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866 Case Matched Comparison of Robotic Versus Laparoscopic Proctectomy for Inflammatory Bowel Disease
864
01/2010 and 06/2014, patients who had robotic proctectomy for IBD were identified and case matched (1:1) with laparoscopic counterparts based on age, ASA score, diagnosis and type of procedure. Data were obtained from an IRB-approved, prospectively maintained institutional database. Results: 21 patients undergoing RP fulfilled the study criteria and were matched with equal number of patients who had laparoscopic proctectomy (LP). Mean postoperative follow-up was 27.2 months. RP was associated with longer operating time (304 vs. 213 mins, p=0.01) and increased estimated blood loss (360 vs. 188, p= 0.002). The groups were comparable with respect to conversion rates (3 vs 4, p=>0.99). Time to first bowel movement (2 vs. 3, p=0.62), length of hospital stay (8 vs. 9, p=0.39), postoperative complications, IPAA related outcomes, Cleveland Clinic Global Quality of Life and SF-12 health survey outcomes (p>0.05) were similar between the two groups (table). Conclusion: RP can safely be performed in IBD patients without worsening the postoperative complications and functional outcomes compared to laparoscopic surgery. Patient demographics and results
A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy With Major Vascular Resection in Pancreatic Cancer: Major Vascular Resection Is Associated With Severe Adverse Postoperative Outcome and Early Recurrence Olga Kantor, Mark Talamonti, Susan J. Stocker, Chi Wang, David J. Winchester, Richard A. Prinz, Marshall Baker Introduction: Recent multi-center retrospective studies in pancreatic cancer (PDAC) report disease specific survival following pancreaticoduodenectomy with major vascular resection (PDVR) to be superior to that for palliative bypass and comparable to that for pancreaticoduodenectomy not requiring vascular resection (PD). These studies have not graded perioperative complications and provide incomplete assessments of the value of PDVR. Methods: We queried our institutional database identifying 24 patients undergoing PDVR for PDAC between 2007 and 2013. Propensity score matching was used to match this cohort (3:1) by age, gender and tumor stage to 72 patients undergoing PD in the same period. Charts were reviewed for all complications and 90-day readmissions. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse postoperative outcomes (SAPO). Grade I, II and IIIa complications requiring more than one interventional procedure or overall lengths of stay (LOS) including readmissions >3 standard deviations beyond the mean for patients without complications were also classified as SAPO. All others were considered minor adverse outcomes. Results: There were no statistical differences in demographics, comorbid disease, preoperative albumin, rates of R0 resection, use of neoadjuvant chemotherapy (NAC), or incidence of recurrent PDAC between groups. Patients undergoing PDVR were more likely to have had antrectomy (75.0 vs 36.1%, p=0.001), had higher intraoperative blood loss (1.3±1.1 vs 0.45±0.3L; p<0.001) and longer operative times (7.5±1.6 vs 5.8±1.1 hrs; p<0.001) than those undergoing PD. PDVR patients were more likely to require readmission (41.7 vs 15.3%, p=0.01), demonstrated longer LOS (22.2±15.8 vs 13.5±8.8 days, p= 0.008), were more likely to have a SAPO (66.7 vs 19.4%, p<0.001) and to miss adjuvant chemotherapy (33.3 vs 4.2%, p=0.001). Disease free and overall survival intervals were shorter in the PDVR group (9.2±8.1 vs 18.9±17.1 mo nt hs an d 1 2. 3± 10 .7 vs 24.2±17.7months; p≤0.002). Multivariate logistic regression adjusted for age, comorbidities, hypoalbuminemia, NAC, tumor size and PDVR identified age ≥70 years (OR 3.62 [1.04,12.67]) and PDVR (OR 11.18 [2.98,41.89]) as independent predictors of SAPO. Coxregression also adjusting for SAPO identified PDVR (HR 2.11 [1.12,3.98]) and tumor size ≥3cm (HR 2.37 [1.48,3.81]) as independent predictors of long term overall mortality. Conclusions: PDVR results in a higher severity complication profile than that seen for PD. Patients requiring PDVR for PDAC are less likely to receive adjuvant chemotherapy and demonstrate earlier disease recurrence than those undergoing PD. Well powered trials carefully evaluating perioperative complications and long term outcomes are required to determine the true value of PDVR for patients with resectable and borderline resectable PDAC. 865
Introduction: Several studies have confirmed the safety of pancreatoduodenectomy with portomesenteric vein resection and reconstruction in select patients. The effect of portal vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portomesenteric vein and long-term survival. Methods: A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000-2014) was performed.Survival was compared with Kaplan-Meier method and log-rank test. P<0.05 was considered statistically significant. Results: After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal vein were excluded, there were 567 eligible patients. Of these, segmental portal vein resection was performed in 90 (16%) with endto-end primary anastomosis in (67) or graft reconstruction (23). Histopathology of patients undergoing portal vein resection revealed a higher rate of perineural invasion (87% vs.74%, p=0.03). Portal vein resection, however, was not associated with differences in hospital stay, postoperative complications or operative mortality. Patients with portal vein resection showed no difference in recurrence rate and comparable overall, and 1-, 3- and 5-year survival rates. On final surgical histopathology, only 53 of 90 (59%) portal vein resections had adenocarcinoma involvement of the venous wall. Of these, invasion extent was at the level of adventitia (9), media/intima (31) and full thickness/intraluminal (10). Venous wall invasion (53) was associated with higher local recurrence but did not significantly influence overall survival (14 vs. 21 months, p=0.08). The extent of invasion did not impact recurrence, site of recurrence, or overall survival (p=0.08, 0.32, 0.58 and 0.5, respectively). Portal vein resection, histopathologic invasion or the extent of invasion were not independent predictors of overall survival in Cox regression analysis. Conclusion: Portal vein resection is technically safe in select patients. Portomesenteric venous resection is not prognostic of overall survival. Direct tumor invasion into the portal vein wall on final surgical histopathology is associated with a higher rate of local recurrence, but did not affect overall survival even when stratified according to extent of venous wall invasion.
BMI: Body Mass Index; ASA: American Society of Anesthesiologists; CD: Crohn's Disease; UC: Ulcerative Colitis; TPC: Total Proctocolectomy; CP: Completion Proctectomy;TNF: Tumor Necrosis Factors: SSI: Surgical Site Infection; DVT: Deep Vein Thrombosis; CGQOL: Cleveland Global Quality Of Life; PCS: Physical Component Summary; MCS: Mental Component Summary. 867 Effect of BMI on Short-Term Outcomes With Robotic-Assisted Laparoscopic Surgery: A Case-Matched Study Nisreen Madhoun, Deborah Keller, Jean-Paul J. LeFave, Madhu Ragupathi, Juan R. Flores, Sergio Ibarra, Eric M. Haas Background: Many benefits of minimally invasive surgery are lost in the obese. Obese patients are reported more likely to experience complications, longer operating times, higher conversion rates, and longer lengths of stay. Robotic Assisted Laparoscopic Surgery (RALS) may offer specific benefits in this population, as technical issues seen in other platforms may not be pertinent. Our goal was compare outcomes for RALS in obese and non-obese patients. Methods: Review of a prospective database was performed to identify patients undergoing an elective colorectal resection using a robotic assisted laparoscopic approach. Patients were stratified into obese (BMI>30 kg/m2) and non-obese cohorts (BMI<30 kg/m2). Patients were then matched on surgeon, age, gender, comorbidity, diagnosis, and procedure performed to compare groups. Demographic, perioperative, and postoperative outcome data were evaluated. The main outcome measures were the operative time, conversion rate, length of stay, and complication, readmission, and reoperation rates. Results: Forty-five patients were evaluated in each cohort. The BMI was significantly different across groups (p<.01). All other demographic parameters were well matched. The primary diagnosis was diverticulitis (40.0%) and procedure performed an anterior rectosigmoidectomy (48.9%) in both groups (p=1.00). There were no significant differences in operative time (p=0.864), blood loss (p= 0.375), intraoperative complications (p=0.54), or conversion rates (p-0.91) across the obese and non-obese cohorts. The length of stay was comparable between groups (p=0.449). Postoperatively, the complication (p=0.87), readmission (p=1.00), and reoperation rates (p= 0. 0.95) were for the obese and non-obese. There were no mortalities in either group. For malignant cases (37.8%), the lymph node yield (p=0.480) and positive margins (p=1.00) were similar and acceptable in both cohorts. Conclusions: Minimally invasive surgery has been reported as technically challenging and associated with inferior outcomes in obese
866 Case Matched Comparison of Robotic Versus Laparoscopic Proctectomy for Inflammatory Bowel Disease Ahmet Rencuzogullari, Emre Gorgun, Meagan Costedio, Erman Aytac, Hermann Kessler, Maher Abbas, Feza H. Remzi Purpose: The utilization of robotic proctectomy (RP) for rectal cancer has recently gained popularity. Role of robotic surgery in patients with inflammatory bowel disease (IBD) remains unclear. The present study assesses peri- and postoperative results including ileal pouchanal anastomosis (IPAA) outcomes in patients undergoing RP for IBD. Methods: Between
S-1121
SSAT Abstracts
SSAT Abstracts
Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma Alexandra M. Roch, Michael G. House, Jessica Cioffi, Eugene P. Ceppa, Nicholas J. Zyromski, Attila Nakeeb, C. Max Schmidt
01/2010 and 06/2014, patients who had robotic proctectomy for IBD were identified and case matched (1:1) with laparoscopic counterparts based on age, ASA score, diagnosis and type of procedure. Data were obtained from an IRB-approved, prospectively maintained institutional database. Results: 21 patients undergoing RP fulfilled the study criteria and were matched with equal number of patients who had laparoscopic proctectomy (LP). Mean postoperative follow-up was 27.2 months. RP was associated with longer operating time (304 vs. 213 mins, p=0.01) and increased estimated blood loss (360 vs. 188, p= 0.002). The groups were comparable with respect to conversion rates (3 vs 4, p=>0.99). Time to first bowel movement (2 vs. 3, p=0.62), length of hospital stay (8 vs. 9, p=0.39), postoperative complications, IPAA related outcomes, Cleveland Clinic Global Quality of Life and SF-12 health survey outcomes (p>0.05) were similar between the two groups (table). Conclusion: RP can safely be performed in IBD patients without worsening the postoperative complications and functional outcomes compared to laparoscopic surgery. Patient demographics and results
A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy With Major Vascular Resection in Pancreatic Cancer: Major Vascular Resection Is Associated With Severe Adverse Postoperative Outcome and Early Recurrence Olga Kantor, Mark Talamonti, Susan J. Stocker, Chi Wang, David J. Winchester, Richard A. Prinz, Marshall Baker Introduction: Recent multi-center retrospective studies in pancreatic cancer (PDAC) report disease specific survival following pancreaticoduodenectomy with major vascular resection (PDVR) to be superior to that for palliative bypass and comparable to that for pancreaticoduodenectomy not requiring vascular resection (PD). These studies have not graded perioperative complications and provide incomplete assessments of the value of PDVR. Methods: We queried our institutional database identifying 24 patients undergoing PDVR for PDAC between 2007 and 2013. Propensity score matching was used to match this cohort (3:1) by age, gender and tumor stage to 72 patients undergoing PD in the same period. Charts were reviewed for all complications and 90-day readmissions. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse postoperative outcomes (SAPO). Grade I, II and IIIa complications requiring more than one interventional procedure or overall lengths of stay (LOS) including readmissions >3 standard deviations beyond the mean for patients without complications were also classified as SAPO. All others were considered minor adverse outcomes. Results: There were no statistical differences in demographics, comorbid disease, preoperative albumin, rates of R0 resection, use of neoadjuvant chemotherapy (NAC), or incidence of recurrent PDAC between groups. Patients undergoing PDVR were more likely to have had antrectomy (75.0 vs 36.1%, p=0.001), had higher intraoperative blood loss (1.3±1.1 vs 0.45±0.3L; p<0.001) and longer operative times (7.5±1.6 vs 5.8±1.1 hrs; p<0.001) than those undergoing PD. PDVR patients were more likely to require readmission (41.7 vs 15.3%, p=0.01), demonstrated longer LOS (22.2±15.8 vs 13.5±8.8 days, p= 0.008), were more likely to have a SAPO (66.7 vs 19.4%, p<0.001) and to miss adjuvant chemotherapy (33.3 vs 4.2%, p=0.001). Disease free and overall survival intervals were shorter in the PDVR group (9.2±8.1 vs 18.9±17.1 mo nt hs an d 1 2. 3± 10 .7 vs 24.2±17.7months; p≤0.002). Multivariate logistic regression adjusted for age, comorbidities, hypoalbuminemia, NAC, tumor size and PDVR identified age ≥70 years (OR 3.62 [1.04,12.67]) and PDVR (OR 11.18 [2.98,41.89]) as independent predictors of SAPO. Coxregression also adjusting for SAPO identified PDVR (HR 2.11 [1.12,3.98]) and tumor size ≥3cm (HR 2.37 [1.48,3.81]) as independent predictors of long term overall mortality. Conclusions: PDVR results in a higher severity complication profile than that seen for PD. Patients requiring PDVR for PDAC are less likely to receive adjuvant chemotherapy and demonstrate earlier disease recurrence than those undergoing PD. Well powered trials carefully evaluating perioperative complications and long term outcomes are required to determine the true value of PDVR for patients with resectable and borderline resectable PDAC. 865
Introduction: Several studies have confirmed the safety of pancreatoduodenectomy with portomesenteric vein resection and reconstruction in select patients. The effect of portal vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portomesenteric vein and long-term survival. Methods: A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000-2014) was performed.Survival was compared with Kaplan-Meier method and log-rank test. P<0.05 was considered statistically significant. Results: After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal vein were excluded, there were 567 eligible patients. Of these, segmental portal vein resection was performed in 90 (16%) with endto-end primary anastomosis in (67) or graft reconstruction (23). Histopathology of patients undergoing portal vein resection revealed a higher rate of perineural invasion (87% vs.74%, p=0.03). Portal vein resection, however, was not associated with differences in hospital stay, postoperative complications or operative mortality. Patients with portal vein resection showed no difference in recurrence rate and comparable overall, and 1-, 3- and 5-year survival rates. On final surgical histopathology, only 53 of 90 (59%) portal vein resections had adenocarcinoma involvement of the venous wall. Of these, invasion extent was at the level of adventitia (9), media/intima (31) and full thickness/intraluminal (10). Venous wall invasion (53) was associated with higher local recurrence but did not significantly influence overall survival (14 vs. 21 months, p=0.08). The extent of invasion did not impact recurrence, site of recurrence, or overall survival (p=0.08, 0.32, 0.58 and 0.5, respectively). Portal vein resection, histopathologic invasion or the extent of invasion were not independent predictors of overall survival in Cox regression analysis. Conclusion: Portal vein resection is technically safe in select patients. Portomesenteric venous resection is not prognostic of overall survival. Direct tumor invasion into the portal vein wall on final surgical histopathology is associated with a higher rate of local recurrence, but did not affect overall survival even when stratified according to extent of venous wall invasion.
BMI: Body Mass Index; ASA: American Society of Anesthesiologists; CD: Crohn's Disease; UC: Ulcerative Colitis; TPC: Total Proctocolectomy; CP: Completion Proctectomy;TNF: Tumor Necrosis Factors: SSI: Surgical Site Infection; DVT: Deep Vein Thrombosis; CGQOL: Cleveland Global Quality Of Life; PCS: Physical Component Summary; MCS: Mental Component Summary. 867 Effect of BMI on Short-Term Outcomes With Robotic-Assisted Laparoscopic Surgery: A Case-Matched Study Nisreen Madhoun, Deborah Keller, Jean-Paul J. LeFave, Madhu Ragupathi, Juan R. Flores, Sergio Ibarra, Eric M. Haas Background: Many benefits of minimally invasive surgery are lost in the obese. Obese patients are reported more likely to experience complications, longer operating times, higher conversion rates, and longer lengths of stay. Robotic Assisted Laparoscopic Surgery (RALS) may offer specific benefits in this population, as technical issues seen in other platforms may not be pertinent. Our goal was compare outcomes for RALS in obese and non-obese patients. Methods: Review of a prospective database was performed to identify patients undergoing an elective colorectal resection using a robotic assisted laparoscopic approach. Patients were stratified into obese (BMI>30 kg/m2) and non-obese cohorts (BMI<30 kg/m2). Patients were then matched on surgeon, age, gender, comorbidity, diagnosis, and procedure performed to compare groups. Demographic, perioperative, and postoperative outcome data were evaluated. The main outcome measures were the operative time, conversion rate, length of stay, and complication, readmission, and reoperation rates. Results: Forty-five patients were evaluated in each cohort. The BMI was significantly different across groups (p<.01). All other demographic parameters were well matched. The primary diagnosis was diverticulitis (40.0%) and procedure performed an anterior rectosigmoidectomy (48.9%) in both groups (p=1.00). There were no significant differences in operative time (p=0.864), blood loss (p= 0.375), intraoperative complications (p=0.54), or conversion rates (p-0.91) across the obese and non-obese cohorts. The length of stay was comparable between groups (p=0.449). Postoperatively, the complication (p=0.87), readmission (p=1.00), and reoperation rates (p= 0. 0.95) were for the obese and non-obese. There were no mortalities in either group. For malignant cases (37.8%), the lymph node yield (p=0.480) and positive margins (p=1.00) were similar and acceptable in both cohorts. Conclusions: Minimally invasive surgery has been reported as technically challenging and associated with inferior outcomes in obese
866 Case Matched Comparison of Robotic Versus Laparoscopic Proctectomy for Inflammatory Bowel Disease Ahmet Rencuzogullari, Emre Gorgun, Meagan Costedio, Erman Aytac, Hermann Kessler, Maher Abbas, Feza H. Remzi Purpose: The utilization of robotic proctectomy (RP) for rectal cancer has recently gained popularity. Role of robotic surgery in patients with inflammatory bowel disease (IBD) remains unclear. The present study assesses peri- and postoperative results including ileal pouchanal anastomosis (IPAA) outcomes in patients undergoing RP for IBD. Methods: Between
S-1121
SSAT Abstracts
SSAT Abstracts
Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma Alexandra M. Roch, Michael G. House, Jessica Cioffi, Eugene P. Ceppa, Nicholas J. Zyromski, Attila Nakeeb, C. Max Schmidt