M. Driedger1, E. Dixon1, F. Sutherland1, O. Bathe1, C. Ball1 1University Of Calgary,Department Of Surgery,Calgary, AB, Canada
Introduction: The single best diagnostic and staging test for pancreatic cancer remains a contrast enhanced computed tomography (CT) scan. It is frequently the only imaging test required prior to surgical resection for solid pancreatic lesions. Unfortunately, many patients undergo additional testing that often delays definitive care.
Methods: A retrospective review of all patients with solid pancreatic lesions concerning for adenocarcinoma referred to a high volume HepatoPancreatoBiliary (HPB) service over 4 years (2008 – 2012) was completed. The time intervals between the initial imaging test and both consultation with HPB surgery and operative intervention, as well as the number of additional tests, were evaluated. Standard statistical methodology was employed (p<0.05).
Results: Among 130 patients with solid pancreatic lesions, the index imaging modality was ultrasound and CT for 75 (58%) and 52 (40%) respectively. Patients underwent a mean of 1.3 diagnostic tests following the index study and prior to consultation with HPB surgery (range: 0–5). There was a significant increase in time to HPB consultation and operative intervention with an increasing number of interval imaging tests (Fig. 1). The mean time to surgical consultation and operation if 0 interval diagnostic tests were performed was 15.9 and 45.4 days respectively. If 4 interval tests were conducted, the mean was 69.4 and 122.6 days respectively. Sixty-two (48%) patients were initially referred to a non-surgical service. The mean time to surgical consultation and operation if an intervening referral occurred was 36.6 and 66.8 days respectively. This compares to 19.8 and 48.1 days respectively in cases of direct referral to an HPB surgeon. The mean number of diagnostic tests performed prior to HPB consultation if a non-surgical referral occurred was 2.1 (vs. 0.7 if direct HPB surgeon referral).
Conclusion: Despite a relatively simple algorithm for the workup of solid pancreatic lesions, considerable heterogeneity remains in how these patients are investigated prior to referral to HPB surgery. As the number of investigations increases following the index imaging test, there is increasing delay to both surgical consultation and definitive intervention. Initial referral to a non-surgeon also resulted in a 3-fold increase in diagnostic tests and a delay in time to surgery. Education is required to expedite care and mitigate excess diagnostic tests.
