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.

85.03 Preoperative Albumin–bilirubin Grade Predicts Recurrences after Radical Gastrectomy.

Posted on January 18, 2018

T. Miwa1, M. Kanda1, C. Tanaka1, D. Kobayashi1, M. Hayashi1, N. Iwata1, N. Hattori1, M. Suenaga1, S. Yamada1, H. Sugimoto1, G. Nakayama1, M. Koike1, M. Fujiwara1, Y. Kodera1  1Nagoya University,Department Of Gastroenterological Surgery (Surgery II),Nagoya, Aichi, Japan

Introduction:
The albumin-bilirubin (ALBI) score was initially developed for assessing liver dysfunction severity and was suggested to have prognostic value in patients with hepatocellular carcinoma. We aimed to evaluate the prognostic impact of ALBI grade in patients with advanced gastric cancer (GC) after radical gastrectomy.

Methods:
This study included 283 patients who underwent radical gastrectomy for pT2-4 GC without preoperative treatment. ALBI was calculated as follows: (log10 bilirubin (μmol/L) × 0.66) + (albumin (g/L) × -0.0852), and categorized into grades 1 (≤ -2.60), 2 (-2.60<, ≤-1.39) and 3 (-1.39<).

Results:
The median ALBI score was -2.96 and numbers of patients in ALBI grades 1, 2 and 3 were 228, 55 and 0, respectively. Patients with ALBI grade 2 had a lower administration rate of adjuvant chemotherapy than those with ALBI grade 1, whereas no significant differences were found in morbidity rate and disease stage. The ALBI grade 2 group was more likely to have shorter overall and disease-free survival compared with the ALBI grade 1 group. Multivariable analysis identified ALBI grade 2 as an independent prognostic factor for recurrence (hazard ratio 1.97, 95% confidence interval 1.10–3.47, p = 0.0242). Survival differences between ALBI grade 1 and 2 groups were increased in the patient subset that received adjuvant chemotherapy. ALBI grade 2 was correlated with a shortened duration of administration of postoperative S-1 adjuvant.

Conclusion:
ALBI grade serves as a simple and promising predictive factor for disease-free and overall survival in patients with pT2-4 GC after radical gastrectomy.
 

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

 

84.13 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. 
 

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

Posted on January 18, 2018

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

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

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

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

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

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

84.10 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.

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

Posted on January 18, 2018

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

Introduction:

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

Methods:

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

Results:

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

Conclusion:

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

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

Posted on January 18, 2018

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

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

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

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

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

 

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

Introduction:
Safety of pancreaticoduodenectomy has improved significantly in the past two decades. Current inpatient and 30-day mortality rates are low. However, incidence and causes of 90-day and 1-year mortality are poorly defined and largely unexplored. 

Methods:
All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution retrospective cohort study.  Distributions of postoperative pancreatectomy-specific morbidity and cause-specific mortality were compared between early (within 90-days) and late (91-365 days) post-operative recovery period.   

Results:
A total of 552 pancreaticoduodenectomies were performed during the study period. Clinically significant pancreatic leak (11.8% versus 0%) and intra-abdominal abscess not related to pancreatic leak (4.0% versus 0.4%) were more common during early rather than late post-operative period (both p<0.001). Proportion of re-operations were higher in early compared to late post-operative period (6.5% versus 3.8%, respectively, p=0.041). Mortality at 30, 90, 180, and 365 days following pancreaticoduodenectomy was 6 (1.1%), 20 (3.6%), 45 (8.2%), and 90 (16.3%) patients, respectively. Causes of early and late mortality varied significantly (p<0.001). The most common cause of death within 90 days was due to intra-abdominal infection, sepsis and multiple system organ failure in 10 (50%) patients, followed by post-pancreatectomy hemorrhage in 4 patients (20%), and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 45 (64%) patients during the late post-operative period between 91 and 365 days. Mortality from failure to thrive and debility, which was most frequently associated with delayed gastric emptying and failure of nutritional recovery, was similar between early (within 90-days) and late (91-365 days) post-operative periods (15% versus 16%, p=0.856). 

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

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

Posted on January 18, 2018

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

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

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

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

Conclusion:

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

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

Posted on January 18, 2018

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

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

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

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

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

 

84.05 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.

84.03 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.

84.04 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.

 

84.01 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.  

 

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.

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