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Tu1568 Ethical Conflicts in the Surgical Treatment of Gastrointestinal Malignancies
(16.0% vs. 9.1% for patients with benign disease, p=0.0002). Conclusions: In this very large multi-institution data set, 30-day mortality for splenectomy for hematologic diseases is as high as 2.1% and is associated with an overall complication rate of 12% for patients with benign conditions and 20% for malignancy. Immediate infectious complications are common following splenectomy for these conditions. A multivariate analysis is underway to determine the specific variables that can account for the significant morbidity and mortality from splenectomy for hematologic disorders. Complications from Splenectomy for Hematologic Disorders
patient-oriented decision making - Surgical decision making in these diseases need to include patient preferences, quality of life and contextual issues to provide sound surgical judgement, with preeminence of respect for autonomy - Ethical conflicts will probably increase in the future and surgical ethics knowledge will prove to be at the core of surgical training - A change of paradigm is envisioned to achieve and provide an optimal surgical care: from the curative model with the goal of curing to the palliative model with the concern to relief suffering Tu1569 Impact of Margin Clearance on Survival After Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: What Is a "True" Negative Margin? Yasushi Hashimoto, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Naru Kondo, Taijiro Sueda
Tu1567
SSAT Abstracts
Perioperative Outcome After Pancreatic Head Resections: Consecutive Single Surgeon Series in a Specialized University Hospital and in a Community Hospital Ulrich Adam, Hartwig Riediger, Ulrich F. Wellner, Tobias Keck, Ulrich T. Hopt, Frank Makowiec Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcomes of individual surgeons in different institutions, however, are scarce. We evaluated the postoperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high volume university department and (later) in a community hospital (with almost no prior institutional experience with pancreatic surgery). Methods: We compared the results after PHR personally performed by a single surgeon between 2001 and 10/2006 in a specialized unit of a German University hospital (n=86; DeptA) with the results after PHR performed in a Community hospital between 11/2006 and 2012 (n=135; DeptB). Before the study period (-2001) the surgeon already had a personal caseload of . 200 PHR. In addition to the 221 PHR analyzed here the surgeon also had teached further . 150 PHR to residents and consulting surgeons. The same surgical and perioperative techniques were applied in both series (e.g. abdominal drains, early enteral feeding, pancreaticojejunostomy or pancreaticogastrostomy in PPPD) with the exception of the use of pancreatic duct drains in some patients in DeptB). The data of both series were prospectively recorded in SPSS-databases. Results: The median age of the patients was lower in DeptA (59 years vs. 67 years in DeptB; p,0.001). Indications for PHR (DeptA n=86 / DeptB n=135) were pancreatic/periampullary cancer (58%/55%), chronic pancreatitis (31%/28%) and various others (11%/17%). Most PHR were PPPD (62%/74%) but the percentage of duodenum-preserving PHR decreased in DeptB (26% vs 14%). Vein resections were performed in 17%/21% (n.s.). Mortality rate was 3.5% in DeptA and 3.7% in DeptB (n.s.). Any complication occurred in 48%/55% (p= 0.25). Pancreatic leak (any grade) was present in 26%/24% (n.s.) but grade C leaks were more frequent in DeptA (8% vs 3% in DeptB; p ,0.05). Using the expanded Accordion classification complications grade 3 or higher were documented in 14% (DeptA) or 16% (DeptB; n.s.). Conclusions: Surgeon volume and a high individual experience, respectively, contribute to low mortality and acceptable complication rates after pancreatic head resection. This personal experience may allow for favorable postoperative outcomes after PHR even in a program with almost no prior experience with pancreatic resections.
BACKGROUND: Microscopic involvement of a resection margin by tumor is associated with a poor prognosis. It is unclear whether a proximity to resection margins by tumor confers a survival benefit over margin involved R1 resection of their pancreatic ductal adenocarcinoma (PDAC) after pancreticoduodenectomy (PD). The aim is to better understand the impact of resection status on clinical and pathologic staging, and long-term survival after PD for PDAC, and to explore the prognostic significance of a proximity to surgical margins. METHODS: We assessed the relationships between margin involvement (R1), the proximity to resection margins (R0-close) and outcome in a cohort of 124 consecutive patients who underwent PD for PDAC between 2002 and 2012. Resected specimens were analyzed according to the improved standardized pathology protocol which included permanent section analysis of the surgical margins. R0-close margin was defined as tumor within 1-mm of the resection margins and a patient with a margin of greater than 1-mm was defined as R0-wide margin. Follow-up data on overall and disease-free survival, presence and site of tumor recurrence were examined. RESULTS: Of the 124 patients, the resection margins were positive (R1) in 30 (24%) and negative (R0) in 94 patients (76%) including 38 patients (31%) with an R0close resection. Patients with R1 resections had an unfavorable survival compared with those with R0 resections (median, 18 vs 35 months; P ,0.01), but survival with R0-close margin were comparable to R1 resections: but both groups had a significantly shorter survival than patients with R0-wide margins (18 vs 32 vs 44 months, respectively; P=0.02). Disease-free survival was shorter in R1/R0-close margins comparing to R0-wide group (median, 12 vs 19 months; P=0.04). By multivariate analysis, predictors of R1/R0-close margins were patients underwent portal vein resection and larger tumor size of greater than 20-mm. The pattern of tumor recurrence had a greater rate of regional metastases in the R1/R0-close margins group comparing to patients with R0-wide margins (48% vs 14%; P=0.01). CONCLUSIONS: These data demonstrate that a margin clearance of more than 1-mm is important for longterm survival in a subgroup of patients. Complete histologic evaluation of the resected PD specimens is important for prognosis in patients with PDAC who underwent PD. More aggressive therapeutic approaches that target locoregional disease such as neoadjuvant radiation therapy may be beneficial in patients with close surgical margins.
Tu1568 Ethical Conflicts in the Surgical Treatment of Gastrointestinal Malignancies Alberto R. Ferreres, Anibal J. Rondan, Marcelo Fasano, Natalia Bongiovi, Gustavo Alarcia, Alejo S. Ferreres, Rosana Trapani Introduction: surgical care of patients with diagnosis of gastrointestinal malignancies involve ethical conficts and decision making to manage these issues requires specific knowledge and expertise . The four ethical principles as introduced by Beauchamp and Childress (respect for autonomy, beneficence, non maleficence and justice) provide a framework for the solution of these issues when arising in clinical practice Objective: to examine prospectively the incidence and the cause of ethical conflicts which lead to a surgical ethics consultation during the process of surgical care of patients with diagnosis of gastrointestinal malignancies Methods: A total of 105 ethical conflicts through the treatment care of 100 patients with gastrointestinal malignancies (of a total of 488) were identified during 2010. Mean age was 58.2 +/- 13.7 years (range: 28 to 96), 56 were females. Two of the authors with expertise in surgical ethics participated when intervention was requested and assisted with the conflict management and resolution. Results: The following situations were identified and some patients presented more than one: 1. Issues involving surgical informed consent process (information, refusal to proposed treatment, cognitive status and competency, surrogates role in future decisions): 35 (33.33 %) 2. Implementation of palliative care: 21 (20%) 3. Advance directives: 15 (14.28%) 4. Advice regarding alternative treatments and "miracle cures": 13 (12.38%) 5. Futile treatments: 7 (6.66%) 6. DNR orders: 6 ( 5.71%) 7. Truth telling: 4 (3.80%) 8. Challenges to develop a trustful surgeon-patient relationship: 2 (1.90%) 9. Surgical residents participation in the procedure. 2 (1.90%) All the conflicts were managed satisfactorily, no need for change of surgical teams was required and no professional liability claims were filed in the following 23 months. Conclusions: - Ethical guidelines and expertise are needed in the management of gastrointestinal malignancies to achieve adequate and
SSAT Abstracts
Tu1570 Surgical Management of Pancreatic Neuroendocrine Tumors: A Single Institution Experience Jeff Kim, Aram N. Demirjian, David K. Imagawa Introduction: Pancreatic neuroendocrine tumors (PancNET) are a comparatively rare, diverse group of neoplasms that account for 1-3% of all pancreatic tumors. While surgery is clearly the first line therapy for patients with disease amenable to resection at any stage of presentation, there are currently many surgical options. Due to both the diversity and rarity of the disease, there are limited data on different surgical outcomes and thus no clearly established guidelines supporting one surgical management option over another exists. Objective: To identify differences in surgical outcomes of PancNET patients treated with various surgical approaches that may contribute to better management decisions in these patients. Participants: Retrospective study of forty-four patients with histologically confirmed diagnosis of pancreatic neuroendocrine tumor, surgically evaluated at the University of California Irvine Medical Center (UCI-MC) between January 2003 and August of 2012. Surgical procedures included both traditional radical resections, such as a Whipple's procedure, total pancreatectomy and distal pancreatectomy with splenectomy, as well as organ
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patient-oriented decision making - Surgical decision making in these diseases need to include patient preferences, quality of life and contextual issues to provide sound surgical judgement, with preeminence of respect for autonomy - Ethical conflicts will probably increase in the future and surgical ethics knowledge will prove to be at the core of surgical training - A change of paradigm is envisioned to achieve and provide an optimal surgical care: from the curative model with the goal of curing to the palliative model with the concern to relief suffering Tu1569 Impact of Margin Clearance on Survival After Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: What Is a "True" Negative Margin? Yasushi Hashimoto, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Naru Kondo, Taijiro Sueda
Tu1567
SSAT Abstracts
Perioperative Outcome After Pancreatic Head Resections: Consecutive Single Surgeon Series in a Specialized University Hospital and in a Community Hospital Ulrich Adam, Hartwig Riediger, Ulrich F. Wellner, Tobias Keck, Ulrich T. Hopt, Frank Makowiec Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcomes of individual surgeons in different institutions, however, are scarce. We evaluated the postoperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high volume university department and (later) in a community hospital (with almost no prior institutional experience with pancreatic surgery). Methods: We compared the results after PHR personally performed by a single surgeon between 2001 and 10/2006 in a specialized unit of a German University hospital (n=86; DeptA) with the results after PHR performed in a Community hospital between 11/2006 and 2012 (n=135; DeptB). Before the study period (-2001) the surgeon already had a personal caseload of . 200 PHR. In addition to the 221 PHR analyzed here the surgeon also had teached further . 150 PHR to residents and consulting surgeons. The same surgical and perioperative techniques were applied in both series (e.g. abdominal drains, early enteral feeding, pancreaticojejunostomy or pancreaticogastrostomy in PPPD) with the exception of the use of pancreatic duct drains in some patients in DeptB). The data of both series were prospectively recorded in SPSS-databases. Results: The median age of the patients was lower in DeptA (59 years vs. 67 years in DeptB; p,0.001). Indications for PHR (DeptA n=86 / DeptB n=135) were pancreatic/periampullary cancer (58%/55%), chronic pancreatitis (31%/28%) and various others (11%/17%). Most PHR were PPPD (62%/74%) but the percentage of duodenum-preserving PHR decreased in DeptB (26% vs 14%). Vein resections were performed in 17%/21% (n.s.). Mortality rate was 3.5% in DeptA and 3.7% in DeptB (n.s.). Any complication occurred in 48%/55% (p= 0.25). Pancreatic leak (any grade) was present in 26%/24% (n.s.) but grade C leaks were more frequent in DeptA (8% vs 3% in DeptB; p ,0.05). Using the expanded Accordion classification complications grade 3 or higher were documented in 14% (DeptA) or 16% (DeptB; n.s.). Conclusions: Surgeon volume and a high individual experience, respectively, contribute to low mortality and acceptable complication rates after pancreatic head resection. This personal experience may allow for favorable postoperative outcomes after PHR even in a program with almost no prior experience with pancreatic resections.
BACKGROUND: Microscopic involvement of a resection margin by tumor is associated with a poor prognosis. It is unclear whether a proximity to resection margins by tumor confers a survival benefit over margin involved R1 resection of their pancreatic ductal adenocarcinoma (PDAC) after pancreticoduodenectomy (PD). The aim is to better understand the impact of resection status on clinical and pathologic staging, and long-term survival after PD for PDAC, and to explore the prognostic significance of a proximity to surgical margins. METHODS: We assessed the relationships between margin involvement (R1), the proximity to resection margins (R0-close) and outcome in a cohort of 124 consecutive patients who underwent PD for PDAC between 2002 and 2012. Resected specimens were analyzed according to the improved standardized pathology protocol which included permanent section analysis of the surgical margins. R0-close margin was defined as tumor within 1-mm of the resection margins and a patient with a margin of greater than 1-mm was defined as R0-wide margin. Follow-up data on overall and disease-free survival, presence and site of tumor recurrence were examined. RESULTS: Of the 124 patients, the resection margins were positive (R1) in 30 (24%) and negative (R0) in 94 patients (76%) including 38 patients (31%) with an R0close resection. Patients with R1 resections had an unfavorable survival compared with those with R0 resections (median, 18 vs 35 months; P ,0.01), but survival with R0-close margin were comparable to R1 resections: but both groups had a significantly shorter survival than patients with R0-wide margins (18 vs 32 vs 44 months, respectively; P=0.02). Disease-free survival was shorter in R1/R0-close margins comparing to R0-wide group (median, 12 vs 19 months; P=0.04). By multivariate analysis, predictors of R1/R0-close margins were patients underwent portal vein resection and larger tumor size of greater than 20-mm. The pattern of tumor recurrence had a greater rate of regional metastases in the R1/R0-close margins group comparing to patients with R0-wide margins (48% vs 14%; P=0.01). CONCLUSIONS: These data demonstrate that a margin clearance of more than 1-mm is important for longterm survival in a subgroup of patients. Complete histologic evaluation of the resected PD specimens is important for prognosis in patients with PDAC who underwent PD. More aggressive therapeutic approaches that target locoregional disease such as neoadjuvant radiation therapy may be beneficial in patients with close surgical margins.
Tu1568 Ethical Conflicts in the Surgical Treatment of Gastrointestinal Malignancies Alberto R. Ferreres, Anibal J. Rondan, Marcelo Fasano, Natalia Bongiovi, Gustavo Alarcia, Alejo S. Ferreres, Rosana Trapani Introduction: surgical care of patients with diagnosis of gastrointestinal malignancies involve ethical conficts and decision making to manage these issues requires specific knowledge and expertise . The four ethical principles as introduced by Beauchamp and Childress (respect for autonomy, beneficence, non maleficence and justice) provide a framework for the solution of these issues when arising in clinical practice Objective: to examine prospectively the incidence and the cause of ethical conflicts which lead to a surgical ethics consultation during the process of surgical care of patients with diagnosis of gastrointestinal malignancies Methods: A total of 105 ethical conflicts through the treatment care of 100 patients with gastrointestinal malignancies (of a total of 488) were identified during 2010. Mean age was 58.2 +/- 13.7 years (range: 28 to 96), 56 were females. Two of the authors with expertise in surgical ethics participated when intervention was requested and assisted with the conflict management and resolution. Results: The following situations were identified and some patients presented more than one: 1. Issues involving surgical informed consent process (information, refusal to proposed treatment, cognitive status and competency, surrogates role in future decisions): 35 (33.33 %) 2. Implementation of palliative care: 21 (20%) 3. Advance directives: 15 (14.28%) 4. Advice regarding alternative treatments and "miracle cures": 13 (12.38%) 5. Futile treatments: 7 (6.66%) 6. DNR orders: 6 ( 5.71%) 7. Truth telling: 4 (3.80%) 8. Challenges to develop a trustful surgeon-patient relationship: 2 (1.90%) 9. Surgical residents participation in the procedure. 2 (1.90%) All the conflicts were managed satisfactorily, no need for change of surgical teams was required and no professional liability claims were filed in the following 23 months. Conclusions: - Ethical guidelines and expertise are needed in the management of gastrointestinal malignancies to achieve adequate and
SSAT Abstracts
Tu1570 Surgical Management of Pancreatic Neuroendocrine Tumors: A Single Institution Experience Jeff Kim, Aram N. Demirjian, David K. Imagawa Introduction: Pancreatic neuroendocrine tumors (PancNET) are a comparatively rare, diverse group of neoplasms that account for 1-3% of all pancreatic tumors. While surgery is clearly the first line therapy for patients with disease amenable to resection at any stage of presentation, there are currently many surgical options. Due to both the diversity and rarity of the disease, there are limited data on different surgical outcomes and thus no clearly established guidelines supporting one surgical management option over another exists. Objective: To identify differences in surgical outcomes of PancNET patients treated with various surgical approaches that may contribute to better management decisions in these patients. Participants: Retrospective study of forty-four patients with histologically confirmed diagnosis of pancreatic neuroendocrine tumor, surgically evaluated at the University of California Irvine Medical Center (UCI-MC) between January 2003 and August of 2012. Surgical procedures included both traditional radical resections, such as a Whipple's procedure, total pancreatectomy and distal pancreatectomy with splenectomy, as well as organ
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