- Email: [email protected]
Mo1647 Outcomes From the Swedish Registry of Gallstone Surgery and ERCP (GallRiks). Clinical Consequences and Implementation During a 10-Year Period
Mo1644
analysis, presence of perineural invasion (hazard ratio [HR] 3.53: 95% confidence interval [CI] 1.52-10.3; P = 0.0021) and lymph node metastasis (HR 2.47; 95% CI 1.56-5.08; P = 0.0005) are identified significant as independent risk factors for poor overall survival. Conclusion The current results suggested that presence of perineural invasion in extrahepatic cholangiocarcinoma was an independent risk factor of poor survival of patients with resectable extrahepatic cholangiocarcinoma, however, NGF expression was probably not associated with perineural invasion, and did not impact on their survival.
Technical Feasibility of Confocal Laser Endomicroscopy in Laparoscopic Surgery: The PERSEE Project Brice Gayet, Pierre Validire, Angelo Pierangelo, Abdelali Benali, David Fuks Rationale: Confocal laser endomicroscopy (CLE) is a novel imaging technique routinely used in endoscopic examinations in the area of gastroenterology and pulmonology for in vivo real time microscopic characterization of the mucosa. The same technique would be helpful during laparoscopic surgery for both real time detection of peritoneal carcinomatosis and real time evaluation of surgical margins. Objective: To evaluate the feasibility and safety of an innovative confocal endomicroscopic device dedicated to the in vivo imaging of tissue for surgical applications during laparoscopic surgery for digestive cancer. Methods: Real time images were obtained as the result of: (a) a robotized confocal mini-probe with a bending distal tip providing access and imaging of peritoneal nodules or a confocal mini-probe including a 19G needle for needle-based CLE (nCLE); (b) a dual wavelength endomicroscopy system that allowed imaging at 2 different wavelengths in the near infrared: 640nm and 785nm (ICG was applied interstitially for lymph nodes staining (1.25 mg/ml) and topically for surface staining (0.25 mg/ml); (c) an audio-visual datalink between the surgeon and the pathologist enabling both real-time transmission of macroscopic and microscopic information and interpretation of "optical biopsies". Results: nCLE and pCLE were successfully performed and endomicroscopic images were obtained on the peritoneum (including normal and fibrous nodules), on the liver and in 2 lymph nodes. No adverse event was reported. The robotized miniprobe enabled easy manipulation by the surgeon and stable images improving image quality. The audio-visual connection between the OR and the pathologist room enabled an efficient real-time information sharing. Conclusion: These preliminary results suggest a promising introduction of robotized CLE in laparoscopic surgery leading to a new way of collaboration between the surgeon and the pathologist.
Mo1647 Outcomes From the Swedish Registry of Gallstone Surgery and ERCP (GallRiks). Clinical Consequences and Implementation During a 10-Year Period Lars Enochsson, Gabriel Sandblom, Johanna Österberg, Anders Thulin, Bengt I. Hallerbäck, gunnar persson Background Cholecystectomy for symptomatic gallstone disease is one of the most common surgical procedures. Whereas the relative risk of postoperative complications is small, the absolute incidence is high due to widespread practice of gallstone surgery. In order to assess the intra- and postoperative complication rates, GallRiks started in May 2005 and now in 2015 celebrates its 10th anniversary. Since nearly 20,000 procedures (12,000 cholecystectomies and 7,500 ERCPs) are registered annually in constitutes a huge database available for clinical research. The aim of this study is to present an overview of the clinical consequences and implementation that GallRiks research may have contributed to on patient Care during a 10-year period. Material and Methods A literature review on studies based on GallRiks data [1-4] and their clinical implications on the outcome and implementation on treatment strategies in cholecystectomy and ERCP during a 10-year period. Results In Sweden there were significant differences regarding the administration of prophylactic antibiotics for elective cholecystectomies. Lundström et al. [4] showed that the administration of prophylactic antibiotics did not reduce the postoperative infection rate. These findings have been presented at annual registry meetings as well as at national and international meetings before publication. The use of prophylactic antibiotics has decreased from 24 (2006) to 13% (2013). Another GallRiks study [3] showed that the risk of bleeding incresed with the use of systemic thromboembolic prophylaxis in laparoscopic cholecystectomy but had no effect on thromboembolic events. Since then thromboembolic prophylaxis in elective cholecystectomy has decreased from 49.7 (2006) to 25.4% (2013). A study on 51,041 cholecystectomies in GallRiks showed the intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy [2]. The intraoperative cholangiography rate in Sweden has increased from 87.1 (2006) to 90.4% (2013). A study on 12,718 ERCP procedures in GallRiks [1] showed that intraoperative rendez-vous ERCP reduces the risk of post-ERCP pancreatitis from 3.6 to 2.2% compared with conventional biliary cannulation. The frequency of intraoperative ERCP in Sweden now has increased from 20 (2006) to 36% (2013). Conclusion The studies based on GallRiks data during this 10-year period have substantially changed the routines regarding treatment of patients with symptomatic gallstone disease in Sweden. A population-based register may improve the diffusion of evidence-based routines in the clinical care. [1] Swahn F et al. The American journal of gastroenterology. 2013;108:552-9. [2] Tornqvist B et al. Bmj. 2012;345:e6457. [3] Persson G et al. The British journal of surgery. 2012;99:979-86. [4] Lundstrom P et al. Journal of gastrointestinal surgery 2010;14:329-34.
Mo1645
SSAT Abstracts
Retrospective Review of Clinical Outcomes in Undetectable Mass of the Pancreatic Head Prior to Pancreatoduodenectomy. Hideo Takahashi, Maitham A. Moslim, Naftali Presser, Sricharan Chalikonda, Gareth Morris-Stiff, R Matthew Walsh BACKGROUND: The classic radiologic description of pancreatic carcinoma on cross-sectional imaging is a mass in the pancreatic head, however not uncommonly, no mass is identified on computed tomography (CT) or magnetic resonance imaging (MRI). The aim of this study was to assess whether the lack of a radiologic mass led to protracted diagnostic evaluation and delayed resection. METHODS: The departmental pancreatic database was interrogated to identify all patients undergoing pancreatoduodenectomy (PD) for primary malignancies of the pancreatic head during the period 2000-2014. The pre-operative evaluation of the patients was reviewed and the presence or absence of a mass on CT and/or MRI was noted. The interval between imaging and surgery was evaluated, and related to the presence of a mass. The relationship between mass/no mass and the pathological profile (tumor size, histopathology [pancreatic, ampullary, cholangiocarcinoma], degree of differentiation, lymph node metastases, lymph node ratio, vascular invasion, neurological invasion, margin status) were also assessed. All analyses were done using R software (version 3.1.0) and significance taken at the 5% level. RESULTS: 904 patients underwent PD during the study period, 514 of which had malignant lesions of the pancreatic head. There was no difference in the interval between the first cross-sectional imaging study and operation for patients with a mass compared with no mass (44 versus 46; p = 0.18). A mass was detected in 317 patients while no masses were seen on cross-sectional imaging in 196 patients. The absence of a mass was more common in cholangiocarcinomas than pancreatic or ampullary cancers (p<0.001). Although the size of the mass on final pathology was greater in the mass group (3.1cm versus 2.6cm; p<0.001), the tumor stage was significantly more advanced in the no mass cohort (p = 0.005). Other oncological factors were not significantly different between groups. CONCLUSIONS: Although the absence of a mass in patients presenting with a periampullary neoplasm does not delay treatment, they are resected at a more advanced stage. Detection of a mass was less likely in patients with a final diagnosis of cholangiocarcinoma.
Mo1648 Outcomes of Surgeon-Performed Endoscopic Retrograde Cholangiopancreatography Edward L. Jones, Teresa S. Jones, Sara E. Martin del Campo, Michael P. Meara, Jeffrey W. Hazey, Vimal K. Narula Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) is the standard for the diagnosis and/or management of biliary and pancreatic obstruction. In the United States, the procedure is performed by both surgeons and gastroenterologists. Upon review of the literature we could find no studies evaluating the overall outcomes of surgeon-performed ERCP. The aim of this study was to assess the outcome and complications following surgeonperformed ERCP. Methods: We retrospectively reviewed all patients undergoing ERCP by a surgeon (JWH, VKN or MPM) between January 2006 and December 2014 at an academic medical center. Results: One thousand one hundred and twenty-one patients underwent ERCP over an eight-year period. The mean age was 53.9 years and 533(48%) patients were male. (Table 1) The most common indication for ERCP was abnormal liver function test (637 patients, 57%) followed by abnormal imaging (282 patients, 25%). Most patients were underwent a therapeutic intervention (704 patients, 63%) and had not a pervious ERCP (773 patients, 69%). Successful cannulation was accomplished in 1,032 patients (92%). The mean procedure duration was 22.4±13 minutes. Post-procedure complications were noted 44 patients (3.9%). Thirty-five patients (3.1%) developed post-operative pancreatitis, 3 patients (0.3%) had bleeding required a blood transfusion, 6 patients (0.5%) developed cholangitis and there were no (0%) perforations. There were no ERCP-specific deaths within 30 days of the procedure. Conclusions: Endoscopic Retrograde Cholangiopancretography is safe and effective in the hands of surgeons. The outcome and complications in our study were comparable to what is reported in the gastroenterology literature.
Mo1646 Impact of Intratumoral Nerve Growth Factor Expression on Perineural Invasion and Prognosis in Resectable Extrahepatic Cholangiocarcinoma Kazuhide Urabe, Yoshiaki Murakami, Kenichiro Uemura, Yasushi Hashimoto, Naru Kondo, Naoya Nakagawa, Hayato Sasaki, Eiso Hiyama, Taijiro Sueda Background Perineural invasion is one of the risk factors of poor survival in extrahepatic cholangiocarcinoma. Intratumoral expression of nerve growth factor (NGF), which is a crucial neurotrophic factor of nerve growth and proliferation in proto neural crest, has been reported to be associated with perineural invasion in several kinds of cancers. However, it is still unclear whether intratumoral NGF expression impacts on perineural invasion and survival in extrahepatic cholangiocarcinoma. The aim of this study was to investigate the association of NGF expression in resected specimens with perineural invasion and survival of patients who underwent surgical resection for extrahepatic cholangiocarcinoma. Materials and Methods Records of 112 patients with extrahepatic cholangiocarcinoma (including 53 with distal cholangiocarcinoma and 59 with perihilar cholangiocarcinoma) who underwent surgical resection between September 1999 and April 2014 were reviewed retrospectively. Intratumoral NGF expression were investigated using immunohistochemical technique. Relationships between NGF expression and clinicopathological factors including perineural invasion in resected specimen were statistically evaluated, and risk factors for poor survival of patients with resectable extrahepatic cholangiocarcinoma were analyzed using univariate and multivariate analyses. Results High and low intratumoral NGF expression was observed in 62 (55%) and 50 (45%) patients, respectively. For all 112 patients, no significant differences was found between NGF expression and presence of perineural invasion (P = 0.94). Moreover, intratumoral NGF expression was not associated overall survival (P = 0.97). In multivariate
SSAT Abstracts
S-1160
analysis, presence of perineural invasion (hazard ratio [HR] 3.53: 95% confidence interval [CI] 1.52-10.3; P = 0.0021) and lymph node metastasis (HR 2.47; 95% CI 1.56-5.08; P = 0.0005) are identified significant as independent risk factors for poor overall survival. Conclusion The current results suggested that presence of perineural invasion in extrahepatic cholangiocarcinoma was an independent risk factor of poor survival of patients with resectable extrahepatic cholangiocarcinoma, however, NGF expression was probably not associated with perineural invasion, and did not impact on their survival.
Technical Feasibility of Confocal Laser Endomicroscopy in Laparoscopic Surgery: The PERSEE Project Brice Gayet, Pierre Validire, Angelo Pierangelo, Abdelali Benali, David Fuks Rationale: Confocal laser endomicroscopy (CLE) is a novel imaging technique routinely used in endoscopic examinations in the area of gastroenterology and pulmonology for in vivo real time microscopic characterization of the mucosa. The same technique would be helpful during laparoscopic surgery for both real time detection of peritoneal carcinomatosis and real time evaluation of surgical margins. Objective: To evaluate the feasibility and safety of an innovative confocal endomicroscopic device dedicated to the in vivo imaging of tissue for surgical applications during laparoscopic surgery for digestive cancer. Methods: Real time images were obtained as the result of: (a) a robotized confocal mini-probe with a bending distal tip providing access and imaging of peritoneal nodules or a confocal mini-probe including a 19G needle for needle-based CLE (nCLE); (b) a dual wavelength endomicroscopy system that allowed imaging at 2 different wavelengths in the near infrared: 640nm and 785nm (ICG was applied interstitially for lymph nodes staining (1.25 mg/ml) and topically for surface staining (0.25 mg/ml); (c) an audio-visual datalink between the surgeon and the pathologist enabling both real-time transmission of macroscopic and microscopic information and interpretation of "optical biopsies". Results: nCLE and pCLE were successfully performed and endomicroscopic images were obtained on the peritoneum (including normal and fibrous nodules), on the liver and in 2 lymph nodes. No adverse event was reported. The robotized miniprobe enabled easy manipulation by the surgeon and stable images improving image quality. The audio-visual connection between the OR and the pathologist room enabled an efficient real-time information sharing. Conclusion: These preliminary results suggest a promising introduction of robotized CLE in laparoscopic surgery leading to a new way of collaboration between the surgeon and the pathologist.
Mo1647 Outcomes From the Swedish Registry of Gallstone Surgery and ERCP (GallRiks). Clinical Consequences and Implementation During a 10-Year Period Lars Enochsson, Gabriel Sandblom, Johanna Österberg, Anders Thulin, Bengt I. Hallerbäck, gunnar persson Background Cholecystectomy for symptomatic gallstone disease is one of the most common surgical procedures. Whereas the relative risk of postoperative complications is small, the absolute incidence is high due to widespread practice of gallstone surgery. In order to assess the intra- and postoperative complication rates, GallRiks started in May 2005 and now in 2015 celebrates its 10th anniversary. Since nearly 20,000 procedures (12,000 cholecystectomies and 7,500 ERCPs) are registered annually in constitutes a huge database available for clinical research. The aim of this study is to present an overview of the clinical consequences and implementation that GallRiks research may have contributed to on patient Care during a 10-year period. Material and Methods A literature review on studies based on GallRiks data [1-4] and their clinical implications on the outcome and implementation on treatment strategies in cholecystectomy and ERCP during a 10-year period. Results In Sweden there were significant differences regarding the administration of prophylactic antibiotics for elective cholecystectomies. Lundström et al. [4] showed that the administration of prophylactic antibiotics did not reduce the postoperative infection rate. These findings have been presented at annual registry meetings as well as at national and international meetings before publication. The use of prophylactic antibiotics has decreased from 24 (2006) to 13% (2013). Another GallRiks study [3] showed that the risk of bleeding incresed with the use of systemic thromboembolic prophylaxis in laparoscopic cholecystectomy but had no effect on thromboembolic events. Since then thromboembolic prophylaxis in elective cholecystectomy has decreased from 49.7 (2006) to 25.4% (2013). A study on 51,041 cholecystectomies in GallRiks showed the intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy [2]. The intraoperative cholangiography rate in Sweden has increased from 87.1 (2006) to 90.4% (2013). A study on 12,718 ERCP procedures in GallRiks [1] showed that intraoperative rendez-vous ERCP reduces the risk of post-ERCP pancreatitis from 3.6 to 2.2% compared with conventional biliary cannulation. The frequency of intraoperative ERCP in Sweden now has increased from 20 (2006) to 36% (2013). Conclusion The studies based on GallRiks data during this 10-year period have substantially changed the routines regarding treatment of patients with symptomatic gallstone disease in Sweden. A population-based register may improve the diffusion of evidence-based routines in the clinical care. [1] Swahn F et al. The American journal of gastroenterology. 2013;108:552-9. [2] Tornqvist B et al. Bmj. 2012;345:e6457. [3] Persson G et al. The British journal of surgery. 2012;99:979-86. [4] Lundstrom P et al. Journal of gastrointestinal surgery 2010;14:329-34.
Mo1645
SSAT Abstracts
Retrospective Review of Clinical Outcomes in Undetectable Mass of the Pancreatic Head Prior to Pancreatoduodenectomy. Hideo Takahashi, Maitham A. Moslim, Naftali Presser, Sricharan Chalikonda, Gareth Morris-Stiff, R Matthew Walsh BACKGROUND: The classic radiologic description of pancreatic carcinoma on cross-sectional imaging is a mass in the pancreatic head, however not uncommonly, no mass is identified on computed tomography (CT) or magnetic resonance imaging (MRI). The aim of this study was to assess whether the lack of a radiologic mass led to protracted diagnostic evaluation and delayed resection. METHODS: The departmental pancreatic database was interrogated to identify all patients undergoing pancreatoduodenectomy (PD) for primary malignancies of the pancreatic head during the period 2000-2014. The pre-operative evaluation of the patients was reviewed and the presence or absence of a mass on CT and/or MRI was noted. The interval between imaging and surgery was evaluated, and related to the presence of a mass. The relationship between mass/no mass and the pathological profile (tumor size, histopathology [pancreatic, ampullary, cholangiocarcinoma], degree of differentiation, lymph node metastases, lymph node ratio, vascular invasion, neurological invasion, margin status) were also assessed. All analyses were done using R software (version 3.1.0) and significance taken at the 5% level. RESULTS: 904 patients underwent PD during the study period, 514 of which had malignant lesions of the pancreatic head. There was no difference in the interval between the first cross-sectional imaging study and operation for patients with a mass compared with no mass (44 versus 46; p = 0.18). A mass was detected in 317 patients while no masses were seen on cross-sectional imaging in 196 patients. The absence of a mass was more common in cholangiocarcinomas than pancreatic or ampullary cancers (p<0.001). Although the size of the mass on final pathology was greater in the mass group (3.1cm versus 2.6cm; p<0.001), the tumor stage was significantly more advanced in the no mass cohort (p = 0.005). Other oncological factors were not significantly different between groups. CONCLUSIONS: Although the absence of a mass in patients presenting with a periampullary neoplasm does not delay treatment, they are resected at a more advanced stage. Detection of a mass was less likely in patients with a final diagnosis of cholangiocarcinoma.
Mo1648 Outcomes of Surgeon-Performed Endoscopic Retrograde Cholangiopancreatography Edward L. Jones, Teresa S. Jones, Sara E. Martin del Campo, Michael P. Meara, Jeffrey W. Hazey, Vimal K. Narula Introduction: Endoscopic Retrograde Cholangiopancreatography (ERCP) is the standard for the diagnosis and/or management of biliary and pancreatic obstruction. In the United States, the procedure is performed by both surgeons and gastroenterologists. Upon review of the literature we could find no studies evaluating the overall outcomes of surgeon-performed ERCP. The aim of this study was to assess the outcome and complications following surgeonperformed ERCP. Methods: We retrospectively reviewed all patients undergoing ERCP by a surgeon (JWH, VKN or MPM) between January 2006 and December 2014 at an academic medical center. Results: One thousand one hundred and twenty-one patients underwent ERCP over an eight-year period. The mean age was 53.9 years and 533(48%) patients were male. (Table 1) The most common indication for ERCP was abnormal liver function test (637 patients, 57%) followed by abnormal imaging (282 patients, 25%). Most patients were underwent a therapeutic intervention (704 patients, 63%) and had not a pervious ERCP (773 patients, 69%). Successful cannulation was accomplished in 1,032 patients (92%). The mean procedure duration was 22.4±13 minutes. Post-procedure complications were noted 44 patients (3.9%). Thirty-five patients (3.1%) developed post-operative pancreatitis, 3 patients (0.3%) had bleeding required a blood transfusion, 6 patients (0.5%) developed cholangitis and there were no (0%) perforations. There were no ERCP-specific deaths within 30 days of the procedure. Conclusions: Endoscopic Retrograde Cholangiopancretography is safe and effective in the hands of surgeons. The outcome and complications in our study were comparable to what is reported in the gastroenterology literature.
Mo1646 Impact of Intratumoral Nerve Growth Factor Expression on Perineural Invasion and Prognosis in Resectable Extrahepatic Cholangiocarcinoma Kazuhide Urabe, Yoshiaki Murakami, Kenichiro Uemura, Yasushi Hashimoto, Naru Kondo, Naoya Nakagawa, Hayato Sasaki, Eiso Hiyama, Taijiro Sueda Background Perineural invasion is one of the risk factors of poor survival in extrahepatic cholangiocarcinoma. Intratumoral expression of nerve growth factor (NGF), which is a crucial neurotrophic factor of nerve growth and proliferation in proto neural crest, has been reported to be associated with perineural invasion in several kinds of cancers. However, it is still unclear whether intratumoral NGF expression impacts on perineural invasion and survival in extrahepatic cholangiocarcinoma. The aim of this study was to investigate the association of NGF expression in resected specimens with perineural invasion and survival of patients who underwent surgical resection for extrahepatic cholangiocarcinoma. Materials and Methods Records of 112 patients with extrahepatic cholangiocarcinoma (including 53 with distal cholangiocarcinoma and 59 with perihilar cholangiocarcinoma) who underwent surgical resection between September 1999 and April 2014 were reviewed retrospectively. Intratumoral NGF expression were investigated using immunohistochemical technique. Relationships between NGF expression and clinicopathological factors including perineural invasion in resected specimen were statistically evaluated, and risk factors for poor survival of patients with resectable extrahepatic cholangiocarcinoma were analyzed using univariate and multivariate analyses. Results High and low intratumoral NGF expression was observed in 62 (55%) and 50 (45%) patients, respectively. For all 112 patients, no significant differences was found between NGF expression and presence of perineural invasion (P = 0.94). Moreover, intratumoral NGF expression was not associated overall survival (P = 0.97). In multivariate
SSAT Abstracts
S-1160