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Reexploration for periampullary carcinoma: Resectability, perioperative results, pathology and long-term outcome
April !998
SSAT A1427
• S0238 LIVER RESECTION FOR NONCOLORECTAL NONNEUROENDOCRINE HEPATIC METASTASES. T. D.Sielaff. B. Lan~,er. T. Van der Meer, B.R. Taylor, P.D. Greig, S. Gallinger. A.W. Hemming, Department of Surgery, University of Toronto. Toronto, Ontario, Canada.
The indications for the resection of noncolorectal/nonneuroendocrine hepatic metastases (NCNNE) have evolved as the safety of hepatic resection has increased. The prognostic features of NCNNE treated surgically were reviewed in order to better define the indications for resection. Methods: A retrospective review of patients undergoing liver resection for NCNNE between 1978 and 1997. Results: Thirty patients were identified. The mean age was 57 years with a median follow up of 18 months. Primary tumor sites included GI adenocarcinoma (bowel n=3, unknown n=2, pancreatic n=2, esophageal n=l), and other (renal cell n=5, testicular n=l, ovarian n=l, sarcoma n=6, adrenal n=3, melanoma n=3, thyroid n=2, and breast n=l). All patients were operated upon for cure. Synchronous metastases were treated in 9 patients. There was no operative mortality. Overall survival is shown in Figure 1. Survival was better in patients with non-GI origin metastases (Figure 2, p=0.04). Long term survivors were seen only in patients with non GI origin metastases. Neither the extent of resection (segmental n=l 1, lobe n---14, extended n=5) nor the presence of synchronous metastases was predictive of outcome.
of laparoscopic (LC) vs open cholecystectomy (OC) under elective or urgent conditions for patients greater than 70 yrs of age. During a 6 year period ending 9/30/97, 145 elderly patients underwent cholecystectomy: 76 (48%) for non-acute cholelithiasis (NAC) and 69 (52%) for acute cholecystitis (AC). Twelve patients presented with biliary pancreatitis and 24 patients (35% of AC patients) had gangrenous cholecystitis. There were 115 men (79%) and 30 women with a mean age of 72 yrs (range (70-90 yrs). The number of patients undergoing successful LC has increased 38% (1997 vs 1991) and for AC it has doubled (Table 1). Seven of 145 patients died for a mortality rate of 5%; NAC 0%, AC 10%, LC 2.6%, OC 7.4%. LOS was effected by diagnosis and technique of cholecystectomy (Table 2). Compared to 3803 patients < 70 y.o. who underwent cholecystectomy, patients > 70 y.o. were predominantly male (79% vs 26%), had a higher prevalence of AC (48% vs 32%), higher operative mortality (5% vs 0.3%), and lower overall LC (1995-1997 period) technical success rate (64% vs 90%) with NAC (79% vs 95%), and AC (41% vs 77%). Despite skilled laparoscopic technique (95% successful LC overall) among our surgeons, we have not been able to improve the low rate of LC in the elderly patients for the past four years. Further improvement in the care of elderly patients depends upon earlier therapeutic intervention for patients with acute cholecystitis to prevent the pathologic progression to gangrene, especially for male patients. Because the rate of successful LC has not incrementally improved in this patient population as in other groups, continued faculty operative participation is mandatory in order to optimize the number of patients successfully undergoing LC.
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Conclusions: Patients with NCNNE hepatic metastases can undergo liver resection with an expectation of prolonged survival. However, patients with GI tract origin non-colorectal adenocarcinoma metastatic to the liver are unlikely to demonstrate extended survival.
• S0239 HOSPITAL PROCEDURE VOLUME AND HOSPITAL TEACHING STATUS DO NOT INFLUENCE OPERATIVE MORTALITY OR LONG-TERM SURVIVAL FOR RECTAL CANCER IN A LARGE GENERAL POPULATION: AN OUTCOMES STUDY. M.Simunovic. E. Si~,urdson, T.To. N.Baxter. A.Balshem, Z.Cohen, R.McLeod and E.Ross. Institute for Clinical Evaluative Sciences, Toronto, Ontario. Fox Chase Cancer Center, Philadelphia, PA. We tested the hypothesis that increased hospital procedure volume and teaching hospital status would improve operative mortality and long-term survival in patients with rectal cancer in Ontario, Canada. All incident cases of colorectal adenocarcinoma, treated within 60 days of diagnosis with abdominoperineal or low-anterior resection, and from years 1988 and 1991 were used. Patient information included age, sex, survival to 1995, and registration at a Regional Cancer Center where all radiotherapy in the province is delivered. Hospitals were stratified by teaching versus non-teaching status, and by volume group - low (_< 10 cases/yr), medium (11-18 c ases/yr), high (>_ 19 cases/yr). Previous work on a subset of similarly selected patients from 1990 showed no difference in disease stage among volume groups. Logistic regression measured odds ratios (OR) for operative mortality, while proportional hazards calculated risk ratios (RR) for time to failure (death). Models controlled for relevant patient and hospital characteristics. For years 1988 and 1991, respectively, there were 1083 and 1143 cases, percentage teaching hospital status was 30.6% and 28.3% (p=.23), unadjusted operative mortality was 3.32% and 3.76% (p=.58), registration for radiotherapy was 17.2% and 35.9% (p<.01), and distribution by volume group was similar. Likelihood of operative mortality was not significantly influenced by teaching versus nonteaching hospital status (OR=0.7, p=.24), or low- versus high-volume group (OR=0.9, p=.83). Time to death was not significantly influenced by year (RR=I.0, p=.55), teaching versus nun-teaching hospital status (RR=0.9, p=.06), or low- versus highvolume group (RR=I.0, p=.90). In conclusion, to improve outcomes for rectal cancer in this large general population, centralization of procedures into fewer higher volume hospitals or teaching hospitals is unlikely to have a major impact, and locally directed initiatives may be necessary such as efforts to improve surgical standards or use of adjuvant therapies. S0240
CHOLECYSTECTOMY IN ELDERLY PATIENTS: METHODS AND OUTCOME. KR Sirinek. WH Schwesinger, GWW Gross, WE Strodel. Dept of Surgery, University of Texas Health Science Center at San Antonio, TX. Advanced age and acuteness of the pathological process have long been known to adversely affect surgical outcome. This study analyzes the success
Successful LC NAC AC
LOS Days NAC AC
N 76 69
OC Pre-op 8.0 7.1
Table 1 1991-3 1993-5 57% 71% 19% 38% Table 2 OC Post-op 6.6 11.4
LC Pre-op 3.9 4.1
1995-7 79% 41%
TOTAL 70% 35%
LC Post-op 2.0 5.7
• S0241 REEXPLORATION FOR PERIAMPULLARY CARCINOMA: RESECTABILITY, PERIOPERATIVE RESULTS, PATHOLOGY AND LONG-TERM OUTCOME. T A Sohn. KD Lillemoe, JL Cameron, H A Pitt, J Huanm RH Hmban, CJ Yeo. Dept of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD.
Many patients are referred to tertiary centers with periampullary carcinoma after having been deemed unresectable at previous laparotomy. In carefully selected patients, it is often possible to resect these tumors; however, the perioperative results and long-term outcome have not been well defined. Methods; Between November 1991 and December 1996 inclusive, 58 patients who underwent previous exploratory laparotomy and/or palliative surgery for suspected periampullary carcinoma underwent reexploration. The operative outcome, resectability rate, pathology and long-term survival were compared to 507 concurrent patients who had not undergone previous exploratory surgery. Results: Forty of the 58 patients (69%) undergoing reexploration were successfully resected via pancreaticoduodenectomy while the remaining 18 patients (31%) were deemed unresectable. Compared to the 507 patients who had not undergone recent related surgery, the reoperative group was similar with respect to age, gender, race and resectability rate (69% vs 71%). The distribution of resectable periampullary cancers by site in the reoperative group was 63%, 20%, 15% and 2% for pancreatic, ampullary, distal bile duct and duodenal tumors respectively. This spectrum comparcd to 67%, 13%, 15% and 5% for the non-reoperative group (p=NS). There was no difference in the intraoperative blood loss or transfusion requirements, but the mean operative time was 7.7 hours which was significantly longer than in the control group (mean=6.8 hours; p<0.0001). On pathologic examination, the percentage of patients with positive lymph nodes was significantly less (48% vs 67% p=0.01) in the reoperative group. The tumor diameter and incidence of positive margins were similar between the two groups. There were no differences in postoperative lengths of stay, complication rates or perioperative mortality (reoperative=l.8% vs. non-reoperative=l.7%). The long-term survival was similar between the two resected groups, with a median survival of 22 months in the reoperative group compared to 20 months in those without previous exploration (p=0.22). Conclusions: These data demonstrate that patients undergoing reoperation for periampullary carcinoma have a similar resectability rate, perioperative morbidity and mortality, and long-term survival as patients undergoing initial exploration. The results suggest that selected patients, considered unresectable at previous surgery, should undergo restaging and reexploration at specialized high-volume centers.
SSAT A1427
• S0238 LIVER RESECTION FOR NONCOLORECTAL NONNEUROENDOCRINE HEPATIC METASTASES. T. D.Sielaff. B. Lan~,er. T. Van der Meer, B.R. Taylor, P.D. Greig, S. Gallinger. A.W. Hemming, Department of Surgery, University of Toronto. Toronto, Ontario, Canada.
The indications for the resection of noncolorectal/nonneuroendocrine hepatic metastases (NCNNE) have evolved as the safety of hepatic resection has increased. The prognostic features of NCNNE treated surgically were reviewed in order to better define the indications for resection. Methods: A retrospective review of patients undergoing liver resection for NCNNE between 1978 and 1997. Results: Thirty patients were identified. The mean age was 57 years with a median follow up of 18 months. Primary tumor sites included GI adenocarcinoma (bowel n=3, unknown n=2, pancreatic n=2, esophageal n=l), and other (renal cell n=5, testicular n=l, ovarian n=l, sarcoma n=6, adrenal n=3, melanoma n=3, thyroid n=2, and breast n=l). All patients were operated upon for cure. Synchronous metastases were treated in 9 patients. There was no operative mortality. Overall survival is shown in Figure 1. Survival was better in patients with non-GI origin metastases (Figure 2, p=0.04). Long term survivors were seen only in patients with non GI origin metastases. Neither the extent of resection (segmental n=l 1, lobe n---14, extended n=5) nor the presence of synchronous metastases was predictive of outcome.
of laparoscopic (LC) vs open cholecystectomy (OC) under elective or urgent conditions for patients greater than 70 yrs of age. During a 6 year period ending 9/30/97, 145 elderly patients underwent cholecystectomy: 76 (48%) for non-acute cholelithiasis (NAC) and 69 (52%) for acute cholecystitis (AC). Twelve patients presented with biliary pancreatitis and 24 patients (35% of AC patients) had gangrenous cholecystitis. There were 115 men (79%) and 30 women with a mean age of 72 yrs (range (70-90 yrs). The number of patients undergoing successful LC has increased 38% (1997 vs 1991) and for AC it has doubled (Table 1). Seven of 145 patients died for a mortality rate of 5%; NAC 0%, AC 10%, LC 2.6%, OC 7.4%. LOS was effected by diagnosis and technique of cholecystectomy (Table 2). Compared to 3803 patients < 70 y.o. who underwent cholecystectomy, patients > 70 y.o. were predominantly male (79% vs 26%), had a higher prevalence of AC (48% vs 32%), higher operative mortality (5% vs 0.3%), and lower overall LC (1995-1997 period) technical success rate (64% vs 90%) with NAC (79% vs 95%), and AC (41% vs 77%). Despite skilled laparoscopic technique (95% successful LC overall) among our surgeons, we have not been able to improve the low rate of LC in the elderly patients for the past four years. Further improvement in the care of elderly patients depends upon earlier therapeutic intervention for patients with acute cholecystitis to prevent the pathologic progression to gangrene, especially for male patients. Because the rate of successful LC has not incrementally improved in this patient population as in other groups, continued faculty operative participation is mandatory in order to optimize the number of patients successfully undergoing LC.
F~r*2 |
L____
ee
~
4
ee
Conclusions: Patients with NCNNE hepatic metastases can undergo liver resection with an expectation of prolonged survival. However, patients with GI tract origin non-colorectal adenocarcinoma metastatic to the liver are unlikely to demonstrate extended survival.
• S0239 HOSPITAL PROCEDURE VOLUME AND HOSPITAL TEACHING STATUS DO NOT INFLUENCE OPERATIVE MORTALITY OR LONG-TERM SURVIVAL FOR RECTAL CANCER IN A LARGE GENERAL POPULATION: AN OUTCOMES STUDY. M.Simunovic. E. Si~,urdson, T.To. N.Baxter. A.Balshem, Z.Cohen, R.McLeod and E.Ross. Institute for Clinical Evaluative Sciences, Toronto, Ontario. Fox Chase Cancer Center, Philadelphia, PA. We tested the hypothesis that increased hospital procedure volume and teaching hospital status would improve operative mortality and long-term survival in patients with rectal cancer in Ontario, Canada. All incident cases of colorectal adenocarcinoma, treated within 60 days of diagnosis with abdominoperineal or low-anterior resection, and from years 1988 and 1991 were used. Patient information included age, sex, survival to 1995, and registration at a Regional Cancer Center where all radiotherapy in the province is delivered. Hospitals were stratified by teaching versus non-teaching status, and by volume group - low (_< 10 cases/yr), medium (11-18 c ases/yr), high (>_ 19 cases/yr). Previous work on a subset of similarly selected patients from 1990 showed no difference in disease stage among volume groups. Logistic regression measured odds ratios (OR) for operative mortality, while proportional hazards calculated risk ratios (RR) for time to failure (death). Models controlled for relevant patient and hospital characteristics. For years 1988 and 1991, respectively, there were 1083 and 1143 cases, percentage teaching hospital status was 30.6% and 28.3% (p=.23), unadjusted operative mortality was 3.32% and 3.76% (p=.58), registration for radiotherapy was 17.2% and 35.9% (p<.01), and distribution by volume group was similar. Likelihood of operative mortality was not significantly influenced by teaching versus nonteaching hospital status (OR=0.7, p=.24), or low- versus high-volume group (OR=0.9, p=.83). Time to death was not significantly influenced by year (RR=I.0, p=.55), teaching versus nun-teaching hospital status (RR=0.9, p=.06), or low- versus highvolume group (RR=I.0, p=.90). In conclusion, to improve outcomes for rectal cancer in this large general population, centralization of procedures into fewer higher volume hospitals or teaching hospitals is unlikely to have a major impact, and locally directed initiatives may be necessary such as efforts to improve surgical standards or use of adjuvant therapies. S0240
CHOLECYSTECTOMY IN ELDERLY PATIENTS: METHODS AND OUTCOME. KR Sirinek. WH Schwesinger, GWW Gross, WE Strodel. Dept of Surgery, University of Texas Health Science Center at San Antonio, TX. Advanced age and acuteness of the pathological process have long been known to adversely affect surgical outcome. This study analyzes the success
Successful LC NAC AC
LOS Days NAC AC
N 76 69
OC Pre-op 8.0 7.1
Table 1 1991-3 1993-5 57% 71% 19% 38% Table 2 OC Post-op 6.6 11.4
LC Pre-op 3.9 4.1
1995-7 79% 41%
TOTAL 70% 35%
LC Post-op 2.0 5.7
• S0241 REEXPLORATION FOR PERIAMPULLARY CARCINOMA: RESECTABILITY, PERIOPERATIVE RESULTS, PATHOLOGY AND LONG-TERM OUTCOME. T A Sohn. KD Lillemoe, JL Cameron, H A Pitt, J Huanm RH Hmban, CJ Yeo. Dept of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD.
Many patients are referred to tertiary centers with periampullary carcinoma after having been deemed unresectable at previous laparotomy. In carefully selected patients, it is often possible to resect these tumors; however, the perioperative results and long-term outcome have not been well defined. Methods; Between November 1991 and December 1996 inclusive, 58 patients who underwent previous exploratory laparotomy and/or palliative surgery for suspected periampullary carcinoma underwent reexploration. The operative outcome, resectability rate, pathology and long-term survival were compared to 507 concurrent patients who had not undergone previous exploratory surgery. Results: Forty of the 58 patients (69%) undergoing reexploration were successfully resected via pancreaticoduodenectomy while the remaining 18 patients (31%) were deemed unresectable. Compared to the 507 patients who had not undergone recent related surgery, the reoperative group was similar with respect to age, gender, race and resectability rate (69% vs 71%). The distribution of resectable periampullary cancers by site in the reoperative group was 63%, 20%, 15% and 2% for pancreatic, ampullary, distal bile duct and duodenal tumors respectively. This spectrum comparcd to 67%, 13%, 15% and 5% for the non-reoperative group (p=NS). There was no difference in the intraoperative blood loss or transfusion requirements, but the mean operative time was 7.7 hours which was significantly longer than in the control group (mean=6.8 hours; p<0.0001). On pathologic examination, the percentage of patients with positive lymph nodes was significantly less (48% vs 67% p=0.01) in the reoperative group. The tumor diameter and incidence of positive margins were similar between the two groups. There were no differences in postoperative lengths of stay, complication rates or perioperative mortality (reoperative=l.8% vs. non-reoperative=l.7%). The long-term survival was similar between the two resected groups, with a median survival of 22 months in the reoperative group compared to 20 months in those without previous exploration (p=0.22). Conclusions: These data demonstrate that patients undergoing reoperation for periampullary carcinoma have a similar resectability rate, perioperative morbidity and mortality, and long-term survival as patients undergoing initial exploration. The results suggest that selected patients, considered unresectable at previous surgery, should undergo restaging and reexploration at specialized high-volume centers.