PP04 Pancreas: Surgical Outcomes (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PP04-001 Nutritional Assessment and Surgical Outcomes in Patients Aged 80 Years and Older Undergoing Pancreaticoduodenectomy
Masashi Utsumi, Japan

M. Utsumi, H. Aoki, Y. Kimura
Department of Surgery, Iwakuni Clinical Center, Japan

Background: Conflicting data exist regarding the safety of Pancreaticoduodenectomy (PD) in elderly patients. This study aimed to evaluate and compare nutritional factors and clinical outcomes of PD between elderly and non-elderly patients.
Methods: A retrospective study was conducted among 116 consecutive patients who underwent PD from April 2008 to August 2019. We compared pre- and post-operative nutritional factors (prognostic nutritional index [PNI], controlling nutritional status [CONUT] score), complication rates, and survival rates between the elderly (age ≥80 years) and non-elderly (age < 80 years) patient groups.
Results: Nineteen elderly patients (18.4%) and 97 non-elderly patients (83.6%) underwent PD. Among preoperative factors, elderly patients had significantly lower PNI and higher CONUT scores than non-elderly patients. The duration of operation and amount of blood loss were similar between the two groups. Three-months post-operation, elderly patients had lower albumin levels and PNI than non-elderly patients. The post-operative complication rates and the incidence rate of pancreatic fistula were similar between the two groups. Median length of hospital stay was significantly longer in elderly patients (41 days) than in non-elderly patients (27 days). The rate of death due to other diseases was relatively higher in elderly patients than in non-elderly patients. Elderly patients had significantly lower overall survival rates than non-elderly patients (1-/3-/5-year overall survival; 83.4/49.7/14.2% vs. 87.1/54.1/47.3%; log-rank test, P=0.008).
Conclusion: Elderly patients had lower nutritional status and lower survival rates than non-elderly patients. Careful patient selection and optimal peri-operative care are necessary for determining whether PD is indicated in elderly patients.
PP04-002 Palliative Pancreaticoduodenectomy
Yi-Ming Shyr, Taiwan, Republic of China

Y.-M. Shyr
Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China

Background: This study was to evaluate the surgical, oncological and survival outcomes after pancreaticoduodenectomy (DP) with superior mesenteric vein (SMV)/ portal vein (PV) resection for borderline resectable periampullary malignancy by either robotic PD (RPD) or open PD (OPD).
Methods: Data for periampullary lesions undergoing PD were retrieved from a prospectively-collected computer database. Surgical risks, oncological and survival outcomes were compared between groups with and without SMV/PV resection.
Results: A total of 391 patients undergoing pancreaticoduodenectomy were included for analysis, including 43 (11.0%) with and 384 (89.0%) without vein resection. Eleven (25.6%) of PDs with vein resection were performed by robotic approach. Operation time in vein resection group was significantly longer (median of 8 vs. 7 hours). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), chyle leakage, wound infection and hospital stay were of no significant different between these two groups. There was no survival difference between these groups, with 1-year and 3-year survival rates of 92.6% and 26.5% respectively for the patients with vein resection, vs. 70.3% and 37.2% without vein resection.
Conclusions: PD with vein resection is technically feasible not only by open approach but also by robotic approach in selected patients. Additional SMV/PV would not increase the surgical risks of PD, and moreover, could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.
PP04-003 The Vulnerable Point of Modified Blumgart Pancreaticojejunostomy Regarding Pancreatic Fistula Learned from 80 Consecutive Pancreaticoduodenectomy
Kwangyeol Paik, Korea, Republic of

K. Paik, J.S. Oh
The Catholic University of Korea College of Medicine, Korea, Republic of

Background: Blumgart Anastomosis (BA) during pancreaticoduodenectomy (PD) had reduced postoperative pancreatic fistula (POPF) after PD in literatures. The aim of this study is to report surgical results of consecutive series of modified BA method.
Methods: Data of consecutive 80 patients who underwent PD using modified BA between September 2011 and August 2019 were prospectively collected and retrospectively analyzed, regarding POPF and other morbidity and mortality.
Results: Overall incidence of POPF was 8.8%, the rate of Grade B POPF was 7.5% (6/80) and Grade C was 1.3% (1/80). Among 80 patients, five post pancreatectomy hemorrhages (6.3%) including two POPF related bleeding, and four abscesses including two POPF related with it were occurred. Fistula Risk Grades were 2 Negligible, 10 Low, 53 Intermediate, and 15 High. They were well improved the clinical courses after radiologic intervention under drainage and angiography except one. The mortality occurred because of POPF followed by the jejunal detachment from the remnant pancreas stump. In case of mortality, jejunum was too slender, comparing the pancreatic thickness.
Conclusions: This retrospective single-center result demonstrated that the modified BA had acceptable rate of POPF. Modified BA may be risky and potentially provoke fatal POPF, conjoining slender jejunum and thick pancreas.
PP04-004 Transition from Open and Laparoscopic to Robotic Pancreaticoduodenectomy in a UK Tertiary Referral Hepatobiliary and Pancreatic Centre - Early Experience of Robotic Pancreaticoduodenectomy
Tamara Gall, United Kingdom

T. Gall, L. Jiao
Imperial College, United Kingdom

Introduction: Pancreaticoduodenectomy is performed using an open technique (OPD) as the gold standard. An increase in those performed laparoscopically (LPD) and robotically (RPD) are now reported. We compared the short-term outcomes of RPD cases with LPD and OPD.
Methods: A retrospective review of a prospectively collected database was undertaken of our first consecutive RPD, our first LPD and consecutive OPD cases. Those requiring venous and/or arterial resection were excluded.
Results: RPD (n=25) had longer operating times (451.9 +/- 92.2 mins) than LPD (n=41)
(338.2 +/- 55.6 mins) and OPD (n=37) (309.6 +/- 81.0 mins, p< 0.0001). On subgroup analysis, after 20 cases, RPD operating time was comparable to OPD (p=0.414). Estimated blood loss and transfusion requirement was less after RPD and LPD compared to OPD (p=0.012 and p< 0.0001 respectively). No RPD cases required conversion to open operation compared to 24.4% of LPD. Morbidity was comparable. 90-day mortality was seen in 0.97% of the total cohort. Length of hospital stay (LOS) was shorter for RPD compared to both LPD (p=0.030) and OPD (p=0.002).
Conclusion: RPD is safe to perform with comparable outcomes to LPD and OPD. Further evidence is provided that a randomised controlled trial for PD techniques is required.
PP04-006 Surgical, Survival and Oncological Outcomes after Vascular Resection in Robotic and Open Pancreaticoduodenectomy
Yi-Ming Shyr, Taiwan, Republic of China

S. Shyr
Surgery, Taipei Veterans General Hospital, Taipeh, Taiwan, Republic of China

Background: To evaluate the surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV)/portal vein (PV) resection by either robotic PD (RPD) or open PD (OPD).
Methods: Data of patients with periampullary lesions undergoing PD were retrieved from a prospectively collected computer database. Surgical risks as well as oncological and survival outcomes were compared between patients with (vein resection group) and without SMV/PV resection (without vein resection group).
Results: A total of 391 patients undergoing pancreaticoduodenectomy were enrolled, including 43 (11.0%) and 384 (89.0%) patients with and without vein resection, respectively. Eleven (25.6%) of PDs with vein resection were performed using the robotic approach. Operation time in the vein resection group was significantly longer (median of 8 vs. 7 hours). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), chyle leakage, wound infection, and hospital stay were not significantly different between the two groups. There was no survival difference between these groups, with 1-year and 3-year survival rates of 92.6% and 26.5%, respectively, for vein resection group, vs. 70.3% and 37.2%, respectively, for the without vein resection group.
Conclusions: PD with vein resection is technically feasible by OPD and RPD in selected patients. Additional SMV/PV would not increase the surgical risks of PD and could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.
PP04-007 Surgical Outcomes of Combined Modified Blumgart Pancreaticojejunostomy and Long Internal Pancreatic Stent for Pancreaticoduodenectomy: A Preliminary Report
Kitti Wongta, Thailand

K. Wongta, V. Tangsirapat, P. Charutragulchai, V. Ohmpornuwat, S. Sripreechapattana, K. Sumtong, P. Sookpotarom
Surgery, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Thailand

Introduction: The modified Blumgart pancreaticojejunostomy is a wellknown technique during the reconstructive phase of pancreaticoduodenectomy. A short stent is often placed across the anastomosis to prevent pancreatic fistula. On the other hand, the long internal stent is rarely used and the outcome is controversial.
Method: We retrospectively analysed the early postoperative results,especially the pancreatic fistula, of 10 patients who underwent pancreaticoduodenectomy during June, 2017 to December,2019 in single center. All pancreaticojejunostomies were reconstructed with combined the modified Blumgart technique and long internal pancreatic stent.
Results: According to the International Study Group on Pancreatic Fistula criteria, the pancreatic fistula occurred in 4 patients(40%). Two patients(20%) had biochemical leakage(Grade A). Another one required percutaneous drainage(Grade B). Only one patient died after the re-operation(Grade C). The 30-day mortality rate was 10(1/10) percents. The median postoperative hospital stay was 15 days(range,12-36).
Conclusion: Combined the modified Blumgart pancreaticojejunostomy and long internal pancreatic stent is a favorable technique to prevent the pancreatic fistula. Simplified management,acceptable mortality rate and shorten postoperative hospital stay are important advantages. Due to the limited sample size, further studies are needed to support our results and clarify the issue.
Postoperative complicationsNo(%)
Pancreatic fistula ; Grade A, Grade B, Grade C4/10(40) ; 2/10(20), 1/10(10), 1/10(10)
Bile leakage ; Grade A, Grade B, Grade C1/10(10) ; 0/10(0), 0/10(0), 1/10(10)
Intraabdominal bleeding1/10(10)
Intraabdominal abscess2/10(20)
Postoperative hospital stay, day(s)15(12-36)
[Postoperative outcomes]

[Modified Blumgart's pancreaticojejunostomy]
PP04-009 Effect of Polyglycolic Acid Mesh for Prevention of Pancreatic Fistula Following Segmental Pancreatectomy: A Systematic Review
Wei Zhang, China

W. Zhang1, Z. Wei2, X. Che1
1Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer / Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China, 2Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China

Background: Postoperative pancreatic fistula (POPF) is the most common and intractable complication after segmental pancreatectomy, with an incidence of 13-64%.Polyglycolic acid (PGA) mesh is a new technique that is designed to prevent POPF, but its effect has been evaluated only in a small number of patients and in retrospective studies. In this study, we systematically and comprehensively analyzed the efficacy of PGA based on reported research.
Methods: We searched Medline, Embase, and Cochrane Library databases in English between January 2010 and October 2019. Analysis was performed by using Review Manger5.3 software.
Results: Three randomized controlled trials and 8 non-randomized studies were eligible with a total of 1598 patients including 884 PGA patients and 714 control patients. For pancreatoduodenectomy (PD), distal pancreatectomy (DP) and segmental pancreatectomy, we found significant statistical differences in overall POPF (RR All= 0.76, 95%CI=0.64-0.89, P=0.0009; RR PD=0.75,95%CI=0.61-0.91, P=0.004; RR DP= 0.74, 95% CI=0.57-0.96,P=0.02, respectively), grade B/C pancreatic fistula (RR All=0.41, 95%CI=0.32-0.52, P < 0.00001; RR PD=0.5, 95%CI=0.37-0.68, P< 0.00001; RRDP=0.31, 95%CI=0.21-0.46, P< 0.00001, respectively), andoverall complications
(RR = 0.77, 95% CI: 0.67-0.88, P =0.0002) in favor of RGA. We did not find significant differences regarding operative time (WMD=-8.86; 95%CI: -27.59-9.87, P=0.35) and hospital stay
(WMD=-2.73; 95%CI: -7.53-2.06, P=0.26).
Conclusions: This meta-analysis shows the benefits of the PGA technique regarding POPF and postoperative complications. Currently, the quality of evidence on the benefits of PGA is low due to the lack of randomized controlled trials and needs to be taken into consideration when evaluating PGA. This will require conducting large randomized control trials.
PP04-010 Prior Renal Transplant Patients Demonstrate Similar Outcomes Following Pancreatectomy
Stavros Stefanopoulos, United States

A. Parsikia1, S. Stefanopoulos2, D. Kaissieh2, J. Sutton3, J. Ortiz4
1Gastroenterology, University of Pennsylvania, United States, 2College of Medicine, University of Toledo Medical Center, United States, 3Division of Surgical Oncology, University of Toledo Medical Center, United States, 4Department of Transplant Surgery, University of Toledo Medical Center, United States

Introduction: The purpose of our study was to evaluate clinical outcomes of previous kidney transplant recipients (KTxRs) undergoing pancreatectomy.
Methods: We queried the National Inpatient Sample (NIS) database from 2005 to 2014 to identify KTxRs with pancreatic lesions (case group) who underwent partial or total pancreatectomy. Propensity matching was used to create a comparative control group of non-KTxRs. Chi-square analyses were utilized to compare the clinical variables between groups, while regression analyses were utilized to compare clinical outcomes as well as hospital charges.
Results: Twenty-five pancreatectomy patients had also undergone prior kidney transplant. KTxRs were more likely to have a benign tumor type (32.0% vs. 14.4%, p=0.020). The KTxR population utilized a greater percentage of government-based health insurance (72.0% vs. 50.0%, p=0.028). On univariate analysis, KTxRs demonstrated a higher rate of blood transfusion during pancreatectomy (40.0% vs 22.2%, p=0.032), and the average total hospital charge for these patients was significantly greater ($108,218 vs $85,858, p=0.047). However, prior receipt of a kidney transplant was not associated with increased mortality, morbidity, length of stay, or total hospital charges on multivariate analysis (all p > 0.05). While KTxRs underwent pancreatectomy mostly at transplant centers (84.0% vs 58.9%, p=0.011), receipt of perioperative pancreatectomy care at transplant centers did not negatively affect any outcome.
Conclusion: KTxR demonstrate similar clinical outcomes with non-KTxR when undergoing pancreatectomy. Prior kidney transplant should not be considered a contraindication to undergoing pancreatic resection.
PP04-011 Early experience of Systematic Mesopancreas Dissection (SMD) for Pancreatic and Periampullary Carcinoma
Paleswan Lakhey, Nepal

P.J. Lakhey
Department of Surgical Gastroenterology, Tribhuvan University Teaching Hospital/Institute of Medicine, Kathmandu, Nepal

Introduction: The incidence of R1 resection is high in pancreatic cancer despite of a good quality surgery. Amongst various techniques of mesopancreas excision, SMD is applicable to pancreatic and other periampullary carcinoma. This study has been conducted to compare the perioperative outcomes, the lymph node yield and the margin status in patients who underwent standard pancreaticoduodenectomy and SMD pancreaticoduodenectomy for pancreatic and periampullary carcinoma.
Methods: A retrospective comparative study was conducted in a single unit of Gastrointestinal and Hepatopancreatobiliary surgery at Tribhuvan University Teaching Hospital, Nepal. The demographics, indication of surgery, duration of surgery, intraoperative blood loss, incidence of procedure-specific complications according to ISGPS, length of hospital stay, perioperative mortality, lymph node yield and margin status were compared.
Results: Total of 17 patients underwent SMD pancreaticoduodenectomy. The demographic data was comparable with the historical data of 45 patients who underwent standard pancreaticoduodenectomy. The duration of surgery was longer in SMD pancreaticoduodenectomy (354.7±51.1 mins vs 276.2 ± 43.1 mins), however, the blood loss was less (502.9 ± 178.1 ml vs 701.1 ± 354.6 ml). The incidence of POPF and perioperative mortality were less as compared to the patients who underwent standard pancreaticoduodenectomy (11.5% vs 14.6% and 5.9% vs 8.5% respectively). The rate of margin negative resection was comparable (88.2% vs 90%). The median lymph node yield was significantly high in patients who underwent SMD pancreaticoduodenectomy (15 vs 6, p < 0.05).
Conclusion: SMD pancreaticoduodenectomy is feasible and should be performed not only for pancreatic carcinoma but also for other periampullary carcinoma.
PP04-012 Pancreatic Resection for Metastatic Tumors to the Pancreas
Kazuhiro Hiramatsu, Japan

K. Hiramatsu, T. Aoba, A. Arimoto, A. Itoh, K. Omiya, T. Kato
General Surgery, Toyohashi Municipal Hospital, Japan

Introduction: The incidence of metastases to the pancreas is rare. Therefore the benefit of their surgery is unclear. Here we assessed the outcome of patients undergoing pancreatic resection for metastatic tumor to the pancreas.
Methods: From January 2010 to September 2019, seven patients underwent pancreatic resection for metastatic tumor to the pancreas in our department. The primary sites were kidney (n=5), Duodenum (n=1), uterus (n=1). One synchronous and six metachronous metastases. Median interval between primary treatment and resection of pancreatic metastasis was 49 months
(0 - 224 months).
Results: Treatments included distal pancreatectomy in five patients, pancreaticoduodenctomy in one patient and remnant total pancreatectomy after pancreaticoduodenectomy in one patient. Associated treatment of extra-pancreatic metastases was performed in one patient performing Radiofrequency ablation for lung metastases. There was no postoperative mortality, but five postoperative morbidities, including two grade 3 pancreatic fistula, one grade 1 pancreatic fistula, one grade 1 pancreatic pseud cyst, and one grade 1 chylorrhea. Median overall survival was 17 months (4.7-100.3 months). Two patients died of recurrent disease at 17 and 100.3 months after pancreatectomy and five patients survived without recurrence.
Conclusions: Pancreatic resection for metastatic tumor to the pancreas should be considered in selected patients, especially metastases limited to the pancreas. Long-term survival or good palliation may be achieved.
PP04-013 A 14-Year Record of Pancreaticoduodenectomy: A Single Institutional Observational Study with Consecutive 2,668 Cases
Ji Hye Jung, Korea, Republic of

J.H. Jung, S.H. Shin, S.J. Yoon, S. Yoon, Y. Ryu, N. Kim, I.W. Han, J.S. Heo, D.W. Choi
Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, Republic of

Introduction: To evaluate clinicopathological features and chronologic changes of postoperative outcomes in patients undergoing pancreaticoduodenectomy(PD).
Methods: We retrospectively reviewed 2,668 cases of PD performed at Samsung Medical Center in Seoul, Korea for 14 years from January 2005 to December 2018. To identify clinicopathologic features, periampullary diseases were classified into 4 locations of pancreas, bile duct, ampulla and duodenum. The chronologic changes in postoperative outcomes were compared between subdivided periods of 1st period (between 2005 and 2011) and 2nd period (between 2012 and 2018). In order to obtain at least 2 years of follow-up data for survival analysis, 2nd period was set between 2012 and 2016.
Results: 1,098 and 1,570 cases were performed in 1st and 2nd periods, respectively. Most of PD were performed on diseases of pancreas, followed by bile duct, ampulla, and duodenum. Benign cases accounted for about 15% of entire cases. When analyzing chronologic changes of postoperative outcomes in entire cases, we identified complication rate was significantly lower, and hospital stay was significantly shorter in 2nd period. The postoperative pancreatic fistula did not significantly differ between two period groups. In survival analysis of cancers of each location, survival rates were significantly higher in 2nd period than in 1st period.
Conclusions: PD has been increasingly being performed to more patients. It was confirmed the incidence of postoperative complications was reduced and survival was improved in our study. Although we cannot conclude PD is sole factor in improving survival, development of PD will lead to therapeutic improvement in periampullary diseases.
PP04-014 Pre and Intraoperative Predictors of Post-Pancreaticoduodenectomy Hemorrhage: A Cohort Study
Ramiro Manuel Fernandez Placencia, Peru

R.M. Fernandez Placencia, E. Ruiz Figueroa, F. Berrospi Espinoza
Abdominal Surgery - HPB Surgery Division, National Cancer Institute, Peru

Introduction: Post-Pancreaticoduodenectomy Hemorrhage is an important cause of morbidity and mortality. We examined the effects of pre and intraoperative factors in the development of this complication.
Methods: This is a retrospective study in a cohort of patients who underwent PD in a tertiary care center (January 2010 - December 2019). Patients with R2 resections and other types of anastomoses than Telescopic and Blumgart were excluded. Morbidity and mortality were logged during a 90-day postoperative follow-up. Severe Morbidity was defined as Clavien-Dindo≥III. Post-Pancreatectomy Hemorrhage (PPH) and Post-operative Pancreatic Fistula (POPF) were defined according to the ISGPS definition and grading.
Results: A total of 182 patients were included. Clinically significant pancreatic fistulas were 29% (n=53). Protective prognostic factors for PPH were serum albumin levels (OR 0.92 CI95% 0.86 - 0.98 p=0.008) and performing a Blumgart anastomosis (OR 0.34 CI95% 0.13 - 0.89 p=0.028) (Table 1). The group of Telescopic anastomosis was 117 and 65 for Blumgart. PPH was present in Telescopic PJ in 22% and 12% in Blumgart PJ. None of the patients in the Blumgart group developed a PPH Type C. No differences in POPF (p=0.981), severe morbidity (p=0.676), hospital stay (p=0.673) and mortality (p=0.878) were found.
Conclusions: Blumgart pancreaticojejunostomy is related to lower PPH rates and severity after Whipple Procedure. Higher serum albumin levels may have a modest effect in decreasing this complication.
[Table 1. Univariate and Multivariate Analysis for Post-Pancreatectomy Hemorrhage (n=182)]
PP04-016 Defining High Volume Center for Minimally Invasive Distal Pancreatectomy
Roheena Panni, United States

R. Panni1, R. Fields2, C. Hammill3, M. Doyle4, S. Strasberg3, W. Chapman4, W. Hawkins3, D. Sanford3
1General Surgery, Washington University in Saint Louis, United States, 2Surgical Oncology, Washington University School of Medicine, United States, 3Hepatobiliary Surgery, Washington University School of Medicine, United States, 4Hepatobiliary & Transplant Surgery, Washington University School of Medicine, United States

Introduction: Minimally Invasive Distal Pancreatectomy (MIDP) is associated with reduced intra-operative blood loss, transfusion requirement, and shorter length of stay compared to open distal pancreatectomy (ODP). Several studies have outlined the relationship between hospital volume and postoperative mortality for patients undergoing pancreatic surgery,but the exact effect of centralization of care for MIDP still needs to be determined.The purpose of this study is to evaluate the association between hospital-procedure-volume and mortality for patients undergoing MIDP to determine an evidence-based threshold of hospital volume associated with improvement in mortality.
Methods: Patients who underwent MIDP were identified using the National Cancer Database (2010-2015). Logistic regression analysis and restricted cubic spline regression analysis were performed to determine the linear and non-linear association between mean hospital volume and mean 90-day mortality.
Results: 2837 patients underwent distal pancreatectomy at 487 different hospitals. 30 and 90-day mortality of the study population was 1.27% (n=36) and 2.54% (n=72), respectively.Baseline characteristics and mean annual mortality of individual hospitals were determined(fig1). A logistic regression and cubic spline analysis was performed, which demonstrated that institutional volume is significantly associated with decreased overall 90-day mortality.The maximum improvement in 90-day mortality is seen if the annual hospital volume was greater than 7 (p< 0.0001).
Conclusion: Our data suggest that the centralization of MIDP results in decreased postoperative mortality. Based on these results, we recommend defining high volume center as hospitals performing eight or more MIDP cases/year. The true impact of this finding on overall survival should be assessed in future studies using large databases with long-term follow-up information.
[Hospital volume and mortality]
PP04-018 Operative Results and Patient Satisfaction after Robotic Pancreaticoduodenectomy
Ching-Yun Kung, Taiwan, Republic of China

C.-Y. Kung, B.-U. Shyr, S.-C. Chen, S.-E. Wang, Y.-M. Shyr
Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan, Republic of China

Background: There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but patient satisfaction after RPD.
Methods: Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD.
Results: The study included 105 patients who underwent RPD, with 44 (41.9%) patients presenting with associated surgical complications. There were no significant differences between the without and with complication groups in median console time (390 min. Vs. 373 min.), blood loss (100 mL vs. 100 mL), and harvested lymph node number (14 vs. 15). There was no surgical mortality in this study. Major complications > Clavien-Dindo III occurred in 7.6% of the 105 patients. The most common complication was chyle leakage (18.1%), followed by postoperative pancreatic fistula (5.7%), intra-abdominal abscess (4.8%), delayed gastric emptying (3.8%), and post pancreatectomy hemorrhage (3.8%). Almost all the patients responded to this RPD-related survey with “fair” to “excellent” grades for all items, except 1 (< 1%) poor grade for operation service and 2 (1.9%) “not good” grades for diet tolerance.
Conclusions: RPD is a feasible procedure with acceptable surgical outcomes. This patient survey with high patient satisfaction rates indicates that RPD provides acceptable satisfaction results, and the robotic approach for a major operation such as RPD has probably a higher priority than cost concerns. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction.
PP04-019 Postoperative Day Five Neutrophil-Lymphocyte Ratio Behaves as an Independent Prognostic Factor in Patients with Pancreatic Cancer
Pablo Marcos-Santos, Spain

P. Marcos-Santos, M. Bailon-Cuadrado, B. Perez-Saborido, E. Asensio-Diaz, P. Pinto-Fuentes, L.M. Diez-Gonzalez, S. Mambrilla-Herrero, A. Centeno-Velasco, D. Pacheco-Sanchez
General and Digestive Surgery, Hospital Universitario Rio Hortega, Spain

Introduction: We have designed this work to relate the postoperative day 5 neutrophil-lymphocyte ratio (POD 5 NLR) to overall survival (OS) and disease-free survival (DFS) in pancreatic cancer surgery.
Methods: We have selected pancreatic cancers operated at our Institution between January 2015 and December 2017. Receiver operating characteristics curve was used to establish the cut-off value of POD 5 NLR. Survival curves were constructed using the Kaplan-Meier method.
Results: Finally, 42 patients were eligible for statistical analysis. POD 5 NLR cut-off value was set at 7.5. The 6-, 12-, 24-month OS were 85.7%, 85.7%, 76.2% for POD 5 NLR < 7.5, and 90.5%, 71.4%, 50.0% for POD 5 NLR ≥ 7.5 (p-value = 0.045). The 6-, 12-, 24-month DFS were 90.0%, 85.0%, 80.0% for POD 5 NLR < 7.5, and 75.4%, 64.6%, 43.1% for POD 5 NLR ≥ 7.5
(p-value = 0.010).
Conclusions: Our work shows that POD 5 NLR behaves as an independent prognostic factor for patients with pancreatic cancer.
PP04-020 Postoperative Day Five C-Reactive Protein Predicts Oncologic Outcomes in Pancreatic Cancer Surgery
Pablo Marcos-Santos, Spain

P. Marcos-Santos, M. Bailon-Cuadrado, B. Perez-Saborido, E. Asensio-Diaz, P. Pinto-Fuentes, L.M. Diez-Gonzalez, S. Mambrilla-Herrero, A. Centeno-Velasco, D. Pacheco-Sanchez
General and Digestive Surgery, Hospital Universitario Rio Hortega, Spain

Introduction: The aim of this work was to relate the postoperative day 5 (POD 5) C-reactive protein to overall survival (OS) and disease-free survival (DFS) in pancreatic cancer.
Methods: We have selected pancreatic cancers operated at our Institution between January 2015 and December 2017. Receiver operating characteristics curve was used to establish the cut-off value of C-reactive protein at POD 5. Survival curves were constructed using the Kaplan-Meier method.
Results: Finally, 41 patients were eligible for statistical analysis. POD 5 C-reactive protein cut-off value was set at 160. The 6-, 12- and 24-month year OS were 88.5%, 84.6% and 76.9% for POD 5 C-reactive protein < 160, and 86.7%, 66.7% and 40.0% for POD 5 C-reactive protein ≥ 160
(p-value = 0.027). The 6-, 12- and 24-month DFS were 87.8%, 79.5% and 70.6% for POD 5 C-reactive protein < 160, and 73.3%, 66.0% and 44.0% for POD 5 C-reactive protein ≥ 160
(p-value = 0.038).
Conclusions: Our work shows that POD 5 C-reactive protein represents a relevant prognostic factor for patients with pancreatic cancer.
PP04-021 Preoperative Pancreatic Resection (PREPARE) Score Predicts Oncologic Outcomes in Patients with Pancreatic Cancer
Pablo Marcos-Santos, Spain

P. Marcos-Santos, M. Bailon-Cuadrado, B. Perez-Saborido, E. Asensio-Diaz, P. Pinto-Fuentes, L.M. Diez-Gonzalez, S. Mambrilla-Herrero, A. Centeno-Velasco, D. Pacheco-Sanchez
General and Digestive Surgery, Hospital Universitario Rio Hortega, Spain

Introduction: We have designed this work to relate the 'preoperative pancreatic resection' (PREPARE) score to overall survival (OS) and disease-free survival (DFS) in pancreatic cancer.
Methods: We have selected pancreatic cancers operated at our Institution between January 2015 and December 2017. PREPARE score classifies patients according to surgical risk in low risk (0-5 points), intermediate risk (6-9 points) and high risk (10-17 points). We have created two groups: low PREPARE (< 10 points) and high PREPARE (≥ 10 points). Survival curves were constructed using the Kaplan-Meier method
Results: Finally, 43 patients were eligible for statistical analysis. 8 patients had a high PREPARE. The 6-, 12- and 24-month OS were 91.4%, 82.9% and 67.9% for low PREPARE, and 75.0%, 62.5% and 50.0% for high PREPARE (p-value = 0.033). The 6-, 12- and 24-month DFS were 88.0%, 81.8% and 65,7% for low PREPARE and 62.3%, 50.0% and 37.5% for high PREPARE
(p-value = 0.029).
Conclusions: PREPARE score appears as an outstanding prognostic factor among patients who undergo pancreatic cancer surgery.
PP04-022 Minimal Invasive Pancreatoduodenectomy Provide Shorter Postoperative Hospital Stay and Early Drain Removal for Elderly Patients: A Propensity Score Matching Study
Shih-Min Yin, Taiwan, Republic of China

S.-M. Yin, Y.-W. Liu, Y.-Y. Liu, C.-S. Yeh
Kaohsiung Chang Gung Memorial Hospital, Taiwan, Republic of China

Introduction: Pancreatoduodenectomy (PD) is the most complex pancreatic operation and entails a challenging reconstruction where major morbidity and mortality may result from anastomotic failure or hemorrhage. This study aim to evaluate the risk and benefit of minimal invasive pancreatoduodenectomy (MIS PD) in elderly patients.
Methods: From 2017 to 2019, we retrospective enroll 121 patient with PD. 22 patients receive MIS PD and other 99 patients receive open PD (OPD). Postoperative mortality and morbidity, short-term outcome. Propensity score matching was apply for further old age (>70-year-old) patient analysis.
Results: Older patient with underwent PD had significantly higher surgical mortality, major complication, longer postoperative hospital stay (POHS), longer ICU stay, longer TPN dependence, later ambulation and drain removal comparing to young age patients. Elderly patient underwent MIS PD had significantly shorter POHS (22 days vs 27 days, p=0.043) and early drain removal
(18 days vs 25 days, p=0.011) comparing to OPD. After 1:3 Propensity score matching, elderly patient receive MIS PD still had significantly shorter POHS (21 days vs 28 days, p=0.023) and early drain removal (19 days vs 25 days, p=0.018). Besides, there was no surgical mortality comparing to open group (0% vs 13.6%, P=0.53).
Conclusions: Elderly patients underwent PD have higher overall surgical risk and slower postoperative recovery course. MIS PD for elderly patients provides shorter POHS and early drain removal. Without increasing mortality and major complication, MIS PD might also provide potential advantage for elder patient in short-term outcome and postoperative recovery over OPD.
PP04-023 The Closure Technique for Reducing Postoperative Pancreatic Fistula after Distal Pancreatectomy
Toru Kojima, Japan

T. Kojima, T. Niguma, T. Fuji, E. Miyake, T. Mimura
Department of Surgery, Okayama Saiseikai General Hospital, Japan

Introduction: The number of patients who performed pancreas division using stapler in distal pancreatectomy has been widely increasing. But, postoperative pancreatic fistula(POPF) still remains important problem. In this study, we analyzed our results retrospectively, and evaluate our new strategy to reduce POPF.
Methods: 180 patients who underwent distal pancreatectomy were retrospectively analyzed. Grade B or C of the grading system of International Study Group of Pancreatic Fistula were considered to be POPF. Because we changed pancreatic division method from January 2005, we separate two periods in this study. The pancreatic stump was closed by hand-sewn suture or using stapler. The thickness of pancreas was measured in preoperative CT.
Results: In first period, there was no significant difference in the incidence of POPF between hand-sewn group(17.0%) and stapler group(17.4%). In stapler group, the average pancreatic thickness in patients with POPF was 18.0mm and in patients without POPF was 13.5mm, respectively. There was significant difference. A 16mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve. Therefore, we used stapler in case with under 16mm of pancreatic thickness and chose hand-sewn closure with over 16mm in second period. The incidence of POPF were 17.2% in first period and 10.9% in second period. The rate of POPF tended to decrease. The incidence of POPF with stapler were 17.4% in first period and 5.4% in second period. There was significant difference.
Conclusions: To limit using stapler with a pancreatic thickness under 16mm, we could reduce the incidence of POPF.
PP04-024 Platelet/lymphocyte Ratio on Day-1 after Pancreatectomy was Predictive Factor for Pancreatic Fistula
Shuji Suzuki, Japan

S. Suzuki, M. Shimoda, J. Shimazaki, T. Maruyama, Y. Oshiro, K. Nishida, R. Udo, R. Imazato
Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Japan

Introduction: The safety of pancreatectomy (Pt) regarding the surgical technique and perioperative care management has increased recently, but postoperative pancreatic fistula (POPF) is a lethal complication. We aimed to evaluate the risk factors of operative and postoperative findings for PF after Pt.
Methods: Between Nov 2014 and Dec 2018, 103 patients who underwent Pt at our center were prospectively examined and classified into Group A, those with no fistula/biochemical leak (n=97),
or B, those with grade B/C POPF (n=6) . Operative (operative time, bleeding volume, blood transfusion, abdominal cavity washing volume), and 1- and 3-day postoperative (white blood cells; Neutropils, lymphocytes; hemoglobin (Hb); Plate; Creatine; Albmin; Total Bilirubin; amylase; C-reactive protein(CRP); neutrophil/lymphocyte ratio; prognostic nutritional index, platelet/lymphocyte ratio (PLR), CRP/Alb ratio (CAR); drain amylase; drainage cell counts, volume, bacteria) factors were collected and analyzed at postoperative day1, and day3. Post-Pt POPF predictors were evaluated using univariate and multivariate analyses.
Results: The mean patient age was 68.7 y ( 67 men, 36 women). The diseases were pancreatic cancer (n=46), intraductal papillary mucinous neoplasms (n=13), bile duct cancer (n=10), papilla Vater cancer (n=8), chronic pancreatitis (n=7), neuroendocrine neoplasms (n=7), and others (n=12). Surgical procedures included PD (n=74) and DP (n=29). PF grade B/C was noted in 6 patients (5.8%), without grade C. Univariate analysis showed that POPF predictors were Hb-day1(p=(p=0.016),PLR-day1 (p=0.011), CAR-day1 (p=0.012), CRP-day1 (p=0.011). Multivariate analysis showed that PLR-day1 was independent risk factor for POPF(p=0.034).
Conclusions: PLR-day1 (33.5≦) was early risk predictor for POPF after Pt.
PP04-026 Alternative Fistula Risk Score Is a Better Predictor of Ideal Outcome in Patients Undergoing Minimally Invasive Pancreaticoduodenectomy
Usman Panni, United States

U. Panni, S. Srinivasa, R. Fields, M. Doyle, W. Chapman, S. Strasberg, W. Hawkins, C. Hammill, D. Sanford
Washington University School of Medicine, United States

Background: The benefit of minimally-invasive (MIPD) versus open pancreaticoduodenectomy (OPD) to patients is controversial. The major driver of morbidity and mortality after pancreaticoduodenectomy is postoperative pancreatic-fistula (POPF). The alternative-fistula risk score (aFRS) is a validated prognostic tool that predicts patients' risk of POPF using three variables (pancreatic duct size, gland texture, and patient BMI). We hypothesized that patients who are not at high risk for POPF benefit most from MIPD.
Methods: Patients undergoing pancreaticoduodenectomy were prospectively followed for 40 months. Perioperative and pathologic covariates and outcomes were compared. Patients were categorized as either aFRS-high risk (POPF-risk >20%) or aFRS-low/intermediate-risk (POPF-risk ≤20%). The ideal-outcome (IO) was defined as shown in Figure-1. Multivariable logistic regression was used to test for independent-associations with IO.
Results: Out of 312 patients, 212 (83.7%) underwent OPD and 51 (16.4%) underwent MIPD. MIPD patients had significantly longer overall operative time (462.8 minvs.378.5 min,p< 0.001), reduced intraoperative blood loss (280.5 mlvs.436.0 ml,p=0.001), and a decreased rate of 90-day readmission (15.7%vs.30.7%,p=0.030) . MIPD patients were significantly more likely to be aFRS-high risk (56.9%vs.40.2%,p=0.028). IO was significantly more frequent in aFRS-low/intermediate-risk patients undergoing MIPD compared to aFRS-low/intermediate-risk patients undergoing OPD, aFRS-high risk patients undergoing either MIPD or OPD (40.9%vs15.4%v6.9% vs14.3%,p=0.007). In multivariate analysis, MIPD in aFRS-low/intermediate-risk patients was independently-associated with an increased likelihood of IO (OR= 4.09, p=0.012).
Conclusions: Patients who are not at high-risk for POPF are most likely to benefit from MIPD. The aFRS could be a useful tool to aid the surgeon experience and expertise in selecting patients for MIPD.
[Ideal Outcome in aFRS high vs.low/intermediate risk patients undergoing MIPD/OPD.]
PP04-027 Laparoscopic Pancreatic Surgery: Single Center Experience
Hee Joon Kim, Korea, Republic of

H.J. Kim1, Y.H. Lee2, Y.H. Hur2, Y.S. Koh2, C.K. Cho2
1Division of HPB Surgery, Department of Surgery, Chonnam National University Hospital, Korea, Republic of, 2Division of HPB Surgery, Department of Surgery, Chonnam National University Hwasun Hospital, Korea, Republic of

Introduction: Laparoscopic pancreatic resections are widely performed. We analyzed short-term operative outcomes of laparoscopic pancreatic surgery, compared to open surgery.
Method: We retrospectively reviewed data of 150 patients who underwent distal pancreatectomy (DP) at Chonnam National University Hospital from 2009 to 2019 and 93 patients who underwent pancreaticoduodenectomy (PD) from 2014 to 2019. We reviewed each patient's age, sex, pathologic diagnosis, hospital stay, operative time, estimated blood loss, morbidity, 30-day mortality, incidence of postoperative pancreatic fistula (POPF), and post-pancreatectomy hemorrhage (PPH).
Results: 81 patients underwent open distal pancreatectomy (ODP) and 69 patients underwent laparoscopic distal pancreatectomy (LDP). Intraoperative estimated blood loss was significantly lower in the LDP group than ODP group (200 vs. 400ml p< 0.01).There was no significant difference in incidence of POPF (p=0.235), morbidity (18 vs. 30 p=0.152 ), PPH, wound infection, hospital stay and readmission. Delayed gastric emptying in LDP group occurred less than in the ODP group. 50 open PD (OPD) and 30 laparoscopic PD (LPD) were performed by single surgeon. Median operation time was 422 minutes (range. 210-695) in OPD and 527 minutes (range, 425-910) in LPD. Blood loss of OPD and LPD was 500ml (range, 200-2300) and 300ml (range, 100-3000), respectively. Median hospital stay was shorter in LPD group (15.5 vs 19 days).
Conclusions: LDP showed more shorten hospital stay and less blood loss than open surgery. Operation time is longer in LPD group than OPD group. However, Hospital stay was shorter in LPD group. In conclusion, Laparoscopic pancreatic surgery is feasible and safe.
PP04-029 The Influence of Diagnosis on Complications After Pancreatoduodenectomy: Results from a Nationwide Audit
Jacob L. van Dam, Netherlands

J.L. van Dam1, B.A. Bonsing2, H.C. van Santvoort3, M.G. Besselink4, C.H.J. van Eijck1, B. Groot Koerkamp1, Dutch Pancreatic Cancer Group
1Department of Surgery, Erasmus MC - University Medical Center, Netherlands, 2Department of Surgery, Leiden University Medical Center, Netherlands, 3Department of Surgery, University Medical Center Utrecht, Netherlands, 4Department of Surgery, Amsterdam UMC, Location AMC, Netherlands

Introduction: Comparison of hospital outcomes after pancreatoduodenectomy requires adjustment for prognostic factors. The objective of this study was to investigate the relation between diagnosis and complications after pancreatoduodenectomy.
Methods: The study was based on the Dutch Pancreatic Cancer Audit that collects data from all 18 hospitals in the Netherlands that perform pancreatoduodenectomy. Complication rates and mortality were compared between pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AAC), distal cholangiocarcinoma (DCC), duodenal carcinoma (DAC), non-invasive intraductal papillary mucinous neoplasm (IPMN), pancreatic neuroendocrine tumors (pNET), chronic pancreatitis (CP) and other diagnoses.
Results: Between 2014 and 2017, 2725 consecutive patients underwent pancreatoduodenectomy and were included. The most common diagnoses were PDAC in 1215 patients (45%), DCC in 356 patients (13%), AAC in 340 patients (13%), DAC in 165 patients (6%), IPMN in 158 patients (6%), pNET in 107 patients (4%), and CP in 81 patients (3%). Major complication rate (Clavien-Dindo grade ≥3) ranged from 14.8% in CP to 43.9% in pNET (p< 0.001). Postoperative pancreatic fistula ranged from 3.7% in CP to 24.3% in pNET (p< 0.001). Post-pancreatectomy hemorrhage occurred more often in AAC with an OR of 2.32 (1.37-3.92, p=0.003). Mortality was higher in DAC compared to PDAC with an OR of 2.37 (95% CI: 1.21-4.62, p=0.019). The proportion of a low-risk diagnosis (i.e. PDAC or CP) varied across hospitals from 24% to 60% (P=0.003).
Conclusions: Diagnosis should be taken into account when informing patients and designing clinical trials. Audits should adjust for case mix factors such as diagnosis when comparing hospitals.
[Figure 1: Odds ratios for complications after pancreatoduodenectomy.]
PP04-030 Pasireotide for the Prevention of Pancreatic Fistula After Pancreatoduodenectomy: Comparison with a Historical Cohort
Jacob L. van Dam, Netherlands

J.L. van Dam, Q.P. Janssen, C.H.J. van Eijck, B. Groot Koerkamp
Department of Surgery, Erasmus MC - University Medical Center, Netherlands

Background: Pasireotide, a somatostatin analogue, aims to reduce the risk of pancreatic fistula after pancreatoduodenectomy. Based on a reduced fistula rate (9 vs. 21%, p=0.006) in a randomized trial, we started the use of postoperative pasireotide twice daily for 7 days after pancreatoduodenectomy.
Methods: All consecutive patients who underwent pancreatoduodenectomy from 2012 to 2018 were analyzed. Transition to pasireotide was in February 2015. The primary endpoint was the development of an International Study Group on Pancreatic Fistula (ISGPF) grade B or C fistula. Multivariable analysis was performed for pancreatic fistula with adjustment for BMI, duct size, and pancreatic texture (hard/fibrotic versus soft/normal).
Results: During this 6-year period, 387 patients underwent pancreatoduodenectomy; 143 patients (37%) before and 244 patients (63%) after pasireotide introduction. Most patients (83%) underwent an open pancreatoduodenectomy and in most patients (98%) 1 or 2 drains were left. In total, 227 patients (93%) received at least one dosage of pasireotide. The median number of pasireotide dosage was 14 (IQR: 9 - 14). Pasireotide was mostly (67%) discontinued early because of nausea and vomiting. Grade B or C fistula occurred in 28 patients (20%) before versus 51 patients (21%) after pasireotide introduction with an unadjusted Odds Ratio (OR) of 1.09 (95% CI: 0.65 - 1.82) and an adjusted OR of 1.16 (95% CI: 0.64 - 2.09).
Conclusions: The rate of clinical relevant pancreatic fistula did not change after introduction of pasireotide prophylaxis following pancreatoduodenectomy.
PP04-032 Mexican Oncological Reference Hospital Outcomes in Complex Pancreatic Surgery after HPB European Fellowship. First Experience Report
Victor Manuel Correa-Santillan, Mexico

V.M. Correa-Santillan1, E. Sotelo-Anaya2
1HPB-Surgical Oncology, Instituto Jalisciense de Cancerologia-Opd Hospital Civil de Guadalajara 'Fray Antonio Alcalde', Mexico, 2Upper G-I Surgery, OPD Hospital Civil de Guadalajara 'Juan I. Menchaca', Mexico

Pancreatic cancer Is the fourth malignancy related cancer death in Mexico and U.S. surgical R0 resection is the only potencial curative treatment.
After a complete European - Henri Bismuth Institute, France - HPB fellowship, outcomes from 81 patients from 2013 to 2018 with pancreatic cancer and complex pancreatic surgery in a reference Mexican Oncological Hospital are reported.
47% of the procedures were done during the last 2 years, average age was 57y, male gender 56.8%, hospital average stay was 12 days (5-30), surgical time 300 minutes (180-510), bleeding 450 ml (180-2000), pylorus preserving cephalic pancreatoduodenectomy was preferred (54.3 %), pancreato-jejunostomy reconstruction was made in 91.4%. venus vascular resection and reconstruction was performed in 15%. Moderately differenciated pancreatic adenocarcinoma was found in 54.3%. most patients reached R1 resection, but R0 resection margins were found in 20%. General morbidity according to clavien-dindo score was 49.4%, (13.5% IIIa-IVa), delayed gastric emptying was the most common (23.4%) followed by pancreatic fistula in 19.8%. 30 days mortality (Clavien-dindo V) was reported in 6 patients (7.4%).
Complex pancreatic surgery in cancer patients is a high risk procedure, with the aim of improving safety and quality outcomes around the world, hospitals with adequate infrastructure and surgeons with a long and formal training in well recognized educational programs in high volume reference centers are mandatory.
PP04-034 Analyses for Clinical Outcomes of GS and GnP Neoadjuvant Therapies Followed by Surgery for Borderline Resectable Pancreatic Cancer
Shigetsugu Takano, Japan

S. Takano, H. Yoshitomi, K. Furukawa, T. Takayashiki, S. Kuboki, D. Suzuki, N. Sakai, S. Kagawa, M. Ohtsuka
Department of General Surgery, Chiba University, Japan

To improve the prognosis of pancreatic ductal adenocarcinoma (PDAC) patients, curative resection with multidisciplinary therapy is needed. Consecutive 116 patients with borderline resectable (BR) PDAC who undergone pancreatectomy from Jan 2008 to Dec 2018 were analyzed. We assessed the clinical significance of neoadjuvant therapy (NAT), and compared the clinical impact between gemcitabine plus S-1 (GS) and gemcitabine plus nab-paclitaxel (GnP) for neoadjuvant chemotherapy (NAC) in BR PDAC (n=62). Comparing between surgery first (SF: n=45) and NAT (n=71) group, the Kaplan-Meier analysis showed that median survival time (MST) for overall survival were 22.2 months for SF and 29.2 months for NAT (p=0.057). Focusing on the differences of strategy for NAT, we compared the clinical outcomes of patients between GS (n=36) and GnP (n=26). The mean of NAC duration was 3.2 months for GS and 2.8 months for GnP. Among the clinico-pathological parameters, no differences of backgrounds for patients were observed between these two regimens. The response rates for RECIST criteria were 33.3% for GS and 38.5% for GnP. The decrease rate of CA19-9 during NAC were 51.6% for GS and 67.7% for GnP (p=0.07), whereas the rate of N2 positive in GS was significantly lower than that in GnP (p=0.009). The MST for overall survival were 29.2 months for GS and 24.2 months for GnP in BR, notably, 40.0 months for GS and 27.1 months for GnP in BR-A. Randomized prospective studies for the optimal NAC will be warranted for the strategy of treatment for patients with BR PDAC.
PP04-035 Advanced Age Is a Strongly Benefit for Patients Undergoing Laparoscopic Pancreaticodoudenectomy, Comparative Study
Maher Hendi, China

M. Hendi1,2, Y. Mou1, C. Lu1, Y. Pan2, X. Wu3, R. Zhang1, K. Chen2, Y. Zhou1
1Department of Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, China, 2Zhejiang University, School of Medicine, Sir Run Run Shaw Hospital, China, 3Fudan University School of Medicine, Oncology Hospital, China

Background: Past papers have reported that elderly patients undergoing laproscopic pancreatoduodenectomy (LPD) are at an increased risk compared to non-elderly patients. The aim of this paper is to compare a single centre risk of LPD in elderly and non-elderly patients.
Methods: Retrospective review (n = 237) of perisurgical outcomes in patients undergoing LPD during the months of September 2013-December 2017. Outcomes in elderly patients (aged ≥75 years) were compared with those in non-elderly patients.
Results: In elderly patients, transfer to ICU was more frequent (odds ratio [OR] 6.49, P = 0.001) and mean hospital stay was lengthier (21.4 days compared with 16.6 days, P = 0.0033) than for non-elderly patients. There was no statistically significant difference in operation time (P=0.494), estimated blood loss (P=0.0519), blood transfusion (P=0.863), decreased gastric emptying (DGE) (P=0.397), abdominal pain (P=0.454), food intake (P=0.241), time to self ambulation (P=1), reoperation (P=0.543), postoperative pancreatic fistula (POPF) grade A (P=0.454), POPF grade B (P=0.736), POPF grade C (P=0.164), hemorrhage (P=0.319), bile leakage (P=0.428), infection (P=0.259), GI bleeding (P=0.286), morbidity (P=0.272) or mortality (P=0.449) between the two groups.
Conclusions: Rate of ICU admission and hospital stay were both increased in elderly patients undergoing LPD when compared with non-elderly ones. LPD can be performed on elderly patients with similar mortality, morbidity and outcomes to younger patients; therefore age alone should not be a contraindication.
Corresponding Author: Yiping Mou
PP04-036 Comparison between Long and Short-Term Venous Patencies after Pancreatoduodenectomy with Portal/Superior Mesenteric Vein Resection Stratified by Reconstruction Type
Kai Siang Chan, Singapore

K.S. Chan1,2, Y.X. Koh1, E.K. Tan1, J.Y. Teo1,3, S.Y. Lee1,3, C.Y. Chan1,3, A.Y.F. Chung1,3, B.K.P. Goh1,3
1Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 3Duke-National University of Singapore (NUS) Medical School, Singapore

Pancreatic surgery was traditionally contraindicated for tumours adherent to the portal vein (PV) and/or superior mesenteric vein (SMV). Recently, venous resection and/or reconstruction has been demonstrated to be feasible and safe for tumours with invasion into PV and/or SMV. This study aims to compare the patency between various venous reconstructions (VR).
This is retrospective study of 76 consecutive patients who underwent pancreaticoduodenectomy or total pancreatectomy with isolated VR from 2006 to 2018. Demographics, tumour histopathology, morbidity, mortality and patency were studied. Kaplan-Meier estimates were performed for primary venous patency.
Sixty-two patients underwent pancreaticoduodenectomy and 14 underwent total pancreatectomy. Forty-seven, 19 and 10 patients underwent primary repair (PR), end-to-end anastomosis and interposition graft (IG) respectively. Overall morbidity, major morbidity (Clavien-Dindo >grade 2) and 30-day mortality were 41/76(53.9%), 14/76(18.4%) and 1/76(1.3%), respectively. Twelve patients (15.8%) had venous occlusion including 4(5.3%) acute occlusions within 30 days. Overall 6-month, 1-year and 2-year primary patency was 89.1%, 92.5% and 92.3% respectively. 1-year primary patency of PR was superior to end-to-end anastomosis and IG (PR 100%, end-to-end anastomosis 81.8%, IG 66.7%, p=0.045). Pairwise comparison also demonstrated superior 1-year patency of PR (adjusted p=0.037). Kaplan-Meier estimates demonstrated 80% cumulative overall 2-year venous patency. There was no significant difference between the cumulative venous patency for each VR method (Figure 1): 84 ± 6% for PR, 75 ± 11% for end-to-end anastomosis, 76 ± 15% for IG (p=0.561).
Comparison between venous patency by reconstruction type demonstrated superior 1-year primary patency of PR compared to end-to-end anastomosis and IG.
[Figure 1]
PP04-037 Implementation of an ERAS Protocol for Pancreaticoduodenectomy in a Low Volume Center for Pancreatic Surgery
Nelio Ferreira, France

T. Zacharias, N. Ferreira, P. Barsotti, S. Dan, E. Valero
Digestive Surgery, Hôpital Emile Muller, France

Introduction: Enhanced Recovery After Surgery (ERAS) pathways were implemented in the perioperative care after pancreaticoduodenectomy (PD) in high volume centers. Evidence is lacking about the safety of an ERAS pathway for PD in low volume centers.
Aim: To study if the implementation of an ERAS pathway for PD in a low volume center was safe.
Methods: Patients undergoing elective pancreaticoduodenectomy within an ERAS protocol between 1 October 2013 and 30 September 2019 were considered for the study and outcome was compared between the first and second periode of the study. Primary endpoint was the achievement of postoperative key targets of the ERAS protocol. Secondary endpoints were complications and mortality within 90 days postoperatively, readmissions and postoperative hospital stay.
Results: Forty-five patients could be analysed. The two groups were balanced for demographic, clinical and histological variables. In the second periode more patients achieved ERAS key targets: nasogastric tube removal, oral fluids, drain removal and hospital discharge at postoperative day (PoD) 9. The rates of postoperative complications, mortality, reoperations and readmissions were not significantly different between both groups and comparable to data reported for high volume centres.
Conclusion: In the present study an ERAS pathway for pancreaticoduodenectomy was implemented safely in a low volume center for pancreatic surgery.
PP04-038 Drainage Tube Management after Pancreaticoduodenectomy Using Fistulography Findings
Hiroyuki Yamamoto, Japan

H. Yamamoto, K. Tanaka, Y. Nakanishi, T. Asano, T. Noji, T. Nakamura, T. Tsuchikawa, K. Okamura, S. Hirano
Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Japan

Introduction: The management of pancreatic fistula (PF) in pancreaticoduodenectomy (PD) is directly related to postoperative outcomes. The purpose of this study is to report drainage management for PF in our department.
Methods: PD with using the modified Blumgart method was performed in 222 patients at our department from 2013 to 2018. The definition of PF was defined as ISGPS classification in 2016. Two drains were placed beside the pancreaticojejunostomy. D-AMY was measured on postoperative day (POD) 1, 3, and 4. When the D-AMY on POD3 exceeded 1000 U/L, the drain was replaced. Moreover, when the only fistula (defined as fistulous type: FT) was shown in contrast examination (C-Ex), it was removed without exchanging.
Results: As for PF, 69 (31.1%) were biochemical leakage (BL), 38 (17.2%) were CR-POPF. There were 155 patients with D-AMY of 1000 U/L or less on POD 3 and 4. CR-POPF was recognized in 10 patients of them. Of the 55 patients with performing C-Ex, 33 showed CR-POPF as a result. When FT findings was shown in first C-Ex, 14(63.6%) developed BL or no leakage and 6(18.2%) developed CR-POPF (p< 0.01). FT findings are thought to be the sign of early recovery from PF. The sensitivity and specificity of CR-POPF using D-AMY (cut-off 1000 U/L on POD3 and 4) and drain removal with C-Ex findings are 73.7% and 81.0%.
Conclusion: High sensitivity and specificity were achieved by the management strategy for drain removal based on contrast findings.
PP04-039 Improved Outcomes with Minimally Invasive Pancreaticoduodenectomy in Patients with Dilated Pancreatic Ducts: A Prospective Study
Sanket Srinivasa, United States

S. Srinivasa, G. Williams, A. Khan, M. Doyle, W. Chapman, W. Hawkins, S. Strasberg, C. Hammill, D. Sanford
HPB Surgery, Washington University in St Louis, United States

Background: We hypothesized that patients with dilated pancreatic ducts have improved postoperative outcomes with MIPD compared to OPD.
Methods: All patients undergoing pancreaticoduodenectomy between April 2016 and July 2019 were prospectively followed, and perioperative and pathologic variables were compared. Patients with dilated pancreatic ducts (≥3mm) who underwent MIPD (Robotic/ Laparoscopic) were propensity score matched to patients with dilated ducts who underwent OPD and outcomes compared. Likewise, patients with non-dilated pancreatic ducts (< 3mm) were similarly compared. The primary outcome was a composite measure termed the ideal outcome (IO) which required patients to achieve negative margins; experience no complications or readmission and be discharged within seven days.
Results: 312 patients underwent PD- 51 (16.4%) MIPD and 212 (83.7%) OPD. Patients who underwent MIPD had significantly longer operative times, less intraoperative blood loss, and a lower rate of 90-day readmission. Patients with dilated pancreatic ducts who underwent MIPD (n=30) had significantly increased intraoperative times, less intraoperative blood loss, less postoperative bleeding/anemia complications, lower overall complication rate, and were discharged from the hospital 3.5 days faster compared to matched OPD patients (n=90) with dilated ducts. MIPD in patients with dilated pancreatic ducts was independently associated with increased IO (OR= 3.04, p=0.021) (Table 3).
Conclusion: Patients with pancreatic ducts ≥3mm appear to derive the most benefit from MIPD in terms of less complications and shorter hospital stay.
PP04-040 Our Experiences with Pancreatoduodenectomy: Risk Factors and Outcomes Analysis
Indah Jamtani, Indonesia

I. Jamtani, A. Nugroho, R.Y. Saunar, A. Widarso, T. Poniman
Surgery, Fatmawati Central General Hospital, Indonesia

Pancreatoduodenectomy (PD) is the main surgical option for pancreatic neoplasms, duodenal neoplasms and other lesions located in the pancreatic head and periampullary region. Despite the prompt progress in surgical technologies and the persistent innovation of postoperative treatments over the last decades, post‑pancreaticoduodenectomy complications (PPCs) remains high, which may lead to several potential poor outcomes, including prolonged hospital stays, increased medical costs and mortality. The purposes of this study were to analyze all type of PPCs and to identify associated factors related.
Cross-sectional design was used. Patients, who underwent PD in Fatmawati General Hospital Jakarta between January 2017 and December 2018 were retrospectively analyzed.
We classify PPCs for 45 patients who had undergone PD, ten variables were considered significant predictors of serious complications. The predictors included age, sex, obesity, smoking status, the presence of a comorbidity, nutritional status, combined vascular resection, intraoperative blood transfusion, serum albumin and bilirubin laboratory. Clinically, the most relevant postoperative complication of PD is a pancreatic fistula (PF), which is often associated with the development of life-threatening intra-abdominal complications.
Pancreaticoduodenectomy remains the only curative option for patients with a malignant neoplasm. Good preoperative assessment and preparation support reduced the morbidity and mortality rate associated with PD
PP04-041 Reappraisal of Clinical Indication Regarding Total Pancreatectomy: Can We Do It for Risky Gland?
Kwangyeol Paik, Korea, Republic of

K. Paik1, J.C. Chung2
1The Catholic University of Korea College of Medicine, Korea, Republic of, 2Soonchunhyang University Bucheon Hospital, Korea, Republic of

Background: Although Total pancreatectomy (TP) is performed at an increasing rate at major pancreatic centers, there is still debate regarding its indications and outcomes. This study aimed to analyze the indications and outcomes of TP.
Methods: We conducted a retrospective study of 64 patients who underwent TP between January 2011 and December 2019 at two academic hospitals using data collected from an institutional database. The preoperative data, including demographic data and clinical picture, operative details, and postoperative data were collected and analyzed.
Results: During study periods, 70 TP were performed for benign and malignant pancreatic diseases. After excluding six TP undergone due to trauma or complication, 64 consecutive elective TP underwent. Indication of TP were for intraductal papillary mucinous neoplasms (IPMN) (n=14, 21.9%), pancreatic adenocarcinoma (n=40, 62.5%), other neoplasm (n=9, 14.1%), and chronic pancreatitis (n=1, 1.6%). We compared clinical data between conventional indication (n=47, 73.4%) and risky glands (n=17, 26.6%). Risky glands were fatty pancreas (n=5), atrophic remnant (n=5), severe inflammation on remnant (n=4), and small p-duct (n=3). There was no significant difference of clinical data between two groups. Thirty-day major morbidity and mortality was 9.4% and 0%, respectively. With a median follow-up length of 21.5 months, 47 (73.4%) patients were alive at last follow-up. Median HbA1c values at 12 months after surgery were 7.8.
Conclusions: Total pancreatectomy appears to be an appropriate option for selected patients with conventional indication and be a viable option for risky glands in terms of surgical safety.
PP04-042 Survival Analysis after Whipple's Pancreaticoduodenectomy for Adenocarcinoma in a Tertiary Referral Centre in India
Hariharan Ramesh, India

K. Tejaswy1, J. Mathew1, H. Ramesh2
1GI and HPB Surgery, Lakeshore Hospital and Research Centre, India, 2GI and HPB Surgery, Lakeshore Hospital and Research Centre, India

Introduction: Prognosis for Pancreatic Cancer remains poor despite advances in multimodality treatment. This study aims to determine the survival of patients undergoing pancreaticoduodenectomy (PD) for adenocarcinoma and also to compare the survival outcomes between standard PD versus with the addition of total mesopancreatic excision(TMpE).
Methods: Retrospective analysis of prospectively compiled data of patients who underwent PD for adenocarcinoma between 2003 - 2017.
Results: The median disease-free survival (DFS) and overall survival (OS) was 30(20 - 39months) and 39 months(30 - 47 months) respectively(N=239). With the addition of TMpE, median DFS was 45months(26 - 49 months) (p- 0.045) and OS was 48 months(28 - 67 months) (0.109). The difference in DFS was statistically significant while there was a trend towards increased OS, however it was not statistically significant. LN yield also increased significantly after addition of TMpE (p - 0.009). On univariate analysis, margin positivity, higher stage of the disease, presence of positive LN, lymphovascular and perineural invasion decreased OS/DFS significantly. Adjuvant chemotherapy increased DFS/OS. Only 1 patient (N-277) had margin positivity since TMpE. On multivariate analysis adjuvant chemotherapy, LN positivity, perineural invasion and higher stage were significantly associated. Patients with tumours arising from pancreas had worst prognosis (p - 0.006) and with tumours from ampulla had best prognosis. Postoperative mortality was 1.08%(N-3), less than all published series from India.
Conclusion: Our study shows better OS and DFS compared to published literature. Survival improved with the addition of TMpE. Radical surgery remains a cornerstone in the multimodality treatment of pancreatic cancer.
PP04-043 Impact of Artery-First Pancreaticoduodenectomy Including Whole Lymphadenectomy Around Superior Mesenteric Artery But Preserving Whole Nerve Plexus for Resectable T3 Ductal Adenocarcinoma of the Pancreatic Head
Hiroshi Nakano, Japan

S. Kobayashi1, H. Nakano1,2, S. Koizumi1, T. Otsubo1
1Gastroenterological Surgery, St. Marianna University School of Medicine, Japan, 2Surgery, NHO Shizuoka Medical Center, Japan

Introduction: Artery-first pancreatoduodenectomy (AF-PD) has a positive impact on short- and long-term outcome as compared to the conventional PD (C-PD). However, appropriate AF-PD may be still unclear when focusing on extent of lymphadenectomy, or that of nerve plexus dissection around the superior mesenteric artery (SMA).
Methods: We investigated recurrence and survival in 88 patients with pancreatic ductal adenocarcinoma of the head (PDAC-H) who underwent PD. Forty-five patients underwent AF-PD with the lymphadenectomy around the SMA but without nerve plexus dissection around SMA (AF-PD group), and forty-three patients underwent PD without artery-first approach, i.e., without left side lymphadenectomy at the SMA (C-PD group).
Results: The median amounts of blood loss were significantly lower in the AF-PD group than in the C-PD group (P=0.0210). The numbers of totally dissected lymph nodes were significantly greater in the AF-PD group than in the C-PD group (P=0.0165). The incidence of recurrence rate of the lymph node (LN) around SMA (No. 14 LN) was significantly lower in the AF-PD group (20%) than in the C-PD group (39.5%, p=0.045). The median survival after PD was significantly higher in the AF-PD group (40.3 months) than in the C-PD group (22.6 months, p=0.014).
Conclusions: The present data showed that PD based on artery-first approach and lymphadenectomy whole around SMA but preserving whole nerve plexus in patients with T3 PDAC-H may prevent LN recurrence around the SMA and may result in longer survival.
PP04-044 Pancreas-Preserving Total Duodenectomy: A Systematic Review
Mario Serradilla-Martín, Spain

M. Serradilla-Martín1, M. Cantalejo-Díaz1, J.M. Ramia-Ángel2, A. Palomares-Cano1, A. Serrablo-Requejo1
1Department of Surgery, Miguel Servet University Hospital, Spain, 2Department of Surgery, Guadalajara University Hospital, Spain

Introduction: The management of the pancreas in patients with duodenal trauma or duodenal tumors remains a controversial issue. Pancreas-preserving total duodenectomy is a procedure that requires a meticulous surgical technique as well as a thorough and detailed knowledge of peripancreatic anatomy. The most common indication is familial duodenal adenomatous polyposis.
The aims of this study are to carry out a systematic review of the literature on the indications for pancreas-preserving total duodenectomy, to highlight the risks and benefits, and to demonstrate the significant reduction in mortality compared with other aggressive surgical techniques.
Methods: Regulated systematic literature review following PRISMA recommendations of all studies published in PubMed, Embase, and Cochrane library with no limits on year of initial publication until 31 May 2019. A total of 30 articles describing 211 patients that met the inclusion criteria were chosen.
Results: The mean age was 48 years. Seventy-five per cent of patients presented an initial surgical indication of familial adenomatous polyposis (98% Spigelman stages III-IV). The mean operating time was 329 minutes, and mean intraoperative bleeding 412 ml. Postoperative morbidity rate was 49.7% (76% with Clavien-Dindo < IIIa) and mortality rate 1.4%. The mean hospital stay was 22 days. Overall survival at 1-3-5 years was > 97.8%.
Conclusions: Pancreas-preserving total duodenectomy is indicated for patients with benign and premalignant duodenal lesions without involvement of the pancreatic head. It is a safe and feasible procedure that reduces risks and increases peri-operative benefits compared to other aggressive surgical techniques. Mortality is below 1.5%.
PP04-045 Decreased National Pancreatic Fistula Rates with Minimally Invasive Pancreaticoduodenectomy: An Evolving Benefit over the Open Approach?
Jorge Zarate Rodriguez, United States

J. Zarate Rodriguez, J. Guerra, R. Panni, W. Hawkins, C. Hammill, D. Sanford
Department of Surgery, Washington University School of Medicine, United States

Introduction: We hypothesized that national minimally invasive pancreaticoduodenectomy (MIPD) outcomes would improve over time to show a benefit over open pancreaticoduodenectomy (OPD), and that the rates of clinically relevant postoperative pancreatic fistula (CR-PF) would decrease.
Methods: All patients in the NSQIP database undergoing MIPD or OPD between 2014 and 2017 were included in the study. Patient variables, outcomes, and rates of CR-PF were compared between each year. Patients were stratified into two eras (2014-2015 and 2016-2017), MIPD patients were propensity score matched to OPD patients (1:3) and their outcomes compared within each era.
Results: 13,373 patients underwent pancreaticoduodenectomy between 2014-2017: 12,303 (92.0%) OPD and 1,070 MIPD (8.0%). When comparing CR-PF rates in each year, CR-PF rates went from being significantly higher after MIPD in 2014 (18.7% vs 13.5%, p= 0.050) to being significantly lower in 2017 (8.6% vs 13.8%, p=0.009) (Figure). After 1:3 propensity score matching MIPD patients (n=440) to OPD patients (n=1320) in era 1, MIPD was associated with a significantly increased rate of 30-day readmission (20.5% vs 14.8%, p=0.005). In era 2, MIPD (n=630) was associated with significantly decreased rates of CR-PF (9.8% vs 14.8%, p=0.002), organ space infection (12.4% vs 16.9%, p=0.007), sepsis (5.7% vs 8.9%, p=0.011), and myocardial infarction (0.2% vs 1.0%, p=0.046) along with a significantly decreased length of stay (9.7 vs 10.7 days, p=0.013) compared to OPD (n=1890).
Conclusion: National MIPD outcomes in the NSQIP database have significantly improved over time, and MIPD has significant perioperative benefits over OPD in recent years.

PP04-046 Investigation of Predictive Factors of Early Recurrence after Pancreatectomy for a Pancreas Cancer
Shoji Kanno, Japan

S. Kanno, H. Nitta, T. Takahara, Y. Hasegawa, H. Katagiri, A. Umemura, T. Ando, T. Kimura, A. Sasaki
Iwate Medical University, Japan

Postoperative early recurrence is a frequently observed serious problem, even after a macroscopically curative resection in patients with pancreatic adenocarcinoma. The effect of adjuvant chemotherapy may be limited in these patients.
A dismal prognosis after early recurrence indicates the limitation of upfront surgery and adjuvant chemotherapy strategy, and alternative strategy, such as neoadjuvant chemotherapy may be suitable for them.
In this study, we retrospectively investigated predictive factors of early recurrence in 176 patients who underwent pancreatectomy for invasive ductal carcinoma of the pancreas in our institution from 2011-2020. Early recurrence was defined as recurrence within 6 months after the operation.
In the multivariate analysis, BMI < 19 and preoperative CA19-9 level > 100 U/ml and, PV invasion and lymph node metastasis in preoperative CT and tumor size > 35 mm were the independent predictive factors of postoperative early recurrence.
The patients with BMI < 19 and preoperative CA19-9 level > 100 U/ml and, PV invasion and lymph node metastasis in preoperative CT and tumor size > 35 mm may be good candidates for neoadjuvant chemotherapy.
PP04-047 Clinical Significance of Carcinoma in Situ at Pancreatic Cut Margin During Pancreatectomy for Pancreatic Cancer
Takahiro Mizui, Japan

T. Mizui, S. Nara, M. Esaki, T. Takamoto, K. Shimada
Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Japan

Introduction: During pancreatectomy for pancreatic ductal adenocarcinoma (PDAC), additional pancreatic resection is generally performed when pancreatic cut margin (PCM) is cancer positive by intra-operative frozen section analysis. However, the clinical significance of carcinoma in situ (CIS) at a pancreatic cut margin has not been established.
Methods: We retrospectively reviewed the records of 792 consecutive patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for PDAC at our hospital from 2000 to 2018. Patients who underwent R2 resection, received preoperative chemotherapy, or died in-hospital were excluded. Based on the final pathologic diagnosis of PCM, patients were divided into the following four groups: Group A, initial PCM negative for cancer; Group B, initial PCM positive for cancer (CIS: Group B-1, invasive cancer: Group B-2), but negative after additional pancreatic resection; Group C, final PCM positive for CIS; and Group D, final PCM positive for invasive cancer. The prognoses of the four groups were compared.
Results: Groups A, B-1, B-2, C, and D consisted of 574, 43, 105, 33, and 37 patients, respectively, with median survival times of 22.7, 26.9, 23.2, 23.8, and 11.9 months, respectively. Overall survival rates of Groups B-1, B-2, and C were not significant differences compared with that of Group A. However overall survival rate of Group D was significantly worse than that of Group A (P=0.021).
Conclusion: Additional pancreatic resection for invasive cancer positive cut margin may improve postoperative survival. However, the presence of CIS at pancreatic cut margin may not always warrant further resection.
PP04-048 Retrospective Study about Seven Cases of Total Remnant Pancreatectomy for Remnant Pancreatic Cancer
Eiki Miyake, Japan

E. Miyake, T. Kojima, T. Niguma, T. Fuji, T. Mimura
Department of Surgery, Okayama Saiseikai General Hospital, Japan

Introduction: There are few reports about the cases of remnant pancreatic cancer after surgery for pancreatic malignancy. However, in recent years, opportunities for total remnant pancreatectomy have increased with the progress of surgery, perioperative management and chemotherapy. We investigated the cases of remnant pancreatectomy in our institute.
Methods: 292 patients underwent pancreatectomy for pancreatic malignancy from May 2007 to December 2019 in our institute. There were seven patients who underwent remnant pancreatectomy for remnant pancreatic cancer. These seven cases were retrospectively analyzed.
Results: The depth of invasion was T1 in 1 case, T3 in 6 cases. Lymph node metastasis was observed in 3 cases. The stage was ⅠA in 1 case, ⅡA in 3 cases and ⅡB in 3 cases. Total remnant pancreatectomy was performed after distal pancreatectomy in 2 cases, and after pancreaticoduodenectomy in 5 cases. Three cases were histologically proven as recurrent pancreatic cancer. On the other hand, four cases had different histological findings. Therefore, these four cases were considered as metachronous pancreatic cancer. The mean disease free survival of recurrent group and metachronous group were 31 months and 62.5 months, respectively. Mean survival time after the first operation of recurrent group and metachronous group were 57 months and 84 months. No significant difference was observed, but it was longer in metachronous cases. Both recurrent and metachronous groups had one case who survived over 3 years each.
Conclusion: Cases of metachronous pancreatic cancer had a longer time to recurrence. Some cases may obtaine long term survival by total remnant pancreatectomy.
PP04-049 Preoperative Biliary Stenting Versus Unstented Pancreaticoduodenectomy (Whipple's Procedure) - A Comparative Study of Early Outcomes
Meghana Taggarsi, United Kingdom

M. Taggarsi1, P. Fardoom1, O. Vaz1, J. Lambert1, R. Dawson1, D. Subar1, L. Vitone2, A. Sultana1
1Department of General Surgery and HPB, East Lancashire NHS Foundation Trust, Royal Blackburn Hospital, United Kingdom, 2Department of General Surgery and Colorectal Surgery, East Lancashire NHS Foundation Trust, Royal Blackburn Hospital, United Kingdom

Introduction: Routine preoperative biliary drainage prior to a Whipple's procedure is still common in the UK. Recent NICE guidelines (2018) recommend proceeding to unstented surgery in suitable patients. There is level 1 evidence that demonstrates preoperative biliary stenting increases post-operative complications as opposed to early surgery. The study was done to review a single centre experience of early outcomes following stented versus unstented Whipple's procedure.
Methods: This is a retrospective review of a prospectively maintained database. 104 patients who underwent a Whipple procedure in 3 years were included. 46 patients underwent preoperative stenting and 58 had Whipple's without stenting. The primary outcomes were rates of pancreatic fistula, bleeding, intra-abdominal collection and wound infections within 90 days post-surgery. The analysis was done using descriptive statistics and non-parametric tests. A two sided significance of p value < 0.05 was considered, with 95% confidence intervals.
Results: In Whipple's with preoperative biliary stenting - postoperative pancreatic fistula was seen in 19.56% of patients, bleeding in 10.86%, intra-abdominal collections in 19.56% while wound infection was noted in 26.08%. In the unstented group 27.58% had pancreatic fistula, 24.13% had collections and 5.175% had wound infection. In our study, patients with unstented Whipple's had similar outcomes (albeit not statistically significant) to stented Whipple's, except the rate of wound infection, which was more in stented (p value -0.004).
Conclusion: Unstented Whipple's has the potential of shortening the patient pathway and time to definitive treatment. Hence, we advocate increasing adoption of the surgery first approach in suitable patients.
OutcomesUnstented (n=58)Stented (n=46)p Value
POPF16 (27.58%)9 (19.56%)0.342
Bleeding3 (5.1755%)5 (10.86%)0.461
Intra-abdominal collection14 (24.13%)9 (19.56%)0.545
Wound infection3 (5.175%)12 (26.08%)0.004
Delayed gastric emptying8 (13.8%)6 (13.04%)0.911
Re-exploration3 (5.175%)5 (10.8%)0.461
Readmissions1 (1.7%)2 (4.34%)0.582
Death within 90 days5 (8.6%)3 (6.52%)0.611
Death within 30 days2 (3.4%)2 (4.34%)0.612
[Analysis of outcomes - primary and secondary.]
PP04-050 Surgical Therapy for Patients with Chronic and Recurrent Acute Pancreatitis: Parenchymal Preserving or Total Pancreatectomy with Autologous Islet Cell Transplant
Chirag Desai, United States

C.S. Desai, B.M. Williams, X. Baldwin, J.S. Vonderau, M. Hanson, T.W. James, T.H. Baron
University of North Carolina, United States

Introduction: Surgeons are often biased for choosing either the parenchymal preserving surgery (PPS) or the total pancreatectomy with autologous islet cell transplant (TPAIT) for chronic or recurrent pancreatitis (CP), depending on their personal beliefs and the availability of the islet isolation facilities. Aim is to evaluate the outcomes of both PPS and TPAIT at a single center having capacity to offer both surgeries.
Methods: 152 patients with CP were evaluated between September 2017 to 2019; 32 were offered surgery based on the algorithm in Figure 1. Each surgery was performed by a single surgeon, alleviating potential bias due to surgeon preference or technical expertise. Quality of life (QOL), glycemic control, and reduction in narcotic use was evaluated in each patient. Outcomes were compared using Pearson's c2 test, student's t-test, and Kruskal-Wallis rank test.
Results: Post-operatively 100% of TPAIT patients and 93.3% of PPS patients reported great improvement in QOL by 3 months (p=0.3). At 2 months only 7 (63.6%) of TPAIT and 6 (60.0%) of PPS patients required narcotics. All PPS patients weaned off narcotics by 3 months; however, 1 TPAIT patient continued to require narcotics at 1 year. Endocrine variables are shown in Table 1. 4 (28.6%) of TPAIT patients completely insulin independent. No hypoglycemic morbidity-mortality occurred.
Conclusion: While TPAIT patients may have insulin requirement post-operatively, overall outcomes are comparable. In patients with non-localized disease, advantages of TPAIT in terms of preventing pain, pancreatic cancer and avoiding hypoglycemic complication cannot be overlooked when compared with PPS surgery.
All patients Insulin dependent, n (%)   
At 3 months9 (75.0)2 (33.3)0.09
At 1 year4 (100)2 (66.7)0.2
Pre-operatively diabetic/pre-diabetic insulin dependent, n (%)   
At 3 months6 (100)2 (66.7)0.1
At 1 year2 (100)2 (66.7)0.8
Pre-operatively non-diabetic insulin dependent, n (%)   
At 3 months3 (50.0)0 (0)0.1
At 1 year2 (100)NRNA
[Table 1. Endocrine outcomes following TPAIT vs. PPS]

[Algorithm for selection of surgical therapy for patients with chronic pancreatitis]
PP04-051 Robotic Pancreatectomy is Safe and Feasible: An Initial Australian Experience
Bartholomew McKay, Australia

B. McKay1, L. Webber1, R. Bryant1, D. Cavallucci1,2, N. O'Rourke1,2
1Royal Brisbane Hospital, Australia, 2The Wesley Hospital, Australia

Introduction: Pancreatic resections remain highly morbid despite advances in techniques and systemic changes such as centralisation. The technical advantages of robotic resection over laparoscopic and open approaches include stable 3D vision, wide range angulation of instruments, elimination of tremor and proficient intra-corporeal knot tying. Robotics also carries inherent risk as a new technology and as such the safety and efficacy of robotic pancreatectomy is still being investigated.
Methods: All patients undergoing robotic pancreatectomy at The Wesley Hospital and Royal Brisbane Hospital (Queensland, Australia) between May 2014 - December 2019 were analysed. Ethics board approval was obtained for the study.
Results: Fifty-one patients underwent robotic pancreatectomy during the study period. There were 25 pancreaticoduodenectomy, 13 distal pancreatectomy with splenectomy, 10 spleen-preserving distal pancreatectomy and 3 enucleations performed. Three unplanned conversions to open occurred (6%) whilst 5 patients had hybrid procedures for vein resections all during pancreaticoduodenectomy. Twenty-three cases were undertaken for malignant pathology with 29% of these cases having R1 (< 1mm) resection margins. Major morbidity (Clavien-Dindo grade 3b or greater) was observed in 10 patients (20%) with 7 cases (14%) of post-operative pancreatic fistula grade B/C. There were two in-hospital mortalities secondary to pulmonary embolus and fulminant hepatic failure, respectively.
Conclusion: Based on this initial Australian experience robotic pancreatectomy is safe and feasible with comparable complication rates to that described in the literature for open and laparoscopic procedures.
PP04-052 Glycemic Outcomes of Parenchymal Preserving Surgery Compared to Total Pancreatectomy with Autologous Islet Cell Transplant when Stratified by Pre-Operative Type 3 Diabetic Status
Jennifer S. Vonderau, United States

B.M. Williams, J.S. Vonderau, X. Baldwin, M. Hanson, C.S. Desai
University of North Carolina, United States

Introduction: Surgery for chronic pancreatitis (CP) can result in type 3c diabetes with severe hypoglycemic events (SHE) and hypoglycemic unawareness (HU). The aim of this study is to compare glycemic outcomes between total pancreatectomy and autologous islet cell transplant (TPAIT) and parenchymal preserving surgery (PPS).
Methods: All patients undergoing CP surgery at a single center from 2017-2019 were included. Glycemic outcomes were compared between 2 groups: (1) TPAIT and (2) PPS and stratified between pre-operatively diabetic/pre-diabetic (DM) and non-diabetic (NDM).
Results: 32 patients underwent surgery, 14 (43.8%) TPAIT and 18 (56.2%) PPS. In Group 1, 6 (42.9%) patients had DM pre-operatively. Following TPAIT, 9 (64.3%) patients were insulin dependent at discharge (6 [100%] DM vs. 3 [37.5%] NDM, p = 0.02). In Group 2, 12 (66.7%) had DM pre-operatively, 2 (16.7%) insulin dependent. While 4 (33.3%) in Group 2 required insulin at discharge, 2 had weaned off by 3-month follow up. Between TPAIT and PPS, there was a significant difference in number of patients requiring insulin in the immediate post-operative period (64.3% vs. 22.2%, p =0.02). However, by 3 months there was no significant difference when stratified by pre-operative DM status. No patient in either group experienced SHE or HU.
Conclusion: While more patients required insulin following TPAIT than PPS, when stratified by pre-operative diabetic status, there was no statistical difference in glycemic outcomes over time. Therefore, apprehension regarding type 3c diabetes should not be a hinderance to choosing TPAIT in patients with diffuse pancreatic disease.
 Total (n= 32)Non-diabetic TPAIT (n= 8)Non-diabetic PPS (n=6)p ValueDM/Pre-DM TPAIT (n= 6)DM/Pre-DM PPS (n=12p Value
Pre- operatively, n (%)3 (9.4%)0 (0)0 (0)NA1 (16.7%)2 (16.7%)1.00
At Discharge, n (%)13 (40.6%)3 (37.5%)0 (0)0.096 (100%)4 (33.3%)0.007
At 1 month, n (%)13 (56.5%)4 (80.0%)0 (0)0.026 (100%)3 (37.5%)0.02
At 3 months, n (%)11 (61.1%)3 (50.0%)0 (0)0.16 (100)2 (66.7)0.1
[Table 1. Number of patients requiring insulin when stratified by pre-operative type 3 diabetic status]
PP04-054 A High Incidence of Nonalcoholic Fatty Liver Disease (NAFLD) after Pancreaticoduodenectomy and the Associated Risk Factors
Asara Thepbunchonchai, Thailand

C. Chamnan1, T. Ruengsawang2, A. Thepbunchonchai1,3, W. Inthasotti1,3, K. Chaiyabutr1,3, S. Subwongcharoen1,3, S.-A. Treepongkaruna1,3
1Surgery, Rajavithi Hospital, Thailand, 2Radiology, Rajavithi Hospital, Thailand, 3Surgery, Rangsit University, Thailand

Introduction: The purposes of this study were to determine the incidence of NAFLD after pancreaticoduodenectomy and search for the risk factors for this complication.
Methods: Two hundred and eighty-four patients who had undergone pancreaticoduodenectomy in Rajavithi Hospital between October 2006 and June 2016 were studied retrospectively. Forty-one patients with preoperative fatty liver, chronic viral hepatitis type B or C, heavy alcohol consumption, loss to follow up during postoperative period, and unavailable postoperative CT scan were excluded. Approximately one year after the operation, an average CT attenuation values in four hepatic segments (segment II, IVa, VIII, and VII) and one splenic area were measured to reach the diagnosis of NAFLD (liver-to-spleen ratio < 0.9). All data of the patients were collected for analysis.
Results: A total of 243 patients were studied, including 118 males and 125 females, with a mean age of 57 years. NAFLD occurred in 42% (n=102) of patients. Multivariate analysis showed that female sex (odds ratio [OR]=2.151, P=0.013), resection of portal vein (OR=2.596, P=0.027), postoperative complications defined by Clavien-Dindo Classification (OR=2.162, P=0.022), postoperative pancreatic fistula (OR=2.812, P=0.041), eating intolerance at 14 days after operation (OR=2.861, P=0.004), and adjuvant radiotherapy (OR=3.156, P=0.035) were associated risk factors for NAFLD.
Conclusion: A high incidence of NAFLD after pancreaticoduodenectomy and many risk factors as the outcomes of this study give consideration to search for the pathogenesis, subsequent morbidity, and interventions to prevent this complication in the future.
PP04-055 The Relationship Between Postoperative Muscle Mass Loss Rate and Nutritional Status after Pancreatectomy
Takeru Maekawa, Japan

T. Maekawa, H. Maehira, H. Iida, H. Mori, D. Yasukawa, N. Nitta, M. Tani
Department of Surgery, Shiga University of Medical Science, Japan

Introduction: To investigated whether perioperative muscle mass loss rates affected postoperative nutritional status after pancreatectomy or not.
Method: This study enrolled 164 patients with pancreatectomy between January 2011 and October 2018. Skeletal muscle area was measured at the height of the third lumbar vertebra before and six months after surgery using an axial view of non-enhanced CT. We examined the relationship between perioperative muscle mass loss rate and postoperative nutritional status.
Result: The median perioperative muscle mass loss rate was 9.4%. We classified patients into high and low loss rate groups by median value. In the high loss rate group, ALB (3.6g/dL vs 4.0g/dL, p< 0.001), CHE (197U/L vs 248U/L, p< 0.001), prognostic nutritional index (PNI) (41.2 vs 46.1, p=0.002), and CT value of the liver (53.2HU vs 56.4HU, p=0.033) were lower and intramuscular adipose tissue content (IMAC) was higher (0.527 vs 0.432, P< 0.001) at six months after surgery. In the high loss rate group of pancreaticoduodenectomy (PD), ALB (3.5g/dL vs 3.9g/dL, p< 0.001), CHE (198U/L vs 232U/L, p=0.010), PNI (41.2 vs 46.1, p=0.002), and CT value of the liver (53.2HU vs 56.4HU, p=0.033) were lower than the low loss rate group. As to distal pancreatectomy cases, only CHE (204 vs 293, p=0.005) was lower. In regard to total pancreatectomy, there were no significant differences in nutritional status.
Conclusion: The nutritional status at six months after pancreatectomy was associated with perioperative muscle mass loss. However, the influence on nutritional status was different according to the operation methods.
PP04-057 Management of Postoperative Drainage after Pancreaticoduodenectomy: Review from the Location of Perianastomotic Fluid Collection during the Early Postoperative Period
Hiromitsu Maehira, Japan

H. Maehira, H. Iida, H. Mori, D. Yasukawa, N. Nitta, T. Maekawa, M. Tani
Department of Surgery, Shiga University of Medical Science, Japan

Introduction: To assess the association between perianastomotic fluid collection (PFC) during the early postoperative period and postoperative pancreatic fistula (POPF) related complications, and to investigate the optical drain location.
Methods: Medical records of 148 patients who had undergone PD and computed tomography (CT) on postoperative day 4 were retrospectively reviewed. The location—superior, inferior, ventral, dorsal, or splenic hilum—and volume of PFC were determined using CT. Postoperative complications were compared between the PFC and non-PFC groups. Association between volume and postoperative complications was assessed.
Results: The PFC group included 102 patients (69%). POPF and organ/space surgical site infection (SSI) were more frequent in the PFC group (p < 0.001 and p=0.020, respectively). According to the location of PFC, superior and ventral PFCs were associated with pseudoaneurysm (p=0.006 and p=0.002, respectively), while inferior and dorsal PFCs were associated with deep incisional SSI (p=0.027 and p=0.034, respectively). In 5 of 9 patients with inferior PFC and deep incisional SSI, the PFC had reached the abdominal wall via the surface of the transverse mesocolon. All of these patients showed a dorsal PFC connected to the inferior PFC on CT performed on POD 4. Therefore, we added drainage tube at the inferior part of PJ for soft pancreas cases after January 2019. We encountered clinically relevant POPF in 3 cases of 10 soft pancreas cases, however we did not experience deep incisional SSI.
Conclusion: The prevention of PFC during the early postoperative period may prevent more severe POPF related complications.
PP04-058 Factors Impacting Survival Outcomes after Curative Resection for Primary Duodenal Adenocarcinoma
Masayuki Urabe, Japan

M. Urabe, J. Shindoh, Y. Kobayashi, S. Okubo, S. Haruta, M. Ueno, M. Hashimoto
Department of Gastroenterological Surgery, Toranomon Hospital, Japan

Introduction: Primary duodenal adenocarcinoma (PDA) is a rare gastrointestinal tumor and factors predicting survival outcomes after curative resection have yet to be fully elucidated.
Method: Applying the Cox proportional hazard model in univariate and multivariate analyses, we retrospectively evaluated associations between overall/relapse-free survivals (OS/RFS) and 18 clinicopathological factors in 33 patients who had undergone R0 resection for PDA.
Results: Univariate analysis revealed worsening RFS to be significantly related to pancreatic invasion, multiple nodal metastases, and the preoperative serum carcinoembryonic antigen level. Pancreatic invasion and multiple nodal metastases were also found to be significantly associated with poorer OS in the univariate analysis. In multivariate analysis, only pancreatic invasion was an independent predictor of OS (hazard ratio [HR] 5.27, 95% confidence interval [CI] 1.15-24.2, P = 0.033). As to RFS, both pancreatic invasion and multiple nodal metastases correlated independently with unfavorable outcomes (HR 42.8, 95% CI 3.59-510, P = 0.003; HR 216, 95% CI 6.86-6.8×103, P = 0.002; respectively). Only one of the 19 patients with PDA limited to the mucosal/submucosal layer developed recurrent disease (local site), while seven patients with pancreatic invasion and/or multiple nodal metastases all experienced metachronous distant recurrence.
Conclusion: In PDA within the mucosa/submucosa, the likelihood of progression to systemic disease after meticulous surgical removal is very low. On the other hand, patients with PDA invading the pancreas and/or metastasizing to multiple lymph nodes are at high risk of developing distant relapse and may benefit from additional systemic therapy.
[Univariate and multivariate Cox regression analyses for overall and relapse-free survival]
PP04-059 Comparison of Longterm Exocrine and Endocrine Function Following Duct to Mucosa versus Dunking Pancreaticojejunostomy in Pancreaticoduodenectomy
Ramesh Rajan, India

R. Rajan, F. Kollanatavalappil, S. Radha Sadasivan Nair, B. Natesh, K. Bairoliya
Surgical Gastroenterology, Trivandrum Medical College, India

Aim: Though survival following Pancreaticoduodenectomy (PD) has improved, long term impairment of exocrine and endocrine function remains problematic. This study aims at evaluating any difference in long term pancreatic function between those who underwent Duct to Mucosa Vs. Dunking PJ (pancreaticojejunostomy) following PD.
Methodology: Patients who underwent PD between the year 2010-18 and were disease free on follow up were evaluated. Patients with chronic pancreatitis were excluded. All survivors beyond 18 months were evaluated for their pancreatic exocrine (Fecal Elastase-1) and endocrine (FBS/PPBS; HbA1c) function as per the Departmental protocol. The risk of developing nutritional impairment was assessed using the Mini Nutritional Assessment (MNA®) tool and by Serum albumin and Hemoglobin.
Results: 136 patients satisfied the inclusion criteria. 30 day mortality was 5, 26 had expired and 53 were lost to follow up. Of the remaining 52 who were evaluated, 32 had dunking PJ, 20 had duct to mucosa PJ. Exocrine insufficiency was present in 29/32(90.6%) of dunking PJ and 17/20(85%) of duct to mucosa PJ (P = 0.24). 11(34.4%) & 4 (20%) had endocrine insufficiency in dunking and duct to mucosa groups respectively (P=0.21). Endocrine insufficiency was significantly higher in adjuvant chemoradiotherapy group (P=0.04). The relative risk of developing nutritional impairment in presence of severe pancreatic exocrine insufficiency was 2.68.
Conclusion: Exocrine and Endocrine dysfunction post PD can occur irrespective of the type of pancreatic anastomosis and is comparable between the two groups. There appears to be a significant risk of nutritional impairment post PD.
PP04-060 Preoperative Biliary Drainage: Blessing or Curse for Patients Undergoing Pancreaticoduodenectomy?
Saleema Begum, Pakistan

S. Begum1, S.I. Kabir1, A.A. Syed2, K. Amjad2
1HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Pakistan, 2Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital, Pakistan

Background: Preoperative biliary drainage by means of endoscopic biliary stenting is thought to improve outcomes by re-establishing enterohepatic circulation prior to pancreaticoduodenectomy. However, recent evidence suggests that it may be associated with increased postoperative infective complications.
Objective: The objective of this study was to evaluate the relationship between preoperative biliary stenting and postoperative infectious complications. We also investigated the correlation of intraoperative bile bacteriology to postoperative bacterial culture from wound infection or deeper collection.
Material and methods: All patients who underwent Pancreaticoduodenectomy at Shaukat Khanum Memorial Cancer Hospital and Research Centre from January 2014 to December 2018 were included in the study.
Results: Out of 161 patients, 119 (74%) patients underwent pre-operative endoscopic biliary stenting before pancreatoduodenectomy. The overall morbidity rate was 65% and 30-day mortality was 3%. Intra-operative bile cultures were positive in 67% patients of which 37% patients had polymicrobial growth. The most common organism isolated was e-coli (35%). Bile and wound cultures had similar microbial growth in 21% patients.
On comparison, bile cultures were positive in 78% of stented patients versus 33.33% in the group with no stents (p= 0.000). We found significantly higher rates of both superficial surgical site and deep incisional infections in the stented group (p=0.012, p=0.045). There was no statistical difference in the overall complications and mortality rates amongst the two groups.
Conclusion: Preoperative ERCP and stent placement is a risk factor for infective complications following pancreaticoduodenectomy.
PP04-061 Is Age Just a Number or a Serious Consideration for Outcomes after Pancreaticoduodenectomy in a Developing Country?
Saleema Begum, Pakistan

S. Begum1, S.I. Kabir1, A.A. Syed2, A. Jamal2
1HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Pakistan, 2Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital, Pakistan

Background: The effect of age on outcomes after pancreaticoduodenectomy has been reported inconsistently. The objective of our study was to review the impact of age on perioperative and oncological outcomes in patients following pancreaticoduodenectomy.
Methods: All patients who underwent pancreaticoduodenectomy from January 2014 to December 2018 at Shaukat Khanum Memorial Cancer Hospital and Research Center were reviewed. Postoperative morbidity and oncological outcomes were compared between patients with age ≤ 60 years (Group A) and age > 60 years (Group B).
Results: A total of 161 patients underwent pancreaticoduodenectomy during the study period including 117 (73%) in group A and 44 (27%) in group B. Mean age was 46±11 years in group A and 67±5 years in group B. Most common pathology was adenocarcinoma (81%), commonest site was periampullary (53%) and most common pancreatic reconstruction technique was pancreaticogastrostomy (68%).
Patients in group B had significantly higher comorbidities including hypertension (p=0.00) and ischemic heart disease (p=0.030). There was no significant difference in morbidity (p=0.856), reoperation (p= 1.000) and 30-day readmission rate (p=0.097) betweenthe two groups. Similarly, there was no difference in disease free survival (p=0.957) and overall survival (p=0.070) in both groups. On multivariate analysis, soft pancreas (p=0.00) and non-dilated pancreatic duct (p=0.00) were associated with postoperative complications while ECOG performance status and ASA score did not show significant association.
Conclusion: Pancreaticoduodenectomy can be performed in elderly patients with comparable morbidity and oncological outcomes as younger patients. Comorbid conditions remain higher in elderly patients and preoperative optimization can prevent worse postoperative outcomes.
PP04-063 Impact of Preoperative Nutritional Support on Patients with Skeletal Muscle Loss Undergoing Pancreatoduodenectomy
Mariko Tsukagoshi, Japan

M. Tsukagoshi, N. Harimoto, K. Araki, N. Kubo, A. Watanabe, T. Igarashi, N. Ishii, K. Shirabe
Division of Hepatobiliary and Pancreatic Surgery, Integrative Center of General Surgery, Gunma University Hospital, Japan

Introduction: Sarcopenia is closely associated with morbidity after pancreatic surgery. However, little is known about the value of preoperative therapy in the management of sarcopenia. Hence, we investigated the impact of preoperative nutritional support on patients with skeletal muscle (SM) loss undergoing pancreatoduodenectomy.
Methods: A retrospective analysis of 101 patients who underwent pancreatoduodenectomy was performed. SM loss was defined using the SM index (cut-off level: 42 cm2/m2 in men and 38 cm2/m2 in women). Preoperative nutritional support, including branched-chain amino acids (BCAAs), was administered in 33 patients. The neutrophil-to-lymphocyte ratio (NLR), Prognostic Nutritional Index (PNI), and modified Glasgow Prognostic Score (mGPS) values were calculated during the first visit and just before surgery.
Results: SM loss was present in 65 of 101 patients (64%) and was significantly correlated with female sex, older age, lower body mass index (BMI), and low PNI. Preoperative nutritional support prevented the decrease in the albumin levels and in the PNI values for the patients with SM loss. The NLR significantly improved in the patients with SM loss who received nutritional support. In the patients with SM loss, the lack of nutritional support was an independent risk factor for postoperative pancreatic fistula.
Conclusion: Decreased incidence of pancreatic fistula could be achieved through preoperative nutritional support for patients with SM loss undergoing pancreatoduodenectomy. The assessment for SM loss and the administration of nutritional support may improve the surgical outcomes of pancreatoduodenectomy.
PP04-065 Synchronous Portal or Superior Mesenteric Vein Resection During Pancreatectomy for Pancreatic Ductal Adenocarcinoma: A Single Center Study
Dong Xu, China

D. Xu, Z. Lu, K. Zhang, K. Jiang, Y. Miao
The First Affiliated Hospital of Nanjing Medical University, China

Background: Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis without surgery. Selected patients with portal or superior mesenteric vein (PV/SMV) infiltration undergo venous resection. The present study aimed to compare the perioperative factors and survival outcomes for pancreatic resection with/without PV/SMV resection in patients with PDAC.
Methods: A total of 108 patients requiring pancreatectomy combined with PV/SMV resection for PDAC between 1/2009 and 12/2017 were included in this retrospective analysis. 216 of 798 resected PDAC patients without PV/SMV resection during the same period were matched to control group by TNM stage, preoperative CA19-9, tumor differentiation, adjuvant chemotherapy and year of operation.
Results: Patients undergoing PV/SMV resection had an increased risk of intraoperative blood loss (400.0 vs. 275.0 ml; P< 0.001), reoperation (1.9% vs. 0%; P=0.045) and 30-day mortality (1.9% vs. 0%; P=0.045) compared with those undergoing standard surgery. A trend toward worse survival in PV/SMV resection was observed from median survival time (13.3 vs 18.3 mo.; P=0.092), although the study was not powered to detect a difference. In PV/SMV resection group, there was a significant difference between tumor axis < 3cm and ≥3cm in terms of median survival time (21.7 vs. 10.8 mo.; P=0.002) while length of PV/SMV resection showed no relation to survival.
Conclusion: PV/SMV resection was associated with increased intraoperative risk and postoperative mortality. PDAC patients with PV/SMV resection seemed to have a worse survival compared with those undergoing standard surgery, especially when the tumor axis ³3cm. This may be related to more advanced disease in this group.
PP04-066 Factors Predicting Postoperative Complications in Whipple Procedure - Single Centre Experience from a Tertiary Care Centre
Rohith Muddasetty, India

R. Muddasetty, C. Kolandasamy, R. Prabhakaran, S. Rajendran, O.L. Naganathbabu
Institute of Surgical Gastroenterology, Madras Medical College, India

Introduction: Pancreaticoduodenectomy is one of the complex surgical procedures. It's associated with high postoperative morbidity and mortality. Several studies are still being done to determine the factors reducing the morbidity.
Methods: This study was retrospective analysis of the database maintained from January 2017 to December 2019. All patients who underwent Whipple procedure included in the study. Various factors related to postoperative pancreatic fistula, delayed gastric emptying, hepaticojejunostomy leak and post pancreatectomy hemorrhage(PPH) were analysed. These complications were defined as per ISGPS classification.
Results: In a period of 3 years, 70 patients underwent Whipple procedure. Male to female ratio was 4:3. Mean duration of surgery was 480min(SD 93.72), blood loss 555ml(SD 413). Clinically relevant pancreatic leak occurred in 34.3%, delayed gastric emptying in 11.4%. PPH occurred in 10%. Hepaticojejunostomy leak occurred in 14.2%. Mean duration of stay in hospital was 19days (SD 7). Female sex and addition of jejunojejunostomy reduced the occurrence, while preoperative biliary drainage and use of energy source for pancreatic transection increased the occurrence of pancreatic fistula. Female sex and prolonged duration of surgery increased the occurrence of delayed gastric emptying. Locally advanced lesion, increased intraoperative blood loss and requirement of intraoperative blood products increased the occurrence of PPH. Preoperative biliary drainage increased risk of hepaticojejunstomy leak.
Conclusion: Female sex, Preoperative biliary drainage, locally advanced tumor, use of energy source for pancreatic transection, prolonged duration of surgery and need for intraoperative blood transfusion increased the risk of complications. Addition of jejunojejunostomy reduced the risk of postoperative pancreatic fistula.
PP04-067 Validation of the SORT Score in Greek Patients with Pancreatic Cancer Undergoing Surgery and Comparison with POSSUM and P-POSSUM
Dimitris Zacharoulis, Greece

D. Magouliotis1,2, M. Fergadi1, D. Symeonidis1, A. Samara1, D. Zacharoulis1
1Department of Surgery, University of Thessaly, Greece, 2Division of Surgery and Interventional Sciences, University College London, United Kingdom

Introduction: The aim of the present study was to validate the Surgical Outcome Risk Tool (SORT) equation for predicting perioperative mortality in Greek adult patients with pancreatic cancer undergoing surgery, and to compare its performance with the POSSUM and Portsmouth (P)-POSSUM models.
Methods: Data was prospectively collected from thirty patients undergoing surgery for pancreatic cancer performed by a single hepato-pancreato-biliary surgical team in a Greek tertiary hospital (January-October 2019). Model discrimination was assessed by calculating the Area Under Receiver Operating Characteristic curve (AUC). The calibration was evaluated by calculating the observed to expected (O:E) ratios and by performing the Hosmer-Lemeshow goodness of fit test.
Results: Two patients (6.7%) died and 5 patients (16.7%) had a major complication within 30 days of surgery. All models overpredicted mortality. SORT had fair discrimination and calibration (AUC: 0.759, p=0.23; H-L: 3.947, p=0.68). POSSUM had the most reliable discrimination (AUC: 0.982, p=0.02) and calibration (H-L: 0.3169, p>0.99). P-POSSUM had also excellent accuracy (AUC: 0.964, p=0.03; H-L: 0.939, p=0.99).
Conclusion: All models overestimated mortality. SORT presented inferior discrimination and calibration compared to POSSUM and P-POSSUM in the context of predicting mortality in Greek patients with pancreatic cancer undergoing surgery.
PP04-069 Three Dimensional Pancreatic Volumetry for Distal Pancreatectomy in Evaluation of Postoperative Glycemic Control
Yu Igata, Japan

Y. Igata1, Y. Kobayashi2, S. Okubo2, J. Shindoh2, M. Hashimoto2
1Department of Gastroenterological Surgery, Toranomon Hospital, Japan, 2Toranomon Hospital, Japan

Introduction: There are few reports on the postoperative glycemic control based on the quantitative measurement of the remnant pancreatic volume (RPV) after distal pancreatectomy (DP). The aim of this study was to evaluate the postoperative glucose tolerance associated with RPV calculated with three-dimensional (3D) simulation software.
Methods: 56 patients who underwent DP between 2013 and 2017 were enrolled. Preoperative total pancreatic volume (TPV) and post-operative RPV were calculated by 3D volume analyzer, SYNAPSE VINCENT®. Patients with diabetes mellitus (DM) and/or preoperative HbA1c greater than 6.0% were defined as DM group. We compared the perioperative outcomes between DM and non-DM groups. Primary endpoint was the change of HbA1c for 2 postoperative years.
Results: Between DM group (n=19) and non-DM group (n=37), there were no significant differences in the patient's background and operative outcomes, except for hospital stays (15d vs. 12d, p=0.047). However, the incidence of newly introducing insulin or oral hypoglycemic agents (step-up DM) were significantly higher in the DM group (55.0% vs. 5.4%, p<0.001). In the non-DM group, there was a negative correlation between the RPV/TPV and the HbA1c elevation rate at the first postoperative months (r= -0.424, p= 0.031), however no significant correlation was observed at the 6, 12, and 24 postoperative months. Multivariable analysis confirmed that preoperative DM was strongly associated with step-up DM (odds ratio,75.4; p< 0.001), however, RPV/TPV was not an independent predictor for step-up DM.
Conclusion: SYNAPSE VINCENT® was useful in the objective evaluation for the transition of the postoperative glycemic control after DP.
PP04-071 Evaluation of the International Study Group on Pancreatic Surgery Definition and Classification of Chyle Leak after Pancreatic Surgery
Tao Ma, China

T. Ma, M. Lao, X. Bai, T. Liang
Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital of Zhejiang University School of Medicine, China

Objective: To reappraise the International Study Group on Pancreatic Surgery (ISGPS) definition and classification of chyle leak (CL) after pancreatic surgery.
Summary background data: CL is a potentially worrisome complication of pancreatic surgery.
Methods: We enrolled patients who underwent pancreatic surgery between January 2017 and January 2019 in our institution. The utility of the ISGPS criteria was evaluated using propensity score-matching (PSM). Outcomes of patients with delay-diagnosed CL (DD-CL) were compared with non-CL and early-diagnosed CL (ED-CL) patients. Risk factors for CL were identified using multivariate regression analysis.
Results: Of the 292 patients enrolled, 49 (16.8%) developed CL (grade A CL, 10 [3.4%]; grade B CL, 39 [13.4%]). Hospital stay and medical costs were comparable between patients with grade A and without CL. After PSM, patients with grade B CL had longer hospital stays than patients with grade A and without CL (P = 0.02). In 54 patients, the non-milky drain fluid had a triglyceride concentration ≥ 1.2 mmol/L on postoperative day 3. Of them, 22 (40.7%) patients were diagnosed with CL (DD-CL) after a median delay of 5 days. Hospital stay (P = 0.036) and medical costs (P = 0.035) were greater in the DD-CL group than in the ED-CL group.
Conclusion: The validity of the ISGPS classification of CL was confirmed. However, the current definition may delay the diagnosis of CL in a large proportion of patients.
PP04-073 Selective Suture Closure of Main Pancreatic Duct in Pancreatic Remnant Reduces Pancreatic Fistula (Pf) Following Open Distal Pancreatectomy (Odp): A Multicenter Study
Nitin Vashistha, India

N. Vashistha1, R. Kakodkar2, U. Somashekar3, D. Singhal4
1Department of Surgical Gastroenterology, Max Super Speciality Hospital, India, 2Department of HPB Surgery & Liver Transplantation, Dr L H Hiranandani Hospital, India, 3Department of Surgery, Netaji Subhash Chandra Bose Medical College, India, 4Department of Surgical Gastroenterology, Max Super Specialty Hospital, India

Introduction: Pancreatic fistula develops in up to 40% patients following ODP of which 9.7 to 23% of patients have ISGPS grade B or C (CR-POPF). However factors responsible for fistula formation are poorly understood.
We analyzed whether different surgical techniques for pancreatic transection and remnant management have role in PF formation after ODP.
Methods: This is a retrospective study of patients who underwent ODP at 3 centers (one each in Central, North and Western India) over 7 - 10 years. CR-POPF was the main outcome measure.
Operative technique: Following initial exploration, pancreatic tail and body was mobilized at least 2-3 cm central to designated transection line. Pancreas was then transected by either scalpel or monopolar electrosurgical energy (MEE). The main pancreatic duct (MPD) in remnant was selectively sutured by PDS 4-0/5-0. The pancreatic remnant was reinforced by sutures or left open.
Results: Study group comprised of 42 ODP patients (26 males: 16 females; mean age 47.5 years). Of these 6 (14.3%) developed PF and 5 (11.9%) developed CR-POPF).
Selective suture ligation of MPD was performed in 38 (90.4%) patients. Of the technical factors analyzed spleen preservation, method of pancreatic transection (scalpel versus MEE) and remnant reinforcement (none versus sutures) had no significant impact on development of PF.
The demographic data, indications, technical details and outcomes are summarized in Table1.
Conclusion: Selective suture closure of MPD resulted in low PF & CR-POPF rates in our study.
Parenchymal transection technique and suture reinforcement of remnant had no impact on PF rates.
DiagnosisCarcinoma / NET / Cystic tumor / Others07 / 10 / 11 / 14 
Operative detailsSpleen preservation: Yes / No07 / 35p=1
 Pancreatic transection: Scalpel / MEE / Stapler18 / 23 / 01p=0.74 (stapled excluded)
 Main pancreatic duct: Sutured / Duval / Stapled / Not localized38 / 02 / 01 / 01 
 Remnant reinforcement (suture): - Yes / No25 / 17p=0.70
 Median surgery duration (range)250 (120-360) min 
OutcomesPancreatic fistula (ISGPF): A / B / C01 / 02 / 03 
 Median LOS (range)7 (5-11) days 
 Mortality01(2.3%) (Pneumonia) 
[Operative details & outcomes of open distal pancreatectomy (n=42)]
PP04-074 Surgical Outcomes of Robotic Single Port Cholecystectomy with Extended Indication
Ji Hun Kim, Korea, Republic of

J.H. Kim, H.-S. Eun, W. Jung, W.H. Kim
Surgery, School of Medicine, Ajou University, Korea, Republic of

Introduction: Minimal invasive cholecystectomy is broadly performed in recently, especially single port cholecystectomy. The aim of this study was to confirm the results of robot single port cholecystectomy and compare robot single port cholecystectomy (RSPC) and laparoscopic single port cholecystectomy (LSPC).
Methods: From feburary 2014 to may 2018, total 79 RSPC was performed with no exclusion criteria. There are two laparoscopic conversion and five port addition group. All patients devided into three groups, difficulty group 1 with simple gallbladder, group 2 with gallbladder mild adhesion to adjacent organ and difficulty group 3 with severe adhesion and severe gallbladder inflammation.
Results: RSPC group had longer operative time than LSPC group (54.9±19.4 min, 47.5±15.6 min, P< 0.05) and possibility of port addition is higher too in RSPC group (9%, 1%, P< 0.05). In RSPC, high difficult group was more possibility of port addition (4%, 10%, 67%, P< 0.05) and group of undergoing emergency operation was higher difficult grade. (Elective operation 85%, 62%, 67%, Emergency operation 15%, 38%, 33%, P< 0.05).
Conclusion: In case of RSPC, severe cholecystitis was more difficult than laparoscopy and more severe results more possible port addition.
PP04-075 Journey of a Tertiary Care Hospital at Puducherry, India, into Becoming a High-volume Centre for Pancreaticoduodenectomy - A Decade of Experience
Souradeep Dutta, India

N.R. Vishnu Prasad1, S. Dutta1, T.P. Elamurugan1, B. Dubhasi2, K. Gunaseelan3
1Unit - 4, HPB Surgery, Dept of Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), India, 2Dept of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), India, 3Dept of Radiotherapy, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), India

Background: This study aims to study the outcomes of the Pancreaticoduodenectomy (PD) procedure- at the department of Surgery, JIPMER, Puducherry, which was in the early process of evolving into a high-volume centre for PDs in the last decade.
Methods: Details of 147 patients who underwent PDs from 2010-2019, were collected retrospectively from the Medical Records Department from 2010-2017, and prospectively in the last 2 years. Independent perioperative variables were compared to outcome variables - morbidity and mortality rates, and analysed.
Results: 29 patients underwent PDs in the first 5-year period, and 118 in the second, with mortality rates decreasing from 27.6% to 10.2% (P-0.029), and to 5.8% in the last year. Overall morbidities remained significantly high, with clinically relevant POPF, DGE and PPH to be 28.2%, 30.1% and 22.6% respectively. Ampullary adenocarcinoma was the commonest malignant tumour (63.3%). Factor significantly associated with perioperative mortality were - the period of surgery (1st vs 2nd 5 year period), ASA scores, Bilirubin levels, Intraop blood loss, CR-POPF, PPH, pneumonia and Sepsis. But variables which significantly increased the risk of mortality by Multivariate Logistic regression were Sepsis (OR - 108.4, p-0.011), and post operative pulmonary complications. Median overall survival was 36 months (19 - 53) months.
Conclusion: As we look back in the last decade, there have been significant improvement in the mortality rates of PD, but morbidity still remains high and has to be looked into as the department goes into a new decade as a young high volume centre.
PP04-078 Emerging Centers Can Provide Textbook Outcomes (TO) for Pancreatoduodenectomy (PD): A Multicenter Study from India
Nitin Vashistha, India

N. Vashistha1, R. Kakodkar2, D. Singhal1
1Department of Surgical Gastroenterology, Max Super Speciality Hospital, India, 2Department of HPB Surgery & Liver Transplantation, Dr L H Hiranandani Hospital, India

Introduction: Textbook Outcome has recently been introduced as novel quality measure for pancreatic surgery. Centralization is one of the strategies proposed in Western Europe and USA for providing quality outcomes following PD.
With large populations and underdeveloped healthcare system, applicability of 'centralization' for low-middle income countries (LMIC) such as India remains debatable.
For LMIC the challenges are:
- Rapid development of well equipped new centers to provide healthcare facilities closer to populations / decrease overwhelming workload of existing centers
- Provide quality care at affordable costs
We investigated whether TO for PD can be achieved at such 'emerging' centers.
Methods: Two surgeons trained at same institution from 2000 - 2005 set up independent centers for major digestive tract surgery in North & Western India. The outcomes of PD were retrospectively analyzed.
Results: Eighty seven patients underwent PD (Team 1 - 39, 10 years; Team 2 - 48, 7 years). TO were achieved in 82.7% patients (Figure1). The median length of stay (postoperative) was 10days. In hospital or 30-day mortality was 2 (2.2%). Three (3.4%) patients had CR-POPF. The cost of treatment ranged from 6000 USD (uncomplicated) to 18,000 -20000 USD (complicated; Clavien-Dindo 4). The demographic, technical details and outcomes for the 2 groups are provided in Table 1.
Conclusion: Well trained surgical teams at emerging centers in LMIC can achieve TO following PD.
Development of new well equipped centers manned by adequately trained personnel is reasonable strategy for LMIC for providing quality care at affordable costs.

ParameterTeam 1 (n=39)Team 2 (n=48)Total (n=87)
Mean Age (range)55.8 (19-71)56.5 (26-78) 
Site: Pancreas / Ampulla / Bile duct / Duodenum09 / 17 / 07 / 0614 / 20 / 08 / 0623 / 37 / 15 / 12
PJ details: Duct-mucosa / Dunking39 / 046 / 0285 / 02
Outcomes: POPF (B & C) / Mortality03 / 020 / 003 / 02
Clavien-Dindo Grade: None / 1 / 2 / 3 / 4 / 511 / 05 / 15 / 04 / 02 / 0211 / 20 / 14 / 03 / 0 / 022 / 25 / 29 / 07 / 02 / 02
Readmission (30 day)020507
Bile leak010102
Textbook Outcomes 29 (74.4%) 43 (89.6%) 72 (82.7%)
[Table 1. Demographic, technical details and outcomes of PD]

[Figure 1. Textbook Outcomes percentages for each parameter]
PP04-082 The Novel Index Using C-reactive Protein and Neutrophil-to-lymphocyte Ratio Predicts Poor Prognosis in Patients with Pancreatic Cancer
Tomohiko Taniai, Japan

T. Taniai, K. Haruki, M. Yanagaki, R. Hamura, Y. Fujiwara, K. Furukawa, T. Gocho, H. Shiba, K. Yanaga
Department of Surgery, The Jikei University School of Medicine, Japan

Introduction: The preoperative systemic inflammation, represented by neutrophil-to-lymphocyte ratio (NLR) and serum C-reactive protein (CRP) -to-albumin ratio (CAR) have been reported to predict tumor recurrence and survival in various cancers, including pancreatic cancer. However, more sensitive biomarkers are required to improve perioperative management of pancreatic cancer. Therefore, we developed a novel indicator using CRP and NLR (C-NLR), which was defined as CRP x NLR. The aim of this study is to evaluate the prognostic significance of C-NLR in patients with pancreatic cancer after pancreatic resection.
Methods: The study comprised 217 patients who had undergone pancreatic resection for pancreatic cancer between January 2001 and December 2016. We retrospectively investigated the relation between C-NLR and disease-free survival (DFS) or overall survival (OS) after pancreatic resection, and compared the prognostic significance of C-NLR with NLR and CAR.
Results: The optimal cut-off level of C-NLR by receiver operating characteristics analysis was 0.206. By multivariate analysis, C-NLR [Hazard ratio (HR): 1.373, 95% confidence interval (CI): 1.005-1.874, p=0.046], age (HR: 0.695, 95% CI: 0.507-0.954, p=0.024), and TNM Stage (HR: 2.197, 95% CI: 1.521-3.174, p=0.000) were independent predictors of DFS. As for OS, C-NLR (HR 1.468, 95% CI: 1.042-2.067, p=0.028), and TNM Stage (HR 1.644, 95% CI: 1.097-2.463, p=0.016) were independent predictors, while NLR and CAR were not.
Conclusion: C-NLR may be an independent and significant indicator of poor long-term outcomes in patients with pancreatic cancer after pancreatic resection.
PP04-083 Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Single Center Retrospective Study
Dakyum Shin, Korea, Republic of

D. Shin
Division of Hepatobiliary and Pancreas Surgery, Asan Medical Center/University of Ulsan College of Medicine, Seoul, Korea, Republic of

Introduction: As distal pancreatectomy with celiac axis resection (DP-CAR) is the only possible cure for pancreatic body and tail cancer with celiac axis involvement, we performed this study to show the post-operative outcomes of DP-CAR.
Method: 48 patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR in Asan medical center between January 2008 and December 2018 were included in the study. We retrospectively reviewed the patient's preoperative, operative and postoperative data. Primary outcome was major morbidity and 90-day mortality, and secondary outcome was overall survival.
Results: Major morbidity occurred in 9 patients (18.8%). 13 patients (27.1%) had pancreatic fistula grade B or C according to ISGPS guideline. There was 1 case (2.1%) of 90-day mortality after operation. Kaplan-Meier estimated median overall survival was 25.0 months.
Conclusions: DP-CAR is a good treatment option for cure in pancreatic body and tail cancer with celiac axis involvement without significant morbidity and mortality.
PP04-084 The Role of Hepaticojejunostomy Leaks after Pancreatoduodenectomy in the Increase of Morbidity and Mortality
Oleksandr Usenko, Ukraine

O. Usenko, M. Nichitaylo, V. Kopchak, P. Ogorodnik, O. Lytvyn, A. Deynichenko
State Institute “Shalimov’s National Institute of Surgery and Transplantation” to National Academy of Medical Sciences of Ukraine, Ukraine

Introduction: Leakage of Hepaticojejunostomy are less frequent than pancreatic leaks after pancreatoduodenectomy, and the current literature suggests comparable outcomes. The main purpose of our study was to establish the hepaticojejunostomy leak adversely affected patient outcomes.
Methods: Consecutive cases of pancreatoduodenectomy (n = 1010) were reviewed at a single high-volume institution in period 2009-2018. BL was defined by the presence of bile in the abdominal drains, radiologically or surgically drained bilioma or biliary peritonitis. BL severity was established according to the Clavien-Dindo classification.
Results: Pancreaticojejunostomy leaks were identified in 216 (21,5%) patients and hepaticojejunostomy leaks were identified in 30 patients (3%); combined hepaticojejunostomy/pancreaticojejunostomy leaks were identified in 32 patients (3%). Those with biliary fistula or combined leaks had a significantly increased risk of morbidity when compared to pancreaticojejunostomy leaks or no leak (53 and 57 vs. 31 and 23%, respectively, p < 0.05). The median length of stay was significantly greater for hepaticojejunostomy leaks or combined leaks when compared to pancreatojejunostomy leaks (19 or 15 vs. 10 days, p = 0.001) and those with no leak (18 or 13 vs. 8 days, p = 0.001). Early (ninthy-days ) mortality for all patients was 2.9%. Hepaticojejunostomy leaks and combined leaks significantly increased 90-day mortality rate (15 and 30%, respectively, p < 0.05).
Conclusions: Hepaticojejunostomy and combined leaks after pancreatoduodenectomy are rarer than pancreaticojejunostomy leaks; these patients are at a significantly increased risk of major morbidity and mortality. Bile leakage remains a major concern after pancreatic operations (PD).
PP04-085 Prognosis and Appropriate Resection Criteria of Conversion Surgery for Locally Advanced Unresectable Pancreatic Cancer
Yasuhisa Ando, Japan

Y. Ando, K. Okano, H. Matsukawa, H. Suto, M. Oshima, Y. Suzuki
Gastroenterological Surgery, Kagawa University, Japan

Introduction: With the improvement of multidisciplinary treatments for locally advanced unresectable (UR-LA) pancreatic cancer, long-term survival has been increasing , especially combined with conversion surgery (CS).
Methods: A retrospective study was performed on 13 patients who underwent CS for UR-LA pancreatic cancer between May 2011 and December 2018. In principle, our institutional criteria to go for conversion surgery are as follows: (1) disappearance of abnormal FDG-PET accumulation and (2) ≥80% reduction in CA19-9 level.
Results: Of the patients, 8 were male and 5 were female, with a median age of 69 years (range, 38-78 years) and median duration of nonsurgical treatment of 6 months (range, 2-9 months). Eleven patients (84%) had an R0 resection. Histopathologically, 6 cases (46%) were Evans classification grade ≥IIb (IIb : 3 cases, III : 2 cases , IV : 1 case). The MST from the start of treatment was 21 months. In 9 patients who were CA19-9/FDG-PET positive before the start of treatment, the prognosis was significantly better in those who met both resection criteria (MST, 34.5 months) than in the non-standard cases (MST, 13 months; p > 0.05).
Conclusion: It is likely that CS should be applied to UR-LA on the basis of the appropriate selection criteria to achieve the better survival.
PP04-086 Förster Resonance Energy Transfer (FRET) Nanoprobe Could Diagnose Pancreatic Juice Activation Due to Postoperative Pancreatic Fistula
Satoshi Mizutani, Japan

S. Mizutani1, M. Murata2, H. Furuki1, R. Nakata1, N. Taniai1, H. Yoshida3
1Digestive Surgery, Nippon Medical School Musashikosugi Hospital, Japan, 2Center for Advanced Medical Innovation, Kyushu University, Japan, 3Department of Surgery, Nippon Medical School, Japan

Introduction: Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy often causes activation of pancreatic juice, resulting in critical complications. In POPF, it is important to diagnose the activity of pancreatic juices in real time, so contributes to the development of postoperative management after pancreatoduodenectomy. This study suggests prosperious results of the clinical application of the FRET nanoprobe that is developed to distinguish between the active and inactive types of pancreatic juice.
Methods: The FRET nanoprobe was a 12nm diameter nanoprotein capsule. It exuded a red color when the capsule structure was maintained. Activation of protease in the pancreatic juice on it, the capsules are reduced quantitatively, and FRET is abolished, changing in color from red to green. Pancreatic juice activation can be measured by the FRET signal. A total of 112 drainage fluid samples from 16 post-pancreatoduodenectomy patients were obtained and evaluated.
Results: The pancreatic juice activation could be determined using the FRET signal with a boundary value of 1.6. Drainage fluid amylase (AMY) level was unrelated to pancreatic juice activation. This results suggested pancreatic juice was activated when drainage fluid was infected.
Conclusion: The FRET nanoprobe enabled detection of the presence or absence of pancreatic fistula activation after pancreatodudenectomy. It was suggested that infection in drainage fluid was the major cause of pancreatic juice activation regardless of drainage fluid AMY levels.
PP04-088 An Outcome Analysis of Central Pancreatectomy: A Single Centre Experience
Gunjan Desai, India

G. Desai, P. Pande, N. Chavan, P. Wagle
Surgical Gastroenterology, Lilavati Hospital and Research Centre, India

Introduction: Central pancreatectomy is a pancreatic resection procedure for selected pancreatic lesions. Literature reveals a higher pancreatic fistula rate compared to Whipple procedure and distal pancreatectomy. This study highlights our indications, technique and outcomes of this procedure.
Methods: This retrospective evaluation of a prospectively maintained data includes 16 consecutive patients who underwent central pancreatectomy from January 2012 to December 2018 at our tertiary centre. Patient demographics, indications, surgical details and outcomes were evaluated.
Results: Of 16 patients, 10 were males and 6 females with median age of 56 years. Four were diabetic. Indications were MCN in 4 patients, branch duct IPMN in 6, NEN in 3, SPEN in 2 and RCC metastasis in 1 patient. In all cases (Figure 1), pancreatic transection was performed with knife. The proximal stump was closed with suture and the distal was managed by a modified Blumgart pancreaticojejunostomy. Mean operative time was 259 minutes and blood loss 178 ml. All had R0 resection. There were 2 ISGPF Grade B pancreatic fistulas, managed conservatively. One patient had postoperative pancreatitis which resolved with conservative management. 3 patients had delayed gastric emptying. 6 patients had surgical site infection. All are alive and well at follow up. The patient with metastatic RCC is on sunitinib.
Conclusion: Central pancreatectomy, a pancreatic parenchyma preserving surgery can be safely performed with acceptable pancreatic fistula rates, contrary to previous literature, at high volume tertiary centres by experienced teams.
[Figure 1: Field after central pancreatectomy and closure of the proximal stump]
PP04-090 Role of Biliary Diversion in Addition to Head Coring in Case of CCP with Head Mass and Biliary Stricture
Sourabh Jindal, India

S. Jindal, M. Srinivaasan, K. Sivakumar, R. Prabhakaran, S. Rajendran, O.L. Naganath Babu
Institute of Surgical Gastroenterology, Madras Medical College, India

Introduction: Biliary strictures as a consequence of Chronic pancreatitis(CP) have long been recognized. Clinical presentation of biliary stricture varies from an incidental finding to overt jaundice and cholangitis. Head coring is the recommended treatment in a subset of patients with head mass who develop biliary symptoms.
Aim: We want to report on our experience regarding surgical management in CP with head mass and benign biliary stricture.
Method: Observational study (Retrospective - prospective study).
Results: Over a period of 3 years, we have managed 80 cases of CP at our institution by surgical intervention. Presenting symptoms, laboratory findings with radio-imaging, operative procedures and follow-up parameters of these patients were collected from our prospective database. Total 21 (26%) patients had biliary obstruction in the background of CP, out of which 15 (19%) patients had a mass lesion in head of pancreas. The most commonly performed operation was Frey's procedure with Choledocho-jejunostomy in 6(40%) patients, while other procedure were Choledocho-duodenostomy in 4(27%), Hepatico-jejunostomy in 1(7%), Cholecysto-jejunostomy in 1(7%), Cholecystectomy in 2(13%) and 1(7%) patient with hard head mass with regional lymphadenopathy had undergone Whipple's procedure. Two patients came with recurrent biliary stricture after 3 years of Frey's Procedure with cholecytectomy, underwent Choledocho-jejunostomy.
Conclusion: Biliary diversion is still the best option for CP with head mass and benign biliary stricture in addition to Frey's procedure, since head coring alone is not an adequate operation in the management of biliary obstruction in CCP with head mass.
PP04-091 Postoperative C-reactive Protein as a Predictor of Postoperative Pancreatic Fistula and Hospital Readmission Following Pancreaticoduodenectomy
Namrata Khadka, Nepal

N. Khadka, P. Joshi Lakhey
GI and General Surgery, Tribhuvan University Teaching Hospital, Nepal

Introduction: Postoperative pancreatic fistula (POPF) is the Achilles heel following Pancreaticoduodenectomy (PD).Early prediction of POPF has direct influence on patient management and outcome. This study aimed at identifying role of C-reactive protein (CRP) on first postoperative day (POD1) as predictor of clinically relevant pancreatic fistula (CR-POPF) and at discharge as a predictor of hospital readmission.
Methods: A prospective observational quantitative study was performed on 49 patients over one year who underwent PD. Clinical, biochemical, intraoperative and pathological characteristics were recorded. Quantitative serum CRP was sent on POD1 and at discharge. POPF was graded according to International Study Group in Pancreatic Surgery 2016.Diagnostic accuracy of CRP on POD1 to predict CR-POPF and at discharge to predict 90 day readmission were assessed by Receiver Operating Characteristics (ROC) curve analysis and cut-off value of CRP was calculated.
Results: Overall morbidity was 57.1% with mortality of 4.1%.Bile leak occurred in 38.8%.CR-POPF developed in 26.5% and cholangitis was independent risk factor(p< 0.05). Readmission rate was 14.3%. ROC curve analysis showed POD1 CRP level >100mg/l as a predictor of CR-POPF (AUC: 0.687; 95%CI [0.522-0.852] and CRP>50mg/L at discharge as a significant predictor of hospital readmission (AUC: 0.807 (95%CI [0.607-0.100], p< 0.05).
Conclusion: CRP is a reliable predictor of CR-POPF and hospital readmission, thus should be utilized in patient management.
Keywords: C-reactive protein; Pancreaticoduodenectomy, Postoperative pancreatic fistula; Readmission
PP04-094 Treatment and Outcome Differences in Patients with Duodenal Adenomas
Nicketti Handy, United States

N. Handy1, A. Crown1, A. Alseidi1, T. Biehl1, W.S. Helton1, S. Irani2, A. Ross2, R. Kozarek2, F. Rocha1
1Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, United States, 2Digestive Disease Institute, Virginia Mason Medical Center, United States

Background: Duodenal adenomas (DA) can be symptomatic and carry risk of malignant transformation, thus resection is recommended in fit candidates. This study examined the perioperative outcome trends associated with three types of resection in DA patients.
Methods: Patients who underwent pancreaticoduodenectomy (PD), local surgical resection (LR), or endoscopic resection (ER) of pathologically-confirmed DA between April 2005-July 2018 at our center were retrospectively reviewed. Outcomes among resection methods were compared with univariate logistic regression with post hoc analysis to identify differences between groups.
Results: During the study period, 77 patients underwent resection for DA; 27 (35.1%) DR, 15 (19.5%) LR, and 35 (45.4%) ER. When compared to the two surgical resection groups, ER had shorter hospital LOS (p< 0.001), fewer postoperative complications (p=0.002) and readmission (p=0.002), but reduced ability to achieve an R0 resection (p=< 0.001) and higher risk of recurrence (21 patients, 60%, p=< 0.001). Between PD and LR, there was higher blood loss in the PD group (259 ± 164 ml vs. 72 ± 52 ml, p=< 0.001) in addition to a trend toward more postoperative complications (p=0.065), hospital readmission (p=0.066), and higher success with achieving R0 resection (p=0.052). There were no perioperative deaths in the entire cohort.
Conclusions: ER of DA results in fewest complications and shorter hospital LOS, but is more likely to result in eventual recurrence from higher incidence of incomplete resection. The most definitive way to resect DA is likely via PD, but this may carry higher intraoperative and postoperative morbidity when compared to LR.
PP04-095 Evaluation of the Current Treatment Strategies for Pancreatic Neuroendocrine Tumors: A Propensity Score Matched Analysis
Kenneth Meredith, United States

K. Meredith1, J. Huston2, R. Shridhar3
1Gastrointestinal Oncology, Florida State University, United States, 2Gastrointestinal Oncology, Sarasota Memorial Institute for Cancer Care, United States, 3Radiation Oncology, Florida Hospital Cancer Institute, United States

Purpose: The management of pancreatic neuroendocrine tumors (PNET) varies between observation(O), pancreatic resection(PR) and enucleation(E). Currently, size, grade and location are used to determine which treatment strategy may be employed. We sought to evaluate each strategy and further clarify the role for surgery.
Methods: Utilizing the National Cancer Database we identified patients with PNET and stratified based upon size < 1cm, 1-2cm and >2cm. Propensity score matching was performed by age, Charleson-Deyo score, and grade. Survival analyses was performed using the Kaplan-Meier method. A p< 0.05 was considered significant.
Results: We identified 17,921 patients(< 1cm, 1214, 1-2cm, 4325, and >2cm, 12,382) with a median age of 61.5 (18-90). Tumors < 1cm and well differentiated(WD) the median and 5-year survival in the O group was not reached (NR)(77%) vs 142.6 month(87%) in the surgery groups, p< 0.04; in the 1-2 cm WD group 95.7 months and 60% vs NR and 94%, p< 0.001. Similarly in the PD tumors < 1cm the median and survival was 32.9 months and 24% in the O vs NR and 81%, p< 001; in the 1-2 cm group 14.8 months and 19% vs NR and 73%, p< 0.001. There were no differences in survival between PR or E, p=0.09.
Conclusions: While observation is acceptable for the management of < 1cm WD PNET, we found an improvement in survival in the patients undergoing surgery. Enucleation and PR did not differ in overall survival. Surgery for PNET should be considered as the first line treatment of these patients.
PP04-096 Risk Factors Associated with Postoperative Pancreatic Fistula after Pancreatoduodenectomy: A Retrospective Analysis
Manoj Kumar Mannem, India

M.K. Mannem, N. N.S
Surgical Gastroenterology and Liver Transplantation, Bangalore Medical College and Research Institute, India

Introduction: Pancreatoduodenectomy is one of the most complex surgeries. It is the main therapy for malignant and some of the benign diseases in the head of pancreas, distal common bile duct and the ampullary region. Postoperative pancreatic fistula(POPF) is the most common complication that occurs post PD and it accounts for other intraabdominal complications such as post pancreatectomy hemorrhage, intraabdominal infection and delayed gastric emptying. The aim of this study is to assess the possible riskfactors associated with POPF.
Methods: 85 patients who underwent PD in the department of Surgical Gastroenterology, Bangalore Medical College between 2014 august to 2019 august were analysed retrospectively. Preoperative factors and intraoperative factors which might be related to POPF were analysed by univariate and multivariate analysis. POPF was defined and graded according to ISGPS definition.
Results: POPF occured in 22 patients (25.8%) after PD. 18 patients had Grade B POPF whereas 4 patients had Grade C POPF. Univariate analysis showed significant association between POPF and the following factors: pancreas texture ( soft vs hard: 34.5% vs 7%, P-0.007), pancreatic duct diameter (< 3mm vs >3mm: 42% vs 7%, P- 0.01) and preoperative serum albumin (< 3.5 g/dl vs >3.5 g/dl: 47% vs 11%, P-0.0002). Multivariate logistic regression analysis showed significant association between POPF and preoperative serum albumin, pancreas texture, pancreatic duct diameter and preoperative serum bilirubin levels.
Conclusion: A soft pancreas, Pancreatic duct diameter of < 3mm and preoperative albumin of < 3.5 g/dl and preoperative bilirubin are independent risk factors for POPF after PD.
PP04-097 Postoperative Day 3 Drain Amylase (PoD3DA) vs Fistula Risk Score (FRS): Predicting Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) Following Pancreatico-Duodenectomy (PD)
Manoj Kumar Mannem, India

M.K. Mannem, N. N.S
Surgical Gastroenterology and Liver Transplantation, Bangalore Medical College and Research Institute, India

Background: Clinically relevant Postoperative pancreatic fistula (CR-POPF) remains the most common cause of perioperative morbidity following pancreatico-duodenectomy (PD). Early and accurate prediction of CR-POPF can be helpful in postoperative drain management as well as stratifying patients for ERAS protocol. Both FRS and postoperative drain amylase levels have been analyzed in past. Present study sought to assess the utility of POD-3DA level as a predictor of CR-POPF in comparison with FRS.
Methods: A retrospective analysis was done on 57 patients who underwent PD at our institute between 2014 to 2018. POPF was defined and graded in accordance with ISGPF definition. Receiver operating characteristic (ROC) analysis predicted a threshold of POD3DA>486 IU/L associated with CR-POPF. Sensitivity, specificity and odds ratios with 95%CI calculated & ROC curves were plotted for POD3DA of ≥500 IU/L and FRS (negligible/low vs. moderate/high) as predictors of CR-POPF.
Results: Incidence of POPF and CR-POPF was 63% & 32% respectively. Sensitivity and specificity of POD3DA ≥500 & moderate/high FRS for predicting CR-POPF were 83%,79% & 78%,51% respectively. Difference between ROC area under the curve (AUC) for POD3DA ≥500 IU/L (0.868) and FRS (0.692) was significant (p = 0.028). Combining FRS and POD3DA ≥500 IU/L improved specificity (87%) at the cost of sensitivity (67%). The negative predictive value of POD3DA < 500 IU/L & negligible/low FRS were 91.2% & 83.3% respectively.
Conclusions: POD3DA level greater than 5 times of upper normal range is more precise at predicting CR-POPF, hence clinically more reliable for drain & postoperative management.
PP04-098 Preoperative Scoring System to Predict Early Recurrence after Surgery for Resectable Pancreatic Cancer: A Multi-Center Retrospective Study
Daisuke Nobuoka, Japan

D. Nobuoka1, R. Yoshida2, M. Hioki3, D. Sato4, T. Kojima5, T. Kojima6, K. Yasui2, T. Yagi2, T. Fujiwara2, Okayama Study Group of Hepato-Briary-Pancreatic Surgery
1Department of Gastroenterological Surgery, Kagawa Prefectural Central Hospital, Japan, 2Department of Gastroenterological Surgery, Okayama University, Japan, 3Fukuyama City Hospital, Japan, 4Hiroshima City Hiroshima Citizen Hospital, Japan, 5Okayama Saiseikai General Hospital, Japan, 6Himeji Red Cross Hospital, Japan

Introduction: The prognosis of the patients with early recurrence after surgery for pancreatic adenocarcinoma (PDAC) is extremely poor, so these patients have no benefit from surgery.
The aim of this study is to create a scoring system to predict early recurrence after surgery for resectable pancreatic cancer (R-PDAC).
Method: This study enrolled 631 patients from 15 institutions of the Okayama Study Group of Hepato-Briary-Pancreatic Surgery. The treatment outcomes after upfront surgery for R-PDAC from 2013 to 2017 were analyzed retrospectively. Univariate and multivariate analyses were utilized to identify preoperative indicators for early recurrence (ER) to create risk scoring system.
Results: ER occurred in 126 patients (20%) with a median survival time (MST) of 10 months. Logistic regression analysis revealed 3 independent predictors for ER: Tumor size>30mm (odds ratio[OR] 1.75, P=0.02), Contact to portal vein or superior mesenteric vein (PV/SMV) (OR 1.65, P=0.02), and preoperative cancer antigen19-9 (CA19-9)>150U/mL (OR 2.47, P< 0.0001). OR was used to determine the allocation of points to each patients: Tumor size>30mm (1point), Contact to portal PV/SMV (1point), CA19-9>150U/mL(2point). The incidence of ER was 37% in high-risk group (score 3-4 point), 19% in the moderate risk group (score 3-4 point) and 10% in the low risk group (score 0 point). There were significant differences in overall survival between the three groups (P< 0.0001).
Conclusions: A preoperative prognostic scoring system for ER after surgery in R-PDAC using tumor size, PV/SMV contact, and CA19-9 is useful to select the patients requiring more multidisciplinary treatment strategy.
PP04-099 Parenteral versus Enteral Nutrition for Pancreatic Fistula: A Systematic Review and Meta-analysis
Pablo Serrano, Canada

P. Serrano1,2,3, T. McKechnie1,2, S. Lee2, Y. Lee1,2, K. Tywonek2, A. Doumouras1,2,4, L. Ruo1,2,3
1Michael G. DeGroote School of Medicine, McMaster University, Canada, 2McMaster University, Canada, 3Department of Surgery, Juravinski Hospital, Canada, 4Department of Surgery, St. Joseph’s Healthcare, Canada

Background: Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following pancreatic surgery. The most effective feeding route for the conservative management of POPF is a topic of debate. We aimed to compare the efficacy of enteral nutrition (intervention) versus parenteral nutrition (control) in the rate of POPF closure.
Methods: Medline, EMBASE, CENTRAL, and Web of Science databases were searched for randomized controlled trials comparing enteral to parenteral nutrition in the conservative management of POPF. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Quality of the evidence was assessed using GRADE. Random-effects meta-analysis was used to estimate the time to POPF closure and corresponding confidence intervals (CI).
Results: From 2,682 relevant citations, three studies (n=167 patients) were analyzed (85 patients in the enteral group and 82 patients in the parenteral group). Mean time to POPF closure was 3.64 days shorter in the enteral group than the parenteral group, which failed to reach statistical significance (95% CI -3.22 to 10.49, P = 0.30, I2). There were no significant differences in postoperative complication rate (OR 1.69, 95% CI 0.52 to 5.47, P = 0.38; very low quality evidence) or length of stay (LOS) between groups (mean difference: 0.76, 95% CI -9.21 to 10.74, P = 0.88; very low quality evidence).
Conclusions: The rates of POPF closure, postoperative complications, and LOS are not significantly different between patients receiving enteral feeds and those receiving parenteral feeds. The quality of evidence was very low and larger comparative studies are required.
PP04-100 Prehabilitation before Oncological Pancreatic Resection: A Systematic Review of Available Evidence
James Bundred, United Kingdom

J. Bundred1, S. Kamarajah2, S. Pandanaboyana3
1Department of Clincal Sciences, University of Leeds, United Kingdom, 2Department of Academic Surgery, University of Newcastle, United Kingdom, 3Department of HPB surgery, Royal Freeman Hospital, United Kingdom

Introduction: Paucity of data exists regarding benefits of prehabilitation before pancreatic surgery. This review aimed to appraise available evidence regarding the role of prehabilitation in patients undergoing pancreatic surgery.
Methods: Systematic literature searches of PUBMED, MEDLINE and EMBASE were conducted to identify articles describing prehabilitation programmes before pancreatic resection for malignancy. Data collected included pre-operative assessments, timing of prehabilitation, type, duration, adherence and outcomes.
Results: Six studies, including 193 patients, average age 67 years, average BMI 23.8, were included in the final analysis. Time from diagnosis to surgery ranged from 2- 22 weeks. Two studies reported a professionally supervised exercise programme, four described unsupervised programmes. Exercise programmes varied from 5 days to 6 months in duration. Two studies included nutritional interventions. Adherence to exercise programmes was better in patients not undergoing neoadjuvant therapy (90% reaching weekly activity goal vs 82%). Supervised programmes reported higher adherence than unsupervised (99% reaching weekly activity goal vs 85%). Two studies reported the impact of prehabilitation on peri-operative outcomes (major complications, gastric emptying, pancreatic leakage, mortality, readmission). Prehabilitation did not change the likelihood of major complications, pancreatic leakage, mortality or readmission in either study. Prehabilitation was associated with a shorter length of stay in both studies. All six studies reported changes in anthropometric and biochemical markers of fitness. In multiple studies, patients undergoing prehabilitation had significant improvements in muscle mass or markers of muscle function.
Discussion: Current studies report diverse exercise and nutrition programmes, with no current consensus regarding optimal timing or duration.
PP04-101 Distal Pancreatectomy with Multivisceral Resection: A Multicenter Study
Mario Serradilla-Martín, Spain

M. Serradilla Martín1, T. Longoria Dubocq2, N. De Armas Conde3, M. Cantalejo Díaz1, S. Esteban Gordillo4, M. Garcés Albir5, A. Carabias Hernández6, A. Manuel Vázquez7, J.M. Ramia Ángel7, ERPANDIS 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: Multivisceral resection is sometimes necessary to achieve disease-free margins in cancer surgery. In 2/3 of the patients it is proven that there is no true neoplastic infiltration, but not performing multivisceral resection increases the recurrence rate, usually with higher morbidity and mortality. In certain patients with pancreatic tumors that invade neighboring organs these must be removed to perform an appropriate oncological surgery.
Methods: Retrospective multicenter observational study from prospective databases focused on distal pancreatectomy in seven Hepato-Pancreato-Biliary Units, from 1/01/2009 to 31/12/2018 (ERPANDIS Project). Inclusion criteria: any distal pancreatectomy with multivisceral resection. Exclusion criteria: DP with celiac trunk resection or portal vein resection.
Results: 435 distal pancreatectomies were performed. In 81.1% (353 patients) multivisceral resection was not performed and in 18.9% (82 cases) some extra organ was resected. Patients with multivisceral resection had superior ASA score (plus ASA III) (p< 0.001) and larger tumors (p=0.001). In the multivisceral resection group, the approach was mostly laparotomic, splenic preservation was not performed, there were more cases of extended distal pancreatectomy and blood losses and the percentage of intraoperative transfusion was higher. The pancreatic fistula rate was the same in both groups. The average stay was double in the multivisceral resection group. The patients who underwent multivisceral resection had larger tumors and the percentage of patients with malignant tumors was higher (43.2% vs 19%).
Conclusion: Multivisceral resection increases morbidity and mortality but within acceptable limits and allows the removal of associated pathology or organs invaded by malignant tumors of the body and tail.
PP04-102 Does Laparoscopic Distal Pancreatectomy Decrease Morbidity? A Multicentre Study (ERPANDIS Project)
Mario Serradilla, Spain

M. Serradilla1, J.V. Del Río Martín2, G. Blanco Fernández3, A. Serrablo Requejo1, F. Rotellar Sastre4, L. Sabater Ortí5, A. Carabias Hernández6, R. Latorre Fragua7, J.M. Ramia Ángel1, ERPANDIS 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: Most of HPB surgeons consider that laparoscopic distal pancreatectomy (LDP) is standard treatment for pancreatic diseases. The cost-effectiveness studies performed does not obtain a clear economical and medical benefit comparing open distal pancreatectomy (ODP) and LDP. The aim of this study is to evaluate morbidity and mortality at 90 days measured and pancreatic fistula rate in a large series of distal pancreatectomies comparing results obtained in ODP and LDP.
Materials and method: Multicentre retrospective observational study. All scheduled ODP and LDP performed in seven hospitals. Period: 01/01/09 - 31/12/18. Postoperative complications were measured with Clavien-Dindo classification and CCI. Major complications were defined as grade IIIa or severe. Pancreatic complications were measured using definitions of ISGPS. Resection margins were categorized using “Royal College of Pathologists” classification. Morbidity and mortality were measured at 90 days.
Results: 419 patients were included. 250 (59.7%) were ODP and 169 (40.3%) were LDP. Both groups were comparable, except Charlson Comorbidity Index, tumor size, type of resection, splenic resection, and vascular resection. Morbidity (Clavien-Dindo), mortality, fistula rate and readmissions are shown in table 1.
Conclusions: LDP is more commonly performed in non-adenocarcinoma cases, closure of stump is usually done with stapler and spleen preservation is almost 25%. ODP is performed in more adenocarcinoma cases and patients with bigger tumors, closure is done with suture and spleen preservation is only 13%. Moreover, morbidity is similar between both groups, but mortality and readmissions are higher in ODP group. Prospective RCT with matched groups is complex but needed.
PP04-103 Survival Analysis According to the New Resectability Criteria in Patients with Pancreatic Cancer
Yuta Ushida, Japan

Y. Ushida, Y. Inoue, H. Ito, T. Sato, Y. Ono, A. Oba, Y. Takahashi
Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Japan

Background: The definition of borderline resectable (BR) for pancreatic cancer (PC) has been based on imaging findings as for anatomical relation between the tumor and vessels (Anatomical R/BR). In fine, not only imaging findings but also other clinical parameters such as tumor makers, general status and nutritional condition are important factors in consideration of resectability. Anatomical R-PC with poor prognosis might be treated with neoadjuvant chemotherapy (NAC) same as Anatomical BR.
Methods: From 2007 to 2014, we intended upfront curative resection in 431 consecutive patients with PC. Among them, 380 patients underwent pancreatectomy and were enrolled. The relationship between preoperative clinical features and survival outcomes were assessed. We adopted modified Glasgow prognostic score (mGPS) and neutrophil/lymphocyte (N/L) ratio for patient's conditional assessment. Patients were stratified due to risk factor, and we distinguish risky group from others.
Results: Patients comprised 291 Anatomical R-PC patients (77%) and 89 BR-PC patients (23%). Multivariable analysis identified mGPS=2, CA19-9>500 U/ml and anatomical BR were independent unfavorable prognostic factors in terms of overall survival. Median survival time of Anatomical R patients with CA 19-9 > 500 U/ml was as poor as that of anatomical BR patients (17.5 vs. 17.8 months, P = 0.483).
Conclusions: It is essential to stratify Anatomical R-PC and distinguish oncologically risky group from the others. Anatomical R with CA 19-9 > 500 U/ml was as unfavourable as Anatomical BR-PC, and we should consider NAC for such “risky R” patients.
PP04-104 Single Center Experience of Thirty Five Consecutive Total Duodenopancreatectomies
Roman Izrailov, Russian Federation

I. Khatkov, V. Tsvirkun, R. Izrailov, M. Baychorov, P. Tytyunnik, A. Andrianov, M. Mikhnevich, P. Agami
High-Tech Surgery, Moscow Clinical Scientific Center, Russian Federation

Introduction: laparoscopic total duodenopancreatectomy (TLDPE) remains one of the colmplex procedures in minimally invasive abdominal surgery.
Objective is to assess the short-term and long-term outcomes of TLDPE.
Methods: 35 patients underwent TLDPE during last 10 years. 22 were females, 13 were males.30 patients were operated on because of malignancies and 5 because of benign diseases. Postoperative complications were assessed in order to evaluate the safety and feasibility of laparoscopic approach.
Results: To date this is one of the largest single-center experiences of TLDPE. Mean operative time was 466 min and mean blood loss was 356 ml. The postoperative course of 22,8% of patients was complicated by Clavien-Dindo IIIa-V complication. Among them CD V - 5,7%. Mean ICU stay was 3,42 days, while mean hospital stay was 14 days. Rate of complications demanding repeat surgeries was 14,3%. Concomitant venous resection was performed in 10 cases. Venous resection was associated with higher blood loss and operation time. R0 resection was obtained in 97% of cases with mean number of lymph nodes harvested of 13. Median overall survival of patients with pancreatic cancer was 26 months with 5-years OSR of 29%. Mean maximum glucose level during the day was 9,8 mmol/l, HbAc 7,1 with mean demand in long-actin insulin 13,8 U. Median weight loss was 5 kg. One third of patients were complaining on diarrhea.
Conclusion: TLDPE is feasible and effective procedure providing satisfactory short-terms and long-term outcomes.
PP04-105 Central Pancreatectomy: A 20 Years Single Institution Experience
Oscar Ricardo Paredes Torres, Peru

O.R. Paredes Torres, E. Ruiz Figueroa, E. Payet Meza, F. Berrospi Espinoza
Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Peru

Background: Central pancreatectomy is an alternative resection to distal pancreatectomy. This procedure is performed in tumors of the neck or proximal body of the pancreas. The aim of this study is to analyze the clinicopathological features, morbidity and mortality rates of patients who underwent this sparring parenchyma procedure.
Methods: Between 2000 and 2019 twenty-three patients with diagnostic of pancreatic tumor underwent a central pancreatectomy. Clinicopathological data were statistically analyzed and also we study the morbidity and mortality of this surgical treatment.
Results: Of the 23 total patients, 20 (87%) were women and 3 (13%) were men. The median age was 43.6(range, 5-76 years). The median tumor size was 5.6 (range, 1.3-12.5 centimeters). All patients had R0 resection and only one had a multi-visceral resection. Indications included 10 solid pseudopapillary neoplasms, 8 serous cystadenomas, 3 neuroendocrine tumors, one pancreatoblastoma, and one mucinous cystadenoma. The median operative time was 285 minutes (range, 180 - 445 minutes) and the median intraoperative blood loss was 273 (range, 50 - 600ml). Eight patients (34.7%) had postoperative complications including six cases of pancreatic fistula, one case of pancreatitis and one case of post pancreatectomy hemorrhage. Only one patient (4.3%) died after surgery because of post pancreatectomy hemorrhage. The median follow up was 46.2 months.
Conclusions: Central pancreatectomy is associated with increased postoperative morbidity, especially pancreatic fistula. Central pancreatectomy should be chosen for special cases and performed by experienced surgeons.

Key Words: Central pancreatectomy; Morbidity; Mortality; Pancreatic fistula.
PP04-106 Radical Antegrade Modular Pancreatosplenectomy vs Standard Distal Pancreatectomy for Pancreatic Adenocarcinoma of the Body and Tail - A Cohort Study from a Single Center
Yin Jie, China

Y. Jie1, L. Zipeng2, W. Pengfei2, Z. Kai2, D. Cuncai2, W. Junli2, G. Wentao2, J. Kuirong2, M. Yi2
1Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, China, 2The First Affiliated Hospital with Nanjing Medical University, China

Background: The aim of this study is to investigate the impact of Radical antegrade modular pancreatosplenectomy (RAMPS) compared with standard standard distal pancreatosplenectomy (DP) on short-term outcomes and long-term survivals.
Methods: 192 patients who underwent RAMPS or SDP from May 2013 to December 2017 were analyzed. The comparisons of short-term and long-term outcomes were performed.
Results: Seventy-eight patients underwent RAMPS and 114 patients underwent SDP. 44(56.4%) patients underwent posterior RAMPS. The average operative time in RAMPS was longer than SDP (230±67min vs. 207±78min, P=0.039), and the median greatest tumor diameter was much larger in RAMPS group (4.5cm vs. 3.5cm, P=0.001). RAMPS had much more T4 (P< 0.001) and stage III (P=0.020) by 8th AJCC TNM staging system, as well as the median number of resected and positive lymph nodes (8 vs. 6, P=0.007; 1 vs. 0, P=0.011). The rate of R0 resection was comparable (94.9% vs. 86.8%, P=0.086). The overall morbidity rate was similar in two groups (39.7% vs. 31.6%, P=0.244). The long-term survival showed that RAMPS had a shorter median survival time (16.7m vs. 20.7m, P=0.479). The subgroup analysis demonstrated the median survival was 16.5 months in RAMPS and 12.7 months in SDP for T4 patients (P=0.122), respectively. In addition, RAMPS group had longer median survival time for high level CA19-9 (≥300) patients (16.5m vs. 13.2m, P=0.227).
Conclusions: RAMPS is a safe and feasible procedure for pancreatic cancer and it may be beneficial to T4 and high level of CA19-9 patients.
PP04-109 Mitigation of Robotic Pancreaticoduodenectomy Learning Curve Through a Comprehensive Training Program
Da Yeon Ryoo, United States

D.Y. Ryoo1, M. Dillhoff1, Y. Li1, J. Cloyd1, A. Manilchuk1, T. Pawlik1, A. Tsung1, C. Schmidt2, A. Ejaz1
1The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, United States, 2West Virginia University, United States

Background: The utilization of robotic surgery for pancreaticoduodenectomy continues to increase. There is an apparent associated lag in the training for this complex operation resulting in a learning curve with the adoption of this technique. We hypothesize that the reported learning curve can be mitigated through a comprehensive graduated training protocol.
Methods: Prior to robotic pancreaticoduodenectomy program implementation, all surgeons (n=3) and operating room staff at The Ohio State University underwent dedicated training. All patients who underwent an open (n=156) or robotic (n=41) pancreaticoduodenectomy following program implementation between 2015-2018 were identified. Operative and post-operative outcomes over time were analyzed. Robotic and open patients were matched 1:1 based on all measurable pre-operative patient- and tumor-specific risk factors.
Results: The unplanned robotic-to-open conversion rate was 19.5% (n=8). Of the remaining 33 robotic whipple operations, operative time plateaued at 11 cases (figure); however, mean operative time did not change over time (P=0.08). Similarly, no difference over time was seen in the rate of grade B/C postoperative pancreatic fistula (POPF) (n=9.1%) or need for blood transfusion (n=4, 12,1%) (P=1.00). After matching, no difference was seen between robotic and open operations in the incidence of grade b/c POPF, delayed gastric emptying, length of stay, readmission, major complications, and death (all P>0.05).
Conclusion: Through a graduated comprehensive training protocol, there was no apparent learning curve associated with the implementation of robotic pancreaticoduodenectomy as described in previous studies. Furthermore, robotic cases had similar postoperative outcomes compared to matched open cases.
PP04-111 Contemporary Perioperative Outcomes for Portal Vein Resection and Reconstruction Following Pancreaticoduodenectomy for Malignancy
Nicketti Handy, United States

N. Handy1, A. Crown1, K. Bertens2, J. Clanton3, A. Alseidi1, T. Biehl1, W.S. Helton1, F. Rocha1
1Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, United States, 2Division of Hepatopancreatobiliary Surgery, The Ottawa Hospital, University of Ottawa, Canada, 3Division of General Surgery, West Virginia University, United States

Background: Portal vein resection and reconstruction (PVRR) can be technically challenging during pancreatectomy for cancer, but is sometimes necessary with disease involvement of the mesenteric vessels. This study examined if PVRR negatively impacted perioperative outcomes in a modern patient cohort.
All patients who underwent pancreaticoduodenectomy (PD) or total pancreatectomy (TP) from 2010-2014 for invasive malignancy at our center were retrospectively reviewed. Clinicopathologic variables were compared and univariate logistic regression was used to compare outcomes between patients who underwent PVRR and those who did not.
During the study period, 309 patients underwent PD or TP for resection of malignancy, with 78 (25.2%) patients requiring PVRR. Primary repair of the defect was the most common method of PVRR (62.8%), followed by end-to-end repair (23.1%), side-to-side repair (5.1%), and autologous vein patch (5.1%). Nonautologous patch repair was used in only 2.6% of cases, with no cases of synthetic graft use. The PVRR group had increased operative time (495±153 vs. 437±130 minutes, p=0.001), decreased formation of pancreatic fistula (10.3% vs. 21.6%, p=0.029), and decreased deep surgical site infection (9.0% vs. 22.1%, p=0.011). There is no difference between groups for all other examined complications, including PV thrombosis (2.6% vs. 1.3%, p=0.603) in short-term follow-up.
Conclusions: Most PVRR can be performed primarily, and synthetic material can be avoided entirely with modern techniques. Despite increased operative time, perioperative complications appear to be either unchanged or reduced in PVRR patients. This may be due to increased utilization of neoadjuvant therapy in this group.
 PVRR (N=78)No PV Resection (N=231)P Value
Operative Time (mins)495 ± 153437 ± 1300.001
Hospital LOS (days)9.3 ± 3.910.4 ± 6.80.177
All Complications36 (46.2%)129 (55.8%)0.150
Superficial SSI9 (11.5%)22 (9.5%)0.663
Deep SSI7 (9.0%)51 (22.1%)0.011
Pancreatic Fistula (grade B or C)8 (10.3%)50 (21.6%)0.029
Required Blood Transfusion13 (16.7%)29 (12.6%)0.347
PV Thrombus2 (2.6%)3 (1.3%)0.603
Reoperation2 (2.6%)9 (3.9%)0.736
[Comparison of outcomes in patients who underwent PVRR and no PVRR during PD/TP for invasive malignancy.]
PP04-112 Post-operative Pancreatitis as a Predictor of Post-operative Pancreatic Fistula in Patients Following Pancreaticoduodenectomy
Nirajan Subedi, Nepal

N. Subedi
Tribhuvan University Teaching Hospital/Institute of Medicine, Kathmandu, Nepal

Introduction: Post-Operative Pancreatic Fistula(POPF) remains the challenge following Pancreaticoduodenectomy(PD). Recently Post Operatve Pancreatitis(POP) has been defined which has been shown to be independent predictor of POPF in retrospective studies.
Method: We Performed a prospective study where Serum Amylase of more than 80U/L on POD0 or POD1 was defined as POP following PD. The end point of the study was to see incidence of POP and its relation with POPF.
Result: There were total 23 PDs. Most of the Patients had final diagnosis of ampullary carcinoma(52%). The incidence of POP and POPF was 56.5% and 60.9%. 84.6% patient who had POP developed POPF(P= 0.008). There was total seven Post Pancreatectomy Hemorrhage, two delayed gastric emptying, one chyle leak and four Mortality. However no statistical correlation could be made between POP and other pancreas specific complications and mortality.
Conclusion: Though the sample size is less but POP seems to predict POPF in Patient following PDs in our study.
Keywords: POP- Post Operative Pancreatitis, POPF- Post Operative Pancreatic Fistula, PD- Pancreaticoduodenctomy.
PP04-113 Low Vascular Density at the Pancreatic Resection Margin Is Associated with Post Operative Pancreatitis after Pancreaticoduodenectomy
Venkatesh Balaraman Sundararajan, India

V. Balaraman Sundararajan1, R. Kilambi1, C. Bihari1, S. Kumar2, N. Patil1, T.K. Chattopadhyay1
1HPB Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, India, 2HPB Surgery & Liver Transplant, Sri Ramachandra Medical College and Research Institute, India

Background: Post operative pancreatitis (POP) may contribute to post operative pancreatic fistula (POPF) High acinar cell score at pancreatic resection margin has been associated with POPF. The aims of this study were:
i) To study the relation between vascular density and acinar score at pancreatic resection margin with POP and POPF;
ii) To study the incidence of POP and its correlation with POPF.
Methods: Consecutive patients in a single unit, who underwent pancreaticoduodenectomy between February 2018 to October 2019 were studied. Serum amylase (Day 1) and drain fluid amylase (day 3) were measured. Vascular density and acinar score were calculated from the histopathological slides of pancreatic resection margin. POP was defined as serum amylase more than upper limit of normal on POD1. POPF was defined as clinically relevant pancreatic fistula (grade B& C) as per ISGPF 2016 update.
Results: Of the 33 patients (mean age: 56 yrs), 20 were men. POP occurred in 54.5% and POPF in 24.2%. Decreased vascular density (< 26.5 microvessels / 20 consecutive high power fields in 20x magnification) was found to be an independent predictor of POP(OR:0.63, p=0.028). Low acinar score was found to be independent predictor of post operative pancreatic fistula (OR:0.92, p=0.04). POP did not correlate with POPF.
Conclusion: Patients who developed POP had low vascular density at the resection margin suggesting that ischemia may play a role in pancreatitis and those who developed POPF had a low acinar score.
PP04-114 Step-up Mini Invasive Surgical Treatment of Patients with Different Morphological Forms of Acute Necrotizing Pancreatitis
Oleksandr Rotar, Ukraine

I. Khomiak1, O. Rotar2, A. Khomiak1, V. Shafraniuk3
1A. Shalimov National Institute of Surgery and Transplantology, Ukraine, 2General Surgery, Bukovinian State Medical University, Ukraine, 3Bukovinian State Medical University, Ukraine

Introduction: Despite significant progress in the treatment strategy of acute necrotizing pancreatitis (ANP), mortality in cases of its severe form remains high. There is no single point of view concerning the indications for the use of mini invasive interventions depending on the nature, extension and localization of the pathological foci of ANP.
Material: We performed a prospective observational cohort study of efficacy of elaborated algorithmic mini invasive step-up approach of surgical treatment of 317 patients with different morphological forms of ANP. The following parameters were collected for each episode: length of hospital stay, mortality, occurrence of organ failure and local complications.
Results: Transcutaneous punction/drainages were applied as the first step in 37 patients with acute necrotic collections (ANC). In the presence of walled-off pancreatic necrosis (WOPN) EUS procedures were preferred in case their close localization to the stomach or duodenum in 65 observations. Initial surgical treatment wasn't effective in 18.8% and video-assisted retroperitoneal debridement (VARD) in patients with ANC or necrosectomies under EUS control in cases of WOPN were applied. Necessary for laparotomic necrosectomies occurred in 14.5% of patients and was the final step of proposed algorithmic approach. During postoperative period complications occurred in 28.3% of patients. They included 7 new episodes of organ failure, 4 cases of arosive hemorrhage, and 5 observations of pancreatic and duodenal fistulas. Overall mortality rate was 3.3%, after interventional treatment - 6.5%.
Conclusion: Surgical treatment in patients with ANP based on elaborated algorithmic step-up approach is followed by acceptable complication and mortality level.
PP04-115 Predicting Post-operative Pancreatic Fistula: A Systematic Review of Scoring Systems
Liam Phelan, United Kingdom

L. Phelan, M. Panikkar, J. Halle-Smith, R. Pande, T. Thorne, J. Hodson, K. Roberts
HPB Surgery, University Hospitals Birmingham, United Kingdom

Background: Post-operative pancreatic fistula (POPF) cause major morbidity following pancreaticoduodenectomy. There are multiple published scoring systems which predict the probability of fistula, but few have undergone rigorous external validation. This systematic review aimed to identify current scoring systems and combine the results of external validation to assess scores clinical validity.
Methods: The area under receiving operator characteristic curve (AUROCs) were extracted from the included studies, and standard error's were derived from 95% confidence intervals, were reported, or estimated from the p-values or numbers of cases otherwise. For risk scores with data available from more than two studies, intercept-only random-effects meta-regression model were then used to produce pooled AUROCs.
Results: Systematic review identified 25 risk scores, of which four were included in the meta-analysis. These were the scores proposed by Mungroop (reported in N=5 studies), Yamamoto (N=3), Roberts (N=4) and Callery (N=11). The overall predictive accuracies were found to be similar for all four scores, with pooled AUROCs of 0.68, 0.68, 0.69 and 0.73, respectively. However, considerably heterogeneity was also observed, with I2 statistics ranging from 83-93%.
Conclusion: There are a multitude of predictive scoring systems, most with no external validation.
Of those that have been externally validated, repeatedly they show similar predictive accuracy.
There is a need for a large, multi-centre study to ascertain clinically important risk factors for POPF and validate a scoring system that performs consistently well regardless of geographic location and that is easy to use.
PP04-117 Long-term Outcomes of Pancreatic Anastomosis after Open and Laparoscopic Pancreatoduodenectomy
Yerlan Taubabek, Korea, Republic of

J.S. Lee, Y. Taubabek, Y.-S. Yoon, H.-S. Han, J.Y. Cho, Y. Choi, B. Lee, J. Kim
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea, Republic of

Introduction: Despite favorable short-term outcomes of laparoscopic pancreaticoduodenectomy (LPD), long-term outcomes after LPD in comparison with open pancreaticoduodenectomy (OPD) have been rarely reported. We compared the long-term outcomes of pancreatic anastomosis between LPD and OPD by evaluating anastomosis stricture and parenchymal atrophy.
Methods: We retrospectively reviewed 212 patients who received OPD (n=121) and LPD (n=91) from a single surgeon, from December 2014 to October 2018. We analyzed the long-term outcomes of pancreatic anastomosis by reviewing the postoperative 1-year CT for anastomosis stricture and parenchymal atrophy. Anastomosis stricture was defined as a 30% increase or more in pancreatic duct diameter, and pancreatic atrophy was defined as a 30% decrease or more in the remnant pancreas parenchyma.
Results: The incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) was 19.8% in LPD and 18.2% in OPD, with no significance. In the OPD group, there were more patients with pancreatic cancer (22 vs 59.5 %, P< 0.001). The LPD group was associated with smaller pancreatic duct (2.3 vs 3.3 mm, P=0.041) and soft pancreas (78.0 vs 48.8%, P< 0.001). There were no differences in anastomosis stricture (16.5 vs 24.0%, P=0.184). There were significantly more patients with pancreas atrophy in the open group (17.6 vs 33.1%, P=0.011). Multivariate analysis of risk factors for anastomosis stricture and pancreas atrophy showed operative method was not a significant factor.
Conclusion: The results of this study revealed that long term outcomes of LPD were not inferior to OPD in terms of patency of the pancreatic duct and pancreatic atrophy.
PP04-118 Interventions to Reduce Post-operative Pancreatic Fistula after Pancreaticoduodenectomy - Do We Need a Change of Direction? A Systematic Review and Meta-analysis
James Halle-Smith, United Kingdom

J. Halle-Smith, L. Hall, R. Pande, K. Roberts
HPB and Transplant Unit, Queen Elizabeth Hospital Birmingham, United Kingdom

Introduction: Various perioperative interventions designed to reduce postoperative pancreatic fistula (POPF) rate after pancreaticoduodenectomy (PD) have been evaluated, but most are unsuccessful. The aim of this study was to provide a contemporary report of the efficacy of different interventions and identify areas for future investigation in this complex field.
Method: A systematic review of the literature for RCTs evaluating perioperative interventions to reduce POPF after PD was performed according to the PRISMA guidelines. Meta-anlayses were performed for each intervention.
Results: Some 20 interventions (n=6,628 patients, 56 studies) were identified. Four interventions reduced POPF after PD on MA: external pancreatic stent vs. no stent (OR 0.42; 95%CI: 0.25-0.70); p< 0.005); invagination PJ vs. duct to mucosa PJ (OR 0.60; 95%CI: 0.40-0.90; p=0.01); pancreaticogastrostomy (PG) vs. PJ (OR 0.69; 95%CI: 0.49-0.99; p=0.04) and omission of intraabdominal drains in patients with low risk PJ anastomoses (OR 0.52; 95%CI: 0.34-0.81; p< 0.005). Two interventions with data available from only one RCT were shown to reduce POPF: end to side vs. classic pancreaticojejunostomy (PJ) (OR 0.25; 95%CI 0.07-0.96; p=0.041) and closed suction drainage of pancreatic duct (OR 0.44; 95%CI: 0.2-0.99; p=0.045). One intervention, acute normovolaemic haemodilution, increased POPF rate in one RCT (OR 3.29 95%CI:1.11-9.77; p=0.045).
Conclusions: Current evidence for perioperative interventions to reduce POPF after PD is heterogenous and frequently from underpowered RCTs. To further clinical knowledge in this complex field future RCTs should be better powered and flexible enough to involve evaluation of the promising novel strategies identified in this review.
PP04-119 Vascular Anomalies in Pancreatic Head Resection Do Not Impact Surgical Outcome in High Volume Center
Isabella Frigerio, Italy

I. Frigerio1, S. Mancini1, V. Allegrini1, A. Giardino1, P. Regi1, R. Girelli1, P. Tinazzi Martini2, F. Scopelliti1, G. Butturini1
1Pancreatic Surgical Unit, Pederzoli Hospital, Italy, 2Radiology, Pederzoli Hospital, Italy

Background: Vascular anomalies(VA)in pancreaticoduodenectomy(PD)may impact both surgical and oncological outcome.Focused preoperative workout aims to detect these anomalies and therefore prevent intraoperative unwanted events.We present our experience of PD in patients with or without VA.
Patients and methods: We retrospectively analysed pre, intra and post-operative data of patients from prospective datatbase with VA undergone PD and compared them to noVA. VA were: replaced and accessory right hepatic artery (rRHA,aRHA)), hepatomesenteric trunk (HMT) and celiac-axis (CA) stenosis. Operative time, blood loss, morbidity, lenght of stay, need of reoperation and R-status were specifically considered.
Statistical analysis: Continous variables were analysed using Student's t-test or Mann-Whitney U test. Categorical variables were compared using Chi-Square test or Fisher's exact test when appropriate.A p-value< 0 .05 was considered as statistically significant.
Results: 72 patients VA underwent PD and were compared with 72pts noVA observed in the same period. Abdominal complications occurred in 79,2% and 52,5% of noVA and VA respectively(p:0,001). Abdominal fluid collection in 38.9% vs 22,2% p:0.04, need for transfusion in 48,6% vs 20,8% p:0.001 and lenght of stay 17days vs 11,5 p:0.001 for noVA and VA respectively.At multivariate analysis LoS is significatively shorter in VA.
Conclusion: In our series patients with VA have a better postoperative outcome and shorter stay: experienced surgeon used to plan preoperative strategy based on imaging and increased attention in lamina and selective vascular dissection when aware of the anomaly may play a role.Technical tricks to intraoperatively detect VA are known and need to be routinely applied.
PP04-120 Pancreaticoduodenectomy Performed by Surgeons in Training and the Risk of Post-operative Fistula: A Systematic Review and Meta-analysis
Damian Broadhurst, United Kingdom

D. Broadhurst, T. Thorne, J. Halle-Smith, R. Pande, K. Roberts
Department of Hepato-Pancreato-Biliary and Liver Transplantation Surgery, University Hospitals Birmingham, United Kingdom

Introduction: The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining vital experience. This meta-analysis sought to establish the POPF rate following PD by trainees or established surgeons.
Methods: A systematic review of the literature was performed using PRISMA guidelines and meta-analysis compared complication rates using RevMan software.
Results: 3 of 53 studies were included for meta-analysis, all defining POPF using ISGPS 2005 criteria. Some 309 PD (16%) were performed by trainees. The rate of POPF after surgery performed by those who had completed training was not different when surgery was performed by trainees (19.6 vs 23.0%; OR: 0.65; 95%CI 0.36-1.18; p=0.07) or mortality (OR: 1.08; 95%CI 0.30-3.97; p=0.60). Neither soft pancreatic texture (OR: 0.62; 95%CI: 0.19-1.99; p=0.042) nor pancreatic duct width significantly differed between the two groups. Gastrointestinal bleeding, blood loss and operative time were greater when operations were performed by trainees but there was no difference in delayed gastric emptying, intra-abdominal collection or mortality.
Conclusions: PD, when performed by trainees, is associated with acceptable outcomes. Evidence of heterogeneity in key variables indicates a need for further studies and it is unclear whether outcomes are similar when trainees perform surgery among patients stratified as low or high risk for POPF using established risk scores. The use of risk adjusted CUSUM as reported recently could be a useful tool to assess trainees performance.
PP04-122 Central Pancreatectomy - Our Experience in a Tertiary Care Centre in Southern India
Madhur Pardasani, India

M. Pardasani, P. Nekarakanti, A. Bansal, V. Thumma, G.S. Varma, N. Kunduru, B. Nagari
Surgical Gastroenterology, Nizams Institute of Medical Sciences, India

Background: Pancreatic benign and low grade malignant tumors located in the body and neck of pancreas pose a challenge to surgeon for extent of pancreatic resection. The study was to done to evaluate the role of central pancreatectomy in intermediate located tumors.
Methodology: The study is a retrospective analysis of prospective maintained database from 2005 to 2019 at a tertiary care hospital in India. Demographic, clinical, operative and postoperative characteristics were recorded and analysed.
Results: Ninteen patients (16 females) underwent central pancreatectomy. The Median Tumor size was 5cm. Proximal stump duct was ligated in all patients. 85% of Distal stump were managed with Pacretaicojejunostomy. Complications seen were Pancreatic fistula (Biochemical leak n=7/19, GradeB n=2/19); Delayed Gastric emptying (GradeA n=6/19; GradeB n=2/19) and Hemorrhage( GradeA n=2/19; GradeB n=1/19) None had in-hospital mortality. Histopathology results showed( serous cystadenoma- 10/19; Solid pseudopapillary tumor (SPEN)- 7/19, Mucinous cystadenoma- 1/19; Focal pancreatitis-1/19).New onset Endocrine insufficiency and endocrine insufficiency was seen in 10% each during median follow up of 72 months.
Conclusion: Central pancreatectomy offers lesser pancreatic insufficiency with acceptable morbidity.
Keywords: Pancreatic Neck and Body tumors, Central Pancreatectomy.
PP04-123 The Oncologic and Long-term Outcomes of Laparoscopic Distal Pancreatectomy for Pancreatic Cancer
Akira Matsushita, Japan

A. Matsushita1, Y. Aoki1, R. Kondo1, T. Kanda1, T. Shimizu1, M. Yoshioka1, Y. Kawano2, Y. Nakamura3, H. Yoshida1
1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Japan, 2Department of Surgery, Nippon Medical School Chiba Hokusou Hospital, Japan, 3Department of Surgery, Kamisu Saiseikai Hospital, Japan

Introduction: The recent advances of surgical techniques and technology allow minimally invasive surgery to be applied in patients with malignant diseases of the pancreas. We report the oncologic outcomes and long-term outcomes of laparoscopic distal pancreatectomy (Lap-DP) for pancreatic cancer compared with open surgery.
Methods: Seventy- three patients underwent laparoscopic and open distal pancreatectomy for pancreatic cancer were included in the study. Patients who had been diagnosed with the tumor in body and tail of the pancreas without suspicion for involvement of major vessels and other organs except left adrenal gland were eligible for Lap-DP. Postoperative, oncologic and long-term outcomes of patients undergoing Lap-DP (n = 47) or Open-DP (n = 26) were compared.
Results: Lap-DP was associated with less blood loss (125 vs. 441 mL, p< 0.05). Operative time was significantly longer in Lap-DP group, when compared with Open-DP group (315 vs. 251 min). Pancreatic fistulas (ISGPF B/ C, 10.6 vs. 7.7 %) were similar between Lap-DP and Open-DP, respectively. There was no mortality in the two groups. Resected lymph nodes (19 vs. 21) were similar in the two groups. Lap-DP was associated with a significantly lower rate of lymph nodes metastasis (35vs. 65%, p< 0.05). Rate of negative margins were similar between Lap-DP and Open-DP, respectively (89 vs. 85%). Long-term outcomes of Lap-DP were similar when compared to Open-DP by Kaplan-Meier method.
Conclusion: Lap-DP for pancreatic cancer is less invasive, feasible. It seems to achieve similar oncologic and long-term outcomes to open approach.
PP04-126 Comparison of Observed vs Predicted Outcomes from NSQIP for Pancreaticoduodenectomy at a Pancreatic Surgery Unit
Izhar-Ul Haque, Australia

I.-U. Haque1, R. Gaszynski2, C. Apostolou2, A. Das2, R. Wilson2, N. Merrett2
1HepatoPancreaticoBiliary Surgery, Bankstown Hospital, Australia, 2HepatoPancreaticoBiliary Surgery, Bankstown Hospital, Australia

Introduction: Although the mortality of pancreaticoduodenectomy has decreased significantly over the last few years, with a current 30 day mortality of 1% in NSW hospitals, the morbidity, length of stay and readmission rates remain high when compared to other complex surgical procedures. Our aim was to ascertain accuracy of the ACS NSQIP risk calculator for pancreaticoduodenectomy. Estimating Perioperative risk accurately can allow future patients to make an informed decision about undergoing Pancreaticoduodenectomy; provide a benchmark for safe, high-quality Pancreatic surgery and help target complication-reduction measures for hospital staff.
Methods: A retrospective analysis of patients undergoing PancreaticoDuodenectomy at our hospital from July 2015 to July 2017 was performed. Patients found to be inoperable during the procedure or who had subtotal or distal pancreatectomy were excluded. For 5 main parameters, observed outcomes were measured against predicted outcomes using ACS-NSQIP Surgical Risk Calculator for Pancreaticoduodenectomy.
Results: During the 24-month period, 45 patients underwent Pancreticodudenectomy for various pathologies, including 16 for pancreatic Adenocarcinoma, 6 for Cholangiocarcinoma, 5 for ampullary adenocarcinoma, 5 NETs, 5 IPMN and 5 others. 30-day mortality was slightly higher than the NSQIP prediction (2 deaths -4.4% vs predicted 1.2% mortality). Return to theatre rate was higher than predicted (8 cases- 17.7% vs 4.3% predicted). There were fewer actual Readmission rates (4.4% vs 11.8% predicted), observed Serious complications (17.7% vs 20.7% predicted) and observed Surgical Site infections (11.1% vs 15.6% predicted).
Conclusions: NSQIP Calculator does not accurately predict Observed outcomes for pancreaticoduodenectomy.
PP04-127 The Effect of Preoperative Immunonutrition on Surgical Outcomes in Patients Undergoing Resection for Pancreatic Malignancy
Michael Rouse, Australia

M. Rouse1, I. Deftereos2,3, O. Onasanya1, J. Choi1, S. Chan1, V. Usatoff1
1Upper GI/HPB Unit, Department of Surgery, Western Health, Australia, 2Nutrition and Dietetics, Western Health, Australia, 3Surgery, Western Health, Footscray, University of Melbourne, Australia

Introduction: The impact of perioperative immunonutrition in pancreatic cancer surgery remains controversial. While some studies have demonstrated a positive impact on outcomes in well-nourished patients, others showed no difference in outcomes. In a recent study examining the effects after pancreatic and gastric cancer surgery, benefits were only identified in malnourished patients. Our goal was to assess the effect of perioperative immunonutrition on the surgical outcomes of patients undergoing pancreatic cancer resections in our institution.
Methods: A retrospective review of a prospectively collected database of 101 consecutive patients undergoing surgery for suspected pancreatic malignancy in our centre over an eight-year period was conducted. The demographics, nutritional status, and other relevant endpoints such as grade of surgical complications and length of stay were obtained.
Results: 8 patients with benign final histology were excluded. Patients with incomplete data on immunonutrition were also excluded from the final analysis. 36 patients received perioperative immunonutrition while 43 patients did not. There was no statistically significant difference in the infective complications between the two groups and the severity of complications including the median lengths of stay were also similar in both groups.
Conclusion: The efficacy of immunonutrition in improving the outcomes of pancreatic cancer resections remains to be proven. Our project is an example of early collaboration with allied health team to improve the outcomes of pancreatic cancer. Given the small sample size of our study and other limitations, further investigations are required to answer this pertinent question.
PP04-128 Long-Term Nutrition Status after Total Pancreatectomy in Elderly Patients
Shimpei Maeda, Japan

S. Maeda, M. Mizuma, H. Ohtsuka, H. Hayashi, K. Nakagawa, T. Morikawa, F. Motoi, T. Kamei, M. Unno
Department of Surgery, Tohoku University Graduate School of Medicine, Japan

Introduction: Total pancreatectomy (TP) is increasingly performed even for elderly patients; however, nutrition status after long-term survival is not well evaluated.
Methods: A retrospective review of 39 patients who underwent TP at our institution between 2007 and 2016 and survived more than 3 years. Patients were divided into 2 groups: 80 years or older (n=6) and younger than 80 years (n=33) at the time of analysis. Nutrition status was categorized as normal, light, moderate, or severe according to CONUT score, and evaluated at 2 time points: 1 year after surgery and the last follow-up.
Results: The median age at analysis was 82 years in the elderly and 67 years in younger patients. Time after surgery was not different between the groups (5.5 vs. 5.0 years). Nutrition status at 1 year after surgery was normal in 4 (67%) patients and light in 2 (33%) in the elderly, and normal in 16 (52%), light in 13 (42%), and moderate in 2 (6%) in younger patients, respectively (p=0.7). Nutrition status at the last follow-up was normal in 3 (50%) patients, light in 1 (17%), and moderate in 2 (33%) in the elderly group, and normal in 14 (42%), light in 11 (33%), moderate in 7 (21%), and severe in 1 (3%) in the younger group, respectively (p=0.8). Distribution of improved or stable nutrition status compared to 1 year after surgery was similar between the groups (67% vs. 68%).
Conclusion: TP can be performed safely for elderly patients from the long-term nutritional viewpoint.
PP04-130 Minimally Invasive Surgery for Cystic Neoplasms of Pancreas - a Single Centre Experience
M Srinivasan, India

M. Srinivasan1, S. Srivatsan Gurumurthy1, P. Senthilnathan1, V. Nalankilli2, N. Anand Vijai2, C. Palanivelu2
1Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India, 2Gem Hospital, India

Introduction: Cystic neoplasms of pancreas are being detected in increasing frequency in recent times owing to frequent use of cross sectional imaging and the role of minimally invasive surgery in the management of cystic neoplasms of pancreas is on the rise.
Methods: A Retrospecive analysis of prospectively maintained database was conducted on all patients who underwent minimally invasive surgery for cystic neoplasms of pancreas from Jan 2009 to Dec 2019. Comparative analysis of perioperative outcomes of Laparoscopic vs Robotic surgery for PD and DPS groups was done.
Results: A total of 43 case of cystic neoplasms of pancreas underwent minimally invasive surgery (Laparoscopic - 31 and robotic - 12) during the study period. Out of the 43 patients, 16 underwent Distal pancreatectomy with splenectomy, 6 underwent spleen preserving Distal pancreatectomy, 12 underwent Pancreaticoduodenectomy, 6 underwent Central pancreatectomy and 3 underwent enucleation.
The mean operative time, blood loss and postoperative stay were 372 +/- 39 mins, 266 +/- 82 ml and 7 +/- 1.5 days for Lap PD vs 480 +/- 42 mins, 263 +/- 84 ml, 7 +/- 1.5 days for Robotic PD respectively. Clinically relevant POPF rates were 7% and 8% respectively. For the DPS group, the mean blood loss was 162 +/- 45 ml for Lap DPS vs 190 +/- 60 ml for Robotic DPS respectively. There was one mortality in PD group.
Conclusion: Minimally invasive surgery for cystic neoplasms of pancreas is safe and feasible. Both laparoscopic and robotic surgery have comparable perioperative outcomes.
PP04-131 Post Operative Outcomes after Pancreaticoduodenectomy: A Single Centre Experience of 212 Case in North India
Ram Daga, India

R. Daga, N. Jangir, L. Yadav, R. Rao, G. Chouhan, S. Gupta
Surgical Gastroenterology, SMS Medical College, India

Introduction: To evaluate outcomes of Pancreaticoduodenectomy (PD) at Surgical Gastroenterology unit at Government Medical College Hospital in North India.
Method: Retrospective analysis of prospectively maintained database of pancreaticodudnectomy patients was done and early postoperative complications and outcomes were evaluated.
Results: A total of 212 patients underwent PD from January 2013 to December 2019. 130 were male and 82 were female. 194 patients underwent open PD and 18 underwent laparoscopic/ laparoscopic assisted PD. 162 operations were done for Periampullay Ca., 26 for carcinoma head of pancreas, 7 for neuroendocrine tumor, 2 for GIST, 1 for carcinoma stomach, 2 for Ca. Gallbladder with ampullary Ca. (dual malignancy) and 2 for tubercular CBD stricture and 10 for chronic pancreatitis. Overall mortality was 4.2% (9 patients). Most common morbidity was surgical site infection in 44 patients (21%). Pancreatic fistula rate was 12.7% (27 patients), of which 20 patient has type A leak, 6 patient has type B leak and 1 patient has type c leak. Incidence of postoperative bleed was 2.83% (6 patients).
Conclusion: With adequate surgical expertise and evidence based perioperative care and multispecialty approach, pancreaticodudenectomy can be performed at medical college hospital with low morbidity and mortality.
PP04-132 Recurrent Bleeding from Ruptured Pseudoaneurysm due to Coil Migration Caused by Tapering Vassopressor after Initial Hepatic Artery Embolizationin Patient with Pancreatoduodenectomy: A Case Report
Naru Kim, Korea, Republic of

N. Kim1, S.H. Choi2
1Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University, Korea, Republic of, 2Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Sungkyunkwan University/Samsung Changwon Hospital, Korea, Republic of

Background: Hemorrhage after pancreatic surgery is dangerous and rebleeding after first bleeding management can be directly related to mortality if it is not managed early.
Method: An 79-year-old male was admitted with hematochezia. He underwent pylorus preserving pancreatoduodenectomy due to distal bile duct cancer 1 month ago. He was diagnosed with pseudoaneurysm rupture at local hospital and took successful common hepatic artery embolization with coil. The patient was admitted to the ICU with continuous infusion of norepinephrine(NE) due to low blood pressure(BP) at the time of admission. The patient's BP was stable and without additional bleeding, reduced NE and stop. Two hours after NE stop, the patient complained of abdominal pain and large amount of hematochezia followed.
Result: The patient's progress was observed with transfusion, but hemoglobin(Hb) level was 4.7g/dl after 10 hours and hematochezia also continue. We decided to repeat diagnostic angiography. The angiogram found that the contrast leak was inside the pseudoaneurysm sac. In the previous procedure, the coil was curled up to the splenic artery branch, which made additional coiling difficult. Further embolization was performed using diluted glue. After re-embolization, there was no more bleeding during the hospital stay and the Hb level rose to 9.2g/dl and the patient's condition gradually stabilized.
Conclusion: After embolization, the patient's condition improves and the vassopressor can be discontinued, causing the arterial wall to relax and the coil to fall out. Therefore, rapid and aggressive angiography during mass recurrent bleeding after embolization can help to find the cause of bleeding.
PP04-133 Compliance and Outcome of Patients in Pancreatic Surgery under ERAS Protocol - The Medical City Experience
Ryan Joseph de Gracia, Philippines

R.J. de Gracia, C. Alfonso
Surgery, Section of HPB, The Medical City, Philippines

ERAS principle on Pancreatic surgery are said to be safe and achievable with good outcomes. After the release of Pancreatic ERAS protocol and our institution being the Center for ERAS, this study aims to apply those principles on our pancreatic surgical cases and test if compliance will result to good outcomes. Data are encoded in the ERAS audit system then results are interpreted. 40 cases encoded as pre ERAS (2010-2017) 17 cases under ERAS (2018-2019). Our Compliance rate has increased 60% from 41% pre ERAS with declining complication rate of 41.2% from 57.5%. Median LOS is almost similar at 6-7 days. Our weakness in compliance is mostly at post Surgery phase where in critical timing for oral intake can either lead to fast recovery or result to complication such as leaks. Mobilization time of patients according to the recommendation from the protocol are sometimes difficult to document due to short personel. ERAS seems to be safe but more cases are needed to fully see the outcomes. Prehabilitation, carbo loading and lesser NPO time can help improve postoperative rate. Resumption of oral intake should be not be immediate and GUT status must be evaluated clinically first to avoid early GUT related complications.
PP04-134 Resection of the Primary Gastrointestinal Neuroendocrine Tumor among Patients with Metastatic Neuroendocrine Tumors Improves Overall Survival
Anghela Paredes, United States

A. Paredes, M. Hyer, D. Tsilimigras, A. Ejaz, J. Cloyd, M. Dillhoff, A. Tsung, T. Pawlik
Department of Surgery, The Ohio State University Wexner Medical Center, United States

Introduction: Among patients with metastatic gastrointestinal (GI) neuroendocrine tumor (NET), the role of primary tumor resection remains unknown. We sought to analyze if primary tumor resection of NET was associated improved overall survival (OS).
Methods: Individuals diagnosed with Stage IV GI NETs were identified in the linked Surveillance, Epidemiology, and End-Results-Medicare database from 2004-2016. OS of patients who did versus did not undergo primary tumor resection was examined using the Kaplan-Meier method.
Results: Overall 3,562 patients (median age: 70, IQR: 64-77; male 53.3%) were identified who had metastatic GI NETs at time of diagnosis. The majority of individuals had a NET in the pancreas (n=1,451, 40.7%); the most common site of metastatic disease was the liver (n=1,684, 47.3%). Overall, 1,425 (40.0%) individuals underwent primary tumor resection whereas a smaller subset (n=264, 7.4%) had liver directed surgery only for metastatic disease. Individuals who had primary tumor resection were slightly younger (71yr, IQR 65-78 vs. 68yr, IQR 63-75) and more commonly had small intestine NET (12.6% vs. 49.6%)(both p< 0.001). After adjusting for demographic factors, as well as tumor grade and receipt of liver directed therapy, primary NET resection remained associated with improved OS (HR: 0.58, 95%CI 0.52-0.64; p< 0.001)(Figure).
Conclusion: Primary NET resection was associated with a survival benefit among individuals presenting with metastatic GI NET.
PP04-135 Pancreatic Ductal Disruption Syndrome - An Aggresive Approach
Vimalakar Reddy, India

V. Reddy, K.V. Dinesh Reddy
Surgical Gastroenterology, Sunshine Hospital, India

Introduction: Pancreatic ductal disruption syndrome is rare complication of pancreatitis causing severe morbidity and mortality.
Pleural effusion as a consequence of acute pancreatitis is transient, usually left sided.
Rarely, it may be right sided causing diagnostic dilemma,difficult to establish as a complication of pancreatitis.
Early diagnosis and intervention reduces morbidity and mortality.
Method: We report a case of acute pancreatitis with ductal disruption , ascites , right sided pleural effusion with severe respiratory distress,managed successfully with distal pancreatectomy.
Case report: A 32- year old gentelman presented with shortness of breath and since 7 days.
Known alchohalic and gutka chewar since 20 years.
Intially managed elsewhere with chest tube and ERCP( stenting ).
Due to shortness of breath reffered to our hospital .
On arriving, immediately an inter costal draining tube was placed which drained 3 liters of fluid.
A ct done which revealed acute pancreatitis with ascites and right pleural effusion
started on octreotide infusion and TPN.
Chest Tube Drain -High Nearly 500ml A Day.
MRCP was done wich revealed distal pancreatic ductal disruption.
So,laparotomy Was Done On 4 th Day Of Admission(Distal Pancreatectomy)
Operative Findings: Free Fluid Of 1 Litre Drained.
Disrupted Distal Pancreatic Duct.

A Complete recovery was seen in a week,with unremarkable follow up.
Conclusion: Early aggressive approach to address the cause of pancreatic ascites that is pancreatic ductal disruption is needed.
In pancreatic ductal disruption with failed ERCP stenting, hemodynamically stable,dispite pleural effusion ,distal pancreatectomy will reduce the hospital stay and morbidity.
PP04-136 Minimally Invasive Pancreaticoduodenectomy in Pancreatic Cancer Patients after Neoadjuvant Chemotherapy - Is it Safe?
Katharine Caldwell, United States

K. Caldwell, C. Hammill, W. Hawkins, D. Sanford
Hepatobiliary Surgery, Washington University in Saint Louis, United States

Background: Neoadjuvant therapy is increasingly being utilized in pancreatic cancer (PDAC) patients. The benefits of minimally invasive pancreaticoduodenectomy (MIPD) over open pancreaticoduodenectomy (OPD) are controversial, and perioperative outcomes of MIPD after neoadjuvant therapy has not been studied.
Methods: The pancreatectomy-targeted American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database was used to examine the outcomes of PDAC patients who underwent MIPD or OPD between 2014--2017. Patients who received neoadjuvant therapy and underwent MIPD were propensity score matched to those who underwent neoadjuvant and OPD based on demographic, oncologic, and operative factors and perioperative outcomes were compared.
Results: 2,313 patients received neoadjuvant therapy and underwent pancreaticoduodenectomy during the study period. 197 (8.5%) underwent MIPD. Compared to OPD, MIPD patients had decreased rates of blood transfusions (15.2% vs 26.3%, p< 0.01), overall complications (47.2% vs 54.7%, p=0.04), and postoperative length of stay (LOS) (7.9 days vs 9.7 days, p< 0.01). MIPD patients had a higher rate of 30-day readmission (20.8% vs 14.7%, p=0.02). There was no difference in 30-day mortality between MIPD and OPD (2.0% vs 1.4%, p=0.49). After 1:3 propensity matching 197 MIPD to 591 OPD patients, MIPD had a decreased rate of blood transfusion (15.2% vs 23.0%, p=0.02) and postoperative LOS (7.9 vs 9.5, p< 0.01), but increased rate of 30-day readmission (20.8% vs 13.4%, p=0.01). There was no significant difference in 30-day mortality between groups (2.0% vs 1.7%, p=0.76).
Conclusion: Among pancreatic cancer patients who receive neoadjuvant therapy, MIPD is safe with comparable perioperative outcomes to OPD.
PP04-138 Applying Benchmark Outcomes in Pancreatoduodenectomy at a Center in Chile
Carlos Derosas, Chile

J. Chapochnick, H. De La Fuente, C. Derosas, L. Paqui, I. Nachari, F. Izquierdo, R. Iñiguez, C. Navarrete
Department of Surgery, Clinica Santa María, Chile

Introduction: Pancreatoduodenectomy (PD) is a high demanding technical procedure, with significant risks of morbidity and mortality. Surgical departments performing this operation around the world should aim for results that are within the best expected outcomes. The aim of this study is to compare our results in PD using the recently published tool for outcome comparisons Benchmarks in Pancreatic Surgery. A Novel Tool for Unbiased Outcome Comparisons. (Ann Surg, 2019 vol. 270 (2) pp. 211-218.)
Methods: We reviewed all our PD performed from January 2015 to January 2020 in our institution and made a comparative table among patients within inclusion criteria and overall sample based on the paper proposal.
Results: The overall sample is 38 patients, the patients within the benchmark inclusion criteria were 28, the comparative results are shown in table.
Outcome BenchmarksWithin inclusion criteria N=28Overall Sample N=38Benchmark
Operative Time (hours)6.5 (4.4-11)6.1 (4.4-11)<7:30
LOS (Days)15.6 (10-53)16.1 (10-80)<15
Overall complication53.8%52.4%<73%
Clavien IV complication7.8%7.4%<5%
Pancreatic Fistula B-C11%18%<19%
In Hospital Mortality00<1.6%
R1 status3.7%5.2%<39%
1 year DFS85%73%>53%
[Benchmarks in PD in Clinica Santa Maria]

Conclusions: The benchmark outcomes stablished in the mentioned paper are a novel and excellent tool to avoid biases at the moment to analyze results, specially in a low volume center as ours. In the other hand is an inspiring tool to reach and improve the outcomes of our patients.
PP04-140 Biliary Complications during Neoadjuvant Therapy for Pancreatic Cancer
Steven Hughes, United States

S. Kirkpatrick, J. Cioffi, J. Trevino, S. Hughes
Surgery, University of Florida, United States

Introduction: Neoadjuvant therapy prior to resection of pancreatic head cancer increases time to surgery and thus the possibility of biliary complications. We determined the frequency and impact of biliary complications during neoadjuvant therapy prior to resection.
Methods: We completed a retrospective study of patients treated with neoadjuvant therapy for pancreatic head adenocarcinoma from May 2014 through March 2019.
Results: Of the 59 patients identified, the average age was 67 and 50.8% were male. Neoadjuvant therapy regimens included gemcitabine and abraxane + chemo-radiation (28 patients, 47.5%), FOLFIRINOX + chemo-radiation (15 patients, 25.4%) and remaining 16 patients received alternative therapeutic combinations based on tolerance. Six (10.1%) patients died prior to completion of neoadjuvant therapy. After completion of all neoadjuvant therapy, 34 (57.6%) patients went on to resection while 19 (32.2%) showed disease progression precluding surgical extirpation. Biliary complications during neoadjuvant therapy affected 16 patients (27%). Biliary interventions included percutaneous cholecystostomy drain (3 patients, 5.1%), ERCP with stent placement or exchange (6 patients, 10.1%), percutaneous transhepatic drain (4 patients, 6.8%) and hospital admission for cholangitis with medical treatment only (2 patients, 3.3%). Eight of the 16 patients with biliary complications went on to surgical resection (50%) compared to 26 of the 43 (60.4%) patients who did not have biliary complications. (χ2=0.18, p = 0.67).
Conclusion: Biliary complications during neoadjuvant therapy for pancreatic head cancer are relatively common, but do not significantly affect proceeding to surgical resection.
PP04-141 Use of Hemopatch as a Sealant at the Pancreaticojejunostomy to Prevent Postoperative Pancreatic Fistula. A Randomized Control Trial
Mario Serradilla-Martín, Spain

M. Serradilla Martín, A. Palomares Cano, M. Cantalejo Díaz, S. Paterna López, M. Gutiérrez Diez, T. Abadía Forcén, M. Allúe Cabañuz, A. Serrablo Requejo
Miguel Servet University Hospital, Spain

Introduction: Postoperative pancreatic fistula (POPF) is a common and most severe complication following pancreaticoduodenectomy (PD) (9.8% to 34.2%). POPF not only prolongs hospital stay and increases healthcare costs, but also plays a central role in the development of life-threatening events such as intra-abdominal abscess and postoperative hemorrhage. We present a new way to decrease POPF after PD using a NHS-PEG patch envolving duct-to-mucosa pancreaticojejunostomy (DTM).
Methods: Randomized control trial (NCT03419676) including 64 consecutive PD were performed from May 2018 to January 2020, using the same tecnique, 32 of them sealing with NHS-PEG patch after DTM. Both groups were statitiscally homogeneus. Demographic data were collected (age, gender, diagnosis, comorbidities), and rates of postopoperative complications (pancreatic fistula, biliary fistula, delayed gastric emptying, hemorrhage, readmission, exitus, and mean stay).
Results: A detailed analysis of the morbidiby rate and mortality at 90 days will be performed. The final results will be presented in the meeting in case of being accepted. (recruitment completed in January 2020).
Conclusion: Preliminary results based on an observational series of 26 patients after PD were presented at the E-AHPBA Meeting in Mainz in 2017. This RCT was conducted based on these previous data. If the results confirm it, sealing with NHS-PEG patch can offer a new posibility to decrease POPF, with less fistula rate B and C, less hospital stay and less healthcare costs.
PP04-142 Intraoperative Evaluation of the Hepatic Artery Blood Flow during Pancreatoduodenectomy (HEPARFLOW Study)
Mohammed Al-Saeedi, Germany

M. Al-Saeedi1, L. Frank-Moldzio1, M. Klauß2, P. Mayer2, T. Bruckner3, A. Mehrabi1, M. Diener1, 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: During pancreatoduodenectomy division of the gastroduodenal artery can disturb liver blood supply and result in liver ischemia in patients with celiac axis stenosis (CAS). We aimed to assess liver blood supply during pancreatoduodenectomy and the associated risk for ischemia.
Methods: This prospective observational study included patients undergoing partial or total pancreatoduodenectomy. Blood flow in the proper hepatic, gastroduodenal, additional arteries and in the portal vein was measured using Doppler flowmetry. Preoperative computed tomography was evaluated with focus on anatomic variations and CAS. Liver perfusion and function failure were recorded based on laboratory parameters. Other complications were also assessed.
Results: Between 04/2018 and 01/2019, 100 patients undergoing pancreatoduodenectomy were analyzed. Proper hepatic artery flow was 190.7±156.3 ml/min before, 187.4±158.8 ml/min after division of the GDA (P=0.431) and had increased by 60% to 305.6±224.6 ml/min at the end of surgery (P< 0.001). In the presence of replaced or accessory hepatic arteries (n=23) the total arterial blood flow per cubic centimeter of liver parenchyma was significantly higher compared to standard vascular anatomy (n=75) (0.29±0.13 ml/(min.cm3) versus 0.23±0.13 ml/(min.cm3); P=0.044). The presence of CAS (n=35) was associated with lower total flow (0.20±0.11 ml/(min.cm3) versus 0.27±0.14 ml/(min.cm3); P=0.031) and with a trend towards increased severe complications (25.8% versus 10.9%; P=0.07).
Conclusion: This is the first study performing systematic intraoperative flow measurement to assess liver blood supply during pancreatoduodenectomy. CAS is a risk factor for reduced hepatic arterial flow and increased morbidity. Additional hepatic arteries increase total arterial flow and may be protective.
PP04-143 Whipple ERAS: Identifying an Actionable Cohort that Fails to Meet Length of Stay (LOS)
Ayala Carlos, United States

A. Carlos1, A. Lu2, A. Wilson3, J. Bergquist1, J. Norton1, G. Poultsides1, B. Visser1, M. Dua1
1Surgery, Stanford University, United States, 2Anesthesia, Stanford University, United States, 3Stanford University, United States

Pancreaticoduodenectomy (PD) is a complex surgical procedure that requires attentive perioperative care. Enhanced Recovery After Surgery (ERAS) protocols have emerged to enhance functional recovery, decrease complications, and reduce hospital length of stay (LOS). We successfully implemented an ERAS pathway for PD to optimize patient care. At our institution,a total of 142 PD procedures utilized the ERAS pathway over two years. We observed a LOS reduction from pre-ERAS vs post-implementation (mean LOS 10.5 vs 8.4 days); but still failed to achieve our target 7-day LOS for 65 patients (46%). The most common reason to fail pathway LOS was either ileus or delayed gastric emptying (36/65, 55%), leading to a longer LOS of 12 days. Within this subgroup, patients who required a nasogastric tube during the admission had longer LOS (13 vs 9 days, p< 0.05). Additional non-gastrointestinal reasons for the remaining “off pathway” patients (29/65, 45%) not meeting target LOS are described in Table 1. Of these 29 patients, 9 underwent computed tomography (on or after POD 7) and only 2 received an inpatient intervention during the extra LOS (1 drain study, 1 percutaneous drain manipulation). In conclusion, we found the most common reasons for PD pathway failure included slow return of gastric or bowel function, which are perhaps inevitable in some patients undergoing PD. The remaining patients not meeting ERAS target were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than pathway modification.
PP04-144 Early Venous Intervention during Resection of Pancreatic Neoplasms with SMV/PV Occlusions
Amy Li, United States

A. Li, J. Bergquist, M. Dua, B. Visser
Stanford University, United States

Introduction: Pancreatic neoplasms with superior mesenteric and/or portal vein (SMV/PV) occlusions present the significant (substantial) surgical challenge of mesenteric hypertension. We present a series of patients who underwent pancreas resection with complete SMV/PV occlusion.
Methods: A retrospective review of patients diagnosed with pancreas tumors with concomitant SMV/PV occlusions, and underwent pancreas resection with vascular intervention in the form of portosystemic shunting, resection and thrombectomy was performed. Demographics, perioperative characteristics and outcomes were reviewed.
Results: Eleven patients, with a median age of 56, underwent pancreas resection with vascular intervention for pancreas neoplasms with SMV/PV occlusion. The median follow-up was 26 months. Six patients were treated for pancreatic neuroendocrine tumor, two for pancreatic adenocarcinoma, two for solid pseudopapillary tumor and one for a cystic lesion believed to be a large cystic tumor (final pathology revealed sclerosing pancreatitis). Two underwent pancreaticoduodenectomy, 6 left sub- or near total pancreatectomy, and 3 total pancreatectomy. Six underwent early mesocaval shunting, with SMV/PV reconstruction following pancreas resection. Four underwent in-line SMV/PV reconstruction with conduit prior to the bulk pancreatic dissection/reconstruction, and one underwent early tumor thrombectomy. The internal jugular vein was graft of choice in nine patients. Median hospital length of stay was 11 days. Five patients developed complications with Clavien-Dindo grade >III. Six patients required readmission. There were no 90-day mortalities.
Conclusion: Despite the technical challenges that arise from the sequelae of SMV/PV occlusion, early mesenteric decompression via mesocaval shunting or immediate in-line SMV/PV reconstruction with graft allows pancreatectomy in the face of SMV/PV occlusion to be performed safely.
PP04-146 A Propensity Score-Matched Analysis of Continuous Vs Interrupted Duct-To-Mucosa Pancreaticojejunostomy in Laparoscopic Pancreaticoduodenectomy
M Srinivasan, India

M. Srinivasan1, S. Srivatsan Gurumurthy1, P. Senthilnathan1, V. Nalankilli2, N. Anand Vijai2, C. Palanivelu1
1Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India, 2Gem Hospital, India

Introduction: Despite marked improvements in postoperative care and widespread adoption of minimally invasive procedures, postoperative pancreatic fistula (POPF) continues to be a major cause of morbidity. While no single technique of PJ has been proven to be superior, a few reports have indicated that continuous duct-to-mucosa anastomosis can reduce operative time and rates of POPF. But, there is limited data on the feasibility and outcomes of this technique in laparoscopic PD.
Methods: Prospectively collected data of laparoscopic PD and their recorded operative videos over the past 5 years were collected. After propensity score matching, 30 cases of patients were chosen in Continuous duct-to-mucosa PJ (C-PJ) group and 30 cases in Interrupted Duct-to-mucosa PJ (I-PJ) group and the data was analysed for PJ anastomosis time, total operative time and POPF rates as primary outcomes and hospital stay as secondary outcome.
Results: The analysis revealed a significantly shorter time for PJ anastomosis in the C-PJ group. However, the overall operative time did not reach statistical significance. There was no difference in the rates of CR-POPF and hospital stay between the two groups.
Conclusion: Continuous suturing for duct-to-mucosa PJ in Laparoscopic PD is feasible even in undilated ducts. Propensity score matched analysis revealed that C-PJ reduces the time for PJ anastomosis while causing no difference in clinically relevant POPF.
PP04-147 Surgical Treatment of IPMN Based on the Preoperative Radiological Findings
Vladimir Djordjevic, Serbia

V. Djordjevic1, J. Djokic Kovac2, M. Micev2, D. Radenkovic1
1First Surgical Clinic, Clinical Center of Serbia, Serbia, 2Clinical Center of Serbia, Serbia

A growing number of patients are being diagnosed with the intraductal papillary mucinous neoplasm (IPMN) of pancreas. The European guide and revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas has been compiled to improve the diagnosis and treatment of these clinical entities. However, the available diagnostic tools lack of sufficient accuracy to be used independently.
The subject of this study will be to evaluate the correlation between preoperative radiological and postoperative pathological findings. Based on this we will assess the role of radiological findings in the choice of appropriate surgical intervention, the extent of resection and the type of digestive organ reconstruction in patients diagnosed with IPMN.
The study includes 63 patients diagnosed with IPMN (according to the classification provided by the World Health Organization) and treated at the First Surgical Clinic of the Clinical Centre of Serbia. The study monitors clinical symptoms and signs, preoperative radiological diagnostics, intraoperative findings with histopathological diagnostics, and postoperative complications. Furthermore, the type of surgical resection and reconstruction of the organ selected on the basis of the radiological examination are also monitored. The monitored radiological parameters include echo abdomen findings, endoscopic ultrasound, MDCT, MRI with MRCP, ERCP with mucin aspiration and histopathological verification.
This study will contribute to the advancement of diagnosis, surgical treatment and general management of patients with IPMN by examining the significance of radiological findings in assessing the need for surgical intervention, and in selecting the type of surgical organ reconstruction based on preoperative diagnostics.
PP04-148 Does the Modified Blumgart Anastomosis Improve the Outcomes of Pancreaticojejunostomy in Patients with Carcinoma of the Papilla of Vater?
Ryosuke Kashiwagi, Japan

R. Kashiwagi, S. Aoki, S. Maeda, M. Mizuma, K. Nakagawa, H. Hayashi, T. Morikawa, F. Motoi, M. Unno
Department of Surgery, Tohoku University Graduate School of Medicine, Japan

Background: Recently, some studies have shown that the modified Blumgart anastomosis (m-BA) for pancreaticojejunostomy is associated with a low postoperative pancreatic fistula (POPF) rate after pancreatoduodenectomy (PD). Patients with carcinoma of the papilla of Vater are likely to have soft pancreas which is a risk factor of POPF. The aim of this study was to evaluate whether m-BA reduced the occurrence of POPF in patients with carcinoma of the papilla of Vater.
Methods: Between 2006 and 2018, 49 patients with carcinoma of the papilla of Vater underwent PD at our institution. The m-BA has been used since 2016. We analyzed the short-term outcomes between the m-BA group (n=15) and the conventional anastomosis group (n=34). Grade B/C POPF was defined according to the 2016 ISGPS update.
Results: There were no significant differences in patient characteristics including sex, age, BMI, and UICC stage between the two groups. The rate of POPF did not differ between the groups (53.3% vs 50.0%). However, postpancreatectomy hemorrhage (PPH) in the m-BA group was significantly lower than the conventional group (0% vs 23.5%, p=0.04). Grade C POPF rate was lower in the m-BA group (0% vs 8.8%) but not statistically significant.
Conclusions: Although the rates of POPF were not dissimilar, the m-BA reduced the occurrence of PPH which is associated with more severe complications.
PP04-150 Treatment of Patients with High Benign Strictures of the Bile Ducts - The Experience of One Specialized Hepatopancreatobiliary Center
Sergei Trifonov, Russian Federation

S. Trifonov, Y. Kovalenko
National Medical Research Center of Surgery, Russian Federation

Relevance: Reconstructive surgeries of the bile duct for benign strictures are characterized by unsatisfactory results in 10-30% of patients. Percutaneous and endoscopic interventions are not always effective in cases of stricture recurrence.
Materials and methods.
From 2012 to 2018 in the Nаtionаl Mediсаl Reseаrсh Center of Surgery were treated 96 patients with benign bile stricture. The age of the patients was between 23 - 82 years, the mean age - 52.9 ± 12. Women - 71 (74%), men - 25 (26%). 53 (55.6 %) patients had a previously formed hepaticojejunostomy. Levels of stricture according to the classification of Bismuth-Strasberg: type E3 - 45, type E4 - 36, type E5 - 15. 72 (75 %) patients underwent hepaticojejunostomy and re HJ, including liver resections: left lateral sectionectomy - 3, right hepatectomy - 2, left hepatectomy - 2. 24 (25%) patients were performed percutaneous transhepatic biliary drainage (PTBD) with balloon dilation.
Long-term results were traced in 85 (89%) patients, follow-up periods 4.8 +/- 1.6 years after reconstructive operations. Excellent and good results (according to Terblanche J.) were achieved in 37 (61%) patients who underwent open reconstructive operations and 18 (78%) in patients after PTBD.
The best treatment results were observed in patients with preserved confluence - 92% of successful interventions. An independent risk of stricture recurrence a high level of stricture (type E4 - E5 according to Bismuth-Strasberg). Surgical treatment of treatment of benign strictures is the method of choice, with the ineffectiveness of endoscopic and percutaneous transhepatic biliary drainage.
PP04-151 The Effect of Perioperative Fluid Volume Restriction in Postoperative Complication of Pancreaticoduodenectomy
Jangho Park, Korea, Republic of

J. Park, H.M. Park, S.-S. Han, S.J. Park, J. Yu, S.-A. Lee, S.-W. Kim
National Cancer Center, Korea, Republic of

Background: Complications following pancreaticoduodenectomy are reported to be still high. Pancreatic fistula has been the most common complication after the surgery. Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. However, there are few studies regarding fluid restriction of pancreatobiliary surgery. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy between fluid restriction group and conventional management group.
Methods: Between September 2017 and January 2020, 64 patients were enrolled for perioperative fluid restriction of pancreaticoduodenectomy. Of 64 patients, 51 patients were finally analyzed in this study. We compared these patients with fluid restriction and the patients managed conventionally. Conventional management group consisted of 145 patients who underwent pancreaticoduodenectomy from March 2013 to March 2016.
Results: The rate of major morbidity which was defined as any complication from grade III to V on the Clavien-Dindo scale in fluid restriction group was not significantly higher than that in conventional management group (21.6% vs. 18.6%; p=0.647). Rate of clinically relevant postoperative pancreatic fistula (CR-POPF) in fluid restriction group was not significantly higher, either (17.6% vs. 12.4%; p=0.351).
Conclusion: Perioperative fluid restriction was not helpful to prevent major morbidity, especially CR-POPF following pancreaticoduodenectomy.
PP04-152 Oncological Outcome after Minimally-Invasive or Open Pancreatoduodenectomy for Pancreatic Cancer: An International Propensity-Score Matched Study
Frederique Vissers, Netherlands

F. Vissers1, S. van Roessel1, S. Klompmaker1, M. Abu Hilal2, M. Besselink1, U. Boggi3
1Surgery, Amsterdam UMC, University of Amsterdam, Netherlands, 2Surgery, Fondazione Poliambulanza Hospital, Italy, 3Surgery, Pisa University Hospital, Italy

Introduction: Minimally-invasive pancreatoduodenectomy (MIPD) has been suggested as an alternative to open pancreatoduodenectomy (OPD). However, large international multicenter studies comparing oncological outcome after MIPD and OPD for pancreatic cancer are lacking.
Methods: A multicenter international propensity-score matched retrospective cohort study including all consecutive patients undergoing MIPD or OPD (January 2010 to July 2019). Patients who had grossly positive resection margins (R2) or metastatic disease were excluded. Patients after MIPD were matched on a 1:1 ratio to OPD controls using propensity scores based on age, sex, BMI, ASA, abdominopelvic surgical history, and tumor size. Propensity score matching is applied to reduce the effect of confounding by indication. Primary outcome was overall survival, secondary outcomes included margin negative resection rate (R0), total number of extracted lymph nodes and chemotherapy rate. Outcomes were addressed by Kaplan-Meier analyses with between group comparisons (log-rank tests) and a multivariable Cox survival model to adjust for remaining confounders unaccounted for by matching (T stage, N stage, tumor grade).
Results: A total of 695 MIPD from 20 centers in 8 countries and 900 OPD from 5 centers in 5 countries were collected. Statistical analyses on survival and oncological outcomes will be finished by the end of February 2020.
Conclusion: This is the first large international multicenter study comparing outcomes after MIPD and OPD for pancreatic cancer. Results will be available upon acceptance for IHPBA 2020.
PP04-154 Surgical and Oncological Outcomes from the Experience of 5,000 Pancreatectomies in Single Institution
Yoonhyeong Byun, Korea, Republic of

Y. Byun, Y. Han, J.S. Kang, Y.J. Choi, H. Kim, W. Kwon, J.-Y. Jang
Department of Surgery, Seoul National University Hospital, Korea, Republic of

Introduction: Pancreatectomy has been performed in limited centers due to the surgical complexities and high operative morbidity/mortality. During 50 years, there are many changes in epidemiology and surgical outcomes regarding pancreatectomy.
Methods: Since the first pancreatectomy in our hospital at 1961, total 5274 pancreatectomies were performed until 2019. According to the time period, diseases entities and short/long-term outcome were investigated.
Results: The overall age and the proportion of pancreatic cancer (PC) has been increased gradually over time. The proportion with PC was most common (30.1%), followed by pancreatic cyst (22.9%), common bile duct (CBD) cancer (16.8%), and ampulla of Vater (AoV) cancer (15.4%). The incidence of postoperative complications tended to be decreased over time (28.6% in 2001-2005, 20.6% in 2016-2019). The 5-year survival rate for malignancies was best in AoV cancer (58.9%), followed by CBD cancer (44.1%), duodenal cancer (38.1%), and PC (23.0%). In comparison of survival outcomes before and after 2000 with each stage of malignancies, PC showed statistically significant improvement (Overall survival; stage I, 32 vs. 84 months, p=0.004; stage II, 13 vs. 25 months, p< 0.001; stage III, 9 vs. 17 months, p=0.001). In a field of minimally invasive surgery, the number of laparoscopic and robotic pancreatectomies has been increased every year.
Discussion: This study shows the trends of pancreatic resection over time. The proportion of PC and pancreatic cyst is increased and its treatment outcomes including complication and survival are also improved.
PP04-155 Preoperative Sarcopenia Is an Independent Risk Factor for Patients with Pancreatic Cancer who Underwent Curative Resection
Toshiya Abe, Japan

T. Abe, S. Kozono, H. Kuga, Y. Abe, K. Nishihara
Kitakyushu Municipal Medical Center, Japan

Background: Preoperative nutritional and immunological patient factors have been found to be associated with prognostic outcomes of malignant tumors; however, the clinical significance of these factors in pancreatic ductal adenocarcinoma (PDAC) remains controversial.
Objective: The purpose of this study was to evaluate the prognostic value of nutritional and immunological factors including sarcopenia in predicting survival of patients with PDAC.
Methods: Retrospective studies of 156 patients who underwent surgical resection for PDAC between 2007 and 2019 were conducted to investigate the prognostic impact of tumor-related factors and patient-related factors, including Skeletal muscle index (SMI), Visceral adipose tissue accumulation, Glasgow Prognostic Score (GPS), modified GPS, Prognostic Nutritional Index, and neutrophil/lymphocyte ratio.
Results: In multivariate analysis, low SMI was an independent factor for OS (HR, 2.82; 95% CI, 1.69-4.71; P < 0.001) and DFS (HR, 1.64 95% CI, 1.02-2.63; P = 0.04). The low SMI group was significantly associated with no adjuvant chemotherapy (P =0.015), BMI (< 22) (P < 0.001), tumor size (>2cm) (P=0.035), Histologic grade (Mod/Poor) (P < 0.001) compared with the high SMI group.
Conclusions: Perioperative nutrition therapy and rehabilitation might contribute to improve prognosis in patients with PDAC.
PP04-157 Prognostic Impact of Simultaneous Venous Resections during Surgery for Resectable Pancreatic Cancer
Stefan Löb, Germany

F. Anger, A. Doering, J. Schuetzler, C.-T. Germer, A. Wiegering, J.-F. Lock, V. Kunzmann, I. Klein, S. Löb
University Hospital Wuerzburg, Germany

Background: The aim of this study was to evaluate the prognostic impact of simultaneous venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) that was preoperatively staged resectable according to NCCN guidelines.
Methods: A retrospective analysis of 153 patients who underwent PD for PDAC was performed. Patients were divided into standard PD and PD with simultaneous vein resection (PDVR). Groups were compared to each other in terms of postoperative morbidity and mortality, disease free (DFS) and overall survival (OS).
Results: 114 patients received PD while 39 patients received PDVR. No differences in terms of postoperative morbidity and mortality between both groups were detected. Patients in the VR group presented with a significantly shorter OS in the median (13 vs. 21 months, P=0.011). In subgroup analysis, resection status did not influence OS in the PDVR group (R0 13 vs. R1 12 months, P=0.471) but in the PD group (R0 23 vs. R1 14 months, P=0.043). PDVR was a risk factor of OS in univariate but not multivariable analysis.
Conclusion: PDVR for PDAC preoperatively staged resectable resulted in significantly shorter OS regardless of resection status. Patients who require PDVR should be considered for adjuvant chemotherapy in addition to other oncological indications.
PP04-158 Results of Double-layer Running Suture Hepatico-jejunostomy in Pancreatoduodenectomy and Total Pancreatectomy
Niccolò Napoli, Italy

R. Caputo, N. Napoli, E.F. Kauffmann, C. Cacace, F. Menonna, A. Tudisco, V.G. Perrone, F. Vistoli, U. Boggi
Division of General and Transplant Surgery, University of Pisa, Italy

Introduction: The purpose of the study was to present the results of double-layer running suture hepatico-jejunostomy performed during pancreatoducodenectomy (PD) and total pancreatectomy (TP) with focus on bile leak (BL) and cholangitis related to anastomotic stricture (C-AS).
Methods: A prospectively maintained database was searched retrospectively for BL and C-AS occurring in a consecutive series of PDs and TPs, performed between 2007 and 2019.In all patients HJ was performed using a double-layer running suture of 5/0 or 6/0 polydioxanone. Biliary stents were never used. Incidence of BL was the primary study endpoint. Incidence of C-AS (≥3 episodes/year) was defined in patients with a minimum follow-up period of 3 years. The study aimed also at identifying factors predictive of BL and C-AS by using univariate and multivariate logistic regression.
Results: A total of 603 PDs and 197 TPs were performed. Incidence of BL was 0.9% (7/800) in the entire series, 0.63% in PD (5/603) and 1.02% in TP (2/197). BL were caused by HJ insufficiency in 5 patients (0.62%) and by patency Luschka's ducts in 2 patients (0.25%). Patients with HJ-related BL were reoperated (n= 4) or managed by biliary drainage (n= 1). C-AS occurred in 28/284 patients (0.9%). Recurrent cholangitis was diagnosed in 21 patients (7.4%) and was managed by either repeat HJ (n= 13; 4.6%) or percutaneous biliary interventions (n=4; 1.4%). Factors predictive of BL and C-AS were reported in table 1.
Conclusion: Double layer running suture HJ is associated with excellent BL rates and acceptable incidence of C-AS.
[Table 1 - Predictive factors of BL and C-AS]
PP04-159 GORE VIABAHN Stent Placement for Hemostasis of Bleeding by Pancreatic Fistula in Four Cases
Nobuyasu Suzuki, Japan

N. Suzuki, T. Abe
Department of HBP Surgery, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku General Hospital, Japan

Introduction: Due to recent advances in surgical techniques, and in perioperative management, the mortality rate after pancreaticoduodenectomy (PD) has significantly decreased. However, the morbidity rate remains significantly high after PD. In perioperative management of pancreatic surgery, postoperative abdominal hemorrhaging from the pseudoaneurysm is often fatal and as yet a treatment method has not been established. In the recent years, transcatheter arterial embolization (TAE) has been used for the treatment of this fatal complication, but it may lead to other organs ischemia. A hemostatic technique using a covered stent was previously reported for preventing ischemia. In early 2016, the GORE VIABAHN stent was approved for use in Japanese national insurance coverage in treating traumatic and iatrogenic vascular injuries.
Methods and results: We reported 4 cases in which the GORE VIABAHN stent was used for hemostasis caused by a pseudoaneurysm. Between January 2016 and December 2019, PD for 74 cases were performed at our hospital. 8 patients suffered from intraabdominal hemorrhages, and we performed a covered stent in 4 patients. In these four patients, the median age was 65.5, one was suffering from pancreatic cancer and the others had cancers of papilla's Vater. One case had a hemorrhage from the Proper hepatic artery, the other from Gastroduodenal artery stump. A liver abscess was caused in one patient due to an obstruction of the stent, but this complication was not fatal.
Conclusion: The GORE VIABAHN stent was a useful and safe procedure in stopping the hemorrhaging from pseudoaneurysm, compared with TAE.