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Staging laparoscopy for pancreatic cancer should be used to select the best palliation, not to increase resection rate
April 1998
SSAT A1407
identified in a prospective database. Only those patients undergoing hepatic lobectomy were analyzed in this study to allow comparison of data in groups undergoing equivalent volume liver resection. Patients previously treated with chemotherapy (n=60) were compared to those never treated (n=32). Liver parenchymal abnormality (Abnorm Path: fatty or fibrosis) and clinical outcomes (perioperative complication and mortality) were compared (Fisher's Exact). Length of hospital stay (LOS), and post-operative liver function including peak bilirubin (Peak Bili), and minimum albumin (Min Alb) were compared (student's t test). Parameter % Abnorm path Peak Bill (mg/dl) Min Alb (g/dl) LOS (days) % Complication % Mortality
No Chemo (n = 32) 28% 2.9 -+ 0.7 2.68 ± 0.07 10.1 + 0.8 46% 6%
Chemo (n = 60) 47% 3.3 -+0.6 2.77 ± 0.04 11.0 ± 0.8 36% 5%
p 0.04 NS NS NS NS NS
Prior exposure to chemotherapy is more commonly associated with liver parenchymal abnormalities. This does not translate into any difference in post-operative liver function, or clinical outcome. Major liver resection is not only potentially curative therapy but is also safe after prior administration of chemotherapy for metastatic colorectal cancer. • S0147 INTRA-OPERATIVE BILIARY MANOMETRY IN THE EVALUATION OF CHRONIC ACALCULOUS CHOLECYSTITIS. Scott W. Luca~ aod Maurice E. Arregui~ St. Vincent Hospital and Health Center. Indianapolis, IN. We performed trans-cystic biliary manometry in patients undergoing laparoscopic cholecystectomy (LC) for chronic acalculous cholecystitis (CAC) to assess the role of sphincter of Oddi dysfunction (SOD) in this disease. Sixty patients diagnosed with CAC agreed to trans-cystic biliary manometry at the time of LC. A perfused triple-lumen catheter was used with a pull-through technique. Abnormal manometry was defined as sustained pressure greater than 40 mm Hg, >8 contractions per minute, high amplitude peak pressures, or >50% retrograde contractions. Operative and pathologic findings were noted, and follow-up was through office visits and telephone contacts. Manometry was successfully completed in 44 of 60 patients. Fifty-two percent of patients had abnormal studies, and 48% were normal. Manometry was unsuccessful in 36% due to technical problems. At an average of 13.2 months follow-up (range 1-38), 50% were asymptomatic and 42% had improvement, while 8% had no improvement. Of those with abnormal manometry, 27% were asymptomatic and 59% improved, and 4% had no change. In the group with normal studies 71% were asymptomatic, 19% improved, and 10% had no improvement. The difference in outcome between these groups was significantly different (p<0.005). In patients in whom manometry was not completed, 50% were asymptomatic, 38% improved, and 13% were unchanged. Biliary manometry is abnormal in a high percentage of patients with CAC, implicating SOD as a frequent etiologic factor. Patients with normal SO manometry are more likely to have complete resolution of symptoms than those with abnormal studies. S0148 ACCURACY OF CANCER REPORTING BY RELATIVES IN INHERITED COLON CANCER REGISTRY. M.A. Luchtefeld. A.J.Senag0re, and L.S. Smith. West Michigan Hereditary Cancer Prevention Network, Blodgett Hospital, Grand Rapids, Michigan.
INTRODUCTION: Constructing an accurate pedigree is essential for making decisions regarding potential genetic testing for patients who may be part of a family with an inherited colorectal cancer syndrome. In the United States, confirming the accuracy of information provided by family members concerning cancers in relatives can be difficult or impossible due to privacy laws. The purpose of this study was to determine the accuracy of reported cancers in an inherited colorectal cancer registry. METHODS: The study population consisted of 31 families suspected of having hereditary nonpolyposis colon cancer (HNPCC) in a recently formed inherited colorectal cancer registry. The data collected included: site and number of HNPCCassociated cancers reported by family members; number of reported cancers that could be confirmed by medical records, pathology reports, or death certificate; accuracy of reporting of cancers by family members; relationship and number of family members reporting cancers in a relative. RESULTS: We were able to confirm 93 of 271 cancers reported at various sites, A total of 94 colorectal cancers were reported and 43 (45.7%) could be confirmed. The colorectal cancers were reported accurately in 39 of the 43 cancers (90.7%). HNPCC-associated cancers were confirmed in 50/120(41.6%). Overall, 45 of 50 (90%) of patients with HNPCC-associated cancers that were confirmed were found to be accurately reported by family members. When evaluating all cancers, first-degree and second-degree relatives were both 82% accurate when reporting cancers in family members. When multiple relatives reported a family member as having a cancer, this report was accurate 87.5% (28/32) compared to an accuracy of 73.8% (45/61) when having a single relative report this cancer. CONCLUSIONS: When family members report colorectal
cancers and HNPCC-associated cancers in relatives, the accuracy is high. The reports are more reliable if more than a single relative reports the cancer and second-degree relatives are as accurate as first-degree relatives when reporting cancer in a family member. • S0149 STAGING LAPAROSCOPY FOR PANCREATIC CANCER SHOULD BE USED TO SELECT THE BEST PALLIATION, NOT TO INCREASE RESECTION RATE. E Luque-de Le6n, GG Tsiotos, BM Balsiger. J Barnwell. L Bureart. MG Sarr. Dept of Surg, Mayo Clinic, Rochester, MN.
Preoperative laparoscopy has been suggested as an appropriate staging procedure based on the assumption that non-operative biliary stenting is the best palliation and will save an "unnecessary" laparotomy in pts with incurable pancreatic cancer. HYPOTHESIS: Patients with clinically resectable cancer of the pancreatic head found to be unresectable only at operation, have different survivals depending on cause of unresectability; optimal palliation (stent vs operative biliary bypass/gastroenterostomy) may differ accordingly. AIM: To determine survival of such pts and infer appropriate use and extent of staging laparoscopy. METHODS: We reviewed charts of 150 consecutive pts with pancreatic head cancer (1985-92). Followup was complete in 148 (99%). All underwent exploration for potential resection (ie good risk pts with clinically resectable lesion based on current imaging techniques), but were unresectable intraoperatively because of I) liver mets (29), II) peritoneal mets (22), III) nodal mets (44) or IV) venous or arterial invasion (53). When more than one site was present, pts were included in the group of more advanced disease. Results: 99 men and 49 women (mean age 65 yr; range: 32-90) had a median survival of 9 months (range: 1-53). Survival by group was I) 6 months with liver mets (range: 1-34), II) 7 months with peritoneal mets (range: 2-36), III) 11 months with distant nodal mets (range: 1-53) and IV) 11 months with vascular involvement (3-30); differences were significant (ANOVA, p<0.001). Survival (corrected Mann-Whitman U-tests) was longer for pts with distant nodal mets or with vascular involvement than those with liver or peritoneal mets (each p<0.03). SUMMARY: Patients with clinically resectable pancreatic head cancer found unresectable at laparotomy, live significantly longer if unresectability is 2° to distant nodal or vascular involvement compared to peritoneal or liver mets. CONCLUSIONS: Staging laparoscopy should aim at identifying pts with liver or peritoneal mets to avoid laparotomy because their expected survival is short (-6 months); short-term endoscopic palliation in this group is satisfactory. Extended laparoscopy to identify nodal or vascular involvement (longer expected survival) is contingent upon which palliative measure (operative vs endoscopic) is considered most appropriate. We avoid extended laparoscopy because we believe operative bypass provides a better, more durable palliation in this specific group of pts (less recurrent jaundice, prevents duodenal obstruction). S0150 LAPAROSCOPIC CHOLECYSTECTOMY: WHAT DOES AFFECT THE OUTCOME? A RETROSPECTIVE MULTIFACTORIAL REGRESSION ANALYSIS. S. Lvass. Y. Perry, M. Ventorero, M. MuggiaSullam. A. Durst, P. Reissman, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
Although laparoscopic cholecystectomy (LC) has become the gold standard procedure for gallstone treatment, the association between various factors and the postoperative outcome has not been thoroughly studied. To date only few reports analyzed the impact of length of procedure on morbidity and length of stay with conflicting results. The aim of this retrospective study was to determine which factors significantly affect patients outcome after LC. Materials and Methods: The medical and operative records of all consecutive patients who underwent LC in our institution from 1991 to 1996 were reviewed. Age, past medical and surgical history, duration of procedure, setup (urgent or elective) and intraoperarive complications, were recorded for each patient. The effect of each parameter on the postoperative complication rate and on the length of postoperative hospital stay (LOS) were analyzed using multiple linear regression and logistic regression analysis. Overall 601 patients were included in the study (158 male, 443 female) with a mean age of 46.6 years (range 17-99). Procedures were performed by attending surgeons and residents. Results: The mean duration of LC was 129 -+ 56 min. (30 - 450 rain.). The median LOS was 2 days (1-24). The factors, which significantly prolonged LOS were age (p=0.0145), acute cholecystitis (p=0.0006), history of ischemic heart disease (IHD) (p=0.0332) and duration of procedure (p<0.0001). A significantly higher postoperative morbidity rate was noted in patients who had a procedure longer then 2 hours compared with patients, who were operated in less the 2 hours (13.6% vs. 3.6% respectively, p<0.0001). Similarly, higher morbidity was noted in aged patients (over 60), compared with younger patients (16% vs. 6.1%, p=0.0005). Other factors which significantly increased postoperative morbidity included: acute cholecystitis (p=0.023), the history of cholangitis (p=0.018) and diabetes (p=0.05). Conclusions: According to this study, advanced age, longer duration of procedure and acute cholecystitis significantly increase both the postoperative morbidity and the LOS. History of IHD significantly increases LOS, but does not increase morbidity after LC.
SSAT A1407
identified in a prospective database. Only those patients undergoing hepatic lobectomy were analyzed in this study to allow comparison of data in groups undergoing equivalent volume liver resection. Patients previously treated with chemotherapy (n=60) were compared to those never treated (n=32). Liver parenchymal abnormality (Abnorm Path: fatty or fibrosis) and clinical outcomes (perioperative complication and mortality) were compared (Fisher's Exact). Length of hospital stay (LOS), and post-operative liver function including peak bilirubin (Peak Bili), and minimum albumin (Min Alb) were compared (student's t test). Parameter % Abnorm path Peak Bill (mg/dl) Min Alb (g/dl) LOS (days) % Complication % Mortality
No Chemo (n = 32) 28% 2.9 -+ 0.7 2.68 ± 0.07 10.1 + 0.8 46% 6%
Chemo (n = 60) 47% 3.3 -+0.6 2.77 ± 0.04 11.0 ± 0.8 36% 5%
p 0.04 NS NS NS NS NS
Prior exposure to chemotherapy is more commonly associated with liver parenchymal abnormalities. This does not translate into any difference in post-operative liver function, or clinical outcome. Major liver resection is not only potentially curative therapy but is also safe after prior administration of chemotherapy for metastatic colorectal cancer. • S0147 INTRA-OPERATIVE BILIARY MANOMETRY IN THE EVALUATION OF CHRONIC ACALCULOUS CHOLECYSTITIS. Scott W. Luca~ aod Maurice E. Arregui~ St. Vincent Hospital and Health Center. Indianapolis, IN. We performed trans-cystic biliary manometry in patients undergoing laparoscopic cholecystectomy (LC) for chronic acalculous cholecystitis (CAC) to assess the role of sphincter of Oddi dysfunction (SOD) in this disease. Sixty patients diagnosed with CAC agreed to trans-cystic biliary manometry at the time of LC. A perfused triple-lumen catheter was used with a pull-through technique. Abnormal manometry was defined as sustained pressure greater than 40 mm Hg, >8 contractions per minute, high amplitude peak pressures, or >50% retrograde contractions. Operative and pathologic findings were noted, and follow-up was through office visits and telephone contacts. Manometry was successfully completed in 44 of 60 patients. Fifty-two percent of patients had abnormal studies, and 48% were normal. Manometry was unsuccessful in 36% due to technical problems. At an average of 13.2 months follow-up (range 1-38), 50% were asymptomatic and 42% had improvement, while 8% had no improvement. Of those with abnormal manometry, 27% were asymptomatic and 59% improved, and 4% had no change. In the group with normal studies 71% were asymptomatic, 19% improved, and 10% had no improvement. The difference in outcome between these groups was significantly different (p<0.005). In patients in whom manometry was not completed, 50% were asymptomatic, 38% improved, and 13% were unchanged. Biliary manometry is abnormal in a high percentage of patients with CAC, implicating SOD as a frequent etiologic factor. Patients with normal SO manometry are more likely to have complete resolution of symptoms than those with abnormal studies. S0148 ACCURACY OF CANCER REPORTING BY RELATIVES IN INHERITED COLON CANCER REGISTRY. M.A. Luchtefeld. A.J.Senag0re, and L.S. Smith. West Michigan Hereditary Cancer Prevention Network, Blodgett Hospital, Grand Rapids, Michigan.
INTRODUCTION: Constructing an accurate pedigree is essential for making decisions regarding potential genetic testing for patients who may be part of a family with an inherited colorectal cancer syndrome. In the United States, confirming the accuracy of information provided by family members concerning cancers in relatives can be difficult or impossible due to privacy laws. The purpose of this study was to determine the accuracy of reported cancers in an inherited colorectal cancer registry. METHODS: The study population consisted of 31 families suspected of having hereditary nonpolyposis colon cancer (HNPCC) in a recently formed inherited colorectal cancer registry. The data collected included: site and number of HNPCCassociated cancers reported by family members; number of reported cancers that could be confirmed by medical records, pathology reports, or death certificate; accuracy of reporting of cancers by family members; relationship and number of family members reporting cancers in a relative. RESULTS: We were able to confirm 93 of 271 cancers reported at various sites, A total of 94 colorectal cancers were reported and 43 (45.7%) could be confirmed. The colorectal cancers were reported accurately in 39 of the 43 cancers (90.7%). HNPCC-associated cancers were confirmed in 50/120(41.6%). Overall, 45 of 50 (90%) of patients with HNPCC-associated cancers that were confirmed were found to be accurately reported by family members. When evaluating all cancers, first-degree and second-degree relatives were both 82% accurate when reporting cancers in family members. When multiple relatives reported a family member as having a cancer, this report was accurate 87.5% (28/32) compared to an accuracy of 73.8% (45/61) when having a single relative report this cancer. CONCLUSIONS: When family members report colorectal
cancers and HNPCC-associated cancers in relatives, the accuracy is high. The reports are more reliable if more than a single relative reports the cancer and second-degree relatives are as accurate as first-degree relatives when reporting cancer in a family member. • S0149 STAGING LAPAROSCOPY FOR PANCREATIC CANCER SHOULD BE USED TO SELECT THE BEST PALLIATION, NOT TO INCREASE RESECTION RATE. E Luque-de Le6n, GG Tsiotos, BM Balsiger. J Barnwell. L Bureart. MG Sarr. Dept of Surg, Mayo Clinic, Rochester, MN.
Preoperative laparoscopy has been suggested as an appropriate staging procedure based on the assumption that non-operative biliary stenting is the best palliation and will save an "unnecessary" laparotomy in pts with incurable pancreatic cancer. HYPOTHESIS: Patients with clinically resectable cancer of the pancreatic head found to be unresectable only at operation, have different survivals depending on cause of unresectability; optimal palliation (stent vs operative biliary bypass/gastroenterostomy) may differ accordingly. AIM: To determine survival of such pts and infer appropriate use and extent of staging laparoscopy. METHODS: We reviewed charts of 150 consecutive pts with pancreatic head cancer (1985-92). Followup was complete in 148 (99%). All underwent exploration for potential resection (ie good risk pts with clinically resectable lesion based on current imaging techniques), but were unresectable intraoperatively because of I) liver mets (29), II) peritoneal mets (22), III) nodal mets (44) or IV) venous or arterial invasion (53). When more than one site was present, pts were included in the group of more advanced disease. Results: 99 men and 49 women (mean age 65 yr; range: 32-90) had a median survival of 9 months (range: 1-53). Survival by group was I) 6 months with liver mets (range: 1-34), II) 7 months with peritoneal mets (range: 2-36), III) 11 months with distant nodal mets (range: 1-53) and IV) 11 months with vascular involvement (3-30); differences were significant (ANOVA, p<0.001). Survival (corrected Mann-Whitman U-tests) was longer for pts with distant nodal mets or with vascular involvement than those with liver or peritoneal mets (each p<0.03). SUMMARY: Patients with clinically resectable pancreatic head cancer found unresectable at laparotomy, live significantly longer if unresectability is 2° to distant nodal or vascular involvement compared to peritoneal or liver mets. CONCLUSIONS: Staging laparoscopy should aim at identifying pts with liver or peritoneal mets to avoid laparotomy because their expected survival is short (-6 months); short-term endoscopic palliation in this group is satisfactory. Extended laparoscopy to identify nodal or vascular involvement (longer expected survival) is contingent upon which palliative measure (operative vs endoscopic) is considered most appropriate. We avoid extended laparoscopy because we believe operative bypass provides a better, more durable palliation in this specific group of pts (less recurrent jaundice, prevents duodenal obstruction). S0150 LAPAROSCOPIC CHOLECYSTECTOMY: WHAT DOES AFFECT THE OUTCOME? A RETROSPECTIVE MULTIFACTORIAL REGRESSION ANALYSIS. S. Lvass. Y. Perry, M. Ventorero, M. MuggiaSullam. A. Durst, P. Reissman, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
Although laparoscopic cholecystectomy (LC) has become the gold standard procedure for gallstone treatment, the association between various factors and the postoperative outcome has not been thoroughly studied. To date only few reports analyzed the impact of length of procedure on morbidity and length of stay with conflicting results. The aim of this retrospective study was to determine which factors significantly affect patients outcome after LC. Materials and Methods: The medical and operative records of all consecutive patients who underwent LC in our institution from 1991 to 1996 were reviewed. Age, past medical and surgical history, duration of procedure, setup (urgent or elective) and intraoperarive complications, were recorded for each patient. The effect of each parameter on the postoperative complication rate and on the length of postoperative hospital stay (LOS) were analyzed using multiple linear regression and logistic regression analysis. Overall 601 patients were included in the study (158 male, 443 female) with a mean age of 46.6 years (range 17-99). Procedures were performed by attending surgeons and residents. Results: The mean duration of LC was 129 -+ 56 min. (30 - 450 rain.). The median LOS was 2 days (1-24). The factors, which significantly prolonged LOS were age (p=0.0145), acute cholecystitis (p=0.0006), history of ischemic heart disease (IHD) (p=0.0332) and duration of procedure (p<0.0001). A significantly higher postoperative morbidity rate was noted in patients who had a procedure longer then 2 hours compared with patients, who were operated in less the 2 hours (13.6% vs. 3.6% respectively, p<0.0001). Similarly, higher morbidity was noted in aged patients (over 60), compared with younger patients (16% vs. 6.1%, p=0.0005). Other factors which significantly increased postoperative morbidity included: acute cholecystitis (p=0.023), the history of cholangitis (p=0.018) and diabetes (p=0.05). Conclusions: According to this study, advanced age, longer duration of procedure and acute cholecystitis significantly increase both the postoperative morbidity and the LOS. History of IHD significantly increases LOS, but does not increase morbidity after LC.