Su1823 Predictors and Diagnostic Strategies of Early Stage Pancreatic Ductal Adenocarcinoma: A Retrospective Review

Su1821 Morbid Obesity Does Not Adversely Affect Mortality or Length of Hospital Stay After Liver Resection: 14 Year Retrospective Analysis Raghavendra Rao, Kenneth W. Bueltmann, Marek Rudnicki Introduction: Obesity is an important co-morbidity present in modern day surgical patients. In addition to affecting wound healing, obesity can present technical difficulties and has an apparent effect upon outcomes due to concomitant liver disease in patients undergoing liver resections. This study was undertaken to test whether morbid obesity affects early outcomes of selected major liver surgeries and if that effect has changed over the observed time period. Methods: The National Inpatient Sample database was queried for all records who had their primary or secondary procedure recorded as hepatic lobectomy (ICD 50.22) or partial hepatectomy (ICD 50.3) or both. The records were then classified into patients with or without morbid obesity (ICD 278.01). Means were calculated for every year from 1998 to 2011 for mortality rate and length of hospital stay. Chi square test was used to test for significance in difference in mortality and Weighted T-test was used to test for significance in difference in lengths of stay. Results: The number of partial hepatectomy or hepatic lobectomy procedures recorded increased 1426 to 3206 (2.25 fold) from 1998 to 2011 (1426 to 3206, 2.25 fold). This increase was more prominent in the morbidly obese population (13 to 319, 24.5 fold). Non obese patients who underwent surgery during the first half of the decade, 1998 to 2004 had higher mortality compared to those in the second half, 2005 to 2011 (4.23%, 312/7384 vs 2.84%, 339/11941 and 6.69%, 262/3915 vs 4.91%, 243/3949) for hepatic lobectomy and partial hepatectomy respectively (p<0.001 for both). This difference was not significant in the morbidly obese population. Partial hepatectomy in the obese population demonstrated reduced mortality in the first half of the decade (6.69 vs 0%) only, while "hepatic lobectomy" had reduced mortality in morbidly obese in the second half of decade (2.84% vs 0.77%), but only compared to the non-obese population. Morbidly obese patients had reduced mortality and length of stay for hepatic lobectomy (0.96%, 11/1144 vs 3.37%, 651/19325, p<0.001 and 7.31 vs 9.32 days, p<0.001) and partial hepatectomy (2.4%, 9/370 vs 5.7%, 505/8864, p<0.001 and 8.5 vs 9.9 days, p<0.01). Conclusion: Morbid obesity did not increase mortality and length of stay after liver resection surgery. Surprisingly, both mortality and length of stay were lower in obese patients undergoing major liver surgeries. While mortality has improved with time in the non-obese population after liver resection, this has not been the case with the morbidly obese population.

Su1823

Background: Pancreatic cancer is the fifth cause of cancer death in Japan. Survivors after resection of pancreatic ductal adenocarcinoma (PDAC) have been gradually increasing, while most PDACs are still diagnosed at advanced stages. To improve the prognosis of the patients with PDACs, establishment of the strategy for early diagnosis is urgently needed. The aim of this study was to clarify the characteristics and diagnostic processes of early stage PDACs. Method: Medical records of consecutive 299 patients who underwent curative resection (R0, R1) for PDACs between 1994 and 2013 were retrospectively reviewed. Clinical characteristics were compared between early stage (stage 0-I according to Japanese General Rules for Pancreatic Cancer) and advanced stage (stage II-IVa) PDAC groups and diagnostic processes were also analyzed. Results: Twenty-four of 299 patients (8%) had early stage PDACs (11 stage 0 and 13 stage I). The proportions of the early stage PDACs during the first and second half decade were 6% (4 / 64) and 9% (20 / 235), respectively (P = 0.80). The survival time of the patients with early stage PDACs was significantly longer than that with advanced stage PDACs (P < 0.01). Univariate and multivariate analyses revealed that the presence of intraductal papillary mucinous neoplasm (IPMN) (P < 0.01), history of pancreatitis (P < 0.01), and history of extrapancreatic malignancies (P = 0.01) were independent predictive factors for the diagnosis of early stage PDACs. Sensitivities of computed tomography (CT), magnetic resonance imaging / cholangiopancreatography (MRI / MRCP), endoscopic ultrasonography (EUS), and cytological examination during endoscopic retrograde pancreatography (ERP cytology) to diagnose early stage PDACs were 29%, 35%, 33%, and 65%, respectively. In early stage group, 10 of 24 patients had IPMN and 9 had a history of pancreatitis. ERP cytology could serve the preoperative diagnosis of PDAC in 13 of 24 patients, and 9 PDACs (38%) were diagnosed only by ERP cytology. Conclusion: Detailed examination using ERP cytology in patients with IPMN or pancreatitis may contribute to the early diagnosis of PDAC.

Su1822 Who Travels for Cancer Care? Regionalization of Pancreatectomy in Massachusetts Lindsay A. Bliss, Theodore P. McDade, Zeling Chau, Jillian K. Smith, Catherine J. Yang, Sing Chau Ng, Bruce B. Cohen, Giles F. Whalen, Mark P. Callery, Jennifer F. Tseng

Su1824 Impact of Preoperative Biliary Drainage on Short- and Long-Term Outcome After Pancreaticoduodenectomy for Cancer of the Head of Pancreas Kenichiro Uemura, Yoshiaki Murakami, Manabu Kawai, Ken-ichi Okada, Ippei Matsumoto, Sadaki Asari, Sohei Satoi, Hiroaki Yanagimoto, Masayuki Sho, Takahiro Akahori, Goro Honda, Masanao Kurata, Fuyuhiko Motoi, Michiaki Unno

Background: Improved outcomes for technically complex procedures have been reported for high-volume centers and surgeons. However, the magnitude and effect of regionalization of pancreatic cancer surgery has not been well characterized. Methods: Retrospective observational cohort review of Massachusetts Department of Public health (MA-DPH) Inpatient Hospital Discharge Database (HDD). Admissions between 2005 and 2009 for pancreatic malignancy identified by ICD-9 were included. Patients without pancreatic resections or with missing or out-of-state ZIP codes were excluded. Hospitals were divided into high volume (≥11 cancer pancreatectomies annually) or low volume (<11 cancer pancreatectomies annually). Traveling distance was calculated as center-to-center geodetic distance between ZIP codes. Outcomes of interest included length of stay (LOS), perioperative mortality, hospital volume status, and distance traveled to treating hospital. Univariate analyses were performed for patient demographics. Multivariate logistic regression was used to identify independent predictors. Results: 704 patients met inclusion criteria and were largely white (87.2%) with median age of 65 years. Median ZIP code income was $54,677. Distance traveled for resection varied from 0 to 112 miles (median 15.4). Median LOS was 8.0 days. Odds of traveling >10 miles for resection was higher among men (p=0.0319), patients less than 65 years of age (p=0.0392), and patients residing in ZIP codes with income >2x the poverty line (p=0.0130). Patients traveling more than 10 miles were more likely to receive care at high-volume hospitals. However, after adjustment, traveling for resection per se did not result in independently improved outcomes. Conclusion: Most Massachusetts pancreatic cancer patients traveled more than 10 miles for resection. Patients who were younger, white, male, or residing in higher income areas were more likely to travel for care, suggesting demographic differences between travelers and nontravelers. Our data suggest some of the described volume effect on pancreatic cancer surgery may be due to patient selection rather than hospital or surgeon expertise.

Background: Recent reports have suggested that preoperative biliary drainage (PBD) increases the perioperative morbidity rate of pancreaticoduodenectomy (PD). However, the effect of PBD on long-term outcome after PD for pancreas head cancer (PHCA) still remains unclear. Aims: To evaluate the impact of PBD on short- and long-term surgical outcome in patients with PHCA undergoing PD. Methods: Retrospective analysis was performed in 932 patients with PHCA who underwent PD with R0 or R1 resection between 2001 and 2012 at 7 highvolume surgical institutions in Japan. Results: 166 patients (18%) underwent preoperative percutaneous transhepatic biliary drainage (PTBD), 407 patients (44%) underwent preoperative endoscopic biliary drainage (EBD), and 359 patients (39%) had no-PBD. The incidence of infectious complications after PD in the patients who underwent preoperative PTBD was significantly higher than those in the patients who had EBD and no-PBD (30%, 20%, and 18%, p=0.010). There were no differences in the incidence of postoperative pancreatic fistula (12%, 9%, and 9%; P=0.498), severe complication (25%, 21%, and 17%; p=0.117), and 30day mortality (0%, 0.9%, and 0.3%; P=0.169) among three groups. Patients who underwent preoperative PTBD had significantly poorer survival than those with EBD and no-PBD (16.7 months, 22.3 months, and 25.7 months; p<0.0001) (Fig). Multivariate analysis revealed that independent prognostic factors included age (P=0.003), blood loss (P<0.001), tumor size (p=0.016), tumor differentiation (p<0.001), lymph node metastasis (p<0.001), surgical margin status (p=0.004), adjuvant chemotherapy (p<0.001), and type of preoperative biliary drainage (p=0.015). Furthermore, preoperative PTBD group had significantly higher incidence of peritoneal metastasis as a primary site of recurrence compared with EBD and noPBD group (26%, 14%, 16%; p=0.017). Multivariate analysis demonstrated that independent risk factors for peritoneal metastasis as a primary site of recurrence included surgical margin status (p<0.001), and preoperative PTBD (p=0.005). Conclusions: Preoperative PTBD, but not EBD had negative impact on short- and long-term surgical outcome in the patients

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SSAT Abstracts

SSAT Abstracts

Predictors and Diagnostic Strategies of Early Stage Pancreatic Ductal Adenocarcinoma: A Retrospective Review Hideyo Kimura, Takao Ohtsuka, Taketo Matsunaga, Yusuke Watanabe, Koji Tamura, Noboru Ideno, Teppei Aso, Yoshihiro Miyasaka, Junji Ueda, Shunichi Takahata, Kazuhiro Mizumoto, Masao Tanaka