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T1740 Pancreatic Exocrine Function in Patients Undergoing Distal Pancreatectomy As Assessed By Human Stool Elastase-1
5-year survival of 42%. Conclusion: Metastatic renal cell carcinoma is typically associated with poor survival. Pancreatic resection for metastases may offer a survival advantage; however, potential patient selection bias and lack of comparative trials limit validation. Pancreatic resection does appear warranted in selected patients where an R0 resection is possible.
Methods: All patients who underwent primary DP (excluding completion pancreatectomy and debridement) between 1/1/1984 and 7/1/2006 were identified. Data on demographics, clinicopathologic features, operative details, complications, and mortality were analyzed. Chi-squared and multivariate logistic regression analyses were performed to identify risk factors for PL. Results: In a cohort of 704 patients undergoing primary DP, the median age was 58 years, 45% were male, and 80% were white. The indications for DP were benign pancreatic neoplasm (34%), malignant pancreatic neoplasm (31%), other neoplasm (15%), chronic pancreatitis (14%), pseudocyst (3%), and trauma (3%). Splenectomy was performed in 89%. The pancreatic remnant was sutured alone in 83%, stapled alone in 5%, and both stapled and sutured in 9%. Duct ligation was performed in 22%. Perioperative mortality was <1%, but overall morbidity was 33%. PL requiring a change in clinical management was seen in 12% of cases. Development of PL was associated with an increase in perioperative mortality from 1% to 4% (P=0.04) and an increase in median length of stay from 7 to 10 days (P<0.001). Of those with PL, 35% required additional percutaneous drainage, but only 2% required reoperative intervention. Multivariate analysis revealed that malignant neoplasm (odds ratio (OR) 1.3, P=0.29) and chronic pancreatitis (OR 1.6, P=0.12) as indications for DP did not change PL risk as compared to benign neoplasm. However, increased risk of PL was seen when DP was performed for trauma (OR 6.2, P=0.001) or pseudocyst (OR 3.3, P=0.02). Tobacco use (OR 2.0, P<0.001) was associated with increased PL risk, while preoperative diabetes was associated with decreased risk (OR 0.33, P=0.003). Neither staple vs. suture closure of the pancreatic remnant (OR 1.4, P=0.65) nor ligation of the pancreatic duct (OR 2.0, P=0.05) affected PL risk. Conclusions: This largest reported series of DP demonstrates that this procedure can be performed with low mortality but still carries a substantial risk of morbidity, particularly PL. DP in the trauma setting significantly increases the risk of PL. In contrast to previous studies, PL risk was not associated with surgical management of the pancreatic remnant. These results emphasize the need for prospective randomized trials to evaluate strategies to reduce PL occurrence.
T1739 Pancreatic Acinar Cell Carcinoma: A Multi-Institutional Study Jesus M. Matos, C. Max Schmidt, Marco Niedergethmann, Hans Detlev Saeger, Nipun Merchant, Keith D. Lillemoe, Robert Grützmann Background: Acinar cell carcinoma of the pancreas (ACC) accounts for approximately 1% of exocrine pancreatic tumors. Prognosis is poor, but recent studies suggest a better prognosis than ductal adenocarcinoma (DA). This study represents pooled data from multiple academic institutions to better understand the natural history and outcomes of patients with this rare form of pancreatic cancer. Methods: Multi-institutional retrospective review of patients with ACC was conducted to evaluate the clinical presentation and outcomes of patients with ACC. Results: Between the years 1988 and 2007, 16 patients were identified with acinar cell carcinoma (ACC) of the pancreas. Median age at presentation was 65 years. Patients commonly presented with abdominal (56%), back pain (44%) and weight loss (40%). Jaundice was not a typical presenting symptom. Fourteen patients underwent 15 operations: pancreaticoduodenectomy (8), distal pancreatectomy (4), and exploratory laparotomy (3). Three patients were found to be unresectable at initial operation, two with regionally advanced tumors and one with occult liver metastases. One patient with a regionally advanced tumor received neoadjuvant chemotherapy and was subsequently resected, and the other underwent chemoradiation but developed distant disease (supraclavicular node). Two patients were referred for surgery, but were managed non-operatively due to metastases. Mean tumor size was 5.5 ± 0.7 cm. AJCC tumor stages were stage I (1); stage II (9); stage III (3); and stage IV (3). In resected cases, 1 year survival was 100% and 5 year survival was 50%. Seven of 12 resected patients remain alive. One, the longest survivor to date (stage II), has survived 83 months. Two experienced hepatic metastases as a first sign of recurrence. One succumbed 13 months after distal pancreatectomy, and the other remains alive 76 months after pancreaticoduodenectomy. Patients with pre-operative metastases managed non-operatively were found to have a broad range of survival (1-63 months). Conclusion: ACC of the pancreas is rare and has a presentation and outcome distinct from pancreatic ductal adenocarcinoma. Tumor size is larger at presentation, and prognosis in resected patients reflects other recent series demonstrating better survival. Patients with advanced disease managed non-operatively experience variable survival. A larger study is needed to examine treatment related outcomes and other predictors of survival in patients with ACC of the pancreas.
T1742 Analysis of Organ Failure, Mortality and Pancreatic Necrosis in Patients with Severe Acute Pancreatitis Tercio De Campos, Cinara Cerqueira, Laise Kuryura, Silvia Solda, Jacqueline Perlingeiro, Jose C. Assef, Samir Rasslan Background: mortality in severe acute pancreatitis varies from 10% to 20%. The early identification of patients with higher risk of complications is crucial to treat them properly. APACHE II is the most used scoring system to determine the severity of acute pancreatitis. However, some problems have been related, as the overestimation of severity, and other scores have been proposed, such as SOFA and Marshall. The aim of this study is to determine variables related to the development of organ failure, mortality and necrotizing pancreatitis in patients with severe acute pancreatitis. Methods: evaluation of all patients with acute pancreatitis admitted in this hospital, including in the analysis only patients with APACHE II > 8 at admission. SOFA score and Marshall score were also obtained. The variables analyzed were age, sex, aetiology, hematocrit, leukocytes, C-reactive protein, computerized tomography and length of stay. These variables were related with the development of organ failure, mortality and necrotizing pancreatitis. Results: One hundred and seventy-five patients were admitted with acute pancreatitis, and 39 (22.3%) were classified as severe acute pancreatitis due to APACHE II > 8. The mean APACHE II value was 11.6 ± 3.1, SOFA score 3.2 ± 2 and Marshall 1.5 ± 1.9. Respiratory failure was present in six (15,4%) patients with severe acute pancreatitis. Eleven patients developed necrotizing pancreatitis. Mortality of patients with APACHE II > 8 was 7.7%. The variables related with organ failure were APACHE II, SOFA > 3 and Marshall > 3, and variables related with mortality were SOFA > 3 and leukocytosis > 19,000. C-reactive protein > 19.5 mg/dl and length of stay were related to necrotizing pancreatitis. Conclusion: the scoring systems, particularly the SOFA score, are related to the development of organ failure and mortality. C-reactive protein demonstrates relationship with necrotizing pancreatitis. There is no relationship between scoring systems and necrotizing pancreatitis in severe acute pancreatitis.
T1740
SSAT Abstracts
Pancreatic Exocrine Function in Patients Undergoing Distal Pancreatectomy As Assessed By Human Stool Elastase-1 James E. Speicher, L. William Traverso Introduction: What impact does distal pancreatectomy have on pancreatic exocrine function? With the recent ability to measure human stool elastase-1 (HSE-1), the evaluation of exocrine insufficiency has become less complex and has a negative predictive value of almost 100%. Our studies have suggested that pancreatic insufficiency after pancreaticoduodenectomy is caused by exocrine atrophy from pancreatic cancer and/or parenchymal loss from resection. Our objective was to use HSE-1 to determine exocrine function after distal pancreatectomy (DP) - this has not previously been studied. Methods: During a 65 month period (July 2002 - November 2007), 100 patients underwent DP by the same surgeon. The pathologic tissue diagnosis and the amount of pancreas resected were recorded. Extent of resection was divided into two categories, those limited to the left of the portal vein (PV) and those extending to the PV or further. HSE-1 values were measured preoperatively in 68 patients and repeated at 3 + 2 months, 12 + 3 months, and 24 + 6 months in 39, 19, and 9 patients, respectively. HSE-1 was expressed as abnormal at <200 µg/g stool. Results: Preoperative HSE-1 values were abnormal in 19% of patients prior to undergoing DP (67% if chronic pancreatitis, 38% if pancreatic adenocarcinoma, and 11% in all other diseases; p<0.001). Postoperative HSE-1 levels were then compared by the amount of pancreas resected. At three months after resection, HSE-1 was normal or became normal in all patients if resection was limited to the left of the PV, but in just 79% if resection extended to the PV (p=0.03). At 12 months, normal HSE-1 was observed in 100% of patients if the resection was to the left of the PV and 88% if resection extended to the PV (p=0.2). At 24 months, our limited results showed normal function in 100% of patients if the resection was to the left of the PV and 75% if resection extended to the PV (p=0.2). In the subgroup with normal preoperative HSE-1 (81% of patients) whose resection was limited to the left of the PV, 100% had normal exocrine function at all timepoints. If the resection extended to the PV, 82% had normal exocrine function at three months (p=0.09), while 100% had normal exocrine function at 12 and 24 months. Conclusion: Of patients undergoing DP, one-fifth will have pancreatic insufficiency, most commonly those with pancreatic adenocarcinoma or chronic pancreatitis. Postoperative pancreatic insufficiency was seen only in those with resection that extended to the PV or beyond, and was transient. Exocrine insufficiency before and after DP is related to both the disease and the extent of resection, and can improve with time.
T1743 Quality of Life in Long-Term Survivors After Pancreaticoduodenectomy Roberto Salvia, Stefano Crippa, Francesca Mazzarella, Claudio Bassi, Stefano Partelli, Massimo Falconi, Giovanni Butturini, Paolo Pederzoli Few data are available with respect to quality of life (QoL) in long-term survivors after pancreaticoduodenectomy (PD). Aim of this study is to evaluate QoL and long-term outcomes in patients who underwent PD between 1990 and 2003 with a minimum follow-up of 48 months. Among 268 patients identified, 168 were still alive and were surveyed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), and with an Institutional questionnaire on long-term complications. Of the 168 surviving patients, 109 (65%) agreed to partecipate at a median of 7.5 years postoperatively. Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed in 75% of cases; 56 patients (51.5%) had malignant neoplasms, 23 (21%) borderline tumors, and 30 (27.5%) benign neoplasms. Intraductal papillary mucinous neoplasms (IPMNs) was the most common indication for surgical resection (27.5%) followed by ductal adenocarcinoma (12%). Postoperative complications were recorded in 63 patients (58%). Overall, 75% of patients reported good scores in their perception of QoL. A significant decrease in QoL was found in patients with malignancy, with IPMNs, in survivors > 10 years, and in those with postoperative complications (P<0.05). Despite no significant differences in overall QoL perception, Whipple resection was more frequetly associated with alterations of functional and symptomatic domains than PPPD. 55% of patients complained of steatorrhea, 40% of dumping syndrome, 54% of weight loss. Dumping syndrome is not associated with Whipple procedure, while weight loss was more frequently observed after pancreo-gastrostomy than pancreo-jejunostomy. New endocrine insufficiency was found in 17% of cases. Recurrent abdominal pain was found in 41% of patients, who had also a significant impairment of QoL. PD is associated with acceptable QoL over time. However a careful long-term followup is necessary given the significant rate of exocrine insufficiency rate and impairments in digestive function. Patients who had complicated postoperative course, malignancies and
T1741 Risk Factors for Pancreatic Leak Following Distal Pancreatectomy Hari Nathan, Michael Choti, Christopher L. Wolfgang, C. Rory Goodwin, Akhil K. Seth, Jordan M. Winter, Edil H. Barish, Richard D. Schulick, Timothy M. Pawlik, John L. Cameron Background: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. We sought to evaluate the incidence of and identify risk factors for the development of PL in patients undergoing distal pancreatectomy (DP).
SSAT Abstracts
A-888
Methods: All patients who underwent primary DP (excluding completion pancreatectomy and debridement) between 1/1/1984 and 7/1/2006 were identified. Data on demographics, clinicopathologic features, operative details, complications, and mortality were analyzed. Chi-squared and multivariate logistic regression analyses were performed to identify risk factors for PL. Results: In a cohort of 704 patients undergoing primary DP, the median age was 58 years, 45% were male, and 80% were white. The indications for DP were benign pancreatic neoplasm (34%), malignant pancreatic neoplasm (31%), other neoplasm (15%), chronic pancreatitis (14%), pseudocyst (3%), and trauma (3%). Splenectomy was performed in 89%. The pancreatic remnant was sutured alone in 83%, stapled alone in 5%, and both stapled and sutured in 9%. Duct ligation was performed in 22%. Perioperative mortality was <1%, but overall morbidity was 33%. PL requiring a change in clinical management was seen in 12% of cases. Development of PL was associated with an increase in perioperative mortality from 1% to 4% (P=0.04) and an increase in median length of stay from 7 to 10 days (P<0.001). Of those with PL, 35% required additional percutaneous drainage, but only 2% required reoperative intervention. Multivariate analysis revealed that malignant neoplasm (odds ratio (OR) 1.3, P=0.29) and chronic pancreatitis (OR 1.6, P=0.12) as indications for DP did not change PL risk as compared to benign neoplasm. However, increased risk of PL was seen when DP was performed for trauma (OR 6.2, P=0.001) or pseudocyst (OR 3.3, P=0.02). Tobacco use (OR 2.0, P<0.001) was associated with increased PL risk, while preoperative diabetes was associated with decreased risk (OR 0.33, P=0.003). Neither staple vs. suture closure of the pancreatic remnant (OR 1.4, P=0.65) nor ligation of the pancreatic duct (OR 2.0, P=0.05) affected PL risk. Conclusions: This largest reported series of DP demonstrates that this procedure can be performed with low mortality but still carries a substantial risk of morbidity, particularly PL. DP in the trauma setting significantly increases the risk of PL. In contrast to previous studies, PL risk was not associated with surgical management of the pancreatic remnant. These results emphasize the need for prospective randomized trials to evaluate strategies to reduce PL occurrence.
T1739 Pancreatic Acinar Cell Carcinoma: A Multi-Institutional Study Jesus M. Matos, C. Max Schmidt, Marco Niedergethmann, Hans Detlev Saeger, Nipun Merchant, Keith D. Lillemoe, Robert Grützmann Background: Acinar cell carcinoma of the pancreas (ACC) accounts for approximately 1% of exocrine pancreatic tumors. Prognosis is poor, but recent studies suggest a better prognosis than ductal adenocarcinoma (DA). This study represents pooled data from multiple academic institutions to better understand the natural history and outcomes of patients with this rare form of pancreatic cancer. Methods: Multi-institutional retrospective review of patients with ACC was conducted to evaluate the clinical presentation and outcomes of patients with ACC. Results: Between the years 1988 and 2007, 16 patients were identified with acinar cell carcinoma (ACC) of the pancreas. Median age at presentation was 65 years. Patients commonly presented with abdominal (56%), back pain (44%) and weight loss (40%). Jaundice was not a typical presenting symptom. Fourteen patients underwent 15 operations: pancreaticoduodenectomy (8), distal pancreatectomy (4), and exploratory laparotomy (3). Three patients were found to be unresectable at initial operation, two with regionally advanced tumors and one with occult liver metastases. One patient with a regionally advanced tumor received neoadjuvant chemotherapy and was subsequently resected, and the other underwent chemoradiation but developed distant disease (supraclavicular node). Two patients were referred for surgery, but were managed non-operatively due to metastases. Mean tumor size was 5.5 ± 0.7 cm. AJCC tumor stages were stage I (1); stage II (9); stage III (3); and stage IV (3). In resected cases, 1 year survival was 100% and 5 year survival was 50%. Seven of 12 resected patients remain alive. One, the longest survivor to date (stage II), has survived 83 months. Two experienced hepatic metastases as a first sign of recurrence. One succumbed 13 months after distal pancreatectomy, and the other remains alive 76 months after pancreaticoduodenectomy. Patients with pre-operative metastases managed non-operatively were found to have a broad range of survival (1-63 months). Conclusion: ACC of the pancreas is rare and has a presentation and outcome distinct from pancreatic ductal adenocarcinoma. Tumor size is larger at presentation, and prognosis in resected patients reflects other recent series demonstrating better survival. Patients with advanced disease managed non-operatively experience variable survival. A larger study is needed to examine treatment related outcomes and other predictors of survival in patients with ACC of the pancreas.
T1742 Analysis of Organ Failure, Mortality and Pancreatic Necrosis in Patients with Severe Acute Pancreatitis Tercio De Campos, Cinara Cerqueira, Laise Kuryura, Silvia Solda, Jacqueline Perlingeiro, Jose C. Assef, Samir Rasslan Background: mortality in severe acute pancreatitis varies from 10% to 20%. The early identification of patients with higher risk of complications is crucial to treat them properly. APACHE II is the most used scoring system to determine the severity of acute pancreatitis. However, some problems have been related, as the overestimation of severity, and other scores have been proposed, such as SOFA and Marshall. The aim of this study is to determine variables related to the development of organ failure, mortality and necrotizing pancreatitis in patients with severe acute pancreatitis. Methods: evaluation of all patients with acute pancreatitis admitted in this hospital, including in the analysis only patients with APACHE II > 8 at admission. SOFA score and Marshall score were also obtained. The variables analyzed were age, sex, aetiology, hematocrit, leukocytes, C-reactive protein, computerized tomography and length of stay. These variables were related with the development of organ failure, mortality and necrotizing pancreatitis. Results: One hundred and seventy-five patients were admitted with acute pancreatitis, and 39 (22.3%) were classified as severe acute pancreatitis due to APACHE II > 8. The mean APACHE II value was 11.6 ± 3.1, SOFA score 3.2 ± 2 and Marshall 1.5 ± 1.9. Respiratory failure was present in six (15,4%) patients with severe acute pancreatitis. Eleven patients developed necrotizing pancreatitis. Mortality of patients with APACHE II > 8 was 7.7%. The variables related with organ failure were APACHE II, SOFA > 3 and Marshall > 3, and variables related with mortality were SOFA > 3 and leukocytosis > 19,000. C-reactive protein > 19.5 mg/dl and length of stay were related to necrotizing pancreatitis. Conclusion: the scoring systems, particularly the SOFA score, are related to the development of organ failure and mortality. C-reactive protein demonstrates relationship with necrotizing pancreatitis. There is no relationship between scoring systems and necrotizing pancreatitis in severe acute pancreatitis.
T1740
SSAT Abstracts
Pancreatic Exocrine Function in Patients Undergoing Distal Pancreatectomy As Assessed By Human Stool Elastase-1 James E. Speicher, L. William Traverso Introduction: What impact does distal pancreatectomy have on pancreatic exocrine function? With the recent ability to measure human stool elastase-1 (HSE-1), the evaluation of exocrine insufficiency has become less complex and has a negative predictive value of almost 100%. Our studies have suggested that pancreatic insufficiency after pancreaticoduodenectomy is caused by exocrine atrophy from pancreatic cancer and/or parenchymal loss from resection. Our objective was to use HSE-1 to determine exocrine function after distal pancreatectomy (DP) - this has not previously been studied. Methods: During a 65 month period (July 2002 - November 2007), 100 patients underwent DP by the same surgeon. The pathologic tissue diagnosis and the amount of pancreas resected were recorded. Extent of resection was divided into two categories, those limited to the left of the portal vein (PV) and those extending to the PV or further. HSE-1 values were measured preoperatively in 68 patients and repeated at 3 + 2 months, 12 + 3 months, and 24 + 6 months in 39, 19, and 9 patients, respectively. HSE-1 was expressed as abnormal at <200 µg/g stool. Results: Preoperative HSE-1 values were abnormal in 19% of patients prior to undergoing DP (67% if chronic pancreatitis, 38% if pancreatic adenocarcinoma, and 11% in all other diseases; p<0.001). Postoperative HSE-1 levels were then compared by the amount of pancreas resected. At three months after resection, HSE-1 was normal or became normal in all patients if resection was limited to the left of the PV, but in just 79% if resection extended to the PV (p=0.03). At 12 months, normal HSE-1 was observed in 100% of patients if the resection was to the left of the PV and 88% if resection extended to the PV (p=0.2). At 24 months, our limited results showed normal function in 100% of patients if the resection was to the left of the PV and 75% if resection extended to the PV (p=0.2). In the subgroup with normal preoperative HSE-1 (81% of patients) whose resection was limited to the left of the PV, 100% had normal exocrine function at all timepoints. If the resection extended to the PV, 82% had normal exocrine function at three months (p=0.09), while 100% had normal exocrine function at 12 and 24 months. Conclusion: Of patients undergoing DP, one-fifth will have pancreatic insufficiency, most commonly those with pancreatic adenocarcinoma or chronic pancreatitis. Postoperative pancreatic insufficiency was seen only in those with resection that extended to the PV or beyond, and was transient. Exocrine insufficiency before and after DP is related to both the disease and the extent of resection, and can improve with time.
T1743 Quality of Life in Long-Term Survivors After Pancreaticoduodenectomy Roberto Salvia, Stefano Crippa, Francesca Mazzarella, Claudio Bassi, Stefano Partelli, Massimo Falconi, Giovanni Butturini, Paolo Pederzoli Few data are available with respect to quality of life (QoL) in long-term survivors after pancreaticoduodenectomy (PD). Aim of this study is to evaluate QoL and long-term outcomes in patients who underwent PD between 1990 and 2003 with a minimum follow-up of 48 months. Among 268 patients identified, 168 were still alive and were surveyed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), and with an Institutional questionnaire on long-term complications. Of the 168 surviving patients, 109 (65%) agreed to partecipate at a median of 7.5 years postoperatively. Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed in 75% of cases; 56 patients (51.5%) had malignant neoplasms, 23 (21%) borderline tumors, and 30 (27.5%) benign neoplasms. Intraductal papillary mucinous neoplasms (IPMNs) was the most common indication for surgical resection (27.5%) followed by ductal adenocarcinoma (12%). Postoperative complications were recorded in 63 patients (58%). Overall, 75% of patients reported good scores in their perception of QoL. A significant decrease in QoL was found in patients with malignancy, with IPMNs, in survivors > 10 years, and in those with postoperative complications (P<0.05). Despite no significant differences in overall QoL perception, Whipple resection was more frequetly associated with alterations of functional and symptomatic domains than PPPD. 55% of patients complained of steatorrhea, 40% of dumping syndrome, 54% of weight loss. Dumping syndrome is not associated with Whipple procedure, while weight loss was more frequently observed after pancreo-gastrostomy than pancreo-jejunostomy. New endocrine insufficiency was found in 17% of cases. Recurrent abdominal pain was found in 41% of patients, who had also a significant impairment of QoL. PD is associated with acceptable QoL over time. However a careful long-term followup is necessary given the significant rate of exocrine insufficiency rate and impairments in digestive function. Patients who had complicated postoperative course, malignancies and
T1741 Risk Factors for Pancreatic Leak Following Distal Pancreatectomy Hari Nathan, Michael Choti, Christopher L. Wolfgang, C. Rory Goodwin, Akhil K. Seth, Jordan M. Winter, Edil H. Barish, Richard D. Schulick, Timothy M. Pawlik, John L. Cameron Background: Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. We sought to evaluate the incidence of and identify risk factors for the development of PL in patients undergoing distal pancreatectomy (DP).
SSAT Abstracts
A-888