9. Cost-Redit Analysis of Work-Up for Pancreatic Cancer

C. Alvarez, E. H. Livingston, S. W. Ashley, M. Schwarz, H. A. Reber Department of Surgery Sepulveda VAMC and University of California, Los Angeles Los Angeles, CA

INTRODUCTION: Patients with suspected pancreatic cancer (PC) often undergo many invasive and expensive diagnostic tests. We reviewed the records of 126 consecutive patients with proven PC to assess the value of such tests. Computed tomographic (CT) scans were done in 120 patients, endoscopic retrograde cholangiopancreatography (ERCP) in 55, and fine needle aspiration (FNA) in 46. Costs of each procedure were as follows: contrast CT $1,426; CT-guided FNA $2,094; and ERCP $2,660.

FNA: In four patients with possible liver metastases, all were positive according to FNA, and no surgery was done. Forty-two patients had FNA of a pancreatic mass, 30 of which were positive and 12 of which were negative. Of the FNA-positive group, 2 had Whipple operations and 8 had bypasses; 14 patients with body PC had no operation. Ten of the FNA-negative patients had surgery; 2 had Whipple operations, and 7 had bypasses.

CT/ERCP: Of the 55 patients who had ERCP, 48 had findings suggestive of PC (87% sensitivity). CT was diagnostic in 92% of these same patients. CT detected 87% of lesions missed by ERCP (1 proved resectable) and failed to detect only four. In all patients in whom CT was done, 95% of lesions were detected, whereas ERCP found only 40% of tumors missed by CT. In the subgroup of 28 jaundiced patients undergoing ERCP, 93% of tumors were detected, and 96% were found by CT. Where pain was the symptom and ERCP was done, the tumor was noted in 83% versus 86% with CT, including the four cases missed by ERCP.

CONCLUSIONS: FNA and ERCP are overused in situations where PC is suspected. In such patients, a diagnostic CT scan generally should be done first. FNA is most helpful when it confirms metastases or proves PC in the body of the gland. It is indicated when a positive result will obviate the need for surgery. ERCP rarely adds information when the CT shows a pancreatic mass. ERCP is appropriate when the CT is equivocal or shows a normal pancreas. With 28,000 new cases of PC annually in the United States, this approach has the potential for significant cost savings. Morbidity associated with these invasive procedures would also be minimized.

10. Ketorolac Prevents Postoperative Ileus in Rats

M. C. Kelly, M. P. Hocking, S. D. Marchand, C. A. Sninsky Veterans Administration Medical Center Departments of Surgery and Medicine University of Florida Gainesville, FL

Ketorolac, a parenteral nonsteroidal anti- inflammatory drug, has potent analgesic properties and may lack the antipropulsive effects of opiates. We hypothesized that ketorolac, compared with morphine, would improve postoperative intestinal motility in rats. A non-nutrient radiolabeled marker was injected through an implanted duodenal cannula, and intestinal transit was calculated as the geometric center (GC) of its distribution in 10 equal segments of small bowel. Higher values for the GC represent enhanced transit. The following five groups were evaluated: group I: no ketorolac, anesthesia, or laparotomy; group II: thiopental alone; group III: laparotomy with thiopental; group IV: ketorolac (1 mg/kg) 10 minutes before and 2 hours after laparotomy with thiopental; and group V: morphine (0.05 mg/kg) before and after laparotomy. Transit results are shown in Table I. Myoelectric activity was measured in a second group of rats with implanted electrodes. A 2-hour baseline was obtained, and saline or ketorolac (1 mg/kg) was injected 10 minutes before or 2 hours after laparotomy. Motility was monitored for an additional 4 hours postoperatively. Results are shown in Table II. Intervals (min) between activity fronts of the migrating myoelectric complex (MMC) were calculated. The postoperative inhibition (min) of the MMC and the number of spikes per 2 hours were determined after laparotomy.

TABLE I GC

15.6 f 0.5

II 5.7 t 0.2 III 2.2 t- 0.2*

IV 5.2 +- 0.2**

V 2.6 z O.l*

l p <O.Ol com-

pared wtih Groups

I and IV.

l *p <O.Ol compared with

Groups III and V

TABLE II Myoeleetric Activity

MMC Inhibition #Spikes/2 h Interval

Baseline - 11 -c 1

Saline 197255 2,157t551 -

Ketorolac 13 * 5t 15 f 1

pr* Ketorolac 59 2 18t 4.809 + 966t 19 + 2

post

+p ~0.05 compared with salme. Values expressed as mean + SEM.

The MMC interval for the saline group is not included because most rats failed to recover within 3 hours. The MMC intervals for both ketorolac groups are included after return of the MMC. The number of spikes per 2 hours is not included in the preoperative ketorolac group because MMCs were present. In summary, we found that: (1) preoperative administration of ketorolac prevents the inhibition of transit and myoelectric activity of the small intestine seen in postoperative ileus; (2) ketorolac has prokinetic effects even when given postoperatively; and (3) prostaglandins may play a role in the development of postoperative ileus. In conclusion, ketorolac may be of benefit in the prevention and treatment of postoperative ileus.

THE AMERICAN JOURNAL OF SURGERY VOLUME 163 JUNE 1992 627