Surgical Referral Patterns for Colorectal Liver Metastases: A Multistate Survey

Vol. 223, No. 4S2, October 2016

Scientific Poster Presentations: 2016 Clinical Congress

INTRODUCTION: Proximity to major vasculature or bile ducts remains an impediment to thermal ablative-therapies. Irreversible electroporation (IRE) has emerged as a novel, safe ablative-therapy for peri-vascular lesions. However, there remains a paucity of data on long-term outcomes. METHODS: A retrospective review of a prospectively maintained hepatic resection database identified patients who underwent microwave (MWA), radiofrequency (RFA), or IRE ablation (20082015). Oncologic outcomes were classified as local hepatic/ablation zone recurrence (LR). Cumulative incidence (CumI) of LR was calculated and competing risks regression assessed factors associated with IRE LR. RESULTS: One hundred seventy-four patients had 331 lesions ablated (IRE 77/331, MW 127/331, RFA 127/331). The majority of lesions were of colorectal origin (94%). Median tumor sizes were IRE-1.3cm (range 0.5 - 6), MWA-0.5cm (range 0.5 e 5.6) and RFA-1cm (range 0.5 e 5). Majority of patients (89%) received systemic therapy prior to ablation. Majority of IRE lesions (69/77, 90%) were <5mm from hepatic veins or portal pedicles. LR CumI were 13% following IRE (95% CI: 7.8 -22.2%; median follow-up 25.7 months), 7% (95% CI: 3-13%, median followup 18 months) after MWA and 21% (95% CI:15-29%, median follow-up 31 months) after RFA. IRE median time to LR was not reached and no LR occurred after 18 months. Variables associated with IRE-LR are depicted in table.

Ablation zone size, cm BMI Pre-IRE bilirubin Other procedures performed (yes vs no) Close to bile duct (yes vs no) Close to major vasculature (yes vs no) Tumor size, cm Age at surgery, y No. of treatments per lesion

INTRODUCTION: As is the nature of surgeons, we are continually improving techniques and technology that in turn may improve patient outcomes and experience. We evaluated the feasibility of single port laparoscopic cholecistectomy with the use of magnetic instruments (SLMC) compared with the conventional multiport laparscopic cholecystectomy (CLC). METHODS: A retrospective review of patients undergoing SLMC over a 5-year period was performed. A cohort of CLC patients over the preceding 5 years was used as historic controls. Demographics, operative data, complications, and cost were compared. Demographics and clinical characteristics were evaluated using the chisquare or Fisher exact test for categorical data and the Student t-test and Mann Withney U test for continuous variables; p<0.05 was accepted as statistically significant. RESULTS: From 2010 to 2015, 71 patients underwent SLMC and 70 underwent CLC. Mean age was 36.8 years for the SLMC patiets and 43.7 years for the CLC (p ¼ 0.010). There were no differences in others demographics variables. There was no difference in conversion rate between SLMC and CLC (0 vs 1%, p¼0.49). Mean operative time for SLMC was greater compared with CLC (81.3 vs 92.0 min, p¼0.102). No significant differences were noted in narcotics used. Postoperative complications rates were higher in CLC (5.7 vs 1.4 p ¼ 0.76). Total cost was greater in CLC group ($4705 vs $1882, p ¼ < 0.0001). CONCLUSIONS: SLMC can be safely performed. Although further study is warranted, initial results indicate that may offer the most benefit in cost for outpatient procedures.

Table. Selected variables of IRE local recurrence

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HR

95% CI

-

2.2] 1.3] 43.9] 1.1]

p Value

1.6 1.2 6.2 0.3

[1.1 [1.1 [0.9 [0.1

0.0093 0.0001 0.07 0.06

1.5 0.7

[0.4 e 5.0] [0.1 e 4.0]

0.54 0.71

1.4 1.0 1.3

[0.9 - 2.1] [0.9 - 1.0] [0.9 e 2.0]

0.17 0.08 0.17

CONCLUSIONS: IRE had similar rates of LR when compared to thermally ablated lesions. Associated factors of IRE-LR included ablation zone size and BMI. IRE may be a beneficial ablative-therapy for lesions in anatomic locations precluding thermal ablation. Single-Incision Laparoscopic Cholecystectomy with the Use of Magnetic Instruments: A Comparison with the Gold Standard Gabriel Garnica, MD, Daniel Arreola, MD, Rafael Contreras Ruiz Velasco, MD ABC Medical Center, Mexico City, Mexico

Surgical Referral Patterns for Colorectal Liver Metastases: A Multistate Survey Isaac Payne, DO, Daniel R Freno, MD, Sandra L Wong, MD, FACS, Marcus Tan, MBBS, FACS University of South Alabama, Mobile, AL, Dartmouth-Hitchcock Medical Center, Lebanon, NH INTRODUCTION: Colorectal cancer rates in the southern United States remain above the national average. Metastatic disease, most commonly to the liver, is the leading cause of mortality for these patients. Despite improved long-term survival with the resection of colorectal liver metastases (CLM), nationwide studies have suggested that liver resection is under-utilized with wide variation in surgical referral patterns for CLM. METHODS: We surveyed medical oncologists throughout the tristate area of Alabama (AL), Mississippi (MS), and the Florida panhandle (FLP) regarding their practice patterns in referring patients with CLM and what characteristics (clinical and tumorassociated) they considered contraindications to liver resection. RESULTS: Sixty percent of oncologists reported they had no liver surgeons in their area. Commonly perceived contraindications to liver resection included >4 metastases (65.1%), extrahepatic metastases (63.5%), bilateral liver disease (55.6%), and metastases larger than 5cm (42.9%). High-referring physicians were as likely as

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J Am Coll Surg

Scientific Poster Presentations: 2016 Clinical Congress

low-referring physicians to refer a patient with low recurrence risk (83% vs 89%, p¼0.56) but were more likely than low-referring physicians to refer patients with a moderate (83% vs 44%, p¼0.03) or high recurrence risk (73% vs 0%, p¼0.0001; 53% vs 0%, p¼0.005). CONCLUSIONS: Medical oncologists in the tri-state area (AL, MS, FLP) have limited access to liver surgeons and appear to have a poor understanding of which patients benefit from resection of CLM. This is consistent with data from other parts of the United States and suggests there is an urgent need to improve access to liver surgeons as well as increase awareness of the appropriate management of CLM.

Systematic Review and Meta-Analysis of Restrictive Perioperative Fluid Management in Pancreaticoduodenectomy Brian P Chen, Marian Chen, Kristina Lemon, Sean Bennett, MD, Karim M Eltawil, MD, Richard Mimeault, Fady K Balaa, Guillaume Martel, MD, FRCSC, FACS University of Ottawa, Ottawa, ON INTRODUCTION: There is significant interest and controversy surrounding the effect of restrictive perioperative fluid management on outcomes in major gastrointestinal surgery. It is most studied in colorectal surgery, although literature in pancreaticoduodenectomy (PD) patients is growing. The aim of this systematic review is to evaluate current evidence for restrictive perioperative fluid management strategies and outcomes for PD. METHODS: MEDLINE, Embase, and Cochrane Library databases from 1946 to January 2016 were searched. A review protocol was utilized and registered with PROSPERO. Primary papers that evaluated fluid management, including those as part of a clinical pathway, in PD were considered. The primary outcome was postoperative pancreatic fistula (PF). Secondary outcomes included delayed gastric emptying (DGE), overall morbidity, length of stay (LOS), mortality, and readmission. RESULTS: Thirteen studies involving 2,099 patients were included (2009-2015), of which 3 were randomized controlled trials. Only 4 studies assessed postoperative fluid management, whereas all but one study assessed intraoperative fluid management. Fluid restriction was significantly favored for complication rate (odds ratio (OR) ¼ 0.72, 95% CI ¼ 0.57-0.91, p ¼ 0.005), and was favored, but not significantly, for PF (OR ¼ 0.75, 95% CI ¼ 0.55-1.02, p ¼ 0.07), DGE (OR ¼ 0.72, 95% CI ¼ 0.52-1.01, p ¼ 0.06), and LOS (mean difference ¼ -1.37, 95% CI ¼ -3.08-0.35, p¼ 0.12). CONCLUSIONS: A body of literature consisting mostly of retrospective studies suggests that restrictive fluid management in PD decreases complication rates while possibly decreasing PF, DGE, and LOS. Adequately powered trials are warranted.

Impact of Distance Traveled on Outcomes after Total Pancreatectomy with Islet Autotransplantation: Retained Efficacy Despite a Wide Catchment Area Joshua S Jolissaint, MD, Linda W Langman, Claire L DeBolt, Jacob A Tatum, Allison N Martin, MD, MPH, Andrew Y Wang, MD, Daniel S Strand, MD, Victor M Zaydfudim, MD, MPH, Reid Adams, MD, Kenneth L Brayman, MD, PhD The University of Virginia, Charlottesville, VA INTRODUCTION: Total pancreatectomy with islet autotransplantation (TPIAT) is an operation that removes the source of pain in chronic pancreatitis (CP) and can prevent the consequent endocrine insufficiency after pancreatectomy. Data regarding the relationship of patient travel distance on perioperative outcomes is poorly defined. METHODS: IRB approval was obtained for this single-institution series utilizing data from the electronic medical record and a telephone-based questionnaire. Islets were isolated using the modified Ricordi method. Pancreas transport solution and final islet preparation were cultured prior to transplantation. Distance traveled for patients’ operations was calculated using Google MapsÒ. RESULTS: During the study period, 27 patients underwent TPIAT with no perioperative mortalities. Patients traveled a median distance of 155 miles for their operation (range 1.3-393 miles). When evaluating outcomes based on distance subgrouping of 100 miles, length of stay (LOS), and ICU stay were not appreciably different (Table). Amongst patients successfully contacted (N¼19), travel distances for patients gaining insulin independence postoperatively (N¼7, 25.9%) did not differ from insulin-dependent patients (N¼12) (142 vs 159 miles respectively, p¼0.93). However, patients who would develop bacterial contaminants in their final islet preparation (N¼6) trended toward greater travel distance than sterile preparations (235 vs 142 miles respectively, p¼0.054). No patient with bacterial contamination became insulin-independent. Table. Comparing LOS and ICU Stay Based on Distance Traveled

Variable

LOS (days), median (range) ICU stay (days), median (range)

1-100 miles (N¼9)

101-200 miles (N¼10)

201-300 miles (N¼5)

 301 miles (N¼4)

7 (6-18)

8.5 (5-52)

8 (6-13)

7.5 (7-8)

0 (0-2)

2 (1-4)

1 (0-5)

0 (0-13)

CONCLUSIONS: TPIAT is a safe procedure performed at specialized institutions, often with wide catchment areas, and outcomes are similar regardless of travel distance. There may be a subset of patients in low-access areas who receive more nonoperative or endoscopic treatment, with consequent bacterial colonization who would benefit from improved outreach and earlier operative intervention.