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W1530 Diagnostic Accuracy of EUS in Detecting Pancreatic Neuroendocrine Tumors: A Meta-Analysis and Systematic Review
0.0002). The spleen was preserved in 19.8% of ODP and 38.8% of LDP (p<0.0001). The laparoscopic approach increased the odds of having a postoperative complication (OR 1.32, 95% CI: 1.02-1.70, p=0.03). The rate for pancreatic fistula was similar for LDP (17.9%) and ODP (14.3%) (OR 1.31, 95% CI: 0.94-1.83, p=0.11). Postoperative pseudocyst (OR 99.85, 95% CI: 6.05-1647.13, p=0.01) and splenic infarct (OR 5.12, 95% CI: 1.38-19.00, p=0.02) were higher in the LPD group. Other complications were more frequent in the ODP group (p=0.02). For example, patients having an ODP were more likely to require reoperation (OR 2.23, 95% CI: 1.01-4.93, p=0.05). The rate of an R1 resection was similar (OPD 1.3%, LDP 1.5%, p=0.80). Lymph node harvest was not consistently reported in the outside series, but among our own patients undergoing LDP, there were fewer nodes (5.3±1.5) examined than in patients who had ODP (9.3±0.7, p=0.01). There was a trend towards increased length of stay for ODP (11.0±1.6 days) compared with LDP (7.5±1.1 days; p= 0.15). Mortality rate (ODP 4.1%, LDP 5.0%, p=0.72) was similar regardless of operative approach. Conclusions: While LDP offers some advantages over ODP, the complication rate appears higher and there may be fewer lymph nodes sampled. Additional studies will be required to reliably asses the pros and cons of laparoscopic pancreatic surgery, and to clarify the technique and indications for specific clinical conditions.
W1530 Diagnostic Accuracy of EUS in Detecting Pancreatic Neuroendocrine Tumors: A Meta-Analysis and Systematic Review Srinivas R. Puli, Matthew L. Bechtold, Jyotsna BK Reddy, Srinivas R. Bapoje, Mainor R. Antillon, William R. Brugge Background: The published data on accuracy of Endoscopic Ultrasound to detect pancreatic neuroendocrine tumors (PNT) has been varied. Detection of PNT is critical from a therapeutic stand point. Aim: To evaluate the accuracy of EUS in detecting PNT. Method: Study Selection Criteria: Only EUS studies confirmed by surgery or appropriate follow-up were selected. Only studies from which a 2 X 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing & allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. 2 X 2 tables were constructed with the data extracted from each study. Statistical Method: Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and by the DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (N = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNT was 87.2% (95% CI: 82.2 - 91.2). EUS had a pooled specificity of 98.0% (95% CI: 94.3 - 99.6). The positive likelihood ratio of EUS was 11.1 (95% CI: 5.34 - 22.8) and negative likelihood ratio was 0.17 (95% CI: 0.13 - 0.24). The diagnostic odds ratio, the odds of having anatomic PNT in positive as compared to negative EUS studies was 94.7 (95% CI: 37.9 - 236.1). All the pooled estimates calculated by fixed and random effect models were similar. SROC curves showed an area under the curve of 0.94. Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (p = 0.16), indication no publication bias. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. Conclusions: EUS has excellent sensitivity and specificity to detect PNT. EUS should be strongly considered for evaluation of PNT.
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SSAT Abstracts
Colectomy in Necrotizing Pancreatitis Portends a Complex Clinical Course Hayder H. Al-Azzawi, Angela M. Bermes, Heidi Kuhlenschmidt, Thomas J. Howard, Eric A. Wiebke, Henry A. Pitt, Attila Nakeeb, C. Max Schmidt, Keith D. Lillemoe, Nicholas J. Zyromski Introduction: Necrotizing pancreatitis (NP) is a severe inflammatory process involving the pancreas, peripancreatic soft tissue, and mesenteric fat particularly in the transverse mesocolon and the root of the small bowel mesentery. Mesocolic involvement with this necrotizing process can directly and indirectly affect the blood supply to the colon resulting in ischemia, end-organ damage, and the need for colectomy. The aim of this study was to define the incidence and clinical outcome of patients requiring colectomy is the setting of NP. Methods: Records of all patients with acute pancreatitis (ICD-9 code 577.0) admitted to Indiana University Hospital between January 1996 and April 2008 were crossed-referenced with radiographic imaging data to identify patients with NP. Of 340 patients with NP, 37 patients required colectomy (Colectomy group). These patients were matched for age, gender, body mass index (BMI), and medical co-morbidities (diabetes, hypertension, coronary artery disease, pulmonary disease) with 37 NP patients who did not require colectomy (control group). Indications for and timing of colectomy were recorded, and clinical outcomes of the two groups were compared. Data were analyzed with Student's t-test, Chi square and Fisher exact test. P value of less than 0.05 was considered statistically significant. Results: Eleven percent of all patients with NP (37/340) required colectomy. Indications for colectomy were: ischemia (20, 54%); fistula (8, 22%); intraoperative perforation (4, 11%); and other (5, 14%). Six percent of patients had colectomy prior to debridement, 40% required colectomy during initial pancreatic debridement, and 54% required the colectomy following the initial debridement. Outcomes for controls and colectomy patients are shown in the Table. Conclusions: These data show that: 1) colonic involvement is common in the setting of necrotizing pancreatitis, 2) ischemia is the most common indication for colectomy, and 3) patients requiring colectomy have significantly longer length of stay, readmission rate, and number of operations compared to those who did not require colectomy. In the setting of necrotizing pancreatitis, colectomy is common and portends a complex clinical course; clinicians must have a high index of suspicion for as well as an appreciation of the consequences of colonic involvement.
W1531 Pancreaticoduodenectomy (PD) At a Non University Tertiary Care Center (Nutcc): Outcomes and Feasibility Amit S. Khithani, David E. Curtis, Christos A. Galanopoulos, D. Rohan Jeyarajah Background: A successful outcome to PD is attributed to a high volume at University Centers. Over the past decade, an association between volume and outcome in PD has been firmly established. Despite studies which suggest that community centers can perform these procedures with favorable outcomes, the underlying issue of where these complex surgeries should be performed is still debated. This paper examines the outcomes of PD in a NUTCC. Methods: Medical records of 122 patients, who underwent PD by a single surgeon between September 2005 to August 2008 at a high volume NUTCC, were analyzed. The patients were managed by a multidisciplinary team consisting of a gastroenterologist, surgeon, hepatobiliary fellow, general surgery residents, ICU nursing staff, operating room team, and a surgery floor nursing staff. The records were reviewed with respect to preoperative and postoperative data, thirty-day mortality, morbidity and histopathology data. Results:A total of 122 patients underwent PD. There was a female predominance with a male to female ratio of 0.84. Comorbidities were documented in 58 % patients. The mean age was 68 yrs. Jaundice was the most common presenting symptom in 68%. Preoperative ERCP with stenting was done in 41% patients. The mean operative time was 237 mins. The mean estimated blood loss was 480 ml. 32% underwent a pylorus preserving PD 35% patients received intraoperative blood transfusions, 20% received blood in the postoperative period. The mean length hospital stay was 13 days. Thirty day mortality was 3.2% and overall morbidity was 49 %. Reoperation was necessary in 5 % patients, mainly for wound problems.64% patients underwent PD for malignancy, of which 39% patients had carcinoma of the pancreatic head.44%patients underwent PD for benign disorders. The mean number of nodes retrieved was 15. Conclusions: PD can be performed at a NUTCC with results that meet and exceed nationally reported outcomes and benchmarks. The key elements to success in this endeavor include an incorporation of a multidisciplinary team for management of the PD patient.
*p <0.01 vs control W1529 Pancreatic Cancer (CAP) Actual Survival At Ten or More Years; Does Therapy Influence Survival? Avram Cooperman, Howard W. Bruckner, Harry Snady, Michael G. Wayne, Franklin Kasmin, Seth A. Cohen, Hillel S. Hammerman, Jerome H. Siegel
W1532 Bridge to Surgery Using Partially Covered Self Expandable Metal Stents (PCMS) in Malignant Biliary Stricture: An Acceptable Paradigm? George H. Pop, James A. Richter, Bryan Sauer, Michele E. Rehan, Henry C. Ho, Melissa S. Phillips, Kristi Ellen, Todd W. Bauer, Reid B. Adams, Vanessa M. Shami, Michel Kahaleh
Actual 10+ yr survival with CaP is uncommon. Most 5 yr survivors die of disease before the 7th yr. One review noted only 13, 10+ yr survivors. Between 1994-2001, 180 Pancreaticoduodenal resections (PDR) were done; 80 for CaP. Thirteen survived 5 or more years (17%). Ten survive(d) ten + yrs (13%). Two others are well at 83, 91 months. One pt. died of metastases from CaP or a subsequent lung cancer at 84 months. 5 other patients treated prior to 1994 survive(d)10+ years. Three treatments were used; surg alone (S), surgery & adjuvant therapy (S&A), or neoadjuvant therapy & surgery (N+S). Of all 10+ yr survivors 2 had (S); 5 (S+A), and 8 (N+S). Two pts survive at 83 & 91 mos after S+A. In this series nearly all 5+ yr survivors of CaP, live(d) 10+ yrs. Nearly all had intense multi-drug chemotherapy; 8/15 10+ yr survivors had unresectable CaP initially and underwent surgery after neoadjuvant therapy . Conclusions: Most 10 yr survivors had neo-adjuvant treatment prior to PDR. The anticipated mortality from metastases was not seen 5+ yrs after surgery, in S+A, or N+S (13/15 survivors). Additional studies, re. N+S are warranted to determine if this improves resectability & prolongs survival with CaP.
SSAT Abstracts
Background and Aim: PCMS (Wallstent, Boston Scientific) have been extensively used for palliation of malignant distal biliary strictures. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS who were subsequently referred for surgery. Methods: Our prospectively established pancreatico-biliary database was retrospectively analyzed, to retrieve all patients undergoing PCMS placement for malignant biliary stricture and then undergoing surgery. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of hospitalization post op and follow-up post surgery were recorded Results: 27 patients (21 men, median age of 66 years, range 39-82) received PCMS (Table 1). Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other cancers (n=4). Median time between stenting and surgery was 32 days (range: 6569). Median hospitalization following surgery was 7 days (0-40). All patients underwent exploratory laparoscopy, followed in 8 (30%) by a Whipple procedure with uneventful
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W1530 Diagnostic Accuracy of EUS in Detecting Pancreatic Neuroendocrine Tumors: A Meta-Analysis and Systematic Review Srinivas R. Puli, Matthew L. Bechtold, Jyotsna BK Reddy, Srinivas R. Bapoje, Mainor R. Antillon, William R. Brugge Background: The published data on accuracy of Endoscopic Ultrasound to detect pancreatic neuroendocrine tumors (PNT) has been varied. Detection of PNT is critical from a therapeutic stand point. Aim: To evaluate the accuracy of EUS in detecting PNT. Method: Study Selection Criteria: Only EUS studies confirmed by surgery or appropriate follow-up were selected. Only studies from which a 2 X 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing & allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. 2 X 2 tables were constructed with the data extracted from each study. Statistical Method: Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and by the DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights. Results: Initial search identified 2610 reference articles, of these 140 relevant articles were selected and reviewed. Data was extracted from 13 studies (N = 456) which met the inclusion criteria. Pooled sensitivity of EUS in detecting a PNT was 87.2% (95% CI: 82.2 - 91.2). EUS had a pooled specificity of 98.0% (95% CI: 94.3 - 99.6). The positive likelihood ratio of EUS was 11.1 (95% CI: 5.34 - 22.8) and negative likelihood ratio was 0.17 (95% CI: 0.13 - 0.24). The diagnostic odds ratio, the odds of having anatomic PNT in positive as compared to negative EUS studies was 94.7 (95% CI: 37.9 - 236.1). All the pooled estimates calculated by fixed and random effect models were similar. SROC curves showed an area under the curve of 0.94. Begg-Mazumdar bias indicator for publication bias gave a Kendall's tau value of 0.31 (p = 0.16), indication no publication bias. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. Conclusions: EUS has excellent sensitivity and specificity to detect PNT. EUS should be strongly considered for evaluation of PNT.
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SSAT Abstracts
Colectomy in Necrotizing Pancreatitis Portends a Complex Clinical Course Hayder H. Al-Azzawi, Angela M. Bermes, Heidi Kuhlenschmidt, Thomas J. Howard, Eric A. Wiebke, Henry A. Pitt, Attila Nakeeb, C. Max Schmidt, Keith D. Lillemoe, Nicholas J. Zyromski Introduction: Necrotizing pancreatitis (NP) is a severe inflammatory process involving the pancreas, peripancreatic soft tissue, and mesenteric fat particularly in the transverse mesocolon and the root of the small bowel mesentery. Mesocolic involvement with this necrotizing process can directly and indirectly affect the blood supply to the colon resulting in ischemia, end-organ damage, and the need for colectomy. The aim of this study was to define the incidence and clinical outcome of patients requiring colectomy is the setting of NP. Methods: Records of all patients with acute pancreatitis (ICD-9 code 577.0) admitted to Indiana University Hospital between January 1996 and April 2008 were crossed-referenced with radiographic imaging data to identify patients with NP. Of 340 patients with NP, 37 patients required colectomy (Colectomy group). These patients were matched for age, gender, body mass index (BMI), and medical co-morbidities (diabetes, hypertension, coronary artery disease, pulmonary disease) with 37 NP patients who did not require colectomy (control group). Indications for and timing of colectomy were recorded, and clinical outcomes of the two groups were compared. Data were analyzed with Student's t-test, Chi square and Fisher exact test. P value of less than 0.05 was considered statistically significant. Results: Eleven percent of all patients with NP (37/340) required colectomy. Indications for colectomy were: ischemia (20, 54%); fistula (8, 22%); intraoperative perforation (4, 11%); and other (5, 14%). Six percent of patients had colectomy prior to debridement, 40% required colectomy during initial pancreatic debridement, and 54% required the colectomy following the initial debridement. Outcomes for controls and colectomy patients are shown in the Table. Conclusions: These data show that: 1) colonic involvement is common in the setting of necrotizing pancreatitis, 2) ischemia is the most common indication for colectomy, and 3) patients requiring colectomy have significantly longer length of stay, readmission rate, and number of operations compared to those who did not require colectomy. In the setting of necrotizing pancreatitis, colectomy is common and portends a complex clinical course; clinicians must have a high index of suspicion for as well as an appreciation of the consequences of colonic involvement.
W1531 Pancreaticoduodenectomy (PD) At a Non University Tertiary Care Center (Nutcc): Outcomes and Feasibility Amit S. Khithani, David E. Curtis, Christos A. Galanopoulos, D. Rohan Jeyarajah Background: A successful outcome to PD is attributed to a high volume at University Centers. Over the past decade, an association between volume and outcome in PD has been firmly established. Despite studies which suggest that community centers can perform these procedures with favorable outcomes, the underlying issue of where these complex surgeries should be performed is still debated. This paper examines the outcomes of PD in a NUTCC. Methods: Medical records of 122 patients, who underwent PD by a single surgeon between September 2005 to August 2008 at a high volume NUTCC, were analyzed. The patients were managed by a multidisciplinary team consisting of a gastroenterologist, surgeon, hepatobiliary fellow, general surgery residents, ICU nursing staff, operating room team, and a surgery floor nursing staff. The records were reviewed with respect to preoperative and postoperative data, thirty-day mortality, morbidity and histopathology data. Results:A total of 122 patients underwent PD. There was a female predominance with a male to female ratio of 0.84. Comorbidities were documented in 58 % patients. The mean age was 68 yrs. Jaundice was the most common presenting symptom in 68%. Preoperative ERCP with stenting was done in 41% patients. The mean operative time was 237 mins. The mean estimated blood loss was 480 ml. 32% underwent a pylorus preserving PD 35% patients received intraoperative blood transfusions, 20% received blood in the postoperative period. The mean length hospital stay was 13 days. Thirty day mortality was 3.2% and overall morbidity was 49 %. Reoperation was necessary in 5 % patients, mainly for wound problems.64% patients underwent PD for malignancy, of which 39% patients had carcinoma of the pancreatic head.44%patients underwent PD for benign disorders. The mean number of nodes retrieved was 15. Conclusions: PD can be performed at a NUTCC with results that meet and exceed nationally reported outcomes and benchmarks. The key elements to success in this endeavor include an incorporation of a multidisciplinary team for management of the PD patient.
*p <0.01 vs control W1529 Pancreatic Cancer (CAP) Actual Survival At Ten or More Years; Does Therapy Influence Survival? Avram Cooperman, Howard W. Bruckner, Harry Snady, Michael G. Wayne, Franklin Kasmin, Seth A. Cohen, Hillel S. Hammerman, Jerome H. Siegel
W1532 Bridge to Surgery Using Partially Covered Self Expandable Metal Stents (PCMS) in Malignant Biliary Stricture: An Acceptable Paradigm? George H. Pop, James A. Richter, Bryan Sauer, Michele E. Rehan, Henry C. Ho, Melissa S. Phillips, Kristi Ellen, Todd W. Bauer, Reid B. Adams, Vanessa M. Shami, Michel Kahaleh
Actual 10+ yr survival with CaP is uncommon. Most 5 yr survivors die of disease before the 7th yr. One review noted only 13, 10+ yr survivors. Between 1994-2001, 180 Pancreaticoduodenal resections (PDR) were done; 80 for CaP. Thirteen survived 5 or more years (17%). Ten survive(d) ten + yrs (13%). Two others are well at 83, 91 months. One pt. died of metastases from CaP or a subsequent lung cancer at 84 months. 5 other patients treated prior to 1994 survive(d)10+ years. Three treatments were used; surg alone (S), surgery & adjuvant therapy (S&A), or neoadjuvant therapy & surgery (N+S). Of all 10+ yr survivors 2 had (S); 5 (S+A), and 8 (N+S). Two pts survive at 83 & 91 mos after S+A. In this series nearly all 5+ yr survivors of CaP, live(d) 10+ yrs. Nearly all had intense multi-drug chemotherapy; 8/15 10+ yr survivors had unresectable CaP initially and underwent surgery after neoadjuvant therapy . Conclusions: Most 10 yr survivors had neo-adjuvant treatment prior to PDR. The anticipated mortality from metastases was not seen 5+ yrs after surgery, in S+A, or N+S (13/15 survivors). Additional studies, re. N+S are warranted to determine if this improves resectability & prolongs survival with CaP.
SSAT Abstracts
Background and Aim: PCMS (Wallstent, Boston Scientific) have been extensively used for palliation of malignant distal biliary strictures. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS who were subsequently referred for surgery. Methods: Our prospectively established pancreatico-biliary database was retrospectively analyzed, to retrieve all patients undergoing PCMS placement for malignant biliary stricture and then undergoing surgery. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of hospitalization post op and follow-up post surgery were recorded Results: 27 patients (21 men, median age of 66 years, range 39-82) received PCMS (Table 1). Indications for placement included biliary stricture related to pancreatic cancer (n=23) or other cancers (n=4). Median time between stenting and surgery was 32 days (range: 6569). Median hospitalization following surgery was 7 days (0-40). All patients underwent exploratory laparoscopy, followed in 8 (30%) by a Whipple procedure with uneventful
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