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An evaluation of the possum scoring system in pancreaticoduodenectomy
Vol. 9, No. 4 2005
drains may not improve outcome and may be harmful. Routine placement of intraperitoneal drains was discontinued 3 years ago by a single surgeon at a tertiary referral center. Data on the outcome of these patients has been collected prospectively. One hundred five patients have been operated without drain placement: 35 pancreaticoduodenectomies, 23 palliative biliary and gastric bypass procedures, 18 hepaticojejunostomies, 15 distal pancreatectomies, 6 pancreaticojejunostomies, 5 pancreatic cyst gastrostomies and 3 ampullectomies. All anastomoses were performed with extramucosal 5.0 PDS sutures. Four patients required reoperation (1 bleed, 1 ileocolostomy leak, 1 pancreatojejunostomy leak, 1 small bowel obstruction). Two patients required percutaineous drain placement for fluid collections (distal pancreatectomies). Five further patients with peripancreatic fluid collections were treated successfully with antibiotic therapy alone. There was one in-hospital death of a palliative bypass patient. Over this time period 4 patients received an intraperitoneal drain (2 pancreaticoduodenectomies, 2 hepaticojejunostomies) because of either extensive contamination or a tenuous anastomosis. Routine drainage of the peritoneal cavity after pancreatobiliary surgery is not necessary.
288 AN EVALUATION OF THE POSSUM SCORING SYSTEM IN PANCREATICODUODENECTOMY Tsuneo Tanaka, MD, Yasuhiro Matsugu, MD, Naoki Kagawa, MD, Yasuhiko Fukuda, MD, Hiroshima Prefectural Hospital, Hiroshima, Japan No useful indicator is available for preoperative risk evaluation when considering treatment with pancreaticoduodenectomy (PD). The aim of this study was to clarify a usefulness of the POSSUM surgical scoring system for PD. From May 1996 to April 2004, 141 patients underwent PD. Postoperative complications were seen in 43 cases (30.5%). The subjects were divided into two groups by the presence or absence of postoperative complications. Twelve preoperative factors and 4 operative factors, and POSSUM parameters were compared between these two groups. In terms of the 12 preoperative factors and 4 operative factors, there was no significant difference between the complicated group and the noncomplicated group. Of the POSSUM parameters analyzed, the physiological score (PS, P ⫽ 0.0001), the operative score (P ⫽ 0.0307), the predicted mortality rate (P ⫽ 0.0001), and the predicted morbidity rate (P ⫽ 0.0001) differed significantly between the two groups. POSSUM is useful as a means of risk assessment in individuals scheduled to undergo PD.
289 CASE-CONTROL COMPARISON OF LAPAROSCOPIC VS. OPEN DISTAL PANCREATECTOMY Vic Velanovich, MD, Henry Ford Hospital, Detroit, MI Laparoscopic distal pancreatectomy with or without splenectomy is become an increasingly used modality in the surgical treatment of pancreatic disease. Like with other laparoscopic surgery, the assumption is that this will lead to shorter hospital stay and faster returned to normal activities. However, actual comparative data between open and laparoscopic distal pancreatectomies is lacking. The purpose of this study is to compare these surgical procedures. All patients who underwent either laparoscopic or open distal pancreatectomies were eligible. 11 patients underwent laparoscopic distal pancreatectomy/ splenectomy through a 4 trocar approach; while 38 underwent open distal pancreatectomy/splenectomy through either an upper, midline or left subcostal incision. The 11 laparoscopic patients were matched to 11 open patients for age, gender, and pancreatic pathology. Data
Abstracts
611
gathered included length of stay, pancreatic leak, postoperative complications, and return to normal activities (as reported by the patient). Data was analyzed using the paired signed rank test, and Fisher’s exact test. Of the 11 laparoscopic patients, 2 were converted to open operations (they are still analyzed in the laparoscopic group). There were 7 females, 4 males, avg. age 65 ⫾ 14 years. Pathology distribution: 2 (18%) ductal adenocarcinoma, 5 (45%) cystic neoplasm, 2 (18%) neuroendocrine tumor, 2 (18%) chronic pancreatitis. Pathology distribution for all open cases: 13 (34%) ductal or cystic adenocarcinoma, 6 (15%) cystic neoplasm, 4 (11%) neuroendocrine tumor, 11 (29%) chronic pancreatitis, 4 (11%) other. All 11 laparoscopic cases were successfully matched to open controls. Length of stay: laparoscopic 6 days (range 3-9), open 8 days (range 6-23) (P ⫽ 0.02). Pancreatic leak: both 18%. Postoperative complications: both 27%. Return to normal activity: laparoscopic 3 weeks (range 2-7), open 6 weeks (range 4-8) (P ⫽ 0.03). Laparoscopic distal pancreatectomy/splenectomy does lead to shorter hospital stay and faster return to normal activity compared to open distal pancreatectomy/splenectomy. Pancreatic leak and complications are similar.
290 PANCREATICODUODENECTOMY FOR NONPERIAMPULLARY PRIMARY TUMORS Rafael Oliveira Albagli, MD, Audrey Tieko Tsunoda, MD, Rafael De Cecco Baldissera, MD, Ernesto Mayer Rymer, MD, PhD, Marciano Anghinoni, MD, Carlos Bernardo Cola, MD, Gustavo Souza De Moura Pierro, MD, Jurandir Almeida Dias, MD, INCA/Instituto Nacional do Caˆncer-Brazil, Rio De Janeiro, Brazil The role of extended resections for locally advanced carcinomas or isolated metastasis infiltrating duodenum and pancreas remains unclear. This review was performed to evaluate the outcome of patients undergoing pancreaticoduodenectomy (PD) for isolated metastasis or locally advanced nonperiampullary tumors (NPAP). Between 1992 and 2003, patients with NPAP invading duodenum and pancreas managed by a single surgical team at INCA-Brazil had their medical records reviewed. The clinical, pathological, and outcome details were analyzed. Thirteen patients were submitted to PD for NPAP. The primary tumor histopathology included colon (n ⫽ 8), stomach (n ⫽ 3), jejunum (n ⫽ 1), and renal cell (n ⫽ 1). Six patients presented with right upper quadrant pain as the first symptom, three with epigastric pain, one with anemia, one with palpable mass, one with jaundice, and one with weight loss. No operative deaths occurred. Ten had locally advanced tumors, while two had local recurrence and one had an isolated metastasis. The median length of hospital stay was 15 days (10 to 35 days). The median follow-up was 26 months. Four patients died for metastatic disease from 8 to 73 months after surgery. Seven patients are alive and free of locally recurrent disease, 3 to 38 months after the operation, but two have actual metastatic disease (23 and 29 months after surgery). PD for NPAP malignancy can be safely performed in locally advanced disease or isolated metastatic tumors, and is associated with a prolonged survival period.
291 DEVELOPING NOVEL BIOLOGICAL THERAPIES THAT DRIVE APOPTOSIS AND OVERCOME CHEMORESISTANCE IN PANCREATIC CANCER CELLS Jirong Bai, DVM, PhD, Aram N. Demirjian, MD, Charles M. Vollmer, Jr., MD, Mark P. Callery, MD, Beth Israel Deaconess Medical Center, Boston, MA
drains may not improve outcome and may be harmful. Routine placement of intraperitoneal drains was discontinued 3 years ago by a single surgeon at a tertiary referral center. Data on the outcome of these patients has been collected prospectively. One hundred five patients have been operated without drain placement: 35 pancreaticoduodenectomies, 23 palliative biliary and gastric bypass procedures, 18 hepaticojejunostomies, 15 distal pancreatectomies, 6 pancreaticojejunostomies, 5 pancreatic cyst gastrostomies and 3 ampullectomies. All anastomoses were performed with extramucosal 5.0 PDS sutures. Four patients required reoperation (1 bleed, 1 ileocolostomy leak, 1 pancreatojejunostomy leak, 1 small bowel obstruction). Two patients required percutaineous drain placement for fluid collections (distal pancreatectomies). Five further patients with peripancreatic fluid collections were treated successfully with antibiotic therapy alone. There was one in-hospital death of a palliative bypass patient. Over this time period 4 patients received an intraperitoneal drain (2 pancreaticoduodenectomies, 2 hepaticojejunostomies) because of either extensive contamination or a tenuous anastomosis. Routine drainage of the peritoneal cavity after pancreatobiliary surgery is not necessary.
288 AN EVALUATION OF THE POSSUM SCORING SYSTEM IN PANCREATICODUODENECTOMY Tsuneo Tanaka, MD, Yasuhiro Matsugu, MD, Naoki Kagawa, MD, Yasuhiko Fukuda, MD, Hiroshima Prefectural Hospital, Hiroshima, Japan No useful indicator is available for preoperative risk evaluation when considering treatment with pancreaticoduodenectomy (PD). The aim of this study was to clarify a usefulness of the POSSUM surgical scoring system for PD. From May 1996 to April 2004, 141 patients underwent PD. Postoperative complications were seen in 43 cases (30.5%). The subjects were divided into two groups by the presence or absence of postoperative complications. Twelve preoperative factors and 4 operative factors, and POSSUM parameters were compared between these two groups. In terms of the 12 preoperative factors and 4 operative factors, there was no significant difference between the complicated group and the noncomplicated group. Of the POSSUM parameters analyzed, the physiological score (PS, P ⫽ 0.0001), the operative score (P ⫽ 0.0307), the predicted mortality rate (P ⫽ 0.0001), and the predicted morbidity rate (P ⫽ 0.0001) differed significantly between the two groups. POSSUM is useful as a means of risk assessment in individuals scheduled to undergo PD.
289 CASE-CONTROL COMPARISON OF LAPAROSCOPIC VS. OPEN DISTAL PANCREATECTOMY Vic Velanovich, MD, Henry Ford Hospital, Detroit, MI Laparoscopic distal pancreatectomy with or without splenectomy is become an increasingly used modality in the surgical treatment of pancreatic disease. Like with other laparoscopic surgery, the assumption is that this will lead to shorter hospital stay and faster returned to normal activities. However, actual comparative data between open and laparoscopic distal pancreatectomies is lacking. The purpose of this study is to compare these surgical procedures. All patients who underwent either laparoscopic or open distal pancreatectomies were eligible. 11 patients underwent laparoscopic distal pancreatectomy/ splenectomy through a 4 trocar approach; while 38 underwent open distal pancreatectomy/splenectomy through either an upper, midline or left subcostal incision. The 11 laparoscopic patients were matched to 11 open patients for age, gender, and pancreatic pathology. Data
Abstracts
611
gathered included length of stay, pancreatic leak, postoperative complications, and return to normal activities (as reported by the patient). Data was analyzed using the paired signed rank test, and Fisher’s exact test. Of the 11 laparoscopic patients, 2 were converted to open operations (they are still analyzed in the laparoscopic group). There were 7 females, 4 males, avg. age 65 ⫾ 14 years. Pathology distribution: 2 (18%) ductal adenocarcinoma, 5 (45%) cystic neoplasm, 2 (18%) neuroendocrine tumor, 2 (18%) chronic pancreatitis. Pathology distribution for all open cases: 13 (34%) ductal or cystic adenocarcinoma, 6 (15%) cystic neoplasm, 4 (11%) neuroendocrine tumor, 11 (29%) chronic pancreatitis, 4 (11%) other. All 11 laparoscopic cases were successfully matched to open controls. Length of stay: laparoscopic 6 days (range 3-9), open 8 days (range 6-23) (P ⫽ 0.02). Pancreatic leak: both 18%. Postoperative complications: both 27%. Return to normal activity: laparoscopic 3 weeks (range 2-7), open 6 weeks (range 4-8) (P ⫽ 0.03). Laparoscopic distal pancreatectomy/splenectomy does lead to shorter hospital stay and faster return to normal activity compared to open distal pancreatectomy/splenectomy. Pancreatic leak and complications are similar.
290 PANCREATICODUODENECTOMY FOR NONPERIAMPULLARY PRIMARY TUMORS Rafael Oliveira Albagli, MD, Audrey Tieko Tsunoda, MD, Rafael De Cecco Baldissera, MD, Ernesto Mayer Rymer, MD, PhD, Marciano Anghinoni, MD, Carlos Bernardo Cola, MD, Gustavo Souza De Moura Pierro, MD, Jurandir Almeida Dias, MD, INCA/Instituto Nacional do Caˆncer-Brazil, Rio De Janeiro, Brazil The role of extended resections for locally advanced carcinomas or isolated metastasis infiltrating duodenum and pancreas remains unclear. This review was performed to evaluate the outcome of patients undergoing pancreaticoduodenectomy (PD) for isolated metastasis or locally advanced nonperiampullary tumors (NPAP). Between 1992 and 2003, patients with NPAP invading duodenum and pancreas managed by a single surgical team at INCA-Brazil had their medical records reviewed. The clinical, pathological, and outcome details were analyzed. Thirteen patients were submitted to PD for NPAP. The primary tumor histopathology included colon (n ⫽ 8), stomach (n ⫽ 3), jejunum (n ⫽ 1), and renal cell (n ⫽ 1). Six patients presented with right upper quadrant pain as the first symptom, three with epigastric pain, one with anemia, one with palpable mass, one with jaundice, and one with weight loss. No operative deaths occurred. Ten had locally advanced tumors, while two had local recurrence and one had an isolated metastasis. The median length of hospital stay was 15 days (10 to 35 days). The median follow-up was 26 months. Four patients died for metastatic disease from 8 to 73 months after surgery. Seven patients are alive and free of locally recurrent disease, 3 to 38 months after the operation, but two have actual metastatic disease (23 and 29 months after surgery). PD for NPAP malignancy can be safely performed in locally advanced disease or isolated metastatic tumors, and is associated with a prolonged survival period.
291 DEVELOPING NOVEL BIOLOGICAL THERAPIES THAT DRIVE APOPTOSIS AND OVERCOME CHEMORESISTANCE IN PANCREATIC CANCER CELLS Jirong Bai, DVM, PhD, Aram N. Demirjian, MD, Charles M. Vollmer, Jr., MD, Mark P. Callery, MD, Beth Israel Deaconess Medical Center, Boston, MA