PP02 Pancreas: Pancreatic Cysts (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PP02-01 Assessment of the Sendai Criteria for Long-Term Follow-Up of Branch-Duct Intraductal Papillary Mucinous Neoplasms. Outcomes of a Tertiary Referral Center
Pablo Giuffrida, Argentina

P. Giuffrida1, D. Biagiola1, P. Uad1, V. Ardiles2, M. Palavecino3, M. De Santibañes2, E. De Santibañes2, J. Pekolj2, O. Mazza2
1General Surgery Service, Hospital Italiano de Buenos Aires, Argentina, 2HPB Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Argentina, 3HPB Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Argentina

Background: The management of Branch-Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN) is still controverted. Our objective was to assess the long-term follow-up of patients with “low risk” BD-IPMN using the Sendai International Consensus Guidelines (ICG-I) to establish the safety of doing so and to evaluate factors associated to the development of pancreatic ductal adenocarcinoma (PDAC).
Methods: We analyzed a retrospective cohort since January 2004 to December 2017. Only patients with BD-IPMN and Sendai-negative Criteria were included. A univariate analysis was performed for factors associated with conversion to positive Sendai Criteria and PDAC. Positive predictive value and negative predictive value of the IGC-I were assessed for the presence of PDAC.
Results: From a total of 219 patients selected for analysis, five (2.2%) developed cancer and seven (3.19%) developed lesions with high grade dysplasia. During a median follow-up of 49 months, 182 patients (83%) didn't develop PDAC. The NPP and PPV of ICG-I for the presence of cancer were 100% and 13.5% respectively. Patients older than 65 years developed cancer more often (OR: 3.57; p=0.015) and their CA-19.9 values were higher (OR: 5.27; p=0.007).
Conclusion: The absence of positive Sendai criteria excludes a malignant disease and the IGC-I were safety for the follow-up of patients with BD-IPMN. In our series, progression to cancer occurred only in 2.2% of the total population and cancer-related mortality was 1.36%. Such risk is similar to the mortality rate of pancreatic surgery. However, with our approach, in 83 % of patients an unnecessary surgery could be avoided.
Demographic AnalysisValue
Patients with negative Sendai criteria, n (%)219 (74.7)
Patients who converted to positive criteria at follow-up, n (%)37 (17)
Female sex, n (%)160 (73)
Age at diagnosis, years Median (range)71 (61-79)
Cyst CharacteristicsValue
Location, n (%) Head Body Tail Diffuse involvement89 (40) 85 (38) 34 (15) 11 (7)
Initial size, mm, median (range) of total population (n=219) with negative criteria15 (10-22)
Single cysts, n (%)128 (58.5)
Multiple cysts, n (%)91 (41.5)
[Demographic Analysis and Cyst Characteristics]

[Survival Curve]
PP02-04 Cancer-Derived Immunoglobulin G: A Novel Marker for Risk Stratification in Intraductal Papillary Mucinous Neoplasms
Ming Cui, China

M. Cui1, Q. Liao1, J. Li2, J. Habib2, B. Kinny-Köster2, C. Wolfgang2, Y. Zhao1, J. Yu2
1Department of General Surgery, Peking Union Medical College Hospital, China, 2Department of Surgery, Johns Hopkins University School of Medicine, United States

Objectives: Cancer-derived immunoglobulin G (CIgG) is a novel molecule plays important roles in carcinogenesis. Previous studies showed that the expression of CIgG was closely related to tumor differentiation of pancreatic cancer. This study aimed to evaluate the expression and potential significance of CIgG in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas.
Methods: Eighty-eight pathological tissues diagnosed with different grades of IPMN were enrolled in the study. The expression of CIgG was assessed by immunohistochemistry. ROC analysis was used to test CIgG's significance in the differential diagnosis between LG-IPMN patients and HG/inv-IPMN patients
Results: CIgG was expressed in both IPMN and pancreatic ductal adenocarcinoma, but not expressed in normal pancreas tissue. The expression of CIgG was significantly elevated during the malignant progression of IPMN (LG-IPMN vs. HG-IPMN, P=0.001; HG-IPMN vs. inv-IPMN, P=0.004; LG-IPMN vs. inv-IPMN, P< 0.001). The AUC for CIgG expression was 0.765 (95% confidence interval (CI), 0.663-0.849; P< 0.001). The sensitivity and specificity of CIgG in discriminating LG-IPMN from HG/inv-IPMN was 61.4% (95% CI 0.455 to 0.756) and 90.9% (95% CI 0.783 to 0.975), respectively.
Conclusions: This study demonstrates that CIgG participates in the malignant progression of IPMN and could serve as a potential diagnostic biomarker for IPMN.
PP02-05 Evaluation of Current Consensus Guidelines for the Management of Mucinous Cystic Lesions of the Pancreas
Rachel Huei-Sook Park, Singapore

R.H.-S. Park1,2, G.R. Lim1, J.J. Wu1, Y.-X. Koh1, S.-Y. Lee1, C.-Y. Chan1, A.Y. Chung1, L.L. Ooi1, B.K.P. Goh1,3
1Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, 2National University of Singapore, Singapore, 3Duke-National University of Singapore (NUS) Medical School, Singapore

Introduction: Over the years, several guidelines have been introduced to guide management of mucinous cystic lesions of the pancreas (mCLP). Presently, there have been limited studies in the literature comparing the 4 main guidelines for the management of Intraductal Papillary Mucinous Neoplasms (IPMN) and Mucinous Neoplasms (MCN). In this study, we aimed to evaluate and compare the clinically utility between the 2006 Sendai (SG06), 2012 Fukuoka (FG12), 2017 updated Fukuoka (FG17) and 2018 European guidelines (EG18).
Methods: One hundred and eighty-eight patients with MCN or IPMN who underwent surgical resection were retrospectively reviewed and classified under the 4 guidelines.
Results: The presence of symptoms, obstructive jaundice, pancreatic, raised CA19-9>37 U/ml, raised CA 19-9>47U/ml, enhancing solid component, main pancreatic duct ≥5mm, main pancreatic duct 5-9.9mm, main pancreatic duct >6mm, main pancreatic duct t ≥
10mm, increasing number of high risk (HR) features: HR (SG06), HR (FG12), HR (FG17), absolute indications (EG18) were associated with a significantly increased likelihood of malignancy. The positive predictive value (PPV) of HR (SG06), HR (FG12), HR (FG17), Absolute indications(EG18) for high grade dysplasia/invasive carcinoma was 54%, 76%, 78% and 56% respectively. The negative predictive value of low risk (LR); LR (SG06), LR (FG12) and LR (FG2017) was 100%, while that of LR (FG2018) was 95%. Only EG18 had 1 malignant (HGD) lesion in the LR group.
Conclusion: All 4 guidelines were useful in the risk stratification and management of mCLP.
PP02-07 Why Is Important to Know How Spleen Survives after Spleen-preserving Distal Pancreatectomy with Splenic Vessels Resection? Experience of 51 Operations without Splenectomies
Viacheslav Egorov, Russian Federation

V. Egorov1, R. Petrov2, N. Starostina3, J. Zhurina2, K. Dmitriyeva4
1Ilyinskaya Hospital, Russian Federation, 2Bakhrushin Brothers City Hospital, Russian Federation, 3IIliinskya Hospital, Russian Federation, 4Vishnevsky Institute of Surgery, Russian Federation

Background: Knowledge of spleen collaterals is important as for distal spleen-preserving pancreatectomy with splenic vessels resection (DSPPSVR), so as for possible upper GI surgery for these patients.
Primary: To clarify the sources of spleen blood supply after DSPPSVR.
Secondary: morbidity and mortality after DSPPSVR.
Methods: Retrospective analysis of case histories and CT angiograms (CТА) before and after DSPPSVR (n51).
Results: Indications for surgery: MCN (37), bd-IPMN (7), CSA(3), NEN(4). Open(41) and laparoscopic (10) surgery were used. No mortality, morbidity - 15(29%), fistula Grade B - 4 (8%), Spleen infarctions- 7 (14%), clinically significant spleen infarctions and splenectomies- 0. CT and CTA revealed three types of splenic blood supply after DSPPSVR: with gastro-epiploic arcade (GEA) as a main collateral artery (n8, 16%), with short gastric arteries (SGA) as a main collateral (n6, 12%) and intermediate type (n36, 72%).
Conclusion: In SPDP SVR in 1/3 of cases only GEA or only SGA are the main collaterals, supplying the spleen, in 2/3 of cases both ways are involved. CT and CTA are mandatory before abdominal surgery for patients after SPDP SVR.
PP02-09 Diagnosis and Treatment of a Solid Pseudopapillary Tumor of the Pancreas. A Rare Tumor in a Female Patient
Samuel Arnulfo Pimentel Melendez, Mexico

S. Pimentel Melendez1,2, M.F. Paez Arteaga1, Y.A. Nacud Bezies1, C.M. Gomez Vela1, P. Villegas Quintero1
1Digestive and Endocrine Surgery, IMSS High Specialty Medical Unit No 25. CMNN, Mexico, 2Surgery, ISSSTE Regional, Mexico

Introduction: Cystic tumors of the pancreas represent the second most common exocrine pancreatic neoplasm, less than 10%, the pseudopapillary tumor is considered a rare form of neoplasm, first described in 1934, predominantly presented in women, with a mean age of presentation at 22 -30 years, clinically with abdominal pain and palpable abdominal tumor. The diagnosis is based on imaging, clinical and histopathological studies of the tumor, surgical resection remains the treatment of choice, requiring vascular or en block reconstructions in some cases, with very low recurrence rates.
Methods: We present a 21-year-old female patient with pain and presence of a two-year-old abdominal tumor, requiring a distal pancreatectomy with splenectomy, the tumor being present at the body of pancreas of approximately 15 x 15 x 20 cm, head, neck and uncinate process with free margins, splenic vein and artery with severe dilation, free hepatic artery, free superior mesenteric artery, spleen of approximately 10 x 8 x 4 cm.
Results: Patient with complete resection of franc tumor without evidence of metastasis, with development of biochemical leakage detected by biochemical and clinical parameters, with conservative management, with favorable response, leaving asymptomatic and stable discharge 8 days after surgery.
Conclusions: The complete surgical resection of dangerous pseudopapular tumors has been described as an effective and safe treatment without evidence for the benefit of adjuvant therapy.
[Macroscopic cystic tumor]
PP02-10 Pancreatic Mucinous Cystic Neoplasms Located in the Distal Pancreas: A Multicenter Study
Mario Serradilla-Martín, Spain

M. Serradilla Martín1, J.V. Del Río Martín2, I. Jaén Torrejimeno3, F. Rotellar Sastre4, E. Muñoz Forner5, A. Carabias Hernández6, A. Serrablo Requejo1, P.J. Hernández Rivera2, J.M. Ramia Ángel7, ERPARDIS Project
1Miguel Servet University Hospital, Spain, 2Hospital Auxilio Mutuo, Puerto Rico, 3Hospital Universitario de Badajoz, Spain, 4Clínica Universitaria de Navarra, Spain, 5Hospital Clínico de Valencia, Spain, 6Hospital Universitario de Getafe, Spain, 7Hospital Universitario de Guadalajara, Spain

Introduction: The rise in the number of abdominal radiological tests performed has increased the diagnosis of pancreatic cystic lesions. Mucinous cystic neoplasms are infrequent, usually unilocular, occurring in postmenopausal women, located in the pancreatic body/tail. The risk of malignancy is 4-12%. The guidelines recommend observation for asymptomatic neoplasms below 4 cm, with no risk factors such as mural nodules.
Methods: Retrospective multicenter observational study of prospectively recorded data regarding distal pancreatectomies carried out at seven Hepato-Pancreato-Biliary Units between 01/01/08 and 31/12/18 (ERPANDIS Project).
Results: 444 distal pancreatectomies were recorded, 47 with mucinous neoplasm (10.6%). Thirty-five were non-invasive tumors (74.5%). 83% were female, 60 % were ASA II. The mean preoperative size was 46 mm. Only 32% were biopsied. Patients with invasive tumors were older (54 vs 63 years). Invasive tumors were larger (6 vs 4 cm), though the difference was not significant (p=0.287). 59.6% were operated laparoscopically. The laparoscopic approach was used in 74.6% of non-invasive tumors and in 16.7% of invasive ones. There was no spleen preservation in the 93.6% of the patients. Postoperative results are in table 1. R0 resection was obtained in all patients. Two patients with local recurrences of invasive tumors were exitus.
Conclusion: In our series, the laparoscopic approach proved feasible and safe. It was mainly used in non-invasive tumors and rarely in invasive ones. Morbidity rates were high, but the mortality was zero. Prospective studies are needed to define risk factors that can guide the decision whether to administer conservative or surgical treatment.
PP02-12 Robotic Assisted Drainage of Pancreatic and Peripancreatic Fluid Collections. Is It the Right Path?
Enrique Jimenz-Chavarria, Mexico

E. Jimenez-Chavarria1, H.F. Noyola Villalobos2, S. Pimentel-Meléndez1
1HPB, Hospital Central Militar, Mexico, 2Surgery, Hospital Central Militar, Mexico

Background: Peri pancreatic fluid collections (PFC), are one of the most common complications in patients with acute pancreatitis. In more than half the cases, the fluid collections will resolve by itself. Surgical management, either endoscopic or minimally invasive treatment, is reserved for patients with systemic or abdominal symptoms or complications.
Aim: To briefly describe our surgical technique with robotic assistance, as well as the morbidity, mortality and length of stay, as well as the clinical success of the robotic assisted cystogastrostomy in the treatment of peripancreatic fluid collections at our institution.
Methods: We included patients with peripancreatic fluid collections, mainly pancreatic necrosis as well as pseudocyst, that required surgical drainage, from October 2016 to October 2019. We determined the morbidity and mortality associated with the procedure, along with the clinical success and recurrence.
Results: We included 28 patients who were diagnosed with PFC, within the last 3 years, who required surgical treatment. Robotic assisted retro gastric cystogastrostomy was performed in all cases, with a primary drainage success rate of 96%, with morbidity of 11%, mortality of 0.%, with a 36 month follow up.
Conclusions: The results that were obtained with the robotic assisted technique, applied at our practice, showed that the approach so far, seams safe, feasible and reproductible, when it comes to the surgical management of peripancreatic fluid collections.
PP02-13 Long Term Surveillance of Pancreatic Cysts and its Value
Kai Siang Chan, Singapore

K.S. Chan1, V. Shelat2, E.H.E. Chan3, J.K. Low2, C.W.T. Huey2, S. Junnarkar2
1Lee Kong Chian School of Medicine, Singapore, 2General Surgery, Tan Tock Seng Hospital, Singapore, 3Ministry of Health Holdings, Singapore

Tsunami of pancreatic cyst detection and referrals has fueled reports and guidelines advocating surveillance strategies due to malignancy risk. Majority of recommendations are opinion-based as evidence is lacking. We report our experience of managing pancreas cysts.
1905 patients with pancreas cyst were investigated over a six-year period from 2010-2016. 212 patients had follow-up of >2 years and 189 patients had complete data. Demographics, radiological findings, histopathology and mortality were studied.
Median age was 70 years and 47.6% (n=90) were male. 77 (40.7%) patients had type 2 diabetes mellitus. Sixty-one (32.3%) had a history of previous and/or current malignancy. Ten (5.3%) and one (0.5%) patient(s) had previous acute and chronic pancreatitis respectively. Ca 19-9 was performed for 149 patients (78.8%): median was 16(IQR 8 - 33) units/mL. Initial radiological diagnoses are shown in Figure 1. Median number of scans and median time interval from first scan to last scan was 5 (IQR 4 - 8) and 32 (16.8 - 58.7) months respectively. Twenty-seven patients (14.8%) developed changes from initial scan: 21 had increase in lesion size (median time 26.6 months), 2 had increase in pancreatic duct diameter (median time 43.4 months) and 1 developed solid component (37.2 months). Twenty-one patients (11.1%) developed other malignancies on interval scans. Surgery was offered to 30 patients (15.9%) but only six underwent. Histology revealed intrapapillary mucinous neoplasm (IPMN)(n=4), mucinous non-cystic adenocarcinoma(n=1) and well-differentiated neuroendocrine tumour(n=1).
Long term surveillance of IPMN detects possible malignant transformation not only in pancreas but other abdominal viscera too.
[Figure 1: Initial radiological diagnoses of all patients with pancreatic cysts detected on imaging]
PP02-15 Long-term Quality of Life after Resection of Pancreatic Neuroendocrine Tumors
Charlotte Heidsma, United States

C. Heidsma1, A. Eskes1, K. Dreijerink2, A. Engelsman3, M. Besselink1, E. Nieveen van Dijkum1
1Surgery, Amsterdam UMC, AMC, Netherlands, 2Endocrinology and Metabolism, Amsterdam UMC, VUmc, Netherlands, 3Surgery, Amsterdam UMC, VUmc, Netherlands

Background: Survival after curative intent surgery for pancreatic neuroendocrine tumors (PNET) is high, yet long-term outcomes including pancreatic insufficiency (EPI), new-onset diabetes (DM) and quality of life (QoL) are poorly investigated. Long-term QoL may very depending on the type of resection performed.
Method: PNETs who underwent curative intent surgery between 1993-2018, with >1-year of follow-up were included. QoL was assessed using 3 validated questionnaires: the EQ-5D-5L, QLQ C-30 and QLQ GI-NET21. QoL was analysed among subgroups based on type of surgery, pancreatoduodenectomy (PD), distal pancreatectomy (DP), or enucleation (EN), and compared to a reference population. Sensitivity analyses included complications Clavien-Dindo grade ≥3 and follow-up duration (≤5, 5-10, ≥10 years).
Results: 93/138 patients responded to the questionnaires. Median follow-up duration was 99 (5-307) months. Thirty (33.7%) patients underwent PD, 29 (32.6%) patients DP, and 29 (32.6%) patients EN. Twenty-five (28.0%) patients had severe postoperative complications, 28 (20%) developed new-onset DM, and 55 (40%) developed EPI. Mean daily-health status and index scores (EQ-5D-5L), and all domains of the QLQ-C30 except for pain, were significantly lower for PNETs than for the general population (change in QoL of >10%, p< 0.05). EN patients had highest over-all QoL in most EQ-5D-5L, QLQ-C30, and GI-NET21 domains. No differences in QoL were seen in the sensitivity analyses.
Conclusion: QoL of resected PNETs was significantly lower than in the general population and this reduction remained stable until more than 10 years after surgery. EN patients had better QoL compared to other types of resections.
PP02-17 Two Cases of Laparoscopic Resection of Epithelial Cyst in an Intrapancreatic Accessory Spleen
Satoshi Amano, Japan

S. Amano, H. Nitta, T. Takahara, Y. Hasegawa, H. Katagiri, S. Kanno, A. Umemura, A. Sasaki
Surgery, Iwate Medical University School of Medicine, Japan

Background: A cystic tumor of the intrapancreatic accessory spleen is rare. Only 52 patients have been reported in the English literature (PubMed keywords: epithelial cyst, epidermoid cyst and intrapancreatic accessory spleen) from 1980 to 2018.
Objectives and methods: We present a literature review and two cases of epithelial cyst in an intrapancreatic accessory spleen (ECIAS) that were performed laparoscopic pancreatectomy.
Case presentation: The first patient was a 70-year-old man with a 12 mm enhanced cystic tumor in the tail of pancreas on abdominal computed tomography (CT) underwent a laparoscopic spleen preserving distal pancreatectomy. The second patient was a 51-year-old man with a 34 mm enhanced cystic tumor in the tail of the pancreas on CT underwent hand-assisted laparoscopic distal pancreatectomy due to obesity. Pathological evaluation revealed an ECIAS in both patients.
Results: Forty-three articles that reported on 52 patients have been published in the English literature. Including the present cases, 22 cases were men and 32 cases were women. The mean age of the patients was 45.4 years (range 12-70 years). Most ECIAS cases were diagnosed after surgical resection based on the pathological characteristics. Only 5 cases (9.2%) among the 54 reported cases were diagnosed preoperatively.
Conclusions: Although the preoperative diagnosis of ECIAS is very difficult, the possibility of ECIAS should be considered in detecting an asymptomatic intrapancreatic mass. Laparoscopic distal pancreatectomy might be a safe and effective procedure in ECIAS cases. We herein report two cases of ECIAS with some literature review.