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Decreased skeletal muscle is associated with poor survival for patients undergoing surgical resection for pancreatic ductal adenocarcinoma
e116
Electronic Poster Abstracts
FP37-03 LAPAROSCOPIC VASCULAR RECONSTRUCTION AMONG 114 TOTAL LAPAROSCOPIC PANCREATODUODENECTOMIES P. Tyutyunnik1,2, I. Khatkov1,2, V. Tsvirkun1, R. Izrailov1,2, A. Khisamov1 and A. V. Andrianov1 1 Moscow Clinical Scientific Center, and 2Moscow State University of Medicine and Dentestry, Russian Federation Introduction: Laparoscopic pancreatic surgery remains one of the most difficult and challenging applications of minimally invasive surgical approaches in spite of great development of these techniques nowadays. Patients and methods: One hundred and thirty one patients with periampullar tumors that planed for laparoscopic Whipple procedure (LPD) between January 2007 and July 2015 were analyzed. In cases when the SMV/PV resection was necessary due to tumor invasion it was performed. Results: One hundred and fourteen consecutive total laparoscopic PD were successfully performed. There were 66 females and 48 males. The mean age was 61 10.9 years. Median BMI 24kg/m2 (range 16 to 37 kg/m2). Fourteen patients (12%) were operated on for benign and 100 (88%) for malignant lesions. Standard Whipple (n69;60%patients), pylorus-preserving PD (n45;40%patients. Median OT was 415min (range 240e 765min). Median blood loss 200ml (range 50e2100 ml). Clinical significant pancreatic fistula (n20;17%patients); grade B (n14;12% patients, grade C (n6;5%patients). Delayed gastric emptying grade B (n5;4,5% patients), grade C (n5;4,5% patients) patients. Postpancreatectomy haemorrhage grade A (n2;1,7% patients), grade B (n8;7% patients, grade C (n3;2,6% patients). Pancreatic adenocarcinoma (n59;51.9%), ampullary adenocarcinoma (n27;23.9%), chronic pancreatitis (n12;10.6%), common bile duct carcinoma (n8;7.1%), IPMN (n2;1.7%), duodenal adenoma (n1;0.8%), undifferentiated cancer of pancreas (n1;0.8%), undifferentiated cancer of common bile duct (n1;0.8%), undifferentiated cancer of duodenum (n1;0.8%), neuroendocrine carcinoma (n1;0.8%), solid pseudopapillary tumor (n1;0.8%). Eight patients had different types of venous resections. Conclusion: Total LPD demands high technical skills from the whole surgical team. Morbidity and mortality are the same like in open procedures, time of the operation is higher at the initial experience and becomes practically equal after performing 50 cases. Major venous reconstruction is possible if needed.
FP37-04 ANALYSIS OF 337 PATIENTS WITH SOLID PSEUDOPAPILLARY TUMORS OF THE PANCREAS e ROLE FOR SURGERY IN METASTATIC DISEASE Z. Jutric1, J. Grendar2, Y. Rozenfeld2, C. Hammill2,3, M. Cassera2, P. Newell2, P. Hansen2,3 and R. Wolf2,3 1 Hepatobiliary Surgery, 2Portland Providence Cancer Center, and 3The Oregon Clinic, United States Introduction: Current literature addressing the treatment of solid pseudopapillary tumors of the pancreas is based on
case series and small single institutional reviews. Due to the rarity of these tumors, the natural history is not well defined. We aim to define predictive indicators of survival in a large series of patients. Methods: The National Cancer Data Base (NCDB) was queried for patients diagnosed with solid pseudopapillary tumors of the pancreas between 1998 and 2011. Single predictor univariate analyses were performed on variables including demographics, tumor characteristics, and surgery outcomes. Multivariate Cox proportional hazards survival analysis was then completed with backward elimination. Results: 337 patients were identified; 82% were female, median age was 39 years. 84% of the patients had no comorbidities. Patients undergoing surgical resection (n = 296) had superior survival (p < 0.0001), as did patients treated at academic centers and those with private insurance (p = 0.009, p = 0.007 respectively). Sex, age, tumor size, presence of lymph node metastases, positive surgical margins and presence of distant metastases were not significant predictors of survival in multivariate analysis. Of 24 patients with distant metastases, seven patients were treated surgically and experienced longer survival (HR = 8.6 for no surgery group). Conclusion: Solid pseudopapillary tumors of the pancreas are rare neoplasms with excellent overall survival. However, in a low number of patients they do metastasize. Patients with and without metastatic disease that underwent resection survived longer. Although retrospective, these data support consideration of resection, even in patients with metastatic disease.
FP37-05 DECREASED SKELETAL MUSCLE IS ASSOCIATED WITH POOR SURVIVAL FOR PATIENTS UNDERGOING SURGICAL RESECTION FOR PANCREATIC DUCTAL ADENOCARCINOMA M. Sugimoto1, N. Takahashi2, D. Nagorney1, M. Kendrick1, M. Truty1, R. Smoot1, S. Chari3, M. Moynagh2, G. Petersen4 and M. Farnell1 1 Department of Subspecialty General Surgery, 2 Department of Radiology, 3Division of Gastroenterology, and 4Department of Health Sciences Research, Mayo Clinic, United States Introduction: The aim of this study was to investigate the impact of skeletal muscle index in patients who underwent surgical resection for pancreatic ductal adenocarcinoma (PDAC). Method: Patients who had surgical resection with curative intent and preoperative abdominal CT in 2000e2014 (n = 391) were identified from the Mayo Clinic SPORE in Pancreatic Cancer. Standardized body composition data including skeletal muscle area was measured from CT at L3 level using in-house developed software. Skeletal muscle index was calculated as the area of skeletal muscle divided by height2 (cm2/m2). Clinicopathological parameters and body composition data were evaluated for association with overall survival using Cox regression analysis. Results: Univariate analysis showed significant association between overall survival and the following parameters: weight loss>10%, radiological tumor size, presence of neoadjuvant therapy, CA19e9 level, skeletal muscle index, histological tumor grade, pathological tumor size, surgical HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts margin status, pathological T-stage, perineural invasion, angiolymphatic invasion, and lymph node positivity. Multivariate analysis found the following significant parameters: CA19e9 level (P < 0.001), skeletal muscle index (P = 0.003), histological tumor grade (P = 0.014), pathological tumor size (P = 0.034), margin positivity (P = 0.033), T-stage (P = 0.004), and lymph node positivity (P = 0.049). Skeletal muscle index was associated with postoperative pancreatic fistula but not with other complications, 30-day readmission or reoperation, or 90-day mortality (logistic regression, P < 0.05). Median survival of patients with sexspecific lowest quartile of skeletal muscle index vs. others was 24 months vs. 28 months (log-rank test, P = 0.039). Conclusions: Low skeletal muscle index is an important prognostic factor for overall survival, independent of other known prognostic factors. HR
95% CI
P
Weight loss > 10% prior to diagnosis
1.323
0.992-1.766
0.057
Radiological tumor size
1.001
0.989-1.013
0.879
Neoadjuvant therapy
0.669
0.440-1.017
0.060
CA19-9
1.183
1.084-1.290
<0.001 0.003
Skeletal muscle index
0.980
0.967-0.993
Histological grade
1.138
1.026-1.261
0.014
Pathological tumor size
1.459
1.029-2.071
0.034
Margin positivity
1.395
1.027-1.895
0.033
pN
1.347
1.001-1.812
0.049
[Multivariate predictive analysis for overall survi]
FP39 e Free Papers 39 (mini oral) e Tricks of the Trade
FP39-01 APPLYING OF “ THE WHITE TEST” IN LAPAROSCOPIC HEPATECTOMY TO IDENTIFY BILE LEAKAGE R. Gandy1,2, A. Das1 and S. Ahmed3 1 Dept of Upper Gastrointestinal Surgery, Liverpool and Bankstown Hospitals, 2University of New South Wales, and 3Nepean Hospital, Australia Introduction: Laparoscopic hepatic parenchymal transection techniques including the use of laparoscopic CUSA, laparoscopic energy devices or staplers can all result in bile leak. Bile leakage from the transected parenchyma can be difficult to detect at laparoscopy and ongoing leak after suture repair may be hard to identify. This may be due increased light absorbance in presence of blood or haemostatic agents, reduced colour contrast in laparoscopic surgery and reduced bile flow due to pneumoperitoneum. We present our experience with rapid transection technique and the use of an intralipid cholangiogram to detect and confirm repair of bile leaks at laparoscopic hepatectomy. Technique (presentation to include video). Dissection of the cystic duct and cannulation with ureteric catheter, high pressure injection of intralipid after application of Pringle tape (both applied through a single epigastric incision adjacent to a working 10mm port). A drain was placed post procedure to identify early bile leakage. Results: The white test was applied, 35 laparoscopic, 70 laparoscopically assisted and 398 open hepatectomies. In
HPB 2016, 18 (S1), e1ee384
e117
the laparoscopic group 1 grade A bile leak was observed and no grade B or C leaks . There were no grade B or C bile leaks. Overall 8 grade A leaks, 3 grade B and only 1 grade C leaks were observed. Conclusion: The intralipid white test can be applied at laparoscopic surgery and is useful in the detection and suture repair of bile leaks.
FP39-03 VASCULAR CONTROL OF THE COELIAC TRUNC BY A RETROPANCREATIC ACCESS IN LAPAROSCOPIC SUBTOTAL LEFT PANCREATECTOMY FOR LARGE TUMORS OF THE NECK OF THE PANCREAS B. I. Røsok1, M. Sahakyan2, A. Fretland3, B. A. Bjørnbeth3 and B. Edwin2 1 Department of HPB Surgery, Oslo University Hospital, 2 Oslo University Hospital e The Intervention Centre, and 3 Department of HPB Surgery, Oslo University Hospital e Rikshospitalet, Norway Introduction: Tumors of the neck of the pancreas are often located in close proximity to the coeliac trunc and its major branches. Division of the splenic artery at the origin is necessary for adequate oncological control. Safe dissection in this area may be difficult due to large tumor masses as well as variations in vascular anatomy. Methods: We use a standardised 4 trocar setup utilising a retropancreatic access to isolate the coelicac trunk to get control on the origin of the splenic artery. The tail of the pancreas is mobilized from left to right and the body and neck at an early stage. When tumor masses makes access difficult, vascular control is obtained by systematically placing vessel-loops on arterial structures, either alone or in combination with intraopeative ultrasound. Applications: The retropancreatic access allows laparoscopic resection of large tumors in the neck of the pancreas. In this area, the laparosopic approach usually only provides access from the inferior margin where the artery is difficult to reach. In this presentation we will provide detailed videos demonstrating several anatomical variants and how these can be safely dealt with using our technique.
[Coeliac trunc exposed]
Electronic Poster Abstracts
FP37-03 LAPAROSCOPIC VASCULAR RECONSTRUCTION AMONG 114 TOTAL LAPAROSCOPIC PANCREATODUODENECTOMIES P. Tyutyunnik1,2, I. Khatkov1,2, V. Tsvirkun1, R. Izrailov1,2, A. Khisamov1 and A. V. Andrianov1 1 Moscow Clinical Scientific Center, and 2Moscow State University of Medicine and Dentestry, Russian Federation Introduction: Laparoscopic pancreatic surgery remains one of the most difficult and challenging applications of minimally invasive surgical approaches in spite of great development of these techniques nowadays. Patients and methods: One hundred and thirty one patients with periampullar tumors that planed for laparoscopic Whipple procedure (LPD) between January 2007 and July 2015 were analyzed. In cases when the SMV/PV resection was necessary due to tumor invasion it was performed. Results: One hundred and fourteen consecutive total laparoscopic PD were successfully performed. There were 66 females and 48 males. The mean age was 61 10.9 years. Median BMI 24kg/m2 (range 16 to 37 kg/m2). Fourteen patients (12%) were operated on for benign and 100 (88%) for malignant lesions. Standard Whipple (n69;60%patients), pylorus-preserving PD (n45;40%patients. Median OT was 415min (range 240e 765min). Median blood loss 200ml (range 50e2100 ml). Clinical significant pancreatic fistula (n20;17%patients); grade B (n14;12% patients, grade C (n6;5%patients). Delayed gastric emptying grade B (n5;4,5% patients), grade C (n5;4,5% patients) patients. Postpancreatectomy haemorrhage grade A (n2;1,7% patients), grade B (n8;7% patients, grade C (n3;2,6% patients). Pancreatic adenocarcinoma (n59;51.9%), ampullary adenocarcinoma (n27;23.9%), chronic pancreatitis (n12;10.6%), common bile duct carcinoma (n8;7.1%), IPMN (n2;1.7%), duodenal adenoma (n1;0.8%), undifferentiated cancer of pancreas (n1;0.8%), undifferentiated cancer of common bile duct (n1;0.8%), undifferentiated cancer of duodenum (n1;0.8%), neuroendocrine carcinoma (n1;0.8%), solid pseudopapillary tumor (n1;0.8%). Eight patients had different types of venous resections. Conclusion: Total LPD demands high technical skills from the whole surgical team. Morbidity and mortality are the same like in open procedures, time of the operation is higher at the initial experience and becomes practically equal after performing 50 cases. Major venous reconstruction is possible if needed.
FP37-04 ANALYSIS OF 337 PATIENTS WITH SOLID PSEUDOPAPILLARY TUMORS OF THE PANCREAS e ROLE FOR SURGERY IN METASTATIC DISEASE Z. Jutric1, J. Grendar2, Y. Rozenfeld2, C. Hammill2,3, M. Cassera2, P. Newell2, P. Hansen2,3 and R. Wolf2,3 1 Hepatobiliary Surgery, 2Portland Providence Cancer Center, and 3The Oregon Clinic, United States Introduction: Current literature addressing the treatment of solid pseudopapillary tumors of the pancreas is based on
case series and small single institutional reviews. Due to the rarity of these tumors, the natural history is not well defined. We aim to define predictive indicators of survival in a large series of patients. Methods: The National Cancer Data Base (NCDB) was queried for patients diagnosed with solid pseudopapillary tumors of the pancreas between 1998 and 2011. Single predictor univariate analyses were performed on variables including demographics, tumor characteristics, and surgery outcomes. Multivariate Cox proportional hazards survival analysis was then completed with backward elimination. Results: 337 patients were identified; 82% were female, median age was 39 years. 84% of the patients had no comorbidities. Patients undergoing surgical resection (n = 296) had superior survival (p < 0.0001), as did patients treated at academic centers and those with private insurance (p = 0.009, p = 0.007 respectively). Sex, age, tumor size, presence of lymph node metastases, positive surgical margins and presence of distant metastases were not significant predictors of survival in multivariate analysis. Of 24 patients with distant metastases, seven patients were treated surgically and experienced longer survival (HR = 8.6 for no surgery group). Conclusion: Solid pseudopapillary tumors of the pancreas are rare neoplasms with excellent overall survival. However, in a low number of patients they do metastasize. Patients with and without metastatic disease that underwent resection survived longer. Although retrospective, these data support consideration of resection, even in patients with metastatic disease.
FP37-05 DECREASED SKELETAL MUSCLE IS ASSOCIATED WITH POOR SURVIVAL FOR PATIENTS UNDERGOING SURGICAL RESECTION FOR PANCREATIC DUCTAL ADENOCARCINOMA M. Sugimoto1, N. Takahashi2, D. Nagorney1, M. Kendrick1, M. Truty1, R. Smoot1, S. Chari3, M. Moynagh2, G. Petersen4 and M. Farnell1 1 Department of Subspecialty General Surgery, 2 Department of Radiology, 3Division of Gastroenterology, and 4Department of Health Sciences Research, Mayo Clinic, United States Introduction: The aim of this study was to investigate the impact of skeletal muscle index in patients who underwent surgical resection for pancreatic ductal adenocarcinoma (PDAC). Method: Patients who had surgical resection with curative intent and preoperative abdominal CT in 2000e2014 (n = 391) were identified from the Mayo Clinic SPORE in Pancreatic Cancer. Standardized body composition data including skeletal muscle area was measured from CT at L3 level using in-house developed software. Skeletal muscle index was calculated as the area of skeletal muscle divided by height2 (cm2/m2). Clinicopathological parameters and body composition data were evaluated for association with overall survival using Cox regression analysis. Results: Univariate analysis showed significant association between overall survival and the following parameters: weight loss>10%, radiological tumor size, presence of neoadjuvant therapy, CA19e9 level, skeletal muscle index, histological tumor grade, pathological tumor size, surgical HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts margin status, pathological T-stage, perineural invasion, angiolymphatic invasion, and lymph node positivity. Multivariate analysis found the following significant parameters: CA19e9 level (P < 0.001), skeletal muscle index (P = 0.003), histological tumor grade (P = 0.014), pathological tumor size (P = 0.034), margin positivity (P = 0.033), T-stage (P = 0.004), and lymph node positivity (P = 0.049). Skeletal muscle index was associated with postoperative pancreatic fistula but not with other complications, 30-day readmission or reoperation, or 90-day mortality (logistic regression, P < 0.05). Median survival of patients with sexspecific lowest quartile of skeletal muscle index vs. others was 24 months vs. 28 months (log-rank test, P = 0.039). Conclusions: Low skeletal muscle index is an important prognostic factor for overall survival, independent of other known prognostic factors. HR
95% CI
P
Weight loss > 10% prior to diagnosis
1.323
0.992-1.766
0.057
Radiological tumor size
1.001
0.989-1.013
0.879
Neoadjuvant therapy
0.669
0.440-1.017
0.060
CA19-9
1.183
1.084-1.290
<0.001 0.003
Skeletal muscle index
0.980
0.967-0.993
Histological grade
1.138
1.026-1.261
0.014
Pathological tumor size
1.459
1.029-2.071
0.034
Margin positivity
1.395
1.027-1.895
0.033
pN
1.347
1.001-1.812
0.049
[Multivariate predictive analysis for overall survi]
FP39 e Free Papers 39 (mini oral) e Tricks of the Trade
FP39-01 APPLYING OF “ THE WHITE TEST” IN LAPAROSCOPIC HEPATECTOMY TO IDENTIFY BILE LEAKAGE R. Gandy1,2, A. Das1 and S. Ahmed3 1 Dept of Upper Gastrointestinal Surgery, Liverpool and Bankstown Hospitals, 2University of New South Wales, and 3Nepean Hospital, Australia Introduction: Laparoscopic hepatic parenchymal transection techniques including the use of laparoscopic CUSA, laparoscopic energy devices or staplers can all result in bile leak. Bile leakage from the transected parenchyma can be difficult to detect at laparoscopy and ongoing leak after suture repair may be hard to identify. This may be due increased light absorbance in presence of blood or haemostatic agents, reduced colour contrast in laparoscopic surgery and reduced bile flow due to pneumoperitoneum. We present our experience with rapid transection technique and the use of an intralipid cholangiogram to detect and confirm repair of bile leaks at laparoscopic hepatectomy. Technique (presentation to include video). Dissection of the cystic duct and cannulation with ureteric catheter, high pressure injection of intralipid after application of Pringle tape (both applied through a single epigastric incision adjacent to a working 10mm port). A drain was placed post procedure to identify early bile leakage. Results: The white test was applied, 35 laparoscopic, 70 laparoscopically assisted and 398 open hepatectomies. In
HPB 2016, 18 (S1), e1ee384
e117
the laparoscopic group 1 grade A bile leak was observed and no grade B or C leaks . There were no grade B or C bile leaks. Overall 8 grade A leaks, 3 grade B and only 1 grade C leaks were observed. Conclusion: The intralipid white test can be applied at laparoscopic surgery and is useful in the detection and suture repair of bile leaks.
FP39-03 VASCULAR CONTROL OF THE COELIAC TRUNC BY A RETROPANCREATIC ACCESS IN LAPAROSCOPIC SUBTOTAL LEFT PANCREATECTOMY FOR LARGE TUMORS OF THE NECK OF THE PANCREAS B. I. Røsok1, M. Sahakyan2, A. Fretland3, B. A. Bjørnbeth3 and B. Edwin2 1 Department of HPB Surgery, Oslo University Hospital, 2 Oslo University Hospital e The Intervention Centre, and 3 Department of HPB Surgery, Oslo University Hospital e Rikshospitalet, Norway Introduction: Tumors of the neck of the pancreas are often located in close proximity to the coeliac trunc and its major branches. Division of the splenic artery at the origin is necessary for adequate oncological control. Safe dissection in this area may be difficult due to large tumor masses as well as variations in vascular anatomy. Methods: We use a standardised 4 trocar setup utilising a retropancreatic access to isolate the coelicac trunk to get control on the origin of the splenic artery. The tail of the pancreas is mobilized from left to right and the body and neck at an early stage. When tumor masses makes access difficult, vascular control is obtained by systematically placing vessel-loops on arterial structures, either alone or in combination with intraopeative ultrasound. Applications: The retropancreatic access allows laparoscopic resection of large tumors in the neck of the pancreas. In this area, the laparosopic approach usually only provides access from the inferior margin where the artery is difficult to reach. In this presentation we will provide detailed videos demonstrating several anatomical variants and how these can be safely dealt with using our technique.
[Coeliac trunc exposed]