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5-year survival of 42%. Conclusion: Metastatic renal cell carcinoma is typically associatedwith poor survival. Pancreatic resection for metastases may offer a survival advantage;however, potential patient selection bias and lack of comparative trials limit validation.Pancreatic resection does appear warranted in selected patients where an R0 resectionis possible.

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Pancreatic Acinar Cell Carcinoma: A Multi-Institutional StudyJesus M. Matos, C. Max Schmidt, Marco Niedergethmann, Hans Detlev Saeger, NipunMerchant, Keith D. Lillemoe, Robert Grützmann

Background: Acinar cell carcinoma of the pancreas (ACC) accounts for approximately 1%of exocrine pancreatic tumors. Prognosis is poor, but recent studies suggest a better prognosisthan ductal adenocarcinoma (DA). This study represents pooled data from multiple academicinstitutions to better understand the natural history and outcomes of patients with this rareform of pancreatic cancer. Methods: Multi-institutional retrospective review of patients withACC was conducted to evaluate the clinical presentation and outcomes of patients withACC. Results: Between the years 1988 and 2007, 16 patients were identified with acinarcell carcinoma (ACC) of the pancreas. Median age at presentation was 65 years. Patientscommonly presented with abdominal (56%), back pain (44%) and weight loss (40%).Jaundice was not a typical presenting symptom. Fourteen patients underwent 15 operations:pancreaticoduodenectomy (8), distal pancreatectomy (4), and exploratory laparotomy (3).Three patients were found to be unresectable at initial operation, two with regionally advancedtumors and one with occult liver metastases. One patient with a regionally advanced tumorreceived neoadjuvant chemotherapy and was subsequently resected, and the other underwentchemoradiation but developed distant disease (supraclavicular node). Two patients werereferred for surgery, but were managed non-operatively due to metastases. Mean tumor sizewas 5.5 ± 0.7 cm. AJCC tumor stages were stage I (1); stage II (9); stage III (3); and stageIV (3). In resected cases, 1 year survival was 100% and 5 year survival was 50%. Seven of12 resected patients remain alive. One, the longest survivor to date (stage II), has survived83 months. Two experienced hepatic metastases as a first sign of recurrence. One succumbed13 months after distal pancreatectomy, and the other remains alive 76 months after pancre-aticoduodenectomy. Patients with pre-operative metastases managed non-operatively werefound to have a broad range of survival (1-63 months). Conclusion: ACC of the pancreasis rare and has a presentation and outcome distinct from pancreatic ductal adenocarcinoma.Tumor size is larger at presentation, and prognosis in resected patients reflects other recentseries demonstrating better survival. Patients with advanced disease managed non-operativelyexperience variable survival. A larger study is needed to examine treatment related outcomesand other predictors of survival in patients with ACC of the pancreas.

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Pancreatic Exocrine Function in Patients Undergoing Distal PancreatectomyAs Assessed By Human Stool Elastase-1James E. Speicher, L. William Traverso

Introduction: What impact does distal pancreatectomy have on pancreatic exocrine function?With the recent ability to measure human stool elastase-1 (HSE-1), the evaluation of exocrineinsufficiency has become less complex and has a negative predictive value of almost 100%.Our studies have suggested that pancreatic insufficiency after pancreaticoduodenectomy iscaused by exocrine atrophy from pancreatic cancer and/or parenchymal loss from resection.Our objective was to use HSE-1 to determine exocrine function after distal pancreatectomy(DP) - this has not previously been studied. Methods: During a 65 month period (July2002 - November 2007), 100 patients underwent DP by the same surgeon. The pathologictissue diagnosis and the amount of pancreas resected were recorded. Extent of resectionwas divided into two categories, those limited to the left of the portal vein (PV) and thoseextending to the PV or further. HSE-1 values were measured preoperatively in 68 patientsand repeated at 3 + 2 months, 12 + 3 months, and 24 + 6 months in 39, 19, and 9 patients,respectively. HSE-1 was expressed as abnormal at <200 µg/g stool. Results: PreoperativeHSE-1 values were abnormal in 19% of patients prior to undergoing DP (67% if chronicpancreatitis, 38% if pancreatic adenocarcinoma, and 11% in all other diseases; p<0.001).Postoperative HSE-1 levels were then compared by the amount of pancreas resected. Atthree months after resection, HSE-1 was normal or became normal in all patients if resectionwas limited to the left of the PV, but in just 79% if resection extended to the PV (p=0.03).At 12 months, normal HSE-1 was observed in 100% of patients if the resection was to theleft of the PV and 88% if resection extended to the PV (p=0.2). At 24 months, our limitedresults showed normal function in 100% of patients if the resection was to the left of thePV and 75% if resection extended to the PV (p=0.2). In the subgroup with normal preoperativeHSE-1 (81% of patients) whose resection was limited to the left of the PV, 100% had normalexocrine function at all timepoints. If the resection extended to the PV, 82% had normalexocrine function at three months (p=0.09), while 100% had normal exocrine function at12 and 24 months. Conclusion: Of patients undergoing DP, one-fifth will have pancreaticinsufficiency, most commonly those with pancreatic adenocarcinoma or chronic pancreatitis.Postoperative pancreatic insufficiency was seen only in those with resection that extendedto the PV or beyond, and was transient. Exocrine insufficiency before and after DP is relatedto both the disease and the extent of resection, and can improve with time.

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Risk Factors for Pancreatic Leak Following Distal PancreatectomyHari Nathan, Michael Choti, Christopher L. Wolfgang, C. Rory Goodwin, Akhil K. Seth,Jordan M. Winter, Edil H. Barish, Richard D. Schulick, Timothy M. Pawlik, John L.Cameron

Background: Pancreatic leak (PL) remains a major cause of postoperative morbidity inpatients undergoing pancreatic resection. We sought to evaluate the incidence of and identifyrisk factors for the development of PL in patients undergoing distal pancreatectomy (DP).

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Methods: All patients who underwent primary DP (excluding completion pancreatectomyand debridement) between 1/1/1984 and 7/1/2006 were identified. Data on demographics,clinicopathologic features, operative details, complications, and mortality were analyzed.Chi-squared and multivariate logistic regression analyses were performed to identify riskfactors for PL. Results: In a cohort of 704 patients undergoing primary DP, the median agewas 58 years, 45% were male, and 80% were white. The indications for DP were benignpancreatic neoplasm (34%), malignant pancreatic neoplasm (31%), other neoplasm (15%),chronic pancreatitis (14%), pseudocyst (3%), and trauma (3%). Splenectomy was performedin 89%. The pancreatic remnant was sutured alone in 83%, stapled alone in 5%, and bothstapled and sutured in 9%. Duct ligation was performed in 22%. Perioperative mortalitywas <1%, but overall morbidity was 33%. PL requiring a change in clinical managementwas seen in 12% of cases. Development of PL was associated with an increase in perioperativemortality from 1% to 4% (P=0.04) and an increase in median length of stay from 7 to 10days (P<0.001). Of those with PL, 35% required additional percutaneous drainage, but only2% required reoperative intervention. Multivariate analysis revealed that malignant neoplasm(odds ratio (OR) 1.3, P=0.29) and chronic pancreatitis (OR 1.6, P=0.12) as indications forDP did not change PL risk as compared to benign neoplasm. However, increased risk ofPL was seen when DP was performed for trauma (OR 6.2, P=0.001) or pseudocyst (OR 3.3,P=0.02). Tobacco use (OR 2.0, P<0.001) was associated with increased PL risk, whilepreoperative diabetes was associated with decreased risk (OR 0.33, P=0.003). Neither staplevs. suture closure of the pancreatic remnant (OR 1.4, P=0.65) nor ligation of the pancreaticduct (OR 2.0, P=0.05) affected PL risk. Conclusions: This largest reported series of DPdemonstrates that this procedure can be performed with low mortality but still carries asubstantial risk of morbidity, particularly PL. DP in the trauma setting significantly increasesthe risk of PL. In contrast to previous studies, PL risk was not associated with surgicalmanagement of the pancreatic remnant. These results emphasize the need for prospectiverandomized trials to evaluate strategies to reduce PL occurrence.

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Analysis of Organ Failure, Mortality and Pancreatic Necrosis in Patients withSevere Acute PancreatitisTercio De Campos, Cinara Cerqueira, Laise Kuryura, Silvia Solda, Jacqueline Perlingeiro,Jose C. Assef, Samir Rasslan

Background: mortality in severe acute pancreatitis varies from 10% to 20%. The earlyidentification of patients with higher risk of complications is crucial to treat them properly.APACHE II is the most used scoring system to determine the severity of acute pancreatitis.However, some problems have been related, as the overestimation of severity, and otherscores have been proposed, such as SOFA and Marshall. The aim of this study is to determinevariables related to the development of organ failure, mortality and necrotizing pancreatitisin patients with severe acute pancreatitis. Methods: evaluation of all patients with acutepancreatitis admitted in this hospital, including in the analysis only patients with APACHEII > 8 at admission. SOFA score and Marshall score were also obtained. The variablesanalyzed were age, sex, aetiology, hematocrit, leukocytes, C-reactive protein, computerizedtomography and length of stay. These variables were related with the development of organfailure, mortality and necrotizing pancreatitis. Results: One hundred and seventy-five patientswere admitted with acute pancreatitis, and 39 (22.3%) were classified as severe acutepancreatitis due to APACHE II > 8. The mean APACHE II value was 11.6 ± 3.1, SOFAscore 3.2 ± 2 and Marshall 1.5 ± 1.9. Respiratory failure was present in six (15,4%) patientswith severe acute pancreatitis. Eleven patients developed necrotizing pancreatitis. Mortalityof patients with APACHE II > 8 was 7.7%. The variables related with organ failure wereAPACHE II, SOFA > 3 and Marshall > 3, and variables related with mortality were SOFA> 3 and leukocytosis > 19,000. C-reactive protein > 19.5 mg/dl and length of stay wererelated to necrotizing pancreatitis. Conclusion: the scoring systems, particularly the SOFAscore, are related to the development of organ failure and mortality. C-reactive proteindemonstrates relationship with necrotizing pancreatitis. There is no relationship betweenscoring systems and necrotizing pancreatitis in severe acute pancreatitis.

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Quality of Life in Long-Term Survivors After PancreaticoduodenectomyRoberto Salvia, Stefano Crippa, Francesca Mazzarella, Claudio Bassi, Stefano Partelli,Massimo Falconi, Giovanni Butturini, Paolo Pederzoli

Few data are available with respect to quality of life (QoL) in long-term survivors afterpancreaticoduodenectomy (PD). Aim of this study is to evaluate QoL and long-term outcomesin patients who underwent PD between 1990 and 2003 with a minimum follow-up of 48months. Among 268 patients identified, 168 were still alive and were surveyed with theEuropean Organization for Research and Treatment of Cancer Quality of Life QuestionnaireC30 (EORTC QLQ-C30), and with an Institutional questionnaire on long-term complications.Of the 168 surviving patients, 109 (65%) agreed to partecipate at a median of 7.5 yearspostoperatively. Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed in 75%of cases; 56 patients (51.5%) had malignant neoplasms, 23 (21%) borderline tumors, and30 (27.5%) benign neoplasms. Intraductal papillary mucinous neoplasms (IPMNs) was themost common indication for surgical resection (27.5%) followed by ductal adenocarcinoma(12%). Postoperative complications were recorded in 63 patients (58%). Overall, 75% ofpatients reported good scores in their perception of QoL. A significant decrease in QoL wasfound in patients with malignancy, with IPMNs, in survivors > 10 years, and in those withpostoperative complications (P<0.05). Despite no significant differences in overall QoLperception, Whipple resection was more frequetly associated with alterations of functionaland symptomatic domains than PPPD. 55% of patients complained of steatorrhea, 40% ofdumping syndrome, 54% of weight loss. Dumping syndrome is not associated with Whippleprocedure, while weight loss was more frequently observed after pancreo-gastrostomy thanpancreo-jejunostomy. New endocrine insufficiency was found in 17% of cases. Recurrentabdominal pain was found in 41% of patients, who had also a significant impairment ofQoL. PD is associated with acceptable QoL over time. However a careful long-term follow-up is necessary given the significant rate of exocrine insufficiency rate and impairments indigestive function. Patients who had complicated postoperative course, malignancies and