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Mo1743 Risk Factors and Management of Postpancreatectomy Hemorrhage in Over 1000 Pancreatic Resections
Mo1742
age: 66 ± 17.5. SAP was alcohol induced in 12% and due to gallstones in 59% of patients. No cause was identified in 25% of patients. Median hospital stay and ITU stay were 14 and 3.23 days respectively. Forty one patients (80%) received antibiotics and thirty five patients (69%) had nutrition support but neither of them seems to have a significant impact on survival (p = 0.6 and 0.06 respectively). The overall mortality rate during the study period (3 years) was 38% (n-19) above national average of 30%. All 7 patients in group IV died; 5 had necrosectomy and 1 had CT guided drainage of infected acute fluid collection. Outcome (death) was statistically correlated with organ dysfunction criteria (Atlanta criteria and APACHE II score). Conclusion: While the presence of 'IN or persistent OF' in SAP (group III) is associated with high mortality, the combination of 'IN and persistent OF' (group IV) is uniformly fatal. Further research is necessary to confirm findings in our study and to explore ways of optimising patients in group III to improve survival.
Clinico-Pathological Features of Solid Pseudopapillary Neoplasms of the Pancreas Pablo E. Serrano, Hassan Al-Ali, Steven Gallinger, Ian D. McGilvray, Carol-Anne Moulton, Alice C. Wei, Stefano Serra, Sean Cleary Background: Solid pseudopapillary neoplasms (SPN) are rare pancreatic tumors with low malignant potential. Methods: This is a retrospective analysis of 24 patients with a diagnosis of SPN who underwent resection. The main objective of this study was to describe the clinicopathological features and surgical management of SPN. Results: Median age at diagnosis was 35.5 years (13 to 64). Most patients were female, 20/24, 83%. Most patients, 14/24, 58% were symptomatic at diagnosis, (11/24, 79% had abdominal pain). Median tumor size was 4.7cm (2.1 to 12) with 15/24, 62.5% occurring in the body or tail and 9/24, 37.5% in the head or neck of the pancreas. Most tumors were solid and cystic in nature (18/24, 75%), without calcifications (6/24, 25%) and encapsulated (16/24, 70%). There were 8/24, 33% pancreaticoduodenectomies, 4/24, 17% spleen-preserving distal pancreatectomies, 10/24, 42% distal pancreatectomy-splenectomy and 2/24, 8% central pancreatectomies. Major complications occurred in 3/24, 12.5% patients, with 6/24, 25% pancreatic leak rate (5/6, 83% ISGPF-type A leak). All cases displayed strong β-catenin, CD56, progesterone receptor, alpha-1 antitrypsin and neuron-specific-enolase staining with loss of E-cadherin. Most cases stained positive for vimentin (11/12, 92%) and CD10 (14/15, 93%). Three SPN were considered malignant, 3 developed liver metastases, 2 of which were initially found at presentation and 2 had local recurrence in the retroperitoneum. Two patients had evidence of lymphovascular invasion; one of them had lymph node involvement and eventually developed liver metastases. Curative resection of metastases was offered to 2 of the 3 patients, the other patient died of disseminated metastatic disease 5 years after diagnosis of recurrence, 10 years after initial pancreatic resection. Chemotherapy (gemcitabine and erlotinib) was given to only one patient with unresectable metastatic disease. Median follow-up period was 30 months (4 to 129), 21/24, 87.5% patients did not have recurrence and all patients except one were alive at the end of the study period. Conclusions: SPN are tumors with a low but real malignant potential. Metastases and lymphovascular invasion are the only features that can predict an aggressive behavior. Resection of liver metastases can offer cure to some of these patients with aggressive SPN.
Mo1745
Introduction: Over the past decade, epidural analgesia and anesthesia (EAA) has become the preferred method of pain management for major abdominal surgery. With regards to pancreaticoduodenectomy (PD), the superior form of analgesia, as evidenced by their respective non-analgesic outcomes, has been debated. In this study, we compare postoperative morbidity and mortality with EAA and IV analgesia in patients who underwent PD. We also examine preoperative factors that lead to epidural discontinuation and the consequence of premature epidural discontinuation on morbidity and mortality. Methods: A retrospective review of a prospective database of PDs performed at a single institution was conducted for the time period between January 2007 and July 2011. Patients receiving IV analgesia (group A) were compared with patients receiving EAA alone or in conjunction with IV analgesia (group B). Endpoints included mortality, major postoperative complications, postoperative hypotension, postoperative fluid requirements, length of stay, and hospital readmission within 30 days. Multivariate logistic regression was performed to measure the predictive success of epidural analgesia in comparison to IV analgesia for each endpoint, as well as to measure the predictive success of preoperative parameters including age, gender, BMI, surgical indication, and comorbidity. Using these same preoperative parameters, Classification and regression tree (CART) analysis for predictive modeling was used to determine predictors of epidural failure. Chi-Squared analysis was also performed to compare patients who had epidural failure with the rest of group B using the previously assessed morbidity and mortality endpoints. Results: Of the 163 patients reviewed, 14 (9%) were in group A and 149 (91%) were in group B. Endpoints were similar between the two groups, however 22 patients (15%) in group B had their epidural discontinued early due to either severe hypotension or epidural malfunction. Within this group, patients older than 72 and with a BMI less than or equal to 20 had their epidural discontinued in 80% of cases compared with 12% of patients not meeting this criteria. There was no significant difference in endpoints between the 22 patients that had their epidural discontinued prematurely and the other 127 patients in group B who did not require premature epidural discontinuation. Conclusion: EAA may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction. However, premature epidural discontinuation was not associated with increased morbidity and mortality. Prospective randomized trials are warranted to further determine if EAA should be avoided in this specific population.
Mo1743 Risk Factors and Management of Postpancreatectomy Hemorrhage in Over 1000 Pancreatic Resections Ulrich Wellner, Frank Makowiec, Hryhoriy Lapshyn, Dirk Bausch, Ulrich T. Hopt, Tobias Keck Introduction Postpancreatectomy Hemorrhage (PPH) is a rare but relevant complication after pancreatic resections. The aim of this study was to analyze risk factors and management of PPH in a large patient collective. Methods The study was carried out retrospectively on the basis of a prospectively maintained database. Patients with major pancreatic resections were included. PPH was defined according to the ISGPS. For statistical analysis, SPSS Software Version 20 was used. Results From 1994 to 2012, n=1082 Patienten aged 9 bis 89 years were included (729 pancreatoduodenektomies (PD), 188 distal pancreatic resections, 123 duodenum-preserving procedures and 42 pankreatectomies). Incidence of PPH was 7% and 3% for severe (Grade C) PPH, 90% were late ( .24h postOP) PPH and about half of PPH had an intraluminal origin. With Grade C PPH, mortality rose significantly to over 30% (overall 1.3%). Primary management consisted in endoscopic, angiographic and operative intervention. For severe PPH, success rate of non-operative therapy was around 50%. Risk factors for PPH were higher age and BMI and pancreatic fistula (POPF). Pancreatogastrostomy (PG) in PD had a significantly higher incidence of PPH than pancreatojejunostomy (PJ) mostly due to intraluminal PPH from the PG site. However, mortality after occurrence of PPH was significantly lower with PG (8% vs 28%, p ,0.05) compared to PJ, and PG was independently associated with lower overall mortality survival in multivariate analysis, while age, POPF and PPH were the relevant risk factors for death. Conclusions PPH is a major determinant of mortality risk in pancreatic surgery. Non-operative management is successful in about half of cases of severe PPH. Intraluminal PPH is more frequent with PG, however mortality after PPH and overall mortality were significantly reduced with PG.
Mo1746 Postoperative Serum Amylase Predicts Pancreatic Fistula Following Pancreaticoduodenectomy Jordan M. Cloyd, Brendan Visser, George A. Poultsides, Zachary Kastenberg, Jeffrey A. Norton
Mo1744 Mortality of Severe Acute Pancreatitis (SAP) Patients With Infected Necrosis or Persistent Organ Failure Is High but May Be Reduced by Specialist Care and Innovative Therapeutic Modalities Omer Jalil, Rami Radwan, Aamer F. Iqbal, Chirag Patel, Ashraf M. Rasheed Introduction: Severe acute pancreatitis (SAP) is best supported in high dependency or intensive therapy units (HDU or ITU) setting and associated with high mortality and morbidity despite best efforts at attaining early diagnosis and timely intervention. Aim: To study management and disease-related mortality of patients admitted to ITU with SAP with specific emphasis on the group that succumbed to the disease in an attempt to understand the circumstances that lead to this event and identify interventions that may have abrogated this eventuality and indicators that may have predicted the fate of these patients. Methods: Retrospective case per case detailed analysis of management and outcome of consecutive patients admitted to ITU with SAP during the period of 2007-2010. Medical records were reviewed by a single abstractor (OJ) for patient characteristics and disease severity scoring. The development of necrosis, infected necrosis (IN) or organ failure (OF) was recorded. Patients were classified into group I (No necrosis, No OF), group II (sterile necrosis or transient OF), group III (IN or persistent OF) and group IV (infected necrosis and persistent OF). The hospital course of the four groups were studied in relation to fluid resuscitation, use and type of prophylactic or therapeutic, use of prophylactic anti-fungal, early introduction of enteral feeding, radiological/surgical intervention and any post-intervention complications. Results: 51 patients admitted to ITU with SAP (APACHE II .8, modified Glasgow score. 3) during the period of 2007-2010. All cases fulfilled the Atlanta criteria of SAP. Median
S-1105
Background: Pancreatic fistula (PF) is the most common complication following pancreaticoduodenectomy (PD) and is associated with high morbidity. Despite this, few preoperative or perioperative risk factors have been identified. In this study, we measured the postoperative serum amylase level and studied its ability to predict the development of PF. Methods: A retrospective review of 176 consecutive PD performed by one surgeon between 2006 and 2011 was conducted. Preoperative demographic, perioperative data and clinical outcomes were recorded. Comparison statistics and logistic regression were used to analyze the association between the serum amylase on postoperative day one and the development of PF. PF was defined and scored based on the International Study Group on Pancreatic Fistula. Results: 146 of 176 consecutive PD cases (83.0%) had serum amylase on postoperative day one recorded. 27 of the 146 developed a PF (18.5%): 6 type A, 19 type B and 2 type C. Patients with a PF had a mean serum amylase on postoperative day one of 659 ± 581 compared to 246 ± 368 in control patients (p ,0.001). Patients with leaks were also younger (60.3 ± 11.3 vs 65.5 ± 11.1, p ,0.05), less likely to have pancreatic adenocarcinoma (40.7% vs 68.9%, p,0.05) and less likely to have a duct-to-mucosa anastomosis (63.0% vs 88.2%, p,0.01). A serum amylase of 140 U/L, the laboratory's upper limit of normal, was empirically chosen as the cutoff value in order to maximize sensitivity while maintaining specificity. On logistic regression analysis, a serum amylase .140 U/L on postoperative day one was strongly associated with developing a PF (OR 5.48, 95% CI 1.94-15.44) as was receiving an intussuscepting anastomosis (OR 4.41, 95% CI 1.69-11.52). Greater age (OR 0.96, 95%
SSAT Abstracts
SSAT Abstracts
Peri-Operative Epidural May Not Be the Preferred Form of Analgesia in Select Patients Undergoing Pancreaticoduodenectomy Trevor Axelrod, Bernardino M. Mendez, Gerard Abood, James Sinacore, Gerard V. Aranha, Margo Shoup
age: 66 ± 17.5. SAP was alcohol induced in 12% and due to gallstones in 59% of patients. No cause was identified in 25% of patients. Median hospital stay and ITU stay were 14 and 3.23 days respectively. Forty one patients (80%) received antibiotics and thirty five patients (69%) had nutrition support but neither of them seems to have a significant impact on survival (p = 0.6 and 0.06 respectively). The overall mortality rate during the study period (3 years) was 38% (n-19) above national average of 30%. All 7 patients in group IV died; 5 had necrosectomy and 1 had CT guided drainage of infected acute fluid collection. Outcome (death) was statistically correlated with organ dysfunction criteria (Atlanta criteria and APACHE II score). Conclusion: While the presence of 'IN or persistent OF' in SAP (group III) is associated with high mortality, the combination of 'IN and persistent OF' (group IV) is uniformly fatal. Further research is necessary to confirm findings in our study and to explore ways of optimising patients in group III to improve survival.
Clinico-Pathological Features of Solid Pseudopapillary Neoplasms of the Pancreas Pablo E. Serrano, Hassan Al-Ali, Steven Gallinger, Ian D. McGilvray, Carol-Anne Moulton, Alice C. Wei, Stefano Serra, Sean Cleary Background: Solid pseudopapillary neoplasms (SPN) are rare pancreatic tumors with low malignant potential. Methods: This is a retrospective analysis of 24 patients with a diagnosis of SPN who underwent resection. The main objective of this study was to describe the clinicopathological features and surgical management of SPN. Results: Median age at diagnosis was 35.5 years (13 to 64). Most patients were female, 20/24, 83%. Most patients, 14/24, 58% were symptomatic at diagnosis, (11/24, 79% had abdominal pain). Median tumor size was 4.7cm (2.1 to 12) with 15/24, 62.5% occurring in the body or tail and 9/24, 37.5% in the head or neck of the pancreas. Most tumors were solid and cystic in nature (18/24, 75%), without calcifications (6/24, 25%) and encapsulated (16/24, 70%). There were 8/24, 33% pancreaticoduodenectomies, 4/24, 17% spleen-preserving distal pancreatectomies, 10/24, 42% distal pancreatectomy-splenectomy and 2/24, 8% central pancreatectomies. Major complications occurred in 3/24, 12.5% patients, with 6/24, 25% pancreatic leak rate (5/6, 83% ISGPF-type A leak). All cases displayed strong β-catenin, CD56, progesterone receptor, alpha-1 antitrypsin and neuron-specific-enolase staining with loss of E-cadherin. Most cases stained positive for vimentin (11/12, 92%) and CD10 (14/15, 93%). Three SPN were considered malignant, 3 developed liver metastases, 2 of which were initially found at presentation and 2 had local recurrence in the retroperitoneum. Two patients had evidence of lymphovascular invasion; one of them had lymph node involvement and eventually developed liver metastases. Curative resection of metastases was offered to 2 of the 3 patients, the other patient died of disseminated metastatic disease 5 years after diagnosis of recurrence, 10 years after initial pancreatic resection. Chemotherapy (gemcitabine and erlotinib) was given to only one patient with unresectable metastatic disease. Median follow-up period was 30 months (4 to 129), 21/24, 87.5% patients did not have recurrence and all patients except one were alive at the end of the study period. Conclusions: SPN are tumors with a low but real malignant potential. Metastases and lymphovascular invasion are the only features that can predict an aggressive behavior. Resection of liver metastases can offer cure to some of these patients with aggressive SPN.
Mo1745
Introduction: Over the past decade, epidural analgesia and anesthesia (EAA) has become the preferred method of pain management for major abdominal surgery. With regards to pancreaticoduodenectomy (PD), the superior form of analgesia, as evidenced by their respective non-analgesic outcomes, has been debated. In this study, we compare postoperative morbidity and mortality with EAA and IV analgesia in patients who underwent PD. We also examine preoperative factors that lead to epidural discontinuation and the consequence of premature epidural discontinuation on morbidity and mortality. Methods: A retrospective review of a prospective database of PDs performed at a single institution was conducted for the time period between January 2007 and July 2011. Patients receiving IV analgesia (group A) were compared with patients receiving EAA alone or in conjunction with IV analgesia (group B). Endpoints included mortality, major postoperative complications, postoperative hypotension, postoperative fluid requirements, length of stay, and hospital readmission within 30 days. Multivariate logistic regression was performed to measure the predictive success of epidural analgesia in comparison to IV analgesia for each endpoint, as well as to measure the predictive success of preoperative parameters including age, gender, BMI, surgical indication, and comorbidity. Using these same preoperative parameters, Classification and regression tree (CART) analysis for predictive modeling was used to determine predictors of epidural failure. Chi-Squared analysis was also performed to compare patients who had epidural failure with the rest of group B using the previously assessed morbidity and mortality endpoints. Results: Of the 163 patients reviewed, 14 (9%) were in group A and 149 (91%) were in group B. Endpoints were similar between the two groups, however 22 patients (15%) in group B had their epidural discontinued early due to either severe hypotension or epidural malfunction. Within this group, patients older than 72 and with a BMI less than or equal to 20 had their epidural discontinued in 80% of cases compared with 12% of patients not meeting this criteria. There was no significant difference in endpoints between the 22 patients that had their epidural discontinued prematurely and the other 127 patients in group B who did not require premature epidural discontinuation. Conclusion: EAA may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction. However, premature epidural discontinuation was not associated with increased morbidity and mortality. Prospective randomized trials are warranted to further determine if EAA should be avoided in this specific population.
Mo1743 Risk Factors and Management of Postpancreatectomy Hemorrhage in Over 1000 Pancreatic Resections Ulrich Wellner, Frank Makowiec, Hryhoriy Lapshyn, Dirk Bausch, Ulrich T. Hopt, Tobias Keck Introduction Postpancreatectomy Hemorrhage (PPH) is a rare but relevant complication after pancreatic resections. The aim of this study was to analyze risk factors and management of PPH in a large patient collective. Methods The study was carried out retrospectively on the basis of a prospectively maintained database. Patients with major pancreatic resections were included. PPH was defined according to the ISGPS. For statistical analysis, SPSS Software Version 20 was used. Results From 1994 to 2012, n=1082 Patienten aged 9 bis 89 years were included (729 pancreatoduodenektomies (PD), 188 distal pancreatic resections, 123 duodenum-preserving procedures and 42 pankreatectomies). Incidence of PPH was 7% and 3% for severe (Grade C) PPH, 90% were late ( .24h postOP) PPH and about half of PPH had an intraluminal origin. With Grade C PPH, mortality rose significantly to over 30% (overall 1.3%). Primary management consisted in endoscopic, angiographic and operative intervention. For severe PPH, success rate of non-operative therapy was around 50%. Risk factors for PPH were higher age and BMI and pancreatic fistula (POPF). Pancreatogastrostomy (PG) in PD had a significantly higher incidence of PPH than pancreatojejunostomy (PJ) mostly due to intraluminal PPH from the PG site. However, mortality after occurrence of PPH was significantly lower with PG (8% vs 28%, p ,0.05) compared to PJ, and PG was independently associated with lower overall mortality survival in multivariate analysis, while age, POPF and PPH were the relevant risk factors for death. Conclusions PPH is a major determinant of mortality risk in pancreatic surgery. Non-operative management is successful in about half of cases of severe PPH. Intraluminal PPH is more frequent with PG, however mortality after PPH and overall mortality were significantly reduced with PG.
Mo1746 Postoperative Serum Amylase Predicts Pancreatic Fistula Following Pancreaticoduodenectomy Jordan M. Cloyd, Brendan Visser, George A. Poultsides, Zachary Kastenberg, Jeffrey A. Norton
Mo1744 Mortality of Severe Acute Pancreatitis (SAP) Patients With Infected Necrosis or Persistent Organ Failure Is High but May Be Reduced by Specialist Care and Innovative Therapeutic Modalities Omer Jalil, Rami Radwan, Aamer F. Iqbal, Chirag Patel, Ashraf M. Rasheed Introduction: Severe acute pancreatitis (SAP) is best supported in high dependency or intensive therapy units (HDU or ITU) setting and associated with high mortality and morbidity despite best efforts at attaining early diagnosis and timely intervention. Aim: To study management and disease-related mortality of patients admitted to ITU with SAP with specific emphasis on the group that succumbed to the disease in an attempt to understand the circumstances that lead to this event and identify interventions that may have abrogated this eventuality and indicators that may have predicted the fate of these patients. Methods: Retrospective case per case detailed analysis of management and outcome of consecutive patients admitted to ITU with SAP during the period of 2007-2010. Medical records were reviewed by a single abstractor (OJ) for patient characteristics and disease severity scoring. The development of necrosis, infected necrosis (IN) or organ failure (OF) was recorded. Patients were classified into group I (No necrosis, No OF), group II (sterile necrosis or transient OF), group III (IN or persistent OF) and group IV (infected necrosis and persistent OF). The hospital course of the four groups were studied in relation to fluid resuscitation, use and type of prophylactic or therapeutic, use of prophylactic anti-fungal, early introduction of enteral feeding, radiological/surgical intervention and any post-intervention complications. Results: 51 patients admitted to ITU with SAP (APACHE II .8, modified Glasgow score. 3) during the period of 2007-2010. All cases fulfilled the Atlanta criteria of SAP. Median
S-1105
Background: Pancreatic fistula (PF) is the most common complication following pancreaticoduodenectomy (PD) and is associated with high morbidity. Despite this, few preoperative or perioperative risk factors have been identified. In this study, we measured the postoperative serum amylase level and studied its ability to predict the development of PF. Methods: A retrospective review of 176 consecutive PD performed by one surgeon between 2006 and 2011 was conducted. Preoperative demographic, perioperative data and clinical outcomes were recorded. Comparison statistics and logistic regression were used to analyze the association between the serum amylase on postoperative day one and the development of PF. PF was defined and scored based on the International Study Group on Pancreatic Fistula. Results: 146 of 176 consecutive PD cases (83.0%) had serum amylase on postoperative day one recorded. 27 of the 146 developed a PF (18.5%): 6 type A, 19 type B and 2 type C. Patients with a PF had a mean serum amylase on postoperative day one of 659 ± 581 compared to 246 ± 368 in control patients (p ,0.001). Patients with leaks were also younger (60.3 ± 11.3 vs 65.5 ± 11.1, p ,0.05), less likely to have pancreatic adenocarcinoma (40.7% vs 68.9%, p,0.05) and less likely to have a duct-to-mucosa anastomosis (63.0% vs 88.2%, p,0.01). A serum amylase of 140 U/L, the laboratory's upper limit of normal, was empirically chosen as the cutoff value in order to maximize sensitivity while maintaining specificity. On logistic regression analysis, a serum amylase .140 U/L on postoperative day one was strongly associated with developing a PF (OR 5.48, 95% CI 1.94-15.44) as was receiving an intussuscepting anastomosis (OR 4.41, 95% CI 1.69-11.52). Greater age (OR 0.96, 95%
SSAT Abstracts
SSAT Abstracts
Peri-Operative Epidural May Not Be the Preferred Form of Analgesia in Select Patients Undergoing Pancreaticoduodenectomy Trevor Axelrod, Bernardino M. Mendez, Gerard Abood, James Sinacore, Gerard V. Aranha, Margo Shoup