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M1522 Prognosis After Surgery of Cholangiocarcinoma: Peripheral Intra-Hepatic Cholangiocarcinoma Versus Peri-Hilar Cholangiocarcinoma
with GERD (p=0.11). Univariate logistic regression identified 10/22 key GERD questions that were significantly associated with DT/DS. In multivariate analyses, only two questions (“Has acid regurgitation awakened you at night?” and “Have you ever had esophageal or gastric disease?”) remained significant; the c-statistic was 0.60 for DT/DS. An expanded analysis incorporated three additional clinically important GERD questions to the model (“How many years since your first onset of symptoms?”, “Has heartburn awakened you at night?”, and “What gender are you?”), and a scoring system was developed. 100% of individuals scoring ≥7 on an 8-point scale had true GERD; specificity and sensitivity for DT/DS were 100% and 14.0%, respectively. Sensitivity for any of these combinations of questions never reached above 70%. Conclusion: No single or combination of components of GERDQ was sensitive enough to rule out patients for esophageal pH monitoring. Though a five-question short questionnaire may be useful for predicting a small subset of patients who have a very high chance of having true GERD, subjective questionnaire information was not useful in predicting which patients did not have GERD.
M1523 Unilateral vs Bilateral Plastic Stenting for Malignant Hilar Stricture: A MetaAnalysis and Systematic Review of Risks Srinivas R. Puli, Matthew L. Bechtold, Jyotsna BK Reddy, Mainor R. Antillon, David L. Carr-Locke Backgound: Plastic stents are used for palliating inoperable malignant hilar strictures. It is unclear if bilateral plastic stenting provides any advantage over unilateral stenting Aim: To compare bilateral and unilateral plastic stenting in malignant hilar strictures. Method: Study Selection Criteria: Studies using plastic stents for palliation in patients with malignant hilar stricture. Data collection & extraction: Articles searched in Medline, Pubmed, Japanese language literature, Ovid journals, CINAH, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Statistical Method: Pooled proportions were calculated using Mantel-Haenszel method (fixed effects model) and by the DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. Results: 1540 reference articles were identified, of which 129 were selected and reviewed. 8 studies (N=367) for bilateral plastic stenting and 8 studies (N=850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in table 1. The pooled estimated by fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. Conclusions: Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30 day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events. Table 1: Comparison of bilateral plastic vs unilateral plastic stenting for malignant hilar obstruction
1085
SSAT Abstracts
Surgical Resection for Locoregional Esophageal Cancer Is Underutilized in the United States Attila Dubecz, Boris Sepesi, Renato Salvador, Marek Polomsky, Carolyn E. Jones, Virginia R. Litle, Daniel Raymond, Thomas J. Watson, Juan P. Wisnivesky, Jeffrey H. Peters Background: While it is commonly reported that over half of patients with esophageal cancer (EC)initially present with systemic metastases, data from the American Cancer Society indicate that at least 55%, and as many as 70%, present with locoregional disease alone. While esophagectomy provides the highest probability of long-term cure, the perception of poor overall survival and high perioperative mortality results in many candidates never being referred for surgical evaluation. We hypothesized that esophagectomy for EC is underutilized and assessed the prevalence of resection in national, state and local cancer data registries. Patients and Methods: Clinical stage, surgical and non-surgical treatments, age, and race of patients with EC were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988-2004), the Hospital Association of NY State registry (HANYS 2007) and a single referral center (2000-2007). SEER identified a total of 25,306 patients with EC(average age: 65.0 years, male-to-female ratio: 3.1); treatment modality was identifiable in 22,617. HANYS identified 1519 admissions for cancer of the esophagus and cardia (average age: 67 years, M:F ratio 3:1); treatment modality was identifiable in all patients, though stage was not available from NY state registry data. A single referral center identified 420 patients (52/ year; average age: 67 years, M:F, 3:1); treatment modality and stage were available in all. For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race and gender. Results: Sixty-three percent of the SEER population (14,240) was classified as having locoregional disease. Surgical resection was performed in 25% (5,644/22,617) of the total and only 39.6% of potentially resectable patients (5,644/14,240) . Similarly, resection was performed in 28.6% (443/1519) of the total admissions from NY State. By comparison, 65% (272/420) of patients at a specialized referral center underwent surgical resection. Fifty seven percent (8,133) of patients in the SEER registry received no operative therapy. Resection rates for EC did not change between 1988 and 2004. Males were more likely to receive operative treatment (OR: 1.1, p<0.05). Whites and blacks were less likely to undergo surgery than Asians (OR: 1.47, p<0.01). Conclusion: Surgical resection for locoregional EC is likely underutilized. Racial variations in esophagectomy are significant. While the pattern of utilization is poorly documented and largely unexplained, we believe that referral to specialized centers may result in an increase in patients considered for surgical therapy.
M1524 Can Pre-Operative Clinical and Imaging Findings Predict the Laparoscopic or Open Approach for Cholecystectomy? a One-Year Study from a Community Based Teaching Hospital Sumeet Virmani, Saravana Balaraman, Michael J. Jacobs, Lorenzo Ferguson, Vijay Mittal Introduction: Laparoscopic cholecystectomy is the gold standard for the treatment of cholelithiasis; however the conversion rate varies from 1-20%. In spite of the recent advances both in terms of surgeon's experience / technique and the availability of newer sophisticated instruments the incidence of conversion is actually true. This conversion is neither a failure nor a complication, but an attempt to avoid complications. Our aim was to evaluate the various preoperative risk factors that could accurately predict the conversion from laparoscopic to open cholecystectomy. Methods: All patients who had undergone cholecystectomy over the 12-month period from July 2007 to June 2008 at our hospital were included in the study. Retrospective analysis of the charts of these patients was done. Clinical, hematological, biochemical, imaging parameters and operative findings were recorded. Patients with additional procedures planned or who had a provisional diagnosis of gall bladder cancer were excluded from the study. Results: Four hundred and seventy one patients successfully underwent cholecystectomy over a 12-month period from July 2007 to June 2008. 1.91% (9/471) patients were directly planned for open cholecystectomy. Overall conversion rate in our study was 4.67% (22/471). The most frequent reason for conversion was severe inflammation and unclear anatomy at calot's triangle (n=12) followed by adhesions (n=6) and gangrenous cholecystitis (n=3). One patient had to be converted to open approach because of severe obesity and failure to create pneumoperitoneum. Multivariate analysis identified elderly patients (>60 years), elevated white cell count (>11,000/cu mm), elevated bilirubin (>1.5mg/dL), CBD stones, evidence of gall bladder wall thickness (>3mm) and/or pericholecystic fluid (either on Ultrasound / CT scan) and a positive HIDA scan as independent predictors of conversion. The post graduate year of resident assisting in the case had no significant effect on conversion rate. Conclusion: Pre-operative clinical and imaging findings can successfully predict in selecting the laparoscopic or open approach or on the least can alert the surgeon for a possible difficult surgery. Apart from choosing the approach, it also improves patient counseling, helps in better perioperative planning and decreases post operative morbidity and hospital costs.
M1522 Prognosis After Surgery of Cholangiocarcinoma: Peripheral Intra-Hepatic Cholangiocarcinoma Versus Peri-Hilar Cholangiocarcinoma Andrea Ruzzenente, Silvia Pachera, Tommaso Campagnaro, Alessandro Valdegamberi, Paola Capelli, Paola Nicoli, Calogero Iacono, Alfredo Guglielmi Background. Cholangiocarcinoma is the second most frequent primary liver cancer, despite improvement of diagnosis only few patients can be submitted to resective surgery with curative intent. According to its location and characteristcs cholangiocarcinoma can be classified into two different categories: peripheral intrahepatic colangiocacinoma (ICC) and perihilar cholangiocarcinoma (PCC). The aim of this study is to compare the results of resective surgery of ICC and PCC. Methods. Ninety-five out of 152 patients observed between January 1990 and December 2007 in a single division of surgery of University of Verona Medical School underwent to surgical resection of a ICC (33 patients) or PCC (62 patients); the resectability rate was 62.5 %. R0 resection was achieved in 73 patients (77%). The surgical resections included 65 (66.%) major liver resections and 60 patients (62%) underwent combined extra-hepatic bile duct resection. Results. The median survival of the entire group was 24 months; actuarial 3- and 5-year survival was respectively 44% and 23%. Univariate analysis showed that the factors associated with survival were tumor type (ICC or PCC) , an R0 resection, lymph node metastasis and macroscopic vascular invasion. Multivariate analysis identified that R0 resection and macroscopic vascular invasion were the most important prognostic factors associated with survival, with hazard ratios of respectively 2.14 and 1.95. Further analysis identify that survival was significantly longer in ICC compared to PCC with a 5 years survival of 26 and 13 %, respectively. The analysis of the different clinico-pathological factors identified a significant higher rate of R+ resection, perineural infiltration, regional lymph node metastases and macro-vascular invasion in PCC compared to ICC. Conclusion. Our results confirm that only R0 resection can provide good long term survival. The macroscopic type of the tumor (ICC or PCC) is an important prognostic factor and the higher frequency of negative clinico-pathological factors can explain the worse prognosis of PCC.
SSAT Abstracts
A-888
M1523 Unilateral vs Bilateral Plastic Stenting for Malignant Hilar Stricture: A MetaAnalysis and Systematic Review of Risks Srinivas R. Puli, Matthew L. Bechtold, Jyotsna BK Reddy, Mainor R. Antillon, David L. Carr-Locke Backgound: Plastic stents are used for palliating inoperable malignant hilar strictures. It is unclear if bilateral plastic stenting provides any advantage over unilateral stenting Aim: To compare bilateral and unilateral plastic stenting in malignant hilar strictures. Method: Study Selection Criteria: Studies using plastic stents for palliation in patients with malignant hilar stricture. Data collection & extraction: Articles searched in Medline, Pubmed, Japanese language literature, Ovid journals, CINAH, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Statistical Method: Pooled proportions were calculated using Mantel-Haenszel method (fixed effects model) and by the DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. Results: 1540 reference articles were identified, of which 129 were selected and reviewed. 8 studies (N=367) for bilateral plastic stenting and 8 studies (N=850) for unilateral plastic stenting which met the inclusion criteria were included in this analysis. Pooled data are shown in table 1. The pooled estimated by fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. Conclusions: Unilateral plastic stenting seems to have similar odds of overall complications, cholangitis, and 30 day mortality when compared to bilateral plastic stenting for malignant hilar strictures. In patients with malignant hilar stricture, unilateral plastic stenting is comparable to bilateral plastic stenting for adverse events. Table 1: Comparison of bilateral plastic vs unilateral plastic stenting for malignant hilar obstruction
1085
SSAT Abstracts
Surgical Resection for Locoregional Esophageal Cancer Is Underutilized in the United States Attila Dubecz, Boris Sepesi, Renato Salvador, Marek Polomsky, Carolyn E. Jones, Virginia R. Litle, Daniel Raymond, Thomas J. Watson, Juan P. Wisnivesky, Jeffrey H. Peters Background: While it is commonly reported that over half of patients with esophageal cancer (EC)initially present with systemic metastases, data from the American Cancer Society indicate that at least 55%, and as many as 70%, present with locoregional disease alone. While esophagectomy provides the highest probability of long-term cure, the perception of poor overall survival and high perioperative mortality results in many candidates never being referred for surgical evaluation. We hypothesized that esophagectomy for EC is underutilized and assessed the prevalence of resection in national, state and local cancer data registries. Patients and Methods: Clinical stage, surgical and non-surgical treatments, age, and race of patients with EC were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988-2004), the Hospital Association of NY State registry (HANYS 2007) and a single referral center (2000-2007). SEER identified a total of 25,306 patients with EC(average age: 65.0 years, male-to-female ratio: 3.1); treatment modality was identifiable in 22,617. HANYS identified 1519 admissions for cancer of the esophagus and cardia (average age: 67 years, M:F ratio 3:1); treatment modality was identifiable in all patients, though stage was not available from NY state registry data. A single referral center identified 420 patients (52/ year; average age: 67 years, M:F, 3:1); treatment modality and stage were available in all. For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race and gender. Results: Sixty-three percent of the SEER population (14,240) was classified as having locoregional disease. Surgical resection was performed in 25% (5,644/22,617) of the total and only 39.6% of potentially resectable patients (5,644/14,240) . Similarly, resection was performed in 28.6% (443/1519) of the total admissions from NY State. By comparison, 65% (272/420) of patients at a specialized referral center underwent surgical resection. Fifty seven percent (8,133) of patients in the SEER registry received no operative therapy. Resection rates for EC did not change between 1988 and 2004. Males were more likely to receive operative treatment (OR: 1.1, p<0.05). Whites and blacks were less likely to undergo surgery than Asians (OR: 1.47, p<0.01). Conclusion: Surgical resection for locoregional EC is likely underutilized. Racial variations in esophagectomy are significant. While the pattern of utilization is poorly documented and largely unexplained, we believe that referral to specialized centers may result in an increase in patients considered for surgical therapy.
M1524 Can Pre-Operative Clinical and Imaging Findings Predict the Laparoscopic or Open Approach for Cholecystectomy? a One-Year Study from a Community Based Teaching Hospital Sumeet Virmani, Saravana Balaraman, Michael J. Jacobs, Lorenzo Ferguson, Vijay Mittal Introduction: Laparoscopic cholecystectomy is the gold standard for the treatment of cholelithiasis; however the conversion rate varies from 1-20%. In spite of the recent advances both in terms of surgeon's experience / technique and the availability of newer sophisticated instruments the incidence of conversion is actually true. This conversion is neither a failure nor a complication, but an attempt to avoid complications. Our aim was to evaluate the various preoperative risk factors that could accurately predict the conversion from laparoscopic to open cholecystectomy. Methods: All patients who had undergone cholecystectomy over the 12-month period from July 2007 to June 2008 at our hospital were included in the study. Retrospective analysis of the charts of these patients was done. Clinical, hematological, biochemical, imaging parameters and operative findings were recorded. Patients with additional procedures planned or who had a provisional diagnosis of gall bladder cancer were excluded from the study. Results: Four hundred and seventy one patients successfully underwent cholecystectomy over a 12-month period from July 2007 to June 2008. 1.91% (9/471) patients were directly planned for open cholecystectomy. Overall conversion rate in our study was 4.67% (22/471). The most frequent reason for conversion was severe inflammation and unclear anatomy at calot's triangle (n=12) followed by adhesions (n=6) and gangrenous cholecystitis (n=3). One patient had to be converted to open approach because of severe obesity and failure to create pneumoperitoneum. Multivariate analysis identified elderly patients (>60 years), elevated white cell count (>11,000/cu mm), elevated bilirubin (>1.5mg/dL), CBD stones, evidence of gall bladder wall thickness (>3mm) and/or pericholecystic fluid (either on Ultrasound / CT scan) and a positive HIDA scan as independent predictors of conversion. The post graduate year of resident assisting in the case had no significant effect on conversion rate. Conclusion: Pre-operative clinical and imaging findings can successfully predict in selecting the laparoscopic or open approach or on the least can alert the surgeon for a possible difficult surgery. Apart from choosing the approach, it also improves patient counseling, helps in better perioperative planning and decreases post operative morbidity and hospital costs.
M1522 Prognosis After Surgery of Cholangiocarcinoma: Peripheral Intra-Hepatic Cholangiocarcinoma Versus Peri-Hilar Cholangiocarcinoma Andrea Ruzzenente, Silvia Pachera, Tommaso Campagnaro, Alessandro Valdegamberi, Paola Capelli, Paola Nicoli, Calogero Iacono, Alfredo Guglielmi Background. Cholangiocarcinoma is the second most frequent primary liver cancer, despite improvement of diagnosis only few patients can be submitted to resective surgery with curative intent. According to its location and characteristcs cholangiocarcinoma can be classified into two different categories: peripheral intrahepatic colangiocacinoma (ICC) and perihilar cholangiocarcinoma (PCC). The aim of this study is to compare the results of resective surgery of ICC and PCC. Methods. Ninety-five out of 152 patients observed between January 1990 and December 2007 in a single division of surgery of University of Verona Medical School underwent to surgical resection of a ICC (33 patients) or PCC (62 patients); the resectability rate was 62.5 %. R0 resection was achieved in 73 patients (77%). The surgical resections included 65 (66.%) major liver resections and 60 patients (62%) underwent combined extra-hepatic bile duct resection. Results. The median survival of the entire group was 24 months; actuarial 3- and 5-year survival was respectively 44% and 23%. Univariate analysis showed that the factors associated with survival were tumor type (ICC or PCC) , an R0 resection, lymph node metastasis and macroscopic vascular invasion. Multivariate analysis identified that R0 resection and macroscopic vascular invasion were the most important prognostic factors associated with survival, with hazard ratios of respectively 2.14 and 1.95. Further analysis identify that survival was significantly longer in ICC compared to PCC with a 5 years survival of 26 and 13 %, respectively. The analysis of the different clinico-pathological factors identified a significant higher rate of R+ resection, perineural infiltration, regional lymph node metastases and macro-vascular invasion in PCC compared to ICC. Conclusion. Our results confirm that only R0 resection can provide good long term survival. The macroscopic type of the tumor (ICC or PCC) is an important prognostic factor and the higher frequency of negative clinico-pathological factors can explain the worse prognosis of PCC.
SSAT Abstracts
A-888