Does the atlanta classification of severe acute pancreatitis really correlate with outcome in patients with pancreatic necrosis?

characteristic (ROC) curve analysis was used for evaluation of the results. Final diagnosis was established using histopathologic evaluation of resected specimen, biopsy, and in 2 patients clinical follow-up. RESULTS:The final diagnosiswas adenocarcinomaof the pancreas in 12 patients (60%) and chronic pancreatitisin 8. Qualitativeevaluationof 18FDG-PETimaging revealed 3 talse-negative and 1 false-positive results. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 75%, 88%, 90%, 70%, and 80%, respectively.The cut-off SUV to differentiate malignant from benign disease was calculatedto be 3.6 demonstrating a sensitivity of 91,7% and a specificity of 75%. There was no significant difference betweenthe qualitative and quantitative results, l~C-acetate-PET did not improve the overall results. CONCLUSION:We could not confirm previous reports of high sensitivity and diagnostic accuracyof ~FDG-PETimaging for differentiating adenocarcinoma of the pancreasfrom chronic pancreatitisin patients presenting with a pancreaticmass. No additional diagnostic benefit could be demonstrated using "C-acetate-PET. 2466 The Value Of Splenic Preservation With Distal Pancreatentomy Margo Shoup, Kertresa McWhite, Denis Leung, David Klimstra, Murray F. Brennan, Kevin C. Conlon, Memorial Sloan-KetteringCancer Ctr, New York, NY Background:Although splenic preservationwith distal pancreatectomy(DP) has recently been described, the value of this technique in terms of short and long term morbidity for patients with benign or low grade malignant tumors (LGMT) is controversial. This study compares the perioperativecourse following splenectomy(SP) or splenic preservation(SPP) in patients with distal pancreatic lesions other than adenocarcinoma. Methods: From a prospective database, 372 patients undergoing pancreatectomyfor lesions other than adenocarcinoma between October 1983 and July 2000 were identified. After excluding those who had other major organ resection, 125 patients had DP with or without splenectomy. Demographic, clinicopathologic and operative variableswere reviewed. Mann-Whitney and Chi-Squaratests were applied for statistical significance. Results: There were 43 males and 82 females with a medianage of 64 years (range 22-84). Pathologyincluded45 (36%) neuroendocrinetumors, 44 (35%) benigncystic tumors, 9 (7.2%) pancreatitis,8 (6.5%) intraductalpapillaryneoplasms, 7 (5.6%) metastatic tumors, and 12 (9.6%) other LGMTs. SP was performed in 79 (63%) and SPP in 46 (37%). Perioperativecomplicationsoccurred in 40/79 (50.6%) patientsundergoing SP comparedto18/46 (39.1%) with SPP (p = 0.21). Perioparativeinfectious complications were 22/79 (27.8%) for SP and 4•46 (8.7%) for SPP (p =0.011). Median postoperativestay (los), length of surgery (Iosurg), estimated blood loss (EBL), blood transfused (Blood tx), and mortality (M) are listed in the table below. Median tumor size was significantly larger with SP (4.9cm) compared to SPP (2.9cm), but size did not corralate with complications, postoperative stay, or EBL. Survival for patients with tumors was similar in both groups. Conclusion: This study suggeststhat splenic preservationis safe and appearsto be associated with a reduction in perioperative infectious complications and length of hospital stay. We believethat splenic preservationshould be consideredin this group of patients. Furtherstudies are required to assess the long-term implications of this approach. -"

N

los (days)

Iosurg(h)

"EBL

Blood tx(u)

M(%)

SP ._.S.P..p

79 46

9* (5-41) 7* (5-26)

3.1(1-7) 2.9(1-6)

600"(50-3250) 350'~(50-2000)

0 (0-13) 0 (0-8)

2 (2.5%) 0 (0%)

2468 Prophylactic Splenectomy For Asymptomatic Splenic Vein Thrombosis During Resection For Chronic Pancreatitis Frank Makowiec, Ulrich Adam, Dept of Surg, Univ of Rostock, Rostock Germany; Stefan Liebe, Dept of Medicine, Univ of Rostock, Rostock Germany; Ulrich T. Hopt, Dept of Surg, Univ of Rostock, Rostock Germany Background Chronic pancreatitis (CP) is the leading cause of splenic vein thrombosis (SVT). Splenic vein thrombosis occurs in about 15 % of all patients with CP and in about 10 % in CP of the pancreatic head. The risk of gastric variceal bleeding in SVT is reported to be approximately 10-15%. In symptomatic SVT (bleeding, thrombocytopenia, leucopenia) splenectomy is the treatment of choice but its ro(e in asymptomatioSVT is discussed controversially. Aim of our study was to evaluatethe peri- and postoperativeoutcome of splenectomy performed during otherwise indicated resection in patients with CP and asymptomatic SVT. Methods Between March 1995 and March 2000 216 pancreatic resections were performed for CP. Twenty-twopatients had preoperativelydocumentedasymptomaticSVT and underwent splenectomyduring pancreaticresection (14 head,0 distal). Sevenpatients had gastric varices and 18 had intraoperativelyconfirmed left-sided portal hypertension. Peri- anti postoperative follow-up data were analyzedto evaluatepossible risks and benefits of splenectomy. Results Intraoperative complications due to splenectomy did not occur. In 8 of 22 (36%) cases difficulties (mainly bleeding) due to leff-sitied portal hypertension before accomplishing splenectomy were noted. Postoperativecomplications occurad in 6 of 22 (27%) patients. Five complications not due to splenectomy were treated conservatively or interventionally. One bleeding after splenectomy led to the only relaparotomy (complication rate of splenectomy: 5%). Duringfollow-up we could not documentany caseof postsplenectomysepsis or thrombosis due to temporary thrombocytosis. Conclusion Complicationsof prophylactic splenectomy are rare and less frequent than episodesof varicealbleeding.In the presenceof an asymptomatic SVT prophylactic splenectomy should be considered during pancreatic resection for CP to facilitate surgery and to avoid potential variceal bleeding. 2469 Surgical Treatment of Sterile Necrosis in Acute Pancrentiffs:Are Patients with Secondary Pancreatic infections a Distinct Entity? Bettina Rau, Dept of Gen Surg, Univ of UIm, Ulm / Donau Germany; Wolfoano Hoffmann, Reiner Isenmann, Hans G. Beger, Dept of Gen Surg, Univ of UIm, UIm Germany The appropriate treatment of sterile necrosis(SN)in severeacute pancreatitis is still a matter of controversies, in this respect surgicaitreatment has been claimed to carry the risk of secondarypancraaticinfections (sP). However, no study has ever addressed this issue in a larger seriesof patients subjectedto surgery of SN. Materials and Methods: Between 05/82 and 12/97 241 pat. with necrotizing pancreatitis were treated by necrosectomy and closed continuous lavageof the lesser sac at our institution. 107 (44.4%) pat. had primary infected necrosis (piN), whereas 134 (55.6%) were found to be sterile by intraoperativebacteriology. In the latter group 119 pat. were further analyzed and stratified into the three entities: I. secondary pancreatic infections (sPI) proven by reinterveutions, I1. contaminations (CON) proven by positive bacteriology from abdominal drains without the need for reinterventions, and IlL sterile courses (STER). Results: In 119 pat. with intraoparativelyproven SN sPI were found in 47 (39.5%), CON in 63 (52.9%), and STER in 9 (7.6%) pat. The diseaseseverity in terms o1 Ranson- (sPI 7 vs CON 3, p 30% shown by contrast-enhancedCT (sPI 57% vs CON 33%, p
*p
2470 Does the Atlanta Classification of Severe Acute PancreatHis Really Correlate with Outcome in Patients with Pancreatic Necrosis? Rainer Isenmann, 6sttina Rau, Uwe Zoellner, Hans G. 6eger, Dept of Gen Surg, Univ of UIm, UIm Germany Acute pancreatitis is classified into mild and severe disease according to criteria found by the Atlanta consensus conference. We investigated whether these criteria correlate with mortality as well as the rate in infected necrosis (IN). Methods Data of 260 patients with necrotizing pancreatitis were analysed. It was recorded how many of the following Atlanta criteria applied to each patient during hospital stay: APACHEII score -8pts., Ranson ->3pts., pulm. insufficiency, renal insufficiency, shock, GI-bleeding, hypocalcaemiaor coagulopathy (definitions given in 1). Patientswere classified into different groups according to the number of positive criteria. Mortality and the rate of IN of each group was comparedto the incidence of this complication in the overall patient population. Results 57 pats. died (21.9%); IN was present in 86 pats (33.1%).Classification of patients according to the number of positive criteria is given in the table. Patients had to fulfill at least 2 criteria to have a risk of death comparable to that of the overall population and at least 7 or more complications for an increasesdrisk. The incidenceof IN is not affectedby the number of complications.Conclusions It is a major drawback of the Atlanta classification of severe acute pancraatifis that patients with one or two complicationsare classified as suffering from severeattacksdespite of having an under-averagerisk of death. 1)BradleyE.L., Arch. Surg. 1993;128:586-590

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2473 No. of positive criteria 0 t 2 3 4 5 6 ->7

No. of patients

Mortality

31 24 36 40 45 28 19 37

0") 1 pat. (4%)*) 2 pats.(6%) 5 pats.(13%) 10 pats. (22%) 6 pats. (21%) 8 pats. (42%) 25 pats. (68%)*)

Rateof infected necrosis 3 pats.(10%)*) 6 pats. (25%) 14 pats. (39%) 19 pats. (48%) 15 pats. (33%) 11 pats. (39%) 6 pats. (31%) 12 pats.(32%)

*) p
2471 Management of Severe Pancrentitis by High Risk Protocol and Staged Abdominal Re-explorations Jatin Dave, Univ of Illinois Coil of Medicine/Carle Foundation Hosp, Urbana, IL; Kurt Norman, Univ of Illinois Coil of Medicine/Carie Foundation Hosp, Urbana; Uretz Oliphant, James Gregory, Univ of Illinois Coil of Medicine/Carle Foundation Hosp, Urbana, IL

Background:Despite improvement in management, the mortality rate of severe pencreatitis remains 30-50%. Managementof patients with severe pancreatitis is complicated by variability in clinical presentation, the difficulty in early diagnosis of surgical complications and lack of agreement about the timing and type of surgical intervention. We present our experiencewith a High Risk Protocol (HRP) and StagedAbdominal Re-explorations(STAR)for the management of patients with severe pancreatitis. Patient and Methods: This retrospective study included 21 patients with severe pancreatitis admitted to a tertiary care hospital in Illinois from July 1991 through June 1997 managed prospectively by HRP and STAR. HRP is a prospectively designed protocol and care map which categorizes patients with severe pencreatitis into subgroups utilizing Cardio/ Pulmonary / Renalstability and dynamic computerized tomography (CT). Criteria for diagnosis of acute pencreatitis included clinical, laboratory and radiological tests. Diagnosis of severe pancreatitis was based on Ranson criteria score on admission of more than three. Indications for STAR were evidence of pancreatic necrosis exceeding 50% of the gland by CT, clinical failure of medical management or the presence of bacteria in the peripancreatic tissue. STAR involved planned re-operation every 48 hours via a standard subcostal incision with interval packing of the retroperitoneum and closure of the abdomen until the retroperitoneal space was free of necrotic material on two successive explorations. Average age of the patients was 61 years (range 38-91 years). STAR and HRP were used in 18 patients, two patients were transfers and one refused the final operation. Results: Overall mortality rate was 23%(5/21). When STAR was used mortality rate was 16% (3/18). Patients underwent an average of 4-+2 operations. The average interval between operations was two days. There were seventeen complications in eight patients: six fistulas, four abscesses, six wound dehiscences and one hemorrhage from a gall bladder fossa. Conclmdna: This study demonstrates the first application of a single surgical and medical protocol, which resulted in acceptable mortality and morbidity rates. This study presents a simple guideline, by which surgeons who infrequently manage this disease can provide surgical consultation.

Long-Term Follow-Up On The Surgical Treatment Of Upper Gastrointestinal Neoplasms In Familial Adenomatous Polyposis Patients. Leyo Rug, Daniel G. Colt, Murray F. Brannan, Jose G Guillem, MSKCC, New York, NY

BackgrounotAdenomatous polyps and adenocarcinomas of the periampullary region are the most common upper gastrointestinal (UGI) neoplasms encountered in familial adenomatous polyposis (FAP) patients. In addition, tumors arising from the liver, biliary tract, and pancreas have also been reported. The purpose of this study was to review a single institution experience with pancraaticoduodenal surgery for FAP-associated UGI neoplasms. Method~ Of the 61 individuals participating in the FAP registry, 8 underwent surgical resection of UGI neoplasms between 1987 and 1998. The charts of these individuals were reviewed for clinical indications, type of surgery, postoperative complications, and outcome. Result~Ofthe 8 patients identified, 7 had gancreaticoduodenectomyand 1 had duodenotomy with ampollectomy. The indications for surgery were perlampullary cancer (3), severe dysplasia within a duodenal villous tumor (4), and pancreatic cancer (1). At the time of UGI surgery, patients ranged in age from 2965 and all but one had undergone colorectal surgery, on average 16 years beforehand. Pancreatic ascites after a pytorus-sparing pancreaticoduodenectomy was the only surgical complication. After a mean follow-up of 77 (range 32-156) months, 2 patients have died, neither from their UGI neoplasm. The only patient with evidenceof recurrent duodenal adenoma underwent duodenotomy and ampollectomy. Another patient developed confluent jejunal adenomas just beyond the gastroenteric anastomosis almost 12 years after pancreaticoduodenectomy for severe dysplasia of a duodenal villous adenoma. Conclusion~Pancreaticoduodenectomy is a safe and appropriate surgical option for FAP patients with villous tumors containing severe dysplasia as well as carcinoma. Postoperative morbidity was minimal and there was no perioperative mortality. This approach not only removes the tumor, but also eliminates the risk of subsequent duodenal cancer. However, adenomas in the small bowel may still develop with prolonged follow-up

2474 Benign ~ 1

Neoplasms: Optimizing Management Strategies

Alexander Parez, Dept of Surg, Brigham and Women's Hosp, Boston, MA; David L. CartLocke, Dept of Medicine, Brigham and Women's Hosp, Boston, MA; Michael J. Zinner, Stanley W. Ashley, Edward E. Whang, Dept of Surg, Brigham and Women's Hosp, Boston,

MA BACKGROUND:Benign duodenal neoplasms are rare, and their optimal management remains undefined. METHODS:We analyzed all cases of benign duodenal neoplams treated during a lO-year period (1/1990 through 1/2000) at Brigham and Women's Hospital. Data is expressed as mean -+ SD. RESULTS: Sixty-five patients had benign duodenal neoplasms. Thirty-eight patients had duodenal adenomas, and 27 patients had the following lesions: Brunner's gland adenoma (9), irdlammatory polyp (10), lipoma (1), leiomyoma (1), hamartoma (2), ectopic pancreatic tissue (1), lymphangioma (1), carcinoid (1), and neurofibroma (1). Of the patients with duodenal adenomas, 13 underwent surgical therapy (pancreaticoduodenectomy (4), poncreas-spedng duodenectomy (6), local tumor excision (3)). Twenty-five patients with duodenal adenomas underwent endoscopic resection. Both surgical and endoscopic groups had similar morbidity and mortality rates (Table 1). Of the patients who had surgery, those treated with pancreaticoduodenectomy had larger lesions (93 ± 55 mm vs 35 -+ 15 ram, p <0.05) than those who had procedures of lesser magnitude. CONCLUSIONS:With appropriate selection of endoscopic and surgical therapy, benign duodenal neoplasms can be treated with minimal morbidity and mortality.

2472 Duodenal Carcinoid Tumors: How Aggressive Should We Be? Nicholas J. Zyromski, Michael L. Kendrick, David M. Nagorney, Clive S. Grant, John H. Donohue, Michael B. Farnell, Geoffrey B. Thompson, Michael G. Sarr, Mayo Clin, Rochester, MN

Table 1.

Duodenal carcinoid tumors are uncommon. It is unknown if they behave more like carcinoids in the appendix (indolent course) or those in the ileum (often virulent)--crucial information for determining the need for radical resection. AIM: To evaluate treatment and outcomes of patients with duodenal carcinoid. METHODS: We conducted a retrospective review of all patients at our tertiary referral center with primary duodenal carcinoid from 1976-1999. Functional islet cell tumors were excluded. RESULTS:27 patients (15 M, 12 F) with a median age of 66 (range 43-86) were evaluated. Over half (52%) were diagnosed in the period 199599. The most common pre-treatment symptom was abdominal pain (50%); other symptoms included nausea, vomiting, weight loss, GI blood loss, pancreatitis, and GERD. Four patients were asymptomatic. Endoscopic biopsy provided diagnosis in 78%. No patient had other synchronous GI carcinoid tumors, but 9 had another primary malignancy. Sixteen carcinoid tumors were located in the first portion of the duodenum (D1), 9 were in D2 (2 periampullary), and 2 in D3/D4. Treatment was by endoscopic excision in 11, transduodenal excision in 8, pencreaticoduodenectomyin 4, segmental excision of D3/D4 in 2, and palliative operation in 1. One patient did not undergo operation due to comorbidities. All 11 patients treated with endoscopic excision had tumors -< 1.0 cm. One was lost to follow up, the other 10 are alive and tumor free (median follow up 3.4 years, range 0.2-8). The one recurrence in this group was successfully treated by endoscopic re-excision (no recurrence 7 years later). Thirteen patients (mean tumor size: 2.3 cm; range: 0.4-8 cm underwent operative excision with curative intent (median follow up: 4.3 years, range 1.5-23); one had nodal metastasis at operation. Three died of tumor, 4 are alive with hepatic metastasis, and 6 remain tumor free. Three patients in this series later developed carcinoid syndrome (flushing, diarrhea, or asthma). CONCLUSION: Duodenal carcinoid tumors appear to act like appendiceal carcinoids with a good prognosis for small tumors, though many are associated with other malignancies. Endoscopic excision of tumors -< 1.0 cm provides appropriate therapy, though endoscopic follow up is indicated. Patients with larger tumors probably benefit from more aggressive Iocoregional resection.

n Size (ram) Morbidity

h~r=my

a, d o ~ y

s.rge~

25 12 -+6 1 (4%)

13 50 ± 33 * 1 (7%)

o (o%)

o (0%)

Morbidity: Bleeding,reoperation,and deepvenousthrombosis • p < 0.05vs Endoscopy

2475 Laparessopic Treatment Of Chronic And Acute Bowel Obstruction: A Valid Alternative J. Arturo Aimeida, Morris E. Franklin, Jeffrey L. Glass, Robert Lp Michaelson, Texas Endosurgery Institute, San Antonio, TX Bowel obstruction is a frequent indication for emergent surgery. Lapamscopic approach has beau considered a relative contraindication due to the potential for bowel distension and risk of intestinal surgery. As experience in laparoscopic surgery has increased, diagnosis and treatmet of this entity can be accomplished laparoscopically. Methods:An unselected group of patients diagnosed of bowel obstruction by clinical signs and symptoms and radiological studies underwent a laparoscogic procedure due to failure of medical treatment. Operative findings, procedure performed, perioperativeand postoperativecourse, early and late complications and conversion rate were all considered. Resuits:167 patients met the inclusion criteria. The most common findings were adhesions,abdominal wall hernias, primary cancer, inflammatory bowel disease, internal hernias and diverficular disease. The average age was 62 years (range 21-98). Laparoscopy was diagnostic in 100% of cases, and in 92.5% the definite treatment was accomplished laparoscopically. The conversion rate was 7.8%, mostly secondan/to massive distension, inability to completely run the bowel, intestinal necrosis or advanced cancer.We have observed that a minimum of 600 cc of CO2 must be insufflated to accomplish the laparos¢opic. Complications included wound infection in 4.2%, delayed ileus in 4.8%, sepsis 2.9%, reobstruction 42%. Overalmortality was 2.4% Conclusion: Laparoscopic surgery is an effective diagnostic tool in bowel obstruction, with the advantagesof a minimally invasive

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