IHPBA 2020 - Session Planner

Oral (pre-recorded) Pancreas
OP01 Pancreas: Pancreatitis
Selection of Presentations from Abstract Submissions
OP01-02	Oncological Superiority of RAMPS to Conventional Distal Pancreatectomy Yoshihiro Mise, Japan Y. Mise¹, F. Ichida¹, T. Mizuno¹, R. Yoshioka¹, Y. Ono², T. Sato², Y. Inoue², Y. Takahashi², A. Saiura¹ ¹Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Juntendo University School of Medicine, Japan, ²Cancer Institute Hospital, Japan Background: To improve local radicality of surgical treatment for left-sided pancreatic cancer, radical antegrade modular pancreatosplenectomy (RAMPS) was developed. However, no evidences are available regarding the superiority of RAMPS to conventional distal pancreatectomy (cDP) in terms of long-term outcomes. Objective: To assess the oncological benefit of RAMPS by comparing outcomes between patients who underwent cDP and RAMPS. Methods: Clinical data of patients undergoing cDP and RAMPS between 2009 and 2016 at two high-volume centers were analyzed. Patients having tumors of less than 5cm in size and those whose CA19-9 was less than 500ng/ml were included. Exclusion criteria were as follows; R2 resection, concomitant portal vein or celiac axis resection. Surgical outcomes were compared between patients who underwent cDP (cDP group) and RAMPS (RAMPS group). Results: The cDP and RAMPS groups were composed of 49 and 56 patients, respectively. No differences were found in tumor characteristics (tumor size, CA19-9 level, and lymph node positive rate) between the two groups. Compared to the cDP group, operation time was longer (cDP/RAMPS: 275min/309min, p=0.03) and the amount of blood loss was larger (125ml/435ml, p< 0.01) in the RAMPS group. However, the incidence of major complications was similar between the two groups (4%/14%, p=0.08). No differences were found in the R0 resection rate (cDP/RAMPS: 92%/95%, p=0.57), 3-year overall survival rate (65.6%/60.1%, p=0.86), and 3-year recurrence-free survival rate (53.3%/52.0%, p=0.68). However, 3-year local recurrence rate was lower in the RAMPS group (26.7%/8.6%, p=0.04). Conclusion: RAMPS is superior to conventional procedure in terms of long-term control of local recurrence.
OP01-03	Acute Gastrointestinal Injury Score and its Prognostic Efficacy in Patients with Acute Necrotizing Pancreatitis Oleksandr Rotar, Ukraine O. Rotar¹, I. Khomiak², V. Rotar¹, O. Hrama¹, O. Poliansky¹ ¹Bukovinian State Medical University, Ukraine, ²A. Shalimov National Institute of Surgery and Transplantology, Ukraine Introduction: Acute necrotizing pancreatitis (ANP) is potentially lethal inflammatory process. Recent researches established that presence of multiorgan failure together with pancreatic infection are major determinants of its mortality. But significance of acute gastrointestinal injury AGI in course of ANP is still remaining unclear. So aim of our study was to determine frequency and significance of AGI on severity and mortality of ANP. Material: We performed a prospective observational cohort study of 151 patients which were admitted to single intensive care department during early phase of ANP. Acute gastrointestinal injury was established according to ESICM recommendations. Clinical and laboratorial variables as well as plasma lipopolysaccharide, sCD14 receptors and citrulline concentrations were studied. Results: Different levels of AGI were diagnosed in 141 (93.4%) of patients with ANP. Risk of intestinal dysfunction (1st grade) was detected in 24.5% cases, feeding intolerance (2nd grade) - in 35.8%, intestinal failure (3rd grade) - in 33.2% and critical intestinal failure (4th grade) - in 8.0%. Intestinal (3rd and 4th grade of AGI), respiratory, cardio-vascular and renal failures were independent factors of mortality in multivariate logistic regression model (Wald's criteria 8.441, 5.464, 5.660 and 3.847, accordingly, p˂0.05). Conclusion: AGI is a frequent event during early phase of ANP. Intestinal failure (3^rd and 4^th grade of AGI) is strongly associated with unfavorable prognosis.
OP01-04	Sequential Organ Failure Assessment (SOFA) Score Is Superior to Classical Prognostic Indices in Prediction of Severity, Intensive Care Unit Admissions and Mortality in Acute Pancreatitis Samantha Baey, Singapore S. Baey¹, T. Tan¹, S.K. Gunasekaran², S.P. Junnarkar², J.K. Low², C.W. Huey², V.G. Shelat² ¹National University of Singapore, Singapore, ²Tan Tock Seng Hospital, Singapore Introduction: Acute Pancreatitis (AP) is common and severe AP is potentially lethal. Many prognostic indices (APACHE-II, BISAP, Glasgow's, HAPS, Ranson's, SOFA) are used to predict severity. We evaluate utility of these indices in predicting severity, need for ICU admission, and mortality. Methodology: A retrospective audit of 653 patients with AP from July 2009 to September 2016 is done. The demographic and clinical profile and patient outcomes were collected. Severe acute pancreatitis (SAP) was defined as per revised Atlanta classification. Results: The mean age was 58.7±17.5 years with 58.7% males. Commonly identified etiologies of AP was gallstones(n=404, 61.9%), alcohol(n=38, 5.8%) and hypertriglyceridemia(n=19, 2.9%). 81(12.4%) patients developed SAP, 20(3.1%) required ICU admission and 12(1.8%) deaths were attributed to SAP. All-cause in-hospital mortality was 36(5.5%); 7(1.1%) cardiovascular causes, and 5(0.8%) pneumonia. Ranson's and APACHE-II demonstrated highest sensitivity in predicting SAP(92.6%, 80.2% respectively), ICU admission(100%) and mortality(100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP(13.6%, 24.7% respectively), ICU admission(40.0%, 25.0% respectively) and mortality(50.0%, 25.5% respectively). SOFA demonstrated highest specificity in predicting SAP(99.7%), ICU admission(99.2%) and mortality(98.9%). SOFA demonstrated highest positive predictive value, positive likelihood ratio, diagnostic odds ratio and overall accuracy in predicting SAP, ICU admission and mortality. The highest Area under Receiver-operator Curves(AUROC) was demonstrated by SOFA and Ranson's cumulative(Ranson score at 48 hours) in predicting SAP(0.966, 0.857 respectively), ICU admission(0.943, 0.946 respectively) and mortality(0.968, 0.917 respectively). Conclusion: SOFA score and Ranson's cumulative are accurate in severity stratification, prediction of ICU admission and mortality in acute pancreatitis. [Area under Receiver-Operator Curve for Prognosticating Severity in Acute Pancreatitis]
OP01-05	Hypertriglyceridemia-Induced Pancreatitis: A 3-Year Retrospective Cohort Study on Clinical Severity and Recurrence Rates Alicia Lim, Australia A. Lim, G. Asokan, J.-E. Thomson, P. Dolan, J. Chen Hepatobiliary Department, Royal Adelaide Hospital, Australia Introduction: Hypertriglyceridemia is a well-recognized cause for acute pancreatitis, however, there is a paucity of information regarding triglyceride (TAG) levels and its impact on disease course. We aimed to identify all hypertriglyceridemia-induced pancreatitis (HTGP) from 2016 to 2019 and to evaluate the impact of TAG levels on disease severity and recurrence rates. Methods: 1457 admissions for pancreatitis were screened and 15 patients with HTGP were found. Information regarding recurrence rates, disease severity, length of stay, management, and mortality were extracted and compared against TAG levels. Results: TAG levels on initial presentation ranged from 5 to 131mmol/L (mean 40mmol/L). There was no relation between TAG levels on initial presentation and recurrence rates. Recurrent pancreatitis occurred in 60% of this cohort (n=9). Frequency of recurrence (>2 episodes per year) was associated with persistently high TAG levels ranging from 10 to 50mmol/L. Those who had recurrent episodes with TAG levels ranging from 6 to 10mmol/L either had poor glycaemic control or a history of alcoholism. Based on the Atlanta criteria, 30% experienced severe pancreatitis (n=5). TAG levels ranged from 10 to 113mmol/L during these severe episodes (median 37mmol/L; mean 53mmol/L). Mean duration of hospitalization for severe pancreatitis was 4 weeks (range: 1-15 weeks). No deaths were directly associated with these episodes of acute pancreatitis. Conclusion: High TAG levels correlate with greater recurrence rates and severe pancreatitis. Poor glycaemic control and alcohol intake also contribute to these outcomes. Early diagnosis and management of HTGP is integral in preventing recurrence and improving long-term outcomes.
OP01-06	Disruption or Disconnection of the Pancreatic Duct in Patients with Severe Acute Pancreatitis: A Large Prospective Multi-center Cohort Hester Timmerhuis, Netherlands H. Timmerhuis¹, S. van Dijk², R. Hollemans¹, C. Sperna Weiland³, R. Voermans², M. Besselink², T. Bollen¹, R. Verdonk¹, H. van Santvoort^1,4, Dutch Pancreatitis Study Group ¹St. Antoniusziekenhuis Nieuwegein, Netherlands, ²Amsterdam UMC, AMC, Netherlands, ³Radboud University Nijmegen Medical Centre, Netherlands, ⁴UMC Utrecht, Netherlands Introduction: Disruption or disconnection of the pancreatic duct is a common finding following severe pancreatitis. Unselected data and guidelines are currently lacking on the exact incidence and clinical impact. Methods: A total of 927 consecutive patients with severe acute pancreatitis, defined by the revised Atlanta Classification were evaluated for a disrupted/disconnection pancreatic duct. We assessed patient characteristics, diagnostic modalities, invasive interventions and clinical impact of disruption/disconnection of the pancreatic duct. Generalized linear models were used to adjust for pre-specified confounders. Results: Disruption/disconnection of the pancreatic duct was diagnosed in 261/927 patients (28%). An association was found for male gender (OR 1.5, 95% CI 1.1 - 2.1, p=0.008) and parenchymal necrosis (OR 4.6, 95% CI 3.2 - 6.7, p< 0.001). An independent effect of a disrupted/disconnected pancreatic duct on readmission (adjusted OR 1.8, 95% CI 1.2 - 2.7, p=0.003), need for invasive intervention (adjusted OR 10.6, 95% CI 5.5 - 20.5, p< 0.001) and organ failure (adjusted OR 1.7, 95% CI 1.2 - 2.4, p=0.003), with no independent effect on mortality beyond the first week (adjusted OR 0.7, 95% CI 0.4 - 1.1, p = 0.143), was found. We found an independent association with abdominal compartment syndrome (adjusted OR 3.1, 95% CI 1.3 - 7.4, p=0.009). Conclusions: Around one third of patients with severe acute pancreatitis develop a disrupted/disconnected pancreatic duct. Diagnostic modalities and treatment strategies vary widely and the clinical impact is considerable. Efforts should be made to define an optimal diagnostic work-up and treatment strategy to improve outcomes.
OP01-08	Does Increasing Experience Improve Outcomes of Surgical 'Step-Up Approach' in Acute Necrotizing Pancreatitis? Lessons Learnt from a Tertiary Referral Center Rajesh Gupta, India R. Gupta¹, A. Kulkarni¹, R. Gupta¹, S. Shenvi¹, R. Babu¹, T. Jain¹, M. Kang², S.S. Rana³ ¹Surgical Gastroenterology Division, Postgraduate Institute of Medical Education and Research, India, ²Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, India, ³Medical Gastroenterology Department, Postgraduate Institute of Medical Education and Research, India Background: Step-up approach is becoming a standard of care for management of acute necrotizing pancreatitis. We aimed to investigate the learning curve effect on management and outcomes of surgical step-up approach Methods: In a retrospective analysis of prospectively maintained database of patients with acute necrotizing pancreatitis referred to our Division, we divided patients into three distinct time periods: Group-1 (2008-2012), Group-2 (2013-2016) and Group-3 (2017-2019). Results: A total of 335 patients were included, with 92 patients in Group-1, 117 in Group-2 and 126 in Group-3. Patients treated on surgical side in later time period had higher incidence of multiorgan failure (26.1% vs. 49.6% vs. 45.2%, p< 0.001), APACHE II scores at presentation (8 vs. 10 vs. 9, p=0.006) and at first intervention (9 vs. 11 vs. 10, p =0.037), as well higher mCTSI score (8 vs. 10 vs. 10, p< 0.001). Over time, median percutaneous drain size (10Fr vs. 12Fr vs. 14 Fr, p< 0.001) as well as sepsis reversal after drainage (40.2% vs. 59% vs. 49.2%, p=0.026) increased, whereas median number of drains (p=0.001) and interventions (4 vs. 3 vs. 3, p=0.005) decreased significantly. Necrosectomy requirement, length of stay and mortality remained similar over time despite more severe cases referred to surgical side. Conclusion: With increasing experience of step-up approach, sicker patients with higher severity of pancreatitis could be managed successfully with fewer drains of bigger size and procedures leading to significantly higher sepsis reversal with drainage, with no increase in surgery requirement, length of stay or mortality.