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Pancreaticoduodenectomy with portal vein resection is safe and results in comparable survival
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Abstracts / Pancreatology 12 (2012) e9–e20
Poster Presentation
1. P53 Analysis is a better predictor of prognosis than histology in pancreatic IPMN J.A. Nicholson, L. Yan, S. Harrison, R. Sutton, J.P. Neoptolemos, F. Campbell, W. Greenhalf
growth (p0.0446) compared with control and studies in combination with gemcitabine are near completion. AT7519 inhibited proliferation in pancreatic cancer cell lines including gemcitabine resistant lines. AT7519 and gemcitabine in combination displayed an additive effect and S phase blockade. Downstream effects were observed with inhibition of phosphorylation of Rb, NPM and pp1-a. Conclusion: AT7519 is a promising agent for combination therapy in pancreatic cancer. Take-home message: AT7519 has displayed efficacy both in vivo and in vitro against pancreatic cancer. AT7519 is a promising agent for further clinical investigation in pancreatic cancer.
NIRH Pancreas Biomedical Research Unit, UCD Building, Daulby Street, Liverpool L69 3GA, UK 3. Category Background: The role of p53 in the development and progression of IPMN is unclear. Currently, radiological size and location (side branch/main duct) are the most quoted pre-operative predictors of malignancy in IPMNs. Aim: To investigate whether p53 mutational status can predict malignancy and outcome in IPMNs. Methods: 29 patients underwent resection for IPMN. p53 analysis was performed on intra-operatively collected pancreatic juice and frozen tissue samples taken from the resection specimens. p53 results were correlated with histological diagnosis and survival data. Results: Histologically, there were 11 IPMNs, 7 IPMNs with invasive adenocarcinoma (IPMCs), 3 conventional PDACs and 8 other benign entities. Eight patients died (median follow-up: 730 days). Tissue sample p53 status correlated with histological malignancy (p ¼ 0.0005). Tissue p53 predicted survival in IPMN and IPMC (p ¼ 0.0001) and was a better predictor of survival than conventional histology (p ¼ 0.01). Tissue p53 mutational status matched that in juice in all but 2 cases (where mutation site lay within the primers). There were no false positive p53 results in pancreatic juice. Conclusions: p53 mutational status can predict poor outcome in IPMNs, regardless of histological grade. Pancreatic juice analysis could potentially be used to identify those patients with IPMN who should be considered for resection. Take-home message: Pancreatic juice analysis could potentially be used to identify those patients with IPMN who should be considered for resection.
2. PRE-clinical investigation of AT7519, a novel CDK inhibitor, as a potential therapeutic agent in pancreatic cancer A. Thomas 1, E. Shaw 1, P. Ghaneh 1, W. Greenhalf 1, M. Davies 1, E. Costello 1, F. Gibbs 1, J. Lyons 2, D.R. Sibson 1, J.P. Neoptolemos 1 1
University of Liverpool, UK, 2 Astex Therapeutics, UK
Category: Malignant Background: Pancreatic cancer continues to carry a poor prognosis. Chemotherapy is used following surgery and in advanced disease; though current agents, e.g.: gemcitabine + capecitabine or FOLFIRINOX, provide modest survival benefit. There is an urgent need for more effective therapies. We evaluated a novel CDK inhibitor, AT7519, in pancreatic cancer. Methods: Cell proliferation assays for IC50 values and isobolar analysis were performed using EZ4U assay. Cell cycle analysis was performed with flow cytometry. Standard western blot analysis with ECL detection was completed to assess downstream markers. In vivo studies were conducted using a murine xenograft model. Tumour volume was assessed with external callipers. Tumour angiogenesis and apoptosis were demonstrated with FMT imaging. Results: AT7519 was tolerated as a single agent and in combination with gemcitabine. Mice treated with AT7519 showed decreased tumour
Utility of Mcm2 as a novel diagnostic marker of intraductal papillary mucinous neoplasms (IPMNS) of the pancreas Hannah R. Dadds 1, Matthew T. Huggett 3, TuVingh Luong 4, Ian Proctor 2, Kai Stoeber 2, Gareth Williams 2, Stephen P. Pereira 3 1
UCL Institute of Hepatology University College London, London, UK, Department of Histopathology, University College London, London, UK, 3 Department of Gastroenterology, University College London Hospitals NHS Foundation Trust (UCLH), UK, 4 Department of Histopathology, Royal Free Hospital, London, UK 2
Category: Benign & Inflammatory Introduction: IPMNs are increasingly recognised but diagnosis remains problematic. We have shown that minichromosome maintenance proteins (Mcms), essential for initiating and regulating eukaryotic DNA replication, are dysregulated in pancreaticobiliary disease. Aims: To assess the expression of Mcm2 protein as a potential diagnostic marker for IPMNs. Methods: Mcm2 protein expression was assessed in formalin-fixed, paraffin-embedded pancreatic tissue from 9 patients with cystic tumours, 18 age- and sex-matched patients with pancreatic cancer, and 22 benign disease controls (normal pancreatic tissue, inflammatory biliary epithelium, benign ampulla, chronic pancreatitis and serous cystadenomas). Consecutive serial sections were cut onto slides, immunostained and primary antibody applied (1:2000). Protein expression analysis was performed by determining the labelling index (LI) of the markers in each tumour. Results: Mcm2 protein expression in IPMNs, pancreatic cancer tissue and benign disease was 51%, 41% and 11%, respectively. Mcm2 protein expression was significantly increased in IPMN and pancreatic cancer tissue compared with benign disease controls (p < 0.001). Mcm2 staining was concentrated in the epithelial wall in the IPMN cystic tissue and dispersed throughout the pancreatic cancer tissue. Conclusion: Mcm2 protein expression correlates positively with an increase in malignant potential, warranting further study as a novel diagnostic/prognostic biomarker of (pre-)malignant cystic neoplasms of the pancreas. Take-home message: Minichromosome maintenance proteins (Mcms), essential for initiating/regulating eukaryotic DNA replication, are dysregulated in pancreaticobiliary disease. We have shown Mcm2 protein expression to correlate positively with an increase in malignant potential, warranting further study as a novel diagnostic/prognostic biomarker of (pre-)malignant cystic neoplasms of the pancreas.
4. Pancreaticoduodenectomy with portal vein resection is safe and results in comparable survival Deep J. Malde, Melissa Oliviera-Cunha, Amer Aldouri, Krishna Menon, Andrew M. Smith The HPB Unit, St James University Hospital, Leeds, UK
Abstracts / Pancreatology 12 (2012) e9–e20
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Category: Malignant 6. Introduction: Combined vascular and pancreatic resection improves long-term survival of patients suffering from ductal adenocarcinoma of the pancreatic head. Methods: From September 2006 to January 2011, there were 39 (27.1%) portal vein resections carried out during 144 pancreaticoduodenectomies for malignancy. Data was analysed to look at morbidity, mortality and survival to evaluate the safety of portal vein resection. Results: There were 20 female and 19 male patients with a mean age of 60.4 years (median 63). 20 (51.3%) patients had pre-operative biliary drainage (ERCP 19 and PTC 1). Post – operative complications occurred in 5 (12.8%) patients with a 30-day mortality of 1 (2.6%). The type of portal vein resection was a wedge resection, with or without a patch, in 27 (69.2%) and complete resection with end to end anastomosis in 11 (28.2%) patients respectively. An interposition vein graft was used in 1 (2.6%) patient. There was no evidence of portal vein thrombosis in any patients during follow up. The median follow up in this study was 13 months (range 0 - 39). The actuarial 1 and 3 year survival was 35.5% and 4.8% respectively, with median disease free survival of 10 months (range 0 – 38.5). Conclusion: Vascular resection combined with pancreaticoduodenectomy for pancreatic cancer increases local resectability without increasing mortality and morbidity rates in the setting of a tertiary referral centre and should not be a contraindication to surgery. Take-home message: Portal vein resection in extended pancreaticoduodenectomy for pancreatic head cancer improves outcome without increase in morbidity and mortality in a tertiary referral centre.
5. Artery first PPPD: Clinical outcome and staging using a standardised pathology protocol Deep J. Malde, Gareth Morris-Stiff, Caroline Verbeke, Andrew M. Smith
Bone mineral density in patients with chronic pancreatitis J.R.A. Skipworth 1, M.H. Chapman 2, G. Johnson 2, S. Vyas 1, G.W. Webster 2, S.P. Pereira 2 1 Department of Hepatopancreaticobiliary Surgery, Royal Free Hospital, London, UK, 2 Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, UK
Category: Malignant Introduction: Abnormal calcium/vitamin D homeostasis and bone mineral density (BMD) have been associated with pancreatic dysfunction and alcohol abuse syndromes but the prevalence of these conditions in patients with chronic pancreatitis (CP) is poorly reported. Methods: Patients with CP with pancreatic insufficiency (PI) were assessed at one tertiary centre by retrospective case notes review. BMD was measured in lumbar spine (L1-4) and femoral neck, utilising a DEXA scanner (t-score: 1–2.5(osteopenia) or >2.5(osteoporosis) standard deviations below mean). Results: 64 patients were assessed (44M; Median age 60(27-85) years; median BMI 23.3(12.7-39.0)kg/m2). Aetiology was alcohol(52%), idiopathic(25%), gallstones(11%) and other(12%). 25(39%) had normal BMD, whereas 27(42%) had osteopenia and 12(19%) osteoporosis. BMI was the strongest predictor of low BMD: median BMI was 25.6(18.8-39.0)kg/m2 in patients with normal BMD, 23.3(18.1-36.8)kg/m2 in patients with osteopenia and 18.0(12.7-29.2)kg/m2 in patients with osteoporosis(p<0.05). Six(50%) osteoporosis patients had diabetes mellitus, as compared to seven(26%) osteopenia and four(16%) normal BMD patients(p<0.05). There was no correlation between aetiology, smoking, bone biochemistry or CP duration with BMD. Conclusion: Patients with CP are at significant risk of osteopenia and osteoporosis. Low BMI may be an important predictor of low BMD, whereas those with diabetes may be at even greater risk. Take-home message: Patients with CP are at significant risk of osteopenia and osteoporosis. Low BMI may be an important predictor of low BMD; whereas, those with diabetes may be at even greater risk.
The HPB Unit, St James University Hospital, Leeds, UK Category: Malignant Background: With increased numbers of borderline locally advanced patients undergoing resection due to the acceptance of portal vein (PV) resection, early dissection of the superior mesenteric artery (SMA) allows definitive assessment of the tumour/SMA relationship and improved control when PV resection is required. Methods: The lymph node yield, resection margins, morbidity and mortality data were compared between patients undergoing Artery first technique of pancreaticoduodenectomy (January 2009 to December 2010) and previous resections (January 2000 to December 2008). Results: 42 resections were carried out using the artery first technique were age, sex and pathology matched with 182 previous resections. Although higher, the increase in the overall R0 resection margins (28.6% vs 36.3%, p¼0.375) and the posterior resection margins (42.9% vs 36.3%, p¼0.481) didn't meet significance. The mean lymph node yield was significantly increased (19 vs 27, p <0.05) but there was no significant difference in the post-operative morbidity and mortality rates between the 2 groups. The actuarial 1 and 2 year survival was 72% and 49.4% for earlier resections and 71.8% and 56.8% for Artery first PPPD respectively. The 1 and 2 year disease free survival was 65.2% and 47% for earlier resections and 67.6% and 64.4% for Artery first PPPD. Conclusion: Artery first resection enhances the clearance at the SMA (a common site for R1 resection) with increased lymph node yield. The 2 year follow up with Artery first PPPD shows a trend towards improving overall and disease free survival. Take-home message: Artery first technique of pancreaticoduodenectomy results in improved lymph node yield and resection margins.
7. Modified early warning score (MEWS): A user friendly and sensitive predictor of poor outcome in acute pancreatitis Aravind Suppiah, Deep J. Malde, Tameem Arab, Mazen Hamed, Amer Aldouri, Krishna Menon, Andrew M. Smith The HPB Unit, St James University Hospital, Leeds, UK Category: Benign & Inflammatory Background: Acute pancreatic (AP) prognostic scoring systems can be invasive &/ or complex. The aim of this study was to assess the Modified Early Warning System (MEWS) in predicting prognosis in AP. Method: Sequential AP patients (January-December 2010). The sensitivity (sn) & specificity (sp), Negative Predictive Value (NPV) and Positive Predictive Value (PPV) of MEWS 2 in any 24-hour period; and mean daily MEWS > 1, for poor outcome was examined. Poor outcome was defined as intensive care admission, complications directly associated with pancreatitis, necrosis or death. Results: 146 consecutive patients were included with 29 having poor outcome. MEWS 2 in any 24 hours was 86.2% (Sn) & 81.2% (Sp) in Day 1, 79.3% (Sn) and 83.8% (Sp) in Day 2, and 75.9% and 88.9% (Sp) in Day 3 for poor outcome. MEWS 2 in any 24-hours in the first 3 days had NPV of 96%, 94.2% and 93.7%; PPV was 53.2%, 54.8% and 62.9% for poor outcome. Mean daily MEWS > 1 was 82.8% (Sn) & 88% (Sp) in Day 1, 72.4% (Sn) & 85.5% (Sp) in Day 2 and 75.9% (Sn) & 93.1% (Sp) in Day 3 for poor outcome. Mean daily MEWS >1 had NPV of 95.4%, 92.6% and 94%, and PPV of 63.1%, 55.3% and 73.3% for poor outcome in Days 1,2 & 3 respectively.
Abstracts / Pancreatology 12 (2012) e9–e20
Poster Presentation
1. P53 Analysis is a better predictor of prognosis than histology in pancreatic IPMN J.A. Nicholson, L. Yan, S. Harrison, R. Sutton, J.P. Neoptolemos, F. Campbell, W. Greenhalf
growth (p0.0446) compared with control and studies in combination with gemcitabine are near completion. AT7519 inhibited proliferation in pancreatic cancer cell lines including gemcitabine resistant lines. AT7519 and gemcitabine in combination displayed an additive effect and S phase blockade. Downstream effects were observed with inhibition of phosphorylation of Rb, NPM and pp1-a. Conclusion: AT7519 is a promising agent for combination therapy in pancreatic cancer. Take-home message: AT7519 has displayed efficacy both in vivo and in vitro against pancreatic cancer. AT7519 is a promising agent for further clinical investigation in pancreatic cancer.
NIRH Pancreas Biomedical Research Unit, UCD Building, Daulby Street, Liverpool L69 3GA, UK 3. Category Background: The role of p53 in the development and progression of IPMN is unclear. Currently, radiological size and location (side branch/main duct) are the most quoted pre-operative predictors of malignancy in IPMNs. Aim: To investigate whether p53 mutational status can predict malignancy and outcome in IPMNs. Methods: 29 patients underwent resection for IPMN. p53 analysis was performed on intra-operatively collected pancreatic juice and frozen tissue samples taken from the resection specimens. p53 results were correlated with histological diagnosis and survival data. Results: Histologically, there were 11 IPMNs, 7 IPMNs with invasive adenocarcinoma (IPMCs), 3 conventional PDACs and 8 other benign entities. Eight patients died (median follow-up: 730 days). Tissue sample p53 status correlated with histological malignancy (p ¼ 0.0005). Tissue p53 predicted survival in IPMN and IPMC (p ¼ 0.0001) and was a better predictor of survival than conventional histology (p ¼ 0.01). Tissue p53 mutational status matched that in juice in all but 2 cases (where mutation site lay within the primers). There were no false positive p53 results in pancreatic juice. Conclusions: p53 mutational status can predict poor outcome in IPMNs, regardless of histological grade. Pancreatic juice analysis could potentially be used to identify those patients with IPMN who should be considered for resection. Take-home message: Pancreatic juice analysis could potentially be used to identify those patients with IPMN who should be considered for resection.
2. PRE-clinical investigation of AT7519, a novel CDK inhibitor, as a potential therapeutic agent in pancreatic cancer A. Thomas 1, E. Shaw 1, P. Ghaneh 1, W. Greenhalf 1, M. Davies 1, E. Costello 1, F. Gibbs 1, J. Lyons 2, D.R. Sibson 1, J.P. Neoptolemos 1 1
University of Liverpool, UK, 2 Astex Therapeutics, UK
Category: Malignant Background: Pancreatic cancer continues to carry a poor prognosis. Chemotherapy is used following surgery and in advanced disease; though current agents, e.g.: gemcitabine + capecitabine or FOLFIRINOX, provide modest survival benefit. There is an urgent need for more effective therapies. We evaluated a novel CDK inhibitor, AT7519, in pancreatic cancer. Methods: Cell proliferation assays for IC50 values and isobolar analysis were performed using EZ4U assay. Cell cycle analysis was performed with flow cytometry. Standard western blot analysis with ECL detection was completed to assess downstream markers. In vivo studies were conducted using a murine xenograft model. Tumour volume was assessed with external callipers. Tumour angiogenesis and apoptosis were demonstrated with FMT imaging. Results: AT7519 was tolerated as a single agent and in combination with gemcitabine. Mice treated with AT7519 showed decreased tumour
Utility of Mcm2 as a novel diagnostic marker of intraductal papillary mucinous neoplasms (IPMNS) of the pancreas Hannah R. Dadds 1, Matthew T. Huggett 3, TuVingh Luong 4, Ian Proctor 2, Kai Stoeber 2, Gareth Williams 2, Stephen P. Pereira 3 1
UCL Institute of Hepatology University College London, London, UK, Department of Histopathology, University College London, London, UK, 3 Department of Gastroenterology, University College London Hospitals NHS Foundation Trust (UCLH), UK, 4 Department of Histopathology, Royal Free Hospital, London, UK 2
Category: Benign & Inflammatory Introduction: IPMNs are increasingly recognised but diagnosis remains problematic. We have shown that minichromosome maintenance proteins (Mcms), essential for initiating and regulating eukaryotic DNA replication, are dysregulated in pancreaticobiliary disease. Aims: To assess the expression of Mcm2 protein as a potential diagnostic marker for IPMNs. Methods: Mcm2 protein expression was assessed in formalin-fixed, paraffin-embedded pancreatic tissue from 9 patients with cystic tumours, 18 age- and sex-matched patients with pancreatic cancer, and 22 benign disease controls (normal pancreatic tissue, inflammatory biliary epithelium, benign ampulla, chronic pancreatitis and serous cystadenomas). Consecutive serial sections were cut onto slides, immunostained and primary antibody applied (1:2000). Protein expression analysis was performed by determining the labelling index (LI) of the markers in each tumour. Results: Mcm2 protein expression in IPMNs, pancreatic cancer tissue and benign disease was 51%, 41% and 11%, respectively. Mcm2 protein expression was significantly increased in IPMN and pancreatic cancer tissue compared with benign disease controls (p < 0.001). Mcm2 staining was concentrated in the epithelial wall in the IPMN cystic tissue and dispersed throughout the pancreatic cancer tissue. Conclusion: Mcm2 protein expression correlates positively with an increase in malignant potential, warranting further study as a novel diagnostic/prognostic biomarker of (pre-)malignant cystic neoplasms of the pancreas. Take-home message: Minichromosome maintenance proteins (Mcms), essential for initiating/regulating eukaryotic DNA replication, are dysregulated in pancreaticobiliary disease. We have shown Mcm2 protein expression to correlate positively with an increase in malignant potential, warranting further study as a novel diagnostic/prognostic biomarker of (pre-)malignant cystic neoplasms of the pancreas.
4. Pancreaticoduodenectomy with portal vein resection is safe and results in comparable survival Deep J. Malde, Melissa Oliviera-Cunha, Amer Aldouri, Krishna Menon, Andrew M. Smith The HPB Unit, St James University Hospital, Leeds, UK
Abstracts / Pancreatology 12 (2012) e9–e20
e11
Category: Malignant 6. Introduction: Combined vascular and pancreatic resection improves long-term survival of patients suffering from ductal adenocarcinoma of the pancreatic head. Methods: From September 2006 to January 2011, there were 39 (27.1%) portal vein resections carried out during 144 pancreaticoduodenectomies for malignancy. Data was analysed to look at morbidity, mortality and survival to evaluate the safety of portal vein resection. Results: There were 20 female and 19 male patients with a mean age of 60.4 years (median 63). 20 (51.3%) patients had pre-operative biliary drainage (ERCP 19 and PTC 1). Post – operative complications occurred in 5 (12.8%) patients with a 30-day mortality of 1 (2.6%). The type of portal vein resection was a wedge resection, with or without a patch, in 27 (69.2%) and complete resection with end to end anastomosis in 11 (28.2%) patients respectively. An interposition vein graft was used in 1 (2.6%) patient. There was no evidence of portal vein thrombosis in any patients during follow up. The median follow up in this study was 13 months (range 0 - 39). The actuarial 1 and 3 year survival was 35.5% and 4.8% respectively, with median disease free survival of 10 months (range 0 – 38.5). Conclusion: Vascular resection combined with pancreaticoduodenectomy for pancreatic cancer increases local resectability without increasing mortality and morbidity rates in the setting of a tertiary referral centre and should not be a contraindication to surgery. Take-home message: Portal vein resection in extended pancreaticoduodenectomy for pancreatic head cancer improves outcome without increase in morbidity and mortality in a tertiary referral centre.
5. Artery first PPPD: Clinical outcome and staging using a standardised pathology protocol Deep J. Malde, Gareth Morris-Stiff, Caroline Verbeke, Andrew M. Smith
Bone mineral density in patients with chronic pancreatitis J.R.A. Skipworth 1, M.H. Chapman 2, G. Johnson 2, S. Vyas 1, G.W. Webster 2, S.P. Pereira 2 1 Department of Hepatopancreaticobiliary Surgery, Royal Free Hospital, London, UK, 2 Department of Gastroenterology, University College Hospitals NHS Foundation Trust, London, UK
Category: Malignant Introduction: Abnormal calcium/vitamin D homeostasis and bone mineral density (BMD) have been associated with pancreatic dysfunction and alcohol abuse syndromes but the prevalence of these conditions in patients with chronic pancreatitis (CP) is poorly reported. Methods: Patients with CP with pancreatic insufficiency (PI) were assessed at one tertiary centre by retrospective case notes review. BMD was measured in lumbar spine (L1-4) and femoral neck, utilising a DEXA scanner (t-score: 1–2.5(osteopenia) or >2.5(osteoporosis) standard deviations below mean). Results: 64 patients were assessed (44M; Median age 60(27-85) years; median BMI 23.3(12.7-39.0)kg/m2). Aetiology was alcohol(52%), idiopathic(25%), gallstones(11%) and other(12%). 25(39%) had normal BMD, whereas 27(42%) had osteopenia and 12(19%) osteoporosis. BMI was the strongest predictor of low BMD: median BMI was 25.6(18.8-39.0)kg/m2 in patients with normal BMD, 23.3(18.1-36.8)kg/m2 in patients with osteopenia and 18.0(12.7-29.2)kg/m2 in patients with osteoporosis(p<0.05). Six(50%) osteoporosis patients had diabetes mellitus, as compared to seven(26%) osteopenia and four(16%) normal BMD patients(p<0.05). There was no correlation between aetiology, smoking, bone biochemistry or CP duration with BMD. Conclusion: Patients with CP are at significant risk of osteopenia and osteoporosis. Low BMI may be an important predictor of low BMD, whereas those with diabetes may be at even greater risk. Take-home message: Patients with CP are at significant risk of osteopenia and osteoporosis. Low BMI may be an important predictor of low BMD; whereas, those with diabetes may be at even greater risk.
The HPB Unit, St James University Hospital, Leeds, UK Category: Malignant Background: With increased numbers of borderline locally advanced patients undergoing resection due to the acceptance of portal vein (PV) resection, early dissection of the superior mesenteric artery (SMA) allows definitive assessment of the tumour/SMA relationship and improved control when PV resection is required. Methods: The lymph node yield, resection margins, morbidity and mortality data were compared between patients undergoing Artery first technique of pancreaticoduodenectomy (January 2009 to December 2010) and previous resections (January 2000 to December 2008). Results: 42 resections were carried out using the artery first technique were age, sex and pathology matched with 182 previous resections. Although higher, the increase in the overall R0 resection margins (28.6% vs 36.3%, p¼0.375) and the posterior resection margins (42.9% vs 36.3%, p¼0.481) didn't meet significance. The mean lymph node yield was significantly increased (19 vs 27, p <0.05) but there was no significant difference in the post-operative morbidity and mortality rates between the 2 groups. The actuarial 1 and 2 year survival was 72% and 49.4% for earlier resections and 71.8% and 56.8% for Artery first PPPD respectively. The 1 and 2 year disease free survival was 65.2% and 47% for earlier resections and 67.6% and 64.4% for Artery first PPPD. Conclusion: Artery first resection enhances the clearance at the SMA (a common site for R1 resection) with increased lymph node yield. The 2 year follow up with Artery first PPPD shows a trend towards improving overall and disease free survival. Take-home message: Artery first technique of pancreaticoduodenectomy results in improved lymph node yield and resection margins.
7. Modified early warning score (MEWS): A user friendly and sensitive predictor of poor outcome in acute pancreatitis Aravind Suppiah, Deep J. Malde, Tameem Arab, Mazen Hamed, Amer Aldouri, Krishna Menon, Andrew M. Smith The HPB Unit, St James University Hospital, Leeds, UK Category: Benign & Inflammatory Background: Acute pancreatic (AP) prognostic scoring systems can be invasive &/ or complex. The aim of this study was to assess the Modified Early Warning System (MEWS) in predicting prognosis in AP. Method: Sequential AP patients (January-December 2010). The sensitivity (sn) & specificity (sp), Negative Predictive Value (NPV) and Positive Predictive Value (PPV) of MEWS 2 in any 24-hour period; and mean daily MEWS > 1, for poor outcome was examined. Poor outcome was defined as intensive care admission, complications directly associated with pancreatitis, necrosis or death. Results: 146 consecutive patients were included with 29 having poor outcome. MEWS 2 in any 24 hours was 86.2% (Sn) & 81.2% (Sp) in Day 1, 79.3% (Sn) and 83.8% (Sp) in Day 2, and 75.9% and 88.9% (Sp) in Day 3 for poor outcome. MEWS 2 in any 24-hours in the first 3 days had NPV of 96%, 94.2% and 93.7%; PPV was 53.2%, 54.8% and 62.9% for poor outcome. Mean daily MEWS > 1 was 82.8% (Sn) & 88% (Sp) in Day 1, 72.4% (Sn) & 85.5% (Sp) in Day 2 and 75.9% (Sn) & 93.1% (Sp) in Day 3 for poor outcome. Mean daily MEWS >1 had NPV of 95.4%, 92.6% and 94%, and PPV of 63.1%, 55.3% and 73.3% for poor outcome in Days 1,2 & 3 respectively.