Potential utility of selective laparoscopy and laparoscopic ultrasound for staging periampullary tumors

pancreatectomy) were performed for malignant disease (55% pancreanc cancer, 22% ampullary cancer, 13% distal bile duct cancer, 10% others~ Ti~.{rty-tw,o patients (21%) had SMPVR (pancreauc cancer 25, ampullary cancer 2, distal bile duct cancer 4, other 1). Twenty of those 32 patienta ~o3%) with SM-PVR had histologically proven malignant vein invasion. The perioperative course was compared in the entire patient group Long-term survival was available and compared in 112 patients with pancreatic or penampufiary cancer using univariate Clog-rank) and multivariate (Cox regression) methods. RESULTS: A margin-negative resection was obtained in 72% (63 % in SM-PVR vs 75% without SM-PVR; p = 0.15). Most cases of margin-positive resections in patients with SM-PVR were due to positive retroperitoneal ntargins and not to positive resection margins of the resected vessel wall In patient~ with SM-PVR vs patients without SM-PVR median duration, of surgeD" was 510 vs. 455 mm~ (p
the patients. Amylase in abdominal drain > 3x serum amylase was seen in 55% of the patients and leucocytosis in 50% of the patients. CT detected signs of leakage in 80% of the panents. Treatment for mild leakage included 11 patients with percutaneous drainage (mortality 9%) and 7 patients with surgical drainage (mortality 14%). Severe pancreatic leakage was seen in 18 patients (4.5%). Treatment was divided in two periods and included 9 patients with salvage pancreatectomy and 9 patients in which the remnant was preserved. Mortality was nil and 3 (33%) respectively and the median 1CU stay was 4 and 11 days. During follow-up, all 9 patiems with salvage pancreatectomy suffered from pancreatic endocrine insufficiency. Patients in which the remnant was preserved suffered from remnant necrosis (n = 1), endocrine pancreas insufficiency (n = 3), pancreaticocutaneous fistulas (n = 3), and pseudocysts (n = 3). Conclusion: Preserving the pancreatic remnant after severe pancreatic leakage was associated with a high mortality, a high rate of long-term complications and long ICU admittance and did not prevent endocrine insufficiency. Therefore, salvage pancreatectomy should be considered for severe pancreatic leakage if drainage fails:

M1972

Pancreatic Fistula After Pancreatic Head Resection: A Problem of The Past? Helmut Friess, Jorg Kleeff, Laps Fischer, Kaspar Zgraggen, Jan Schmidt, Waldemar Uhl, Markus Buechler Introduction: Major pancreatic resections are still associated with a considerable risk of postoperative morbidity and mortality. A demanding task in pancreatic surgery is the performance of a safe pancreatic anastomosis after pancreatic head resection or the adequate secure closure of the pancreatic remnant after distal pancreatectomy. In the literature in centers of pancreatic surgery a pancreatic fistula rate between 3-10% has been reported following major resection. This indicates that also in experienced hands with high patient load pancreatic fistula still represents a significant problem. Patients and Methods: Since October 2001, all patients undergoing pancreatic surgery were prospecnveiy recorded in a computerized database. A pancreatic fistula was defined as a drainage secretion of more than 30 ml of amylase rich fluid (more than 1000 uints/ml) per day for more than 5 days. The closure of the pancreatic stump after left resection was routinely carried out with a stapler device. Results: Within one year 154 pancreatic resecuons were performed in tumors (64%) and other indications (36%), respectively. Hospital mortality was zero and postoperative surgical morbidity was 21%. 3.9% of the patients (6/154) had to be re-operated for bleeding, ilens and wound dehiscence. The median postoperative hospital stay was 11 days. 102 and 41 patients underwent pancreatic head and left (including segraemal) resections, respectively. The pancreatic fistula rate was 0% in pancreatic head resections versus 9.7% (4/41) in left resections (p<0.01). Conclusion: 1"his is a first series of more than 100 head resections without pancreatic fistula. By anastomosing the pancreas, pancreatic hstula after head resection can be safely avoided, as against the situation after pancreatic left resection where simple closure of the pancreatic stump still carries a significant t'Lstula risk.

M1970 Potential Utility of Selective Laparoscopy and Laparoscopic Ultrasound for Staging Periampullary Tumors Charles M Vollmer Jr., Elijah Dixon, Mark S. Cattral, David R Grant, Bryce R. Taylor, Steven Gallinger, Paul D Greig Background: Staging lapamscopy (SL), in combination with laparoscopic ultrasound (LUS), has been advocated for staging of periampufiary malignancies. Reported series suggest that SL can identity unresectability in up to 20% of potentially resectable lesions, and LUS can identify an additional 10-15%, improving resectibility rates to 85 - 90%. However, advances in preoperative imaging may render these techniques less valuable. This study analyses the potential utility of SL and LUS at a center where they have not been part of the staging algorithm. Methods: Over 17 months from July 2001 to Nov. 2002, 88 patients with potenuaLly resectab[e periampullary tumors underwent Laparotomy with curative intent. Preopetatwe staging consisted of a thin-slice helical, pancreatic protocal CT scan in 86~ and transabdominal US in 65. Unresectable cases were analysed to determine if SL or LUS would have identified unresectability Criteria for unresectahility were: For SL - liver metastases or peritoneal seeding, and for LUS - celiac or hepatic artery involvement, encasement of portal structures superior to the pancreas, or PV/SMV encasement. Results: Fifty-one patients underwent pancreaticoduodenectomy for an overall resectability rate of 58%. Thirty-seven cases (42%) were unresectable. Twelve cases (14%) had findings that would have been found by SL alone. In 16 cases (18%), LUS would likely have demonstrated unresectahility. In 9 cases SL and LUS would not have added value, most often due to tumor involvement of the SMA or mesocolon Overall the resectabifity rate would increase to 85% Most predicted benefit would have occurred for patients with pancreatic adenocarcinoma or choiangiocarcinoma (see table). Mean length of stay for unresected patients was 10.4 days, and 35% had a post-op complication. Conclusion: This analysis confirms the potential value of SL in con3unction with LUS, particularly in staging pancreatic adenocarcinoma and cholangiocarcinoma. The addition of laparoscopic assessment to current pre-operative imaging modalities for staging periampullary tumors may improve overall resectabifity rates to 85%.

M1973 Distal Pancreatectomy for Carcinoma of the Body and Tail of the Pancreas Yuichi Kitagawa, Jyuinchi Kamiya, Masato Nagino, Koji Oda, Norihiro Yuasa, Toshiyuki Arai, Hideki Nishio, Hideo Yamamoto, Naokazu Hayakawa, Yuji Nimura Background & Aim: tn pancreatic cancer, curative resection of the tumor is one of the most important prognostic factors. In some patients with carcinoma of the body and/or tail of the pancreas (PCBT), some major vessels (e.g. portal vein, celiac artery) and/or adjacent organs were resected with distal pancreatectomy (DP) for curative resection. The goal of our study was to examine a large number of PCBT patients to elucidate the relation between survival and combined resections including major vessels. Patients and Methods: In 187 resected patients with pancreatic cancer until 2002, 37 patients underwent distal pancreatectomy for PCBT, one had partial pancreatectomy for PCBT, 30 received total pancreatectomy for pancreatic cancer of the head or body and tail and 119 underwent pancreatoduodenectomy for cancer of the head. 37 patients with DP were investigated as the study subject. Each patient's demographic data, operative procedure, and pathological findings were retrospectively collected. Postoperative survival was calculated using Kaplan-Meier method, and survival curves were analyzed by Mantel-Cox test. P value less than 0.05 was considered as sigmficant. Results: Nineteen male and 18 female with age 62.8+~8.2 registered this study. All patients received DP, however, a patient received superior-dorsal pancreas head resection for coincidental adenomas. 10 patients received combined resection of adjacent organs (AO) (stomach, 7; colon, 6; adrenal gland, 2; renal vein, 2; kidney, 2; liver, 1 and diaphragm, 1), 9 underwent celiac and common hepatic artery resection (CH) and 7 had portal vein resection (PV). Pathological findings of the specimen showed invasive ductal carcinoma in 31 patients, mucinons carcinoma in 2, adenosquamous carcinoma in 2 and anaplastic carcinoma in 2. Twanty-seven patients without AO survived longer than 10 patients with AO (p=0.031). But, there was no difference between 30 patients without PV and 7 with PV (p=0.612). Also, there was no difference between 28 patients without CH and 9 with CH (p=0.708). Conclusion: Patients with portal vein resection or celiac and common hepatic artery resection survived as long as the patients without these procedures. These procedures are useful for curative resection of carcinoma of the body and/or tail of the pancreas. However, combined resection of adjacent organs should be re-considered.

Potential Rnectablllty Rates Disease

N

Pan CA Cho/mng/o Ampullary Ouodenal Other Total

44 12 16 8 8 88

ActuallyResectable 17/44(39%) 7/12 (58%) 15/16 (94%) 518(63%) 7/8 (88%) 51/88 (58%)

Ruled-outby Ruled.outby SL LUS 9 (21%) 12 {27%) 2 (17%) 3 (25%) 0 0 0 1 (13%) 1 (13%) 0 12 (14'/,) 16 (19~

PotentiallyResectable 17/23 (74*/,) 7/7 (f00%) 15/16(94%) 5/7 (71%) 7/7 (100%) 51/60 (85%)

M1971

Management of Severe Pancreatic Leakage After Pancreaticoduodenectomy: Salvage Pancreatectomy or Preserve the Remnant Steve M. M. De Castro, Kurt F. D. Kuhlmann, Olivier R C Busch. Thomas M. Van Gufik, Hugo Obertop, Dirk J. Gouma Background: Pancreatic leakage is one of the most leared complications after pancreaticoduodenectomy. Treatment modafities include percutaneous or surgical drainage for mild leakage and salvage pancreatectomy for severe leakage. Salvage pancreatectomy is an adequate therapy but results in severe pancreatic endocnne insufficiency. In order to prevent pancreatic endocnne insufficiency we decided to consecutively disconnect the anastomosis and preserve approximately 4 cm. of the remnant when confronted with pancreatic leakage (1997-2002). The aim of this study was to compare different treatments for severe pancreatic leakage and specifically to analyse whether or not preserving the remnant is beneficial compared with salvage pancreatectomy (1992-1996). Methods: Between 1992 and 2002, 400 patients underwent pancreaticoduodenectomy. Leakage was defined as amylase in abdominal drain > 3x serum amylase, leakage proven radiologically or findings at laparotomy suggestive for pancreatic leakage. Symptoms and diagnostic procedures were recorded. Results: Pancreatic leakage occurred in 36/400 patients (9%). Symptoms occurred 6 days after surgeD and consisted mostly of abdominal pain (83%) and dyspnoea (67%) while fever was seen in only 36% of

SSAT Abstracts

M1974 Gastric acidity following Pylorus-preserving Pancrnatieoduodenectomy: Pancreaticogastrostomy versus Pancreatieojejunostomy Hiroyuki Shinchi, Sonshin Takao, Kosei Maemura, Takashi Aikou Background: In general, pancreaticojejunnstomy (PJ) or pancreaticugastrostomy (PG) has been performed after Whipple resection or pylorus-preserving pancreaticoduodanectomy (PPPD). Although the physiologic alteration in the stomach is important for the correlation between gastric and pancreatic functions, the actual intragastric pH profile after PG or PJ is still unclear. This study was conducted to investigate the physiologic changes in gastric

A-822