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M1647 Laparoscopic Enucleation for Neuroendocrine Pancreatic Tumors: Pancreas Related Complications
M1647
± 17.48 (P=0.5). Etiologies were as follow, 48(59%) biliary, 9(11%) alcoholic, 11(14%) hypertriglyceridemia and 13(16%) idiopathic. Most cases of biliary pancreatitis (94%, P= 0.0001) were managed in a SS. Using APACHE II, 63(78%) patients were classified as mild pancreatitis and 18(22%) as severe [8(17%) in SS vs. 10(29%) in MS (P=0.2)]. Patients with a diagnosis of diabetes mellitus (DM) were more frequently admitted to MS 11(32%) than to SS 4(8.5%) (P=0.009). Other co-morbidities were also more frequent in MS (P=0.0001). Seventy-two percent of patients admitted to a SS received antibiotics during hospitalization compared to 53% of those in MS (P=0.1). Total parenteral nutrition (TPN) was used in 11% of patients in SS and 6(18%) in MS, (P=0.5). A nasogastric tube (NG) was placed in 17% of patients in SS vs. 15% in MS, (P=1). Patients with DM had significantly more severe AP than non-DM patients (P=0.003), however, mortality was not significantly different among DM and non-DM patients (P=0.1). Length of stay (LOS) was 7.94 days in SS vs. 8.53 days in MS, (P=0.6). Overall mortality was 9% (7/81), 4/43 in SS vs. 3/31 in MS (P= 0.6). Conclusions: At our institution, surgical services tend to use more antibiotics and treat patients with less co-morbidity than medical services. Despite minor variations in management of AP and different etiologies among surgical and medical services, outcomes are not significantly different.
Laparoscopic Enucleation for Neuroendocrine Pancreatic Tumors: Pancreas Related Complications Laureano Fernández-Cruz, Miguel Angel López-Boado, Amalia Pelegrina Background: In the majority of cases enucleation represents definitive treatment for neuroendocrine pancreatic tumors (NEPT). However, enucleation is not a simple procedure, whether performed open or laparoscopically. It offers clear advantages to patients but pancreas related complications may occur. When NEPT arise in the head-neck of the pancreas can represent a surgical challenge. Aim: To define the complication rate and incidence of pancreatic fistula (PF) according to ISGPF in patients undergoing enucleation for NEPT. Material and Method: Between April 1998 and September 2009 52 patients underwent laparoscopic surgery for NEPT, 25 sporadic insulinoma and 27 non-functioning tumors. NEPT were localized in the pancreatic head in 6 patients, in the pancreatic neck in 9 patients, in the body in 28 patients and in the tail of the pancreas in 9 patients. We reviewed the operative results and postoperative courses in these patients. Intraoperative ultrasonography was used in all cases. Results: Mean diameter of sporadic insulinoma was 1-4 cm (range 0.6-20 mm) and of non functioning tumors was 3 cm (range 2.5-3.2 cm). 18 patients (76%) with sporadic insulinoma and 12 patients (44%) of non-functioning tumors underwent successful laparoscopic enucleation. Conversion rate to an open procedure was 6.6%. Overall PF after LapEn was observed in 12 patients (40%), however 50% was biochemical PF (grade A). The frequency of PF was significantly higher (P<0.01) after LapEn from the head (100%) comparing with from the neck (50%) and from the body of the pancreas (29%). ISGPF grade B and C was also higher after LapEn from the head-neck of the pancreas (41.6%) comparing with the body of the pancreas (8%). No patient required reoperation. Conclusion: This study confirmed the technical feasibility and acceptable morbidity associated with LapEn for NEPT. There was no operative mortality. Sixty percent of the patients who had LapEn had no complications. A major concern with LapEn from the head-neck of the pancreas is the possibility of PF however can often be managed with prolonged drainage without bowel rest.
M1650 Route of Gastroenteric Anastomosis in Pancreatoduodenectomy and Delayed Gastric Emptying - A Retrospective Analysis Wietse J. Eshuis, Jan Willem Van Dalen, Olivier R. Busch, Thomas M. Van Gulik, Dirk J. Gouma Background: Delayed gastric emptying (DGE) is a frequent and bothersome complication after pancreatoduodenectomy. Some authors suggest that an antecolic route of the gastroenteric anastomosis (duodenojejunostomy, DJ or gastrojejunostomy, GJ) lowers the incidence of DGE, compared to a retrocolic route. In our institution, a retrocolic route has been routinely used until 2005, after which an antecolic route became more frequent. Aim: To investigate the relation between the route of gastroenteric anastomosis and the incidence of DGE after pancreatoduodenectomy. Methods: In a consecutive series of 203 patients from our prospective pancreatoduodenectomy database, the route of gastroenteric anastomosis was established by reviewing operation reports. Hospital course and follow-up were prospectively recorded. Patients with antecolic DJ or GJ were compared to patients with retrocolic DJ or GJ. Main outcome measure was the incidence of DGE according to the criteria of the International Study Group of Pancreatic Surgery. Secondary outcome measures were other complications and length of hospital stay. Results: In 47 patients the route of gastroenteric anastomosis could not be determined. Two patients were excluded because they had Rouxen-Y reconstruction. In the remaining 154 patients, 77 had a retrocolic anastomosis and 77 had an antecolic anastomosis. In the retrocolic group, DGE occurred in 58% of patients (25% grade A, 17% grade B and 17% grade C). In the antecolic group, 52% had DGE (21% grade A, 16% grade B and 16% grade C). This difference was not significant. ‘Primary' DGE of any grade (not due to other intra-abdominal complications) occurred in 36% of the retrocolic group and 20% of the antecolic group (p 0.02). ‘Primary' clinically relevant DGE (grade B or C) occurred in 18% and 10%, respectively (p 0.17). There was no difference in need for (par)enteral nutritional support, other complications, hospital mortality or length of hospital stay. Conclusions: The route of DJ or GJ had no influence on the overall postoperative incidence of DGE. Clinically relevant DGE (overall and ‘primary') was not different between the retrocolic and antecolic group. ‘Primary' DGE (any grade) was more frequent in the retrocolic group, mainly due to a higher incidence of DGE grade A. The preferred route for gastroenteric anastomosis in pancreatoduodenectomy remains to be confirmed in a well-powered randomized controlled trial.
M1648
SSAT Abstracts
Postoperative Acute Pancreatitis After Pancreaticoduodenectomy is Associated With Postoperative Pancreatic Fistula Kenichiro Uemura, Yoshiaki Murakami, Yasuo Hayashidani, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Emi Fukuda, Taijiro Sueda [Background and aims] The urine trypsinogen-2 has been used successfully in the diagnosis of pancreatitis of various etiologies, but has been rarely studied in postoperative pancreatitis following pancreatic surgery. The aim of this study was to reveal the risk factors for the postoperative acute pancreatitis after pancreaticoduodenectomy, and also to analyze the possible association of postoperative acute pancreatitis and postoperative pancreatic fistula. [Methods] 131 patients undergoing pancreaticoduodenectomy who measured postoperative urine trypsinogen-2 were included in this study: 56 females and 75 males (median age 68 years; range 19-88). The pancreatic anastomosis was reconstructed with a two-layered ductto-mucosa pancreaticogastrostomy with internal stent into the posterior wall of the stomach. The concentration of trypsinogen-2 in the urine samples on the postoperative day 3 was measured by a quantitative immunofluorometric assay. Postoperative acute pancreatitis was defined chemically as the elevation of urine trypsinogen-2 levels more than 50 μg/l. Levels of drain amylase was also measured daily, and postoperative pancreatic fistula was classified into three categories by International Study Group Pancreatic Fistula (ISGPF) criteria. We analyzed the risk factors of postoperative acute pancreatitis by logistic regression analysis, and also analyze the association of postoperative acute pancreatitis and postoperative pancreatic fistula. [Results] The incidence of postoperative acute pancreatitis was 35/131 (27%). Univariate analysis revealed that the soft pancreatic parenchyma, non pancreatic adenocarcinoma, main pancreatic duct diameter less than 3mm, and preoperative biliary drainage were significant risk factors for the development of postoperative acute pancreatitis. Multivariate analysis demonstrated that the independent risk factor for postoperative acute pancreatitis is soft pancreatic parenchyma. The rate of ISGPF was 18 of 131 patients (14%). Of these, 14 patients (11%) had grade A, three patients (2%) had grade B, and one patient (1%) had grade C by ISGPF criteria. Postoperative acute pancreatitis was significantly associated with postoperative pancreatic fistula (ISGPF grade A+B+C, p< 0.01) and it was also associated with clinically relevant pancreatic fistula (ISGPF grade B+C, p<0.05). [Conclusion] Soft pancreatic parenchyma is an independent risk factor for postoperative acute pancreatitis defined by urine trypsinogen-2 levels. Postoperative acute pancreatitis might play an important role in the pathogenesis of postoperative pancreatic fistula following pancreaticoduodenectomy.
M1651 Pancreaticoduodenectomy Can Be Performed Safely in Patients Aged 80 Years and Older Minna K. Lee, Joseph DiNorcia, Patrick L. Reavey, Marc M. Holden, James A. Lee, Beth A. Schrope, John A. Chabot, John D. Allendorf Background Surgery offers the only chance for cure in patients with pancreatic adenocarcinoma, and a growing number of elderly patients with the disease are being offered resection. Recent studies report safety and long-term survival for pancreaticoduodenectomy in patients older than 70 years, yet few specifically evaluate patients older than 80 years. Objective The aim of this study was to examine morbidity, mortality, and survival of patients aged 80 years and older undergoing pancreaticoduodenectomy. Methods Between February 1992 and June 2009, 105 patients aged 80 years and older were brought to the operating room for pancreatic resection. Of these patients, 96 underwent pancreatic resection with 68 undergoing pancreaticoduodenectomy. During this time period, 658 patients less than 80 years old also underwent pancreaticoduodenectomy. These records were retrospectively reviewed to compare demographics, perioperative characteristics, and outcomes between patients older and younger than 80 years. Continuous variables were compared using Student's t-test or Wilcoxon rank-sum test. Categorical variables were compared using chi-square or Fisher's exact test. For survival, Kaplan-Meier analysis was performed, and median survival was compared with the log-rank test. Results In patients 80 years and older, pancreaticoduodenectomy was most commonly performed for pancreatic adenocarcinoma (n=43, 63%), intraductal papillary mucinous neoplasm (n=5), ampullary adenoma (n=5), ampullary adenocarcinoma (n=4), cystadenoma (n=3), and pancreatic neuroendocrine neoplasm (n=2). Patients 80 years and older were statistically similar with respect to sex, race, median blood loss, reoperation rate, postoperative length of stay, and readmission rate when compared with younger patients who also underwent pancreaticoduodenectomy. Patients 80 years and older had shorter mean operative times (410 minutes vs. 510 minutes, p<0.0001). There were no differences in overall complications (50% vs. 53%, p=0.67), major complications (16% vs. 25%, p=0.12), and mortality (4% vs. 4%, p=0.76). In a subset of all patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, patients 80 years and older (n=42) had a median survival of 11.6 months compared to 17.8 months in younger patients (n=322; p=0.004). Conclusion Pancreaticoduodenectomy can be performed safely in patients aged 80 years and older, and age alone should not dissuade surgeons
M1649 Management and Outcomes of Patients With Acute Pancreatitis. Differences According to Admitting Service Antonio Ramos-De la Medina, Salvador Ramirez-Cortés, Jose Maria Remes Troche, María del Mar Anitúa-Valdovinos, Jorge Sempé-Minvielle Introduction: Management and prognosis of patients with acute pancreatitis (AP) vary depending on the different etiologies. Differences in management and outcomes based on whether a patient is admitted to a medical or surgical service may exist, but few studies have addressed this issue. Our aim was to analyze the effect of medical or surgical admission on management and outcomes of AP. Methods: We conducted a retrospective review of all patients admitted to a single institution with a diagnosis of acute pancreatitis during January 2007 and June 2008. Clinical, biochemical, demographic, management and outcome variables were obtained. Descriptive statistics were used according to the type of variable measured. The statistical significance of the associations was evaluated by the χ2 test and Fisher's exact test where appropriate. For continuous variables, Student's t test was performed. Results: Eighty-one consecutive patients were included and analyzed. Fifty-three patients (65%) were female. Forty-seven (58%) were admitted to a surgical service (SS) and 34(42%) to a medical service (MS). Mean age of patients admitted to a SS was 37.2 ± 14.95 vs. 39.2
SSAT Abstracts
S-874
± 17.48 (P=0.5). Etiologies were as follow, 48(59%) biliary, 9(11%) alcoholic, 11(14%) hypertriglyceridemia and 13(16%) idiopathic. Most cases of biliary pancreatitis (94%, P= 0.0001) were managed in a SS. Using APACHE II, 63(78%) patients were classified as mild pancreatitis and 18(22%) as severe [8(17%) in SS vs. 10(29%) in MS (P=0.2)]. Patients with a diagnosis of diabetes mellitus (DM) were more frequently admitted to MS 11(32%) than to SS 4(8.5%) (P=0.009). Other co-morbidities were also more frequent in MS (P=0.0001). Seventy-two percent of patients admitted to a SS received antibiotics during hospitalization compared to 53% of those in MS (P=0.1). Total parenteral nutrition (TPN) was used in 11% of patients in SS and 6(18%) in MS, (P=0.5). A nasogastric tube (NG) was placed in 17% of patients in SS vs. 15% in MS, (P=1). Patients with DM had significantly more severe AP than non-DM patients (P=0.003), however, mortality was not significantly different among DM and non-DM patients (P=0.1). Length of stay (LOS) was 7.94 days in SS vs. 8.53 days in MS, (P=0.6). Overall mortality was 9% (7/81), 4/43 in SS vs. 3/31 in MS (P= 0.6). Conclusions: At our institution, surgical services tend to use more antibiotics and treat patients with less co-morbidity than medical services. Despite minor variations in management of AP and different etiologies among surgical and medical services, outcomes are not significantly different.
Laparoscopic Enucleation for Neuroendocrine Pancreatic Tumors: Pancreas Related Complications Laureano Fernández-Cruz, Miguel Angel López-Boado, Amalia Pelegrina Background: In the majority of cases enucleation represents definitive treatment for neuroendocrine pancreatic tumors (NEPT). However, enucleation is not a simple procedure, whether performed open or laparoscopically. It offers clear advantages to patients but pancreas related complications may occur. When NEPT arise in the head-neck of the pancreas can represent a surgical challenge. Aim: To define the complication rate and incidence of pancreatic fistula (PF) according to ISGPF in patients undergoing enucleation for NEPT. Material and Method: Between April 1998 and September 2009 52 patients underwent laparoscopic surgery for NEPT, 25 sporadic insulinoma and 27 non-functioning tumors. NEPT were localized in the pancreatic head in 6 patients, in the pancreatic neck in 9 patients, in the body in 28 patients and in the tail of the pancreas in 9 patients. We reviewed the operative results and postoperative courses in these patients. Intraoperative ultrasonography was used in all cases. Results: Mean diameter of sporadic insulinoma was 1-4 cm (range 0.6-20 mm) and of non functioning tumors was 3 cm (range 2.5-3.2 cm). 18 patients (76%) with sporadic insulinoma and 12 patients (44%) of non-functioning tumors underwent successful laparoscopic enucleation. Conversion rate to an open procedure was 6.6%. Overall PF after LapEn was observed in 12 patients (40%), however 50% was biochemical PF (grade A). The frequency of PF was significantly higher (P<0.01) after LapEn from the head (100%) comparing with from the neck (50%) and from the body of the pancreas (29%). ISGPF grade B and C was also higher after LapEn from the head-neck of the pancreas (41.6%) comparing with the body of the pancreas (8%). No patient required reoperation. Conclusion: This study confirmed the technical feasibility and acceptable morbidity associated with LapEn for NEPT. There was no operative mortality. Sixty percent of the patients who had LapEn had no complications. A major concern with LapEn from the head-neck of the pancreas is the possibility of PF however can often be managed with prolonged drainage without bowel rest.
M1650 Route of Gastroenteric Anastomosis in Pancreatoduodenectomy and Delayed Gastric Emptying - A Retrospective Analysis Wietse J. Eshuis, Jan Willem Van Dalen, Olivier R. Busch, Thomas M. Van Gulik, Dirk J. Gouma Background: Delayed gastric emptying (DGE) is a frequent and bothersome complication after pancreatoduodenectomy. Some authors suggest that an antecolic route of the gastroenteric anastomosis (duodenojejunostomy, DJ or gastrojejunostomy, GJ) lowers the incidence of DGE, compared to a retrocolic route. In our institution, a retrocolic route has been routinely used until 2005, after which an antecolic route became more frequent. Aim: To investigate the relation between the route of gastroenteric anastomosis and the incidence of DGE after pancreatoduodenectomy. Methods: In a consecutive series of 203 patients from our prospective pancreatoduodenectomy database, the route of gastroenteric anastomosis was established by reviewing operation reports. Hospital course and follow-up were prospectively recorded. Patients with antecolic DJ or GJ were compared to patients with retrocolic DJ or GJ. Main outcome measure was the incidence of DGE according to the criteria of the International Study Group of Pancreatic Surgery. Secondary outcome measures were other complications and length of hospital stay. Results: In 47 patients the route of gastroenteric anastomosis could not be determined. Two patients were excluded because they had Rouxen-Y reconstruction. In the remaining 154 patients, 77 had a retrocolic anastomosis and 77 had an antecolic anastomosis. In the retrocolic group, DGE occurred in 58% of patients (25% grade A, 17% grade B and 17% grade C). In the antecolic group, 52% had DGE (21% grade A, 16% grade B and 16% grade C). This difference was not significant. ‘Primary' DGE of any grade (not due to other intra-abdominal complications) occurred in 36% of the retrocolic group and 20% of the antecolic group (p 0.02). ‘Primary' clinically relevant DGE (grade B or C) occurred in 18% and 10%, respectively (p 0.17). There was no difference in need for (par)enteral nutritional support, other complications, hospital mortality or length of hospital stay. Conclusions: The route of DJ or GJ had no influence on the overall postoperative incidence of DGE. Clinically relevant DGE (overall and ‘primary') was not different between the retrocolic and antecolic group. ‘Primary' DGE (any grade) was more frequent in the retrocolic group, mainly due to a higher incidence of DGE grade A. The preferred route for gastroenteric anastomosis in pancreatoduodenectomy remains to be confirmed in a well-powered randomized controlled trial.
M1648
SSAT Abstracts
Postoperative Acute Pancreatitis After Pancreaticoduodenectomy is Associated With Postoperative Pancreatic Fistula Kenichiro Uemura, Yoshiaki Murakami, Yasuo Hayashidani, Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Emi Fukuda, Taijiro Sueda [Background and aims] The urine trypsinogen-2 has been used successfully in the diagnosis of pancreatitis of various etiologies, but has been rarely studied in postoperative pancreatitis following pancreatic surgery. The aim of this study was to reveal the risk factors for the postoperative acute pancreatitis after pancreaticoduodenectomy, and also to analyze the possible association of postoperative acute pancreatitis and postoperative pancreatic fistula. [Methods] 131 patients undergoing pancreaticoduodenectomy who measured postoperative urine trypsinogen-2 were included in this study: 56 females and 75 males (median age 68 years; range 19-88). The pancreatic anastomosis was reconstructed with a two-layered ductto-mucosa pancreaticogastrostomy with internal stent into the posterior wall of the stomach. The concentration of trypsinogen-2 in the urine samples on the postoperative day 3 was measured by a quantitative immunofluorometric assay. Postoperative acute pancreatitis was defined chemically as the elevation of urine trypsinogen-2 levels more than 50 μg/l. Levels of drain amylase was also measured daily, and postoperative pancreatic fistula was classified into three categories by International Study Group Pancreatic Fistula (ISGPF) criteria. We analyzed the risk factors of postoperative acute pancreatitis by logistic regression analysis, and also analyze the association of postoperative acute pancreatitis and postoperative pancreatic fistula. [Results] The incidence of postoperative acute pancreatitis was 35/131 (27%). Univariate analysis revealed that the soft pancreatic parenchyma, non pancreatic adenocarcinoma, main pancreatic duct diameter less than 3mm, and preoperative biliary drainage were significant risk factors for the development of postoperative acute pancreatitis. Multivariate analysis demonstrated that the independent risk factor for postoperative acute pancreatitis is soft pancreatic parenchyma. The rate of ISGPF was 18 of 131 patients (14%). Of these, 14 patients (11%) had grade A, three patients (2%) had grade B, and one patient (1%) had grade C by ISGPF criteria. Postoperative acute pancreatitis was significantly associated with postoperative pancreatic fistula (ISGPF grade A+B+C, p< 0.01) and it was also associated with clinically relevant pancreatic fistula (ISGPF grade B+C, p<0.05). [Conclusion] Soft pancreatic parenchyma is an independent risk factor for postoperative acute pancreatitis defined by urine trypsinogen-2 levels. Postoperative acute pancreatitis might play an important role in the pathogenesis of postoperative pancreatic fistula following pancreaticoduodenectomy.
M1651 Pancreaticoduodenectomy Can Be Performed Safely in Patients Aged 80 Years and Older Minna K. Lee, Joseph DiNorcia, Patrick L. Reavey, Marc M. Holden, James A. Lee, Beth A. Schrope, John A. Chabot, John D. Allendorf Background Surgery offers the only chance for cure in patients with pancreatic adenocarcinoma, and a growing number of elderly patients with the disease are being offered resection. Recent studies report safety and long-term survival for pancreaticoduodenectomy in patients older than 70 years, yet few specifically evaluate patients older than 80 years. Objective The aim of this study was to examine morbidity, mortality, and survival of patients aged 80 years and older undergoing pancreaticoduodenectomy. Methods Between February 1992 and June 2009, 105 patients aged 80 years and older were brought to the operating room for pancreatic resection. Of these patients, 96 underwent pancreatic resection with 68 undergoing pancreaticoduodenectomy. During this time period, 658 patients less than 80 years old also underwent pancreaticoduodenectomy. These records were retrospectively reviewed to compare demographics, perioperative characteristics, and outcomes between patients older and younger than 80 years. Continuous variables were compared using Student's t-test or Wilcoxon rank-sum test. Categorical variables were compared using chi-square or Fisher's exact test. For survival, Kaplan-Meier analysis was performed, and median survival was compared with the log-rank test. Results In patients 80 years and older, pancreaticoduodenectomy was most commonly performed for pancreatic adenocarcinoma (n=43, 63%), intraductal papillary mucinous neoplasm (n=5), ampullary adenoma (n=5), ampullary adenocarcinoma (n=4), cystadenoma (n=3), and pancreatic neuroendocrine neoplasm (n=2). Patients 80 years and older were statistically similar with respect to sex, race, median blood loss, reoperation rate, postoperative length of stay, and readmission rate when compared with younger patients who also underwent pancreaticoduodenectomy. Patients 80 years and older had shorter mean operative times (410 minutes vs. 510 minutes, p<0.0001). There were no differences in overall complications (50% vs. 53%, p=0.67), major complications (16% vs. 25%, p=0.12), and mortality (4% vs. 4%, p=0.76). In a subset of all patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, patients 80 years and older (n=42) had a median survival of 11.6 months compared to 17.8 months in younger patients (n=322; p=0.004). Conclusion Pancreaticoduodenectomy can be performed safely in patients aged 80 years and older, and age alone should not dissuade surgeons
M1649 Management and Outcomes of Patients With Acute Pancreatitis. Differences According to Admitting Service Antonio Ramos-De la Medina, Salvador Ramirez-Cortés, Jose Maria Remes Troche, María del Mar Anitúa-Valdovinos, Jorge Sempé-Minvielle Introduction: Management and prognosis of patients with acute pancreatitis (AP) vary depending on the different etiologies. Differences in management and outcomes based on whether a patient is admitted to a medical or surgical service may exist, but few studies have addressed this issue. Our aim was to analyze the effect of medical or surgical admission on management and outcomes of AP. Methods: We conducted a retrospective review of all patients admitted to a single institution with a diagnosis of acute pancreatitis during January 2007 and June 2008. Clinical, biochemical, demographic, management and outcome variables were obtained. Descriptive statistics were used according to the type of variable measured. The statistical significance of the associations was evaluated by the χ2 test and Fisher's exact test where appropriate. For continuous variables, Student's t test was performed. Results: Eighty-one consecutive patients were included and analyzed. Fifty-three patients (65%) were female. Forty-seven (58%) were admitted to a surgical service (SS) and 34(42%) to a medical service (MS). Mean age of patients admitted to a SS was 37.2 ± 14.95 vs. 39.2
SSAT Abstracts
S-874