Distal Pancreatectomy with Celiac Axis Resection: What Are the Added Risks? Joal D. Beane, MD a, Michael G. House, MD a, Susan C. Pitt, MD c, E. Molly Kilbane a, Bruce L. Hall c, Abishek Parmar d, Taylor. S. Riall d, Henry A. Pitt MD b Departments of Surgery, a Indiana University School of Medicine, b Temple University School of Medicine, c Washington University School of Medicine, d University of Texas Medical Branch
DISCLOSURES Bruce Hall serves as a consultant for the American College of Surgeons National Surgical Quality Improvement Program
PANCREATIC CANCER Fifth leading cause of cancer deaths Resection provides the only chance for long-term survival Most present with advanced stage disease Conlon, Klimstra, and Brennan, Ann Surgery 1996 11% 53% 9% 28% Localized Regional Distant Unknown SEER 18 2004-2010
APPLEBY PROCEDURE 1953, Lyon Appleby for locally advanced gastric cancer Modified Appleby Procedure for locally advanced pancreatic cancer Baumgartner et al., J Gastrointest Surg, 2012
PREVIOUS EXPERIENCE Technically feasible Comparable morbidity to distal pancreatectomy Long term survivors Reduced pain compared to unresectable patients Increased mortality compared to historic controls AIM To report a multicenter series of modified Appleby procedures with a comparison group to determine the relative risks associated with this operation
PANCREATECTOMY DEMONSTRATION PROJECT 256 Health Insurance Portability and Accountability Act (HIPAA) compliant variables collected Gathered prospectively on 2805 patients undergoing pancreatic resection from 43 institutions median = 68 per institution, range 3 213 From November 2011 through December 2012
PANCREATECTOMY DEMONSTRATION PROJECT Preoperative: Jaundice, Biliary stent placement, Neoadjuvant chemotherapy/radiation Intraoperative: Type of operation, Operative approach, Pylorus-preservation, Pancreatic duct size, Pancreatic gland texture, Vascular resection, Method of reconstruction, Intraop drain placement (PJ/HJ, both) Postoperative: Drain management, Pancreatic fistula, Percutaneous drainage, Delayed gastric emptying Pathology: Malignant Type, T,N,M staging, Benign, Type Tumor size
PATIENT POPULATION DP DP+CAR p-value Total patients n 172 20 Age, y 66 (29-89) 64 (35-83) 0.71 Gender n, (%) Male 57 (33) 6 (30) 1.00 Female 115 (67) 14 (70) Race White 151 (88) 18 (90) 1.00 Black 12 (7) 1 (5) Other 9 (5) 1 (5) Body mass index, kg/m2 26.6 (16.1-42.6) 25.3 (20.0-38.0) 0.93 Albumin, g/dl 4.1 (3.1-5.3) 4.2 (3.3-4.8) 0.65 Creatinine, g/dl 0.80 (0.48-2.18) 0.80 (0.60-1.66) 0.49 ASA score 2.70+/-0.04 2.60 +/-0.11 0.47
SURGICAL PATHOLOGY DP DP+CAR p-value Adenocarcinoma 109 (61) 12 (60) 0.79 Endocrine Neoplasm 22 (12) 3 (15) IPMN 8 (4) 1 (5) Cystic neoplasm 11 (6) 1 (5) Other 22 (12) 3 (15) Neoadjuvant Therapy N (%) 9/109 (8) 3/12 (25) 0.10
OPERATIVE FACTORS DP DP+CAR p-value Total patients n 172 20 Operative Approach n (%) Open 129 (75) 18 (90) 0.17 Laparoscopic 36 (21) 2 (10) Robotic 7 (4) 0 (0) Gland Texture, n (%) Soft 45 (26) 7 (35) 0.16 Intermediate 5 (3) 1 (5) Hard 20 (12) 4 (20) Intraoperative drain 148 (86) 14 (70) 0.10 Operative time (range) 207 (66-581) 276 (164-617) <0.01
OPERATIVE FACTORS
POST OPERATIVE OUTCOMES DP DP+CAR p-value Total patients n 172 20 Percutaneous drain 15 (9) 1 (5) 1.00 Reoperation 3 (2) 2 (10) 0.09 DGE 8 (5) 0 (0) 1.00 Pancreatic Fistula 24 (15) 2 (10) 1.00 Length of stay, days 6 (2-43) 8 (4-14) 0.65 Overall Morbidity 74 (36) 9 (35) 1.00
POST OPERATIVE OUTCOMES
CONCLUSIONS Distal pancreatectomy with celiac axis resection is associated with increased operative time, postoperative acute kidney injury, and a 10% operative mortality The decision to offer an Appleby-type operation should be made with full disclosure of the increased risks
The authors would like to acknowledge the surgical clinical reviewers, surgeon champions, and pancreatic surgeons who participated in the Pancreatectomy Demonstration Project at the institutions listed below: Albany Medical Center Baptist Memphis Baylor University Baystate Medical Center Beth Israel Deaconess Boston Medical Center Brigham & Women s California Pacific Medical Center Cleveland Clinic Emory University Hospital University Pennsylvania Intermountain IU University IU Methodist Johns Hopkins Kaiser Walnut Leigh Valley Massachusetts General Mayo- Methodist Mayo-St Mary s Northwestern University Ohio State University Oregon Health Sciences Center Penn State University Providence Portland Sacred Heart Stanford University Tampa General Thomas Jefferson University University Alabama UC Irvine UC San Diego University Iowa Universit of Kentucky University of Minnesota Universityof Texas Medical Branch University of Virginia University of Wisconsin Vanderbilt University Wake Forest University Washington University St. Louis Winthrop University