Poster
Pancreas 		  
PP01 Pancreas: Pancreatitis (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PP01-01 Laparoscopic Cholecystectomy in Acute Mild Gallstone Pancreatitis: How Early Is Safe?
Pablo Giuffrida, Argentina

P. Giuffrida1, D. Biagiola2, V. Ardiles1, P. Uad2, R. Sanchez-Clariá3, M. De Santibañes1, E. De Santibañes3, J. Pekolj1, O. Mazza1
1HPB Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Argentina, 2General Surgery Service, Hospital Italiano de Buenos Aires, Argentina, 3HPB Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Argentina

Introduction: There is still controversies about which surgical strategy is most appropriate to resolve the underlying biliary pathology in patients with Acute Gallstone-Pancreatitis (AGP).The aim was to evaluate the safety and effectiveness of Early Laparoscopic Cholecystectomy (ELC)in patients with Mild-AGP.
Methods: Retrospective cohort of consecutive patients diagnosed with mild-AGP according to the Atlanta Guidelines from January 2009 to July 2019. Patients were assigned to surgery on the first available shift after 48 hours after symptoms onset. Univariate analysis was performed to determine association between AGP and Grades of Balthazar(A,B and C)with time to surgery, days of hospitalization and postoperative complications.
Results: From 239 patients evaluated, 238 (99.58%) were operated by laparoscopic approach. Intraoperative cholangiogram(IOC)was performed routinely.Common bile duct stones, if present, were simultaneously and successfully treated.Significant association were found between Balthazar-Grades and time to surgery (median of 3 days, p=0.003), with length hospitalization and from surgery to discharge, with median of 4 days (p=0.0001) and 2 days (p=0.003) respectively. Of the entire cohort, 118 patients (49.3%) were operated at 48 hours since the symptoms onset. Mild postoperative complications (CD I/II) were observed in 22/239 patients(9.2%). This represents 2% of patients with Grade A of Balthazar, 9% of grade B and 14% of grade C (p=0.016). No severe and deaths were observed.
Conclusions: ELC with routine IOC and common bile duct exploration performed on the first available surgical shift after 48h since onset of pancreatitis symptoms,is a viable, effective and a safe strategy for the resolution Mild-AGP and its underlying biliary pathology.
Baltazhar GradeClavien-Dindo I/II n=22Length of stay(range)Days from surgery to discharge (range)p
An = 2/723 (3 - 5)2 (1 - 2) 
Bn = 6/654 (4 - 5)2 (1 - 2)0.001
Cn = 14/974 (4 - 5)2 (1 - 3) 
[Postoperative complications according to Balthazar Grades.Times and variables associated with Balthazar Grades.]

[Flowchart of study participants]
PP01-03 World-Wide Variation in Reporting of the Longitudinal Pancreatojejunostomy with Partial Pancreatic Head Resection (Frey Procedure)
Harry VM Spiers, United Kingdom

M. Baltatzis1, H.V. Spiers2, S. Jegatheeswaran1, A. Siriwardena1,3
1Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom, 2Regional Hepato-Pancreato-Biliary Unit, Addenbrooke’s Hospital, Cambridge, United Kingdom, 3Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom

Introduction: The Frey pancreatojejunostomy combines a longitudinal decompression of the main pancreatic duct with a partial, duodenum-preserving head resection. Although widely adopted and reported since its original description the procedure is not standardized. For example, although the amount of parenchyma excised from the head of the pancreas is clearly defined in the original report this is interpreted differently in subsequent papers. This study assesses the reports of the Frey prcedure to identify areas of concordance and discordance in reporting.
Methods: A computerized search of the literature using the Scopus database (Scopus; Elsevier B.V Amsterdam, The Netherlands) was undertaken covering the period between January 1970 and January 2019. 36 articles reporting the Frey pancreatojejunostomy were identified. Data were extracted on clinical demographics, operative detail and outcome.
Results: The median (range) number of patients per series is 35 [6-141]. Median (range) accrual time is 9 [2-18] years. Weight of resected pancreas was reported in 4 (11%) studies and varied between 2gr and 78gr. 33 studies (92%) report postoperative mortality of 0.8%. Opiate independence was reported in 31%. Heterogeneity of reporting does not permit correlation between opiate independence and extent of parenchyma removed.
Conclusions: The published literature demonstrates that there is substantial variation between centres in reporting of the Frey operation. Under-reporting of critical parameters regarding the operation itself and the outcome was also observed. This variance compromises the value of comparative outcomes of this procedure and highlights the need for better standardization of the reporting of outcomes of surgery for chronic pancreatitis.
PP01-05 Contemporary Management of Pancreatic Trauma in a Tertiary Hepato-Pancreato-Biliary Centre
Nadia Matias, United Kingdom

N. Matias1, S. Jegatheeswaran1, V. Nadarajah2, A. Sheen1, A. Siriwardena1, S. Jamdar1
1HPB, Manchester Royal Infirmary, United Kingdom, 2Radiology, Manchester Royal Infirmary, United Kingdom

Aims: Pancreatic trauma accounts for 0.2- 1% of all trauma-related injuries worldwide. Traditionally, operative management was advocated for major pancreatic injuries. However, advances in interventional radiology and gastroenterology techniques have increased non-operative options. The aim of this study is to evaluate the management of a series of patients presenting with pancreatic injury.
Methods: Between 2015 to 2019, patients presenting to a specialist Hepato-Pancreato-Biliary (HPB) centre, with pancreatic trauma, were identified using hospital databases. Severity of injury was assessed from operative notes and radiological studies. Management and outcomes were recorded from clinical notes. These were compared with American Association for the study of Trauma (AAST) guidelines to evaluate.
Results: There were 20 patients with pancreatic trauma admitted from 2015 to 2019. 13 (65%) were male. Median (range) age was 22 (2-65) years. 10 patients were children below 18 years of age. 16 (80%) sustained blunt trauma and 4 (20%) penetrating trauma. There were no AAST Grade 5 injuries. 8 (40%) were Grade 4; 5(25%) were Grade 3 and 7(35%) were Grade 1. Overall, 16 (80%) were managed non-operatively. Of the 4(20%) who had surgery, there were 3 that underwent distal pancreatectomies and 1 pancreatoduodenectomy. 10 (50%) patients had blood or blood product transfusions on admission. Complications were due to infected collections- 9 (45%); upper GI bleed- 3(15%) and hypocalcaemia- 1(5%). There were no deaths.
Conclusions: This is a small series but the results demonstrate that a conservative policy of management of pancreatic trauma is associated with acceptable outcomes.
PP01-06 Four Cases of IgG4-Related Pancreatitis Preoperatively Diagnosed as Malignancy
Kenri Akamine, Japan

K. Akamine, N. Ishizaki, K. Sasaki, T. Watanabe, M. Osako
Surgery, Kagoshima Medical Association Hospital, Japan

IgG4-related pancreatitis is known to be difficult to distinguish from pancreatic or bile duct cancer. Though endoscopic ultrasound-fine needle aspiration is useful for diagnosis, it is not easy to completely rule out malignancy. Four cases IgG4-related pancreatitis who underwent resection were enrolled at our institute from 2000 to 2019 in the study. Preoperative diagnoses of two cases were bile duct cancer and the two others were pancreatic cancer. Preoperative diagnosis was made by dynamic images of CT, MRI, ERCP, and/or subsequent cytology. These examinations couldn't rule out malignancy because biliary cytology demonstrated positive in one case and class Ⅲ in another one. As a result, the resections were performed under the enough informed consent. In all four cases, the histological diagnoses were IgG4-related pancreatitis. Fortunately, all patients discharged on foot. If precise preoperative diagnosis of IgG4-related pancreatitis could be made, conservative therapy such as steroid administration might have been taken. The combination of CA 19-9 and IgG4 is considered to be useful for distinguishing patients with autoimmune pancreatitis from those with cancer. But, when malignancy such as pancreatic or bile duct cancer couldn't be ruled out, serious consequence after overlooking the possibility of malignancy should be considered. Therefore, resection could be an option for treatment under the surgeons who are familiar with such a difficult operation. Precise diagnostic method and throughout recognition seemed to be essential for IgG4-related pancreatitis.
PP01-07 A Network Meta-Analysis of Surgery for Chronic Pancreatitis: Impact on Pain and Quality of Life
Bathiya Ratnayake, New Zealand

B. Ratnayake1, S. Kamarajah2, 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: The surgical operation associated with improved pain and quality of life (QoL) in patients with chronic pancreatitis (CP) is unknown.
Method: The Scopus, EMBASE, Medline and Cochrane databases were systematically searched until May 2019 and all randomised trials (RCTs) comparing surgical operations for CP pain were included in a network meta-analysis (NMA).
Results: Four surgical operations for treating CP were directly compared in eight RCTs including 597 patients. Patients were mainly male (79%, 474/597) with alcoholic CP (85%, 382/452). Surgical operations included were pancreatoduodenectomy (224, 38%), Berne procedure (168, 28%), Beger procedure (133, 22%), and Frey procedure (72, 12%). NMA revealed that the Beger procedure ranked best for pain relief, while the Frey procedure ranked best for postoperative QoL, postoperative pancreatic fistula rate and postoperative exocrine insufficiency rate. Overall the Frey procedure ranked best for the combination of primary outcome measures based on surface under cumulative ranking curve scores.
Conclusions: Overall the Frey procedure is the best operation for both pain relief and postoperative QoL in patients with CP. New validated tools to assess CP pain and the influence of various types of pain patterns on QoL will allow future trials to better stratify patients. Given the different inclusion criteria, pain and QoL assessment and duration of symptoms, and increasing uptake of enhanced recovery protocols, further trials are required to investigate the role of surgery for different CP phenotypes, timing of surgery and in defining the role of surgery in relation to endotherapy.
PP01-08 A Case of Intrahepatic Pancreatic Pseudocyst Developed as a Complication of Pancreatitis
Chol Kyoon Cho, Korea, Republic of

C.K. Cho, Y.H. Lee, H.J. Kim
Surgery, Chonnam National University Medical School, Korea, Republic of

Introduction: Pancreatic pseudocyst is located usually in lesser sac and peripancreatic space and is rarely developed in the liver. The intrahepatic pancreatic pseudocyst(IHPP) following acute pancreatitis is extremely rare with very limited number of clinical reports about IHPP.
Methods: A 70-year-old woman was referred because of upper abdominal pain of 3 days' duration. An abdominal CT scan revealed 11x10 cm sized cystic mass in the left lateral section of liver. On EUS findings, a huge hypoechoic lesion with internal echogenicity was noted in the lesser sac. EUS-guided gastrocystostomy was performed and analysis of cystic fluid showed a high level of amylase (21,200 U/L). After the endoscopic procedure, severe abdominal pain developed and physical examination showed peritoneal irritation sign. An emergency operation was performed.
Results: On operation findings, a huge cystic tumor was located in the left lateral section of liver without direct communication with pancreas. However, mass-like necrotic tissue was filled with in the hepatoduodenal ligament, hepatogastric ligament, and Glisson sheath of the left hepatic lobe. Left lateral sectionectomy was performed. Pathologic examination confirmed the pseudocyst with findings of non-epithelialized granulation tissue of the cystic wall.
Conclusion: IHPP should be considered when a huge intrahepatic cystic lesion is found in patients with recent episodes of pancreatitis. The high level of amylase on cystic fluid analysis plays a key role in the diagnosis of IHPP. Drainage procedure or surgical resection can be considered, if necessary, for the treatment of IHPP.
PP01-09 Splenic Artery Embolization for the Treatment of Gastric Variceal Bleeding Caused by Splenic Vein Thrombosis in Necrotizing Pancreatitis: Report of a Case
Chol Kyoon Cho, Korea, Republic of

C.K. Cho, Y.H. Lee, H.J. Kim
Surgery, Chonnam National University Medical School, Korea, Republic of

Introduction: Splenic vein thrombosis(SVT) is a relatively common finding in pancreatitis and SVT associated gastric variceal bleeding(GVB) could be sometimes a life-threatening complication. Traditionally splenectomy is considered the treatment of choice for SVT, however, surgical procedure in necrotizing pancreatitis is difficult and risky because of severe inflammation, adhesion, and bleeding tendency. Herein, we report a case of GVB secondary to SVT complicated by necrotizing pancreatitis which was successfully treated with splenic artery embolization(SAE).
Methods: A 42-year-old man was referred to our hospital for treatment of a necrotizing pancreatitis. Initial intensive medical treatment was performed and following operative necrosectomy was done after 8 weeks from admission. On postoperative day 13, hematemesis developed and abdominal CT scan revealed extravasation of contrast media at gastric cardia and fundus. Emergency EGD was fail to control the bleeding due to ongoing active bleeding. Emergency angiography was performed and celiac arteriography revealed no active bleeding from arterial system. Under suspicion of GVB SAE was performed.
Results: After SAE, splenic blood flow was remarkably decreased and bleeding stopped immediately, and no more episode of gastrointestinal bleeding was observed. An abdominal CT scan 2 days following the SAE showed no more active bleeding and small splenic infarction less than only 10% of total splenic volume was observed.
Conclusion: SAE could be the best treatment option for gastric variceal bleeding when splenectomy is difficult such as in case associated with severe acute pancreatitis or associated with severe adhesion, or when in patients with high operation risk.
PP01-10 Crosstalk Between Inflammation and Coagulation in Acute Kindey Injury in Experimental and Clinic Acute Pancreatitis
Serhii Chuklin, Ukraine

S. Chuklin, S. Chooklin, G. Shershen
Lviv Regional Clinical Hospital, Ukraine

Background: Acute pancreatitis (AP) is an inflammatory syndrome with unpredictable progression to systemic inflammation and MODS. Acute renal failure (ARF) is an early severe complication of AP.
Materials and methods: AP was induced in 42 Wistar albino rats by intraperitoneal injection with 3 g/kg L-ornithine-HCl in 26 rats. 16 rats - control group. In experiment we determined the levels of amylase, creatinine, H2S, fibrinogen and time of recalcification in serum, activity of NO-synthase and myeloperoxidase in pancreas, the pathological changes of pancreas and kidneys were shown by hematoxylin and eosin staining.
We examined 98 patients with moderate AP and 57 patients with severe AP. Disorders of kidney function were in 48 patients. We determined the creatinine level, indicators of hemostasis and inflammation.
Results: In rats ARF was proved by histology. The concentration of creatinine in serum increased at 86.86%. The level of creatinine directly correlated with myeloperoxidase and activity of iNOS in the pancreas, amylase in serum, reverse with H2S in serum. ARF was accompanied by hypercoagulation.
Relationship of inflammation and hemostasis in patients with AP and ARF is accompanied by decreased of aPTT, increased of TT, fibrinogen, D-dimers and level of SFMC, lack of activity of antithrombin III, increased of CRP, IL-2, IL-6, and TNF-α.
There was also direct correlation between severity of renal failure and concentrations of IL-6 CRP, D-dimers, SFMC and TT.
Conclusion: The inflammatory cascades and hypercoagulative state initiate ARF following ANP. Understanding of this process is important for the treatment of patients with severe AP.
PP01-11 Laparoscopic and Open Frey Procedure
Roman Izrailov, Russian Federation

A. Andrianov1, R. Izrailov1, V. Tsvirkun1, E. Diubcova1, K. Nikolskaia2, I. Savina2, M. Malih2, J. Osipenko2
1Hi-Tech and Endoscopic Surgery, Moscow Clinical Scientific Center, Russian Federation, 2Disease of Pancreas, Moscow Clinical Scientific Center, Russian Federation

Introduction: To compare the efficiency of open and laparoscopic Frey procedure.
Materials and Methods: From November 2004 to December 2019 Frey procedure were performed in 77 patients with chronic pancreatitis type C (classification of M.Buchler). All patients were divided for 2 group: I group - laparoscopic approach (n-49), II group - open approach (n-28). The age of the patients was 47 (23-69) years in I group and 47 (32-67) years in II group (p 0,8). The median size of the pancreatic head was 32 (17-65) mm in I group and 40 (22-73) mm in II group (p 0,005), the median diameter of the main pancreatic duct was 9 (4-16) mm and 8 (4-14) mm (p 0,18), respectively.
Results: Totally laparoscopic Frey procedure was successfully performed on 44 patients (89.8%). Conversion was needed in 4 cases (8.1%). The operating time was 420 (290-685) minutes in I group and 320 (179-515) minutes in II group (p< 0,01). Blood loss was 100 (30-700) and 250 (50-1200) ml (p< 0,01), respectively. The postoperative stay period was 6 (3-25) days in I group and 9 (5-31) days in II group (p< 0,01). There were 11 (25%) complications in I group and 7 (25.9%) in II group (p 0,07). The follow-up was 36 (2-68) months in I group and 48 (6-60) months in II group. Pain relief was complete in all groups.
Conclusions: Laparoscopic Frey procedure are safe and feasible and can be considered as a possible alternative to the open procedure.
PP01-12 Pancreatic Pseudocysts Located in the Spleen: Diagnostics and Minimally Invasive Treatment
Yulia Stepanova, Russian Federation

Y. Stepanova, D. Ionkin, M. Alimurzaeva, O. Zhavoronkova, Y. Gavrilov
Oncology, A.V. Vishnevsky National Medical Research Center of Surgery, Russian Federation

Pancreatogenic pseudocysts (PP) located in the spleen are rare. Intra-splenic PP localization is dangerous due to the possibility of massive hemorrhage and rupture of the organ.
Objective: To analyse the experience of diagnostics and treatment of PP located in spleen.
Materials and methods: 34 patients with PP located in spleen were estimated (ultrasound, MSCT or/and MRI) and treated (1985-2019). Men prevailed (88,2%), average age 45±6,6 years.
Results: Ultrasound, besides characteristics of spleen PP, allowed to define manifestations of pancreatitis and its prevalence also, that was important criteria in definition of treatment tactics. Additional examination (MSCT/MRI) in order to clarify the pancreas state and the prevalence of the lesion needed to be performed in 7 (20.6%) cases.
Pus-like contents in spleen PP was in 85,3%. External drainage under US-control, as the only treatment, is executed to 11 (32,4%) patients, distal resection with splenectomy against calculous pancreatitis with primary damage of the pancreas tail executed to 23 (69,6%) cases.
High level of amylase was revealed in pseudocysts contents in all cases of minimally invasive treatment.
Conclusion: PP located in spleen come to light not at once more often as their clinical manifestations mask manifestations of the main disease - pancreatitis. Ultrasound, MSCT or/and MRI, allows to estimate a condition of the patient and define treatment tactics.
Using of the external minimally invasive manuals under US-control allows to improve the results of treatment at this group of patients as preoperative sanitation, and also as a final type of treatment, in an optimum case.
PP01-13 Necrosectomy? An Old Fashioned Idea in the Era of Interventional Radiological Drainage?
Somaiah Aroori, United Kingdom

P. Jenkins, N. Rajaretnam, N. Gafoor, S. Aroori
University Hospital Plymouth NHS Trust, United Kingdom

Necrotising pancreatitis is a life threatening complication which has traditionally been managed with surgical resection. Radiological drainage (IR) had been offered as a replacement or adjunct to necrosectomy (PN).
Aim: Review of 15 year experience of all patients with pancreatitis with necrosis/symptomatic peri-pancreaitc collections.
Retrospective review of patients with biochemical/radiological diagnosis of acute pancreatitis (December 2004 - December 2017). Data was obtained from coding and was cross referenced with patient records. IT systems and correspondence were reviewed for patients that underwent IR or PN.
A total of 3323 admissions were identified with 80 patients requiring intervention. 47 (58.8%) (Median age 62) (32Male, 15Female) underwent only IR. 33(41.2%) (Median age 60) (20Male, 13Female) patients received PN. Of these 33, 17(51.5%) patients received no IR with 16 patients (48.5%) receiving a combination of IR and PN.
26/47(55.3%) (IR group) and 11/33 (33.3%) (PN group) were admitted to ITU (Pvalue 0.52). 10/47(21.2%) (IR group) and 5/33 (15.2%) (PN group) did not survive to three months or 1 year (Pvalue 0.48). Median length of stay was 25 (Range 4-131) for the IR group and 10 (Range 4-131) for the PN group.
No difference in the survival outcomes between patients requiring IR and PN was demonstrated. Overall mortality in patients with severe necrotizing pancreatitis remains high. A significant difference in the mortality at 3 months or 1 year was not observed. However, comparison of radiological drainage and necrosectomy is challenging due to the variable patient journey, severity of illness and clinician preference.
PP01-14 Endoscopic Drainage of Walled-off Pancreatic Necrosis: Is Necrosectomy and Delayed Drainage Necessary?
Yi Ma, Australia

Y. Ma1, F. Ong1, S. Hew2, D. Croagh1,3
1Department of Upper GI and HPB Surgery, Monash Medical Centre, Australia, 2Department of Gastroenterology and Hepatology, Monash Medical Centre, Australia, 3Department of Surgery, Monash University, Australia

Introduction: While studies have suggested that endoscopic step up approach with delayed drainage (more than 28 days from symptom onset) produce the best outcome in the treatment of walled-off pancreatic necrosis (WOPN), we assessed our single centre experience with endoscopic drainage of WOPN, in particular, the necessity of necrosectomy and delayed drainage.
Methods: Patients who underwent endoscopic drainage for WOPN between October 2011 and June 2019 in Monash Health were identified. They were excluded if follow up data were missing. The included patients' medical records, pathology results, imaging findings and procedure reports were retrospectively reviewed. The outcomes were then compared between early drainage (within 28 days of symptom onset) and delayed drainage cohorts.
Results: 38 patients were included for analysis. The population underwent an average of 2.45 endoscopic drainages per patient with none requiring endoscopic necrosectomy. 31.58%% of patients required percutaneous drainage for distant collections and 2 patients received surgical necrosectomy. A disease related mortality of 15.8% and an average length of stay (LOS) of 75.71 days were reported. No statistically significant difference was shown in disease -related mortality (27.3% vs. 11.1%, p = 0.215) or LOS (90.9 vs 69.5, p=0.2905) between early and delayed drainage cohorts, but patients who received early drainage were more unwell at day 18 of symptom onset (qDOFA score 1 vs. 0.3, p= 0.033).
Conclusion: Endoscopic drainage in combination with selective percutaneous drainage is effective in the management of walled-off pancreatic necrosis. Early drainage should be considered for patient who remained unstable despite conservative management.
PP01-15 Combined Minimally Invasive Management of Infected Peripancreatic Necrosis: Two Cases Report
Woo Young Kim, Korea, Republic of

W.Y. Kim1, Y.N. Lee2, C.G. Park2
1HBP Surgery, Presbyterian Mecical Center, Korea, Republic of, 2HBP SURGERY, Presbyterian Mecical Center, Korea, Republic of

Infected peripancreatic necrosis (IPN) is the most threatening complication of severe acute pancreatitis. Surgical necrosectomy is still the procedure of choice in the treatment of IPN and debridement is usually performed through laparotomy.
Case 1: A 40-year-old man was referred for the complication of the acute pancreatitis after endoscopic ampullectomy due to tubular adenoma with severe dysplasia. CT scans revealed a diffuse acute necrotic collection (ANC) involving the body and tail of the pancreas which extended anterior and inferior to the pelvic cavity. The patient received maximal conservative treatment including intensive fluid replacement, enteral and parenteral nutrition after endoscopic pancreatic duct insertion. The patient's clinical condition deteriorated during the 4 week of the disease with fever and increased serum C-reactive protein of 28.mg/dL despite of antibiotics, endoscopic pancreatic drainage and two times of ultrasono-guided PCD. He underwent laparoscopic pancreatic necrosectomy through mesocolic window. The postnecrosectomy cavity was thoroughly irrigated and closed suction drains were left for negative pressue drainage. Patient was discharged on the 35th days after laparoscopic surgery and patient remains asymptomatic for 4 years.
Case 2: Fifty six year-old man was admitted for abdominal pain after heavily alcoholic drinking. An abdominal CT showed diffuse infiltrating inflammation around the pancreas suggesting acute pancreatitis. Despite of conservative treatment, follow up CT showed huge infected peripancrtic necrotic abscess. H received multiple procedures for percutaneous cavity drainage(PCD) but failed in persistent fever. So he underwent laparoscopic peripancreatic necrosectomy and multiple drainages. He was improved with almost complete resolution during 3 month period.
PP01-16 Should We Revisit Treatment Algorithm for the Groove Pancreatitis? Pancreas-preserving Duodenal Resections vs Pancreatoduodenectomy for the Cystic Dystrophy of the Duodenal Wall (Groove Pancreatitis)
Viacheslav Egorov, Russian Federation

V. Egorov1, R. Petrov2, A. Schegolev3, E. Dubova4, A. Vankovich5, E. Kondratiev6, A. Dobriakov2, N. Schvetz2, E. Poputchikova2
1Surgical Oncology, Ilyinskaya Hospital, Russian Federation, 2Bakhrushin Brothers City Hospital, Russian Federation, 3Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Russian Federation, 4Buranazian Federal Medical and Biological Center of the FMB Agency of the Russian Federation, Russian Federation, 5Loginov Moscow Clinical Scientific Center, Russian Federation, 6Radiology, IIliinskya Hospital, Saint Kitts and Nevis

Background: Management of the cystic dystrophy of the duodenal wall (CDDW), or groove pancreatitis (GP), remains controversial. Although pancreatoduodenectomy (PD) is considered as the most suitable operation for CDDW, pancreas-preserving duodenal resection (PPDR) has also been suggested as an alternative for pure form of GP (isolated CDDW). There are no studies comparing PD and PPDR for this disease.
Aim: To compare the safety, efficacy, short- and long-term results of PD and PPDR in 85 patients with CDDW.
Methods: A retrospective analysis of prospectively collected clinical, radiologic, pathologic, intra- and postoperative data in 85 patients with CDDW (2004-2019) and comparison of safety and efficacy of PD and PPDR was performed.
Results: Symptoms: abdominal pain (100%), weight loss (76%), vomiting (30%) and jaundice (18%). The diagnosis was established by CT, MRI, and EUS. CDDW was treated conservatively(n13), by pancreatico- or cystoenterostomies(n8), by duodenum-preserving pancreatic head resections (DPPHR)(n6), by PD(n43), and PPDR(n15) without mortality. Weight gain was significantly higher after PD or PPDR compared to other treatment modalities. Сomplete pain control was achieved after PPDR (93%), PD (83%), DPPHR and draining procedures (18%each). New onset diabetes mellitus (23%) and severe exocrine insufficiency (12%) were not uncommon after PD, but never occurred after PPDR.
Conclusion: Pure form of CDDW is a duodenal disease and PD is an overtreatment for it. PPDR is similar in safety and better in efficacy compared to PD in patients with CDDW and may be the optimal operation for the isolated form of CDDW. Early detection of CDDW saves pancreas.
PP01-17 Duodenum-preserving Surgical Approach to the Treatment of Paraduodenal Pancreatitis
Oleksandr Rotar, Ukraine

O. Usenko, I. Khomiak, A. Khomiak, I. Tereshkevich, O. Rotar, A. Malik
Department of Pancreatic and Bile Duct Surgery, Shalimov National Institute of Surgery and Transplantology, Ukraine

Introduction: Paraduodenal pancreatitis (PDP) is an uncommon form of chronic pancreatitis. To date, no consensus exists regarding surgical timing and technique for the treatment of PDP. The aim of our study was to investigate the role of duodenum-preserving pancreatic head resections (DPPHR) in the treatment of PDP.
Methods: Retrospective analysis of the 1409 patients with chronic pancreatitis treated in our clinic from 2015 to 2019 was performed, out of which 112 patients with PDP were identified. Results of the treatment of patients who required DPPHR were analyzed. Such modifications of DPPHR as Berne`s, Beger`s and Frey`s procedures were used depending on the extent of the inflammation and anatomical variations. Pain was assessed preoperatively and at 18 months after surgery using visual analogue pain scores (VAS) and results were converted to values from 0 to 100.
Results: A total of 45 DPPHR were performed. Mean duration of operative procedure was 144 min with mean blood loss of 122 ml. Hospital length of stay was 14,2 ± 1,5 (95% CI) days and complication rate was 11,1%. No mortality was recorded. Preoperative and postoperative VAS results for pain were 86 and 17 respectfully.
Conclusion: DPPHR is safe (complication rate 11,1%) procedure for the treatment of paraduodenal pancreatitis. It achieved good results in terms of pain control at 18 months after surgery with the results of VAS pain assessment dropping from 86 to 17.
PP01-19 Kynurenine Monooxygenase Regulates Inflammation During Critical Illness and Recovery in Experimental Acute Pancreatitis
Alastair Hayes, United Kingdom

A. Hayes1,2, L. Neyton3, T. Murray1, X. Zheng2, N. Bochkina4, J. Iredale5, D. Mole1,2, the KMO Team
1Clinical Surgery, University of Edinburgh, United Kingdom, 2MRC Centre for Inflammation Research, University of Edinburgh, United Kingdom, 3The Roslin Institute, University of Edinburgh, United Kingdom, 4School of Mathematics, University of Edinburgh, United Kingdom, 5Pro Vice Chancellor Health and Life Sciences, University of Bristol, United Kingdom

Introduction: Kynurenine monooxygenase (KMO) inhibitors are a promising new class of medicine to treat acute pancreatitis (AP). Metabolic flux through KMO correlates with severity in human AP, and KMO blockade protects against organ failure during experimental AP. Our aim was to define the molecular mechanisms that link KMO metabolism and systemic inflammation.
Methods: Genetically-altered KMO wildtype, global KMO knockout, and novel hepatocyte-restricted KMO knockout (Kmoalb-cre) mice underwent experimental AP by intraductal taurocholate infusion. Kynurenine metabolites were measured in plasma by LC-MS/MS. RNAseq transcriptomics were measured in liver homogenate. Physiology and sickness behaviour were monitored by implanted telemetry. A novel highly-selective KMO inhibitor (GSK898) was given by osmotic mini-pump for 7-day AP studies. Kynurenine metabolite ± cytokine potency in vitro was tested by caspase activation in HMVEC-L endothelial cells.
Results: The KMO product 3-hydroxykynurenine (3HK) primed inflammatory gene pathway transcription and exacerbated systemic inflammation during AP. A hepatocyte-restricted role for KMO was observed, wherein mice lacking Kmo solely in hepatocytes (Kmoalb-cre) had elevated plasma 3HK levels, reduced 13C6-3-hydroxykynurenine tracer clearance, and also had altered inflammatory signalling pathway gene transcription. 3HK synergised with interleukin-1beta to induce cellular apoptosis. Kmoalb-cre mice succumbed fatally earlier and more readily to experimental AP. Therapeutically, systemic administration of the KMO inhibitor rescued the Kmoalb-cre phenotype by reducing 3HK to undetectable levels and protected against early critical illness.
Conclusions: These findings establish the KMO product, 3HK, as a regulator of inflammation and the innate immune response to sterile inflammatory injury which can be rescued by systemic KMO blockade.
PP01-20 Biliary - Pancreatic - Digestive Bypass for Chronic Obstructive Pancreatitis
Vichin Puri, United States

V. Puri1, R. Dickerman2, R. Bradshaw2
1Hepatobiliary and Pancreatic Surgery and Abdominal Transplantation, Methodist Dallas Medical Center, United States, 2Methodist Dallas Medical Center, United States

Introduction: In patients with chronic pancreatitis, common bile duct obstruction is reported in 3.2-45.6% of patients, off whom only 5-10% require operative decompression. Obstruction of the duodenum is much less common occurring in less than 1-2% of patients. Pancreaticoduodenectomy with or without a drainage procedure or isolated bypass procedures to the biliary tract or stomach are common procedures in the algorithm to treat this disease. Also, improvement in endoscopic techniques have decreased the need for surgical intervention overall. That being said, triple bypass (biliary-pancreatic and digestive) in patients with chronic pancreatitis causing pancreatic duct obstruction, biliary stricture and duodenal stenosis should be part of the armamentarium.
Methods: This case reports the treatment of a 59 year old male who underwent a Roux-en-y choledocho-jejunostomy, lateral pancreatico-jejunostomy (Puestow) and gastro-jejunostomy to bypass the biliary stricture, duodenal stenosis and pancreatic duct obstruction due to alcoholic pancreatitis not amenable to endoscopic therapy. CT imaging demonstrated severe narrowing of the portal vein with possible cavernous transformation. Also, intra-operative pancreatic abscess and inflammation involving the head of the pancreas precluded a safe pancreaticoduodenectomy.
Results: The surgery lasted 302 minutes with no intra-operative complications or blood transfusion. Hospital stay was 7 days. The patient has done well with improved nutrition, decreased pain and narcotic use 6 months after surgery.
Conclusions: The triple pancreas bypass is a useful surgical procedure in patients with chronic pancreatitis presenting with biliary, duodenal and pancreatic duct obstruction not amenable to endoscopic treatment or conventional surgical resection or drainage procedures.
[Bypass and Imaging]
PP01-22 Recurrent Pancreatitis in the Setting of Gallbladder Agenesis, Ansa Pancreatica and Santorinicoele
Sun Woo Lee, Australia

S.W. Lee, C.J. Davidson, Y. Kia, S. Godinho, M. Appleyard, M.D. Chandrasegaram
University of Queensland, Australia

Gallbladder agenesis is a rare condition. Patients with gallbladder agenesis can present with biliary type symptoms and rarely pancreatitis. We present the case of a 35-year-old gentleman who was admitted and treated for recurrent pancreatitis on a background of gallbladder agenesis, ansa pancreatica and Santorinicoele.
Whilst these anatomical variants have been described to result in pancreatitis in their own respective ways, this case study describes a patient who has had concurrent anatomical variants. The hypothesis is that the common finding with these variants of hindering adequate excretion of bile and pancreatic juice through their respective mechanisms, ultimately results in recurrent acute pancreatitis from raised intraductal pressure.
Figure 1: Magnetic Resonance Cholangiopancreatography (MRCP) image confirming an absent gallbladder and defining the biliary anatomy. The main pancreatic duct (hollow red arrow) is shown. There is a dilated duct of Santorini draining into the minor papilla (solid red arrow) and an ansa pancreatica (yellow solid arrow) connecting the main pancreatic duct and duct of Santorini
Figure 2: MRCP showing mild intrahepatic duct dilatation and a dilated common bile duct which measures 8 mm at the porta hepatis and 15 mm at the mid CBD with smooth distal tapering. The main pancreatic duct (hollow red arrow) is prominent at 3 mm, there is a Santorinicoele (solid red arrow) draining into minor papilla and an ansa pancreatica (yellow solid arrow) between the main pancreatic duct and Santorinicoele which is more prominent and dilated compared to Figure 1 which was the MRCP the month prior.
[Figure]
PP01-23 Laparoscopic Necrosectomy for Acute Necrotizing Pancreatitis: Retrospective Analysis of a Decade Long Experience from a Tertiary Centre
S Srivatsan Gurumurthy, India

S. Srivatsan Gurumurthy, M. Srinivasan, P. Senthilnathan, C. Palanivelu
Dept. of HPB, Minimally Invasive Surgery & Liver Transplant, Gem Hospital, India

Introduction: To evaluate the role of minimally invasive surgery for management of
necrotizing pancreatitis in the acute setting and to propose tailor made approaches to deal with various locations of pancreatic necrosis.
Methods: A total of 112 patients (75 males, 37 females) with mean age of 41.5+10.3
years, with necrotizing pancreatitis underwent minimally invasive necrosectomy between January 2009 and May 2019. Laparoscopic necrosectomy was performed by transperitoneal approach in 81 patients , by retroperitoneoscopy in 18 patients and combined approach in 13 patients. Out of 81 patients treated by transperitoneal approach, 21 were approached through lesser sac, 48 through mesocolic route and 12 through paracolic route. In cases of retroperitoneoscopy, all cases were accessed through the left flank.
Results: All patients tolerated the procedure well. Mean BMI was 26.45±3.78 kg/sqm.
Mean operating time was 56.40±20.48 minutes and mean blood loss was 120±31.45 ml.Eight patients required reoperation (6 underwent open procedure and 2 underwent
laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean
duration of return of bowel function was 5±1.8 days. The mean length of hospital stay
after surgery was 8.19 ±4.09 days. There were no major wound related complications.
Conclusion: Minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with adequate expertise . In addition to careful case selection, proper timing and optimal route of access determines the outcome. Minimally invasive procedures are suitable alternatives especially in critically ill patients providing lower morbidity and mortality rates.
PP01-24 Outcome of Open Necrosectomy Versus Minimally Invasive Retroperitoneal Necrosectomy Following Percutaneous Drainage in Infected Necrotising Pancreatitis
Tathagata Karan, India

T. Karan, C. Kolandasamy, R. Prabhakaran, S. Rajendran, O.L. Naganath Babu
Institute of Surgical Gastroenterology, Rajiv Gandhi Government General Hospital, Madras Medical College, Chennai, India

Introduction: Percutaneous drainage is the very first step in well established “step - up” approach in management of infective necrotising pancreatitis. This study intended to compare the outcome of open necrosectomy and MIRP following percutaneous drainage.
Method: Single centre ,retrospective analysis of 32 patients between 2016-2019 with the diagnosis of infective necrotising pancreatitis, following pcd insertion, those who underwent further necrosectomy procedure are included in this study.
Result: Among 32 patients, 21(65.63%) patients underrwent open necrosectomy. The most common cause was due to alcohol intake(71.88%). Mean interval of necrosectomy following PCD was 25.31±12.72 day. Total mortality was 31.25% (n = 10), while 33.33% (p- 0.705) following open necrosectomy. 46.88% patients developed major complications other than organ failure(15.63%). Pancreatic fistula was the most common complication (15.63%). Open necrosectomy causes more blood loss (216.66±184.88 ml, p-0.463) and takes more time (161.90±58.61 mins) than MIRP.
Conclusion: Initial percutaneous drainage decreases the infective and others proinflammatory mediators load,resulting in decrease inflammatory cascade and delaying the need for further surgical necrosectomy. In this study there was no significant difference in morbidity or mortality between open necrosectomy and MIRP in patients of infective necrosis following initial percutaneous drainage.
PP01-25 Efficacy of MRCP in Gallstone Pancreatitis
Madhu Chaudhury, United Kingdom

M. Chaudhury1, Y.M. Goh2, Y.L. Goh3, A. Kausar4
1King's College Hospital, United Kingdom, 2Surgery, Imperial College London, United Kingdom, 3Imperial College London, United Kingdom, 4General Surgery, Royal Blackburn Hospital, United Kingdom

Background/Aims: Latest BSG guidelines from 2016 in the management of acute gallstone pancreatitis(GSP) in combination with jaundice and/or dilated common bile duct(CBD) warrants an ERCP within 72 hours of presentation. Literature suggests that 50% of CBD stones will pass spontaneously and do not need CBD intervention.This study assesses the use of MRCP in the management of GSP.
Methodology: This is a retrospective study of patients presenting with GSP from April 2010 to July 2019.Data collected included age, sex, serum bilirubin levels at presentation, ultrasound(US) findings, MRCP and ERCP investigations and severity of pancreatitis. Factors were analysed for significance predicting presence of gallstones(GS) in the CBD on admission. Statistical analysis was conducted using SPSSv20.
Results: There were 440 patients with GSP in this study. 416 patients had US confirming GS. Amongst them, the trend for the presence of either dilated CBD on US( p=0.068) with stone seen in CBD (p=0.063) or bilirubin>22µmol/L(p=0.071) to predict the presence of CBD stones on MRCP. Severe pancreatitis(p=0.034) and presence of stones on MRCP(p< 0.001) predicted presence of stones on ERCP. On multivariate analysis, presence of stones on MRCP was predictive of stones on ERCP(p=0.006).
Conclusions: Patients who present with GSP should have further investigations to confirm the presence of GS in the CBD to assess the necessity for ERCP or CBD exploration.
PP01-27 Roux-en-Y Fistulojejunostomy as a Salvage Procedure for Displaced Pancreatic Stent in Disconnected Pancreatic Duct Syndrome with Refractory External Pancreatic Fistula
Nairuthya Shivathirthan, India

N. Shivathirthan, S. Devapatla, M. Joshi
Dept of Surgical Gastroenterology, Apollo BGS Hospital, India

Introduction: Disconnected Pancreatic Duct Syndrome (DPDS), is the circumferential discontinuity of pancreatic duct such that the distal pancreas does not drain downstream into the duodenum as a result of severe acute or necrotising pancreatitis and can present either as pancreatic ascites or as external pancreatic fistula.
Method: 37year old male, Post Necrotising Pancreatitis presented with Disconnected Pancreatic Duct Syndrome (DPDS) with left sided portal hypertension. He was initially managed with pig tail drainage which resulted in an controlled External Pancreatic Fistula. ERCP and Pancreatic stenting was done but failed in closure of the fistula. CECT abdomen showed features suggestive of displaced pancreatic duct stent. He underwent EXPLORATORY LAPAROTOMY WITH ROUX-EN-Y FISTULOJEJUNOSTOMY. Intraoperatively there was complete disruption of the pancreatic duct with an intrapancreatic collection of 2x2 cm, tip of the pig tail drain and pancreatic duct stent could be seen outside the parenchyma. Post operatively patient recovered satisfactorily.
Result: ERCP with trans-papillary stenting or surgery remain the two pathways oftreatment but with high recurrence rates.When nonsurgical measures fail, surgical intervention may be warranted and roux en y internal drainage has been considered as optimal therapy. Surgical intervention may involve debridement, resection or drainage procedure. In patient with concomitant left sided portal hypertension drainage procedure may be a safer option.
Conclusion: DDS needs multidisciplinary approaches to mend it and can be challenging and time consuming. Roux-en-Y Fistulojejunostomy is a good salvage procedure for Displaced Pancreatic Stent in Disconnected Pancreatic Duct Syndrome with Refractory External Pancreatic Fistula.
PP01-31 Spectrum of Vascular Complications in Acute Pancreatitis - Challenges in Management
Sakthivel Harikrishnan, India

S. Harikrishnan1, J. Sathyanesan1, S. Devakumar2, S. C1
1Department of Surgical Gastroenterology and Liver Transplant, Government Stanley Medical College, India, 2Department of Surgical Gastroenterology and Liver Transplanturgical Gastroenterology and Liver Transplant, Government Stanley Medical College, India

Background: Vascular complication of pancreatitis is a rare entity. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the spectrum of manifestations, challenges in the diagnosis and management of vascular complications of acute pancreatitis.
Methods: Patients who were managed for vascular complication of acute / chronic pancreatitis were retrospectively analysed from the year 2000 to 2019.
Results: There were a total of 79 patients ( 71 Male:8 Female) with a mean age of 34.8 years . 27 patients had chronic alcoholic pancreatitis 27- Tropical pancreatitis , 18- acute pancreatitis , 3- idiopathic and 1 had post traumatic pancreatitis. 8 patients were managed conservatively. Selective arterial embolization was attempted in 55 of 70 (78.5%) patients and was successful in 44 of the 55 (80 %). 27 of 76 (31.5%) patients required surgery. Overall mortality was 7.8 %.
Conclusion: Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.
[Table showing the statistics of the patient managed]
PP01-32 A Novel Technique of Intrapancreatic Choledochoplasty during Frey´s Procedure for Chronic Pancreatitis Induced Biliary Strictures
Manpreet Uppal, India

M. Uppal, V. Moond, N.R. Dash
Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, India

Introduction: Biliary stricture is a well-known complication of chronic pancreatitis which may require surgical drainage in the form of bilioenteric anastomosis. We report a novel technique for surgical management of such strictures - intrapancreatic choledochoplasty during Frey's procedure (FP), where we lay open the intrapancreatic CBD and fix it to the pancreatic tissue/capsule in the head to keep it patent.
Methods: The study was carried out at a tertiary care centre in India from January 2017 to December 2019. Patients of chronic pancreatitis with associated biliary strictures who were candidates for FP were evaluated for suitability for the procedure. Strictures confined to the intrapancreatic CBD requiring biliary drainage underwent choledochoplasty in addition to FP.
Results: 10 patients underwent choledochoplasty (8:2 - males:female). The mean age was 39 years. Pain was reported for a median duration of 36 months (6 - 96 months) and jaundice for a median of 12 months (1 -36 months). 80% patients had at least one episode of cholangitis. Exocrine and endocrine insufficiency was present in 60% and 80% patients respectively. Preoperative stent was placed in the CBD/MPD in 40% patients each. Mean duration of surgery was 300 minutes and mean blood loss was 300 ml. The mean post-operative hospital stay was 8.5 days with no grade III - V complications. On followup, LFT was normal in all patients.
Conclusions: We describe our technique of intrapancreatic choledochoplasty during FP, which is an effective substitute to bilioenteric anastomosis in surgical management of chronic pancreatitis induced intrapancreatic CBD strictures.
PP01-33 Observation and Spontaneous Regression of Asymptomatic Walled Pancreatic Necrosis
María Sánchez, Paraguay

M. Sánchez1, F. Heiberger2, R. Rojas2, R. Sánchez3, G. Parquet3, S. Trinidad3, K. Garay2
1Cirugia Sala X, Hospital de Clínicas, Paraguay, 2Cirugia Sala X, Hospital de Clínicas, Paraguay, 3Cirugía Mínima Invasiva, Instituto de Previsión Social, Paraguay

Introduction: WON is a late complication of acute pancreatitis, usually occurs four weeks after remission, with necrosis and liquefaction of pancreatic tissue, can cause mass effect or become infected. Management depends on the symptoms and location of the collection, and in 40% they resolve spontaneously, conservative treatment may be appropriate in asymptomatic patients. We present two cases of WON, conservative management, with asymptomatic observation over a long period of time.
Case1: female, 37 years old, history of severe acute biliary pancreatitis, 4 weeks after the acute condition presents extrinsic compression of the gastric antrum in the endoscopy and collection image in the pancreatic body. Remains clinically asymptomatic, and 2 months later cholecystectomy is scheduled, without inconvenience. At 2 months after surgery, favorable evolution, asymptomatic and with reduced collection size.
Case2: female, 31 years old, history of severe acute biliary pancreatitis, 3 weeks after the acute condition, presents a collection image in the body and pancreatic tail, extrinsic compression of the gastric body in endoscopy. In asymptomatic clinically controls, with persistence of collection. After 10 months of observation, cholecystectomy is programmed, without problems. At 4 months after surgery, favorable evolution, asymptomatic and with reduced collection size.
Conclusion: careful observation of patients with clinically asymptomatic WON can be an efficient and safe treatment. In these two cases, long-term observation demonstrated a spontaneous regression of asymptomatic WON without the need for interventional treatment.
PP01-34 Safety of Early Cholecystectomy in Acute Biliary Pancreatitis
Juan Mollo, Chile

J. Mollo, A. Perez - Castilla, L. Paqui, P. Peñailillo, N. Marquez, G. Campaña, J.P. Castro, W. Martinez, R. Fernandez
Departamento Digestivo Alto, Clinica Indisa, Chile

Introduction: The worldwide incidence of pancreatitis is 4.9 to 35 / 100,000 inhabitants, whose numbers are increasing. In Chile, the most common cause is that of biliary origin, ranging from 60% to 80%. Classically, cholecystectomy was contraindicated before the 7th day of onset of pancreatitis. Multiple works support this claim, however, no clear consensus has been established.
Objective: To determine the safety of cholecystectomy in patients with mild acute pancreatitis of biliary origin.
Methods: Retrospective, descriptive study of patients with mild acute pancreatitis of biliary origin surgically operated before 48 hrs.
Results: The sample was 112 patients, 5 were excluded with 107 patients remaining. Two groups were established based on ultrasound findings and liver profile. Group 1: 69 patients with ultrasound showing cholelithiasis and normal bile duct and group 2: 38 patients with ultrasound showing dilated bile duct, suggestive magnetic cholangioresonance choledocholithiasis, cholestasic liver profile. Both groups underwent laparoscopic cholecystectomy before 48 hours. According to the finding, ERCP was performed. Without surgical complications .. without average readmissions of hospitalization was 3.3 days. 12-month follow-up . No mortality was reported.
Conclusions: It was shown that laparoscopic cholecystectomy at 48 hrs is safe with decreased days of hospitalization and low morbidity.
PP01-35 Surgical Treatment of Stent Migration to Pancreatic Duct: Case Report
Ana Isabel Argueta Contreras, Guatemala

A.I. Argueta Contreras1, I.W. Lopez Muralles1, J.R. Ixcayau Hernandez1, D.E. Porras Aguilar.1, L.A. Segovia2
1Instituto Guatemalteco de Seguridad Social, Guatemala, 2Surgery, Instituto Guatemalteco de Seguridad Social, Guatemala

Endoprotheses are common in the treatment of biliary system disorders. Long term biliary plastic stenosis placement is known to cause several complications, 1.7-6 % of stents migrate. Treatment is mostly done by conventional endoscopic procedures, however 10 % will require surgical intervention. One reason for the failure of the endoscopic treatment is the de novo stent stone complex formation.
In this case we are reporting a stent migration to the pancreatic duct and the de novo stent stone complex formation caused failure of the endoscopic treatment.
We report the case of a 48-year-old Hispanic female who presents to the emergency department with abdominal pain for the last 72 hours. In her past medical history she reported recurrent abdominal pain similar to the actual episode. She also reported choledocholithiasis treated with ERCP and stent two years ago with no follow up. Pancreatitis was documented, diagnostic studies show a dilated Wirsung duct with three images that correspond to stones and a migrated stent in the lumen of the pancreatic duct. She was diagnosed with chronic pancreatitis. ERCP was unable to remove the stent. A pancreaticojejunostomy (Puestow procedure) and a stent removal was performed.
The patient had an uncomplicated post operative course with complete resolution of abdominal pain. She remains asymptomatic tree months after surgery.
Follow up after stent placement is important to avoid unintentional retention. In the case this occurs, first line treatment is the endoscopic approach, occasionally surgery is needed for resolution.
[Stent removal from pancreatic duct.]
[Stent removal from pancreatic duct.]
PP01-38 Clinical Presentation and Management and Outcomes of Disconnected Pancreatic Duct Syndrome: A Systematic Review and Meta-analysis
Eric Jing Fu Chong, New Zealand

E.J.F. Chong1, C.B. Ratnayake1, J.A. Windsor1, S. Pandanaboyana2
1Department of Surgery, University of Auckland, New Zealand, 2Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, United Kingdom

Background: This systematic review and meta-analysis aimed to review the clinical presentation, definitions and treatment outcomes for DPDS.
Methods: The PubMed, EMBASE, MEDLINE and SCOPUS databases were systematically searched until June 2019 using the PRISMA framework.
Results: Twenty-six studies were included in the quantitative analysis comprising 1057 patients. Acute pancreatitis was the most common aetiology (92.8%, 596/642) followed by chronic pancreatitis (4.7%, 30/642). DPDS commonly presented with pancreatic fluid collections (PFC) (516/614, 84.0%) followed by external pancreatic fistulae (EPF) (14.7%, 90/614) and pancreatic ascites (1.3%, 8/614). Seven studies defined DPDS as the presence of extravasation or total cut-off of contrast material injected into main pancreatic duct (MPD) and a viable upstream pancreas, five studies further included either >2cm necrotic pancreatic segment or persistent PFC/EPF as a criteria, two studies defined DPDS intraoperatively and five studies lacked a definition. The success of endoscopic or surgical intervention was defined as resolution of symptoms without recurrence of PFC, EPF or ascites. The weighted success rate among those undergoing a transmural drainage (91.6%, 95%-CI 81.2-96.5) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical drainage which were 82% (weighted 95%-CI 68.6-90.5) and 87.3% (95%-CI 79.2-92.5) respectively, (P=0.389).
Conclusion: Transmural drainage was superior to transpapillary drainage for management of DPDS. Both surgery and endoscopy have comparable success rates. There remains a significant variability in the definitions and treatment strategies for DPDS.
Keywords: Pancreatic duct disruption, DPDS, complete duct disruption
PP01-40 A Study of CBD Evaluation in Cases of Mild Gall Stone Pancreatitis
Uppalapati Srinivasulu, India

U. Srinivasulu, M. Ibrarullah, H. Wani, M.S. Modi, S.K. Parida, L. Narayan Mohanty
Surgical Gastroenterology, Apollo Hospital, India

Introduction: Gall stones as an aetiology represent 40-60% cases of acute pancreatitis with variations due to diagnostic efforts and availability of imaging tools. Accurate diagnosis of acute biliary pancreatitis(ABP) is of utmost importance because clearance of lithiasis (gallbladder and common bile duct, CBD) rules out recurrences, very frequent otherwise, with 30% to 50% of the patients developing recurrent acute pancreatitis relatively soon after discharge (average time 108 d), some of them maybe more severe than the previous episode. Therefore, All patients should undergo specific imaging, preferably MRCP, to exclude choledocholithiasis as LFTs and ultrasonography are inaccurate in predicting common bile duct stones.
Methods: An analytical observational study was carried out at an eastern indian Tertiary care centre from January 2012 to October 2019. All patients with mild acute gall stone pancreatitis were included in the study. MRCP was done at the time of index admission. All patients underwent laproscopic cholecystectomy. Additional ERCP was done for those with CBD stones on MRCP
Results: 70% (56 out of 80) patients came to the hospital within 1 week of onset of symptoms. The cumulative rate of choledocholithiasis was 12.5% that is 10 out of 80 patients at index admission, of which 60% were within the 1st week of onset of symptoms
Conclusion: Early performance of MRCP can help in selecting patients for ERCP before cholecystectomy. Therefore routine CBD evaluation should be encouraged in cases of mild biliary pancreatitis.