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Laparoscopic Compared with Open Pancreaticoduodenectomy Is Safe and Effective in the Elderly
Vol. 223, No. 4S1, October 2016
Table. Association Between Timing of Cholecystectomy for Acute Cholecystitis and Total Health Care Utilization and Postoperative Outcomes LaparoscopicTotal days Total to-open Major bile in hospital, charges, conversion, duct injury, IRR (CI) IRR (CI) OR (CI) OR (CI) 1.63 (1.26e2.09) 0.62 (0.22e1.76) 0.77 (0.62e0.95) 0.28 (0.15e0.56)
Scientific Forum Abstracts
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(p¼0.9582) were not associated with mortality. Hepatic resection at an ACP was associated with a significantly longer 10-year survival (25.5%) compared with CCCP (22.1%) and CCP (18.1%) (all p<0.0001) (Figure).
Variable Propensity score Timing of cholecystectomy Early, 2 d 1.83 (1.70e1.96) 1.49 (1.06e2.09) 1.24 (1.16e1.33) 1.62 (1.27e2.06) Late, > 2 d
1.41 (1.28e1.55) 1.42 (0.98e2.05) 0.97 (0.87e1.07) 2.42 (1.77e3.31)
IRR, incidence rate ratio; OR, odds ratio.
CONCLUSIONS: Despite evidence from randomized controlled trials, almost one-third of patients seemingly do not receive an evidence-based approach that has a significant negative impact on outcomes. Understanding the drivers behind such clinical decision making remains very important to changing behavior and improving outcomes. Hepatic Resection for Hepatocellular Carcinoma at an Academic Medical Center Is Associated with Improved Long-Term Survival Brandon C Chapman, MD, Alessandro Paniccia, MD, Douglas M Overbey, MD, Patrick Hosokawa, William G Henderson, MPH, PhD, Ana Gleisner, MD, PhD, Martin D McCarter, MD, FACS, Barish H Edil, MD, FACS, Richard D Schulick, MD, MBA, FACS, Csaba Gajdos, MD, FACS University of Colorado, Aurora, CO INTRODUCTION: Previous studies have demonstrated improved outcomes after hepatic resection for hepatocellular carcinoma (HCC) in high-volume hospitals. The objective of this study was to evaluate long-term survival in patients undergoing hepatic resection of HCC at various facility types. METHODS: Using the National Cancer Database (1998 to 2011), we evaluated patients undergoing hepatic resection for HCC at comprehensive community cancer programs (CCCP), community cancer programs (CCP), and academic cancer programs (ACP). Patients undergoing hepatic transplantation were excluded. Multivariate Cox proportional hazard models were applied to estimate hazard ratios (HR) of predictors of mortality. The Kaplan-Meier method was used to generate survival curves, and survival rates between facility type were compared using the log-rank test. RESULTS: We identified 12,757 patients undergoing hepatic resection for HCC: CCP (n¼483), CCCP (n¼3,870), and ACP (n¼8,404). On multivariate analysis, both CCP and CCCP were independent predictors of mortality (HR 1.312, 95% CI 1.1721.463 and HR 1.127, 95% CI 1.072-1.185, respectively). Additional predictors of mortality included age, sex, race, TNM stage, grade, tumor size, income, T-stage, Charlson-Deyo score, node positive, alpha fetoprotein level, insurance status, year of diagnosis, international normalized ratio, underlying cirrhosis, procedure type, and M-stage (all p<0.001). Radiation (p¼0.4485), chemotherapy (p¼0.2207), education (p¼0.6998), and living location
Figure. Adjusted Kaplan-Meier Plot Stratified by Facility Type
CONCLUSIONS: Hepatic resections performed at ACPs are associated with improved long-term survival. Further studies are needed to define which patients benefit from undergoing surgery at ACPs. Laparoscopic Compared with Open Pancreaticoduodenectomy Is Safe and Effective in the Elderly Brandon C Chapman, MD, Csaba Gajdos, MD, FACS, Patrick Hosokawa, William G Henderson, MPH, PhD, Alessandro Paniccia, MD, Douglas M Overbey, MD, Ana Gleisner, MD, PhD, Martin D McCarter, MD, FACS, Richard D Schulick, MD, MBA, FACS, Barish H Edil, MD, FACS University of Colorado School of Medicine, Aurora, CO INTRODUCTION: Open pancreaticoduodenectomy (OPD) in elderly patients is performed with acceptable morbidity and mortality. This study is the first to compare perioperative outcomes in elderly patients undergoing total laparoscopic pancreaticoduodenectomy (TLPD) and OPD. METHODS: Patients aged 65 years or older with pancreatic adenocarcinoma, undergoing TLPD or OPD, were identified from the National Cancer Database (2010-2011). Robotic and TLPD converted to OPD were excluded. Differences in baseline characteristics were compared using a Student’s t-test and chi-square test, as appropriate. Perioperative outcomes between TLPD and OPD were compared using multivariate logistic regression. RESULTS: We identified 1,990 elderly patients who underwent TLPD (n¼176) or OPD (n¼1,814). The use of TLPD increased significantly from 2010 to 2011 (p¼0.0004). There were no differences in baseline characteristics including age, sex, race, and Charlson-Deyo score (all p>0.05); however, patients in the TLPD group
S76
J Am Coll Surg
Scientific Forum Abstracts
traveled greater distances (p<0.0001) and were more likely to have surgery at an academic center (p¼0.0137). Pathologic characteristics were similar between the groups: tumor size, grade, T-stage, N-stage, neoadjuvant chemotherapy and radiotherapy, and stage (all p>0.05). On multivariate analysis, TLPD was associated with a lower positive margin rate (odds ratio [OR] 0.629, 95% CI 0.413, 0.932). There was no difference in number of nodes examined, lymph node ratio, length of stay, readmission (all p>0.05). Similarly, 30-day mortality was equivalent (TLPD 5.7% vs OPD 5.1%, p¼0.60). CONCLUSIONS: TLPD performed in elderly patients is safe, feasible, and may be associated with improved oncologic outcomes; however, randomized controlled trials are needed to avoid selection bias. Laparoscopic-Assisted Transgastric ERCP Decreases Length of Stay Compared with Common Bile Duct Exploration in the Treatment of Choledocholithiasis after Gastric Surgery Russell C Kirks, Jr, MD, Patrick D Lorimer, MD, Mike Fruscione, MD, Allyson R Cochran, Stephen E Deal, MD, FACG, Erin H Baker, MD, John B Martinie, MD, FACS, David A Iannitti, MD, FACS, Dionisios Vrochides, MD, PhD, FACS, FRCSC Carolinas Medical Center, Charlotte, NC
Table. Variable Age, y, median (range) BMI, kg/m,2 median Antrectomy, n (%) Gastric bypass, n (%) Cholangitis, n (%) Choledocholithiasis, n (%) Biliary stricture or obstruction, n (%) Surgical LOS, d, median (range)
Transgastric ERCP CBDE (n ¼ 14) (n ¼ 16) 61.5 (39e69) 66.5 (40e79) 33.5 24.6 0 (0.0) 8 (50) 14 (100) 8 (50) 2 (14.3) 1 (6.3) 8 (57.1) 5 (31.3) 4 (28.6) 10 (62.5) 2 (1e15) 4.5 (2e28)
p Value 0.091 0.019
0.464 0.153 0.063 0.011
CONCLUSIONS: T-ERCP is a minimally invasive option for treatment of choledocholithiasis after gastric surgery when gastroduodenal anatomy is preserved. T-ERCP facilitates shorter LOS and demonstrates similar efficacy when compared with CBDE. Developing dedicated perioperative pathways incorporating surgical and endoscopic interventions may allow T-ERCP to be performed as an observation admission.
Minimally Invasive Surgical Approaches Offer Earlier Time to Adjuvant Chemotherapy but Are Not Yet Associated with Improved Survival in Resected Pancreatic Cancer Katelin A Mirkin, MD, Erin K Greenleaf, MD, Christopher S Hollenbeak, PhD, Joyce Wong, MD Penn State Hershey, Hershey, PA
INTRODUCTION: Endoscopic stone extraction during cholecystectomy has been suggested as an overnight admission to manage choledocholithiasis. Post-gastrojejunostomy anatomy complicates endoscopic biliary access. Optimal encounter length has not been explored in these patients.
INTRODUCTION: Pancreatic surgery encompasses complex operations with significant potential morbidity. Greater experience in minimally invasive surgery (MIS) have allowed resections to be performed laparoscopically and robotically. This study evaluated the impact of surgical approach in resected pancreatic cancer.
METHODS: We examined records of patients with a history of distal gastrectomy with gastrojejunostomy and gastric bypass, who required surgical biliary intervention at a single institution from January 1, 2008 to September 30, 2015. Demographics, comorbidities, operative variables, outcomes, and complications were compared between patients receiving laparoscopic-assisted transgastric ERCP (T-ERCP) and common bile duct exploration (CBDE).
METHODS: The National Cancer Data Base (2010-2012) was reviewed for patients with stages I-III resected pancreatic carcinoma, stratified by surgical approach.
RESULTS: Of 30 patients included, 8 underwent Billroth II reconstruction and 22 underwent gastric bypass. Fourteen postbypass patients underwent T-ERCP. Median surgical length of stay (LOS) was shorter after T-ERCP than after CBDE (2 vs 4.5 days; p ¼ 0.001). Additional procedures were performed on all patients undergoing T-ERCP. No differences were observed between groups in age, estimated blood loss, operative time, and postoperative complications (Table). BMI was higher in patients who underwent T-ERCP (33.5 vs 24.6 kg/m2, p ¼ 0.019). No patient was readmitted within 30 days of T-ERCP; 3 readmissions occurred within 30 days of other biliary procedures (p ¼ 0.08).
RESULTS: There were 9,047 patients evaluated; surgical approach was open in 7,511 (83%), laparoscopic in 992 (11%), and robotic in 131 (1%). The laparoscopic and robotic conversion rates to open were 39% (n¼387) and 20% (n¼26), respectively. Compared with open, MIS was associated with greater distal resections (13.5%, 24.3%, respectively, p < 0.0001), shorter hospital length of stay (LOS) (11.3 days; 9.5 days, respectively, p < 0.0001), greater margin-negative resections (75%, 79%, p¼0.038), and quicker time to initiation of chemotherapy (TTC) (59.1 days; 56.3 days, respectively, p ¼ 0.0316) (Table). There was no difference in number of lymph nodes obtained based on surgical approach (p¼0.5385). When stratified by type of resection (head, distal, or total), MIS offered significantly shorter LOS in all types. Multivariate analysis demonstrated no survival benefit for MIS relative to open (hazard ratio [HR] 1.03, 95% CI 0.92, 1.15, p¼0.633).When adjusted for patient, disease, and surgery characteristics, however, those with TTC after 57 days had a 39% greater hazard of mortality at 5 years, p<0.0001.
Table. Association Between Timing of Cholecystectomy for Acute Cholecystitis and Total Health Care Utilization and Postoperative Outcomes LaparoscopicTotal days Total to-open Major bile in hospital, charges, conversion, duct injury, IRR (CI) IRR (CI) OR (CI) OR (CI) 1.63 (1.26e2.09) 0.62 (0.22e1.76) 0.77 (0.62e0.95) 0.28 (0.15e0.56)
Scientific Forum Abstracts
S75
(p¼0.9582) were not associated with mortality. Hepatic resection at an ACP was associated with a significantly longer 10-year survival (25.5%) compared with CCCP (22.1%) and CCP (18.1%) (all p<0.0001) (Figure).
Variable Propensity score Timing of cholecystectomy Early, 2 d 1.83 (1.70e1.96) 1.49 (1.06e2.09) 1.24 (1.16e1.33) 1.62 (1.27e2.06) Late, > 2 d
1.41 (1.28e1.55) 1.42 (0.98e2.05) 0.97 (0.87e1.07) 2.42 (1.77e3.31)
IRR, incidence rate ratio; OR, odds ratio.
CONCLUSIONS: Despite evidence from randomized controlled trials, almost one-third of patients seemingly do not receive an evidence-based approach that has a significant negative impact on outcomes. Understanding the drivers behind such clinical decision making remains very important to changing behavior and improving outcomes. Hepatic Resection for Hepatocellular Carcinoma at an Academic Medical Center Is Associated with Improved Long-Term Survival Brandon C Chapman, MD, Alessandro Paniccia, MD, Douglas M Overbey, MD, Patrick Hosokawa, William G Henderson, MPH, PhD, Ana Gleisner, MD, PhD, Martin D McCarter, MD, FACS, Barish H Edil, MD, FACS, Richard D Schulick, MD, MBA, FACS, Csaba Gajdos, MD, FACS University of Colorado, Aurora, CO INTRODUCTION: Previous studies have demonstrated improved outcomes after hepatic resection for hepatocellular carcinoma (HCC) in high-volume hospitals. The objective of this study was to evaluate long-term survival in patients undergoing hepatic resection of HCC at various facility types. METHODS: Using the National Cancer Database (1998 to 2011), we evaluated patients undergoing hepatic resection for HCC at comprehensive community cancer programs (CCCP), community cancer programs (CCP), and academic cancer programs (ACP). Patients undergoing hepatic transplantation were excluded. Multivariate Cox proportional hazard models were applied to estimate hazard ratios (HR) of predictors of mortality. The Kaplan-Meier method was used to generate survival curves, and survival rates between facility type were compared using the log-rank test. RESULTS: We identified 12,757 patients undergoing hepatic resection for HCC: CCP (n¼483), CCCP (n¼3,870), and ACP (n¼8,404). On multivariate analysis, both CCP and CCCP were independent predictors of mortality (HR 1.312, 95% CI 1.1721.463 and HR 1.127, 95% CI 1.072-1.185, respectively). Additional predictors of mortality included age, sex, race, TNM stage, grade, tumor size, income, T-stage, Charlson-Deyo score, node positive, alpha fetoprotein level, insurance status, year of diagnosis, international normalized ratio, underlying cirrhosis, procedure type, and M-stage (all p<0.001). Radiation (p¼0.4485), chemotherapy (p¼0.2207), education (p¼0.6998), and living location
Figure. Adjusted Kaplan-Meier Plot Stratified by Facility Type
CONCLUSIONS: Hepatic resections performed at ACPs are associated with improved long-term survival. Further studies are needed to define which patients benefit from undergoing surgery at ACPs. Laparoscopic Compared with Open Pancreaticoduodenectomy Is Safe and Effective in the Elderly Brandon C Chapman, MD, Csaba Gajdos, MD, FACS, Patrick Hosokawa, William G Henderson, MPH, PhD, Alessandro Paniccia, MD, Douglas M Overbey, MD, Ana Gleisner, MD, PhD, Martin D McCarter, MD, FACS, Richard D Schulick, MD, MBA, FACS, Barish H Edil, MD, FACS University of Colorado School of Medicine, Aurora, CO INTRODUCTION: Open pancreaticoduodenectomy (OPD) in elderly patients is performed with acceptable morbidity and mortality. This study is the first to compare perioperative outcomes in elderly patients undergoing total laparoscopic pancreaticoduodenectomy (TLPD) and OPD. METHODS: Patients aged 65 years or older with pancreatic adenocarcinoma, undergoing TLPD or OPD, were identified from the National Cancer Database (2010-2011). Robotic and TLPD converted to OPD were excluded. Differences in baseline characteristics were compared using a Student’s t-test and chi-square test, as appropriate. Perioperative outcomes between TLPD and OPD were compared using multivariate logistic regression. RESULTS: We identified 1,990 elderly patients who underwent TLPD (n¼176) or OPD (n¼1,814). The use of TLPD increased significantly from 2010 to 2011 (p¼0.0004). There were no differences in baseline characteristics including age, sex, race, and Charlson-Deyo score (all p>0.05); however, patients in the TLPD group
S76
J Am Coll Surg
Scientific Forum Abstracts
traveled greater distances (p<0.0001) and were more likely to have surgery at an academic center (p¼0.0137). Pathologic characteristics were similar between the groups: tumor size, grade, T-stage, N-stage, neoadjuvant chemotherapy and radiotherapy, and stage (all p>0.05). On multivariate analysis, TLPD was associated with a lower positive margin rate (odds ratio [OR] 0.629, 95% CI 0.413, 0.932). There was no difference in number of nodes examined, lymph node ratio, length of stay, readmission (all p>0.05). Similarly, 30-day mortality was equivalent (TLPD 5.7% vs OPD 5.1%, p¼0.60). CONCLUSIONS: TLPD performed in elderly patients is safe, feasible, and may be associated with improved oncologic outcomes; however, randomized controlled trials are needed to avoid selection bias. Laparoscopic-Assisted Transgastric ERCP Decreases Length of Stay Compared with Common Bile Duct Exploration in the Treatment of Choledocholithiasis after Gastric Surgery Russell C Kirks, Jr, MD, Patrick D Lorimer, MD, Mike Fruscione, MD, Allyson R Cochran, Stephen E Deal, MD, FACG, Erin H Baker, MD, John B Martinie, MD, FACS, David A Iannitti, MD, FACS, Dionisios Vrochides, MD, PhD, FACS, FRCSC Carolinas Medical Center, Charlotte, NC
Table. Variable Age, y, median (range) BMI, kg/m,2 median Antrectomy, n (%) Gastric bypass, n (%) Cholangitis, n (%) Choledocholithiasis, n (%) Biliary stricture or obstruction, n (%) Surgical LOS, d, median (range)
Transgastric ERCP CBDE (n ¼ 14) (n ¼ 16) 61.5 (39e69) 66.5 (40e79) 33.5 24.6 0 (0.0) 8 (50) 14 (100) 8 (50) 2 (14.3) 1 (6.3) 8 (57.1) 5 (31.3) 4 (28.6) 10 (62.5) 2 (1e15) 4.5 (2e28)
p Value 0.091 0.019
0.464 0.153 0.063 0.011
CONCLUSIONS: T-ERCP is a minimally invasive option for treatment of choledocholithiasis after gastric surgery when gastroduodenal anatomy is preserved. T-ERCP facilitates shorter LOS and demonstrates similar efficacy when compared with CBDE. Developing dedicated perioperative pathways incorporating surgical and endoscopic interventions may allow T-ERCP to be performed as an observation admission.
Minimally Invasive Surgical Approaches Offer Earlier Time to Adjuvant Chemotherapy but Are Not Yet Associated with Improved Survival in Resected Pancreatic Cancer Katelin A Mirkin, MD, Erin K Greenleaf, MD, Christopher S Hollenbeak, PhD, Joyce Wong, MD Penn State Hershey, Hershey, PA
INTRODUCTION: Endoscopic stone extraction during cholecystectomy has been suggested as an overnight admission to manage choledocholithiasis. Post-gastrojejunostomy anatomy complicates endoscopic biliary access. Optimal encounter length has not been explored in these patients.
INTRODUCTION: Pancreatic surgery encompasses complex operations with significant potential morbidity. Greater experience in minimally invasive surgery (MIS) have allowed resections to be performed laparoscopically and robotically. This study evaluated the impact of surgical approach in resected pancreatic cancer.
METHODS: We examined records of patients with a history of distal gastrectomy with gastrojejunostomy and gastric bypass, who required surgical biliary intervention at a single institution from January 1, 2008 to September 30, 2015. Demographics, comorbidities, operative variables, outcomes, and complications were compared between patients receiving laparoscopic-assisted transgastric ERCP (T-ERCP) and common bile duct exploration (CBDE).
METHODS: The National Cancer Data Base (2010-2012) was reviewed for patients with stages I-III resected pancreatic carcinoma, stratified by surgical approach.
RESULTS: Of 30 patients included, 8 underwent Billroth II reconstruction and 22 underwent gastric bypass. Fourteen postbypass patients underwent T-ERCP. Median surgical length of stay (LOS) was shorter after T-ERCP than after CBDE (2 vs 4.5 days; p ¼ 0.001). Additional procedures were performed on all patients undergoing T-ERCP. No differences were observed between groups in age, estimated blood loss, operative time, and postoperative complications (Table). BMI was higher in patients who underwent T-ERCP (33.5 vs 24.6 kg/m2, p ¼ 0.019). No patient was readmitted within 30 days of T-ERCP; 3 readmissions occurred within 30 days of other biliary procedures (p ¼ 0.08).
RESULTS: There were 9,047 patients evaluated; surgical approach was open in 7,511 (83%), laparoscopic in 992 (11%), and robotic in 131 (1%). The laparoscopic and robotic conversion rates to open were 39% (n¼387) and 20% (n¼26), respectively. Compared with open, MIS was associated with greater distal resections (13.5%, 24.3%, respectively, p < 0.0001), shorter hospital length of stay (LOS) (11.3 days; 9.5 days, respectively, p < 0.0001), greater margin-negative resections (75%, 79%, p¼0.038), and quicker time to initiation of chemotherapy (TTC) (59.1 days; 56.3 days, respectively, p ¼ 0.0316) (Table). There was no difference in number of lymph nodes obtained based on surgical approach (p¼0.5385). When stratified by type of resection (head, distal, or total), MIS offered significantly shorter LOS in all types. Multivariate analysis demonstrated no survival benefit for MIS relative to open (hazard ratio [HR] 1.03, 95% CI 0.92, 1.15, p¼0.633).When adjusted for patient, disease, and surgery characteristics, however, those with TTC after 57 days had a 39% greater hazard of mortality at 5 years, p<0.0001.