IHPBA 2020 - Session Planner

Poster Pancreas
PP05 Pancreas: Technical Surgery (ePoster)
Selection of ePoster Presentations from Abstract Submissions
PP05-01	Chyle Leakage after Robotic and Open Pancreaticoduodenectomy Bor-Uei Shyr, Taiwan, Republic of China B.-U. Shyr Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China Background: Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). However, no study examined the incidence of chyle leakage after robotic PD (RPD). This study aimed to evaluate chyle leakage after RPD or open PD (OPD). Methods: Data regarding chyle leakage, including perioperative parameters and daily drainage volumes from the surgical drains, were prospectively collected from patients undergoing RPD or OPD, and these values were analyzed. Results: The study included 283 patients, with 118 RPD and 165 OPD. The incidence of chyle leakage was 12.0% for overall patients, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment with dietary measures. The drainage volumes were significantly higher in patients with chyle leakage from postoperative days (PODs) 1 to 7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and the presence of pancreatic head adenocarcinomas affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not. Conclusions: Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not. Enteral feeding should be judiciously delayed for those with a high drainage volume.
PP05-02	Inferior Pancreaticoduodenal Artery Pseudoaneurysm Rupture Caused by the Pancreatic Neuroendocrine Tumor: A Case Report Tsuyoshi Sano, Japan T. Sano, Y. Fukami, T. Arikawa, T. Osawa, S. Kurahashi, T. Matsumura, T. Saito, S. Komatsu, K. Kaneko Department of Surgery, Aichi Medical University, Japan Introduction: Inferior pancreaticoduodenal artery (IPDA) pseudoaneurysms rupture caused by the pancreatic neuroendocrine tumor (PNET) are extremely rare. Methods: Here we report an interesting case of emerging IPDA pseudoaneurysm rupture caused by PNET. Results: A 49-year-old man was referred to our hospital for epigastric pain. Dynamic computed tomography showed a heterogeneously enhancing pancreatic head mass measuring 12 cm in diameter with hypervascular lesion. In addition, an irregular aneurysm was found in the branch from the superior mesenteric artery (SMA) to the pancreatic head. Selective angiography of the SMA confirmed an aneurysm of the IPDA, from which a jet blood flow was observed into the pancreatic head mass. The high blood flow resulted in the cavernomatous transformation of the hepatoduodenal ligament. The next day, total pancreatectomy was performed in the hybrid operating room. Laparotomy revealed a large pancreatic head mass, 12 cm in diameter and highly vascular. Left side pancreas demonstrated necrotizing pancreatitis, so the distal pancreatosplenectomy was performed in advance. The intermittent inflow occlusion of IPDA was obtained by a balloon catheter, and pancreaticoduodenectomy was safely achievable. The pseudoaneurysm at the root of IPDA was blocked with vascular clip. The postoperative course was uneventful. Immunohistochemical examination was positive for chromogranin A and synaptophysin. The final pathological diagnosis was PNET G1. In addition, arterial invasion of tumor cells was observed. Conclusions: This case demonstrates that PNET can cause IPDA pseudoaneurysm rupture. The hybrid operation is advisable in pancreatic surgery for patients associating complicated vascular event.
PP05-03	Frey Procedure for Chronic Pancreatitis in Adolescent with Recurrent Bleeding: A Case Report Adianto Nugroho, Indonesia A. Nugroho¹, A. Rachmawati², I. Jamtani¹, R. Saunar¹, A. Widarso¹, T. Poniman¹ ¹HPB Unit, Digestive Surgery, Fatmawati Central General Hospital, Indonesia, ²Pediatric Surgery, Fatmawati Central General Hospital, Indonesia Background: Chronic pancreatitis is rare in children and commonly unresponsive to medical therapy, associated with a higher complication and mortality rate. Abdominal pain is the major presenting symptom. Case presentation: A 13-year-old female presented with severe abdominal pain and massive hematemesis recurred several times during a period of 3 months, always crescendo-decrescendo followed by hemorrhage - starting once every 3-4 weeks and gradually became more frequent. Upper endoscopy found an active bleeding came out of the papilla Vater, with subacute bleeding intra-pseudocyst, suggestive of chronic arterial injury at the splenic artery (4 cm from the proximal part of coeliac trunk) and no dilatation of Intra- and extra-biliary was showed in MRCP. Results: Surgical exploration revealed a chronic pancreatitis with multiple pancreatic duct stone and pseudocyst. A pseudoaneurysm also found in the pseudocyt. Frey procedure was carried out. The post-operative course went uneventfully, and patient was discharged on post-operative day 14. Conclusions: Surgical failures in the management of chronic pancreatitis have been attributed to inadequate decompression of the head of the pancreas, The Frey procedure adds anterior resection of the head of the pancreas to the LPJ and was created to improve decompression of the head of the gland, with relatively lower morbidity compared to Beger procedure.
PP05-06	Triks of the Trade Cattel-Braasch Maneuver in Pancreatic Surgery. Never Tneeded a Venous Graft for Vascular Resection Emanuele Felli, France E. Felli¹, E. Muttillo², D. Mutter², P. Pessaux² ¹HPB Unit, Nouvel Hopital Civil, France, ²Nouvel Hopital Civil, France Background: During pancreaticoduodenectomy vascular resection has become a routine task in referral centers. Nevertheless, in relation to portal or mesenteric vein length resection the need of a vascular graft is often needed and autologous, heterologous or PTFE graft are usually used in common practice. The use of Cattell-Braasch maneuver -the entire right colon, mesenteric root and duodenopancreatic block mobilization- allows a direct venous anastomosis without graft interposition, no matter the length of resection. This maneuver is performed in the very beginning of the operation. It starts with the right parieto-colic gutter incision with complete mobilization of right colon. Then the primary root of the mesentery is sectioned allowing progressive mobilization of the entire intestine and exposing the retroperitoneal space. The dissection passes behind D2-D3 and behind pancreatic head with the exposure of the left renal vein and the origin of the superior mesenteric artery. Then the pancreaticoduodenectomy continues as usual with progressive resection of the different structures leaving the portal/superior mesenteric vein to be resected as the last attachment of the specimen. Once the venous has been sectioned an end to end direct venous anastomosis is easily performed as the entire mesentery can be pulled up without tension. During this phase temporary superior mesenteric artery clamping is suggested to avoid visceral congestion.
PP05-07	The Alternative Arterial Source during Pancreatoduodenectomy when Patient with Total Replaced Hepatic Artery from Superior Mesenteric Artery Cheng Hsi Yeh, Taiwan, Republic of China C.H. Yeh¹, T.S. Lin², Y.W. Liu¹ ¹General Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan, Republic of China, ²Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan, Republic of China Introduction: During pancreatoduodenectomy(PD), the gastroduodenal artery (GDA) which lied on the groove between duodenum and pancreatic head should be sacrificed. However if the source of the hepatic artery(HA) was replaced from celiac axis(CA) to superior mesenteric artery(SMA), it always followed the GDA direction and need to be segmental resection with end to end anastomosis for clear surgical margin. Unfortunately the tension of the anastomosis site may be large and the location was just behind the P duct anastomosis. Above of them increased the chance of HA anastomosis bleeding. Herein we wound share an alternative arterial source to prevent such adversity. Method: A 45-year-old man was admitted due to right upper abdominal pain with jaundice looking for 2 weeks. The hyperbilirubinemia (total bilirubin 11 mg/dl) was found. After full abdominal study, the narrowing distal biliary duct (BD) with diffused biliary tract dilatation was noted and biliary stenting was done for drainage. Then the PD was performed after the intraoperative frozen section of common BD showed adenocarcinoma. However the segmental GDA was dense adhered with tumor and in addition the HA was totally replaced with GDA-SMA. Then segmental resection of the vessel was done. Then we chose the left gastric artery (LGA) as the arterial source due to the less anastomosis tension and not in the dependent site. Results: Then post-operative was smooth and the patient was discharge 1 month after operation. Conclusions: The LGA was a feasible arterial source during PD when patient with total replaced HA from SMA.
PP05-08	Splenic Vessels First Approach Laparoscopic Spleen-Preserving Distal Pancreatectomy with Kimura technique (With Short Video Clip) Qiang Yan, China Q. Yan¹, J. Mao², X. Sun¹, Z. Shen¹ ¹General Surgery, Zhejiang University Huzhou Hospital, China, ²Department of Surgery, Zhejiang University School of Medicine, China Aim: In order to improve the success rate of spleen preservation in laparoscopic distal pancreatectomy with Kimura technique, we use a new splenic vessels control procedure which we call splenic vessels first approach. Method: We begin the operation with dividing the gastrosplenic ligament in order to expose the body and tail of the pancreas. We are now dissecting out the splenic artery first. With opening the capsule of the superior border of the pancreas, here the splenic artery comes into view. The proximal splenic artery is blocked with a bulldog. The next step wiil be distal splenic vein mobilization and blockage. We dissect at left side of the inferior border of the pancreas tail near the splenic hilus and block the distal splenic vein with another bulldog. After fully blocking the proximal splenic artery and distal splenic vein, we perform laparoscopic spleen-preserving distal pancreatectomy with standard Kimura technique. Result: With fully controlling the inflow of splenic artery and outflow of distal splenic vein , the distal pancrease is easy dissected with the splenic vessels presevation. We have successfully fulfilled all 10 cases of laparoscopic spleen-preserving distal pancreatectomy with Kimura technique. No postoperative splenic complications such as splenic infarction and abscess have been founded by far. Conclusions: Splenic vessels first approach laparoscopic spleen-preserving distal pancreatectomy is a safe procedure and offers technique advantages of lesser blood loss, operation time spare and higher success rate of spleen preservation over the conventional Kimura technique, while no extra postoperative morbidity founded. [Splenic Vessels First Approach]
PP05-10	Novel Standardized Stapling Technique for Soft Pancreas in Laparoscopic Distal Pancreatectomy: A Preliminary Study Hideki Sasanuma, Japan H. Sasanuma, Y. Sakuma, K. Morishima, K. Shimodaira, H. Miyato, A. Yoshida, K. Endo, A. Lefor, N. Sata Surgery, Jichi Medical University, Japan Introduction: The incidence of postoperative pancreatic fistula (POPF) remains high after laparoscopic distal pancreatectomy (Lap-DP). To find the most appropriate stapling technique for the soft pancreas, we standardized a stapling procedure using a newly developed electric-powered stapler. Methods: From Mar. 2016 to Dec. 2019, 20 consecutive patients (8 male and 12 female) underwent Lap-DP for benign pancreatic tumors using an electric-powered stapler. Seven patients had mucinous cyst neoplasms, 3 serous cyst neoplasms, 3 solid pseudopapillary, 3 intraductal papillary mucinous neoplasms, 3 pancreatic neuroendocrine tumors, and 1 malignant lymphoma. The standardized procedure has four steps including 5 minutes compression (Step 1), 5 minutes adaptation (pre-compression, Step 2), 5 minutes cutting (Step 3), and 5 minutes adaptation (post-compression, Step 4). Dividing the pancreas took a total of 20 minutes. Drain amylase was measured on postoperative days (POD) 1, 3, 5, and 7 to evaluate POPF according to the 2016 update International Study Group in Pancreatic Surgery definition. Postoperative complications are evaluated in accordance with the Clavien-Dindo (CD) classification. Pancreatic thickness was measured at the resection line on preoperative computed tomography scan. Results: POPFs in 20 patients were all biochemical leakage. There were no serious complications greater than CD Classification grade III. Mean pancreatic thickness in stump was 14.0 (2.5-28.7) mm. All patients were discharged by POD 12. Conclusions: In Lap-DP, this novel standardized technique using an electric-powered stapler is safe and reduces the rate of POPF for the soft pancreas with a thickness to 29mm.
PP05-12	Innovative Device to Prevent Postoperative Pancreatic Fistula in Distal Pancreatectomy Yuji Kaneda, Japan Y. Kaneda, Y. Kimura, A. Saito, H. Ohzawa, M. Koizumi, H. Sasanuma, A. Lefor, Y. Sakuma, Y. Hosoya Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Japan Introduction: New techniques have been introduced to minimize postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP), but the incidence remains still high. We developed the surgical ligature band (SLB) to prevent POPF after DP. Methods: SLB is a surgical device developed for ligating a pancreatic stump atraumatically. (A) Twenty pancreases were isolated from pigs. The main pancreatic duct (MPD) was cannulated with a catheter connected to the cannula. After closing the pancreatic stump by either SLB (n=10) or a stapler (n=10), the MPD pressure was elevated by filling the cannula with contrast media. The pressure capacity was estimated by checking leakage at the pancreatic stump by X-ray fluoroscopy. (B) We performed DP with two pigs and closed the pancreatic stump by SLB. After one week, we checked the fluid collection around pancreatic stump by CT and performed autopsies. Results: (A) The median pressure capacities with SLB and a stapler were 40.7 mmHg and 34.3 mmHg, respectively. Leakage from the staple line or into pancreatic parenchyma was found in six cases in the stapler group. The rate of cases with a pressure capacity less than 30 mmHg in the stapler group were significantly higher than those of the SLB group (p=0.033). (B) No fluid collection or necrosis was found in either cases. Conclusions: SLB successfully ligated the pancreatic stump atraumatically with a high pressure capacity while maintaining the blood flow to the pancreatic stump. We propose SLB as a new device for preventing POPF in DP. [Figure]
PP05-13	Evaluating the Relationships between Splenic Artery and Pancreatic Parenchyma Using Three Dimensional CT for Laparoscopic Distal Pancreatectomy Kohei Nakata, Japan K. Nakata, T. Ohtsuka, Y. Watanabe, Y. Mori, N. Ikenaga, M. Nakamura Surgery and Oncology, Kyushu University, Japan Background: Isolating the root of splenic artery (SPA) is essential for conventional distal pancreatectomy, while remains challenging in laparoscopic procedure due to the complexity in anatomical variation around SPA. This study aimed to investigate the usefulness of preoperative evaluation of the relationships between SPA and pancreatic parenchyma using 3D-CT. Methods: A total of 104 patients who underwent distal pancreatectomy (74 with laparoscopic procedure and 30 with open procedure) were evaluated. The relationship between SPA and pancreatic parenchyma was classified into two types with preoperative 3D-CT, namely “Buried type” and “Non-buried type”. Video clips of 50 patients were reviewed to investigate whether this classification would be related with the difficulty of isolating the SPA. In addition, the distribution of dorsal pancreatic artery (DPA) was also evaluated. Results: DPA from SPA was identified in 94 (91.3%) patients and the number was four in one patient, three in 8, two in 29, and one in 56. Fifty-eight (55.8%) patients had DPA within 30mm of the root of the SPA. Of the 50 assessed patients who underwent LDP, there were “Buried-type” in 30 (60.0%) and “Non-buried” type in 20 (40.0%). The median time for isolating SPA in “Buried-type” (25.8 min; range, 4.0 to 101) was significantly longer than that in “Non-buried type” (7.0 min, range, 1.0 to 27.0) (P< 0.001). Conclusion: Preoperative 3D anatomical image analysis around pancreas is practical to predict the difficulty of isolating the root of SPA and to provide the safety of the procedure.
PP05-15	Laparoscopic Distal Pancreatectomy I.G. Merlo, J. Grondona, R. Bracco, D. Fernández, P. Angiolini, F. García, F. De Francesco, D. Huerta, M. Andrade UNACIR HPB, Argentina Introduction: Laparoscopic distal pancreatectomy (LDP) is progressively expanding. The aim of this study is to report our experience regarding the beneﬁt of the laparoscopic approach of varied distal pancreatic lesions. Methods: Between 2013 and 2019, a total of 34 LDP including 23 females (67.6%) and 11 males (32.4%) were carried out in our HPB Oncological Centre. Tumoral locations were: 16 in tail (47.1%), 12 in body (35.3%) and 6 (17.6%) in both tail and body. Size average of lesions was 44.1 mm (range: 17-120). LDP was carried out with the standard laparoscopic technique and the section, seal and close of the pancreatic parenchyma was performed with linear staplers. Results: No 90-day postoperative mortality occurred. In 9 out of 17 pancreatic closures with vascular linear staplers a type A pancreatic fistula (52.9%) was observed. But in 2 of 17 cases with visceral linear staplers the type A fistula rate was 11.8% (p = 0.026; IC 95% 1.22-92.48; OR: 7.88). Histopathological examination revealed 8 serous cystoadenomas, 6 mucinous cystoadenomas, 2 simple cysts, 3 IPMN type II, 8 ductal adenocarcinomas, 4 benign neuroendocrine tumors, 1 malignant neuroendocrine tumour, 2 metachronous metastasis (1 colorectal and 1 of renal cell carcinoma). In all cancer specimens the surgical margins were tumor free (R0). Conclusions: LDP is recognized worldwide as a feasible, safe and beneficial procedure. The closure of the pancreatic parenchyma with linear visceral staplers would appear to produce less pancreatic fistula than with vascular staplers. All fistulas were type A with easy postoperative management.
PP05-17	Efficacy of our Standardized Procedure with Mesh-reinforced Stapler to Prevent Pancreatic Fistula after Distal Pancreatectomy Shin Sasaki, Japan S. Sasaki, T. Ryu, Y. Takami, Y. Wada, H. Imamura, H. Ureshino, H. Saitsu Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan Background: The aim of this study was to evaluate whether our standardized procedure with mesh-reinforced stapler (Endo-GIA^TM with Tri-Staple^TM technology; black reload; 60-m long; Covidien) can reduce the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy. Methods: A total of 60 patients underwent mesh-reinforced stapled distal pancreatectomy at our institute from July 2016 to November 2019. Laparoscopic distal pancreatectomy was performed in 43 (71.7%) patients. The incidence of clinically relevant POPF (grade B or C based on the International Study Group on Pancreatic Fistula criteria) was retrospectively analyzed. Surgical procedures: The pancreatic parenchyma was transected by stapler on the transection line with safety margin from the lesion. The closure jaw was carefully clamped over a 1-min period at a fixed speed. The stapler was slowly fired over a 6-min period and then released. Careful, gentle handling of the stapler was required during transection of the pancreatic parenchyma. A closed-suction drain was always placed near the stump of the remnant pancreas. Results: The median operative time was 274min (133-585), and median operative blood loss was 170g (1-2519). The incidence of clinically relevant POPF occurred in 4 patients (6.7%). We have never experienced POPF grade C. The major morbidity rate (Clavien-Dindo classification grade ≥III) occurred in 7 patients (15%). Complications other than POPF grade B occurred in 3 patients (ileus, n=2; delayed gastric emptying, n=1). No surgical mortality or in-hospital death occurred in this study. Conclusions: Our standardized technique with mesh-reinforced stapler can reduce clinically relevant POPF after distal pancreatectomy.
PP05-18	Empirical Coil Embolization of Splenic Artery as a Salvage Life Saving Procedure in Post Pancreatectomy Hemorrhage and Hemosuccus Pancreaticus Ramesh Rajan, India R. Rajan¹, S. Radha Sadasivan Nair¹, B. Natesh¹, S. Sreekumar¹, J. Valakada², E. Jayadevan², S. Santhosh² ¹Surgical Gastroenterology, Trivandrum Medical College, India, ²Interventional Radiology, SCTIMST, India Introduction: Computerised Tomography Angiogram (CTA) is the diagnostic modality in Post pancreatectomy Haemorrhage (PPH) and Hemosuccus Pancreaticus (HP). However, occasionally, the offending aneurysm or the source of bleed may not be evident by CTA or conventional angiography. Intraluminal bleeds, especially after Dunking Pancreaticojejunostomy, may be from small pseudoaneurysms in the territory of splenic artery or from cut end of pancreas that are difficult to pick up by CTA. We evaluated the efficacy of empirical segmental Coil embolisation of pancreatic segment of splenic artery in the setting of intraluminal PPH as well as HP following Acute /Chronic pancreatitis. Methods: A cross sectional study was done by analysing the prospectively held pancreatic database from January 2009-december 2018. All consecutive patients with PPH following any type of Pancreatectomy as well as Hemosuccus Pancreaticus (in Acute and chronic pancreatitis) who underwent empirical coil embolization of splenic artery were included. Those who showed blush on CTA or conventional angiography and those who were managed primarily with surgery for PPH were excluded. The rebleeding and mortality rates were assessed at 72-hour and 30-days respectively. Results: There were 137 Pancreaticoduodenectomies, 68 Distal Pancreatectomies, 11 median pancreatectomies and 134 admissions for Acute pancreatitis/ exacerbation of Chronic pancreatitis during the period. Overall, 6/7 (85.7%) with negative CTA had successful coil embolization. No re-intervention/ continued bleed/ splenic infarcts/ no requirement of transfusion or abscess were seen in any of these six patients. Conclusion: Empirical coil embolization of splenic artery in pancreatic bleed holds promise as a salvage life-saving procedure.
PP05-19	Updated DP-CAR: mAppleby Procedure with Resection of Left or Right Hepatic Artery without Reconstruction. How to Use it Systematically Roman Petrov, Russian Federation V. Egorov¹, R. Petrov², J. Zhurina², P. Zelter³, K. Petrov⁴, A. Sorokin⁵, M. Grigorievsky² ¹Ilyinskaya Hospital, Russian Federation, ²Bakhrushin Brothers City Hospital, Russian Federation, ³Samara State Medical University, Russian Federation, ⁴Medscan Diagnostic Centers, Russian Federation, ⁵Plekhanov State University of Economy, Russian Federation Background: Distal Pancreatectomy with Celiac Artery(CA) resection (DP-CAR) is a justified option for treatment of Pancreatic Body ductal adenocarcinoma with CA involvement. Theoretically risk of ipsilateral liver lobe ischemia after DP-CAR has to increase in cases of left hepatic artery(LHA) resection and/or replaced LHA(MichelsII,IV,VIIIb), or right hepatic artery(RHA), originating from CA. Aim: To assess safety and oncological results of DP-CARs with resection of one of the main hepatic arteries. Methods: Analysis of intraoperative data, ischemic and other complications after 4 DP-CARs with resection of replaced LHA for Michels type II,IV,VIIIb(2), gastroduodenal(1) and 2 DP CARs with resection of RHA, originating from CA without reconstruction. The main tool for assessment live arterial blood flow adequacy was IOUS, ICG fluorescence and postop CTA. Results: Among 34 DP-CARs in six cases of aberrant arterial anatomy left or right hepatic artery were excised. In all six cases R0 posterior RAMPS were done with portal-superior mesenteric vein resection in one case. There were no mortality and ischemic complications. The main source of blood supply for “devascularized” liver lobe was communicating interlobar artery. Pancreatic Grade B fistula rate was 50%. Mean IO blood loss 230(100-650) ml, operating time 259(195-310)min., LOS 14 (9-26)days. Chemotherapy was neoadjuvant (FOLFIRINOX n5) and neoajuvant (gem+Abraksane, n1). MS- 24 months. One patient died 26, others disease free 100,28, 14,17,14 months after treatment beginning. Conclusion: DP CAR with resection of RHA or LHA can be safe, controllable and oncologicaly justified. Ischemic complications can be predicted by IOUS and ICG fluorescence.
PP05-20	How to Make “Unresectable” Resectable? “Low” Locally Advanced Pancreatic Cancer with the Involvement of SMV and All its Tributaries Viacheslav Egorov, Russian Federation V. Egorov¹, R. Petrov², A. Koligin¹, M. Viborny¹, M. Feldsherov¹, A. Amiaga¹ ¹Ilyinskaya Hospital, Russian Federation, ²Bakhrushin Brothers City Hospital, Russian Federation Background: Pancreatic ductal adenocarcinoma(PDAC) involving superior mesenteric vein (SMV) and all its tributaries consider unresectable because of impossibility of venous reconstruction. Aim: To show technical possibility of R0-resection in abovementioned situation Patients and methods: Database retrospective analysis of 202 vein resections during 594 pancreatic surgeries. Five patients were found who underwent R0-resections for locally advanced PDAC involving SMV and all its tributaries. Age: 52-71y.; Neoadjuvant chemotherapy FOLFIRINOX 4-12 courses. Results: Excision of SMV and all its suppliers associated with Whipple procedure without reconstruction in 3 cases and total duodenopancreatectomy with replantation of inferior mesenteric (IMV) in the stump of splenic (SV) vein, once with resection and reconstruction of SMA were performed (2012 -2020). True vein involvement was found in 100% of cases. Temporary (2-14 days) postoperative bowel edema was the constant symptom, lymphorrhea of more than 500 ml longer than 3 days was revealed in 3 cases. All the patients alive, functional and four disease-free 21, 18, 13,12 and 11 months after treatment. The mandatory condition for selection for this surgery is the functioning venous Riolan arch, which can be delineated by CT preoperatively and confirmed at surgery together with adequate portal blood flow, which should not be less than 10 cm/sec. Conclusion: Neoadjuvant therapy, definite controllable anatomical, physiological and technical conditions make systemic performance of R0-resections for locally advanced PDAC involving SMV and all its tributaries feasible, which can reduce number of unresectable cases for PDAC.
PP05-21	Functioning Arterial or Venous Riolan Arch in Localized Pancreatic Cancer. How it Can Change Tactics? Viacheslav Egorov, Russian Federation V. Egorov¹, R. Petrov², J. Zhurina², K. Petrov³, M. Feldsherov¹, A. Amiaga¹ ¹Ilyinskaya Hospital, Russian Federation, ²Bakhrushin Brothers City Hospital, Russian Federation, ³Medscan Diagnostic Centers, Russian Federation Background: CT are obligatory before pancreatic surgery. Discovery of functioning arterial or venous Riolan arch (FRA) can have substantial influence on tactics. Aim: To assess importance of FRA discloser for decision making before pancreatic surgery. Patients: Retrospective analysis of 554 patients' consecutive preoperative CT data revealed arterial(n2) and venous(n5) FRA in 7 cases. Modification of treatment were assessed. Results: Arterial FRA was found in pancreatic body cancer(n2). 1.atherosclerotic occlusion of CA and SMA with symptomatic abdominal ischemia; 2.tumor involved CA on the background of endoluminally unreсonstructable SMA occlusion. In the first case CA stenting before distal pancreatectomy eliminated symptoms fully. In the second case after FOLFIRINOXn12 R0 DPCAR without SMA reconstruction was done because of good collateral supply. Uneventful postop period, discharge on days 10 and 13. Venous FRA in all the cases of PDAC of the head±body were the sign of full block of all SMV tributaries and already formed outflow through the splenic(SV) and/or inferior mesenteric(IMV) vein. In all these cases efficient neoadjuvant therapy and venous FRA were the weighty argument for pancreatic resection. Thrice it was done without venous reconstruction, twice with IMV transposition in SV, once with SMA resection. Uneventful postop period, discharge on days 10-19. One patient died 44 month (distant mets), the second died 19 months disease-free (MI), others alive 21,18,13,12 and 11 months after treatment. Conclusion: Delineation of FRA before pancreatic surgery is the indication for tactics change: endovascular treatment for arterial FRA and more aggressive surgery in case of venous FRA.
PP05-22	Central Pancreatectomy: A Technique for the Resection of Selected Pancreatic Neck and Body Tumours Naga Sudha Ashok Reddipalli, India N.S.A. Reddipalli Surgical Gastroenterology, Yashodha Super Speciality Hospital, Hyderabad, India Introduction: Pancreatic tumors located in the neck and body region usually require pancreaticoduodenectomy or splenopancreatectomy. For small benign tumors enucleation is not usually feasible due to their size and localization; then pancreatectomy is often needed. Central pancreatectomy consists of a limited resection of the midportion of the pancreas and can be offered in benign and low-grade malignant tumors of the neck of the pancreas. Methods: In this study over a period of 5 years, we performed central pancreatectomy in nine selected patients. Preoperative evaluation and operative frozen section biopsy in indicated cases allowed proper selection for the procedure. Operative details, complications and follow-up were recorded. Results: Nine patients, three with serous cystadenoma, two with mucinous cystadenoma, two with non functional islet cell tumour ,one with insulinoma and one with a hydatid cyst, were identified for the procedure. The mean tumor size was 2.7cm,the mean operative time was 216 minutes, and the mean blood loss was 363 ml.No morbidity or mortality in this series. No endocrine or exocrine deficiency was observed during a mean follow-up of 24 months Conclusion: Central pancreatectomy is a procedure that offers excellent results in benign and low-grade malignant tumors preserving functional elements of the pancreas and eliminating the infective and hematological effects of splenectomy. Thus, central pancreatectomy should be included in the armamentarium of pancreatic surgery, and to obtain good results, proper indications and adequate experience are recommended.
PP05-23	Outcomes of Tube Pancreatogastrostomy Reconstruction after Pancreatoduodenectomy - The Montenegro Binding Technique Filipe Kunzler Maia, United States F. Kunzler Maia¹, L. Olival², H. J Asbun¹, R. Montenegro Costa² ¹Miami Cancer Institute, United States, ²Clínica Montenegro, Brazil Introduction: Pancreatic surgery has come a long way in the past century, with marked improvements in survival albeit lingering complication rates. Postoperative pancreatic fistula (POPF) is a field in need of improvement, with current evidence pointing to a 10 to 20% incidence rate. Methods: The Montenegro's binding technique (MBT) is a type of reconstruction developed in 2005 to decrease POPF, speeding patient recovery and facilitating their treatment resumption. The technique consists of intussuscepting the pancreas into a tube made out of the greater curvature of the stomach, and securing it with a purse string suture placed in the outer edge of the tube. A prospective database was started in 2018 to further evaluate the benefits of the MBT. Results: The first eleven patients accrued are presented here. Patients were 57.7 ± 5.8 years-of-age, predominantly female (7:4), with an ASA score of 2 (1.5-2, median/IRQ). Surgery was performed either partially laparoscopic, or purely open. Operative time was 362.7 ± 83.1, with EBL of 181.1 ± 104.5 ml. There was no case of ISGPS POPF (BL, B & C), being the highest amylase drain level on POD 5 292mg/dl. There was one case of biliary fistula managed conservatively and two cases of Clavien-Dindo ≥3. One of them was a patient that required reoperation due to gastric outlet obstruction secondary to gastric torsion. Conclusions: MBT is a technically undemanding reconstruction, which likely servers both the purpose of facilitating pancreatic reconstruction and mitigating POPFs.
PP05-24	Application of Pancreaticojejunostomy with Pancreatic Duct-jejunum-mucosal Continuous Suture in Total Laparoscopic Pancreaticoduodenectomy Hong Ma, China H. Ma The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China Objective: To evaluate the clinical effect of pancreatic duct-jejunum -mucosal continuous suture in laparoscopic pancreaticoduodenectomy. Methods: The data of 100 patients who underwent laparoscopic pancreaticoduodenectomy in the department of general surgery, affiliated hospital of xuzhou medical university from February 2017 to October 2019 were retrospectively analyzed. Of these patients, 51 cases received continuous suture pancreaticojejunostomy and 49 cases received“8-character” suture pancreatojejunostomy for LPD. We compared and analysed the operation time, anastomosis time and incidence of postoperative complications between the patients in the two groups. Results: All the operations were successfully performed，with no transfer to open surgery．The operation time, anastomosis time in the continuous suture group was obviously lower than that of the control group (305.8±60.7min vs 354.3±69.1min; 28.6±6.3min vs 39.4±11.9min P< 0.001), and the postoperative hospital stay was also shorter（12.9±3.8min vs 15.4±5.8min P< 0.05） in the continuous suture group. There was no significant difference in pancreatic duct diameter between the two groups. There was also no significant difference in the incidence of pancreatic fistula between the continuous suture group and the "8-character " suture group. Conclusion: Continuous suture of pancreatic duct and jejunal mucosa in laparoscopic pancreaticoduodenectomy can further shorten the operation time, reduce the length of hospital stay, and is safe and feasible.
PP05-30	The Efficacy of Radiofrequency Ablation (RFA) in Locally Advanced Pancreatic Ductal Adenocarcinoma Olympia Hadjicosta, United Kingdom O. Hadjicosta¹, D. Christou², A. Christodoulou³, P. Hadjicostas⁴ ¹Barts and the London School of Medicine and Dentistry, United Kingdom, ²Surgery, Larnaca General Hospital, Cyprus, ³Larnaca General Hospital, Cyprus, ⁴Hippocrateion Private Hospital, Cyprus Introduction: Pancreatic ductal adenocarcinoma (PDAC) presents a challenge for the surgeon due to its aggressiveness and to the stagnation of the management options in cases where complete resection is impossible. Radiofrequency ablation (RFA) in locally advanced pancreatic cancer is described as a promising technique. The aim of this study is to examine and assess the outcome of this local thermal ablative therapy RFA, in locally advanced unresectable PDAC. Methods: Data was collected from all patients who undergone an RFA procedure during laparotomy, followed by palliative Biliary and Gastric bypass procedures. The efficiency and safety of the RFA procedure was evaluated via the post-op complications and the morphological changes of the tumour shown on CT scan at 1 & 6 month post-op as well as patients' survival. Results: The patients had a relatively uneventful postoperative period, with significant improvement in pain relief. The size and morphology of the tumour were remarkably changed on a repeat CT scan. The mean survival with the RFA was 21.8 months (6 - 32 months). Conclusions: This study suggests that RFA for locally advanced and unresectable PDAC in carefully selected patients (excluding multifocal disease) presents a promising, effective and safe weapon in the surgeon's armamentarium. RFA can be safely used as a complementary method of palliative therapy as it improves local tumour growth, prolongs survival and improves the quality of life.
PP05-32	Hybrid Laparoscopy-assisted Pancreaticoduodenectomy: The Buddha's Middle Path Ameet Kumar, India A. Kumar, S. Kaistha GI Surgery, Command Hospital Air Force, India Introduction: Laparoscopic pancreaticoduodenectomy (LPD) is not universally accepted due to its steep learning curve and the technical complexity discourages many surgeons from attempting it. We believe that Hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) has all benefits of LPD without its drawbacks and combines the ease of open surgery and the benefits of minimal access surgery. We assessed outcomes of HLAPD compared with open pancreaticoduodenectomy (OPD); the objectives being perioperative, short-term clinical and oncological outcomes. Methods: Retrospective review of prospectively maintained database; study period from 2013 to 2018. Till 2015 we did only OPD. In 2016, we started with LPD but soon switched to HLAPD. Complete resection part was done laparoscopically and reconstruction through a 10 cm mini-laparotomy. Results: We did 33 PD; 19 OPD and 14 laparoscopic (04 LPD and 10 HLAPD). Demographic data of the two groups were comparable. The duration of surgery was significantly longer in the HLAPD group (360 Vs 410 min; p= 0.01) while the blood loss and hospital stay was longer in the OPD group (520 Vs 340 ml; p= 0.03 and 13 Vs 10 days; p= 0.08, respectively). Clinically significant complication rates including delayed gastric emptying and postoperative pancreatic fistula were not different in either group. No patients in HLAPD group had wound-related/pulmonary complications. Lymph node yield was similar in both groups (20 Vs 22) and we had 100% R0 resections. Conclusions: HLAPD was better than OPD in terms of short term outcomes and was not inferior to OPD in terms of complications and oncological outcomes.
PP05-33	“Tricks of the Trade” Robotic Pancreaticojejunostomy Mary Dillhoff, United States A. Ejaz, A. Manilchuk, A. Tsung, T. Pawlik, M. Dillhoff Ohio State University, Wexner Medical Center, United States Background: Several methods of pancreaticojejunostomy (PJ) have been shown to decrease complications after whipple. With the increased utilization of the robotic platform, it is important to refine the technique. Herein, we discuss variations in technical aspects of robotic PJ. Methods: Multiple methods of PJ that are employed depending on the particular anatomy of the patient, gland texture, and size of the pancreatic duct. One of the most common techniques utilized in both open and robotic PJ is the modified Blumgart technique. Three 3-0 silk mattress sutures (cut to 7cm) are placed through the gland and tied down before the duct to mucosa is performed. This approximates the jejunum to the pancreas and effectively alleviates tension off the inner duct-to-mucosa layer. The middle mattress suture is placed straddling the pancreatic duct (technique 1, figure) or can be eliminated altogether (technique 2). Care must be taken not to cause narrowing of the pancreatic duct when tying this suture. To facilitate exposure for small pancreatic ducts, a 1-millimeter cardiac vascular probe is used to locate, expose, and dilate the pancreatic duct. Typically, all ducts can be dilated to accommodate a four-french pancreatic stent, if desired. Other methods such as running and dunking methods for the outer capsule-to-serosa layer (technique 3) can be used as appropriate. We've found these method to result in equivalent grade B/C fistula rate even with a higher proportion of soft glands (n=70). Conclusion: We've found these techniques of PJ to be useful in minimizing fistula rates and optimizing outcomes.
PP05-34	Virtual Reality Simulation in Laparoscopic Pancreatic Surgery Yasuji Seyama, Japan Y. Seyama¹, M. Matsumura¹, K. Tani¹, S. Nemoto¹, Y. Ome², M. Sugimoto³ ¹Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan, ²Department of Digestive Surgery, New Tokyo Hospital, Japan, ³Innovation Lab, Teikyo University School of MedicineOkinaga Research Institute, Japan Introduction: Laparoscopic distal pancreatectomy (Lap-DP) has become common, and Lap-RAMPS (Radical antegrade modular pancreatosplenectomy) for pancreatic cancer is also established (Ome Y. et. Al. Ann Surg Oncol 26 (13): 4464-446; 2019). However, since Lap-RAMPS and spleen-preserving DP (SPDP) are not so easy, preoperative simulation is indispensable. In this study, we introduced the Virtual Reality (VR) technology in the pancreatic resection simulation. Methods: Pancreatic 3D analysis was performed from preoperative contrast-enhanced CT. Using 3D analysis information, a VR simulation with a head-mounted display was performed, and observation was performed with a focus on the vascular anatomy around the pancreas. As a simulation, a head-mounted display (Mirage solo) was used before surgery and a hologram by Hololens was used during surgery. Results: VR simulation was performed on a total of 12 cases, Lap-RAMPS 5 cases and Lap-DP 3 cases for advanced pancreatic cancer (all after preoperative chemoradiotherapy), Lap-SPDP 4 cases for low-grade tumors. In Lap-RAMPS for pancreatic cancer, we were able to experience an image of retroperitoneal dissection before and during surgery. In Lap-SPDP cases, Kimura method was performed in 2 cases and Warshaw method in 2 cases. In both cases, grasping the anatomy of the splenic artery and vein was useful for the surgical technique. The median amount of bleeding was 105 g (0-200 g), and the median operation time was 356 minutes (288-537 minutes). Conclusion: VR simulation was useful in complicated laparoscopic pancreatic tail resection. [3D images for Lap-RAMPS]
PP05-35	Ultrasound Guided Percutaneous Irreversible Electroporation for Treatment of Locally Recurrent Pancreatic Cancer Christopher Månsson, Sweden C. Månsson¹, A. Nilsson¹, P. Nygren², B.-M. Karlson¹ ¹Departement of Surgical Sciences, Uppsala University, Sweden, ²Department of Immunology, Genetics and Pathology, Uppsala University, Sweden Introduction: Irreversible electroporation (IRE) has recently been used as an experimental treatment for cancer including locally advanced pancreatic cancer. There is almost no data on IRE as a treatment on local recurrence of pancreatic cancer after surgical resection. The aim of this study was to evaluate the safety and primary efficacy of IRE on local recurrence after surgical resection. Methods: Ten patients with radiological clear signs of a local recurrence without distant metastases after surgical resection were included and treated with ultrasound guided IRE under general anesthesia. Results: Two of the ten patients had a severe complication after the treatment. One had an occlusion of the hepatic artery and later the superior mesenteric artery and died from the complications, the other was a pancreatitis with peritonitis that went to laparotomy and later developed a pancreatic fistula. Two patients had minor complications with pain and diarrhoea after the IRE. Overall median survival after the IRE and the resection was 16.5 and 42.7 months respectively. Two patients are alive 42.1 and 23.9 months after the IRE, the others have died. Conclusion: IRE in locally recurrent pancreatic cancer following curative resection is feasible but should be regarded as a high-risk procedure at present. IRE in this situation cannot be recommended outside of clinical trials. More research is needed to select patients that might benefit from this treatment.
PP05-36	Laparoscopic Pancreaticoduodenectomy: CUSUM Analysis in a Developing Single Surgeon Jung Woo Lee, Korea, Republic of J.W. Lee Department of Surgery, Hallym Unversity Medical Center, Anyang-si, Korea, Republic of Introduction: Laparoscopic pancreaticoduodenectomy(LPD) was the one of most technically challenging operations of minimally invasive surgery(MIS). This retrospective study aimed to analyze the learning curve of a single surgeon who carried out 63 LPD in a single center. Methods: from August 2015 to August 2018, 63 patient underwent laparoscopic pancreaticoduodenectomy in hallym sacred heart hospital by a single surgeon. The patient characteristics, perioperative variables, and immediate postoperative outcomes were retrospectively collected and analysed. The cumulative sum(CUSUM) analysis was used to identify the inflexion points which corresponded to the learning curve. Results: From the CUSUM analysis, two distinct phase of the learning curve were identified(early group:1-34 cases and late group:35-63 cases). Among two groups, there was no significant difference in perioperative oucomes. Non-significant reduction were observed in operation time(mean, 448min vs. 425min, p=0.239), conversion rate(8.8% vs. 3.4%, p=0.618), postoperative complication(Clavien-Dindo grade III or higher, 26.5% vs. 20.7%, p=0.768), and intraoperative transfusion rate(35.3% vs. 20.7%, p=0.267). Except pancreas adenocarcinoma, two distinct phase of the learning curve were identified(early group:1-31 cases and late group:32-45 cases). there was significant difference in operation time(mean, 439min vs. 367min, p< 0.001) and intraoperative transfusion rate(35.5% vs. 7.1%, p=0.07). Non-significant reduction were observed in conversion rate, postoperative stay, and complication. Conclusion: Laparoscopic pancreaticoduodenectomy can be safely and feasibly performed selected cases by experienced hepatobiliary-pancreas surgeons. Conservatively, the learning curve was completed after about 30 LPD in excluding PDAC.
PP05-40	Laparoscopic RAMPS Oleksandr Kvasivka, Ukraine O. Kvasivka, K. Kopchak HPB, National Cancer Institute, Ukraine Pancreatic adenocarcinoma is very aggressive cancer. Laparoscopic treatment of this kind of cancer is developing and is being improved. Today there are a large number of studies that prove that laparoscopic treatment of left-side pancreatic cancer it`s a gold standard. Conventional retrograde distal pancreatectomy and splenectomy for pancreatic adenocarcinoma of the body and tail have been associated with high rates of positive margins, low lymph node retrieval, and poor overall survival. Radical antegrade modular pancreatosplenectomy (RAMPS) was introduced in 2003 to overcome these limitations. A systematic literature search was performed, and articles reviewed to determine that RAMPS or standard distal pancreatectomy and splenectomy offer better survival. This issue remains controversial today. One thing that has been precisely proven as an advantage of RAMPS is the removal of a larger number of regional lymph nodes. In National Cancer Institute of Ukraine, we started performing laparoscopic RAMPS in 2018 and in this video-presentation want to show our experience and our results. In National Cancer Institute of Ukraine, we started performing laparoscopic RAMPS in 2018. Today we have experience of 5 cases of RAMPS and one case of conversion. All patients underwent careful selection since we are at the stage of accumulating experience Laparoscopic RAMPS is feasible in performing minimally invasive, curative resection for well-selected left-sided pancreatic cancer.
PP05-42	The "Omental Tutu" as a Protecrive Barrier in Pancreatic Enteric Reconstruction after PD Catherine Teh, Philippines C. Teh^1,2,3 ¹Surgery, St Luke's Medical Center, Quezon City, Philippines, ²Surgery, National Kidney & Transplant Institute, Quezon City, Philippines, ³Surgery, Makati Medical Center, Makati, Philippines Pancreaticoduodenectomy (PD) still carries a high risk of POPF in general. POPF often leads to postoperative hemorrhage which carries a high mortality rate. Although mortality after pancraetoduodenectomy has decreased to less than 5% in high volume centers, global data on PD still shows PD as high risk surgery with high morbidity and mortality rate especially in LMIC. Following an R0 resection, the common hepatic artery, portal vein, superior mesenteric vein, right side of the superior mesenteric artery are all exposed. Although no studies have shown any relation between bleeding from the erosion of exposed vessels weakening its integrity, its is possible that leak of pancreatic juice and bile surrounding these structures may pose a threat to vascular integrity causing hemorrhage. A protective barrier may help to reduce this harmful effect.with the use of omentum to shield the underlying vascular structures from a hostile environment if leaks are encountered. A part of omentum is selected and a small slit is made just enough to accomodate the pancreas remnant after its mobilization from the splenic vessels Posterior. The pancreas is gently inserted into the slit made and the surrounding omentum overlays the vessels underneath. Reconstruction of PJ or PD is then continued to complete the reconstruction. We have used this technique we call as an "omental tutu" as it serves like a skirt around the remnant pancreas. [The Omental tutu]
PP05-43	Laparoscopic Subtotal Pancreatectomy and Splenectomy for Pancreatic Body Tumor; Case Presentation with Video Mohamed Sharshar, Egypt M. Sharshar Surgery Department, Alexandria University, Alexandria, Egypt Background: The development of cross-section imaging increased the number of diagnosed pancreatic cystic tumors (PCNs). Many of these lesions, located frequently in the body or tail of the pancreas, require resection. Aim: My aim is to present a case of female patient underwent laparoscopic subtotal pancreatectomy and splenectomy for PCNs located in the pancreatic body, describing the technique along with the post-operative course. Methods and results: A case of female patient underwent a laparoscopic subtotal pancreatectomy and splenectomy using a five ports technique and surgical staplers for pancreatic transaction and vascular control. Specimen was retrieved through small Fanestiel incision. No morbidity or mortality happened. Specimen came as mucinous cystic tumor. Conclusion: Laparoscopic approach is feasible and safe for subtotal pancreatectomy and splenectomy for pancreatic body tumor resection.
PP05-46	Resection and Reconstruction of the Superior Mesenteric Artery Resection during Pancreatectomy: Post-operative Results and Survival Niccolò Napoli, Italy C. Cacace, N. Napoli, E.F. Kauffmann, F. Menonna, S. Iacopi, A. Tudisco, V.G. Perrone, F. Vistoli, U. Boggi Division of General and Transplant Surgery, University of Pisa, Italy Introduction: We herein report our experience with en-bloc resection and reconstruction of the superior mesenteric artery (SMA) during pancreatectomy (SMA-P). Methods: We performed a retrospective analysis of patients who underwent SMA-P between 1994 and 2019. Kaplan-Meier curve was used to evaluate long-term survival and univariate cox proportional hazard regression to identify prognostic factors. Results: Among a total of 154 patients who received a pancreatectomy with arterial resection during the study period, 60 meet the inclusion criteria. Simultaneous resection of celiac trunk/hepatic artery and portal/superior mesenteric vein was required in 19 (31.7%) and 57 (95%) patients, respectively. SMA was reconstructed by direct anastomosis in 35 patients (58.3%), using a jump graft, either autologous or cadaveric, in 9 patients (15 %) and switching the splenic artery in 16 patients (26.7 %). Median length of hospital stay was 22 days (15.3-31.8). Severe complications occurred in 15 patients (25%) (IIIB: 4 [6.6%]; IVA: 1 [1.7%]; IVB: 1 [1.7%]; V: 9 [15%]). Forty-five patients (75%) had a pancreatic ductal adenocarcinoma (PDAC). R0 resection was achieved in 50 patients (83.3 %). Lymph nodes (LN) metastasis were present in 47 (78.3%) (N1= 28 [46.7%], N2= 19 [31.7%]) patients with a median LN ratio of 3.4 (1.3-7.4) and a mean LODDS of -3.2±1.2. Median disease specific survival (DSS) for PDAC was 25.3 (15.7-80.4) months. The median LN ratio (HR= 1.14; p=0.02) and the mean LODDS (HR= 2.60; p=0.005) both affected the median DSS. Conclusion: SMA-P is a formidable operation rarely associated with long-term results. Further research is needed.
PP05-47	A Further Modification of the Blumgart Pancreatojejunostomy: Results of a Propensity Score-matched Analysis versus Cattel-Warren Pancreatojejunostomy in Open and Robotic Pancreatoduodenectomy Niccolò Napoli, Italy F. Menonna, N. Napoli, E.F. Kauffmann, C. Cacace, S. Iacopi, A. Tudisco, V.G. Perrone, F. Vistoli, U. Boggi Division of General and Transplant Surgery, University of Pisa, Italy Introduction: Appropriate surgical technique is key to reduce incidence and severity of post-operative pancreatic fistula (POPF). Method: Blumgart pancreatojejunostomy was further modified (m-BPJ), by reducing to 2 the number of transparenchimal sutures and by adding two two “half purse-string sutures” at the corners. m-BPJ was compared to Cattell-Warren pancreatojejunostomy (C-WPJ) before and after propensity score matching in both open (OPD) and robotic (RPD) pancreatoduodenectomy. The primary study endpoint was incidence of clinically relevant POPF (CR-POPF). Results: mBPJ was used in 190 patients (124 OPD; 66 RPD). C-WPJ was employed in 225 patients (143 OPD and 82 RPD). The incidence of CR-POPF was 13.7% and 29.8% (p< 0.0001; OR=0.37) in mBPJ and C-WPJ, respectively. Equivalent figures in OPD and RPD subgroups were 13.7% and 28.8% (p< 0.003; OR= 0.40) and 13.6% and 31.7% (p< 0.01; OR= 0.34), respectively. Grade C POPF occurred in 9 patients after C-WPJ (4.0%) and in 1 patient after mBPJ (0.5%) (p=0.02). Predictors of CR-POPF are reported in table 1. The matching process identified 107 pairs (78 OPD and 29 RPD). In the global population the adjusted OR decreased to 0.40 (p=0.0007). CR-POPF occurred in 12.8% and 28.2% (p=0.01) OPDs, and in 6.9% and 41.4% (p=0.002) RPDs using mBPJ and C-WPJ, respectively. In propensity score matched analysis OR for CR-POPF of mBPJ decreased to 0.36 (p=0.18) and to 0.09 (p=0.01) in OPDs and RPDs, respectively. Conclusion: In our analysis mBPJ decreased incidence of CR-POPF as compared to C-WPJ in the general population, in OPD and RPD. [Table 1 - Predictive factors of CR-POPF]