- Email: [email protected]
M1661 Small Bowel Adenocarcinoma in Crohn's Disease
tissue and nodal resection was significantly greater in the DP group. Laparoscopic-assisted spleen preserving distal pancreatectomy is a safe operation that should be reserved for patients with benign tumors. In patients in whom a malignancy suspected a laparoscopic distal pancreatomy should be performed.
patients had traditional methods of stump closure compared with 21 patients who had radiofrequency closure of the pancreatic parenchyma. Leak rate, operative time and blood loss were compared. Twenty-two of the 33 traditional patients underwent open distal pancreatectomy (DP) (66.7%) and the remaining 11 underwent laparoscopic DP. Seven of the 21 RF dissection patients underwent open DP (33.3%) and the remaining patients underwent laparoscopic DP. Results Stump leaks occurred in 12 of 33 (36%) patients with traditional stump closure compared to 1 of 21 leaks (4.6%) in patients with RF closure. This resulted in an 87% reduction of stump leaks (p<0.01). Operative time (314 min versus 211 min [p<0.01]) and blood loss (364 mL to 212 mL [p<0.05]) were also decreased in the RF closure group. Length of stay decreased from 7.8 days to 6 days, however this was not statistically significant (p=.09). Conclusions The use of radiofrequency stump closure in distal pancreatectomy can be used effectively for pancreatic surgery with low rates of stump leaks. RF closure should be studied further in prospective studies.
M1657 Does BMI / Morbid Obesity Influence Outcomes in Patients Who Have Undergone Pancreatoduodenectomy for Pancreatic Adenocarcinoma? Saboor Khan, Guido M. Sclabas, Kaye Reid Lombardo, Michael G. Sarr, David M. Nagorney, Michael L. Kendrick, John H. Donohue, Florencia G. Que, Marianne Huebner, Michael B. Farnell INTRODUCTION: The obesity epidemic coupled with epidemiologic evidence of a link between pancreatic cancer and obesity has raised the interest in the impact of BMI (body mass index) on outcomes for patients undergoing curative resection for pancreatic ductal adenocarcinoma. HYPOTHESIS: Obesity increases operative time and blood loss, increases aggressiveness of pancreatic cancer, and decreases overall survival. AIM: To determine effect of obesity on outcome of patients undergoing curative resection of pancreatic ductal adenocarcinoma. METHODS: All consecutive patients undergoing ‘curative' (R0,R1) pancreatoduodenectomy (PD) for pancreatic adenocarcinoma from 1981 to 2007 were categorized into four groups according to their BMI (<25, 25 to <29.9, 30 to <34.9 and ≥35). Association of BMI groups with peri-operative variables (operating time, blood loss, complications, and in-hospital mortality) pathologic characteristics (tumor size, tumor stage, differentiation, lymph nodal status, and R0 status), and long-term overall and disease-free survival were evaluated using Kruskal-Wallis and chi-square tests, logistic regression, and Cox proportional hazards regression. A second set of analyses were performed by dichotomizing patients into morbidly obese (BMI ≥35) in comparison to the rest. RESULTS: Of the 586 patients studied, there were 232 (40%) with BMI <25, 232 (40%) with BMI 25 to <29.9, 89 (15%) with BMI 30 to <34.9, and 33 (6%) with BMI ≥35. Operating time and intra-operative blood loss increased directly with BMI (P<0.003 each), although none of the remaining perioperative features differed among BMI groups. There were no associations between BMI and the pathologic features studied. In particular, BMI was not associated with lymph nodal status even after adjusting for tumor size and the number of lymph nodes resected. Most importantly, Cox regression did not demonstrate any association between BMI and overall or disease-free survival. All the analyses were then repeated for the morbidly obese group and the results were similar. CONCLUSIONS: BMI (and morbid obesity) does not influence long-term outcomes for patients undergoing PD for pancreatic adenocarcinoma. Surgeons should however be vigilant of the greater risk of peri-operative blood loss with increasing BMI, which may lead to serious short- and long-term consequences.
M1660 Management of ERCP-Related Duodenal Perforations Attila Dubecz, Rudolf J. Stadlhuber, Hubert J. Stein BACKGROUND: Although endoscopic retrograde cholangiopancreatography (ERCP) is widely regarded as a safe procedure, it is associated with significant morbidity and mortality. Duodenal perforation is one of the most serious complication of ERCP. Its management is still controversial, some authors recommend surgical, others conservative treatment. METHODS: A retrospective chart review was conducted to identify 11 patients (men, n=6, women, n=5, mean age: 71.3 years) treated at our institution for ERCP-related duodenal perforations. Between January 2000 and October 2009 4,015 ERCP procedures were performed (perforation rate: 0.4%; in one patient ERCP was performed elsewhere). Study variables included indication of ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of hospital stay, and survival. RESULTS: Four of the perforations were discovered during ERCP, five requiring radiologic imaging for diagnosis. In one patient diagnosis was made only at autopsy, in another patient perforation came 3 years after the procedure through a dislocated stent. Four of 11 perforations were stent related, in two patients ERCP was performed in a non-anatomical situation (Billroth II gastroenterostomy). Four patients (36%) were treated surgically with nil mortality. Five patients were managed conservatively with a successful outcome, and two patients died after conservative treatment (18%). Three of four patients underwent surgery within 24 h after the ERCP, with only one patient undergoing surgery after 24 h. Operative treatment included: hepaticojejunostomy and duodenostomy (in one patient), suture of the perforation with T-drain (in one patient) suture only (in two patients). Average length of stay was 20.1 days. CONCLUSIONS: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate radiological evaluation and close surgical monitoring is needed. Management should be individually tailored based on clinical and radiological findings. A treatment algorithm is suggested based on the study result.
M1658
SSAT Abstracts
Lack of Benefit to Perioperative Epidural Analgesia Among Patients Undergoing Elective Gastric and Pancreatic Resections Jack E. Russo, Richard J. Bold, Steve R. Martinez, Steven L. Chen, Jodi M. Coates, Robert J. Canter
M1661 Small Bowel Adenocarcinoma in Crohn's Disease Maria Widmar, Alexander J. Greenstein, David B. Sachar, Noam Harpaz, Adrian J. Greenstein
Background: Epidural pain catheters are purported to improve perioperative pain control and decrease rates of ileus, pneumonia, and venous thromboembolism. Since these data are primarily limited to gynecologic and thoracic surgical procedures, we hypothesized that use of epidural pain catheters would demonstrate benefit among patients undergoing gastric and pancreatic resections. Methods. From January 2007 to June 2009, 126 patients underwent elective gastric and pancreatic resections for space-occupying lesions at an academic university hospital. Emergency, traumatic, pediatric, and disseminated cancer cases were excluded. Clinicopathologic data were reviewed among epidural (E) and non-epidural (NE) patients for their association with perioperative outcomes. Data were analyzed using parametric and non-parametric methods as appropriate. Results. 91 patients (72%) received an epidural, and 35 (28%) did not. Pancreaticoduodenectomy was performed in 71 patients (56%), distal pancreatectomy in 25 patients (20%), and partial gastrectomy in 24 patients (19%). There were no significant differences in mean postoperative pain scores or ketorolac use among E and NE patients. 21% of E patients had their catheter removed within 48 hours because of poor pain control or hemodynamic issues. 14% of E patients also received concomitant intravenous narcotic infusion with a functioning E. The prevalence of overall complications (40% E versus 34% NE, P=0.68), prolonged ileus (13% E versus 11% NE, P=1.00), pneumonia (12% E versus 6% NE, P=0.51), venous thromboembolism (8% E versus 6% NE, P= 1.00), and length of stay (median 8 days E versus 7 days NE, P=0.58) were not significantly different between the two groups. Subgroup analysis of patients without complications (N= 78) demonstrated no significant differences in pain scores, return of bowel function, or length of stay between E and NE patients. Conclusions. The use of epidural pain catheters does not alter perioperative outcomes among patients undergoing elective gastric and pancreatic resections. Routine use of epidurals in this subgroup of patients may not be indicated.
Background: An association between small bowel adenocarcinoma and Crohn's Disease (CD) is well-established. Crohn's-related small bowel cancers are male predominant, distal, surrounded by dysplasia, and carry a poor prognosis, particularly in the setting of excluded intestinal loops. As suggested in an earlier published series from our center (1991), clinical indicators of small bowel cancer in CD include recurrent obstructive symptoms after periods of quiescence and bowel obstruction that is refractory to conservative management.1 We present our recent experience with this entity in order to further elucidate its clinicopathological features and clinical indicators. Methods: A retrospective review was undertaken of all surgical patients with small bowel adenocarcinoma and CD seen at our institution between 1994-2009. The data included demographics, pathology, hospital and post-operative course. Follow-up was assessed until time of death or by interview with survivors. Patients were classified into two groups according to lymph node status (Stages 1&2 vs. 3&4); survival was calculated for all patients and compared between these groups using Kaplan Meier curves. Results: 28 patients (9F, 19M) were identified and followed for a median of 2 years. The median age at onset of CD symptoms was 25, and the median age at cancer diagnosis was 54.9, for a mean interval of 28.3 years. Twenty-one cancers were ileal and five were jejunal. There were no cancers in excluded intestinal loops. Significant differences in 2-year survival were determined for: node-negative (83.3%, 95%CI 62.4-14.5%) versus nodepositive cancers (45.5 %, 95%CI 17.7-73.3%), and for localized (90.9%, 95%CI 73.8-108%) versus metastatic disease (33.3%, 95%CI 6.6-60%). Overall 36-month survival was 68% (95%CI 49.6-86.4%), compared to 40% among those without excluded loops in our series from 1991. Fifteen of 22 patients had long periods of quiescent disease before diagnosis (7-45 years), and 13 of 22 patients required surgery for refractory bowel obstruction. Adequate information was not retrievable for 6 patients. Conclusions: A comparison to our previous series reveals similar male predominance, long duration to development of cancer, and a high rate of node-positive cancer at diagnosis. Our findings also confirm 2 important clinical indicators of malignancy: recrudescent symptoms after long periods of relative quiescence, and persistent small bowel obstruction that is refractory to medical therapy. 1 Ribeiro MB, Greenstein AJ, Heimann TM, Yamazaki Y, Aufses AH Jr., Surg Gynecol Obstet. 1991 Nov;173(5):343-9.
M1659 Novel Method of Stump Closure for Distal Pancreatectomy Results in 87% Reduction in Leak Rates Megan Rapp, William E. Strodel, David G. Sheldon, Sucandy Iswanto, Ravi Chokshi, Joseph A. Blansfield Introduction Pancreatic stump leak is a significant problem for patients undergoing distal pancreatectomy with documented leak rates up to 40%. Leaks can lead to substantial morbidity, additional procedures and added cost. Radiofrequency dissectors have shown decreased bile leak rates after partial hepatectomies. This technology has yet to be applied and studied in distal pancreatectomies. The objective of this study was to compare the use of radiofrequency (RF) dissector as compared with traditional methods of stump closure. Methods Fifty-four patients underwent distal pancreatectomy at our institution between 2002 and 2009 by the Surgical Oncology Section of the Division of Surgery. Thirty-three
SSAT Abstracts
S-876
patients had traditional methods of stump closure compared with 21 patients who had radiofrequency closure of the pancreatic parenchyma. Leak rate, operative time and blood loss were compared. Twenty-two of the 33 traditional patients underwent open distal pancreatectomy (DP) (66.7%) and the remaining 11 underwent laparoscopic DP. Seven of the 21 RF dissection patients underwent open DP (33.3%) and the remaining patients underwent laparoscopic DP. Results Stump leaks occurred in 12 of 33 (36%) patients with traditional stump closure compared to 1 of 21 leaks (4.6%) in patients with RF closure. This resulted in an 87% reduction of stump leaks (p<0.01). Operative time (314 min versus 211 min [p<0.01]) and blood loss (364 mL to 212 mL [p<0.05]) were also decreased in the RF closure group. Length of stay decreased from 7.8 days to 6 days, however this was not statistically significant (p=.09). Conclusions The use of radiofrequency stump closure in distal pancreatectomy can be used effectively for pancreatic surgery with low rates of stump leaks. RF closure should be studied further in prospective studies.
M1657 Does BMI / Morbid Obesity Influence Outcomes in Patients Who Have Undergone Pancreatoduodenectomy for Pancreatic Adenocarcinoma? Saboor Khan, Guido M. Sclabas, Kaye Reid Lombardo, Michael G. Sarr, David M. Nagorney, Michael L. Kendrick, John H. Donohue, Florencia G. Que, Marianne Huebner, Michael B. Farnell INTRODUCTION: The obesity epidemic coupled with epidemiologic evidence of a link between pancreatic cancer and obesity has raised the interest in the impact of BMI (body mass index) on outcomes for patients undergoing curative resection for pancreatic ductal adenocarcinoma. HYPOTHESIS: Obesity increases operative time and blood loss, increases aggressiveness of pancreatic cancer, and decreases overall survival. AIM: To determine effect of obesity on outcome of patients undergoing curative resection of pancreatic ductal adenocarcinoma. METHODS: All consecutive patients undergoing ‘curative' (R0,R1) pancreatoduodenectomy (PD) for pancreatic adenocarcinoma from 1981 to 2007 were categorized into four groups according to their BMI (<25, 25 to <29.9, 30 to <34.9 and ≥35). Association of BMI groups with peri-operative variables (operating time, blood loss, complications, and in-hospital mortality) pathologic characteristics (tumor size, tumor stage, differentiation, lymph nodal status, and R0 status), and long-term overall and disease-free survival were evaluated using Kruskal-Wallis and chi-square tests, logistic regression, and Cox proportional hazards regression. A second set of analyses were performed by dichotomizing patients into morbidly obese (BMI ≥35) in comparison to the rest. RESULTS: Of the 586 patients studied, there were 232 (40%) with BMI <25, 232 (40%) with BMI 25 to <29.9, 89 (15%) with BMI 30 to <34.9, and 33 (6%) with BMI ≥35. Operating time and intra-operative blood loss increased directly with BMI (P<0.003 each), although none of the remaining perioperative features differed among BMI groups. There were no associations between BMI and the pathologic features studied. In particular, BMI was not associated with lymph nodal status even after adjusting for tumor size and the number of lymph nodes resected. Most importantly, Cox regression did not demonstrate any association between BMI and overall or disease-free survival. All the analyses were then repeated for the morbidly obese group and the results were similar. CONCLUSIONS: BMI (and morbid obesity) does not influence long-term outcomes for patients undergoing PD for pancreatic adenocarcinoma. Surgeons should however be vigilant of the greater risk of peri-operative blood loss with increasing BMI, which may lead to serious short- and long-term consequences.
M1660 Management of ERCP-Related Duodenal Perforations Attila Dubecz, Rudolf J. Stadlhuber, Hubert J. Stein BACKGROUND: Although endoscopic retrograde cholangiopancreatography (ERCP) is widely regarded as a safe procedure, it is associated with significant morbidity and mortality. Duodenal perforation is one of the most serious complication of ERCP. Its management is still controversial, some authors recommend surgical, others conservative treatment. METHODS: A retrospective chart review was conducted to identify 11 patients (men, n=6, women, n=5, mean age: 71.3 years) treated at our institution for ERCP-related duodenal perforations. Between January 2000 and October 2009 4,015 ERCP procedures were performed (perforation rate: 0.4%; in one patient ERCP was performed elsewhere). Study variables included indication of ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of hospital stay, and survival. RESULTS: Four of the perforations were discovered during ERCP, five requiring radiologic imaging for diagnosis. In one patient diagnosis was made only at autopsy, in another patient perforation came 3 years after the procedure through a dislocated stent. Four of 11 perforations were stent related, in two patients ERCP was performed in a non-anatomical situation (Billroth II gastroenterostomy). Four patients (36%) were treated surgically with nil mortality. Five patients were managed conservatively with a successful outcome, and two patients died after conservative treatment (18%). Three of four patients underwent surgery within 24 h after the ERCP, with only one patient undergoing surgery after 24 h. Operative treatment included: hepaticojejunostomy and duodenostomy (in one patient), suture of the perforation with T-drain (in one patient) suture only (in two patients). Average length of stay was 20.1 days. CONCLUSIONS: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate radiological evaluation and close surgical monitoring is needed. Management should be individually tailored based on clinical and radiological findings. A treatment algorithm is suggested based on the study result.
M1658
SSAT Abstracts
Lack of Benefit to Perioperative Epidural Analgesia Among Patients Undergoing Elective Gastric and Pancreatic Resections Jack E. Russo, Richard J. Bold, Steve R. Martinez, Steven L. Chen, Jodi M. Coates, Robert J. Canter
M1661 Small Bowel Adenocarcinoma in Crohn's Disease Maria Widmar, Alexander J. Greenstein, David B. Sachar, Noam Harpaz, Adrian J. Greenstein
Background: Epidural pain catheters are purported to improve perioperative pain control and decrease rates of ileus, pneumonia, and venous thromboembolism. Since these data are primarily limited to gynecologic and thoracic surgical procedures, we hypothesized that use of epidural pain catheters would demonstrate benefit among patients undergoing gastric and pancreatic resections. Methods. From January 2007 to June 2009, 126 patients underwent elective gastric and pancreatic resections for space-occupying lesions at an academic university hospital. Emergency, traumatic, pediatric, and disseminated cancer cases were excluded. Clinicopathologic data were reviewed among epidural (E) and non-epidural (NE) patients for their association with perioperative outcomes. Data were analyzed using parametric and non-parametric methods as appropriate. Results. 91 patients (72%) received an epidural, and 35 (28%) did not. Pancreaticoduodenectomy was performed in 71 patients (56%), distal pancreatectomy in 25 patients (20%), and partial gastrectomy in 24 patients (19%). There were no significant differences in mean postoperative pain scores or ketorolac use among E and NE patients. 21% of E patients had their catheter removed within 48 hours because of poor pain control or hemodynamic issues. 14% of E patients also received concomitant intravenous narcotic infusion with a functioning E. The prevalence of overall complications (40% E versus 34% NE, P=0.68), prolonged ileus (13% E versus 11% NE, P=1.00), pneumonia (12% E versus 6% NE, P=0.51), venous thromboembolism (8% E versus 6% NE, P= 1.00), and length of stay (median 8 days E versus 7 days NE, P=0.58) were not significantly different between the two groups. Subgroup analysis of patients without complications (N= 78) demonstrated no significant differences in pain scores, return of bowel function, or length of stay between E and NE patients. Conclusions. The use of epidural pain catheters does not alter perioperative outcomes among patients undergoing elective gastric and pancreatic resections. Routine use of epidurals in this subgroup of patients may not be indicated.
Background: An association between small bowel adenocarcinoma and Crohn's Disease (CD) is well-established. Crohn's-related small bowel cancers are male predominant, distal, surrounded by dysplasia, and carry a poor prognosis, particularly in the setting of excluded intestinal loops. As suggested in an earlier published series from our center (1991), clinical indicators of small bowel cancer in CD include recurrent obstructive symptoms after periods of quiescence and bowel obstruction that is refractory to conservative management.1 We present our recent experience with this entity in order to further elucidate its clinicopathological features and clinical indicators. Methods: A retrospective review was undertaken of all surgical patients with small bowel adenocarcinoma and CD seen at our institution between 1994-2009. The data included demographics, pathology, hospital and post-operative course. Follow-up was assessed until time of death or by interview with survivors. Patients were classified into two groups according to lymph node status (Stages 1&2 vs. 3&4); survival was calculated for all patients and compared between these groups using Kaplan Meier curves. Results: 28 patients (9F, 19M) were identified and followed for a median of 2 years. The median age at onset of CD symptoms was 25, and the median age at cancer diagnosis was 54.9, for a mean interval of 28.3 years. Twenty-one cancers were ileal and five were jejunal. There were no cancers in excluded intestinal loops. Significant differences in 2-year survival were determined for: node-negative (83.3%, 95%CI 62.4-14.5%) versus nodepositive cancers (45.5 %, 95%CI 17.7-73.3%), and for localized (90.9%, 95%CI 73.8-108%) versus metastatic disease (33.3%, 95%CI 6.6-60%). Overall 36-month survival was 68% (95%CI 49.6-86.4%), compared to 40% among those without excluded loops in our series from 1991. Fifteen of 22 patients had long periods of quiescent disease before diagnosis (7-45 years), and 13 of 22 patients required surgery for refractory bowel obstruction. Adequate information was not retrievable for 6 patients. Conclusions: A comparison to our previous series reveals similar male predominance, long duration to development of cancer, and a high rate of node-positive cancer at diagnosis. Our findings also confirm 2 important clinical indicators of malignancy: recrudescent symptoms after long periods of relative quiescence, and persistent small bowel obstruction that is refractory to medical therapy. 1 Ribeiro MB, Greenstein AJ, Heimann TM, Yamazaki Y, Aufses AH Jr., Surg Gynecol Obstet. 1991 Nov;173(5):343-9.
M1659 Novel Method of Stump Closure for Distal Pancreatectomy Results in 87% Reduction in Leak Rates Megan Rapp, William E. Strodel, David G. Sheldon, Sucandy Iswanto, Ravi Chokshi, Joseph A. Blansfield Introduction Pancreatic stump leak is a significant problem for patients undergoing distal pancreatectomy with documented leak rates up to 40%. Leaks can lead to substantial morbidity, additional procedures and added cost. Radiofrequency dissectors have shown decreased bile leak rates after partial hepatectomies. This technology has yet to be applied and studied in distal pancreatectomies. The objective of this study was to compare the use of radiofrequency (RF) dissector as compared with traditional methods of stump closure. Methods Fifty-four patients underwent distal pancreatectomy at our institution between 2002 and 2009 by the Surgical Oncology Section of the Division of Surgery. Thirty-three
SSAT Abstracts
S-876