to CT; or (3) CT was obtained in patients with a BMI ≥ 35.  Pathology results were reviewed to determine effect on diagnostic accuracy. 

Results:
CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.6% (78/283) with p<0.0001.  Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation (Figure 1).  Adherence to the pathway was 90.1% (255/283).  In the post-pathway period, US sensitivity was 70.8% and US specificity was 96.5%, while CT sensitivity was 91.3% and CT specificity was 90.9%.  Negative appendectomy rates remained low in the post-pathway period at 2.4% (2/85). 

Conclusion:
Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in computed tomography use without compromising diagnostic accuracy.  Continued adherence to and effectiveness of a voluntary pathway that relies on safe imaging is reassuring and highlights the importance of ongoing assessment of the long-term impact of an institution’s pathways.
 

86.05 Pediatric Breast Masses: Should They Be Excised?

Posted on January 18, 2018

C. M. McLaughlin1, J. Gonzalez-Hernandez5, M. Bennett3, H. G. Piper2,5  5University Of Texas Southwestern Medical Center,Dallas, TX, USA 1Baylor University Medical Center,General Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 3Baylor Scott & White Health,Office Of The Chief Quality Officer,Dallas, TX, USA

Introduction:
Pediatric breast masses can be a diagnostic challenge. Nearly all are benign, but there is no consensus on which should be removed. The purpose of this study was to describe children who underwent breast mass excision at a single pediatric hospital and define which patients can be safely observed. 

Methods:
We performed a retrospective review of children (≤18 years) who underwent breast mass excision at a single institution from 2008-2016. Male patients with gynecomastia, those who had needle biopsy without formal excision, and those who had debridement or incision and drainage procedures were excluded. 

Results:
One hundred ninety-six patients were included (96% female). Mean age was 15.2 +/- 2.9 y. Most (71%) had painless masses. Pre-operative ultrasound was obtained in 70%. Pathology included fibroadenoma (81.5%), tubular adenoma (5%) benign Phyllodes tumor (3%), benign fibroepithelial neoplasm (0.5%) and other benign lesions (10%). There were no malignant lesions. Ultrasound size had a Pearson correlation of 0.84 with pathologic size (p < 0.0001). There was no association between the size and pathologic diagnosis. 

Conclusion:
The overwhelming majority of breast masses in children are benign, most commonly fibroadenoma. Ultrasound is an accurate predictor of size, but large lesions do not necessarily confer a high malignancy risk. Observation is appropriate for asymptomatic breast masses in children. 
 

86.02 Nationwide Survival Analysis of Sentinel Lymph Node Biopsy in Pediatric Malignancies

Posted on January 18, 2018

P. P. Parikh1, J. E. Sola1, E. A. Perez1  1University Of Miami,Surgery,Miami, FL, USA

Introduction: There remains a paucity of literature on survival outcomes related to sentinel lymph node biopsy (SLNB) use in pediatric cancer cases with surgical management often extrapolated from the adult experience. The purpose of this study was to determine the surgical management (SLNB with or without lymph node dissection (LND) vs none) and survival outcomes of several types of cancers in pediatric patients.

Methods: The Surveillance, Epidemiology, and End Results (SEER) registry was analyzed for all patients <20 years old with a malignancy from 2003-2014. Patients were stratified by those who underwent SLNB, with or without subsequent LND either during simultaneous or follow-up surgery, or no SLNB. Parameters analyzed included demographics, tumor type, disease severity and surgical management. Chi-square analysis for categorical and Student’s t test for continuous data were used. Multivariate analysis was performed to identify independent predictors of survival.

Results: Overall, 2,770 patients were identified as having a malignancy including malignant melanoma (39%), thyroid cancer (25%), other non-rhabdomyosarcomas (25%) and rhabdomyosarcoma (11%). The average age was 14 ± 4 where most patients were white (83%) and female (62%). When stratified by disease severity, most patients had localized disease (77%) followed by regional (23%) disease. Whereas majority of patients had no SLNB performed (80%), SLNB (with or without LND) was performed in 20% of patients. On univariate analysis, 15-year survival for all patients was not significantly greater for those undergoing SLNB and subsequent LND vs no SLNB (94% vs 92%, respectively; P=0.118). However, when stratified by tumor type, there was significant difference in 15-year survival between patients who underwent SLNB and subsequent LND vs no SLNB for malignant melanoma (95% vs 97%, respectively; P=0.009). On multivariate analysis, SLNB and subsequent LND vs no SLNB was not an independent predictor of survival. This was true for the whole group as for each tumor in independent multivariate models. Regional disease was associated with significantly greater 15-year survival when SLNB and subsequent LND were performed vs no SLNB (89% vs 80%, respectively; P=0.018).

Conclusion: Overall, limited surgical management for certain pediatric malignancies that are localized or regionally metastasized may be adequate treatment. More extensive surgery involving SLNB and subsequent LND may be of limited utility for optimizing patient survival, but further studies need to be performed to clarify the utility of SLNB in the pediatric patient

86.01 Metabolic abnormalities are not different in morbid (BMI>35) and Super obese (BMI>50) Adolescents.

Posted on January 18, 2018

B. Farber1, S. Burjonrappa1  1Montefiore Medical Center,Pediatric Surgery,Bronx, NY, USA

Purpose:

Obesity rates have been increasing in adolescents (14-21 years) over the past 30 years, and bariatric surgery has been increasingly used to facilitate weight loss and optimize health in this age group. We reviewed preoperative nutritional parameters in these patients to identify nutritional deficiencies that will need to be carefully addressed in the pre and post operative phases.

Methods:  

We retrospectively reviewed the records of adolescent patients who had undergone evaluation for bariatric surgery at our institution between 2016 and 2017. Variables assessed included age, gender, preoperative body mass index (BMI), nutritional parameters, lipid profiles and iron studies. Continuous variables were evaluated using a student’s t test and categorical variables were evaluated with chi square analysis.

Results:

Thirty-nine patients with morbid obesity underwent evaluation for bariatric surgery during the study period. Twenty-two were female (56%) and 17 were male (44%). Median age was 18 years (range 14-21 years). Patients with BMI over 50 (super obese) were more likely to be male gender (p<0.05). In the overall study population more than 60% had Iron deficiency, 20% had dyslipidemias, 25% had anemia, and 100% had Vitamin D deficiency. Levels of other B vitamins were normal for most of the study population. No statistical difference in incidence of nutritional and metabolic abnormalities was noted between morbidly obese and super obese adolescents(Table 1).  

 

Conclusions: 

Preoperative nutritional parameters and metabolic profiles do not differ amongst morbidly obese and super obese adolescent bariatric patients.

 

85.18 Colorectal Cancer in Patients with Type 2 Diabetes Mellitus: Patterns in Molecular Profiling

Posted on January 18, 2018

F. Lambreton1, W. Ward1, J. Purchla1, N. Nweze1, N. Goel1, S. Reddy1, E. Sigurdson1, J. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA

Introduction: Type 2 Diabetes mellitus (DM2) is a known risk factor for the development of colorectal cancer (CRC). Although evidence suggests that patients with both CRC and DM2 have a worse prognosis, an exact pathologic mechanism has not been elucidated. Our aim was to define mutation patterns in CRC patients with DM2.

Methods: Patients who underwent molecular profiling (MP) while receiving treatment for CRC at Fox Chase Cancer Center between 2006 and 2017 were retrospectively reviewed. Patients who were tested with our in-house targeted cancer panel, Caris or Foundation One were also included. The samples were obtained from primary tumors or metastases. Relevant clinical and pathological data were also recorded.

Results: A total of 57 patients diagnosed with CRC and DM2 were identified who underwent MP. Mean age was 66 years (range=45-86). Fourteen (24.5%) patients were stage III and 19 (33.3%) were stage IV. Of these patients, 27 (47.3%) had a mutation. Mutations in P53 and APC genes were present in 10 (37%) patients each. KRAS mutation was present in 8 (29.6%) patients, while BRAF was abnormal in 2 (7.4%) patients. Other mutations found include PIK3CA in 3 (11.1%) cases, SMAD4 in 2 (7.4%), PTEN in 1 (3.7%),  and STK11 in 1 (3.7%) patient. Eleven (40.7%) patients displayed microsatellite instability (MSI).  The mean number of mutations per patient was 2.0 (range= 1-5). Mean overall survival for the whole cohort was 16 months.

Conclusion: Mutation rates in the genes studied in our cohort approach those previously reported by other authors in patients with CRC but without DM2. This suggests that mutation status might not be a contributing factor into the poorer prognosis observed in this cohort. Further, larger studies are needed to confirm these results.

85.13 Comparing Different Preoperative Workflows in Surgical Oncology Clinics

Posted on January 18, 2018

A. S. Manjunathan1, S. Gupta1, S. S. Yang1, C. E. Kein1, A. A. Mazurek1, R. M. Reddy1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:  Although many institutions have focused on improving patient-centered care, there has been little study on how preoperative clinic workflows affect patients. We hypothesized that a streamlined clinic workflow is associated with decreased burden of cost and time on patients in a surgical oncology clinic.

Methods:  A retrospective chart review was performed for all adult patients who underwent surgical treatment for esophageal cancer within a Thoracic Surgery clinic and pancreatic, liver, or biliary cancer within a Hepatopancreaticobiliary (HPB) clinic in a single tertiary care center in 2016. The clinics varied in preoperative visit and test scheduling practices, with the Thoracic clinic focused on minimizing patient visits prior to surgery. Data collected included the number of clinic visits, testing visits, and phone calls during the patient’s workup. Distance traveled to appointments, cost of travel, and total time burden were estimated. Visits, phone calls, travel costs, and time spent were compared using t-tests. 

Results: We compared 70 esophageal cancer and 60 HPB cancer patients, who were demographically similar in age (63.3 +/- 10.7 vs. 63.5 +/- 11.6, respectively; p=0.93).  Patients undergoing workup in the Thoracic Surgery clinic required significantly fewer preoperative appointments compared to patients in the HPB clinic (2.4 +/- 0.7 vs. 4.0 +/- 1.9, respectively; p<0.00001). 45 of 60 patients in the HPB cohort had an extra visit the day prior to surgery for lab work, whereas the Thoracic clinic incorporated this into the patient’s last clinic visit. There was no significant difference in the average number of phone calls received, which we used as an indicator of clinic resource utilization, in the Thoracic versus HPB clinic (7.4 +/- 4.9 vs. 6.4 +/- 6.2, respectively; p=0.31). The mean distance travelled in miles by patients in the Thoracic versus HPB clinic was not significantly different (105.9 +/- 109.2 vs. 93.5 +/- 59.3, respectively; p=0.44); however, the estimated total cost burden due to gas was significantly lower for Thoracic clinic patients than HPB clinic patients ($44.0 +/- 43.0 vs. $73.6 +/- 63.0, respectively; p=0.0029). There was also a significant reduction in time burden for patients in the Thoracic versus HPB clinic (11.3hrs +/- 6.7 vs. 18.5hrs +/- 11.7, respectively; p<0.00001).

Conclusion: This study demonstrated that with a streamlined preoperative workflow that consolidates necessary tests into fewer visits, one clinic has reduced cost and time burden to patients without a significant increase in clinic resource use. Furthermore, the true burden to patients is likely far greater, given potential lost wages and unnecessary stress. These findings should encourage all surgical clinics to evaluate their own preoperative workflow to identify areas in which care can be streamlined in an effort to improve patient-centered care.

85.10 The Impact of Lymph Node Involvement on Survival in Stage II and III Esophageal Adenocarcinoma

Posted on January 18, 2018

S. Cresse1, O. Picado1, B. Azab1, D. Franceschi1, A. Livingstone1, D. Yakoub1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Surgical Oncology, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:

Esophageal adenocarcinoma presents with high incidence of lymph node metastases even in early disease. We aimed to evaluate the impact of regional lymph node involvement on survival of locally advanced stage II and III esophageal adenocarcinoma.

Methods:  

The National Cancer Database (2004-2013) was used to identify patients with clinical stage II and III esophageal adenocarcinoma who had esophagectomy and regional lymphadenectomy. Patients with ≥15 lymph nodes sampled (as recommended by NCCN) were analyzed. The proportion of positive lymph nodes for metastatic disease was identified. The association between pathological N stage, positive/examined lymph node ratio and hazard of death was assessed using Kaplan-Meier method and Cox regression model.

Results: 

We identified 3123 with clinical stage II and III esophageal adenocarcinoma. Mean age was 61 years. M/F ratio was 9:1. Perioperative chemotherapy was administered to 2808 (90%) patients with or without radiation. Patients were distributed as follows, clinical T1, T2, T3 and T4 in 4%, 22%, 71%, and 1%, respectively. Clinical N0, N1, N2, and N3 were present in 33% 56%, 8%, and 1%, respectively. Upon histopathological examination of surgical specimens, 9% of cN0/cN1 were pathologically upstaged to pN1, pN2 and pN3, while 60% of cN2/cN3 were downstaged to pN0 and pN1. Median follow-up time was 39 months. Increasing pathological T stage was associated with worse overall survival. Analysis of pathological N stage showed a median overall survival of 60, 26, 24, and 20 months for N0, N1, N2 and N3, respectively. N0 had significantly better survival than N1-3 (p<0.001). Among N1, 2 and 3 there was no difference in survival. However, analysis of positive/examined lymph node ratio showed that overall survival significantly dropped when the positive/examined lymph node ratio was above 0.25 (18 months vs. 31 months, p<0.05).

Conclusion: 

Lymph node involvement is the major determinant of poor survival in stage II and III esophageal adenocarcinoma patients. Positive/examined lymph node ratio greater than 0.25 is associated with significantly worse survival.

85.08 Gastric Cancer: Experience with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2018

C. U. Ihemelandu1, C. U. Ihemelandu1  1MedStar Washington Hospital Center,Surgical Oncology,Washington, DC, USA

Introduction: Most stage IV gastric cancer patients present with non-operable disease, and even in those with operable disease, rates of relapse are high and prognosis is poor. Our aim was to analyze the clinicopathologic characteristics, prognostic factors, and overall survival associated with stage IV gastric cancer

Methods: A retrospective analysis of a tumor registry for all patients treated for stage IV gastric cancer between 1991-2016 at a tertiary institution. 

Results:Of 231 patients there were 127(55.0%) males vs. 104(45.0%) females.  The mean age at diagnosis was 66 years. Seventy-eight (33.8%) patients presented with a signet ring vs. 153(66.2%) with an intestinal histology. Twenty-six (11.3%) patients were treated with CS and HIPEC vs. 64(27.7%) and 141(61%) respectively who were treated with surgery and systemic chemotherapy, and no surgical intervention. In univarate analysis signet ring tumors had a better overall median survival 5 vs. 3 months (p= 0.04). Amongst the cohort of patients treated with CS and HIPEC the median survival was 40 months for the signet ring histology vs. 8 months for the intestinal. Median survival time was 14 months for patients treated with CS and HIPEC vs. 6 and 2 months respectively for those treated with surgery and systemic chemotherapy or no surgery. One, 3 and 5 year survival was 51%, 38% and 29% respectively for patients treated with CS and HIPEC vs.39%, 16% and 9%, and 14%, 2% and 0% for surgery and no surgery. Significant predictors of an improved survival in multivariate analysis were a young age at diagnosis (p<0.000), treatment with CS and HIPEC (p<0.000). Gender, race, tumor pathology, use of radiation therapy and systemic chemotherapy did not achieve significant status.

Conclusion:Young age at diagnosis and use of CS and HIPEC are independent predictors for an improved overall survival in patients diagnosed with stage IV gastric cancer. Paradoxically signet ring pathology demonstrated an improved survival over an intestinal pathology when treated with CS and HIPEC.

 

85.06 Impact of Age on Surgically Resected Retroperitoneal Sarcoma at a High-Volume Tertiary Center

Posted on January 18, 2018

H. N. Overton1, F. Gani1, J. Singh1, A. Blair1, M. Umair3, C. Meyer2, F. M. Johnston1, N. Ahuja1  1Johns Hopkins University School Of Medicine,Division Of Surgical Oncology, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Division Of Oncology, Department Of Medicine,Baltimore, MD, USA 3Saint Louis University School Of Medicine,Department Of Radiology,Saint Louis, MO, USA

Introduction:
Retroperitoneal sarcoma (RPS) is a rare tumor type that accounts for approximately 15% of soft tissue sarcomas. An expanding elderly population in the United States presents a need to understand associations between age and outcomes in primary or recurrent RPS. We investigated features of RPS in a cohort of surgical patients to determine if any differences exist along the spectrum of adult age.

Methods:
Patients undergoing surgery for RPS with curative intent at the Johns Hopkins Hospital between 1994 and 2015 were identified. Overall (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meir method. Univariable and multivariable Cox proportional hazards regression analysis was performed to identify factors associated with worse OS and DFS.

Results:
A total of 223 patients were identified who met inclusion criteria. The median age at time of index surgery was 61 years (IQR: 51-68) with 57.5% (n=106) of patients being female. Among all patients, 168 patients (75.3%) presented with primary RPS while 55 (24.6%) presented with recurrent disease. Pathology was 48.9% (n=109) liposarcoma, 34.5% (n=77) leiomyosarcoma, and 16.6% (n=37) other. Median tumor size was 12cm (IQR: 7-20). High grade tumors were most common at 48.8% (n=105) compared to 28.8% (n=62) grade 1 and 22.3% (n=48) grade 2. Complete resection (R0/R1) was achieved in 86.8% (n=191) of patients. Administration of chemotherapy was significantly different among age groups (39.4% <45years, 25.5% 45-64 years, 13.7% 65-79years, 0.00% ≥ 80 years, p=0.007) as was likelihood of an incomplete (R2) resection (21.2% <45years, 6.6% 45-64 years, 16.9% 65-79years, 30.0% ≥ 80 years, p=0.027). Postoperatively, 61.3%  (n=119) developed a tumor recurrence; 54.6% (n=65) developed local disease while 38.6% (n=46) developed distant disease and 6.7 % (n=8) developed local and distant disease. The median OS and DFS were 67.5 months (IQR: 27.4-130.6) and 17.8 months (IQR 6.4 -47.4), respectively. On multivariable analysis, increasing patient age was associated with a shorter OS (Hazard Ratio [HR] = 1.02, 95% CI:1.00-1.04, p=0.046) but was not associated with DFS (HR= 1.001, 95% CI:0.98-1.02, p=.879). Of note, other risk factors associated with poor OS were high grade tumor (G1/G2 vs G3) (HR = 2.83, 95% CI:1.47-5.44, p=0.002) and postoperative recurrence (HR= 6.11, 95% CI: 2.92-12.79, p<0.001, Figure 1).

Conclusion:
Increasing age at time of index operation for primary or recurrent RPS, high grade tumor and post-operative recurrence correlates with decreased OS. Further study is needed to understand the characteristics and interactions of pathology, multiple recurrences and aggressive surgical and medical therapy on different age categories of patients with RPS.
 

85.07 Can It Wait? – Delayed Operative Intervention for Small Gastric GIST

Posted on January 18, 2018

Z. E. Stiles1, P. V. Dickson1, M. G. Martin2, E. S. Glazer1, S. W. Behrman1, J. L. Deneve1  1University Of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA 2West Cancer Center,Memphis, TN, USA

Introduction:
Potentially curative therapy for gastrointestinal stromal tumors (GISTs) involves surgical resection.  Recently, it has been suggested that there is a subgroup of patients with small (≤ 2 cm) gastric GISTs that may undergo regular endoscopic surveillance in lieu of surgical resection given their likely indolent nature.  The purpose of this study was to examine the pathologic and known prognostic features of tumors within this subgroup and to compare outcomes among patients undergoing resection at different time points.

Methods:
A retrospective review of the 2004 – 2014 National Cancer Database was performed. Patients with tumors ≤ 2 cm were compared to those with larger tumors with regard to clinical and pathologic features.  Among tumors ≤ 2 cm, short and long term outcomes were then evaluated for patients undergoing surgical resection at different time periods: early (0 – 90 days), and late (> 90 days).

Results:
Patients with tumors ≤ 2 cm (n = 1732) were more often younger (median age 65 vs 66, p < 0.001), female (59.2% vs 49.8%, p < 0.001) and Caucasian (72.7% vs 68.2%, p = 0.001) compared to those with tumors > 2 cm (n = 10518).  A smaller proportion of tumors ≤ 2 cm were found to be high grade (2.4% vs 11.0%, p < 0.001) and small tumors were less likely to be associated with distant metastases (2.5% vs 10.3%, p < 0.001).  Among patients with tumors ≤ 2 cm, no significant differences were seen with regard to margin status, LOS, unplanned readmission, 30-day, or 90-day mortality based on the timing of surgical resection (all p > 0.4).  Overall survival (OS) was favorable for all patients with tumors ≤ 2 cm as the median OS was not reached (NR) (mean 116.9 months). No difference in OS was observed based on the time from diagnosis to surgical resection (mean OS 117.8 months [95% CI 112.6 – 122.9] vs. 107.5 months [95% CI 84.4 – 130.6], log rank p = 0.804).

Conclusion:
In this large database, patients with small gastric GIST exhibited overall favorable findings compared to larger tumors.  Delayed resection (> 90 days) was not associated with a negative impact on short term outcomes or overall survival for small gastric GIST.  Prospective evaluation of a protocol involving longitudinal surveillance of small gastric GISTs is warranted.
 

85.05 Does Oncoplastic Surgery Offer Low Positive Margin Rate Using New SSO/ASBrS/ASTRO Margin Guidelines?

Posted on January 18, 2018

M. Jonczyk1, K. Patel1, R. Graham1, S. Naber1, L. Chen1, A. Chatterjee1  1Tufts Medical Center,Surgery,Boston, MA, USA

Introduction:
Large volume displacement oncoplastic surgery (LVOS) is a technique that uses reconstructive mastopexy and breast reduction techniques to allow for larger oncologic resections while providing good aesthetic outcomes in a single operation. To date, however, no study has used the most recent the Society of Surgical Oncology, American Society of Breast Surgeons, American Society for Radiation Oncology (SSO/ASBrS/ASTRO) surgical margin recommendations to assess oncoplastic surgery. Recent guidelines established no ink on tumor as an adequate margin for invasive breast cancer and at least 2mm as adequate margins for ductal carcinoma in situ. The purpose of this study was to investigate the surgical margin rates of LVOS using the new guidelines. We presumed that under the stricter guidelines, LVOS would have a higher positive margin rate than reported in the past literature.

Methods:
First, a literature review to assess margin rates before the introduction of SSO/ASBrS/ASTRO guidelines was done using PRISMA guidelines with an international Pubmed search and reviewed by two blinded authors. The search included keywords such as “oncoplastic breast surgery,” “lumpectomy,” “partial mastectomy,” and “positive margins associated with breast surgery.” All articles either pertained to LVOS, standard lumpectomy (SL) or both. The inclusion criteria for our study included histology discrepancy, and new guideline margin status. From this, we determined the published positive margin for SL and LVOS.  Second, we analyzed all LVOS performed at our institution since the adoption of the new margin guidelines and compared these margin rates to the literature review outcomes.

Results:
Our study consisted of 1702 patients. There were 847 patients in LVOS group and 855 patients in the SL group. 34 of 45 papers evaluated were not included due to exclusion criteria (missing: new margin guidelines, histology, or margin status). The pre-guideline positive margin rate for LVOS was lower than with SL (12.51% vs. 20.4%, P-value <0.001). Of the 50 LVOS operations done at our institution since adoption of the margin guidelines, no statistical difference in the positive margin rates was noted when compared to the literature rates (10% vs. 12.67% respectively, P-value 0.5796). Positive margin rates for LVOS at our institution were lower than SL margin rates reported in the literature (P-value 0.0358).

Conclusion:
This study demonstrates that even with the stricter margin guidelines, LVOS still has a low positive margin rate comparable to pre-guideline literature reports. LVOS continues to have a significantly lower positive margin rate than SL.  This is the first study to report margin rates for LVOS after the adoption of the SSO/ASBrS/ASTRO guidelines, and confirms the importance of LVOS in providing optimal oncologic outcomes for patient with large locally advanced breast cancer.

85.01 Pancreatic Adenosquamous Carcinoma with Worse Clinicial Outcome Compared to Pancreatic Adenocarcinoma

Posted on January 18, 2018

C. A. Hester1, M. R. Porembka1, M. A. Choti1, P. M. Polanco1,2, J. C. Mansour1, R. M. Minter1, S. C. Wang1, A. C. Yopp1  1University Of Texas Southwestern Medical Center,Surgical Oncology,Dallas, TX, USA 2Department Of Veterans Affairs North Texas Health Care System,Surgical Oncology,Dallas, TX, USA

Introduction:
Pancreatic adenosquamous carcinoma (PASC) is a histopathologic diagnosis distinct from pancreatic adenocarcinoma (PAC), characterized by ≥ 30% malignant keratinized squamous cell histology admixed with ductal adenocarcinoma.  A paucity of data regarding the natural history of PASC and clinicopathological variables associated with outcome has limited value in individual patient counseling and therapeutic decision-making, especially in comparison to the more prevalent PAC histology. The aims of this study are to characterize the clinicopathological variables of PASC associated with outcome and compare these variables with PAC in surgically resected patients.

Methods:
We conducted a retrospective analysis of the prospectively collected National Cancer Database participant user file between 2004 and 2012. All patients with ICD-O-3 morphological codes corresponding to PASC and PAC were included for analysis. Patients with missing vital status data or in situ disease were excluded.  Demographics, tumor characteristics, treatment regimens, and outcomes were abstracted. Differences between the groups were determined with Fisher’s exact and Chi-squared tests. Survival was estimated and compared using Kaplan-Meier and log-rank. Multivariate analysis was performed to determine variables associated with overall survival.

Results:
Of the 207,073 patients meeting the inclusion/exclusion criteria, 205,328 PAC and 1,745 PASC histologies were identified. There was no significant difference in age, race/ethnicity and insurance status between patients with PAC and PASC. PASC patients have tumors that are significantly larger (56% vs 33% with tumors ≥ 4 cm, p<0.001), more likely to originate in the pancreatic body and tail (36% vs 24%, p<0.001), undifferentiated histology (41% vs 17%, p<0.001), higher rate of positive lymph nodes (22% vs 15%, p<0.001), and presention at AJCC stage I/II (39% vs 32%, p<0.001). Patients with stage I and II PASC are more likely to undergo curative-intent surgery compared to PAC (75% vs 54%, p<0.001) and have lower rates of lymph node involvement within surgical specimens (29% vs 39%, p<0.001).  There is no significant difference in overall survival when comparing all patients with PAC and PASC (6.2 months and 5.7 months, p=0.601). However, patients with PASC undergoing curative-intent surgery have significantly worse outcome (median survival 12.9 months vs 19.1 months, p<0.001).  In patients with PASC, increased Charlson comorbidity score, positive lymph node status, AJCC stage III/IV, and lack of receipt of treatment (surgical, chemotherapy, and/or radiotherapy) were associated with worse overall survival.

Conclusion:

Although curative-intent surgery is more often performed in PASC patients, PAC histology is more favorable with regards to overall survival. Despite relative infavorable biology, receipt of therapy is associated with improved survival in patients with early and late stage PASC.
 

85.02 Is Perioperative Serum Albumin Predictive of Outcomes Following Esophageal Resection?

Posted on January 18, 2018

S. Saeed1, S. Hoffe1, M. Cameron1, K. Almhanna1, J. Frakes1, J. P. Fontaine1, J. Pimiento1  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA

Introduction:  Low preoperative serum albumin has been recognized as a risk factor for adverse post-operative outcomes. However, the role of post-operative serum albumin testing has not been clearly defined. Albumin’s role as a marker of the acute stress response has been proposed, while albumin can also be used as a marker of fluid resuscitation level after surgical stress. We aim to assess the predictive value of preoperative serum albumin and postoperative change in albumin for outcomes following esophageal resection for cancer.

Methods:  We retrospectively reviewed an IRB approved database of patients undergoing esophageal resection for esophageal cancer at our tertiary care center. Of 1026 patients included in the database, we identified 190 patients with preoperative albumin levels reported within 1 month of surgery, and 58 patients with early post-operative albumin evaluation (post-operative day 1). Low preoperative albumin level was defined as lower than 3.6 g/dl as described in the literature. Postoperative change in albumin was studied by division into percentiles with percentile 75 equal to >11% change from pre-operative albumin. Chi-squared, ANOVA and Kaplan Meier survival analysis were performed on the previously defined groups. Patient demographics, postoperative complications, survival, and length of hospital stay (LOS) were evaluated.

Results: One hundred and ninety patients (158 male, 32 female) with a median age of 63.75 (range=30-82) were stratified into two groups based on preoperative serum albumin levels—those with levels above (n=168) and below (n=22) 3.6 g/dl. Serum albumin below 3.6 g/dl was associated with a significantly longer LOS (p=0.02). However, pre-operative serum albumin was not predictive of overall survival after surgery (p=0.60), 30-day mortality (p=0.90) or postoperative complication rate (p=0.43). Postoperative change in serum albumin was also calculated for patients with serum albumin levels recorded on postoperative day 1. Fifty-eight patients (47 male, 11 female) with median age of 62.3 (32-77) were included in this sub-analysis. Postoperative decrease in serum albumin below 11% was associated with a greater LOS (p=0.03), but was not predictive of complications (p=0.67), 30-day mortality (p=0.60) or overall survival (p=0.08). 

Conclusion: Preoperative hypoalbuminemia in this modern series was associated with prolonged LOS but not with decreased overall survival. Limited postoperative decrease in serum albumin may be associated with increased postoperative length of hospital stay and may be a reflection of inadequate fluid resuscitation of patients undergoing extensive surgical procedures or of other specific physiologic factors in malnourished patients. Future prospective studies should clarify the potential predictive value of preoperative hypoalbuminemia and postoperative decrease in serum albumin for postsurgical complications.

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.  
 

84.13 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. 
 

84.10 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.

84.08 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. 
 

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