|OP04 Pancreas: Surgical Outcomes
|Selection of Presentations from Abstract Submissions
|OP04-02 ||Laparoscopic Distal Pancreatectomy Shortens Hospital Stay: Results from a Single-Center, Randomized Controlled Trial (LAPOP)
Bergthor Björnsson, Sweden
B. Björnsson1, A. Lindhoff Larsson1, C. Hjalmarsson2,3, T. Gasslander1, P. Sandström1
1Department of Surgery, University of Linköping, Sweden, 2Department of Surgery, Blekinge Hospital, Sweden, 3Department of Clinical Sciences, Lund University, Sweden
Introduction: Nonrandomized retrospective studies have suggested
that laparoscopic distal pancreatectomy (LDP) is advantageous compared to open (ODP)
regarding hospital stay, blood loss and recovery. The only randomized study is
available shows enhanced functional recovery after LDP.
Methods: Sixty patients, evaluated at a multidisciplinary tumor
board and planed for standard distal pancreatectomy were prospectively
randomized to LDP or ODP in a parallel group, single-center superiority trial. The primary outcome was postoperative hospital stay with the hypothesis that LDP would shorten it.
Results: Fifty-eight patients, 34 male and 24 female, were assigned to LDP (n=29, mean age 68 years) vs. to ODP (n=29, mean age 63 years) and included in a
intention-to-treat analysis. The postoperative hospital stay was 5 (IQR 4-5) days in the LDP group
vs. 6 (5-7) days in the ODP group (P=0.002). Functional recovery was reached
after 4 (2-6) vs. 6 (4-7) days (P=0.007), and the operation time was 120
minutes in both groups (P=0.48). Blood loss was reduced with LDP,
50 (25-150) compared
to 100 mL (100-300) (P=0.018). No difference was found in the complication
rates with 4 vs. 8 patients in the LDP and ODP groups respectively experiencing
complication of Clavien-Dindo grade 3 or higher. Similarly, the rate of post
pancreatectomy fistula did not differ between the groups (9 vs. 11 patients).
LDP is associated
with shorter hospital stay, enhanced functional recovery and less bleeding as
compared to ODP, and should therefore be considered the as the treatment
standard for patients in need of distal pancreatectomy.
|OP04-03 ||Factors Associated with Overall Survival in Pancreatic Cancer Treated with Neoadjuvant Therapy and Surgery
Rebecca Kim, United States
R. Kim1, S. Tsai1, M. Aldakkak1, B. George2, M. Kamgar2, B. Erickson3, N. Kulkarni4, D. Evans1, K. Christians1
1Surgery, Medical College of Wisconsin, Milwaukee, United States, 2Medical Oncology, Medical College of Wisconsin, Milwaukee, United States, 3Radiation Oncology, Medical College of Wisconsin, Milwaukee, United States, 4Gastroenterology, Medical College of Wisconsin, Milwaukee, United States
Introduction: Median survival following surgical resection of pancreatic cancer
(PC) has increased due to advances in chemotherapy, radiotherapy, and surgical
technique. We examined clinical factors
associated with overall survival (OS) in patients with PC who received
neoadjuvant therapy and surgery.
Method: We conducted a retrospective review of a prospectively
maintained PC database at high-volume referral center. Patients with
non-metastatic PC who received neoadjuvant therapy and underwent surgical
resection between 2009 and 2019 were included. Demographic, clinical, and
pathologic variables were examined with Cox proportional hazards models to
identify prognostic factors on OS.
Results: Neoadjuvant therapy and surgery was completed in 460 consecutive
patients; 227 (49.4%) patients were female. The median age was 64 (IQR[58, 71])
years. Median OS was 40.2 (IQR[23.4, 87.3]) months. On bivariate analysis, elevated
CA19-9 prior to surgery
(HR 1.8 [1.4,2.3]), vein resection (HR 1.6 [1.2, 2.1]),
lymphovascular invasion (HR 1.5 [1.1, 2.0]), positive superior mesenteric
artery margin (HR 1.8 [1.2, 2.7]) and higher nodal stage were associated with
worse OS. On multivariate analysis, shorter OS was associated with increased CA19-9 (HR 1.6 [1.2,2.2]), higher nodal stage (HR 1.5 [1.0, 2.1] for N1; HR 1.9 [1.2,
3.0] for N2), and liver as the first site of disease recurrence. Preoperative
clinical stage was not a significance predictor of OS.
Conclusions: We report OS outcomes from one of the largest cohorts of
resected PC in the era of neoadjuvant therapy. Preoperative CA19-9 after neoadjuvant
therapy was associated with OS, emphasizing the impact of treatment response on
|OP04-04 ||Recurrence Following Neoadjuvant Therapy and Resection for Pancreatic Ductal Adenocarcinoma: A Comprehensive Meta-Analysis and Meta-Regression
Bathiya Ratnayake, New Zealand
B. Ratnayake1, A. Savastyuk1, J. Hammond2, G. Sen2, S. White2, J. French2, S. Pandanaboyana2
1Department of Surgery, University of Auckland, New Zealand, 2Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, United Kingdom
Background: This review aims
to provide a comprehensive analysis of recurrence patterns in patients
undergoing neoadjuvant therapy (NAT) in comparison to those undergoing up-front
surgery (US) for PDAC.
Methods: The EMBASE,
SCOPUS, PubMed and Cochrane library databases were systematically searched to
identify eligible comparative studies. The primary outcome was time to first
recurrence and location of recurrence.
articles were identified including 4822 patients undergoing resection. The
weighted mean follow-up interval for recurrence outcomes was 40.8months (CI
33.4-48.1). The weighted mean overall recurrence rate was 63.4% (CI 51.8-73.%)
for NAT, significantly lower than the 74% (CI 68.7-80%) weighted overall recurrence
rate of the US cohort (OR 0.67 (CI 0.52-0.87), P=0.006). NAT was also
associated with a significantly longer weighted mean time to first recurrence (NAT
18.8months US 15.7months, P=0.015). The
weighted locoregional recurrence (NAT 12%, US 27%, P=0.004) and liver recurrence
(NAT 19.4%, US 30.1% P=0.023) rates were markedly improved among NAT patients.
Weighted lung and peritoneal recurrence rates did not differ (P=0.705 and
P=0.549 respectively). NAT was further associated with a greater two- (NAT 39%,
US 22% OR 1.84 (CI 1.22-2.78), P=0.007) and five-year (NAT 24%, US 13% OR 1.95
(CI 1.03-3.69), P=0.043) recurrence free survival. Borderline resectability, presence
of perineural invasion and a lower N0 nodal status were positive predictors of
overall recurrence in the NAT cohort.
is associated with improved overall recurrence rates and longer time to first
recurrence, an observation likely attributed to the improved rates of
locoregional and liver recurrence.
|OP04-05 ||Efficacy of Peri Operative Hydrocortisone and Indomethacin Treatment in Reducing Major Complications after Whipple's Pancreaticoduodenectomy, Randomized Controlled Clinical Trial
Rohit Dama, India
R. Dama1, K. Kant1, P. Rebala1, G. Rao1, D. Reddy2
1Surgical Gastroenterology, Asian Institute of Gastroenterology, India, 2Medical Gastroenterology, Asian Institute of Gastroenterology, India
Introduction: Post Whipple's
Pancreatico-duodenectomy (PD) the major concern is pancreaticojejunostomy (PJ)
leak which leads to post operative pancreatic fistula (POPF), post
pancreatectomy haemorrhage(PPH), delayed gastric emptying (DGE) ,sepsis. sometimes mortality.Hydrocortisone and indomethacin have been postulated to reduce post operative
pancreatitis and thus PJ leak.
Jan 2018 - April 2019, 146 patients for Whipple's PD were included. Only high
risk patient (n= 105)with >40% of acini (marker of soft pancreas) on frozen
section of transection margin were randomized to intravenous (iv)
hydrocortisone, per rectal (PR) indomethacin or placebo (3 groups ,35 in each
received total 8 doses of iv treatment (8 hourly) and 6 doses of PR treatment
(12 hourly). 100 ml NS and glycerin suppository were the placebo drugs. Primary
end-points were overall major complications(Clavien Dindo 2-5).
group had less major complications compared to placebo
(overall 14.3% vs 40.0%;
P value = 0.003).
(8.6% vs 20%) and DGE (14.3% vs 22.9%) were also lower in hydrocortisone group
group did not reduce major complications compared to placebo (overall, 37.2%
vs 40%; p value = 1.00). POPF (17.1% vs 20%) and PPH (11.4% vs 14.3%) Although, DGE
is significantly less in indomethacin group (14.3% vs 22.9%; p value = 0.001).
mortality was zero in all the groups.
treatment significantly reduces major postoperative complications in high risk
patients after Whipple's PD whereas Indomethacin treatment does not as compared
|OP04-07 ||Preoperative Prediction of Clinically Relevant Postoperative Pancreatic Fistula after Pancreaticoduodenectomy
Hirohisa Kitagawa, Japan
H. Kitagawa1,2, K. Hashida1, J. Muto1, K. Hamai1, M. Okabe1, K. Kawamoto1, I. Makino2, F. Toshima3, D. Inoue3
1Surgery, Kurashiki Central Hospital, Japan, 2Surgery, Kanazawa University, Japan, 3Radiology, Kanazawa University, Japan
Introductions: Clinically relevant postoperative
pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) can
complicate postoperative course and it is stressful for surgeons. It's ideal to
predict CR-POPF preoperatively and take precautions against serious
complications in advance.
The aim of this study was to clarify objective
and predictive preoperative parameters of CR-POPF.
Methods: A consecutive cohort of PD patients from 2011
to 2017 were identified from a prospectively collected institutional database. CR-POPF
was diagnosed according to the Revised 2016 ISGPS classification. Surgery-related
factors (age, sex, bleeding volume and disease), morphologic
and imaging parameters by CT (main pancreatic duct diameter, pancreatic
parenchymal thickness, ratio of
pancreatic parenchyma diameter to main pancreatic duct diameter above portal
vein in CT axial images [P/D ratio], and contrast effect of pancrearic parenchyma [CE]
in various phase) and signal intensity of MRI (in T1WI, T2WI, arterial phase,
portal phase, and late phase) were examined.
patients were included in the analysis. Overall, 32 (31%) patients developed a
CR-POPF. Multivariate analysis was performed on significant factors by
univariate analysis, the P/D
ratio (odds ratio [OR] 3.77, 95% confidence interval 1.27 to 11.93; P=0.017) and
CE in late phase ([OR] 4.23, 95% confidence interval 1.20 to 18.11; P=0.024) were
Conclusions: P/D ratio and CE in
late phase were significant factors for predicting CR-POPF preoperatively. For
high-risk patients, effective measures should be considered to prevent serious
complications caused by POPF preoperatively.
|OP04-08 ||Comparison of Outcomes of Minimally Invasive versus Open Pancreaticoduodenectomy after Neoadjuvant Therapy in a National Cohort of Patients with Pancreatic Adenocarcinoma
Amr Al Abbas, United States
A. Al Abbas, C.A. Hester, J. Yan, H. Zhu, H.J. Zeh III, P.M. Polanco
Surgery, University of Texas Southwestern Medical Center, United States
Introduction: The recently published “Miami International Evidence-based Guidelines on Minimally Invasive Pancreatic Resection”, endorsed by IHPBA, noted lack of evidence on which pancreaticoduodenectomy (PD) approach was optimal for pancreatic adenocarcinoma (PDAC) patients post-neoadjuvant therapy (NAT). We aim to compare 30-day-outcomes in PDAC patients that underwent open (OPD) versus minimally-invasive approach (MIPD) post-NAT.
Methods: PDAC patients that underwent NAT followed by either MIPD (laparoscopic/robotic) or OPD were identified in the U.S. Procedure-Targeted-Pancreatectomy NSQIP dataset (2014-2017). Preoperative and postoperative parameters were compared among both approaches. Subsequent analysis based on operative approach and NAT modality (chemotherapy alone or chemoradiation) was performed using multiple logistic regression models.
Results: Of 2428 patients with PDAC that received NAT, 2219 (91.4%) and 209 (8.6%) underwent OPD and MIPD respectively. MIPD patients were more likely to receive chemotherapy alone (70.8 vs 57.5%,P< 0.001), less likely to undergo vascular resection (21.2vs37.5%, P< 0.001), had longer OR-Time(P=0.043), and shorter Length-Of-Stay
(P< 0.001). For patients undergoing chemoradiation, MIPD was independently predictive of lower incidence of major complications (OR:0.22, P< 0.001). For patients who underwent chemotherapy alone, MIPD was independently predictive of a lower incidence of minor complications (OR:0.76, P=0.032) and a shorter LOS (Estimate:-2days,
P=< 0.001).There were no significant differences in mortality, Delayed-Gastric-Emptying (DGE), and Clinically-relevant-pancreatic-fistula(CR-POPF) among operative approaches and NAT modalities.
Conclusions: MIPD is safe and feasible in PDAC patients undergoing NAT in centers with expertise in this approach. No differences in mortality,DGE and CR-POF were found. MIPD was associated with a lower incidence of major complications in the chemoradiation group and shorter LOS with lower incidence of minor complications in the chemotherapy-only group.
[Multivariable Analysis for Major Complications by Operative Approach and Neoadjuvant Therapy]
|OP04-11 ||Assessment of Glucose Metabolism Alterations after Partial Pancreatectomy Using Biochemical Markers: A Prospective Observational Study
Jun Suh Lee, Korea, Republic of
J.S. Lee, Y.-S. Yoon, B. Lee, J.Y. Cho, H.-S. Han
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University Bundang Hospital, Korea, Republic of
Introduction: Most previous studies on glucose metabolism after
pancreatectomy used medical records as diagnostic criteria of DM. This study aimed
to evaluate the incidence and characteristics of new-onset DM (NODM) and worsened preexisting
DM after pancreatectomy using serial assessment of biochemical markers in a
Method: Data was prospectively collected for 224 patients
who received PD (n=149) and DP (n=75) between 2015 and 2018. Diabetes related
parameters were assessed preoperatively and postoperatively (at 3 months and 1
year): oral glucose tolerance test, HbA1c, fasting insulin, and stimulated
insulin. Homeostasis model assessment (HOMA) was calculated for IR (insulin
resistance) and B (beta cell function).
Results: The incidence of NODM
(14% vs. 45%, P=0.001) and worsened DM (21% vs. 60%, P< 0.001) was significantly higher after
DP than PD at postoperative 1
year. There was more DM resolution after PD. (41% vs. 9%, P=< 0.001) BMI
and type of surgery (DP) were risk factors of NODM, while only type of surgery
(DP) was a risk factor of worsened DM. In DP patients without preoperative DM,
those who developed NODM had a significantly lower preoperative HOMA-B level
compared to those who did not. (P=0.035) PD patients who developed NODM showed
a sustained decrease in HOMA-B postoperatively, whereas those who did not
showed a plateau, after an initial decrease.
Conclusions: DP had higher risk of NODM development and DM
worsening that PD. Patient education and surveillance for the development of DM
after pancreatectomy should be tailored according to type of resection.
|OP04-12 ||Impact of Radical Pancreaticoduodenectomy with Portal Vein Resection and Extensive Surrounding Soft Tissues on the Long-term Outcomes for Pancreatic Head Cancer
Akio Saiura, Japan
A. Saiura1,2, H. Ito2, A. Oba2, Y. Inoue2, Y. Mise1, Y. Takahashi2, Y. Ono2, T. Sato2, R. Yoshioka1
1Hepato-Biliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, Japan, 2Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japan
Pancreaticoduodenectomy (PD) with portal vein PV resection (PVR) is a standard
operation for pancreatic ductal adenocarcinoma (PDAC) with PV invasion;
however, the positive margin rates remain high. We hypothesized that radical pancreaticoduodenectomy
(RPD) in which soft tissue around the PV is resected enbloc could enhance
oncological clearance. Herein, we describe our RPD and address the short- and long-term outcomes
compared to standard PD with PVR.
The study included 268 consecutive patients who underwent PD with PVR using
anterior artery-first approach. While, the PV was skeletonized with the
surrounding soft tissue dissected in the standard PD with PVR (n = 177), the
retro-pancreatic segment of PV was resected enbloc with its surrounding soft
tissue during the RPD (n = 91). The extent of lymphadenectomy was not different
between the procedures.
R0 resection was achieved in 80% of patients in the RPD group, compared with
66% in the PD group (P = 0.011),
while the perioperative outcomes were comparable between groups. The median
recurrence-free survival (RFS) and overall survival (OS) were 17 months and 31
months, respectively, for the RPD group, compared to 11 months and 21 months
for the PD group, (P = 0.004 for RFS
and P = 0.003 for OS).
Conclusion: We described a novel, radical operation for locally advanced PDAC. Our RPD is safe and feasible, and it enhances local disease control resulting in
improved OS. Further prospective evaluation of RPD is warranted in the setting
of current multidisciplinary management.
|OP04-13 ||Neoadjuvant Treatment Mitigates the Survival Impact of Major Complications after Resection of Pancreatic Adenocarcinoma
Timothy E. Newhook, United States
T. Newhook, L. Prakash, M. Bruno, W. Dewhurst, N. Ikoma, M. Kim, J.E. Lee, M. Katz, C.W. Tzeng
MD Anderson Cancer Center, United States
major complications (PMCs) may prevent multimodality therapy (MMT) for
pancreatic ductal adenocarcinoma (PDAC) patients by delaying adjuvant therapy
(AT) following surgery-first (SF) sequencing. We hypothesized that neoadjuvant therapy (NT) mitigates
the detrimental effect of PMCs on outcomes of resected patients.
of consecutive resected PDAC patients 7/2011-10/2018 were abstracted from a prospective
database. PMCs were defined at 90-days as
ACCORDION Grade ≥3. Overall survival
(OS) was compared between patients with and without PMCs.
373 patients, most underwent NT (75%). PMCs
occurred in 22% of SF and 20% of NT patients (p=0.71). Most went on to receive some form of AT (90%
SF vs. 70% NT,p< 0.001). Median OS for
NT and SF patients was 46 vs. 36 months (p=0.037). PMCs negatively impacted OS, with median OS
59 months for NT(-)PMC, 34 months for NT(+)PMC, 45 months for SF(-)PMC, and 20
months for SF(+)PMC (p< 0.001;Fig. 1A).
There was a trend toward worse OS in NT(+)PMCs (p=0.06, Figure 1B). PMCs
were not independent predictors of OS for NT patients. However, after adjustment
for clinical classification, treatment sequencing, tumor size, and margin
status, PMCs were independently-associated with OS (HR-1.60,p=0.010) among all
patients, along with perineural invasion (HR-1.83, p=0.024), nodal positivity (HR-2.1,p< 0.001),
and AT (HR-0.69,p=0.039).
deleterious effects of PMCs on OS for PDAC patients may be mitigated by NT. NT
sequencing should be routinely considered given the significant risk of
|OP04-15 ||Clinical Relevance Between Survival Outcomes and Invasion of Splenic Vessels in Pancreatic Body or Tail Adenocarcinoma
Jae Seung Kang, Korea, Republic of
J.S. Kang, Y.J. Choi, Y. Byun, Y. Han, E. Kim, H. Kim, W. Kwon, J.-Y. Jang
Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Korea, Republic of
Introduction: Little was known about clinical impact of splenic vessels invasion (SpVI) of pancreatic body or tail adenocarcinoma in terms of survival outcomes. This study was to compare the survival outcomes between pancreatic adenocarcinomas (PDACs) with SpVI and those with no invasion, and to investigate the prognostic factors associated with adverse outcomes.
Methods: Between 2005 and 2018, patients who underwent distal pancreatectomy were enrolled. Patients who underwent neoadjuvant chemotherapy were excluded. Degree of SpVI was categorized with three groups (Group 1, no invasion; Group 2, 0 - 180 degree; Group 3, ≥180 degree) and formation of collateral vessels was investigated in preoperative computed tomography. Clinical variables, postoperative surgical outcomes, and survival outcomes were evaluated. Multivariate Cox-proportional analysis was performed for evaluating the prognostic factors.
Results: Total 249 patients were included. Operation time was longer (185 vs. 159 min, P=0.001) and intraoperative blood loss (415 vs. 278 mL, P=0.003) was higher in SpVI patients. Tumor size was larger (3.9 vs. 2.9cm, P=0.001) in SpVI patients, but the number of metastatic lymph nodes were comparable (1.7 vs. 1.4, P=0.241). 5-year overall survival rate was significantly different among three groups (Group 1, 38.4%; Group 2, 16.8%; Group 3, 9.7%, P< 0.001). In the Cox-proportional analysis, adjuvant treatment, R0 resection, SpVI, and collateral vessels formation were independent prognostic factors in survival outcome.
Conclusions: SpVI was associated with adverse survival outcomes in PDAC. Different approach such as neoadjuvant treatment would be needed in patients with SpVI invasion.
|OP04-16 ||Changes in the Perioperative and Postoperative Long-term Quality of Life after Total Pancreatectomy
Moon Young Oh, Korea, Republic of
M.Y. Oh, E.J. Kim, W. Kwon, H. Kim, Y.H. Byun, Y.J. Choi, J.S. Kang, Y. Han, J.-Y. Jang
Department of Surgery, Seoul National University Hospital, Korea, Republic of
Background: Quality of Life (QoL) is widely known to be
poor after total pancreatectomy. This study was designed to evaluate the
short-term and long-term consequences of endocrine and exocrine insufficiency
and their associated effects on QoL and nutritional status.
Methods: Prospective data was collected from
patients who underwent total pancreatectomy at Seoul National University
Hospital during an interval of 4 years and followed up for at least 1 year.
QoL, and nutritional status were assessed by administering validated
questionnaires (EORTC QLQ C-30, PAN26, GIQLI, MNA), preoperatively and 3, 12
Results: A total of 30 patients were eligible for
the study. 3 months after receiving total pancreatectomy, the global heath
score (GHS) showed no significant difference (preoperatively 57.2 vs. 3 months
postoperatively 68.3; P=0.119). By the 1st postoperative year, the GHS still
showed no significant difference (preoperatively 57 vs. 1 year postoperatively
52.4; P=0.2) and no significant differences in most of the QoL
categories. However, poor physical function (79.2 vs. 67.6; P=0.01), digestive
difficulties (14.9 vs. 36.9; P=0.03) and altered bowel habits (9.2 vs. 25.6;
P=0.03) continued even 1 year after surgery.
Conclusion: The overall QoL score after total
pancreatectomy was comparable to the preoperative QoL score. Some symptoms
after total pancreatectomy significantly worsen after 3 months postoperatively,
but then improve to a comparable level 1 year after surgery. Because some
symptoms persist even after time has passed, supportive management is needed
for total pancreatectomy patients, including nutritional support with
pancreatic enzyme replacement and education for diabetes and diet.
|OP04-17 ||Comparative Long-term Outcomes for Pancreatic Volume Change, Nutritional Status, and Incidence of New-onset Diabetes between Pancreatogastrostomy and Pancreatojejunostomy after Pancreaticoduodenectomy
Bong Jun Kwak, Korea, Republic of
B.J. Kwak1, H.J. Choi2, Y.K. You2,2, T.H. Hong2
1Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea, Republic of, 2Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea, Republic of
Introduction: The difference in volume change in a pancreatic remnant
according to the type of pancreaticoenterostomy after pancreaticoduodenectomy
(PD) for long-term follow-up is unknown. This study aimed to compare serial
pancreatic volume changes in pancreatic remnants between pancreatogastrostomy
(PG) and pancreatojejunostomy (PJ) after PD and to evaluate the difference in
general nutritional status and incidence of NODM between PG and PJ.
Methods: This study enrolled 115 patients who had survived for more
than three years after PD. They were divided into the PG group and the PJ
group. Their clinicopathologic factors were collected and analyzed. We
calculated serial pancreas volume and pancreatic duct size precisely from
preoperative stage to five years after surgery by image-processing software.
Consecutive changes of albumin and BMI as related to general
nutritional status were compared. Postoperative NODM was evaluated.
Results: Most patient demographics were not significantly different
between the PG group (n=45) and PJ group (n=70). There was no significant
difference in volume reduction between the groups from postoperative one month
to five years (PG group −18.21±14.66 mL versus PJ group −14.43±13.05 mL,
P=0.209). There was no significant difference in the change of total serum
albumin and BMI between the groups for five years after surgery. The incidence
of NODM was not significantly different between the groups (P=0.995).
Conclusions: PG and PJ following PD induced similar pancreatic volume
reduction during long-term follow-up. There was no difference in general nutritional
status or incidence of NODM between the groups after PD.
|OP04-18 ||Comparisons of Short-term and Long-term Outcomes Between Open and Laparoscopic Distal Pancreatectomy in Patients with Pancreatic Ductal Adenocarcinoma
Jung Min Lee, Korea, Republic of
J.M. Lee, J.S. Kang, Y. Byun, Y.J. Choi, Y. Han, H. Kim, W. Kwon, J.-Y. Jang
Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Korea, Republic of
Safety and feasibility of laparoscopic
distal pancreatectomy (LDP) in regards to the pancreatic adenocarcinoma (PDAC)
were not well-known. The present study aimed to compare the short-term and
long-term outcomes of LDP with those of open distal pancreatectomy (ODP).
This was a retrospective study with
prospectively collected medical data. Between 2009 and 2017, patients who
underwent distal pancreatectomy and pathologically confirmed as PDAC were
enrolled. Clinical and pathologic variables were investigated. To reduce
selection bias, 1:1 propensity score matching (PSM) was performed with T and N stage of 8th American
Joint Committee on Cancer staging system. Survival outcomes and cumulative
recurrence rates were calculated with Kaplan-Meier method.
Total 210 patients were enrolled.
LDPs and ODPs were performed in 35 patients (16.7%) and 175 patients (83.3%),
respectively. After 1:1 PSM, age, sex, underlying diseases were comparable
between two groups. In terms of short-term outcomes, operation time (128 vs.
164 minute, P=0.001) and postoperative hospital stay (11.1 vs. 16.5 days,
P=0.011) were significantly different between two groups. Tumor size (3.2 vs.
3.1 cm, P=0.889), number of harvested lymph nodes (12.6 vs. 14.4, P=0.365), and
R0 resection rates (91.4 vs. 80.0%, P=0.172) were comparable. 5-year overall
survival rates (26.4 vs. 24.6%, P=0.742) and cumulative recurrence rates (56.3 vs.
61.4%, P=0.582) were comparable between two groups.
LDP has similar or better perioperative
outcomes (operation time, postoperative hospital stay) and shows similar
survival outcomes, and recurrence patterns in PDAC patients, compared with ODP.
LDP is a safe and feasible procedure in PDAC patients.
|OP04-19 ||Somatostatin Prevents Clinically Relevant Pancreatic Fistula in Intermediate Risk Patients after Pancreaticoduodenectomy (SPEED): A Multi-center, Randomized, Controlled Study
Zhe Cao, China
Z. Cao1, J. Qiu1, T. Zhang1, B. Sun2, R. Qin3, R. Chen4, Y. Miao5, W. Lou6, Y. Zhao1
1General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China, 2Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Harbin Medical University, China, 3Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China, 4Pancreatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, China, 5General Surgery, The First Affiliated Hospital, Nanjing Medical University, China, 6Pancreatic Surgery, Zhong Shan Hospital, Fudan University, China
Introduction: Post-operative pancreatic fistula (POPF) remains the lethal complication after pancreaticoduodenectomy, and the objective
of the study is evaluating the preventive effect of somatostatin on POPF in
intermediate risk patients.
Methods: A multi-center,
randomized, controlled study was conducted in six high-volume pancreas centers
in China between June 2018 and April 2019. Patients undergoing pancreaticoduodenectomy with intermediate risk of POPF were enrolled. Patients were
randomly assigned to somatostatin group
(intravenous somatostatin of 250µg/h for 120 hours) and control group. The
primary endpoint was clinically relevant POPF (CR-POPF) (according to 2016
International Study Group on Pancreatic Fistula criteria). This trial was
registered with Clinical Trial (NCT03349424).
Results: 205 patients were
enrolled and 99 in somatostatin group and 100 in
control group were included for final analysis. The rate of CR-POPF in somatostatin group decreased significantly (13% vs 25%, p=0.032),
both in open and laparoscopic pancreaticoduodenectomy. But the rates of overall POPF (65% vs 69%,
p=0.51) and biochemical leak (52% vs 44%, p=0.29) were not significantly
different. Medical costs (¥115069 vs ¥115803, p=0.92) and other complications:
biliary fistula (6% vs 6%, p=0.99), abdominal infection (19% vs 18%, p=0.83), chylous fistula (5% vs 4%, p=0.75), late postoperative hemorrhage (7% vs 12%, p=0.24) had no significant
However, the somatostatin group had higher
rate of delayed gastric emptying (33% vs 21%, p=0.0504).
Conclusion: In patients with
intermediate risk of POPF after pancreaticoduodenectomy, prophylactic use of
somatostatin can reduce the CR-POPF, but seems to
increase the rate of delayed gastric emptying.
| ||Overall (n=199)||somatostatin group
|Age, mean (SD), yrs||58.8||57.92 (11.4)||59.18 (10.7)|
|Male sex||123(62%)||57 (57%)||66 (66%)|
|BMI, mean (SD) (kg/m2)||22.9||22.58 (3.2)||23.26 (3.2)|
|Hypertension inmedical history||56(28%)||56(28%)||32 (32%)|
|Diabetes mellitus in medical history||33(17%)||16 (16%)||17 (17%)|
|Chronic pancreatitis in medical history||2(1%)||2 (2%)||0(0%)|
|Acute pancreatitis in medical history||5(3%)||0(0%)||5 (5%)|
[The baseline characteristics of study participants.]
[The rates of POPF and other complications in somatostatin and control group.]
|OP04-20 ||The European Registry for Minimally Invasive Pancreatic Surgery (E-MIPS): First Year Experience
Nicky van der Heijde, Netherlands
N. van der Heijde1,2, F. Vissers1,2, F. Can3, T. Hackert4, I. Khatkov5, O. Saint-Marc6, G. Zimmitti2, M. Besselink1, M. Abu Hilal2,7, European consortium of Minimally Invasive Pancreatic Surgery (E-MIPS)
1Department of Surgery, Amsterdam University Medical Center, Location AMC, Netherlands, 2Department of Surgery, Fondazione Poliambulanza Hospital, Italy, 3Department of Surgery, Lokman Hekim University School of Medicine, Turkey, 4Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany, 5Department of Surgery, Moscow Clinical Scientific Center, Russian Federation, 6Department of Surgery, Centre Hospitalier Régional Orleans, France, 7Department of Surgery, University Hospital Southampton NHS, United Kingdom
Introduction: The European-African Hepato-Pancreato-Biliary Association (E-AHPBA)
has endorsed the European consortium on Minimally Invasive Pancreatic Surgery
(E-MIPS) to set up a registry which aims to collect data of minimally invasive
pancreatic surgery (MIPS) in all low- and high-volume centers across Europe. The
aim is to monitor and report on safety and quality outcomes of MIPS in daily
Methods: This is a pan-European,
multicenter prospective observational cohort study, including data of the first
year (2019) of the E-MIPS registry. All patients undergoing MIPS in the participating
centers are included. Main study parameters are patient demographics, perioperative- and oncological outcomes.
Results: A total of 398
patients from 38 centers in 15 countries were included, with a median (inter
quartile range) volume of 11 (8-20) for MI-distal pancreatectomy. MI-pancreatoduodenectomy
was performed in 23 centers, with a median (IQR) of 8 (2-20). There were 31 (81.6%)
low volume (< 20 MIPD annually) centers and 7 (18.4%) high-volume centers. Laparoscopy
was the most frequent approach (n=245, 61.3%), followed by robotic (n=134, 33.5%)
and hybrid-laparoscopic (n=19, 4.8%). Overall, 240 patients (60%) were operated
for a malignancy, of which 13 (5.4%) received a type of neoadjuvant treatment. The
90-day mortality rate was 2.6% (n=10). Table 1 shows summarized outcomes divided
between the five procedures performed most often.
Conclusion: This is the
first overview of collected data from all centers in the E-MIPS registry. Due
to the large scale, this registry provides insight into the current MIPS
practice in Europe.
| ||Robotic pancreatoduodenectomy (n=70)||laparoscopic pancreatoduodenectomy (n=61)||Hybrid-laparoscopic pancreatoduodenectomy (n=18)||Robotic distal pancreatectomy (n=70)||laparoscopic distal pancreatectomy (n=144)|
|Age, years, mean (SD)||64 (11)||63 (12)||68 (10)||60 (16)||63 (15)|
|Conversion, n (%)||5 (7.1)||11 (13.4)||6 (33.3)||5 (7.1)||20 (14.1)|
|Length of stay, med (IQR)||10 (8-16)||11 (8-16)||8 (6-12)||7 (6-10)||6 (5-10)|
|POPF grade B/C, n (%)||11 (15.7)||13 (15.9)||2 (11.1)||9 (15.5)||32 (22.7)|
|PPH grade B/C, n (%)||5 (7.1)||6 (7.3)||0 (0)||3 (5.2)||5 (3.5)|
|Reoperation ≤30 days, n (%)||8 (11.4)||8 (9.8)||1 (5.6)||1 (1.6)||7 (4.9)|
|Readmission ≤30 days, n (%)||5 (7.1)||10 (12.2)||4 (22.2)||7 (11.5)||23 (16.0)|
|R0 resection, n (%)*||39 (68.4)||59 (83.1)||10 (71.4)||29 (90.6)||65 (82.3)|
|90-day mortality, n (%)||2 (2.9)||7 (8.5)||0 (0)||1 (1.6)||1 (0.7)|
[Baseline characteristics and perioperative outcomes of the European minimally invasive pancreatic surgery (E-MIPS)registry]
|OP04-21 ||Increased Operative Difficulty and Poorer Outcomes after Multiple Endotherapies for Chronic Pancreatitis: An Analysis of 48 Consecutive Frey's Procedures
Prasad Pande, India
P. Pande, G. Desai, R. Narkhede, P. Wagle
Lilavati Hospital and Research Centre, India
Introduction: Chronic pancreatitis (CP) is being increasingly
treated by endotherapy as part of the step-up approach. Multiple sessions of
endotherapy have led to shrinking indications and delayed referrals for
surgery. This study analyses the impact of multiple endotherapy sessions on
difficulty of Frey's procedure and outcomes of surgery.
Methods: This prospective study included 48 consecutive
Frey's procedures done for CP between 2016 and 2019 at our tertiary
hepatopancreatobiliary centre. Demographic data, duration of CP, number of
endotherapies [≥3 (group A) or < 3 (group B)], operative difficulty [operative
time, intra-operative blood loss], pain relief [Visual Analog Scale (VAS)], and
quality of life [EORTC-QLQ-C30 questionnaire (QoL score)] at 6 months were
Results: 28 (58.33%) out of 48 patients were in group A, and
20 (41.67%) in group B. The mean operative time was 153.22±24.1 minutes in
group A vs 138.33±15.29 minutes in group B (p< 0.05). The mean blood loss was
156.11±43.28 mL in group A compared to 116.04±34.42 mL in group B (p< 0.01). Improvement
in VAS at 6 months was 3.22±0.83 in group A and 4.79±1.58 in group B (p< 0.01).
Improvement in QoL score at 6 months was 36.44±9.34 in group A and 35.62±12.42
in group B (p=0.85).
Conclusion: Multiple endotherapy sessions increase the operative
time and intra-operative blood loss, thus increasing the operative difficulty,
in addition to giving poorer pain relief. Early referral for surgery without
subjecting patient to multiple endotherapies would improve operative and
|Parameter||≥3endotherapies (group A)||<3 endotherapies (group B)||p-value|
|Number of patients||28 (58.33%)||20 (41.67%)|| |
|Mean duration of surgery (minutes)||153.22 ± 24.1||138.33 ± 15.29||<0.05*|
|Mean blood loss (mL)||156.11 ± 43.28||116.04 ± 34.42||<0.01*|
|Change in VAS at 6 months||3.22 ± 0.83||4.79 ± 1.58||<0.01*|
|Change in QoL score at 6 months||36.44 ± 9.34||35.62 ± 12.42||0.85|
[Correlation of number of endotherapies with operative difficulty and outcomes]
|OP04-22 ||Predictive Value of Elevated CA 19-9 for Positive Resection Margins after Pancreaticoduodenectomy for Pancreatic Tumors
Namita Chavan, India
N. Chavan, P. Pande, G. Desai, R. Shah, P. Jagannath
Lilavati Hospital and Research Centre, India
Introduction: Elevated Carbohydrate antigen (CA) 19-9 levels have
predicted poor prognosis and decreased survivals after pancreaticoduodenectomy
for pancreatic head carcinoma. This study analyzes the predictive value of
elevated CA 19-9 for positive resection margin in these cases.
Material and methods: Retrospective analysis of prospectively entered data
from 2011 to 2019 revealed 202 cases at our specialized hepatopancreatobiliary
centre. Demographic details, imaging findings, liver function tests and pre-operative
tumor markers were recorded. Histopathology data regarding tumor and nodal
status and resection margins were recorded as per Leeds protocol. Positive
margins were considered as < 1mm from the tumor.
Results: 106 of 202 (52.4%) patients had CA 19-9 >100 U/mL
(Normal: < 37 U/mL) in absence of jaundice. 63 (31.2%) patients had node
positive disease, and 78 (38.6%) had lymphovascular/perineural invasion.
Retroperitoneal (SMA) margin was positive in 16 (15.1%) patients with elevated
CA 19-9 and 4 (4.1%) patients with normal CA 19-9. SMV margin was positive in
38 (35.8%) patients with elevated CA 19-9 and 11 (11.4%) patients with normal
CA 19-9. Pancreatic ductal margin was positive in 3 (3.1%) patients with
elevated Ca 19-9. 57 (53.7%) patients with elevated CA 19-9 and 15 (15.6%)
patients with normal Ca 19-9 had positive margins. This difference is
statistically significant (p< 0.05) using student's t-test.
Conclusion: Elevated CA 19-9 level is a strong predictor of margin
positivity after pancreaticoduodenectomy irrespective of T stage. These cases
may be better suited for neoadjuvant therapy and needs evaluation in a
|Parameter||CA 19-9 >100 U/mL||CA 19-9 <100 U/mL||p-value|
|Number of patients||106 (52.4%)||96 (47.5%)|| |
|N+ disease||63 (31.2%)||21 (10.3%)||<0.05*|
|Median LN ratio||0.33±0.26||0.14±0.12||<0.05*|
|LVI/PNI||78 (38.6%)||35 (17.3%)||<0.05*|
|Positive SMA margin||16 (15.1%)||4 (4.1%)||<0.05*|
|Positive SMV margin||38 (35.8%)||11 (11.4%)||<0.05*|
|Positive duct margin||3 (3.1%)||0|| |
|Positive margin status||57 (53.7%)||15 (15.6%)||<0.05*|
[Histopathology and margin status in pancreaticoduodenectomy]
|OP04-23 ||Relevance of Celiac Axis Stenosis in Pancreatoduodenectomy
Mohammed Al-Saeedi, Germany
M. Al-Saeedi1, H. Sauer1, J. Koch1, L. Frank-Moldzio1, P. Mayer2, T. Hackert1, T. Bruckner3, M.W. Büchler1, O. Strobel1
1Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Germany, 2Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Germany, 3Institute of Medical Biometry and Informatics, University Hospital of Heidelberg, Germany
Introduction: Celiac axis stenosis (CAS) may result in
enhanced risk of ischemic complications during pancreatoduodenectomy. However,
the prevalence and relevance of CAS remains unknown.
Methods: All patients undergoing partial or total
pancreatoduodenectomy from 2014 to 2017 after preoperative computed tomography
(CT) with arterial phase were identified from a prospective database. Preoperative
CT scans were evaluated for CAS. Postoperative complications were assessed.
Results: Of 998 patients 273 (27.4%) had CAS. The
degree of radiological CAS was 30-50% in 7.7%, 50-80% in 8.3%, and 80-100% in 1.3%
of patients. CAS (of any degree above 30%) was associated with increased
morbidity including intra-abdominal collections (p=0.022), gastric ischemia (p=0.001),
liver ischemia (p< 0.001), pancreatic fistula (p=0.003), sepsis (p=0.007), as
well as with longer hospital stay (p< 0.001) and ICU stay (p=0.016). Patients
with CAS required significantly more surgical reinterventions (p=0.001)
including gastric (p< 0.001) and pancreas reoperations (p=0.007). Rate and severity
of complications including liver ischemia and pancreatic fistula increased with
higher degree of CAS. Among patients with 80-100% stenosis, both grade B/C
pancreatic fistula and at least moderate liver failure occurred in 46% of
patients. Multivariable analyses confirmed CAS as independent risk factor both for liver
ischemia (p=0.010) and for pancreatic fistula (p=0.007).
Conclusion: CAS is common and represents
an underestimated risk for relevant complications after pancreatoduodenectomy. Already
a radiological stenosis of 30-50% is associated with increased risk of
morbidity. Precise radiological assessment of the celiac axis may help to
identify risk, to address relevant CAS, and, thus, to avoid postoperative
|OP04-24 ||Short-Term Clinical Outcomes after Total Pancreatectomy: A Prospective Multicenter European Snapshot Study
Anouk Latenstein, Netherlands
A. Latenstein1, L. Scholten1, M. Erkan2, J. Kleeff3, M. Lesurtel4, M. de Pastena5, A. Halimi6, M. Besselink1, J. Ramia-Angel1, Scientific and Research Committee of the E-AHPBA
1Amsterdam UMC, Location AMC, Netherlands, 2Koç University Hospital, Turkey, 3Martin Luther University, Germany, 4University Hospital of Zurich, Switzerland, 5University and Hospital Trust of Verona, Italy, 6Karolinska University Hospital, Sweden
multicenter studies on clinical outcomes after total pancreatectomy (TP) are not
reflecting current practice due to long study periods and inclusion of mainly
high-volume centers. The aim of this prospective multicenter European snapshot
study is to assess short-term clinical outcomes after elective TP.
who underwent elective TP for malignant or benign disease between June 2018 and
June 2019 were prospectively included from 42 hospitals. Hospitals were divided
based on annual volume (low 1-9, medium 10-19, and high ≥20 TPs). Variables
associated with major postoperative complications (Clavien Dindo ≥3) and 90-day mortality were assessed in
multivariable logistic regression.
total, 276 patients underwent TP, mostly for malignant disease (73%). Minimally
invasive TP was performed in 11 (4%) patients. Major postoperative
complications occurred in 25% and predictors were ASA score ≥3 (OR 2.41 [95%CI
1.27-4.55] p=0.007), blood loss (OR 1.00 [95%CI 1.00-1.00] p=0.009), and
low-volume centers (OR 2.28 [95%CI 1.15-4.52], p=0.019). Median hospital stay
was 12 days (IQR 9-18) and the 90-day readmission rate was 14%. The 30-day and
90-day mortality rates were 4% and 8%, respectively. In multivariable analysis,
only age (OR 1.07 [95%CI 1.02-1.13], p=0.008), BMI (OR 1.11 [95%CI 1.01-1.23],
p=0.039) and hospitals with 1-9 patients (reference ≥20 patients, OR 4.78
[95%CI 1.56-14.71], p=0.006) were predictors for 30-day mortality.
prospective multicenter study found 25% major postoperative complications and
8% 90-day mortality after TP and evidence to suggest that also for TP a higher
volume may reduce postoperative mortality.
|OP04-25 ||Minimally Invasive Pancreaticoduodenectomy (MIPD) at a Tertiary Centre over 2 Decades- "Lessons Learnt & Techniques Modified"
S Srivatsan Gurumurthy, India
S. Srivatsan Gurumurthy, M. Srinivasan, N. Anand Vijai, P. Senthilnathan, C. Palanivelu
Dept. of HPB, Minimally Invasive Surgery & Liver Transplant, Gem Hospital, India
Introduction: In 1998, the first totally Laparoscopic pancreaticoduodenectomy (LPD) for periampullary carcinoma was
performed in our institute. 22 years since then ,MIPD at our institute has
undergone several technical modifications, the recent addition ,over the last 2
years being Robotic
Pancreaticoduodenectomy (RPD). Lessons
learnt and techniques modified in this journey over the past 2 decades have
Methods: A retrospective analysis of prospectively maintained
database was carried out for all MIPD cases (418 LPD & 42 RPD ) done at our institute from Dec
1998 to Dec 2019. A subgroup analyses was done to compare the outcomes of LPD in
the first decade versus the second decade.
Results: The authors observed a
reduction in operative time and estimated blood loss between the first decade
and the second decade. The mean number of lymph nodes removed was higher in the
second decade , though not statistically significant (p= 0.07) Estimated blood
loss was comparable with laparoscopic and robotic PD (203.23+/- 84.37 vs 206.17
+/- 82.82, p=0.87) However robotic PD took a significantly longer time compared
to LPD (392 +/- 124.26 vs 312 +/- 39.62 , p=0.02) in this series.
Conclusion: MIPD provides several advantages
like decreased length of hospitalization, reduced blood loss and need for transfusion,
more meticulous oncologic dissection and higher lymph node yield. Accumulation of
surgical experience, better optics, improved energy sources and adoption of
robotic technology have refined the outcomes of MIPD at our institute and
worldwide, in recent times.
|OP04-26 ||Risk Factors of Serious Postoperative Complications after Laparoscopic Pancreatoduodenectomy: Single Center Retrospective Study
Roman Izrailov, Russian Federation
I. Khatkov, R. Izrailov, O. Vasnev, M. Baychorov, P. Tytyunnik, A. Andrianov, M. Mikhnevich, P. Agami
High-Tech Surgery, Moscow Clinical Scientific Center, Russian Federation
Background: Two hundred and ninety laparoscopic
pancreatoduodenectomies (LPDE) were performed by single surgical team.
Objective: to assess the short-term and
long-term outcomes of LPDE and to reveal the risk factors for having the
Clavien-Dindo IIIa-V complication.
underwent LPDE during last 10 years. 169 were females and 131 were
males. Mean age was 60 years (range 29-82). 244 patients were operated on
because of malignancies and 46 because of benign diseases. Postoperative
complications were graded according Clavien-Dindo classification. 109 perioperative
factors and parameters including laboratory test results were analyzed in order
to reveal their influence on developing of postoperative complications.
Results: Mean operative time was 419min and
mean blood loss was 350cc. Total Clavien-Dindo IIIa-V complications (CRPOC)
rate was 36.8% (107 patients). Among them IIIa - 16,2%, IIIb - 10.7%, IV - 3,8%,
V - 6,2%. CRPOPF were diagnosed in total of 20,3% patients (15,5% grade B POPF,
4,8% grade C). DGE was diagnosed in 4,8% of patients. PPH complicates the
postoperative course of 20 patients (6,9%). Sixteen of them had concomitant PF.
Univariate analysis revealed that the age ≥65, male sex, the soft pancreatic
tissue, absent of pancreatic hypertension, high intraoperative blood loss (≥400 cc), high BMI (≥30), diagnosis other than pancreatic
adenocarcinoma, were independent risk factors for having serious complications.
Conclusion: age ≥65, male sex, the soft pancreatic
tissue, absent of pancreatic hypertension, high intraoperative blood loss (≥400 cc), high BMI (≥30), diagnosis other than pancreatic
adenocarcinoma were independent risk factors for having serious complications.
|OP04-27 ||Neoadjuvant Chemoradiotherapy with S1 for Resectable Pancreatic Cancer
Masaru Matsumura, Japan
M. Matsumura1, S. Nemoto1, K. Tani1, Y. Ome2, G. Honda2, Y. Seyama1
1Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Japan, 2Gastrointestinal Surgery, New Tokyo Hospital, Japan
Introduction: The efficacy of neoadjuvant chemoradiotherapy (NACRT) with S1 for resectable pancreatic invasive ductal adenocarcinoma (R-PDAC) has not been clarified.
Method: Clinical data of 124 patients who underwent NACRT with S1 for R-PDAC from October 2009 to December 2018 were reviewed and compared with those of 45 patients who underwent up-front surgery for R-PDAC on the same period. The regimen of NACRT was concomitant daily 80 - 120 mg of S1 with 1.8 Gy of radiation for 28 days up to 50.4 Gy.
Results: Levels of CA19-9 before treatment were not different between two groups (NACRT median 82.4 U/L [IQR 18.3 - 199.4] vs. up-front surgery: 72.6 U/L [27.5 - 167.8]). Disease control rate of NACRT was 88.7%. Resection rate was 84.7% in NACRT and 93.3% in up-front surgery(p=0.25). Morbidity of Clavien-Dindo classification ≥ Grade 3a was 11.4% and 21.4% (p=0.13). R0 resection rate was 98.1% vs. 83.3% (p< 0.01) and percentage of patients with pathological lymph node metastases was 24.5% vs. 54.8% (p< 0.01). Adjuvant chemotherapy was administered in 81.9% of NACRT and 81.0% of up-front surgery (p=0.89). Overall survival (OS) of intention to treat population were significantly different between two groups (median survival time [MST]: 49.0 months vs. 43.4 months, 3 year-OS 59.0% vs. 55% [p=0.39]). For cohorts with resection followed by adjuvant chemotherapy, NACRT has significantly better survival than up-front surgery (MST 83.7 months vs. 43.9 months, 3 year-OS 77.0% vs. 61.0% [p=0.03]).
Conclusions: NACRT with S1 is feasible strategy for R-PDAC.
[OS of Intention to treat population and cohorts with resection and adjuvant chemotherapy]
|OP04-28 ||Impact of Neoadjuvant Therapy on Postoperative Pancreatic Fistula: A Systematic Review and Meta-analysis
June Oo, Australia
J. Oo1, S. Kamarajah2,3, J. Bundred4, C. Boyle2, S. Pandanaboyana2, B. Loveday1,5,6
1Peter MacCallum Cancer Centre, Australia, 2Freeman Hospital, United Kingdom, 3Newcastle University Trust Hospitals, United Kingdom, 4University of Birmingham, United Kingdom, 5Royal Melbourne Hospital, Australia, 6University of Auckland, New Zealand
Introduction: The use of neoadjuvant therapy (NAT) for pancreatic cancer is increasing,
although its impact on postoperative pancreatic fistula (POPF) is variably
reported. This systematic review and meta-analysis aimed to assess the impact
of NAT on POPF.
Methods: A systematic literature search until October 2019 identified studies
reporting POPF following NAT (radiotherapy, chemotherapy or chemoradiotherapy)
vs. upfront resection. The primary outcome was overall POPF. Secondary outcomes
included Grade B/C POPF, delayed gastric emptying (DGE), postoperative
pancreatic haemorrhage (PPH), and overall and major complications.
Results: The search identified 24 studies:
pancreaticoduodenectomy (PD), 19 studies (n=19,893); distal pancreatectomy
(DP), 5 studies (n=477). Local staging was reported in 17 studies, with borderline
resectable and locally advanced disease comprising 6% (0 - 100%) and 1% (0 - 33%)
of the population, respectively. For PD, any NAT was significantly associated
with lower rates of overall POPF (OR: 0.57, p< 0.001) and Grade B/C POPF (OR:
0.55, p< 0.001). In DP, NAT was not associated with significantly lower rates
of overall or Grade B/C POPF.
Conclusion: NAT is associated with significantly lower
rates of POPF after PD but not after DP. Further studies are required to
determine whether NAT should be added to POPF risk calculators.
|OP04-29 ||Comparison with Short- and Long-term Neoadjuvant Chemoradiotherapy for Resectable and Borderline Resectable Pancreatic Adenocarcinoma
Hironobu Suto, Japan
H. Suto, K. Okano, M. Oshima, Y. Ando, H. Matsukawa, Y. Suzuki
Gastroenterological Surgery, Kagawa University, Japan
Introduction: The indications of preoperative treatment for resectable (R) borderline
resectable (BR) pancreatic ductal adenocarcinoma (PDAC) are still obscure, and
the protocol has not yet been standardized.
patients were divided into R, BR with venous involvement (BR-V) according to
the 2019 NCCN guidelines. Between September 2009 and May 2016, short
neoadjuvant chemoradiotherapy (NACRT) (3Gy x 10fr.+S-1) in 2 weeks was given to
patients with R(n=33), BR-V(n=19). Subsequently, since
June 2016, long NACRT (2Gy x 25fr.+S-1) in 5 weeks was given
to patients with R(n=51) and BR-V(n=14) PDAC.
Results: There was no significant
difference in adverse event rate and
completion rate of NACRT protocol between short and long NACRT. The reduction rates of CA19-9 level and SUV max were both
significantly higher in patients with long NACRT than those with short NACRT
(64%vs30%:P=0.009 and 51%vs23%:P< 0.0001, respectively). There was no
significant difference in operation time, R0
reduction rate, Evans grade, and induction and completion rates of
postoperative adjuvant chemotherapy between the two groups. However, resection
rate was significantly lower in long NACRT group (96% vs 85%, P=0.041)
because distant metastasis was more frequently detected before surgery. There was
no significant difference in OS and RFS between R patients with short and long NACRT (P=0.871 and P=0.743, respectively). In contrast, BR-V patients with long
NACRT had significantly better OS and RFS than those with short NACRT (P=0.004 and P=0.022, respectively).
Conclusions: There was no significant difference
between short and long NACRT in R-PDAC. Long NACRT might be more effective
against BR-V PDAC.
|OP04-30 ||A National Analysis of the Incidence and Sequelae of Pancreatogenic Diabetes Following Pancreatic Resection
Jennifer Underhill, United States
J. Underhill, J.M. Hyer, C. Aquina, J. Cloyd, M. Dillhoff, A. Manilchuk, A. Tsung, T. Pawlik, A. Ejaz
The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, United States
Introduction: New-onset diabetes following pancreatic resection (pancreatogenic diabetes mellitus, P-DM) is a known risk factor. However, the long-term incidence of P-DM and its clinical impact following pancreatic resection remains unknown.
Methods: The Medicare 100% Standard Analytic File (2013-2017) was queried for all patients who underwent partial pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy). The primary outcome was the development of postoperative P-DM following surgery.
Results: We identified 4,255 patients who underwent a pancreaticoduodenectomy (n=2,989, 70.2%) or distal pancreatectomy (n=1,266, 29.8%). After a median follow-up of 0.9 years, the incidence of P-DM was 25.4% (n=863) and occurred at a median of 0.3 years following surgery. Risk factors for developing P-DM included undergoing a distal pancreatectomy (OR 1.98, 95%CI 1.67-2.34), having a malignant diagnosis (OR 1.66, 95%CI 1.35-2.05), and a family history of diabetes (OR 2.10, 95%CI 1.46-3.03) all (p< 0.001). Patients who developed P-DM were more commonly readmitted within 90 days (43% vs. 33.7%) and had higher postoperative healthcare expenditures in the year following surgery ($24,440 USD vs. $16,130 USD) (both p< 0.001) compared to patients who remained diabetes-free.
Conclusion: Approximately 1 in 4 Medicare beneficiaries who undergo a pancreatic resection develop pancreatogenic diabetes following pancreatic resection. Appropriate screening and improved patient education should be conducted for these patients, particularly those at highest risk.
|OP04-31 ||Pre-operative Prediction of Outcome in Patients Undergoing Whipple's Pancreatoduodenectomy: Prospective Validation of a Novel Risk Scoring
Samrat Ray, India
S. Ray1, S. Das1, V. Mangla1, A. Yadav1, P. Chugh2, N. Mehta1, S. Nundy1
1Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India, 2Research and Biostatistics, Sir Ganga Ram Hospital, India
Introduction: Despite a high morbidity following Whipple's pancreatoduodenectomy, there is a lack of an objective pre-operative tool, based only on clinical and biochemical parameters to predict the outcome following pancreatoduodenectomy that could be implemented on an outpatient basis.
Methods: Using a multivariate regression model, the significant predictors of post-operative outcome were identified in a set of retrospective database of patients (2006-2017), and a risk score developed by binary logistic regression method. This was validated in a set of prospective patients (2017-2020). The model's predictive accuracy and discriminative ability were assessed using the receiver operating characteristics (ROC) analysis and Hosmer-Lemeshow goodness of fit tests respectively.
Results: On multivariate analysis in the retrospective cohort (n=442), the significant predictors of post-operative outcome were identified as peak bilirubin levels, pre-operative stenting and diagnosis (benign/malignant). A risk score was derived and validated on the prospective cohort (n=185) [Table 1]. The mean risk for an unfavourable outcome was 24% for a score of < /=7, 44% for a score of 8-14 and 70% for a score of >/=15. This was further tested on the validation cohort for individual risk scores (AUC=0.708) and scores categorised (AUC=0.698). There was no significant difference between observed and expected risk of major complications (p=0.31).
Conclusion: The risk score showed a fair accuracy in predicting post-operative morbidity in the prospective cohort. Therefore, we propose this be used as a quick aid to predict the operative outcome in patients posted for pancreatoduodenectomy on an outpatient basis using simple pre-operative clinical and laboratory variables.
|Variables||Categories||Beta Coefficient||P value||Risk score|
|Peak Bilirubin||1) < 2 mg/dl;
2) 2-5 mg/dl;
3) 5-10 mg/dl;
4) 10-20 mg/dl;
5) >20 mg/dl||0.006||0.001||1) 0;
2) Unstented||1.143||<0.001||1) 0;
2) Malignant||0.661||<0.001||1) 0;
|Total|| || || ||25 (max)|
[Pre-operative risk scoring model]
|OP04-32 ||Artery-First Pancreatectomy with Superior Mesenteric - Portal Vein Resection and Reconstruction: Two Large Institutions Experience from East and West
Atsushi Oba, Japan
A. Oba1,2, K. Tanaka3,4, E. Rangelova3, Y. Inoue1, H. Ito1, Y. Takahashi1, A. Saiura1, R. Schulick2, M. Del Chiaro2,3
1Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan, 2University of Colorado School of Medicine, United States, 3Karolinska Institutet, Sweden, 4Hokkaido University Faculty of Medicine, Japan
benefits of pancreatectomies associated to vein resection (PAVR) for pancreatic
cancer are still contradictory. Although some recent papers suggested
artery-first approach facilitated PAVR, evidence is sparse. The aim of this
study is to analyze outcomes of artery-first approach with PAVR by using two
large institutions from different regions.
Methods: We identified
consecutive series of patients with pancreatic cancer who underwent artery-first
approach with PAVR in Karolinska University Hospital (KUH) and Cancer institute
hospital, Japanese foundation of cancer research (JFCR) from 2008 to 2018. We
compared the short- and long-term results between two centers.
Results: Among total 506 patients,
211 patients were from KUH and 295 patients were from JFCR. The higher
incidence of total pancreatectomy was shown in KUH (24.6% vs 0.3%, P
< 0.001). The higher incidence of primary end-to-end anastomosis was shown
in JFCR (92.5% vs 62.6%, P = 0.017). There was no significant difference
in intraoperative estimated blood loss (KUH: 630ml, JFCR: 600ml), severe
complications rate (8.5%, 5.1%), and mortality (2.4%, 0.7%). Primary end-to-end
anastomosis was mainly performed even if the length of PV/SMV resection was 5cm
or more and achieved successfully without thrombus (overall cases: 98.0%, 5cm
or more: 93.5%)
We reported favorable short-term outcomes and
acceptable long-term outcomes of artery-first approach with PAVR for pancreatic
cancer from the two high-volume centers in the east and west. Primary
end-to-end anastomosis after artery-first pancreatectomy was safe and feasible
even if the length of PV/SMV resection was 5cm or more.
[The types of vein reconstruction for each length of PV/SMV resection and the rate of no thrombus]
|OP04-34 ||Laparoscopic versus Open Pancreatoduodenectomy: An Individual Patient Data Meta-analysis of Randomized Controlled Trials
Frederique Vissers, Netherlands
F. Vissers1, J. van Hilst1,2, F. Burdio3, S. Sabnis4, M. Dijkgraaf5, S. Festen2, C. Palanivelu4, I. Poves3, M. Besselink1
1Surgery, Amsterdam UMC, University of Amsterdam, Netherlands, 2Surgery, OLVG, Netherlands, 3Surgery, Hospital del Mar, Spain, 4Surgery, Gem Hospital, India, 5Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Netherlands
randomized controlled trials (RCT) comparing LPD to OPD have been published
recently with conflicting results where observational studies show less postoperative complications. An
individual patient data meta-analysis (IPDMA) may give more insight in the
putative differences, including in subgroups.
systematic literature search was performed in Pubmed, Embase and the Cochrane
library. Out of 1410 studies, three RCT's comparing LPD to OPD were identified.
The primary outcome was major postoperative complications (Clavien-Dindo grade
≥ III). Subgroup analyses were performed for high-risk groups including
patients with a BMI of ≥25 kg/m2, either a BMI of ≥25 kg/m2 and/or a pancreatic
duct < 3mm, age ≥70 years, and malignancy were performed.
patient data from 224 patients included from 6 centers were collected. After
LPD, major complications occurred in 33/114 (29%) patients compared to in
34/110 (31%) patients after OPD (adjusted OR 0.62; 95%CI 0.27 - 1.41, p =
0.257). No differences were seen for postoperative pancreatic fistula (adjusted
OR 0.78; 95%CI 0.316 - 1.943, p = 0.599), delayed gastric emptying (adjusted OR
0.56; 95%CI 0.220 - 1.418), p=0.220) and 90-day mortality [8 (7%) vs 4 (4%)]
(adjusted OR 0.15; 95% CI 0.02 - 1.26, P=0.08) after LPD vs OPD. With LPD,
operative time was longer (420 vs 318 minutes, p< 0.001) and primary LOHS
was shorter (mean difference -6.97 days).
does not show benefits nor disadvantages for LPD as compared to OPD besides a
shorter LOHS. Subgroup analyses showed similar postoperative outcomes in the
|OP04-33 ||Impact of Borderline Resectability in Pancreatic Head Cancer on Patient Survival: Biology Matters According to the New International Consensus Criteria
Stefan Löb, Germany
F. Anger1, A. Doering1, J.-F. Lock1, C.-T. Germer1, I. Klein1, A. Wiegering1, V. Kunzmann2, C. van Eijck3, S. Löb1
1Department of General-, Visceral- and Transplantsurgery, University Hospital Wuerzburg, Germany, 2Department of Internal Medicine II, University Hospital Wuerzburg, Germany, 3Erasmus MC - University Medical Center, Netherlands
Background: International consensus criteria (ICC) have redefined borderline resectability for pancreatic ductal adenocarcinoma (PDAC) according to three dimensions: anatomical (BR-A), biological (BR-B) and conditional (BR-C). Aim of this study was to evaluate the impact of the novel consensus criteria defining BR-PDAC compared to current NCCN guidelines on patient survival after upfront pancreaticoduodenectomy.
Methods: Patients' tumours were retrospectively defined borderline resectable according to ICC. The study cohort was grouped into either BR-A or BR-B and compared to patients considered primarily resectable (R). Differences in postoperative complications, pathological reports, overall (OS) and disease-free survival (DFS) were assessed.
Results: 223 patients underwent resection for PDAC. By applying ICC in routine preoperative assessment, 20 patients were classified as stage BR-A and 36 patients as stage BR-B. 167 patients were considered resectable (R). The cohort did not contain BR-C patients. No differences in postoperative complications were detected. Median OS was significantly shorter in BR-A (12 months) and BR-B (14 months) compared to R (20 months) patients (BR-A vs. R: p=0.036 and BR-B vs R: p=0.016). CA19-9, as the determining factor of BR-B patients, turned out to be an independent prognostic risk factor for OS.
Conclusion: Preoperative staging defining surgical resectability in PDAC according to ICC is crucial for patient survival. Patients with PDAC BR-B should be considered for multimodal neoadjuvant therapy.
|OP04-35 ||Total Pancreatectomy Risk Model for Severe Postoperative Complications Derived from 2,167 Patients Recorded in a Nationwide Clinical Database
Daisuke Hashimoto, Japan
D. Hashimoto1, M. Mizuma2, H. Kumamaru3, S. Satoi1, H. Yamaue4, M. Yamamoto5, Y. Kakeji6, M. Unno2, K. Okazaki7
1Department of Surgery, Kansai Medical University, Japan, 2Department of Surgery, Tohoku University, Japan, 3Department of Healthcare Quality Assessment, The University of Tokyo, Japan, 4Second Department of Surgery, Wakayama Medical University, Japan, 5Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan, 6Division of Gastrointestinal Surgery, Department of Surgery, Kobe University, Japan, 7Department of Gastroenterology and Hepatology, Kansai Medical University, Japan
pancreatectomy is required to completely clear tumors that are locally advanced
or located in the center of the pancreas. However, reports describing the
clinical outcomes after total pancreatectomy are rare. The aim of this
retrospective observational study was to assess the clinical outcomes following
total pancreatectomy using a nationwide registry and to create a risk model for
severe postoperative complications.
Patients who underwent total pancreatectomy from 2013-2017 and who were
recorded in the Japan Society for Gastroenterological Surgery and Japanese
Society of Hepato-Biliary-Pancreatic Surgery database were included. Severe
complications at 30 days were defined as Clavien-Dindo grade III with
reoperation or grade IV/V. We modeled the occurrence of severe complications
among the patients from 2013-2016 and tested the accuracy of the model among
the patients from 2017 using c-statistics and a calibration plot.
included 2167 patients undergoing total pancreatectomy. Postoperative 30-day
and in-hospital mortality occurred in 1.0 per cent (22/2167) and 2.7 per cent (58/2167)
of patients, respectively, and severe complications occurred in 6.0 per cent (131/2167)
of patients. Factors showing a strong positive association with outcome in this
risk model were the American Society of Anesthesiologists performance status
and combined arterial resection. In the testing cohort, the c-statistic of the
model was 0.70 (95 per cent confidence interval: 0.59-0.81).
risk model for severe postoperative complications after total pancreatectomy based
on a nationwide clinical database showed good calibration and may improve the
quality of pancreatic surgery.
|OP04-36 ||Minimally Invasive versus Open Distal Pancreatectomy: An Individual Patient Data Meta-analysis of Two Randomized Controlled Trials
Maarten Korrel, Netherlands
M. Korrel1, F. Vissers1, S. Festen2, B. Groot Koerkamp3, M. Luyer4, P. Sandström5, M. Abu Hilal6, M. Besselink1, B. Björnsson5, International Minimally Invasive Pancreatic Resection Trialists Group
1Amsterdam UMC, University of Amsterdam, Netherlands, 2OLVG, Netherlands, 3Erasmus University Medical Center, Netherlands, 4Catharina Hospital Eindhoven, Netherlands, 5Linköping University Hospital, Sweden, 6Brescia University Hospital, Italy
Background: Minimally invasive
distal pancreatectomy (MIDP) may reduce overall complications and hospital stay
as compared to open distal pancreatectomy (ODP). This study aimed to combine
data of randomized controlled trials (RCTs) comparing MIDP vs. ODP and assess treatment
effects in different high-risk subgroups by conducting an individual patient
Methods: The principal investigators of the LEOPARD
trial from the Netherlands and the LAPOP trial from Sweden agreed to perform
this study upon completion of the trials. After completion of both trials,
individual patient data will be obtained, and data collection, definitions, and
outcomes harmonized. The primary endpoint is the overall rate of major
(Clavien-Dindo ≥III) complications. Secondary outcomes include length of stay
and individual major complications. Sensitivity analyses will be performed in
three pre-specified subgroups (i.e. BMI ≥25 kg/m2, severe
comorbidity and malignant disease).
Results: Results of the LAPOP trial are not yet
published. These results will have been published during IHPBA 2020, and
therefore, results of this individual patient data meta-analysis will become
available when the congress will take place.
Conclusions: This is the first
individual patient data meta-analysis including RCTs on MIDP vs. ODP, creating
the largest sample of randomized patients in this field. In this study, two individual
trial teams, jointly working together as the International Minimally Invasive
Pancreatic Resection Trialists Group, will combine individual patient data. Results
of this individual patient data meta-analysis will be presented when accepted
for IHPBA 2020.
|OP04-40 ||The Role of Radical Antegrade Modular Pancreatosplenectomy Compared to Conventional Distal Pancreatosplenectomy in Patients with Left-sided Pancreatic Cancer: A Retrospective Multicenter Propensity- Score Matching Analysis
Naru Kim, Korea, Republic of
N. Kim1, C.-S. Lim2, Y.C. Shin3, W.H. Jung4, J.S. Heo1, D.W. Choi1, S.H. Shin1, I.W. Han1
1Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, Korea, Republic of, 2Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Korea, Republic of, 3Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Korea, Republic of, 4Department of Surgery, Ajou University School of Medicine, Korea, Republic of
Introduction: The purpose of this study aimed to evaluate
the role of radical antegrade modular pancreatosplenectomy (RAMPS) in terms of postoperative outcomes compared
to conventional distal pancreatosplenectomy (DPS) in patients with left- sided
pancreatic ductal adenocarcinoma (PDAC).
Method: From 2005 to 2017, consecutive 316
left-sided PDAC patients who underwent RAMPS (n=236) or DPS (n=80) for curative
intent in four tertiary referral hospitals in Korea were included in this
study. Among these, after 1:2 Propensity score matching with age, sex,
differentiation, T and N stage, 71 patients with DPS and 139 patients with
RAMPS were analyzed for clinicopathological outcomes.
Result: There was no difference in complication
rate between the two groups. RAMPS was superior than DPS in terms of R0 rate
(99.3% vs 88.6%, p< 0.01) and harvested LN numbers (16.3±10.57 vs. 10.3±7.06,
p< 0.01). RAMPS showed prolonged DFS (median survival 11 vs 9months), but
statistically not significant (p=0.148). In a subgroup analysis with
node-negative patients (n=107), RAMPS showed superior disease-free survival
than DPS with statistically marginal significance (MS 15 vs 9m, p= 0.05). After
multivariate analysis, preoperative CA19-9≥37, tail cancer, poorly or
undifferentiated carcinoma, R1 resection, and absence of adjuvant treatment
were identified as independent risk factors for survival. Also, preoperative
CA19-9≥37, advanced T stage, LN metastasis, poorly or undifferentiated
carcinoma were independent risk.
Conclusion: Although we could not find an eminent
survival benefit of RAMPS, it could be considered a standard surgical method
for left-sided PDAC because of the similar complication rate and several
|OP04-42 ||The Yonsei Experience of Minimal Invasive Pancreaticoduodenectomies: A Propensity Score‑Matched Analysis with Open Pancreaticoduodenectomy
Munseok Choi, Korea, Republic of
M. Choi, H.K. Hwang, W.J. Lee, C.M. Kang
Department of Surgery, Yonsei University College of Medicine, Korea, Republic of
Introduction: With continued technical advances in
surgical instruments and growing expertise, several surgeons have performed minimal
invasive pancreaticoduodenectomy (MIPD) safely with good results, and the
approach is being performed more frequently. We performed over 200 cases of MIPD
and compared their outcomes to those of open pancreaticoduodenectomy (OPD)
using the large sample size. The aim of the present study was to evaluate the
safety and feasibility of MIPD compared with OPD.
Methods: From September 2012 to December 2019,
pancreaticoduodenectomy was performed for 352 patients at Yonsei University
Severance Hospital by a single surgeon. Patients were divided into two groups:
those who underwent OPD (n=132) and those who underwent MIPD (n=220). We
performed a 1:1 propensity score-matched analysis and retrospectively analyzed
the demographic and surgical outcomes.
Results: After Propensity score matching analysis,
the mean operation time for the MIPD group was similar and estimated blood loss
was lower than the OPD group. The postoperative pancreatic fistula (POPF) grade
B and C did not differ significantly between the 2 groups (p=0.204). There was
no difference in 30-day mortality rates between the two groups (p=1.000).
Conclusions: MIPD can be a good alternative option
for well-selected patients with periampullary lesions requiring pancreaticoduodenectomy.
|OP04-43 ||The Outcome of Laparoscopic Pancreaticoduodenectomy Is Improved with the Learning Curve and Patients' Selection. Analysis in 130 Patients
Béatrice Aussilhou, France
S. Dokmak, B. Aussilhou, F.S. Ftériche, O. Soubrane, A. Sauvanet
HBP Departement and Liver Transplantation, Beaujon Hospital, France
Introduction: In our first
experience Laparoscopic pancreaticoduodenectmoy (LPD) was associated with
higher morbidity. Since we restrict LPD to patients at lower risk of pancreatic
fistula (PF) and we ameliorate our surgical technique. We analyzed our recent
Methods and patients: Between 2011-2018, 130 pure LPD were performed, divided in 3 consecutive periods: period 1
(n=43), period 2 (n=43=) and period 3 (n=44) and were compared.
Results: In the third period, more females (48%,
46%, 59%, p=0.12), IPMN become the first indication of LPD (12%, 39%, 34%; p=0.037)
followed by ampulloma (30%, 9%, 20%), less resection for pancreatic adenocarcinoma
(35%, 16%, 16%; p=0.004), and more dilated (>3mm) wirsung duct > 3 mm (16%,
27% and 57%; p< 0.001). The third period showed less operative time (330,
345, 270; p< 0.001) and blood loss (300, 200 125; p< 0.001). Similar
mortality (4%, 4%, 2%; p=0.53), decrease in all complications including mainly grades
B/C PF (44%, 28%, 20%; p=0.017), bleeding (28% ,21%, 14%, p=0.26), re-intervention
(19%, 14%, 9%; p=0.43) and hospital stay (26, 19, 18; p=0.045). In patients
with adenocarcinoma (n=69), similar tumor size but more harvested lymph nodes (21,
19, 25; p=0.031) and R0 resection (70%, 79%, 84%; p=0.5). On multivariate analysis protective factors
against grades B/C PF were female gender, pancreatic adenocarcinoma, BMI
< 22.5 and the third period.
Conclusion: With patient
selection and the learning curve, the results of LPD are improved. These
results are important for the safe implementation of this technique.
|OP04-44 ||Peripancreatic Bacterial Contamination Can Lead to the Development of Postoperative Pancreatic Fistula after Pancreaticoduodenectomy
Norihisa Kimura, Japan
N. Kimura, K. Ishido, T. Wakiya, H. Nagase, K. Hakamada
Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
Introduction: The aim of
this study was to analyze the relationship between
bacterial contamination (PPBC) and postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) and
to investigate the bacterial species in the peripancreatic fluid and identify
useful antibiotics to prevent POPF.
Methods: Three hundred twenty consecutive patients underwent PD between May 2012 and December 2019. Amylase (D-AMY)
and microbial culture have been routinely obtained from the peripancreatic drain on postoperative day (POD) 1, 3, and 6
since May 2012 and Modified Blumgart pancreaticojejunostomy (MBPJ) (N=158) has
been adopted since May 2016. POPF was defined as grade B/C according to the
Results: POPF occurred in 26 (16.5%)
of 158 patients with MBPJ. In univariate analysis, non-pancreatic disease (P=0.026), body mass index (BMI) >25
kg/m2 (P=0.016), soft
pancreas (P=0.009), D-AMY on POD1
>5000 U/L (P< 0.001), and PPBC on POD1 or 3 (P< 0.001) were significantly associated with POPF. In multivariate
analysis, BMI >25kg/m2 (Odds ratio [OR]=3.61; P=0.022), D-AMY on POD1 >5000 U/L
(OR=5.28; P=0.004) and PPBC on POD1 or 3 (OR=4.96; P=0.003) were independent risk factors of POPF. Of all 320 patients, PPBC gradually increased from POD1 to 6. The
most commonly isolated bacteria on POD1 or 3 were Enterococcus sp. (10.9%), Pseudomonas sp. (2.5%), and Enterobacter sp. (1.9%) which were sensitive to piperacillin, imipenem, meropenem, and
Conclusions: Early PPBC after PD can cause the development of POPF. The patients suspected of PPBC should receive
more sensitive antibiotics in the early postoperative period to prevent severe POPF.
|OP04-45 ||Delayed Gastric Emptying in Diabetic Patients Undergoing Pancreaticoduodenctomy: A Procedure-targeted NSQIP Analysis
Alissa Greenbaum, United States
A. Greenbaum, A. Kangas-Dick, D. Moore, E. Kenny, V. Gall, D. August
Rutgers Cancer Institute of New Jersey, United States
gastric emptying (DGE) is a major source of morbidity after
pancreaticoduodenctomy (PD). Patients with diabetes mellitus
(DM) have a propensity for gastric dysmotility, however the relationship between
DGE and DM is not clearly established. The
aim of this study was to determine the incidence of DGE in patients with and
without DM after PD.
American College of Surgeons National Quality Improvement Project procedure-targeted pancreatectomy database was queried from 2014-2017 for
patients undergoing PD and combined with the main database. Variables were compared by DM
status. The primary outcome was DGE.
Results: 14,735 patients met inclusion
criteria, including 10,930 non-DM (74.2%) and 3805 DM patients
(25.8%). DGE occurred in 17.1% (n=2519); 17.2% in non-DM and 16.8% in DM patients (p=0.60). DM patients had increased
rates of hypertension and pancreatic adenocarcinoma,
larger duct size, harder gland texture, and required more vascular
resections (p< 0.001). DM patients had
equivalent rates of postoperative infections compared to non-DM patients. IDDM had better outcomes
compared to non-IDDM patients in organ space infections (8.8 vs 14.2%;p< 0.001) and pancreatic fistula (11.7 vs 18.3%;p< 0.001). Rates of DGE
were 18.0% (n=337) in non-IDDM and 15.7% in IDDM patients (p=0.162). On multivariate regression, male sex, advanced age, smoking, pancreatic fistula, and organ space
infection were associated with DGE.
Conclusion: No differences in rates of DGE between DM and
non-DM patients after PD were found. IDDM patients demonstrated better
postsurgical outcomes compared to non-IDDM patients, suggesting a potential role of monitored
insulin or hyperglycemia regulation.
|OP04-46 ||Laparoscopic Central Pancreatectomy: Results in 81 Patients
Béatrice Aussilhou, France
S. Dokmak, B. Aussilhou, F.S. Ftériche, O. Soubrane, A. Sauvanet
HBP Departement and Liver Transplantation, Beaujon Hospital, France
Introduction: Central pancreatectomy (CP) is a
good indication to the laparoscopic approach related to the absence of oncological
or vascular contraindications. The aim of this study was to analyze our
Methods: Between 2008-2018, were performed 540 laparoscopic
pancreatic resections and 81 laparoscopic CP. CP was indicated if enucleation
was not feasible, in non-diabetic patients and if the distal pancreas was >
5 cm. One layer pancreato-gastric anastomosis. All clinical, operative and
postoperative data were recorded prospectively and were analyzed.
Results: The mean age was 50 (17-77), including 55 female
(68%), with a mean BMI at 25 (16-36). Indications for resection were for
neuroendocrine tumor (24; 30%), IPMN (16; 20%), solid pseudopapillary tumor (12;
15%), mucinous cystadenoma (11; 14%), pancreatitis with disconnected duct
syndrome (5; 6%), and other (13; 15%). The mean operative time was 183
(90-285), the mean blood loss 107 (0-800), and one
conversion (1%). No 90 days mortality and the overall morbidity was observed in
58 patients (72%) including grade B/C pancreatic fistula (21; 26%), bleeding (10;
12%), drained collection (2; 3%), delayed gastric emptying (2; 3%), re-intervention
(5; 6%). the mean hospital stay was 22 days (5-54) with readmission in 2 (2%).
The mean number of harvested lymph nodes was 3 (0-19) and R0 resection in 71 (88%)
Conclusion: The applicability of laparoscopic central pancreatectomy
is high and the morbidity is acceptable. There is a real advantage on the
preservation of the pancreatic function and abdominal wall in these young
patients with no malignancy.
|OP04-48 ||Surgical Complications after Preoperative Chemoradiotherapy in Patients with Resectable and Borderline Resectable Pancreatic Cancer in a Multicentre, Randomised Controlled Clinical Trial (PREOPANC-1)
Jelle Corneel van Dongen, Netherlands
J.C. van Dongen1, E. Versteijne2, M. Suker1, B.A. Bonsing3, M.G. Besselink2, O.R. Busch2, G. van Tienhoven2, B. Groot Koerkamp1, C.H. van Eijck1, Dutch Pancreatic Cancer Group
1Erasmus MC - University Medical Center, Netherlands, 2Amsterdam UMC, University of Amsterdam, Netherlands, 3Department of Surgery, Leiden University Medical Center, Netherlands
Background: Preoperative chemoradiotherapy is increasingly being used in patients
with (borderline-)resectable pancreatic cancer. However, randomised studies
investigating the effect of preoperative therapy on the surgical complication
rate after pancreatic resection are lacking.
Objectives: To investigate the effect of preoperative chemoradiotherapy on surgical
complications in patients after pancreatic resection for (borderline-)resectable
Methods: In this prospective, multicentre, randomised controlled trial, patients
with (borderline-)resectable pancreatic cancer were randomly assigned (1:1) to upfront
surgery, followed by adjuvant therapy or to preoperative chemoradiotherapy followed
by surgery and adjuvant chemotherapy. The endpoints of our study were the rate
of postoperative pancreatic fistula (POPF), post pancreatectomy haemorrhage
(PPH), delayed gastric emptying (DGE), bile leakage, intra-abdominal
infections, major complications and mortality.
Results: This study included 218 patients, of which 84 underwent curative resection
in the upfront surgery group (75%) and 60 in the preoperative therapy group (57.1%).
There was a higher incidence of POPF in the group who underwent upfront surgery
compared to preoperative chemoradiotherapy (10.7% vs. 0%, p = 0.011). The
incidence of PPH did not differ significantly between the two treatment groups (7.6% vs. 10.7%, p=0.553, respectively), but a different etiology was observed.
The upfront surgery group included five (6.0%) patients with late extra-luminal
PPH, compared to zero in the preoperative chemoradiotherapy group (p=0.076). No
significant differences were found regarding other surgical complications.
Conclusion: Preoperative chemoradiotherapy does not increase the incidence of
surgical complications or mortality. In contrast, it was associated with a
reduced POPF rate.