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W1676 The Role of Procalcitonin in the Early Diagnosis of Postoperative Pancreatic Fistula After Pancreatic Resection
resection performed (pylorus-preserving PD or standard PD, with or without vascular resection) OR time, estimated blood loss and transfusions, tumor size and histology, lymph node status, postoperative hematocrit and leukocyte count and postoperative NSAID use. We defined DGE as failure to tolerate a regular diet by postoperative day seven. Data was analyzed with alpha=0.05 using Fisher exact test for categorical variables and Mann-Whitney U test for continuous variables. RESULTS: A total of 114 patients with DGE were compared with 134 patients without DGE. Patients who suffered DGE were significantly more likely to have smaller tumors (p=0.015) and fewer positive lymph nodes (p=0.025), while patients without DGE were more likely to have received preoperative chemotherapy (p= 0.005) or preoperative radiation (p= 0.010). A possible explanation for these results is that patients with malignant disease have less normal functioning pancreatic parenchyma and are consequently less at risk for digestive symptoms resulting from pancreatic injury and inflammation. In addition, DGE was associated with an infection during hospitalization (p=0.008.) Hematocrit on the third postoperative day was significantly lower (p=0.019) for patients who experienced DGE , excluding patients who experienced post-operative bleeding. We hypothesize that DGE patients experienced more postoperative third space sequestration and bowel edema, resulting in greater hemodilution when sequestered fluid redistributed back into the vasculature. CONCLUSIONS: Contrary to our expectations, patients with smaller tumors and benign disease were more likely to experience DGE than patients with more advanced, malignant disease. As our ability to diagnose premalignant lesions improves, there will likely be more PD performed for benign disease, with a subsequent increase in the frequency of patients with DGE.
initial stent placement and stent replacement was 70.8 days (± 32). Median survival time for pat. treated only with endoscopic stent implantation (Group 1) was significantly (p<0.001) shorter than that of pat. who were first stented and subsequently treated with hepaticojejunostomy (Group 2) (5.1 vs. 9.4 months). None of the pat. who underwent surgery were rehospitalized for recurrent jaundice. In conclusion, we found that surgical hepaticojejunostomy can be performed with adequate results and an acceptable complications. Considering that biliary stents need to be replaced (mean time to stent replacement 70 days),management by hepaticojejunostomy may be superior to endoscopic stenting, especially for pat. with a life expectancy of greater than 6 months. The operative approach should be especially favored in patients whose disease is first found to be unresectable in the intraoperative setting. W1676 The Role of Procalcitonin in the Early Diagnosis of Postoperative Pancreatic Fistula After Pancreatic Resection Dominique Suelberg, Franziska Beuschel, Christiane Kotschenreuther, Torsten Herzog, Ansgar M. Chromik, Waldemar Uhl Background: Postoperative pancreatic fistula (PF) are frequent major complications after pancreatic surgery. Detection of amylase in drainage-fluid and serum-CRP are well established diagnostic parameters. The importance of Procalcitonin (PCT) in the diagnosis of PF remains to be elucidated. Aim of the study was therefore, to evaluate of PCT in the diagnostic of PF and major complications following pancreatic surgery (PS). Methods: All patients with PS were prospectively collected from Jan. 2009 - Sept. 2009. Serum-PCT, -CRP as well as amylase in drainage-fluid were measured every second postoperative day. Following parameters were analyzed: diagnosis, age, operation, complications (major, minor, secondary), PF (grade A, B and C; according to the ISGPF-definition). Results: During the observation period, n = 107 pat. received PS and developed n = 15 minor, n = 12 major and n = 3 secondary complications. Among major complications, n = 9 PF (8.9%) were diagnosed in the drainage-fluid, thereof n = 3 grade A, n = 2 grade B and n = 4 grade C. CRP and PCT were significantly increased in pat. with PF and other major complications after the 10th postop. day (p ≤ 0.001; Anova). In the detection of PF, the ROC-Analysis for PCT revealed an AUC of 0.736 with a sensitivity of 83% and a specificity of 72% for the cut-off-value of 17.8ng/ml. For CRP the AUC was 0.855 with a sensitivity of 86% and a specificity of 83% for the cut-off-value of 77.1mg/l. For the detection of major complications, the ROC-Analysis of PCT resulted in an AUC of 0.977 with a sensitivity of 100% and a specificity of 93% for the cut-off-value of 20.9 ng/l. For CRP, the AUC was 0.770 with a sensitivity of 73% and a specificity of 84% for the cut-off-value of 77.1 mg/l. Conclusion: Our results demonstrate that PCT is equivalent with CRP in the early diagnosis of postoperative pancreatic fistula, however superior in the diagnosis of all major complications following PS. Therefore we advocate the routine use of PCT and CRP following PS.
W1674 Diagnostic Laparoscopy for Pancreatic Cancer in an MRI Driven Practice: What's it Worth? Elliot Tapper, Bobby Kalb, Diego R. Martin, David Kooby, N. Volkan Adsay, Juan M. Sarmiento Introduction: For many patients with pancreatic cancer, CT is inadequate in determining unresectability; 10-48% of patients deemed resectable receive an unnecessary laparotomy. Accordingly, many groups have studied the role for diagnostic laparoscopy (DL) though none have evaluated it in an MRI driven practice. Methods: All MRI's administered for suspected pancreatic cancer between December 2004 and 2008 were evaluated. Radiographic diagnoses were prospective judged resectability based on the presence of metastases and relationship of the tumor with the surrounding vasculature. Unresectable disease received endoscopic biliary and duodenal stenting. Resectable and borderline disease received Whipples and double bypasses if unresectable intraoperatively. We performed a decision analysis for the cost-effectiveness of incorporating DL. We queried our billing database to render average costs for all inpatients with pancreatic cancer who received Whipples, doublebypasses and double-stenting procedures. We did not include professional fees. The marginal cost of DL was derived from the itemized costs of the materials, space and ancillary staff, presuming routine utilization, no missed metastases, and no complications. Results: Preoperative MRI deemed 94 patients' tumors resectable; 86 agreed to a laparotomy. Six patients were found to have metastases intraoperatively and 15 patients had unresectable disease (vascular involvement or benign pancreatitis) and thus received double-bypass procedures for which the average total cost of the hospitalization was $21,957.18. Whipples were provided to 65 patients at an average cost of $26,122.43. DL would thus be offered to 86 patients. For the 6 patients with metastases, it would be the only operation ($3604.07). This would be added to the cost of endoscopic stenting procedures, which results in an average total cost of hospitalization of $18,451.41. For the patients without metastases, the marginal cost of DL before a laparotomy would be $2651.71, which we added to the total costs above. Conclusions: For DL to be cost-effective, it would have to increase the rate at which we diverted patients to the GI lab for palliative stenting. In our model, DL would increase our costs by $191,072.18, equivalent to the total cost of hospitalization for treating 7 patients with Whipple procedures. Given our rate of missed metastases - 6% - and presuming perfect yield from DL, 15 patients would have unnecessary DL for every patient with occult metastases. For DL to be cost-effective, its intraoperative yield would have to be 70%.
W1677
Background: Determination of fecal elastase-1 is well established in the diagnosis of exocrine pancreatic insufficiency (EPI). However, accelerated gastro-intestinal passage could result in false positive results. Serum-beta-Carotin is an indirect parameter to measure the malassimilation of lipids, but is not determined in the diagnostic of EPI yet. Aim of the study was to evaluate the validity of Serum-beta-Carotin in the EPI-diagnostic pre- and postoperatively. Methods: All patients underwent pancreatic surgery were prospectively collected from Jan.2009-Sept. 2009. Fecal Elastase-1, serum-beta-Carotin and clinical features were analyzed preoperatively and 1 week, 3 and 6 month postoperatively together with surgical procedure and diagnosis. Ergebnisse: During the observation period 125 patients underwent pancreatic surgery. The results of preoperative fecal elastase-1 and serum-beta-Carotin showed significant lower values in pat. with chronic pancreatitis (CP) in contrast to pat. with benign and malign tumors (p≤0.005; Anova). One week postoperatively, serum-beta-Carotin was significantly decreased in pat. after pancreatic head resection (PHR) in contrast to pat. after left pancreatic resection (LPR) or bypass-procedures (BP) (p≤0.05; Anova). In contrast, one week postoperatively fecal elastase-1 was decreased in all groups regardless of the surgical procedure without any differences in the clinical features. The follow-up revealed reduced values for both parameters in pat. with PHR compared to pat. with LPR or BP. Overall, postoperative serum-beta-Carotin was more frequently in normal range than the values of fecal elastase-1 in patients without clinical signs of exocrine insufficiency. Conclusion: Our data demonstrate that serum-beta-Carotin is equivalent with fecal elastase-1 in the diagnosis of exocrine pancreatic insufficiency following pancreatic surgery. Moreover, the validity of serum-beta-Carotin seems to be superior to fecal Elastase-1.
W1675 Palliative Treatment of Obstructive Jaundice in Patients With Carcinoma of the Pancreatic Head or Distal Biliary Tree: Endoscopic Stent Placement vs. Hepaticojejunostomy Marius Distler, Stephan Kersting, Felix Rückert, Frank Dobrowolski, Stephan Miehlke, Robert Grützmann, Hans D. Saeger Only 20-30% of patients with malignant neoplasms of the pancreatic head or distal biliary tree can be cured by surgery. Palliative procedures play an important role in their management. We sought to determine if surgical or non-surgical management was the most appropriate therapy for the treatment of obstructive jaundice in the palliative setting. We retrospectively analyzed the outcomes of our pat. with regard to method of treatment and complications as well as the survival times.The pat. were divided into three groups based on treatment. Pat. in Group 1 underwent endoscopic bile duct stent placement.Group 2 underwent preoperative stenting followed by laparotomy with curative intent. When pat. were found to have unresectable or metastatic disease intraoperatively, a palliative hepaticojejunostomy was performed. Moreover,hepaticojejunostomy was performed in pat. with stent failure and unresectable disease.Group 3 underwent hepaticojejunostomy without preoperative stenting. For pat. in Group 1, we determined the frequency of rehospitalization for recurrent jaundice. In these pat., a new endoprosthesis was placed when possible.Over an 8-year period, 342 pat. (151women, 191men) with adenocarcinoma of the pancreatic head or distal biliary tree received palliative treatment. Median age was 63ys (range 36-89.Symptoms of obstructive jaundice were exhibited by 26 pat.(76%). In 14 pat., none of the aforementioned procedures were performed. The remaining 247 pat. were divided into the groups described: Group 1(n=138,56%);Group 2(n= 68,28%);Group 3(n=41,16%).The 30-day mortality rates for pat. in Groups 1,2,and 3 were 2.2%,0%,and 2.4%. The morbidity rates were 6.5%,19.1%,and 14.6%, respectively. For the pat. treated with endoscopic stenting, the mean interval between
W1678 Will Ki-67 Predict Lymph Node Status in Pancreatic Endocrine Tumors? Derick Christian, Amit S. Khithani, A. Joe Saad, Joshua G. Barton, Jeffrey D. Linder, Prabhleen Chahal, Riteshkumar Patel, D. Rohan Jeyarajah Background: Pancreatic endocrine tumors (PET) are rare and exhibit an uncertain biological behavior. Many studies have suggested that certain tumor markers and factors such as size and mitotic count may predict the behavior of PET. However the role of Ki-67 proliferative index is much debated. Aims and objectives: To evaluate the significance of tumor size and Ki-67 proliferative index with lymph node status in PET. Methods: Records of patients who underwent surgical resection for PET between September 2005 to September 2009 by a single surgeon were reviewed. Pathologic variables were tumor size, lymph node status and ki-67 proliferative index. Results: Of the 248 pancreatic resections performed at our Non University Tertiary care center (NUTCC), a total of 24 pancreatic resections were performed for PET. Of these, 18 (75%) underwent distal pancreatectomy and 6 (24%) underwent pancreatoduodenectomy. PET was limited to the pancreas or regional lymph nodes in 23
S-901
SSAT Abstracts
SSAT Abstracts
Diagnostic of Exocrine Pancreatic Insufficiency - Fecal Elastase-1 vs. serumbeta-Carotin Dominique Suelberg, Johanna Krause, Orlin Belyaev, Ansgar M. Chromik, Waldemar Uhl
initial stent placement and stent replacement was 70.8 days (± 32). Median survival time for pat. treated only with endoscopic stent implantation (Group 1) was significantly (p<0.001) shorter than that of pat. who were first stented and subsequently treated with hepaticojejunostomy (Group 2) (5.1 vs. 9.4 months). None of the pat. who underwent surgery were rehospitalized for recurrent jaundice. In conclusion, we found that surgical hepaticojejunostomy can be performed with adequate results and an acceptable complications. Considering that biliary stents need to be replaced (mean time to stent replacement 70 days),management by hepaticojejunostomy may be superior to endoscopic stenting, especially for pat. with a life expectancy of greater than 6 months. The operative approach should be especially favored in patients whose disease is first found to be unresectable in the intraoperative setting. W1676 The Role of Procalcitonin in the Early Diagnosis of Postoperative Pancreatic Fistula After Pancreatic Resection Dominique Suelberg, Franziska Beuschel, Christiane Kotschenreuther, Torsten Herzog, Ansgar M. Chromik, Waldemar Uhl Background: Postoperative pancreatic fistula (PF) are frequent major complications after pancreatic surgery. Detection of amylase in drainage-fluid and serum-CRP are well established diagnostic parameters. The importance of Procalcitonin (PCT) in the diagnosis of PF remains to be elucidated. Aim of the study was therefore, to evaluate of PCT in the diagnostic of PF and major complications following pancreatic surgery (PS). Methods: All patients with PS were prospectively collected from Jan. 2009 - Sept. 2009. Serum-PCT, -CRP as well as amylase in drainage-fluid were measured every second postoperative day. Following parameters were analyzed: diagnosis, age, operation, complications (major, minor, secondary), PF (grade A, B and C; according to the ISGPF-definition). Results: During the observation period, n = 107 pat. received PS and developed n = 15 minor, n = 12 major and n = 3 secondary complications. Among major complications, n = 9 PF (8.9%) were diagnosed in the drainage-fluid, thereof n = 3 grade A, n = 2 grade B and n = 4 grade C. CRP and PCT were significantly increased in pat. with PF and other major complications after the 10th postop. day (p ≤ 0.001; Anova). In the detection of PF, the ROC-Analysis for PCT revealed an AUC of 0.736 with a sensitivity of 83% and a specificity of 72% for the cut-off-value of 17.8ng/ml. For CRP the AUC was 0.855 with a sensitivity of 86% and a specificity of 83% for the cut-off-value of 77.1mg/l. For the detection of major complications, the ROC-Analysis of PCT resulted in an AUC of 0.977 with a sensitivity of 100% and a specificity of 93% for the cut-off-value of 20.9 ng/l. For CRP, the AUC was 0.770 with a sensitivity of 73% and a specificity of 84% for the cut-off-value of 77.1 mg/l. Conclusion: Our results demonstrate that PCT is equivalent with CRP in the early diagnosis of postoperative pancreatic fistula, however superior in the diagnosis of all major complications following PS. Therefore we advocate the routine use of PCT and CRP following PS.
W1674 Diagnostic Laparoscopy for Pancreatic Cancer in an MRI Driven Practice: What's it Worth? Elliot Tapper, Bobby Kalb, Diego R. Martin, David Kooby, N. Volkan Adsay, Juan M. Sarmiento Introduction: For many patients with pancreatic cancer, CT is inadequate in determining unresectability; 10-48% of patients deemed resectable receive an unnecessary laparotomy. Accordingly, many groups have studied the role for diagnostic laparoscopy (DL) though none have evaluated it in an MRI driven practice. Methods: All MRI's administered for suspected pancreatic cancer between December 2004 and 2008 were evaluated. Radiographic diagnoses were prospective judged resectability based on the presence of metastases and relationship of the tumor with the surrounding vasculature. Unresectable disease received endoscopic biliary and duodenal stenting. Resectable and borderline disease received Whipples and double bypasses if unresectable intraoperatively. We performed a decision analysis for the cost-effectiveness of incorporating DL. We queried our billing database to render average costs for all inpatients with pancreatic cancer who received Whipples, doublebypasses and double-stenting procedures. We did not include professional fees. The marginal cost of DL was derived from the itemized costs of the materials, space and ancillary staff, presuming routine utilization, no missed metastases, and no complications. Results: Preoperative MRI deemed 94 patients' tumors resectable; 86 agreed to a laparotomy. Six patients were found to have metastases intraoperatively and 15 patients had unresectable disease (vascular involvement or benign pancreatitis) and thus received double-bypass procedures for which the average total cost of the hospitalization was $21,957.18. Whipples were provided to 65 patients at an average cost of $26,122.43. DL would thus be offered to 86 patients. For the 6 patients with metastases, it would be the only operation ($3604.07). This would be added to the cost of endoscopic stenting procedures, which results in an average total cost of hospitalization of $18,451.41. For the patients without metastases, the marginal cost of DL before a laparotomy would be $2651.71, which we added to the total costs above. Conclusions: For DL to be cost-effective, it would have to increase the rate at which we diverted patients to the GI lab for palliative stenting. In our model, DL would increase our costs by $191,072.18, equivalent to the total cost of hospitalization for treating 7 patients with Whipple procedures. Given our rate of missed metastases - 6% - and presuming perfect yield from DL, 15 patients would have unnecessary DL for every patient with occult metastases. For DL to be cost-effective, its intraoperative yield would have to be 70%.
W1677
Background: Determination of fecal elastase-1 is well established in the diagnosis of exocrine pancreatic insufficiency (EPI). However, accelerated gastro-intestinal passage could result in false positive results. Serum-beta-Carotin is an indirect parameter to measure the malassimilation of lipids, but is not determined in the diagnostic of EPI yet. Aim of the study was to evaluate the validity of Serum-beta-Carotin in the EPI-diagnostic pre- and postoperatively. Methods: All patients underwent pancreatic surgery were prospectively collected from Jan.2009-Sept. 2009. Fecal Elastase-1, serum-beta-Carotin and clinical features were analyzed preoperatively and 1 week, 3 and 6 month postoperatively together with surgical procedure and diagnosis. Ergebnisse: During the observation period 125 patients underwent pancreatic surgery. The results of preoperative fecal elastase-1 and serum-beta-Carotin showed significant lower values in pat. with chronic pancreatitis (CP) in contrast to pat. with benign and malign tumors (p≤0.005; Anova). One week postoperatively, serum-beta-Carotin was significantly decreased in pat. after pancreatic head resection (PHR) in contrast to pat. after left pancreatic resection (LPR) or bypass-procedures (BP) (p≤0.05; Anova). In contrast, one week postoperatively fecal elastase-1 was decreased in all groups regardless of the surgical procedure without any differences in the clinical features. The follow-up revealed reduced values for both parameters in pat. with PHR compared to pat. with LPR or BP. Overall, postoperative serum-beta-Carotin was more frequently in normal range than the values of fecal elastase-1 in patients without clinical signs of exocrine insufficiency. Conclusion: Our data demonstrate that serum-beta-Carotin is equivalent with fecal elastase-1 in the diagnosis of exocrine pancreatic insufficiency following pancreatic surgery. Moreover, the validity of serum-beta-Carotin seems to be superior to fecal Elastase-1.
W1675 Palliative Treatment of Obstructive Jaundice in Patients With Carcinoma of the Pancreatic Head or Distal Biliary Tree: Endoscopic Stent Placement vs. Hepaticojejunostomy Marius Distler, Stephan Kersting, Felix Rückert, Frank Dobrowolski, Stephan Miehlke, Robert Grützmann, Hans D. Saeger Only 20-30% of patients with malignant neoplasms of the pancreatic head or distal biliary tree can be cured by surgery. Palliative procedures play an important role in their management. We sought to determine if surgical or non-surgical management was the most appropriate therapy for the treatment of obstructive jaundice in the palliative setting. We retrospectively analyzed the outcomes of our pat. with regard to method of treatment and complications as well as the survival times.The pat. were divided into three groups based on treatment. Pat. in Group 1 underwent endoscopic bile duct stent placement.Group 2 underwent preoperative stenting followed by laparotomy with curative intent. When pat. were found to have unresectable or metastatic disease intraoperatively, a palliative hepaticojejunostomy was performed. Moreover,hepaticojejunostomy was performed in pat. with stent failure and unresectable disease.Group 3 underwent hepaticojejunostomy without preoperative stenting. For pat. in Group 1, we determined the frequency of rehospitalization for recurrent jaundice. In these pat., a new endoprosthesis was placed when possible.Over an 8-year period, 342 pat. (151women, 191men) with adenocarcinoma of the pancreatic head or distal biliary tree received palliative treatment. Median age was 63ys (range 36-89.Symptoms of obstructive jaundice were exhibited by 26 pat.(76%). In 14 pat., none of the aforementioned procedures were performed. The remaining 247 pat. were divided into the groups described: Group 1(n=138,56%);Group 2(n= 68,28%);Group 3(n=41,16%).The 30-day mortality rates for pat. in Groups 1,2,and 3 were 2.2%,0%,and 2.4%. The morbidity rates were 6.5%,19.1%,and 14.6%, respectively. For the pat. treated with endoscopic stenting, the mean interval between
W1678 Will Ki-67 Predict Lymph Node Status in Pancreatic Endocrine Tumors? Derick Christian, Amit S. Khithani, A. Joe Saad, Joshua G. Barton, Jeffrey D. Linder, Prabhleen Chahal, Riteshkumar Patel, D. Rohan Jeyarajah Background: Pancreatic endocrine tumors (PET) are rare and exhibit an uncertain biological behavior. Many studies have suggested that certain tumor markers and factors such as size and mitotic count may predict the behavior of PET. However the role of Ki-67 proliferative index is much debated. Aims and objectives: To evaluate the significance of tumor size and Ki-67 proliferative index with lymph node status in PET. Methods: Records of patients who underwent surgical resection for PET between September 2005 to September 2009 by a single surgeon were reviewed. Pathologic variables were tumor size, lymph node status and ki-67 proliferative index. Results: Of the 248 pancreatic resections performed at our Non University Tertiary care center (NUTCC), a total of 24 pancreatic resections were performed for PET. Of these, 18 (75%) underwent distal pancreatectomy and 6 (24%) underwent pancreatoduodenectomy. PET was limited to the pancreas or regional lymph nodes in 23
S-901
SSAT Abstracts
SSAT Abstracts
Diagnostic of Exocrine Pancreatic Insufficiency - Fecal Elastase-1 vs. serumbeta-Carotin Dominique Suelberg, Johanna Krause, Orlin Belyaev, Ansgar M. Chromik, Waldemar Uhl