QS30. Incorporation of Laparoscopic Distal Pancreatectomy into an Established Academic Pancreatic Surgery Practice - Early Experience

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS 281 undergo resection. Methods: Between July 1981 and March 2007, 335 patients with pancreatic cancer including 45 No. 16 (⫹) patients underwent extended radical surgery at the Department of Surgery II, Nagoya University. The overall survival rates and clinicopathological parameters were analyzed using univariate and multivariate analyses. Results: Although there was no significant difference in survival between the No.16 (⫹) patients and the unresectable cases, there were some long-term survivors among the No.16 (⫹) patients. Multivariate analysis of the No. 16 (⫹) patients identified age (ⱕ 59 years), tumor size (⬎ 4 cm), and pathologically confirmed portal invasion (pPV⫹) as independent prognostic factors. The survival of No. 16 (⫹) patients without these factors was significantly better than the unresectable cases. The survival of patients with only one metastatic para-aortic lymph node also was significantly better than the unresectable cases, and tended to be better than those with more than two metastatic nodes. Conclusions: No. 16 (⫹) pancreatic cancer patients with age ⱖ 60 years, tumor size ⱕ 4 cm, pPV(⫺), and involvement of only one para-aortic node may benefit from surgical resection. QS28. TIMING OF SURGERY IN PATIENTS WITH IPMN UNDER FOLLOW UP: DOES CHANGES IN DIAMETER OF CYSTIC LESIONS SUGGEST MALIGNANCY? Yoshihiko Sadakari, Jun Ienaga, Reiko Tanabe, Norihiro Sato, Shunichi Takahata, Hiroki Toma, Toshinaga Nabae, Masafumi Nakamura, Koji Yamaguchi, Masao Tanaka; Kyushu University, Fukuoka, Japan Backgrounds: The number of patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas is markedly increasing presumably due to increased awareness of this entity. Timing of surgery is of paramount importance in patients with IPMNs on follow-up for adequate treatment of possibly malignant IPMNs. Aims: (1) To analyze changes in the diameter over time of IPMNs on follow-up and examine the relationship to malignancy pathologically proven by resection after follow-up. (2) To determine the fate of small IPMNs recurring or remaining after pancreatectomy. Patients and Methods: From 1987 to 2005, 157 patients were diagnosed as having IPMN in our department. (1) 67 patients with IPMNs were not subjected to surgery due to the imaging findings of the cysts or the patients’ reluctance. Follow-up imaging data were available in 42 of them (4 main duct IPMN, 38 branch duct IPMN). We focused on the relationship between the existence of a mural nodule(s) and/or the change in the diameter of cystic lesions. The relationship between the rate of growth of the cysts and the pathological diagnosis of malignancy was examined in 15 patients (3 main duct IPMN, 12 branch duct IPMN) who underwent resection after a certain period of follow-up. The % increase of the cyst size per month was calculated using the following equation.

(2) In 105 patients with IPMN resected in our department, 7 patients had branch duct IPMNs remaining in the residual pancreas after pancreatectomy and 2 other patients had recurrent IPMNs. Results: (1) In the 42 patients followed-up by imaging studies 16 patients (38%) showed a recognizable increase in the size of IPMNs. All patients who had a mural nodule (8/42, 3 main duct type, 5 branch duct type) showed an increase in the diameter of the cyst. The frequency of the growth was higher in those with a mural nodule (8/8) than in 34 patients without mural nodule (8/34, p⬍0.05). In branch duct IPMNs the % increase of the cyst size per month was significantly greater in malignant cases (6.15⫾3.8(SD)%) than in benign cases (1.89⫾1.68%) (p⬍0.05), although the size of branch duct IPMNs and the existence of a mural nodule did not necessarily reflect malignant disease. (2) Both residual IPMNs (n⫽7) and recurrent IPMNs (n⫽2) were of branch duct type with a diameter less than 2 cm and demonstrated no growth during the mean follow up of

27.3 months. Conclusions: The rapid growth of IPMNs during follow-up may be a useful indicator of malignant transformation and hence the need of surgery. Branch duct IPMNs remaining or recurring in the residual pancreas after pancreatectomy with a diameter less than 2cm do not show rapid growth and can be observed at long intervals. QS29. IMPLEMENTATION OF A CRITICAL PATHWAY FOR DISTAL PANCREATECTOMY AT AN ACADEMIC INSTITUTION. Eugene P. Kennedy, Tyler R. Grenda, Patricia K. Sauter, Ernest L. Rosato, Karen A. Chojnacki, Francis E. Rosato, Jr., Bernadette C. Profeta, Cataldo Doria, Adam C. Berger, Charles J. Yeo; Thomas Jefferson University, Philadelphia, PA Objective: This study was designed to identify quantifiable parameters to track performance improvements brought about by the implementation of a critical pathway for complex alimentary tract surgery. Background: Distal pancreatectomy is a complex general surgical procedure performed in varying numbers at many academic institutions. Once associated with significant perioperative morbidity and mortality, multiple studies have now shown that this operation can be performed quite safely at high volume institutions that develop a particular expertise. Critical pathways are one of the key tools used to achieve consistently excellent outcomes as these institutions. It remains to be determined if implementation of a critical pathway at an academic institution with prior moderate experience with distal pancreatectomy will result in performance gains and improved outcomes. Methods: Between January 1, 2003 and August 15, 2007, 111 patients underwent distal pancreatectomy. 40 patients underwent resection during the 34 month period before the implementation of a critical pathway on October 15, 2005, and 71 during the 20 months after. Patients undergoing both open and laparoscopic procedures were included. Perioperative and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes. Results: The two groups were not significantly different with respect to age, sex, race, diagnosis, operative blood loss or mean operative duration. Post-operative length of hospital stay was significantly shorter when comparing pre to post pathway implementation as was the rate of readmission to the hospital after discharge. Hospital costs were also reduced.

Parameter Mean postoperative length of hospital stay (days) Rate of hospital readmission Percent performed laparoscopically Hospital costs

Pre pathway (n ⫽ 40)

Post pathway (n⫽71)

P value

10.2

6.8

0.046

25%

7%

0.027

0%

17%

0.003

$26,393

$22,806

0.46

Conclusion: Implementation of a critical pathway for a complex procedure can be demonstrated to improve short-term outcomes at an academic institution. This improvement can be quantified and tracked and has implications for better utilization of resources and overall cost containment while maintaining or improving upon an already high level of care. QS30. INCORPORATION OF LAPAROSCOPIC DISTAL PANCREATECTOMY INTO AN ESTABLISHED ACADEMIC PANCREATIC SURGERY PRACTICE - EARLY EXPERIENCE. Karen A. Chojnacki, Eugene P. Kennedy, Tyler R. Grenda, Patricia K. Sauter, Bernadette C. Profeta, Francis E. Rosato, Jr., Charles J. Yeo, Ernest L. Rosato; Thomas Jefferson University, Philadelphia, PA

282 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS Objective: This study was designed to assess the short term outcomes of patients undergoing laparoscopic distal pancreatectomy during the initiation phase at an academic medical center. Background: Distal pancreatectomy is one of an increasing number of complex alimentary tract procedures that are being performed using laparoscopy. Over a period of twenty years, laparoscopy has gone from an experimental approach for gallbladder surgery to a standard and often preferable technique. It holds the promise of less patient discomfort, shorter hospital stays, and faster recovery. As this technology is applied to additional, more complex procedures, outcomes must be quantified to assure that anticipated improvements do occur while current high standards of patient care are maintained. Methods: Between January 1, 2006 and August 15, 2007, a total of 69 patients underwent distal pancreatectomy at our institution. 13 patients underwent a laparoscopic procedure while 56 had a traditional open resection. Splenic preservation was practiced when clinically appropriate and technically feasible in both groups. Perioperative and postoperative parameters were analyzed retrospectively to identify those that could be used to track performance improvement and outcomes. Results: The two groups were similar with respect to age, sex, race, and operative duration. There was no change in the overall rate of perioperative morbidity. 60 day mortality was 0% in both groups. Estimated blood loss and post-operative length of hospital stay were both significantly reduced. There was a trend towards an increased rate of splenic preservation in the laparoscopic group. There was also an increase in pancreatic fistulas but this did not reach significance. Finally, there was a difference in final pathology, with significantly more patients undergoing distal pancreatectomy for pancreatic adenocarcinoma in the open group.

Parameter Mean postoperative length of hospital stay (days) Estimated blood loss (cc) Rate of splenic preservation Rate of postoperative fistula Diagnosis of adenocarcinoma

Open (n ⫽ 56) 7.0

549 12.5% 5.4%

43%

Laparoscopic (n ⫽ 13)

P value

5.4

0.016

215

0.001

30.8%

0.09

23.1%

0.06

7.7%

0.001

Conclusions: Laparoscopic distal pancreatectomy can be performed safely with outcomes at least equivalent to conventional open surgery. Currently, it is being offered to those patients with preoperative imaging indicative of potentially benign disease. Differences in postoperative fistula rate can be explained by differences in underlying pathology and associated pancreatic texture (benign lesions with soft pancreatic texture) and represent an area for improvements in techniques and technology. QS31. IMPACT OF OBESITY ON PERIOPERATIVE MORBIDITY AND MORTALITY FOLLOWING PANCREATICODUODENECTOMY (PD). Timothy Williams, Ernest L. Rosato, Eugene P. Kennedy, Karen A. Chojnacki, Cataldo Doria, Patricia Sauter, Charles Y. Yeo, Adam C. Berger; Thomas Jefferson University, Philadelphia, PA Introduction: Increasing body mass index (BMI) has been demonstrated to be an important factor predicting perioperative morbidity and mortality in patients undergoing numerous operations. BMI also appears to serve as a risk factor for several intra- abdominal malignancies, including pancreatic cancer. The aim of this study was determine the impact of BMI on morbidity and mortality in patients

undergoing PD. Methods: Data on BMI, operative details, and postoperative course were collected on 262 consecutive patients who underwent PD of whom, 241 had BMI data available. Complications were graded according to the previous published scale of Clavien et al [AnnSurg, 2006; 244:931-9]. Patients categorized as obese (BMI ⬎30 kg/m2) or overweight (BMI ⬍30, ⬎25) were compared with normal weight (BMI⬍25) patients using Student’s t-test. Results: At the time of surgery, 104 (43%) patients were normal weight, 71 (29%) were overweight, and 66 (27%) were obese. The majority (n⫽179, 74%) of operations were performed for malignancy. There were 5 perioperative deaths (2%): 2 patients in the normal weight group (1.9%), 1 in the overweight group (1.4%), and 2 in the obese group (3.0%). There was no significant difference in median operative times among the groups (358, 369, 432 minutes, respectively). Compared to the normal weight group, obese and overweight patients had significantly higher blood loss (median⫽650 vs. 500 ml, p⫽0.05, obese vs. normal; median⫽650 vs. 500 ml, p⫽0.03, overweight vs. normal). Furthermore, length of stay was significantly longer for obese patients (median⫽9.5 vs 7.5 days, p⫽0.01) compared to normal weight patients. However, there was no significant difference in length of stay between overweight and normal weight patients. Although there were no significant differences in overall complication rates across the groups, obese patients did have an increased rate of serious complications (Clavien grades 3 to 5) compared to overweight and normal patients (25.7% vs. 16.9% and 16.4%, respectively). Conclusions: Obese patients undergoing PD have a significantly increased blood loss and length of stay compared to normal weight subjects. Although obese patients have a higher incidence of serious perioperative/postoperative complications compared to overweight and normal weight patients, this should not preclude them from undergoing definitive surgery. QS32. VALUE OF PANCREATIC RESECTION FOR CANCER METASTATIC TO THE PANCREAS. Alex Daniel Sweeney, William E. Fisher, Meng-Fen Wu, Susan G. Hilsenbeck, F. Charles Brunicardi; Baylor College of Medicine, Houston, TX Background: The prognosis with pancreatic adenocarcinoma is the worst of all cancers with only 15% of patients presenting with resectable disease. Even among resected patients, the median survival is about 20 months and the five-year survival is at best 20% which has caused some clinicians to question the value of surgery. However, most clinicians agree that surgery offers the best palliation and the only chance for a meaningful increase in survival for patients with primary pancreatic adenocarcinoma. Cancer metastatic to the pancreas from other primary sites is uncommon. Cancer metastatic to the pancreas has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. Although it has been done, the value of pancreatic resection in this setting is even less clear than in primary pancreatic cancer. The purpose of this study was to examine the outcome of pancreatic resection for cancer metastatic to the pancreas. Methods: We review our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics including the site of the primary tumor, treatment and overall survival were summarized using descriptive statistics. Results: 219 total patients with pancreatic metastasis were analyzed. The most common presenting symptoms were jaundice (n ⫽ 32, 25.8%) and abdominal pain (n ⫽ 24, 19.4%), and the most common location was the head of the pancreas (n ⫽ 79, 42.0%). The primary tumor site was most commonly kidney (n ⫽ 155, 70.8%). Surgical resection was attempted in 176 of 219 patients with a median overall survival of 18 months, (range 0.6 to 133.8 months) regardless of tumor origin or time elapsed following diagnosis of the primary cancer. Conclusion: Survival after resection of cancer with isolated metastasis to the pancreas appears to be similar to survival after resection of primary