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⁎4701 A randomized trial comparing a clinical pathway versus usual care for patients with non-low risk upper gastrointestinal hemorrhage.
*4699 MALIGNANT INTRADUCTAL PAPILLARY MUCINOUS TUMORS OF THE PANCREAS: PROGNOSTIC FACTORS AFTER SURGERY. F. Maire, P. Hammel, B. Terris, P. Rufat, F. Paye, C. Partensky, E. Cuillerier, M. Barthet, J. Sahel, P. Bernades, J. Belghiti, P. Ruszniewski, Hosp Beaujon, Clichy, France; Hosp E Herriot, Lyon, France; Hosp Laennec, Paris, France; Hosp Nord, Marseille, France; Hosp Sainte Marguerite, Marseille, France. Background: Prognosis of IPMT depends on the risk of malignant transformation. The aims of this study were to assess : (1) prognostic factors of malignant IPMT after curative resection, (2) long term survival as compared with patients with “usual” pancreatic adenocarcinoma. Methods: Seventy-three patients (49 men, 24 women, mean age 63 years) underwent surgery for malignant IPMT between 1987 and 1999. Clinical, biochemical, treatment and follow-up were reviewed. Histological data were analysed by one pathologist. Thereafter, 25 patients with invasive malignant IPMT were paired with 25 patients with “usual” pancreatic carcinoma with respect to age and TNM staging, in order to compare survival. Results: Surgical resection consisted of pancreaticoduodenectomy (n=46), distal (n=14), total (n=11) or segmentary (n=2) pancreatectomy. Operative mortality was 4%. Severe dysplasia was found in 22 patients and invasive carcinoma in 51. In patients with invasive carcinoma, lymph node metastasis and peripancreatic extension were present in 33% and 65%, respectively. Mean follow-up after surgery was 33 months. Median survival was 47 months. Three-year survival rates in patients with severe dyplasia and invasive carcinoma were 88% and 43%, respectively. Tumor relapse occurred in 28 patients; 5 patients underwent second tumor resection and 23 had palliative treatment. Postoperative survival was negatively influenced by abdominal pain, high serum CA 19.9 levels, caudal localization, invasive carcinoma, lymph node metastasis and peripancreatic extension. Using multivariate analysis, only lymph node metastasis were associated with an unfavorable prognosis (OR 7.5, p<0.0001). There was no significant difference in survival between patients with malignant IPMT or “usual” pancreatic carcinoma, according to TNM staging. Conclusions: IPMT with severe dysplasia or invasive localized carcinoma have a favorable prognosis. However, if peripancreatic extension is present, survival is similar to that of pancreatic carcinoma. These results suggest that patients undergoing resection for malignant IPMT with peripancreatic extension and/or lymph node metastasis should be enrolled in adjuvant protocols.
*4700 INTRADUCTAL TISSUE SAMPLING IN MUCIN-SECRETING AND CYSTIC TUMORS OF THE PANCREAS - A MULTICENTER SERIES. Benedict M. Devereaux, Kevin P. Block, Grace H. Elta, Douglas A. Howell, James Madura, Donato Ciaccia, Stuart Sherman, Cem Kalayci, Joseph E. Geenen, Marc F. Catalano, Indiana Univ Med Ctr, Indianapolis, IN; Univ of Wisconsin, Madison, WI; Univ of Michigan, Ann Arbor, MI; Portland Gastroenterology, Portland, ME; Marmara Univ Hosp, Istanbul, Turkey; 2901 W Kinnickinnic River Pkwy, #570, Milwaukee, WI. INTRODUCTION: Optimal management of patients with mucin secreting and cystic pancreatic neoplasms is dependent on the accurate detection of malignancy. AIM: This large multicenter series reports the cancer detection sensitivity of endoscopic pancreatic intraductal tissue and juice sampling techniques. METHODS: A series of 206 mucin-secreting or cystic tumors of the pancreas have been recorded by the Midwest Pancreaticobiliary Group. Of these, 92 patients underwent ERCP with tissue and/or juice sampling and have surgical pathology to confirm the final diagnosis. The sampling technique was at the discretion of the endoscopist. Specimens were reported as benign or malignant and for the purposes of this analysis, all grades of cellular atypia were classified as benign. RESULTS: See table. All 38 benign lesions had at least 1 benign and no malignant tissue specimens. Twelve of the 54 (22%) malignant lesions had at least one positive specimen. SUMMARY: The sensitivity of multiple tissue sampling techniques in detecting malignant mucin secreting or cystic pancreatic tumors was only 22%. All benign pancreatic lesions sampled had benign tissue specimens. CONCLUSIONS: Improved endoscopic tissue sampling techniques are required in order to classify mucin secreting and cystic lesions of the pancreas as either benign or malignant. **And Members of the Midwest Pancreatobiliary Group.
VOLUME 51, NO. 4, PART 2, 2000
Benign Lesions* Malignant Lesions* Intraductal Papillary Intraductal Papillary Mucinous Tumor; Mucinous Tumor; Serous Mucinous Cystadenoma Cystadenocarcinoma Number of patients Juice aspirate cytology Brush cytology Forceps biopsy histology FNA cytology
38 0/18 0/19 0/8 0/12
54 5/31 6/35 3/14 5/12
*Fraction of specimens taken showing malignant cells.
*4701 A RANDOMIZED TRIAL COMPARING A CLINICAL PATHWAY VERSUS USUAL CARE FOR PATIENTS WITH NON-LOW RISK UPPER GASTROINTESTINAL HEMORRHAGE. James R. Dyer, Glenn L. Alexander, Giles R. Locke, Rita K. Balm, Mayo Clin, Rochester, MN. Background: Clinical pathways for the treatment of upper gastrointestinal hemorrhage (UGIH) have been proposed to standardize care and reduce hospital length of stay (LOS). Previous retrospective studies have shown UGIH treatment pathways to safely decrease LOS in low-risk patients to 2-3 days. Prior to this study, median LOS at our hospital for non-low risk (NLR) UGIH patients was 5 days. Aims: 1) To assess if a clinical pathway decreases LOS in patients with NLR UGIH. 2) To compare rates of adverse outcomes between pathway and usual care in NLR patients with UGIH. Methods: 54 patients with signs of UGIH were assessed in the emergency room and designated as NLR by clinical and/or endoscopic criteria and admitted to either a medical floor (28) or ICU (26). Patients were then randomized to receive either usual care or pathway care consisting of a standardized orders set to assess stability and expedite discharge. Adverse outcomes (exacerbation of comorbid conditions, rebleeding, need for surgery, death), transfusion requirement and LOS were compared between groups. Phone interviews were conducted 7 and 30 days after discharge. Results: Both groups were similar with respect to age, sex, comorbidities, initial hemoglobin, cause of bleeding, high risk stigmata, and endoscopic therapy. Outcomes were similar between groups (Table). All adverse outcomes were secondary to rebleeding. Only 1 of 54 patients developed an adverse event from 3-14 days from time of admission. Conclusion: 1) LOS of pathway and usual care groups were similar but decreased as compared to pre-pathway care. 2) Adverse outcomes were comparable between groups and uncommon after 48 hours of admission.
Outcome Exacerbation of comorbid condition Rebleeding Surgery required Death Transfusions (pRBC) (median, range) Length of stay (median, range)
Pathway (n=26)
Usual Care (n=28)
P-value
0 5 2 1
0 5 2 0
NS NS NS NS
2, 0-16
1.5, 0-10
NS
2, 1-16
2, 1-11
NS
GASTROINTESTINAL ENDOSCOPY
AB207
*4700 INTRADUCTAL TISSUE SAMPLING IN MUCIN-SECRETING AND CYSTIC TUMORS OF THE PANCREAS - A MULTICENTER SERIES. Benedict M. Devereaux, Kevin P. Block, Grace H. Elta, Douglas A. Howell, James Madura, Donato Ciaccia, Stuart Sherman, Cem Kalayci, Joseph E. Geenen, Marc F. Catalano, Indiana Univ Med Ctr, Indianapolis, IN; Univ of Wisconsin, Madison, WI; Univ of Michigan, Ann Arbor, MI; Portland Gastroenterology, Portland, ME; Marmara Univ Hosp, Istanbul, Turkey; 2901 W Kinnickinnic River Pkwy, #570, Milwaukee, WI. INTRODUCTION: Optimal management of patients with mucin secreting and cystic pancreatic neoplasms is dependent on the accurate detection of malignancy. AIM: This large multicenter series reports the cancer detection sensitivity of endoscopic pancreatic intraductal tissue and juice sampling techniques. METHODS: A series of 206 mucin-secreting or cystic tumors of the pancreas have been recorded by the Midwest Pancreaticobiliary Group. Of these, 92 patients underwent ERCP with tissue and/or juice sampling and have surgical pathology to confirm the final diagnosis. The sampling technique was at the discretion of the endoscopist. Specimens were reported as benign or malignant and for the purposes of this analysis, all grades of cellular atypia were classified as benign. RESULTS: See table. All 38 benign lesions had at least 1 benign and no malignant tissue specimens. Twelve of the 54 (22%) malignant lesions had at least one positive specimen. SUMMARY: The sensitivity of multiple tissue sampling techniques in detecting malignant mucin secreting or cystic pancreatic tumors was only 22%. All benign pancreatic lesions sampled had benign tissue specimens. CONCLUSIONS: Improved endoscopic tissue sampling techniques are required in order to classify mucin secreting and cystic lesions of the pancreas as either benign or malignant. **And Members of the Midwest Pancreatobiliary Group.
VOLUME 51, NO. 4, PART 2, 2000
Benign Lesions* Malignant Lesions* Intraductal Papillary Intraductal Papillary Mucinous Tumor; Mucinous Tumor; Serous Mucinous Cystadenoma Cystadenocarcinoma Number of patients Juice aspirate cytology Brush cytology Forceps biopsy histology FNA cytology
38 0/18 0/19 0/8 0/12
54 5/31 6/35 3/14 5/12
*Fraction of specimens taken showing malignant cells.
*4701 A RANDOMIZED TRIAL COMPARING A CLINICAL PATHWAY VERSUS USUAL CARE FOR PATIENTS WITH NON-LOW RISK UPPER GASTROINTESTINAL HEMORRHAGE. James R. Dyer, Glenn L. Alexander, Giles R. Locke, Rita K. Balm, Mayo Clin, Rochester, MN. Background: Clinical pathways for the treatment of upper gastrointestinal hemorrhage (UGIH) have been proposed to standardize care and reduce hospital length of stay (LOS). Previous retrospective studies have shown UGIH treatment pathways to safely decrease LOS in low-risk patients to 2-3 days. Prior to this study, median LOS at our hospital for non-low risk (NLR) UGIH patients was 5 days. Aims: 1) To assess if a clinical pathway decreases LOS in patients with NLR UGIH. 2) To compare rates of adverse outcomes between pathway and usual care in NLR patients with UGIH. Methods: 54 patients with signs of UGIH were assessed in the emergency room and designated as NLR by clinical and/or endoscopic criteria and admitted to either a medical floor (28) or ICU (26). Patients were then randomized to receive either usual care or pathway care consisting of a standardized orders set to assess stability and expedite discharge. Adverse outcomes (exacerbation of comorbid conditions, rebleeding, need for surgery, death), transfusion requirement and LOS were compared between groups. Phone interviews were conducted 7 and 30 days after discharge. Results: Both groups were similar with respect to age, sex, comorbidities, initial hemoglobin, cause of bleeding, high risk stigmata, and endoscopic therapy. Outcomes were similar between groups (Table). All adverse outcomes were secondary to rebleeding. Only 1 of 54 patients developed an adverse event from 3-14 days from time of admission. Conclusion: 1) LOS of pathway and usual care groups were similar but decreased as compared to pre-pathway care. 2) Adverse outcomes were comparable between groups and uncommon after 48 hours of admission.
Outcome Exacerbation of comorbid condition Rebleeding Surgery required Death Transfusions (pRBC) (median, range) Length of stay (median, range)
Pathway (n=26)
Usual Care (n=28)
P-value
0 5 2 1
0 5 2 0
NS NS NS NS
2, 0-16
1.5, 0-10
NS
2, 1-16
2, 1-11
NS
GASTROINTESTINAL ENDOSCOPY
AB207