317 Image-Guided Stereotactic Radiosurgery for Locally Advanced Pancreatic Adenocarcinoma Results of...
1
SSAT Abstracts (62%) were detected intraoperatively using a combination of palpation and intraoperative ultrasonography. rCR of one or more lesions was observed in 54 patients (31%). In 26 of these patients (48%), all rCR lesions were detected intraoperatively. In 28 patients, at least one lesion remained undetected intraoperatively. Of these, 23 (82%) had rCR sites that were left untreated. When comparing outcomes between patients with completely treated vs. untreated rCR sites, one year intrahepatic recurrence rate was higher in those with untreated rCR sites (32% vs 43%, p=0.05). However, the majority of these patients were able to undergo repeat surgical therapy upon recurrence and the overall survival was not statistically different between groups (3-yr OS 78% vs. 66%, p=0.64) Conclusions: In our study, we found rCR to occur commonly in patients undergoing preoperative chemotherapy for CRLM. However, the majority of these rCR lesions were indentified intraoperatively. Among those patients with undetected and untreated lesions, long-term outcome was good despite a high rate of intrahepatic recurrence. This finding may be related to favorable tumor biology, patient selection, and opportunities for salvage surgery. Therefore, aggressive surgical therapy should be considered in patients with marked response to chemotherapy, even when all rCR sites cannot be identified. 316 Radiation Dose From Computed Tomography in Patients With Necrotizing Pancreatitis: How Much is Too Much? Chad G. Ball, Camilo Correa-Gallego, Thomas J. Howard, Nicholas J. Zyromski, Michael House, Henry A. Pitt, Attila Nakeeb, C. Max Schmidt, Keith D. Lillemoe Objectives: Low-dose ionizing radiation from medical imaging has been indirectly associated with the subsequent development of solid cancers and leukemia. The non-invasive, gold standard modality for defining the initial extent, as well as the evolution of pancreatic necrosis is computed tomography (CT). The goals of this study were to identify: (1) the frequency of CT imaging, (2) the effective radiation dose per patient, (3) the rate of therapeutic intervention following CT, and (4) the mean direct hospital cost for these patients. Methods: All patients with necrotizing pancreatitis (2003-2007) treated at a tertiary care referral center were retrospectively analyzed. Standard statistical methodology was employed (significance = p<0.05). Results: Of the 1290 patients with acute pancreatitis, 238 (18%) were necrotizing (mean age = 53 years, hospital/ICU lengths of stay = 23/7 days, mortality = 9%). A median of 5 CT scans per patient (range = 1 to 28) were performed during the mean 8.3 month imaging interval. The average effective dose was 40 mSv per patient. This dose is equivalent to 2000 chest x-rays or 13.2-years of background radiation or a 1/250 increased risk of fatal cancer. Twenty percent of CT scans were followed by a direct intervention (199 interventional radiology, 118 operative, 12 endoscopic)(median = 1; range = 1 to 7) or change in management. This proportion increased to 31% in physiologically ill patients (p<0.05). MRI use did not have a CT-sparing effect (p>0.05). The modality of intervention did not alter the total number of, or the time intervals between, CT scans (p>0.05). Mean direct hospital costs increased in a stepwise manner parallel to the number of CT scans (R= 0.7, p<0.05). Conclusions: The effective radiation dose received by patients with necrotizing pancreatitis is significant. Changes in management following individual CT scans occur in a minority of patients (20% to 31%). The ubiquitous use of CT imaging in necrotizing pancreatitis raises substantial public health concerns and mandates a careful reassessment of its utility. 317 Image-Guided Stereotactic Radiosurgery for Locally Advanced Pancreatic Adenocarcinoma Results of First 85 Patients Mukund S. Didolkar, Cardella Coleman, Mark J. Brenner, Kyo U. Chu, Elizabeth Stanwyck, Airong Yu, Nicole Olexa, Nagaraj Neerchal BACKGROUND:Locally advanced unresectable pancreatic adenocarcinoma is characterized by poor survival despite chemotherapy and conventional radiation therapy. Recent advances in real time image-guided stereotactic radiosurgery (SRS) has made it possible to treat these cancers in 3-4 fractions followed by systemic chemotherapy. AIMS:1. To obtain local control of the disease. 2. To improve the survival of these unresectable patients. 3. To evaluate the toxicity of SRS. 4. Report results of the largest series from a single center. METHODS: Pancreatic SRS involves delivery of high doses of accurately targeted radiation given non- invasively in 2-4 fractions. We treated 85 consecutive patients with locally advanced and recurrent pancreatic adenocarcinoma from Feb 2004 to Aug 2009. Age range: 36-87, mean 65 years; Sex: males 50, females 35; Race: Caucasian 74, others 11; Histology: adenocarcin- oma 82, islet cell 2, other 1; T stage III/IV 81, TX 4; N stage N+ 39, NX 46; M stage M0 60, M1 25. No prior surgical resection in 70 patients, and 15 had local recurrence after surgical resection. 30 patients had progression of disease after prior conventional radiation therapy (RT). Location of the tumor: head 55, body and tail 30. All patients received gemcitabine-based chemotherapy regimen after SRS and some had additional chemotherapy before SRS. Median tumor volume 62 cc. PET/CT scans done in latter 43 patients showed an average SUV of 6.9. Pain score (1-10): <3 35, >4 50. SRS doses ranged from 15 to 30 Gy with the mean dose of 25.5 Gy delivered in 3 days (range 2-5 days) divided in equal fractions. Mean conformity index of 1.6 and mean isodose line of 80%. RESULTS: Tumor control: complete, partial, and stable disease was observed in 75 patients for the duration of 3-36 mos. Pain relief was noted in 45 of 50 patients. Most of the patients died of distant progression. SURVIVAL: Survival of was calculated by Kaplan-Meier method. Overall mean survival 23.9 mos and from SRS was 13.7 mos. For the group of 41 patients without prior surgical resection or conventional RT and no distant metasteses, the average survival was 17.7 mos from the diagnosis and 13.5 mos from SRS. TOXICITY:Grade III and IV duodenitis 8 (9.4%), gastritis 12 (14.1%), diarrhea 3 (3.5%), renal failure 1 (1.2%). 6 week post mortality was 0%. CONCLUSIONS: SRS for unresectable pancreatic carcinoma can be delivered in 3 fractions with minimal morbidity and a local tumor control rate of 88.2%.The survival is better compared to the reported results for advanced pancreatic cancer, specifically for the group of previously untreated patients with unresectable tumors. S-850 SSAT Abstracts 416 Single Incision Laparoscopic Liver Resection of Colorectal Liver Metastases Ameet G. Patel, Ajay P. Belgaumkar, Jojo James, Beth Murgatroyd, Kirstin Carswell We present a case of a 53 year old woman with a segment 2 colorectal liver metastasis. A left lateral sectionectomy was performed laparoscopically through a single umbilical incision. Hepatic parenchyma was divided using ultrasonic coagulation. Inflow and outflow pedicles were divided with laparoscopic staplers. The resected liver specimen was extracted by extending the umbilical incision to 5 cm length. The patient made an uncomplicated recovery. resuming oral diet and ambulation within 24 hours. The resection margin was clear. The aim of the video is to demonstrate the single incision approach is technically feasible and safe in selected patients requiring liver resection. 417 Single-Incision Laparoscopic Completion Proctectomy and Ileal J-Pouch-Anal Anastomosis in an 18 Year-Old Male With Ulcerative Colitis Refractory to Medical Therapy Alexandre Bouchard, Tonia M. Young-Fadok Laparoscopic-assisted completion proctectomy and ileal pouch-anal anastomosis (IPAA) is usually performed with multiple ports and an extraction incision. To further reduce the number of incisions and abdominal wall trauma, we used a single-incision (SI) device to introduce 2 instruments and the laparoscope through the same small abdominal opening. The patient underwent a previous SI laparoscopic total colectomy through the ileostomy site. For the second stage, we introduced the SI device in the same site. At the end of the procedure, the only incision on the patient's abdomen was that used for the diverting loop ileostomy. A SI proctectomy and IPAA is feasible, and can be performed safely. 418 Intra-Operative Ultrasound During Laparoscopic Cholecystectomy: A Video Library Jason M. Pfluke, Michael Parker, Horacio J. Asbun, C. Daniel Smith, Steven P. Bowers Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgical opera- tions in the United States. Despite this, bile duct injuries remain problematic. Intra-operative ultrasound (IOUS) performed during LC has been reported to decrease the risk of bile duct injury, provide cost-savings compared with routine use of intra-operative cholangiogram, and lower the conversion rate to open cholecystectomy. IOUS is relatively easy to perform, but few surgeons routinely utilize this technique. We present a video library of normal and abnormal ultrasound findings during LC in an effort to assist other surgeons in mastering this valuable skill. 419 Laparoscopic-Assisted Isolated Caudate Lobe Resections Edward Lin, Juan M. Sarmiento Two cases of laparoscopic caudate lobe resection for focal nodular hyperplasia are demon- strated, one approached from the right side and the other from the left side. The laparoscopic technique is nearly identical to the open method, but has superior anatomic views and details. Both cases utilized a 7 cm hand-assist port in the upper midline through which the tumors were removed. The estimated blood loss were under 200 cc, and both patients were discharged home within 4 days. Pathology reports demonstrated normal liver parenchyma surrounding the FNH and post-surgery imaging confirmed complete tumor resection. 420 Laparoscopic Low Anterior Resection With Transrectal Specimen Extraction and Intracorporeal Anastomosis Philip A. Omotosho, Jin S. Yoo, Aurora D. Pryor Laparoscopic colorectal resection is associated with reduction in 30-day postoperative mor- bidity without compromising long-term patient outcome. Minimally invasive approaches continue to be refined. Employing hybrid natural orifice techniques, we demonstrate laparo- scopic anterior resection with transrectal specimen extraction and intracorporeal anastomosis. Potential benefits of this approach include reduction in postoperative wound infection rates, currently around 6%, as well as incisional hernia rates, which can be up to 10% in some series reporting on laparoscopic colorectal resections. A prospective study using this technique is required to make definitive recommendations. 421 Laparoscopic Ventral Mesh Rectopexy for Rectal Prolapse Pierpaolo Sileri, Vito M. Stolfi, Domenico Benavoli, Luana Franceschilli, Lodovico Patrizi, Achille Gaspari Laparoscopic Ventral Rectopexy (LVR) is a novel procedure for internal/external rectal prolapse, with excellent outcomes and minimal morbidity. It improves obstructed defecation symptoms, without inducing new-onset constipation, evident with posterior rectopexy. A preoperative multidisciplinary workup and selection is mandatory. Ideal surgery should correct anatomy, preserve/improve function, treat anterior/middle compartments, avoid sequels and be mini-invasive. In this video, LVR resumes all these key qualities: anterior rectal mobilization (avoiding autonomic nerve injury), use of a mesh (biologic/not) to support anterior wall and middle compartment, all through mini-invasive approach.
Transcript of 317 Image-Guided Stereotactic Radiosurgery for Locally Advanced Pancreatic Adenocarcinoma Results of...
SS
AT
Ab
stra
cts
(62%) were detected intraoperatively using a combination of palpation and intraoperativeultrasonography. rCR of one or more lesions was observed in 54 patients (31%). In 26 ofthese patients (48%), all rCR lesions were detected intraoperatively. In 28 patients, at leastone lesion remained undetected intraoperatively. Of these, 23 (82%) had rCR sites that wereleft untreated. When comparing outcomes between patients with completely treated vs.untreated rCR sites, one year intrahepatic recurrence rate was higher in those with untreatedrCR sites (32% vs 43%, p=0.05). However, the majority of these patients were able toundergo repeat surgical therapy upon recurrence and the overall survival was not statisticallydifferent between groups (3-yr OS 78% vs. 66%, p=0.64) Conclusions: In our study, wefound rCR to occur commonly in patients undergoing preoperative chemotherapy for CRLM.However, the majority of these rCR lesions were indentified intraoperatively. Among thosepatients with undetected and untreated lesions, long-term outcome was good despite a highrate of intrahepatic recurrence. This finding may be related to favorable tumor biology,patient selection, and opportunities for salvage surgery. Therefore, aggressive surgical therapyshould be considered in patients with marked response to chemotherapy, even when allrCR sites cannot be identified.
316
Radiation Dose From Computed Tomography in Patients With NecrotizingPancreatitis: How Much is Too Much?Chad G. Ball, Camilo Correa-Gallego, Thomas J. Howard, Nicholas J. Zyromski, MichaelHouse, Henry A. Pitt, Attila Nakeeb, C. Max Schmidt, Keith D. Lillemoe
Objectives: Low-dose ionizing radiation from medical imaging has been indirectly associatedwith the subsequent development of solid cancers and leukemia. The non-invasive, goldstandard modality for defining the initial extent, as well as the evolution of pancreaticnecrosis is computed tomography (CT). The goals of this study were to identify: (1) thefrequency of CT imaging, (2) the effective radiation dose per patient, (3) the rate of therapeuticintervention following CT, and (4) the mean direct hospital cost for these patients. Methods:All patients with necrotizing pancreatitis (2003-2007) treated at a tertiary care referral centerwere retrospectively analyzed. Standard statistical methodology was employed (significance =p<0.05). Results: Of the 1290 patients with acute pancreatitis, 238 (18%) were necrotizing(mean age = 53 years, hospital/ICU lengths of stay = 23/7 days, mortality = 9%). A medianof 5 CT scans per patient (range = 1 to 28) were performed during the mean 8.3 monthimaging interval. The average effective dose was 40 mSv per patient. This dose is equivalentto 2000 chest x-rays or 13.2-years of background radiation or a 1/250 increased risk offatal cancer. Twenty percent of CT scans were followed by a direct intervention (199interventional radiology, 118 operative, 12 endoscopic)(median = 1; range = 1 to 7) orchange in management. This proportion increased to 31% in physiologically ill patients(p<0.05). MRI use did not have a CT-sparing effect (p>0.05). The modality of interventiondid not alter the total number of, or the time intervals between, CT scans (p>0.05). Meandirect hospital costs increased in a stepwise manner parallel to the number of CT scans (R=0.7, p<0.05). Conclusions: The effective radiation dose received by patients with necrotizingpancreatitis is significant. Changes in management following individual CT scans occur ina minority of patients (20% to 31%). The ubiquitous use of CT imaging in necrotizingpancreatitis raises substantial public health concerns and mandates a careful reassessmentof its utility.
317
Image-Guided Stereotactic Radiosurgery for Locally Advanced PancreaticAdenocarcinoma Results of First 85 PatientsMukund S. Didolkar, Cardella Coleman, Mark J. Brenner, Kyo U. Chu, ElizabethStanwyck, Airong Yu, Nicole Olexa, Nagaraj Neerchal
BACKGROUND:Locally advanced unresectable pancreatic adenocarcinoma is characterizedby poor survival despite chemotherapy and conventional radiation therapy. Recent advancesin real time image-guided stereotactic radiosurgery (SRS) has made it possible to treat thesecancers in 3-4 fractions followed by systemic chemotherapy. AIMS:1. To obtain local controlof the disease. 2. To improve the survival of these unresectable patients. 3. To evaluate thetoxicity of SRS. 4. Report results of the largest series from a single center. METHODS:Pancreatic SRS involves delivery of high doses of accurately targeted radiation given non-invasively in 2-4 fractions. We treated 85 consecutive patients with locally advanced andrecurrent pancreatic adenocarcinoma from Feb 2004 to Aug 2009. Age range: 36-87, mean65 years; Sex: males 50, females 35; Race: Caucasian 74, others 11; Histology: adenocarcin-oma 82, islet cell 2, other 1; T stage III/IV 81, TX 4; N stage N+ 39, NX 46; M stage M060, M1 25. No prior surgical resection in 70 patients, and 15 had local recurrence aftersurgical resection. 30 patients had progression of disease after prior conventional radiationtherapy (RT). Location of the tumor: head 55, body and tail 30. All patients receivedgemcitabine-based chemotherapy regimen after SRS and some had additional chemotherapybefore SRS. Median tumor volume 62 cc. PET/CT scans done in latter 43 patients showedan average SUV of 6.9. Pain score (1-10): <3 35, >4 50. SRS doses ranged from 15 to 30Gy with the mean dose of 25.5 Gy delivered in 3 days (range 2-5 days) divided in equalfractions. Mean conformity index of 1.6 and mean isodose line of 80%. RESULTS: Tumorcontrol: complete, partial, and stable disease was observed in 75 patients for the durationof 3-36 mos. Pain relief was noted in 45 of 50 patients. Most of the patients died of distantprogression. SURVIVAL: Survival of was calculated by Kaplan-Meier method. Overall meansurvival 23.9 mos and from SRS was 13.7 mos. For the group of 41 patients without priorsurgical resection or conventional RT and no distant metasteses, the average survival was17.7 mos from the diagnosis and 13.5 mos from SRS. TOXICITY:Grade III and IV duodenitis8 (9.4%), gastritis 12 (14.1%), diarrhea 3 (3.5%), renal failure 1 (1.2%). 6 week postmortality was 0%. CONCLUSIONS: SRS for unresectable pancreatic carcinoma can bedelivered in 3 fractions with minimal morbidity and a local tumor control rate of 88.2%.Thesurvival is better compared to the reported results for advanced pancreatic cancer, specificallyfor the group of previously untreated patients with unresectable tumors.
S-850SSAT Abstracts
416
Single Incision Laparoscopic Liver Resection of Colorectal Liver MetastasesAmeet G. Patel, Ajay P. Belgaumkar, Jojo James, Beth Murgatroyd, Kirstin Carswell
We present a case of a 53 year old woman with a segment 2 colorectal liver metastasis. Aleft lateral sectionectomy was performed laparoscopically through a single umbilical incision.Hepatic parenchyma was divided using ultrasonic coagulation. Inflow and outflow pedicleswere divided with laparoscopic staplers. The resected liver specimen was extracted byextending the umbilical incision to 5 cm length. The patient made an uncomplicated recovery.resuming oral diet and ambulation within 24 hours. The resection margin was clear. Theaim of the video is to demonstrate the single incision approach is technically feasible andsafe in selected patients requiring liver resection.
417
Single-Incision Laparoscopic Completion Proctectomy and Ileal J-Pouch-AnalAnastomosis in an 18 Year-Old Male With Ulcerative Colitis Refractory toMedical TherapyAlexandre Bouchard, Tonia M. Young-Fadok
Laparoscopic-assisted completion proctectomy and ileal pouch-anal anastomosis (IPAA) isusually performed with multiple ports and an extraction incision. To further reduce thenumber of incisions and abdominal wall trauma, we used a single-incision (SI) device tointroduce 2 instruments and the laparoscope through the same small abdominal opening.The patient underwent a previous SI laparoscopic total colectomy through the ileostomysite. For the second stage, we introduced the SI device in the same site. At the end of theprocedure, the only incision on the patient's abdomen was that used for the diverting loopileostomy. A SI proctectomy and IPAA is feasible, and can be performed safely.
418
Intra-Operative Ultrasound During Laparoscopic Cholecystectomy: A VideoLibraryJason M. Pfluke, Michael Parker, Horacio J. Asbun, C. Daniel Smith, Steven P. Bowers
Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgical opera-tions in the United States. Despite this, bile duct injuries remain problematic. Intra-operativeultrasound (IOUS) performed during LC has been reported to decrease the risk of bile ductinjury, provide cost-savings compared with routine use of intra-operative cholangiogram,and lower the conversion rate to open cholecystectomy. IOUS is relatively easy to perform,but few surgeons routinely utilize this technique. We present a video library of normal andabnormal ultrasound findings during LC in an effort to assist other surgeons in masteringthis valuable skill.
419
Laparoscopic-Assisted Isolated Caudate Lobe ResectionsEdward Lin, Juan M. Sarmiento
Two cases of laparoscopic caudate lobe resection for focal nodular hyperplasia are demon-strated, one approached from the right side and the other from the left side. The laparoscopictechnique is nearly identical to the open method, but has superior anatomic views anddetails. Both cases utilized a 7 cm hand-assist port in the upper midline through which thetumors were removed. The estimated blood loss were under 200 cc, and both patients weredischarged home within 4 days. Pathology reports demonstrated normal liver parenchymasurrounding the FNH and post-surgery imaging confirmed complete tumor resection.
420
Laparoscopic Low Anterior Resection With Transrectal Specimen Extractionand Intracorporeal AnastomosisPhilip A. Omotosho, Jin S. Yoo, Aurora D. Pryor
Laparoscopic colorectal resection is associated with reduction in 30-day postoperative mor-bidity without compromising long-term patient outcome. Minimally invasive approachescontinue to be refined. Employing hybrid natural orifice techniques, we demonstrate laparo-scopic anterior resection with transrectal specimen extraction and intracorporeal anastomosis.Potential benefits of this approach include reduction in postoperative wound infection rates,currently around 6%, as well as incisional hernia rates, which can be up to 10% in someseries reporting on laparoscopic colorectal resections. A prospective study using this techniqueis required to make definitive recommendations.
421
Laparoscopic Ventral Mesh Rectopexy for Rectal ProlapsePierpaolo Sileri, Vito M. Stolfi, Domenico Benavoli, Luana Franceschilli, Lodovico Patrizi,Achille Gaspari
Laparoscopic Ventral Rectopexy (LVR) is a novel procedure for internal/external rectalprolapse, with excellent outcomes and minimal morbidity. It improves obstructed defecationsymptoms, without inducing new-onset constipation, evident with posterior rectopexy. Apreoperative multidisciplinary workup and selection is mandatory. Ideal surgery shouldcorrect anatomy, preserve/improve function, treat anterior/middle compartments, avoidsequels and be mini-invasive. In this video, LVR resumes all these key qualities: anteriorrectal mobilization (avoiding autonomic nerve injury), use of a mesh (biologic/not) to supportanterior wall and middle compartment, all through mini-invasive approach.
