Mo1507

Risk Factors, Hospital Cost, and Complications Associated With Transfusionin Elective PancreatectomyRaphael C. Sun, Anna M. Button, Brian J. Smith, Hisakazu Hoshi, Richard F. LeBlond,Howe R. James, James J. Mezhir

Background: There is now increased awareness of the detrimental effects of transfusion inelective general surgical procedures. Our objectives are to determine 1) which preoperativeclinical variables can predict the need for intraoperative transfusion and 2) the impact oftransfusion on hospital costs and complications in pancreatectomy. Methods: Using ourprospective institutional and ACS-NSQIP database, we identified 173 patients who hadelective pancreatectomy from 9/2007 to 9/2011. Univariate and multivariate analyses wereperformed using 24 preoperative clinical variables to identify risk factors associated withtransfusion. Preoperative severity of illness (SOI) and mortality risk were determined usingthe Agency for Health Research and Quality (AHRQ) Risk Adjustment Score, a standardizedmetric used by the University Health System Consortium. Hospital costs and operativecomplications were also evaluated. Results: Patients had left pancreatectomy (n=60) orpancreaticoduodenectomy (n=113) to treat malignant (n=134) or benign (n=39) disease.Median OR time was 7.4 hours (2.4-12.3). Median LOS was 10 days (4-77) and 51 patients(29%) spent at least one night in the ICU. 98 patients (56.6%) had a complication and 90-day mortality was 2.9% (n=5). SOI at admission was minor in 21 patients (12.1%), moderatein 59 (34.1%), and major/extreme in 43 (24.8%). Risk of mortality at admission was: minor(n=91, 53%), moderate (n=58, 34%), and major (n=24, 14%). There were 78 patients (45%)who received at least 1 unit of blood and the median number of intraoperative transfusionswas 3.0 units (1-55); 11 of these patients (6.4%) also received plasma. Mean total hospitalcosts observed was $39,434 ($13,285-$251,157). Compared to patients who did not receivea transfusion, those who received at least one blood product had a higher mean hospitalcost and hospital charges (Table). Among transfused patients, 65% (n=51) experienced atleast one complication vs. 49% (n=47) of patients not transfused (p=0.036), includinginfectious complications and pancreatic fistula/leak/abscess (Table). In multivariate analysis,independent predictors of increased transfusion likelihood included lower hematocrit,increased BMI, and worse AHRQ SOI and mortality risk scores. Age, gender, comorbidities,diagnosis, ASA class, procedure, OR time, and ICU stay were not independent predictorsof transfusion risk. Conclusions: Blood transfusion is associated with increased hospital costand morbidity in pancreatectomy. Factors associated with increased risk for transfusion suchas preoperative hematocrit, BMI and AHRQ scores can be utilized to stratify patients inclinical trials and inform patients of their risk for transfusion. Further research is neededto determine the extent to which transfusion contributes to morbidity and cost independentlyof SOI.Table. Cost and complications associated with transfusion in pancreatectomy

*p-values determined using (a) two-sample t-tests and (b) chi-square tests.

Mo1508

Laparoscopic Distal Pancreatectomy for Benign and Malignant Lesions: ANationwide Analysis of Patient OutcomesHop S. Tran Cao, David Chang, Andrew M. Lowy, Michael Bouvet, Mark A. Talamini,Jason K. Sicklick

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) was first reported in 1996. Sincethen, all publications evaluating LDP have consisted of single center or multi-institutionalcase series. We hypothesized that a national database inquiry could offer insight into theindications and outcomes of LDP. METHODS: The Nationwide Inpatient Sample was queriedfor patients undergoing LDP for benign and malignant pancreatic lesions from 1998 to2009. Univariate and multivariate analyses were performed using logistic regression models,adjusting for age, gender, ethnicity, and comorbidities. RESULTS: 1,908 LDPswere performedbetween 1998 and 2009. 506 cases were excluded due to unclearly coded ICD-9 diagnoses.The remaining 1,402 LDPs were coded for benign (57.8%) or malignant (42.2%) diseasesof the pancreas. The groups were similar for gender, ethnicity, and in-hospital mortalityrates but cancer patients were on average 6.9 years older (P=0.0001) and had higher Charlsoncomorbidity indices (scores ≥ 2: 75.5% vs. 50.8%, P=0.0001). On univariate analyses,patients undergoing LDPs for malignancies had longer lengths of stay (8.95 vs. 6.89 days,P=0.02), higher overall complication rates (34.4% vs. 22.0%, P=0.045), more inadvertentorgan injuries (5.5% vs. 1.1%, P=0.03), higher splenectomy rates (93.8% vs. 71.4%,P<0.0001) and increased requirements for blood transfusions (15.8 vs. 6.6%, P=0.019). Onmultivariate analyses, LDPs performed for cancer were associatedwith a statistically significantincrease in the incidence of splenectomy (OR 5.92, 95% CI 2.32-15.1). In contrast, therewere no differences in individual complication rates, including fistulae, infections/abscesses,hemorrhage/hematomas, inadvertent organ injuries, wound complications, organ dysfunc-tion, thromboembolic events, or in-hospital mortality based upon disease indication forLDP. CONCLUSIONS: The reported experiences of single or multiple institutions with LDPfor cancerous lesions of the pancreas remain limited. We now report the nationwide experi-ence and outcomes of LDP for patients with benign and malignant pancreatic diseasesutilizing a national database. We show that patients undergoing LDP for pancreatic cancertend to be older, have more comorbities, and are more likely to undergo concurrent splenec-tomy. However, on multivariate analyses, this does not result in increased in-hospital morbid-ity or mortality rates. In summary, the application of laparoscopic distal pancreatic resectionsfor malignancies has emerged as a feasible and safe approach with comparable outcomes toresections performed for benign pancreatic lesions. However, long-term oncological outcomesneed to be better studied before this technique can be widely accepted as standard of care.

S-1081 SSAT Abstracts

Mo1509

Contemporary Treatment and Outcomes of Periampullary Adenocarcinomas ata Single InstitutionVei Shaun Siow, Zhi Ven Fong, Harish Lavu, Eugene P. Kennedy, Patricia K. Sauter,Leonidas Koniaris, Ernest L. Rosato, Charles J. Yeo, Jordan M. Winter

Introduction: Periampullary adenocarcinoma (PA) is the most common indication for pancre-aticoduodenectomy (PD). The four cancers that comprise the PAs include pancreatic ductal(PDA), ampullary (AA), distal common bile duct (CBDA), and duodenal adenocarcinoma(DA). While PDA has been studied extensively, it is unclear whether these data are applicableto the rarer PAs. Methods: We queried our institutional PD database for patients treated forPA from November 2005 to October 2011. Out of 650 resections, 390 (60%) patients hadPA. Clinicopathologic data were analyzed, and statistical comparisons between PA subtypeswere made with respect to PDA, unless otherwise indicated. We aimed to identify thedifferences in the biology, natural history, and treatment patterns between PAs. Results: The390 resected PAs included 293 (75%) PDAs, 48 (12%) AAs, 28 (7%) distal CBDAs, and 21(5%) DAs. Pre-operative CA 19-9 levels were elevated in 76% of patients with PDA, 56%with distal CBDs (p=0.04), 62% with AA (p=0.071), and 55% with DA (p=0.06). In general,resected PDAs and CBDAs had the more aggressive pathologic features. Specifically, perineu-ral invasion was identified in 92% of PDAs, 93% of distal CBDAs (p=1.0), 51% of AAs(p<0.0001) and 34% of DAs (p<0.0001). Lymph node metastases were identified in 74%of PDAs, 50% of distal CBDAs (p=0.013) 60% of AAs (p=0.05) and 57% of DAs (p=0.1).Documented recurrence patterns were available in a subset of patients (22%) followed atour own institution. Due to the small number of patients, non-pancreatic PAs were analyzedtogether. The site of first recurrence was the surgical bed in 24% of PDAs and 20% of non-pancreatic PAs. A distant metastasis was identified in 76% of PDAs and 80% of non-pancreatic PAs (p=1.0). With regards to treatment patterns at our institution (N=158 withtreatment data), patients with PDA and distal CBDAs are virtually always treated withadjuvant gemcitabine (91%), as compared to the other two subtypes (55%, p<0.0001) whichare frequently treated with a 5-FU based regimen. The median and 2-year survivals associatedwith each PA were (Figure): PDA, 19 months and 39%; CBDA, 18 months and 37% (p=0.8); AA, 43 months and 65% (p=0.002); and DA, median not reached and 67% (p=0.04).After adjusting for lymph node metastases, AA was still more favorable than PDA (hazardratio=0.73, p=0.01) while DA showed a trend but was not significantly more favorable(hazard ratio, 0.8, p=0.1). Conclusions: These findings support the notion that PAs are aheterogeneous group. As compared to AAs and DAs, PDAs had more aggressive pathologicfeatures and worse long-term survival. In addition, CA19-9 was a more sensitive test forPDAs than the non-pancreatic PAs. Our practice patterns approach pancreatobiliary cancersprimarily with gemcitabine-based treatment, which differs from the approach with theother subtypes.

Kaplan-Meier survival curves for patients with periampullary adenocarcinoma.

Mo1511

Predictive Factors of Pancreatic Fistula and Postoperative Complications AfterPancreatic Resections in Two High Volume Centers: Comparison BetweenPosterior Invagination and Duct-to-Mucosa PancreaticogastrostomyFilippo Scopelliti, Giovanni Butturini, Carlo Frola, Mohammad Abu Hilal, Claudio Bassi

Introduction. Pancreatic fistula (PF) is a major complication after pancreatic resections. Wellknown risk factors are soft pancreatic remnant and small duct. The most widely usedtechniques to reconstruct the pancreo-digestive continuity are pancreojejunostomy (PJ) andpancreogastrostomy (PG), either executable by invagination or duct-to-mucosa. Unlike PJ,there are no studies evaluating short term outcome and PF rate comparing invaginationversus duct-to-mucosa PG.Methods. In this dual-institution retrospective study, 345 patients,reconstructed by invagination or duct-to-mucosa PG after pancreatic resections, were strati-fied in two groups by the type of PG performed. The invagination group consists of 173patients from 2000 and 2010 at the same institution, selected for having soft pancreaticremnant. The duct-to-mucosa group consists of 172 consecutive patients from 2007 and2010 at the other institution. Primary end point was to compare the two groups in termsof postoperative complications, including PF rate and grading, as defined by the InternationalStudy Group of Pancreatic Fistula. Secondary end point was the assessment of possiblepredictive risk factors of PF, unrelated to the type of anastomosis. Results. No differencesin demographic data between the two groups were found except of the median age, signific-antly higher in duct-to-mucosa group (67 vs 62 years; P=0,001). In invagination group90,1% of patients had a soft pancreatic remnant vs 48,2% in the duct-to-mucosa group (P=0,0001). There were 47 PFs (27,2%) in the invagination group and 44 (25,6%) in the duct-to-mucosa group (P=NS). Furthermore no differences in PF grading were found. The patientin duct-to-mucosa group experienced abdominal collections in 42 cases (24,2%) respect ofthe 18 patients (10,4%) in the invagination group (P=0,001). Also delayed gastric emptying

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