Major hepatectomy in elderly patients: possible benefit from robotic platform utilization

INTRODUCTION

Robotic surgery has been increasingly utilized, yet its application for hepato-pancreato-biliary (HPB) procedures remains low due to technical complexity, perceived financial burden, and unproven clinical benefits. We hypothesized that the robotic approach would be associated with improved clinical outcomes following major hepatectomy compared with the laparoscopic approach among elderly patients who would benefit from the advantages of minimally invasive surgery.

METHODS

A retrospective review of consecutive patients who underwent major hepatectomy between January 2010 and December 2021 at Carolinas Medical Center was performed. Inclusion criteria were age ≥ 65 years and major hepatectomy of three segments or more. Patients who underwent multiple liver resections, vascular/biliary reconstruction, or concomitant extrahepatic procedures (except cholecystectomy) were excluded. Categorical variables were compared using Chi-square or Fisher's exact test when more than 20% of cells had expected frequencies less than five, and Wilcoxon two-sample or Kruskal-Wallis tests were used for continuous or ordinal variables. Results are described as median and interquartile range (IQR). Multivariate analyses were used on postoperative admission days.

RESULTS

There were 399 major hepatectomies performed during this time period, of which 125 met the criteria and were included. There were no differences in perioperative demographics among patients who underwent robotic hepatectomy (RH, n = 39) and laparoscopic hepatectomy (LH, n = 32). There was no difference in operative time, blood loss, or major complication rates. However, RH had lower rates of conversion to an open procedure (2.6% versus 31.3%, p = 0.002), shorter length of hospital stay [LOS, 4 (3-7) versus 6 (4-8.5) days, p ≤ 0.0001], cumulative LOS [4 (3-7) versus 6 (4.5-9) days, p ≤ 0.0001], and lower rates of intensive care unit (ICU) admission (7.7% versus 75%, p ≤ 0.001), with a trend toward fewer rehabilitation requirements.

CONCLUSIONS

Robot major hepatectomy shows clinical advantages in elderly patients, including shorter hospital and ICU stays. These advantages, as well as reduced rehabilitation requirements associated with minimally invasive surgery, could overcome the current perceived financial disadvantages of robotic hepatectomy.

P077 LONG-TERM CLINICAL OUTCOMES OF AN ANTIBIOTIC-COATED NON-CROSSLINKED PORCINE ACELLULAR DERMAL GRAFT IN HIGH-RISK ABDOMINAL WALL RECONSTRUCTION

Aim

Abdominal wall reconstruction in high-risk and contaminated cases remains a challenging surgical dilemma. We report long-term clinical outcomes for a rifampin/minocycline-coated acellular dermal graft (XenMatrix™ AB) in complex abdominal wall reconstruction for patients with a prior open abdomen or contaminated wounds.

Material and Methods

Patients undergoing abdominal wall reconstruction at our institution at high risk for surgical site occurrence and reconstructed with XenMatrix™ AB with intent-to-treat between 2014 through 2017 were included. Demographics, operative characteristics, and outcomes were collected. Primary outcome was hernia recurrence. Secondary outcomes included length of stay, surgical site occurrence, readmission, morbidity, and mortality.

Results

Twenty-two patients underwent abdominal wall reconstruction using XenMatrix™ AB during the study period. Two patients died while inpatient from progression of their comorbid diseases and were excluded. Sixty percent of patients had an open abdomen at time of repair. All patients were Modified VHWG class 2 or 3.

There was a total of four 30-day infectious complications including superficial cellulitis/fat necrosis (15%) and one intraperitoneal abscess (5%). No patients required re-operation or graft excision.

Median clinical follow-up was 35.1 months with a mean of 32.2 +/- 16.5 months. Two asymptomatic recurrences and one symptomatic recurrence were noted during this period. Follow-up was extended by phone interview which identified no additional recurrences at a median of 45.5 and mean of 50.5 +/-12.7 months.

Conclusions

We present long-term outcomes for patients with high-risk and contaminated wounds who underwent abdominal wall reconstruction reinforced with XenMatrix™ AB to achieve early, permanent abdominal closure. Acceptable outcomes were noted.

Objective evaluation of technical dexterity in robotic hepaticojejunostomy: Assessment of hepatopancreatobiliary fellows using cumulative sum analytics

BACKGROUND

The development of technical dexterity is a critical for surgeons in training. This study describes and assesses the feasibility of an objective method for the evaluation of procedure-specific technical dexterity in hepatopancreatobiliary (HPB) surgery using cumulative sum (CUSUM) analysis.

METHODS

Dry-lab HPB procedures were divided into procedural steps with binary outcomes (success or failure). Two HPB fellows completed 20 dry lab hepaticojejunostomy (HJ) procedures. Participant progress was tracked over time with CUSUM analytics to establish a learning curve for procedural proficiency.

RESULTS

The CUSUM charts for 20 consecutive dry-lab HJ procedures were analysed. A learning curve was created and used to identify areas of weakness to facilitate improvement in technical proficiency.

CONCLUSIONS

CUSUM is effective tool for objective evaluation of technical dexterity offering both simplicity and adaptability. We demonstrate its use and feasibility for surgical education and plan to expand its' application to assess residents performing general surgery procedures.

Bile Leak Reduction with Laparoscopic Versus Open Liver Resection: A Multi-institutional Propensity Score-Adjusted Multivariable Regression Analysis

INTRODUCTION

The reported rate of postoperative bile leak is variable between 3 and 33%. Recent data would suggest a minimally invasive approach to liver surgery has decreased this incidence.

METHODS

This multi-institutional case-control study utilized databases from three high-volume surgeons. All consecutive open and minimally invasive liver resection cases were analyzed in a propensity score-adjusted multivariable regression. A p value < 0.05 was considered significant.

RESULTS

In 1388 consecutive liver resections, the average age was 56.9 ± 14.0 years, 730 (52.59%) were male gender, and 599 (43.16%) underwent minimally invasive liver resection. Thirty-nine (2.81%) in the series were identified with post-resection bile duct leaks. Leaks were associated with major resections and increased blood loss (p < 0.05). Propensity score-adjusted multivariable regression identified minimally invasive liver resection significantly and independently reduced the odds of bile duct leak (OR 0.48, p = 0.046) even controlling for BMI, ASA, cirrhosis, major resection, and resection year.

CONCLUSIONS

Our data suggest the incidence of bile leaks in a large-volume center series is far less than previously reported and that a minimally invasive approach to liver resection reduces the incidence of postoperative bile leak.

Prehabilitation for Hepatopancreatobiliary Surgical Patients: Interim Analysis Demonstrates a Protective Effect From Neoadjuvant Chemotherapy and Improvement in the Frailty Phenotype

BACKGROUND

Prehabilitation encompasses multidisciplinary interventions to improve health and lessen incidence of surgical deterioration by reducing physiologic stress and functional decline. This study presents an interim analysis to demonstrate prehabilitation for hepatopancreatobiliary (HPB) surgical patients.

METHODS

In 2018, a structured prehabilitation pilot program was implemented. Eligibility required HPB malignancy, neoadjuvant chemotherapy, and residence within hour drive. Patients were enrolled into the 4-month program. The fitness component was composed of timed up and go test and grip strength with exercise recommendations. Nutrition involved evaluation of sarcopenic obesity, glucose management, and smoking and alcohol counseling. Psychological services included psychosocial assessments and advanced care planning, with social work referrals. Component were evaluated monthly by a physician using laboratory results, nutritional data and questionnaires, psychological assessments, and validated fitness tests. Nurse navigators spoke with patients weekly to monitor compliance.

RESULTS

At 12 months, nineteen patients were enrolled. Ten completed prehabilitation, neoadjuvant chemotherapy and underwent their surgical procedure. There were no differences found after prehabilitation in functional status, physical performance, psychosocial assessments, or nutrition. Frailty, as assessed by Fried frailty criteria, improved significantly after prehabilitation (P < .0001). Symptom severity and laboratory values did not change. Length of stay was 6.5 days and all patients were discharged to home. There was 1 readmission for transient ischemic attack and 90-day mortality rate was 0%.

DISCUSSION

Prehabilitation to improve recovery is a promising concept encompassing a wide array of multidisciplinary assessments and interventions. It may demonstrate a protective effect on physiologic decline from chemotherapy and may reverse frailty phenotypes.

Current trends in vena cava reconstructive techniques with major liver resection: a systematic review

PURPOSE

Historically, invasion of the inferior vena cava (IVC) represented advanced and often unresectable hepatic disease. With surgical and anesthetic innovations, IVC resection and reconstruction have become feasible in selected patients. This review assesses technical variations in reconstructive techniques and post-operative management.

METHODS

A comprehensive literature search was performed according to PRISMA. Inclusion criteria were (i) peer-reviewed articles in English; (ii) at least three cases; (iii) hepatic IVC resection and reconstruction (January 2015-March 2020). Primary outcomes were reconstructive technique, anti-thrombotic regimen, post-operative IVC patency, and infection. Secondary outcomes included post-operative complications and malignant disease survival.

RESULTS

Fourteen articles were included allowing for investigation of 351 individual patients. Analysis demonstrated significant heterogeneity in surgical reconstructive technique, anti-thrombotic management, and post-operative monitoring of patency. There was increased utilization of ex vivo approaches and decreased use of venovenous bypass compared with previously published reviews.

CONCLUSION

This review of literature published between 2015 and 2020 reveals persistent heterogeneity of hepatic IVC reconstructive techniques and peri-operative management. Increased utilization of ex vivo approaches and decreased use of venovenous bypass point towards improved operative techniques, peri-operative management, and anesthesia. In order to gain evidence for consensus on management, a registry would be beneficial.

Faster Return to Intended Oncologic Treatment (RIOT) After Trisectionectomy Does Not Translate to Better Outcomes

BACKGROUND

Resection with trisectionectomy may necessitate liver molding for adequate future liver remnant (FLR), and subsequent complications can impact return to intended oncologic therapy (RIOT). This study evaluated whether a difference in RIOT exists with the use of molding and between liver molding techniques (associating liver partition and portal vein ligation for staged hepatectomy [ALPPS] and portal vein embolization [PVE]) with trisectionectomy.

METHODS

A retrospective review evaluated trisectionectomies for malignancy. Outcomes were compared with and without molding, and RIOT was determined.

RESULTS

Fifty-one patients underwent trisectionectomy: 11 ALPPS, 14 PVE, 26 without molding. 73% of ALPPS, 64% of PVE, and 58% without molding achieved RIOT (P = .971). There were no differences found in baseline characteristics, R0 rate, length of stay, readmission, complications, or mortality. Time to RIOT was significantly different (ALPPS: 3.3 months; PVE: 5.2 months; none: 2.4 months, P = .0203). There were no differences in recurrence or survival.

CONCLUSIONS

Liver molding should not cause apprehension as there are no differences in achieving RIOT. Although technique alters time to RIOT, this does not translate into improved outcomes, implicating disease biology, and regeneration stimulus.

Oncologic Outcomes of Robotic Left Pancreatectomy for Pancreatic Adenocarcinoma: A Single-Center Comparison to Laparoscopic Resection

BACKGROUND

Feasibility and safety of robotic surgery for pancreatic disease has been well demonstrated; however, there is scarce literature on long-term oncologic outcomes. We compared perioperative and oncologic outcomes between robotic left pancreatectomy (RLP) and laparoscopic left pancreatectomy (LLP) for pancreatic adenocarcinoma.

METHODS

A retrospective review evaluated left pancreatectomies performed for pancreatic adenocarcinoma from 2009 to 2019 in a tertiary institution. Baseline characteristics, operative and oncologic outcomes were compared between RLP and LLP.

RESULTS

There were 75 minimally invasive left pancreatectomy cases for pancreatic adenocarcinoma identified of which 33 cases were done robotically and 42 laparoscopically. Baseline characteristics demonstrated no difference in gender, age, BMI, T stage, N stage, neoadjuvant, or adjuvant chemotherapy. An analysis of operative variables demonstrated no difference in blood loss, increased duration, and higher lymph node yield with RLP (20 vs 12; P = .0029). Postoperatively, both cohorts had 30% pancreatic fistulas and no difference in complications. There were no differences in length of stay (LOS), 30- or 90-day readmission rates, or 90-day mortality. The analysis of oncologic outcomes demonstrated similar R0 resections (RLP: 72% vs OLP: 67%), recurrence rates (RLP: 36% vs OLP: 41%), and time to recurrence (RLP: 324 vs OLP 218 days). There was increased survival in the RLP cohort that was not significant (32 vs 19 months).

CONCLUSION

This analysis demonstrates RLP is at least equivalent to LLP in perioperative and oncologic outcomes. The significantly higher lymph node yield and trend toward an improved survival suggests oncologic advantage. Randomized controlled studies are needed to clarify benefit.

The annual AHPBA HPB fellows' course: an analysis of impact and feedback

BACKGROUND

Since 2012, the AHPBA has hosted an annual HPB Fellows' Course at Carolinas Medical Center. All fellows training in an accredited HPB fellowship are eligible to attend. The aim of this study was to evaluate the impact of this conference and assess possible areas of improvement.

METHODS

The Carolinas Fellows' Course (CFC) is a structured educational activity involving didactics, skills labs, and live case presentations. The course emphasizes minimally invasive surgery (MIS) and intraoperative ultrasound (IOUS) technique. This is a retrospective review of a survey emailed to 95 fellows who have attended the course over a 7-year period.

RESULTS

Fifty-two attendees completed the survey (54.7% response rate). Sixty-eight percent of respondents now practice primarily HPB surgery. Seventy-six percent agreed that the CFC encouraged them to incorporate IOUS into their practice, while 74% were encouraged to incorporate MIS HPB procedures into their practice. Eighty percent felt that the course laid groundwork for long term communication with peers.

CONCLUSION

The study demonstrates that a multisite instructional course can be an effective way to encourage the development of new skills, boost operational confidence, impact real world practices, and foster long term communication and networking among fellows after graduation.

Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study

BACKGROUND

The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma.

METHODS

A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann-Whitney U test, log rank tests, and Kaplan-Meier methods.

RESULTS

Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months; p = 0.1105) and longer time to recurrence (402 vs. 284 days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence.

CONCLUSIONS

While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.

A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations

As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.

A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations

As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.

Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010-2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3-21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.

Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010–2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3–21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.

Perioperative Care Implementation: Evidence-Based Practice for Patients With Pancreaticoduodenectomy Using the Enhanced Recovery After Surgery Guidelines

BACKGROUND

Pancreatic adenocarcinoma is an aggressive cancer that carries a poor prognosis. Pancreaticoduodenectomy (PD) offers the only potential cure, but the associated morbidity is high. The Enhanced Recovery After Surgery (ERAS) evidence-based guidelines for perioperative care for PD can be used to reduce variations in practice.
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OBJECTIVES

The primary aim was to evaluate the feasibility of the ERAS guidelines for patients undergoing PD. Secondary aims were to assess length of stay (LOS), readmission within 30 days, 30-day mortality, and total surgical complication rates.
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METHODS

Guideline feasibility was evaluated by percentage completion and compliance to each of the perioperative phases of the guideline. Hospital LOS, 30-day readmission, 30-day mortality, and total surgical complication rates were compared before and after ERAS implementation. 
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FINDINGS

The ERAS guidelines were feasible and safely implemented with no change in LOS, readmission, morbidity, and mortality rates.

The Post-SIR-Spheres Surgery Study (P4S): Retrospective Analysis of Safety Following Hepatic Resection or Transplantation in Patients Previously Treated with Selective Internal Radiation Therapy with Yttrium-90 Resin Microspheres

BACKGROUND

Reports show that selective internal radiation therapy (SIRT) may downsize inoperable liver tumors to resection or transplantation, or enable a bridge-to-transplant. A small-cohort study found that long-term survival in patients undergoing resection following SIRT appears possible but no robust studies on postsurgical safety outcomes exist. The Post-SIR-Spheres Surgery Study was an international, multicenter, retrospective study to assess safety outcomes of liver resection or transplantation following SIRT with yttrium-90 (Y-90) resin microspheres (SIR-Spheres^®; Sirtex).

METHODS

Data were captured retrospectively at participating SIRT centers, with Y-90 resin microspheres, surgery (resection or transplantation), and follow-up for all eligible patients. Primary endpoints were perioperative and 90-day postoperative morbidity and mortality. Standard statistical methods were used.

RESULTS

The study included 100 patients [hepatocellular carcinoma: 49; metastatic colorectal cancer (mCRC): 30; cholangiocarcinoma, metastatic neuroendocrine tumor, other: 7 each]; 36% of patients had one or more lines of chemotherapy pre-SIRT. Sixty-three percent of patients had comorbidities, including hypertension (44%), diabetes (26%), and cardiopathy (16%). Post-SIRT, 71 patients were resected and 29 received a liver transplant. Grade 3+ peri/postoperative complications and any grade of liver failure were experienced by 24 and 7% of patients, respectively. Four patients died <90 days postsurgery; all were trisectionectomies (mCRC: 3; cholangiocarcinoma: 1) and typically had one or more previous chemotherapy lines and presurgical comorbidities.

CONCLUSIONS

In 100 patients undergoing liver surgery after receiving SIRT, mortality and complication rates appeared acceptable given the risk profile of the recruited patients.

The Post-SIR-Spheres Surgery Study (P4S): Retrospective Analysis of Safety Following Hepatic Resection or Transplantation in Patients Previously Treated with Selective Internal Radiation Therapy with Yttrium-90 Resin Microspheres

BACKGROUND

Reports show that selective internal radiation therapy (SIRT) may downsize inoperable liver tumors to resection or transplantation, or enable a bridge-to-transplant. A small-cohort study found that long-term survival in patients undergoing resection following SIRT appears possible but no robust studies on postsurgical safety outcomes exist. The Post-SIR-Spheres Surgery Study was an international, multicenter, retrospective study to assess safety outcomes of liver resection or transplantation following SIRT with yttrium-90 (Y-90) resin microspheres (SIR-Spheres^®; Sirtex).

METHODS

Data were captured retrospectively at participating SIRT centers, with Y-90 resin microspheres, surgery (resection or transplantation), and follow-up for all eligible patients. Primary endpoints were perioperative and 90-day postoperative morbidity and mortality. Standard statistical methods were used.

RESULTS

The study included 100 patients [hepatocellular carcinoma: 49; metastatic colorectal cancer (mCRC): 30; cholangiocarcinoma, metastatic neuroendocrine tumor, other: 7 each]; 36% of patients had one or more lines of chemotherapy pre-SIRT. Sixty-three percent of patients had comorbidities, including hypertension (44%), diabetes (26%), and cardiopathy (16%). Post-SIRT, 71 patients were resected and 29 received a liver transplant. Grade 3+ peri/postoperative complications and any grade of liver failure were experienced by 24 and 7% of patients, respectively. Four patients died <90 days postsurgery; all were trisectionectomies (mCRC: 3; cholangiocarcinoma: 1) and typically had one or more previous chemotherapy lines and presurgical comorbidities.

CONCLUSIONS

In 100 patients undergoing liver surgery after receiving SIRT, mortality and complication rates appeared acceptable given the risk profile of the recruited patients.

Irreversible electroporation in locally advanced pancreatic cancer: A call for standardization of energy delivery

Irreversible Electroporation (IRE) is used to treat locally advanced cancers, commonly of the pancreas, liver, kidney, and other soft tissues. Precise eligibility for IRE should be established in each individual patient by a multidisciplinary team based on comprehensive clinical, imaging, and laboratory assessment. Standardization of IRE technique and protocols is expected to improve safety, lead to reproducible outcomes, and facilitate further research into IRE. The present article provides a set of technical recommendations for the use of IRE in the treatment of locally advanced pancreatic cancer. J. Surg. Oncol. 2016;114:865-871. © 2016 2016 Wiley Periodicals, Inc.

Training and practice of the next generation HPB surgeon: analysis of the 2014 AHPBA residents' and fellows' symposium survey

BACKGROUND

Hepato-pancreato-biliary (HPB) surgery is a complex subspecialty drawing from varied training pools, and the need for competency is rapidly growing. However, no board certification process or standardized training metrics in HPB surgery exist in the Americas. This study aims to assess the attitudes of current trainees and HPB surgeons regarding the state of training, surgical practice and the HPB surgical job market in the Americas.

STUDY DESIGN

A 20-question survey was distributed to members of Americas Hepato-Pancreato-Biliary Association (AHPBA) with a valid e-mail address who attended the 2014 AHPBA. Descriptive statistics were generated for both the aggregate survey responses and by training category.

RESULTS

There were 176 responses with evenly distributed training tracks; surgical oncology (44, 28%), transplant (39, 24.8%) and HPB (38, 24.2%). The remaining tracks were HPB/Complex gastrointestinal (GI) and HPB/minimally invasive surgery (MIS) (29, 16% and 7, 4%). 51.2% of respondents thought a dedicated HPB surgery fellowship would be the best way to train HPB surgeons, and 68.1% felt the optimal training period would be a 2-year clinical fellowship with research opportunities. This corresponded to the 67.5% of the practicing HPB surgeons who said they would prefer to attend an HPB fellowship for 2 years as well. Overall, most respondents indicated their ideal job description was clinical practice with the ability to engage in clinical and/or outcomes research (52.3%).

CONCLUSIONS

This survey has demonstrated that HPB surgery has many training routes and practice patterns in the Americas. It highlights the need for specialized HPB surgical training and career education. This survey shows that there are many ways to train in HPB. A 2-year HPB fellowship was felt to be the best way to train to prepare for a clinically active HPB practice with clinical and outcomes research focus.

Transgene expression up to 7 years in nonhuman primates following hepatic transduction with helper-dependent adenoviral vectors

Helper-dependent adenoviral vectors (HDAd) have been shown to mediate a considerably longer duration of transgene expression than first-generation adenoviral vectors. We have previously shown that transgene expression from HDAd-transduced hepatocytes can persist at high levels for up to 2.6 years in nonhuman primates following a single-vector administration. Because duration of transgene expression and long-term toxicity are critical for risk:benefit assessment, we have continued to monitor these animals. We report here that transgene expression has persisted for the entire observation period of up to 7 years for all animals without long-term adverse effects. However, in all cases, transgene expression level slowly declined over time to less than 10% of peak values by the end of the observation period but remained 2.3-111-fold above baseline values. These results will provide important information for a more informed risk:benefit assessment before clinical application of HDAd.

Development of a Functional, Internet-Accessible Department of Surgery Outcomes Database

The need for surgical outcomes data is increasing due to pressure from insurance companies, patients, and the need for surgeons to keep their own “report card”. Current data management systems are limited by inability to stratify outcomes based on patients, surgeons, and differences in surgical technique. Surgeons along with research and informatics personnel from an academic, hospital-based Department of Surgery and a state university's Department of Information Technology formed a partnership to develop a dynamic, internet-based, clinical data warehouse. A five-component model was used: data dictionary development, web application creation, participating center education and management, statistics applications, and data interpretation. A data dictionary was developed from a list of data elements to address needs of research, quality assurance, industry, and centers of excellence. A user-friendly web interface was developed with menu-driven check boxes, multiple electronic data entry points, direct downloads from hospital billing information, and web-based patient portals. Data were collected on a Health Insurance Portability and Accountability Act-compliant server with a secure firewall. Protected health information was de-identified. Data management strategies included automated auditing, on-site training, a trouble-shooting hotline, and Institutional Review Board oversight. Real-time, daily, monthly, and quarterly data reports were generated. Fifty-eight publications and 109 abstracts have been generated from the database during its development and implementation. Seven national academic departments now use the database to track patient outcomes. The development of a robust surgical outcomes database requires a combination of clinical, informatics, and research expertise. Benefits of surgeon involvement in outcomes research include: tracking individual performance, patient safety, surgical research, legal defense, and the ability to provide accurate information to patient and payers.

Development of a functional, internet-accessible department of surgery outcomes database

The need for surgical outcomes data is increasing due to pressure from insurance companies, patients, and the need for surgeons to keep their own "report card". Current data management systems are limited by inability to stratify outcomes based on patients, surgeons, and differences in surgical technique. Surgeons along with research and informatics personnel from an academic, hospital-based Department of Surgery and a state university's Department of Information Technology formed a partnership to develop a dynamic, internet-based, clinical data warehouse. A five-component model was used: data dictionary development, web application creation, participating center education and management, statistics applications, and data interpretation. A data dictionary was developed from a list of data elements to address needs of research, quality assurance, industry, and centers of excellence. A user-friendly web interface was developed with menu-driven check boxes, multiple electronic data entry points, direct downloads from hospital billing information, and web-based patient portals. Data were collected on a Health Insurance Portability and Accountability Act-compliant server with a secure firewall. Protected health information was de-identified. Data management strategies included automated auditing, on-site training, a trouble-shooting hotline, and Institutional Review Board oversight. Real-time, daily, monthly, and quarterly data reports were generated. Fifty-eight publications and 109 abstracts have been generated from the database during its development and implementation. Seven national academic departments now use the database to track patient outcomes. The development of a robust surgical outcomes database requires a combination of clinical, informatics, and research expertise. Benefits of surgeon involvement in outcomes research include: tracking individual performance, patient safety, surgical research, legal defense, and the ability to provide accurate information to patient and payers.

Docetaxel, capecitabine and carboplatin in metastatic esophagogastric cancer: a phase II study

PURPOSE

A Phase I investigation of docetaxel, carboplatin, and capecitabine at our institution demonstrated the safety and tolerability of this regimen in patients with metastatic esophagogastric cancer. The objectives of this Phase II study were to determine the response rate, toxicity, and survival for patients with metastatic esophagogastric cancer treated with this regimen.

MATERIALS AND METHODS

Chemotherapy naïve patients with metastatic esophageal or gastric cancer received a regimen comprised of docetaxel 40 mg/m(2), days 1 and 8, carboplatin AUC = 2, Days 1 and 8, and capecitabine 2000 mg/m(2), Days 1-10 in 21-Day cycles. Patients were treated until disease progression or unacceptable toxicity.

RESULTS

Twenty-five patients were treated with a median of 4 cycles of chemotherapy. Twelve of 25 patients (48 percent) had a Grade 3/4 toxicity. There were no Grade 4 nonhematologic toxicities, and 1 patient (4 percent) had neutropenic fever. There were 3 complete responses, and 9 partial responses, for an overall response rate of 48 percent. The median survival was 8 months (95% confidence interval, 5.5-13 months), and the 1-year survival was 36 percent.

CONCLUSIONS

Weekly docetaxel and carboplatin with capecitabine was an easily administered outpatient regimen. The response rate and 1-year survival were similar to more complex regimens. Future trials may investigate the substitution of carboplatin with more active agents.

Paclitaxel poliglumex (PPX-Xyotax) and concurrent radiation for esophageal and gastric cancer: a phase I study

OBJECTIVES

To determine the maximal tolerated dose (MTD) and dose limiting toxicities of poly(l-glutamic acid)-paclitaxel (PPX) and concurrent radiation (PPX/RT) for patients with esophageal and gastric cancer.

METHODS

Patients with esophageal or gastric cancer receiving chemoradiation for loco-regional, adjuvant, or palliative intent were eligible. The initial dose of PPX was 40 mg/m2/wk, for 6 weeks with 50.4 Gy radiation. Dose levels were increased in increments of 10 mg/m2/wk of PPX.

RESULTS

Twenty-one patients were enrolled over 5 dose levels. Sixteen patients had esophageal cancer and 5 had gastric cancer. Twelve patients received PPX/RT as definitive loco-regional therapy, 4 patients had undergone resection and received adjuvant PPX/RT, and 5 patients had metastatic disease and received PPX/RT for palliation of dysphagia. Dose limiting toxicities of gastritis, esophagitis, neutropenia, and dehydration developed in 3 of 4 patients treated at the 80 mg/m2 dose level. Four of 12 patients (33%) with loco-regional disease had a complete clinical response.

CONCLUSIONS

The maximally tolerated dose of PPX with concurrent radiotherapy is 70 mg/m2/wk for patients with esophageal and gastric cancer.

Hepatic arterial infusion (HAI) of oxaliplatin in advanced hepatocellular cancer (HCC): A phase I study

14010

Background: We performed this phase I study is to evaluate the feasibility and determine the Maximally Tolerated Dose of HAI-oxaliplatin given every 3 weeks in advanced HCC. Methods: Patients (pts) with unresectable or recurrent HCC were eligible for therapy on this protocol. HAI-oxaliplatin was administered over 2 hours via a percutaneously placed hepatic arterial catheter or a surgically inserted hepatic arterial infusion pump. Therapy was continued until disease progression or excessive toxicity not amenable to appropriate modifications. Restaging was performed after every 2 cycles. Dose escalation levels for HAI-oxaliplatin are 90 mg/m2, 110 mg/m2, 130 mg/m2 and 150 mg/m2 given every 3 weeks. Results: A total of 16 patients have been enrolled and toxicity data are available for all patients. Median age was 61 yrs (range 47–84 yrs), there were 15 men and 1 woman. The stage distribution is: stage II-3 pts, stage III- 7 pts, stage IV- 6 pts. Prior therapies including chemoembolization (CE) in 3 pts, radiofrequency ablation (RFA) in 3 pts, and both RFA and CE in 1 pt. A total of 37 cycles (range 1–3) have been delivered. Levels 1 and 3 had to be expanded to 6 pts each due to major toxicity in 2 pts at each level. Level 2 was expanded as 1 pt was non-compliant. Major toxicities are shown below. One patient developed embolic bowel ischemia after his HAI procedure. There was one episode each of duodenal perforation and duodenal ulceration. Traditional grade 3/4 hematologic and gastrointestinal toxicities were infrequent. Among 13 pts receiving at least 2 cycles, 3 pts had partial responses (PR) and 4 pts had stable disease (SD). Greater than 50% reduction in AFP was seen in the 3 pts with PR and 2 pts with SD. Conclusions: HAI-oxaliplatin is feasible, well tolerable, and demonstrates activity in this population of pts with advanced HCC. [Table: see text]

No significant financial relationships to disclose.

GW572016, gemcitabine and GW572016, gemcitabine, oxaliplatin, a two-stage, phase I study for advanced pancreaticobiliary cancer

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Background: GW572016 is an orally active small molecule that reversibly inhibits ErbB1 and ErbB2 tyrosine kinases. ErbB1 is commonly expressed in pancreaticobiliary cancers. ErbB2 is the preferred heterodimer partner for other ErbB receptors. Baerman et al demonstrated that GW572016 was active against pancreatic cancer cell lines (ASCO GI 2005). We have completed a two-stage, phase I evaluation of GW572016 and gemcitabine (gem), and GW572016 with the combination of gemcitabine and oxaliplatin (GEMOX). Methods: Patients with advanced adenocarcinoma of the pancreas or bile ducts were treated with GW572016 and either weekly gemcitabine (1gm/m2/week, 3 weeks on, 1 week off) or GEMOX (gemcitabine 1g/m2 over 100 minutes and oxaliplatin 100 mg/m2, every 14 days). Cohort 1: Weekly gem + GW572016, 1000mg/day. Cohort 2: Weekly gem + GW572016, 1500 mg/day. Cohort 3: GEMOX + GW572016 1000 mg/day. Cohort 4: GEMOX + GW572016 1500 mg/day. Results: Twenty-one patients have been treated; pancreatic cancer (n=15), biliary cancer (n=6). The median age was 64 (41–78). One of six patients in cohort 2 had grade 3 diarrhea. Dose limiting grade 3 nausea occurred in 2 of 5 patients in cohort 4. Two patients had a temporary decrease in cardiac ejection fraction. Five of 20 evaluable patients (25%) responded. Conclusions: GW572016 1500 mg/day can be administered will full dosage gem. The MTD of GW572016 is 1000mg/day with GEMOX. Dramatic responses have been demonstrated in patients with diffuse liver and peritoneal metastases suggesting that erbB1/erbB2 signaling is important in pancreaticobiliary cancers. Further evaluation of GW572016 in pancreaticobiliary cancer is indicated.

[Table: see text]

Erlotinib and chemoradiation followed by maintenance erlotinib for locally advanced pancreatic cancer: a phase I study

OBJECTIVES

A phase I trial was conducted to determine the maximally tolerated dose of erlotinib with concurrent gemcitabine, paclitaxel, and radiation for patients with locally advanced pancreatic cancer and to gather preliminary data on maintenance erlotinib after chemoradiation.

METHODS

Patients received gemcitabine, 75 mg/m2, and paclitaxel, 40 mg/m, weekly for 6 weeks with 50.4 radiation to the primary tumor and draining lymph nodes with a 2- to 3-cm margin. Erlotinib was administered over 3-dose levels (50-100 mg/d) with chemoradiation then all patients received 150 mg/d maintenance until disease progression.

RESULTS

Seventeen patients were assessable for toxicity; 13 with locally advanced disease and 4 who had undergone resection but had positive margins. At erlotinib dosages > or =75 mg/d with chemoradiation the dose-limiting toxicities were diarrhea, dehydration, rash, myelosuppression, and small bowel stricture. Maintenance erlotinib, 150 mg/d, was well tolerated. The median survival of the 13 patients with locally advanced disease was 14.0 months and 6 of 13 (46%) had a partial response.

CONCLUSIONS

The maximum tolerated dose of erlotinib with gemcitabine, paclitaxel and concurrent radiation is 50 mg/d for patients with locally advanced pancreatic cancer. Full dose maintenance erlotinib is well tolerated. Promising preliminary activity and overall survival were demonstrated.

Phase I study of docetaxel, capecitabine, and carboplatin in metastatic esophagogastric cancer

OBJECTIVES

A phase I trial was conducted to determine the maximally tolerated dose (MTD) and dose-limiting toxicities (DLTs) of docetaxel, capecitabine, and carboplatin for first-line treatment of patients with metastatic esophageal and gastric cancers.

METHODS

Twenty-eight patients were treated over 5 dose levels in a 21-day cycle. Patients received carboplatin (AUC = 2) on days 1 and 8, docetaxel (35-40 mg/m2) on days 1 and 8, and capecitabine (500-2000 mg/m2) on days 1 to 10.

RESULTS

There were no DLTs in the first cycle of treatment. Dose reductions were required in 10 of 15 patients at the final dose level due to neutropenia, nausea, vomiting, diarrhea, dehydration, and hand/foot syndrome following a median of 3 cycles of treatment. Therefore, escalation beyond dose level 5 was not attempted. The MTD was docetaxel, 40 mg/m2 days 1 and 8; carboplatin, AUC = 2 days 1 and 8; and capecitabine, 1500 to 2000 mg/m2 days 1 to 10 in a 21-day cycle. Ten of 25 patients who could be evaluated (40%) responded and 8 of 14 patients treated at the final dose level responded (57%).

CONCLUSIONS

Cumulative gastrointestinal toxicities and neutropenia were the DLTs of docetaxel, capecitabine, and carboplatin. This combination represents an easily administered, active regimen for patients with metastatic gastric and esophageal cancers. Further evaluation of this regimen is indicated.

Herceptin and gemcitabine for metastatic pancreatic cancers that overexpress HER-2/neu

PURPOSE

To determine the response rate and toxicities of Herceptin and gemcitabine for patients with metastatic pancreatic adenocarcinomas that overexpress HER-2/neu.

METHODS AND MATERIALS

Patients with metastatic pancreatic cancer with 2+/3 + HER-2/neu expression by immunohistochemistry were eligible. Patients received gemcitabine, 1 g/m2/week, for 7 of 8 weeks followed by 3 of every 4 weeks, and Herceptin, 4 mg/kg loading dose, followed by 2 mg/kg/week.

RESULTS

Screening logs demonstrated the rate of HER-2/neu overexpression was 16%. Thirty-four patients were enrolled. Thirty patients (88%) had pancreatic cancers with 2+ overexpression and 4 patients (12%) had 3+ overexpression. Toxicity was similar to gemcitabine alone. Confirmed partial responses were observed in 2 of 32 patients (6%). Thirteen of 32 patients (41%) had either a partial response or a >50% reduction in CA 19-9. The median survival for all 34 patients was 7 months, and the 1-year survival was 19%.

CONCLUSION

The response rate of Herceptin and gemcitabine is similar to gemcitabine alone. The 7-month median survival in patients with metastatic pancreatic cancer suggests there may be a modest benefit for some patients. Infrequent HER-2/neu overexpression limits the role of targeting the HER-2/neu gene and prevents definitive conclusions on the addition of Herceptin to gemcibine for patients with pancreatic cancer.

Herceptin and gemcitabine for metastatic pancreatic cancers that overexpress HER-2/neu

PURPOSE

To determine the response rate and toxicities of Herceptin and gemcitabine for patients with metastatic pancreatic adenocarcinomas that overexpress HER-2/neu.

METHODS AND MATERIALS

Patients with metastatic pancreatic cancer with 2+/3 + HER-2/neu expression by immunohistochemistry were eligible. Patients received gemcitabine, 1 g/m2/week, for 7 of 8 weeks followed by 3 of every 4 weeks, and Herceptin, 4 mg/kg loading dose, followed by 2 mg/kg/week.

RESULTS

Screening logs demonstrated the rate of HER-2/neu overexpression was 16%. Thirty-four patients were enrolled. Thirty patients (88%) had pancreatic cancers with 2+ overexpression and 4 patients (12%) had 3+ overexpression. Toxicity was similar to gemcitabine alone. Confirmed partial responses were observed in 2 of 32 patients (6%). Thirteen of 32 patients (41%) had either a partial response or a >50% reduction in CA 19-9. The median survival for all 34 patients was 7 months, and the 1-year survival was 19%.

CONCLUSION

The response rate of Herceptin and gemcitabine is similar to gemcitabine alone. The 7-month median survival in patients with metastatic pancreatic cancer suggests there may be a modest benefit for some patients. Infrequent HER-2/neu overexpression limits the role of targeting the HER-2/neu gene and prevents definitive conclusions on the addition of Herceptin to gemcibine for patients with pancreatic cancer.

Gemcitabine, paclitaxel, and radiation for locally advanced pancreatic cancer: a Phase I trial

PURPOSE

To determine the maximum tolerated dose (MTD) and dose-limiting toxicities of gemcitabine, paclitaxel, and concurrent radiation for pancreatic cancer.

METHODS AND MATERIALS

Twenty patients with locally unresectable pancreatic cancer were studied. The initial dose level was gemcitabine 75 mg/m(2) and paclitaxel 40 mg/m(2) weekly for 6 weeks. Concurrent radiation to 50.4 Gy was delivered in 1.8 Gy fractions. The radiation fields included the primary tumor, plus the regional peripancreatic, celiac, and porta hepatis lymph nodes.

RESULTS

Dose-limiting toxicities of diarrhea, dehydration, nausea, and anorexia occurred in 3 of 3 patients at the second dose level of gemcitabine, 150 mg/m(2)/week. An intermediate dose level of gemcitabine, 110 mg/m(2)/week, was added, but gastrointestinal toxicity and pulmonary pneumonitis were encountered. The MTD therefore was gemcitabine 75 mg/m(2)/week with paclitaxel 40 mg/m(2)/week and concurrent radiation. Two of 11 patients treated at the MTD had Grade 3/4 toxicity. Four of 10 assessable patients treated at the MTD responded (40%), including one pathologic complete response.

CONCLUSION

The maximum tolerated dosage of gemcitabine is 75 mg/m(2)/week with paclitaxel 40 mg/m(2)/week and conventional 50.4 Gy radiation fields. A Phase II Radiation Therapy Oncology Group study is under way.

Overexpression of the HER-2/neu oncogene in pancreatic adenocarcinoma

Novel systemic treatments are needed in pancreatic cancer. The authors sought to establish the frequency of overexpression of the HER-2/neu oncogene in patients with pancreatic adenocarcinoma to determine the potential role of trastuzumab (Herceptin) as a therapeutic agent in this disease. Tumor specimens from patients with pancreatic adenocarcinoma were analyzed by staining for p185HER2 protein using the DAKO immunohistochemical assay. Patients with and without HER-2/neu overexpression by immunohistochemistry were compared with respect to clinical and pathologic characteristics. HER-2/neu gene amplification was also evaluated by fluorescence in situ hybridization (FISH). Thirty-two of 154 patients (21%) had pancreatic adenocarcinoma that demonstrated HER-2/neu overexpression by immunohistochemistry. At initial diagnosis, 16% of resectable cancers, 17% of locally advanced cancers, and 26% of metastatic cancers were determined to have HER-2/neu overexpression. Three of 11 (27%) patients with HER-2/neu overexpression by immunohistochemistry had gene amplification by FISH. HER-2/neu overexpression occurs in a subset of pancreatic cancer. Evaluation of the efficacy of trastuzumab for patients with pancreatic cancer who overexpress HER-2/neu appears indicated.

Paclitaxel and concurrent radiation for locally advanced pancreatic cancer

PURPOSE

To determine the activity and toxicity of paclitaxel and concurrent radiation for pancreatic cancer.

METHODS AND MATERIALS

Forty-four patients with locally unresectable pancreatic cancer were studied. Patients received paclitaxel, 50 mg/m(2) by 3 h i.v. (IV) infusion, weekly, on Days 1, 8, 15, 22 and 29. Radiation was administered concurrently to a total dose of 50.4 Gy, in 1.80 Gy fractions, for 28 treatments.

RESULTS

Nausea and vomiting were the most common toxicities, Grade 3 in five patients (12%). Two patients (5%) had Grade 4 hypersensitivity reactions to their first dose of paclitaxel. Of 42 evaluable patients, the overall response rate was 26%. The median survival was 8 months, and the 1-year survival was 30%.

CONCLUSION

Concurrent paclitaxel and radiation demonstrate local-regional activity in pancreatic cancer. Future investigations combining paclitaxel with other local-regional and systemic treatments are warranted.

Paclitaxel and concurrent radiation for locally advanced pancreatic carcinoma

An effective local-regional therapy is needed for adenocarcinomas of the pancreas. Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton NJ) may enhance the effect of radiation therapy. Paclitaxel synchronizes cells at G2/M, a relatively radiosensitive phase of the cell cycle. We have shown that response to paclitaxel and concurrent radiation (paclitaxel/RT) was not affected by p53 mutations in non-small cell lung cancer (NSCLC). This suggested that paclitaxel/RT was a rationale treatment approach for other malignancies which frequently harbor p53 mutations such as upper gastrointestinal malignancies. We have completed a phase I study of paclitaxel/RT for locally advanced pancreatic and gastric cancers. The maximum tolerated dose (MTD) of paclitaxel was 50 mg/m2/week for 6 weeks with abdominal radiation. The dose limiting toxicities were abdominal pain within the radiation field, nausea and anorexia. Twenty-five patients with locally advanced pancreatic cancer have now completed treatment at the phase II dose level of paclitaxel 50 mg/m2/week with 50 Gy concurrent RT. Thus far, the only grade 3/4 toxicities have been hypersensitivity reactions in 2 patients, asymptomatic grade 4 neutropenia in 3 patients, and non-neutropenic biliary sepsis in 1 patient. Of the first 22 assessable patients treated at the phase II study, 8 obtained a partial response (PR) for a preliminary response rate of 36%. These findings demonstrate that paclitaxel/RT is well tolerated with substantial activity for locally advanced pancreatic cancer.

Peritoneal drainage as definitive treatment for intestinal perforation in infants with extremely low birth weight (<750 g)

BACKGROUND

Advances in neonatal intensive care have improved the survival of the extremely premature infant. However, survival at less than 25 weeks' gestational age remains tenuous, with intestinal perforation presenting a significant mortality.

METHODS

During an 18-month period from 1995 to 1996, nine patients weighing less than 750 g (range, 485 to 740 g; mean, 615 g) presented with intestinal perforation. All patients were treated with peritoneal drainage. Drains were removed after clinical improvement and the cessation of peritoneal drainage.

RESULTS

Seven patients survived the initial drainage procedure (78%). At a mean follow-up of 12 months, the six long-term survivors are all tolerating full enteral feeds, and none developed intestinal strictures or intraabdominal abscess. No patient required subsequent celiotomy. Peritoneal drainage has previously been considered in some centers as temporary therapy in extremely ill neonates deemed unlikely to survive operation. The authors have adopted drainage as the sole treatment in selected patients.

CONCLUSION

Peritoneal drainage alone may be considered definitive therapy for intestinal perforation in the majority of micropremature infants.