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Surgery for Pancreatic Neoplasms: How Accurate are our Indications?
E-HPBA: Poster Abstracts Aims: Studies on short- and long-term outcome after surgical resection in patients with pancreatic neuroendocrine tumor (pNET) are often small and no randomized controlled trials are available. Aim of this study was to systematically review all studies on postoperative complications and survival in patients with a pNET. Methods: A systematic search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE was performed from 2000e2013. All study types were included if they included resected patients with pNET and described the postoperative complication rate separately for each surgical procedure and/or the 5 year overall survival (OS) and disease specific survival (DSS) after resection. Studies must have enrolled at least 10 patients. Two review authors independently screened all the studies for inclusion. Since the diversity in data, the random-effect model was used to analyze the proportions. Results: Proportion of pancreatic fistula after enucleation, pancreatoduodenectomy and distal pancreatectomy were resp. 45% (95%CI: 34e57), 14% (95%CI: 9e21) and 14% (95%CI: 10e19). The proportion of delayed gastric emptying were resp. 5% (95%CI: 2e10), 18% (95%CI: 10e31) and 2% (95%CI: 1e19). The proportion of postoperative hemorrhage were resp. 6% (95%CI: 3e12), 7% (95%CI: 3e15) and 1% (95%CI: 0e9). Mortality was resp. 3% (95%CI 2e5), 6% (95%CI: 3e12) and 4% (95%CI: 2e 7). The 5 year OS and DSS of curative resected pNET without synchronous resected liver metastases was resp. 85% (95%CI: 78e90) and 93% (95%CI: 88e96). Heterogeneity between included studies on curative resected pNET with synchronous resected liver metastases was too high to perform a meta-analysis for OS. The DSS was 80% (95%CI: 66e90). Conclusions: Morbidity and mortality after pancreatic resection for pNET were low and the survival in curative resected pNET without metastases was high. However, heterogeneity between studies on survival was notable.
PANCREAS CANCER 0529 SURVIVAL AFTER CURATIVE RESECTION IN PATIENTS WITH A GRADE THREE PANCREATIC NEUROENDOCRINE TUMOR A. P. J. Jilesen1, C. H. J. van Eijck2, H. J. Klümpen1, D. J. Gouma1 and E. J. M. Nieveen van Dijkum1 1 Academic Medical Center Amsterdam; 2Erasmus Medical Center Rotterdam, Netherlands Aims: Since little is known about survival after curative surgery in patients with a grade 3 non-functional pancreatic neuroendocrine tumor (NF-pNET). Therefore the aim was to analyze survival in these patients after curative resection. Methods: Retrospectively all resected NF-pNET from 1997e2013 of two academic institutions were included and patients with distant metastases at diagnosis or hereditary syndromes were excluded. Pathology was revised according WHO classification 2010. Short- and long-term followup was analyzed. Recurrent disease was defined as local tumor recurrence, lymph nodes or distant metastases. Results: Overall, 107 patients with NF-pNET were included, 63 had G1, 36 had G2 and 8 patients G3 tumor and 5 year disease specific survival (DSS) was resp. 98%, 93% and 0%. Median DSS of patients with G3 tumor was
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23 months (IQR 17-29). Of these 8 patients, median age was 60 yr.(IQR 44-67), 50% was female. Median tumor size was 43mm(IQR 36-79) and median Ki67-index was 35%(IQR 26-50). Pre-operative Octreoscans were performed in 6 patients, 4 scans were positive for the primary tumor. After resection, 5 patients (63%) had positive lymph nodes in the resected specimen, 2 patients had perineural invasion (25%) and 3 patients had vascular invasion (38%). All patients developed recurrent disease within 5 years, median time to recurrence was 11 months (IQR 4-18). Time to recurrent disease or survival was not correlated with the level of Ki67index. None of the patients received adjuvant treatment. Recurrent disease was treated with palliative chemotherapy (Cisplatin/Etoposide) in 2 patients, however both patients remained to have progressive disease. Two other patients underwent debulking surgery and 1 patient was treated with palliative I-131 MIBG therapy. Conclusions: As suspected DSS was 23 months in G3 patients after curative resection and all patients developed recurrent disease. Since randomized studies in this rare patient group is impossible, adjuvant treatment should be studies prospectively.
PANCREAS CANCER 0545 SURGERY FOR PANCREATIC NEOPLASMS: HOW ACCURATE ARE OUR INDICATIONS? D. J. Birnbaum1, J. Berbis2, S. Gaujoux1, J. Cros1, S. Dokmak1, B. Aussilhou1, M. P. Vullierme1, P. Hammel1, P. Levy1, P. Ruszniewski1, J. Belghiti1 and A. Sauvanet1 1 Hospital Beaujon; 2Hospital de la Timone, France Aims: Pancreatic tumors can be benign (BT), potentially malignant (PMT) or malignant (MT). Accurate preoperative diagnosis is mandatory for relevant surgical indication and technique. This work evaluated accuracy of indications by comparing preoperative diagnosis to results of pathologic examination obtained after resection. Methods: From 2005 to 2013, 851 patients (median age = 58 years, 55% female and 38% asymptomatic) had pancreatectomies (ampullary, biliary, duodenal tumors and non-neoplastic lesions excluded). Preoperative diagnosis was established during a multidisciplinary board and compared to pathologic examination according to demographics, symptoms, and diagnostic work-up including at least a dedicated CT or MRI; EUS+/-fine needle aspiration (FNA) for biopsy or cyst fluid analysis, octreoscan and PETscan were performed when indicated. Results: Mean number of examinations was 3,2 and 35% of patients had CT+MRI+EUS+FNA. Radical pancreatectomy (Whipple/distal) was performed in 663 (78%), while 177 (20%) had limited resection (114 enucleations, 63 central). Morbidity and mortality rates were 65% and 1%, respectively. Pathologically, there were 67 (8%) BT, 370 (43%) PMT and 414 (49%) MT. Preoperative diagnosis was confirmed in 757 (89%) patients (82%, 89% and 92% for BT, PMT and MT, respectively). Comparatively to patients with PMT, patients with BT were significantly younger, symptomatic and harbouring a cystic lesion whereas patients with MT were significantly older, symptomatic and diabetic, respectively. Rate of misdiagnosis
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was increased for cystic lesions and lesions <2 cm. For cystic lesions <2 cm, diagnostic accuracy was increased when CT+MRI+EUS+FNA were used. In the 94 patients with misdiagnosis, surgery was ultimately clinically relevant (MT, PMT or symptomatic BT) in 48 but was inappropriate in 46 (5%). In these 46, multivariate analysis identified age <50 y., familial history of cancer and cystic tumor as risk factors of misdiagnosis. Conclusions: Accurate preoperative diagnosis is presently possible for 89% of PT. Misdiagnosis leads to inappropriate surgery in only 5% of cases. For cystic tumors <2 cm, to increase number of preoperative examinations could increase diagnostic accuracy.
PANCREAS CANCER 0552 COMPREHENSIVE MULTICOMPONENT LEARNING CURVE ANALYSIS OF A SINGLE-SURGEON SERIES OF LAPAROSCOPIC DISTAL PANCREATECTOMY: OUTCOMES IMPROVE EVEN WITH INCREASING COMPLEXITY OF CASES A. P. Belgaumkar, J. Richardson, B. Jaber and M. Abu Hilal University Hospital Southampton, UK Aims: Although multiple studies have analysed learning curves using operating times, this single outcome measure cannot account for evolution of case mix and surgical practice. We evaluated the learning curve (LC) of a single surgeon undertaking laparoscopic distal pancreatectomy (LDP) in a tertiary HPB unit. Methods: 94 LDP were performed between June 2007 and January 2015, including 15 cases of adenocarcinoma. Data were collected in a prospectively maintained database. The cohort was split into thirds and halves to explore differences in outcomes. Control charts, including CUSUM curves, were plotted for continuous and dichotomous data to assess changes in outcomes, including operating times (OpTime), blood loss, occurrence of complications, and post-operative pancreatic fistula (POPF). Results: Mean OpTime was 210 mins (SEM +/- 8) and median blood loss was 200mls (IQR 100-300). These did not differ significantly between different time periods or after exclusion of malignant cases and multivisceral resections (3 in first half versus 9 in second half). The only statistically significant predictor of longer OpTime on regression analysis was malignant tumour, although unlikely to be of clinical significance [Mean OpTime for benign cases 197.6mins (SD+/_72) versus for malignant cases 235.5(+/_69), p = 0.019]. Visual inspection of CUSUM curves showed the peak of the Clavien-Dindo 3+ complications curve occurs at case 30, implying an end of the LC (see Figure). In the first 30 cases, 22 complications occurred including 8 Clavien-Dindo 3+ and 7 readmissions, compared with 19 complications, 3 Clavien-Dindo 3+ and 5 readmissions in the last 64 cases. Similarly 15 POPF occurred in the first 30 cases (50%) compared with 24 in the last 64 cases (38%). Conclusions: Operating times and blood loss are not accurate indicators of proficiency in complex operations. Despite the increasing complexity of cases undertaken,
operating times remained static. We demonstrate that after 30 cases of LDP, patient outcomes improve.
PANCREAS CANCER 0574 DISCUSSION ABOUT PG VERSUS PJ IN (PP)PD FOR PANCREATIC ADENOCARCINOMA IS NONSENSE, STANDARDIZATION THROUGH VOLUME IS THE KEY! F. Berrevoet, A. Vanlander, J. Verlinden and S. Laurent Ghent University Hospital, Belgium Aims: Complications following PD have a negative effect on quality of life and survival. However, acquiring accurate hospital specific data for comparison of outcomes remains a challenge. Furthermore, only recently established quality metrics have been reported. It was the aim of this analysis to evaluate the impact of standardization of surgical technique and pre- and postoperative management on quality metrics in a tertiary referral center in Belgium. Methods: From 1/1/2011 till 1/1/2015 all patients that underwent a pancreatic resection for oncological reasons were extracted from a prospective database. Following parameters were analysed: number of procedures per surgeon, indications, basic characteristics, operating time, type of procedure, lymph node ratio, major and minor complication rate including pancreatic fistula, delayed gastric emptying and infectious complications. Results: In total 153 pancreatic resections for malignant disease were performed during this study period. 112 pancreaticoduodenectomies (PD), 28 body- and tail resections with splenectomy and 13 total pancreatectomies were performed. Mean operating time was 348 minutes 41 and mean hospital stay was 1’ days. In all patients a standardized duct-to-mucosa pancreaticojejunostomy was performed. Postoperative complications consisted of 7.4% type A fistula (according to ISGPF classification), 2.6% type B and 0.7% type C fistula with reoperation. Using a standardized antecolic duodenoenterostomy delayed gastric emptying was only diagnosed in 6% of patients after PPPD. Fistula rate was higher in the tail and body- and tail resections when compared to PPPD. Conclusions: When standardized perioperative care and surgical strategies can be implemented in large volume centers, low fistula rates can be achieved regardless the type of pancreatic anastomosis in contrast with current literature. Delayed gastric emptying is no longer a significant problem using antecolic anastomoses and overall patient morbidity is acceptable and below 25% in this series. In current oncological care standardized treatment is the key to success.
PANCREAS CANCER 0576 PANCREATOGASTROSTOMY WITH ONE CONTINUOUS SEROMUSCULAR CIRCULAR SUTURE D. V. Kostov1 and G. L. Kobakov2 1 Naval Hospital; 2Department of Oncology, Bulgaria Aims: Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are the preferred methods of anastomosis after pancreatoduodenectomy (PD). We reported a new anastomosis technique using one continuous seromuscular circular suture without transpancreas sutures for submucosal PG. This
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PANCREAS CANCER 0529 SURVIVAL AFTER CURATIVE RESECTION IN PATIENTS WITH A GRADE THREE PANCREATIC NEUROENDOCRINE TUMOR A. P. J. Jilesen1, C. H. J. van Eijck2, H. J. Klümpen1, D. J. Gouma1 and E. J. M. Nieveen van Dijkum1 1 Academic Medical Center Amsterdam; 2Erasmus Medical Center Rotterdam, Netherlands Aims: Since little is known about survival after curative surgery in patients with a grade 3 non-functional pancreatic neuroendocrine tumor (NF-pNET). Therefore the aim was to analyze survival in these patients after curative resection. Methods: Retrospectively all resected NF-pNET from 1997e2013 of two academic institutions were included and patients with distant metastases at diagnosis or hereditary syndromes were excluded. Pathology was revised according WHO classification 2010. Short- and long-term followup was analyzed. Recurrent disease was defined as local tumor recurrence, lymph nodes or distant metastases. Results: Overall, 107 patients with NF-pNET were included, 63 had G1, 36 had G2 and 8 patients G3 tumor and 5 year disease specific survival (DSS) was resp. 98%, 93% and 0%. Median DSS of patients with G3 tumor was
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23 months (IQR 17-29). Of these 8 patients, median age was 60 yr.(IQR 44-67), 50% was female. Median tumor size was 43mm(IQR 36-79) and median Ki67-index was 35%(IQR 26-50). Pre-operative Octreoscans were performed in 6 patients, 4 scans were positive for the primary tumor. After resection, 5 patients (63%) had positive lymph nodes in the resected specimen, 2 patients had perineural invasion (25%) and 3 patients had vascular invasion (38%). All patients developed recurrent disease within 5 years, median time to recurrence was 11 months (IQR 4-18). Time to recurrent disease or survival was not correlated with the level of Ki67index. None of the patients received adjuvant treatment. Recurrent disease was treated with palliative chemotherapy (Cisplatin/Etoposide) in 2 patients, however both patients remained to have progressive disease. Two other patients underwent debulking surgery and 1 patient was treated with palliative I-131 MIBG therapy. Conclusions: As suspected DSS was 23 months in G3 patients after curative resection and all patients developed recurrent disease. Since randomized studies in this rare patient group is impossible, adjuvant treatment should be studies prospectively.
PANCREAS CANCER 0545 SURGERY FOR PANCREATIC NEOPLASMS: HOW ACCURATE ARE OUR INDICATIONS? D. J. Birnbaum1, J. Berbis2, S. Gaujoux1, J. Cros1, S. Dokmak1, B. Aussilhou1, M. P. Vullierme1, P. Hammel1, P. Levy1, P. Ruszniewski1, J. Belghiti1 and A. Sauvanet1 1 Hospital Beaujon; 2Hospital de la Timone, France Aims: Pancreatic tumors can be benign (BT), potentially malignant (PMT) or malignant (MT). Accurate preoperative diagnosis is mandatory for relevant surgical indication and technique. This work evaluated accuracy of indications by comparing preoperative diagnosis to results of pathologic examination obtained after resection. Methods: From 2005 to 2013, 851 patients (median age = 58 years, 55% female and 38% asymptomatic) had pancreatectomies (ampullary, biliary, duodenal tumors and non-neoplastic lesions excluded). Preoperative diagnosis was established during a multidisciplinary board and compared to pathologic examination according to demographics, symptoms, and diagnostic work-up including at least a dedicated CT or MRI; EUS+/-fine needle aspiration (FNA) for biopsy or cyst fluid analysis, octreoscan and PETscan were performed when indicated. Results: Mean number of examinations was 3,2 and 35% of patients had CT+MRI+EUS+FNA. Radical pancreatectomy (Whipple/distal) was performed in 663 (78%), while 177 (20%) had limited resection (114 enucleations, 63 central). Morbidity and mortality rates were 65% and 1%, respectively. Pathologically, there were 67 (8%) BT, 370 (43%) PMT and 414 (49%) MT. Preoperative diagnosis was confirmed in 757 (89%) patients (82%, 89% and 92% for BT, PMT and MT, respectively). Comparatively to patients with PMT, patients with BT were significantly younger, symptomatic and harbouring a cystic lesion whereas patients with MT were significantly older, symptomatic and diabetic, respectively. Rate of misdiagnosis
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was increased for cystic lesions and lesions <2 cm. For cystic lesions <2 cm, diagnostic accuracy was increased when CT+MRI+EUS+FNA were used. In the 94 patients with misdiagnosis, surgery was ultimately clinically relevant (MT, PMT or symptomatic BT) in 48 but was inappropriate in 46 (5%). In these 46, multivariate analysis identified age <50 y., familial history of cancer and cystic tumor as risk factors of misdiagnosis. Conclusions: Accurate preoperative diagnosis is presently possible for 89% of PT. Misdiagnosis leads to inappropriate surgery in only 5% of cases. For cystic tumors <2 cm, to increase number of preoperative examinations could increase diagnostic accuracy.
PANCREAS CANCER 0552 COMPREHENSIVE MULTICOMPONENT LEARNING CURVE ANALYSIS OF A SINGLE-SURGEON SERIES OF LAPAROSCOPIC DISTAL PANCREATECTOMY: OUTCOMES IMPROVE EVEN WITH INCREASING COMPLEXITY OF CASES A. P. Belgaumkar, J. Richardson, B. Jaber and M. Abu Hilal University Hospital Southampton, UK Aims: Although multiple studies have analysed learning curves using operating times, this single outcome measure cannot account for evolution of case mix and surgical practice. We evaluated the learning curve (LC) of a single surgeon undertaking laparoscopic distal pancreatectomy (LDP) in a tertiary HPB unit. Methods: 94 LDP were performed between June 2007 and January 2015, including 15 cases of adenocarcinoma. Data were collected in a prospectively maintained database. The cohort was split into thirds and halves to explore differences in outcomes. Control charts, including CUSUM curves, were plotted for continuous and dichotomous data to assess changes in outcomes, including operating times (OpTime), blood loss, occurrence of complications, and post-operative pancreatic fistula (POPF). Results: Mean OpTime was 210 mins (SEM +/- 8) and median blood loss was 200mls (IQR 100-300). These did not differ significantly between different time periods or after exclusion of malignant cases and multivisceral resections (3 in first half versus 9 in second half). The only statistically significant predictor of longer OpTime on regression analysis was malignant tumour, although unlikely to be of clinical significance [Mean OpTime for benign cases 197.6mins (SD+/_72) versus for malignant cases 235.5(+/_69), p = 0.019]. Visual inspection of CUSUM curves showed the peak of the Clavien-Dindo 3+ complications curve occurs at case 30, implying an end of the LC (see Figure). In the first 30 cases, 22 complications occurred including 8 Clavien-Dindo 3+ and 7 readmissions, compared with 19 complications, 3 Clavien-Dindo 3+ and 5 readmissions in the last 64 cases. Similarly 15 POPF occurred in the first 30 cases (50%) compared with 24 in the last 64 cases (38%). Conclusions: Operating times and blood loss are not accurate indicators of proficiency in complex operations. Despite the increasing complexity of cases undertaken,
operating times remained static. We demonstrate that after 30 cases of LDP, patient outcomes improve.
PANCREAS CANCER 0574 DISCUSSION ABOUT PG VERSUS PJ IN (PP)PD FOR PANCREATIC ADENOCARCINOMA IS NONSENSE, STANDARDIZATION THROUGH VOLUME IS THE KEY! F. Berrevoet, A. Vanlander, J. Verlinden and S. Laurent Ghent University Hospital, Belgium Aims: Complications following PD have a negative effect on quality of life and survival. However, acquiring accurate hospital specific data for comparison of outcomes remains a challenge. Furthermore, only recently established quality metrics have been reported. It was the aim of this analysis to evaluate the impact of standardization of surgical technique and pre- and postoperative management on quality metrics in a tertiary referral center in Belgium. Methods: From 1/1/2011 till 1/1/2015 all patients that underwent a pancreatic resection for oncological reasons were extracted from a prospective database. Following parameters were analysed: number of procedures per surgeon, indications, basic characteristics, operating time, type of procedure, lymph node ratio, major and minor complication rate including pancreatic fistula, delayed gastric emptying and infectious complications. Results: In total 153 pancreatic resections for malignant disease were performed during this study period. 112 pancreaticoduodenectomies (PD), 28 body- and tail resections with splenectomy and 13 total pancreatectomies were performed. Mean operating time was 348 minutes 41 and mean hospital stay was 1’ days. In all patients a standardized duct-to-mucosa pancreaticojejunostomy was performed. Postoperative complications consisted of 7.4% type A fistula (according to ISGPF classification), 2.6% type B and 0.7% type C fistula with reoperation. Using a standardized antecolic duodenoenterostomy delayed gastric emptying was only diagnosed in 6% of patients after PPPD. Fistula rate was higher in the tail and body- and tail resections when compared to PPPD. Conclusions: When standardized perioperative care and surgical strategies can be implemented in large volume centers, low fistula rates can be achieved regardless the type of pancreatic anastomosis in contrast with current literature. Delayed gastric emptying is no longer a significant problem using antecolic anastomoses and overall patient morbidity is acceptable and below 25% in this series. In current oncological care standardized treatment is the key to success.
PANCREAS CANCER 0576 PANCREATOGASTROSTOMY WITH ONE CONTINUOUS SEROMUSCULAR CIRCULAR SUTURE D. V. Kostov1 and G. L. Kobakov2 1 Naval Hospital; 2Department of Oncology, Bulgaria Aims: Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are the preferred methods of anastomosis after pancreatoduodenectomy (PD). We reported a new anastomosis technique using one continuous seromuscular circular suture without transpancreas sutures for submucosal PG. This
HPB 2016, 18 (S2), e747ee781