Poster
Pancreas 		  
PP06 Pancreas: Miscellaneous (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PP06-01 Treatment at a High Volume Academic Research Program Mitigates Racial/Ethnic Disparities in Pancreatic Adenocarcinoma
Quyen Chu, United States

Q. Chu1, Y. Chu2, M.-C. Hsieh3, T. Lagraff4, G. Zibari5, H. Shokouh-Amiri5, J. Gibbs6, X.-C. Wu3
1Surgery, LSU Health - Shreveport, United States, 2Caddo Magnate High School, United States, 3LSU New Orleans, United States, 4Union College, United States, 5John C McDonald Regional Transplant Center, Willis Knighton Health System, United States, 6Surgery, Hackensack Meridan Medical Group, United States

African Americans (AA) have lower overall survival (OS) rates from pancreatic adenocarcinoma compared with Caucasians (C). Socioeconomic status and biology are attributable factors. There is a paucity of data to show which factor(s) will mitigate such disparities. We determined whether treatment at a high-volume center and an academic research program reduces the racial disparity in pancreatic cancer outcomes.
Methods: A cohort of 12,950 patients diagnosed with Stage I-III pancreatic adenocarcinoma from 2003-2011 and treated at high-volume (≥ 12 cases/year) academic research programs (ARP) were evaluated from the National Cancer Database. Sociodemographic, clinico-pathological, and treatment variables were compared between AA and C. The 5-year overall survival (OS) was calculated using the Kaplan-Meier method. Cox regression model was used to assess factors associated with OS. P-value ≤ 0.05 was considered significant.
Results: In univariable analysis, race was a predictor of OS; AA (N=1,127) had a significantly higher OS than C (N=11,823), despite having significantly lower income, lower education level, more stage III disease, more Medicaid recipients, and higher comorbidity index (P< 0.0001). The 5-yr unadjusted OS for AA and C was 28.6% and 23.9%, respectively and the median survival time (months) was 25.2 and 23.7, respectively (P< 0.015). There was no significant difference in surgical margin status or receipt of chemoradiation between the two cohorts. In multivariable analysis, race was not a significant predictor of OS (P=0.096).
Conclusion: Treatment at a high volume, academic research program can mitigate racial/ethnic disparities in pancreatic cancer.
PP06-02 Rural Residence Does Not Predict Outcome for Resected Pancreatic Adenocarcinoma
Quyen Chu, United States

Q. Chu1, Y. Chu2, M.-C. Hsieh3, T. Lagraff4, G. Zibari5, H. Shokouh-Amiri5, J. Gibbs6, T.-W. Tan7, X.-C. Wu3
1Surgery, LSU Health - Shreveport, United States, 2Caddo Magnate High School, United States, 3LSU New Orleans, United States, 4Union College, United States, 5John C McDonald Regional Transplant Center, Willis Knighton Health System, United States, 6Surgery, Hackensack Meridan Medical Group, United States, 7Surgery, University of Arizona Health Sciences College of Medicine, United States

Studies are equivocal on the role of rural residence in cancer outcome. Whether rural residence has an influence on outcome following resection for pancreatic cancer is not clear. We hypothesize that rather than being an independent predictor of survival, rural residence serves as a proxy for other socioeconomic determinants.
Methods: A cohort of 32,319 patients with Stage I-III pancreatic adenocarcinoma diagnosed from 2003-2011 who underwent resection were evaluated from the National Cancer Database. Sociodemographic, clinico-pathological, and treatment variables were compared between rural and urban residences. The 5-year overall survival (OS) was calculated using the Kaplan-Meier method. Cox regression model was used to assess factors associated with OS. P-value ≤ 0.05 was considered significant.
Results: In univariable analysis, rural residence was a predictor of OS; rural (N=634) had significantly lower OS than urban (N=31,688). The 5-yr OS for rural and urban was 17.2% and 22.0%, respectively and the median survival time (months) was 18.8 and 21.3, respectively
(P< 0.007). In multivariable analysis, residence was not a significant predictor of OS (P=0.63). Independent predictors of worse OS were male (P < 0.0001), old age (P< 0.0001), high comorbidity index (P< 0.0001), low income (P< 0.0001), low education level (P< 0.00001), community cancer program (P< 0.0001), advanced stage (P< 0.0001), high grade (P< 0.0001), great circle distance ≥ 50 miles (P=0.003), and lack of receipt of chemotherapy (P< 0.0001).
Conclusion: Rural residence was not associated with worse outcome for resected pancreatic adenocarcinoma. Socioeconomic and tumor factors were independent determinants of pancreatic cancer outcomes.
PP06-03 Arterial Blood Supply from Accessary Middle Colic Artery to the Pancreas
Kyoji Ito, Japan

K. Ito, F. Mihara, N. Takemura, N. Kokudo
Surgery, National Center for Global Health and Medicine, Japan

Background: An accessory middle colic artery (AMCA) is an aberrant artery feeding the splenic flexure of the colon. Little is known about the branching pattern of the AMCA to the pancreas. We aimed to evaluate the branching pattern of the AMCA from the superior mesenteric artery (SMA) with special reference to the pancreatic artery using multidetector-row computed tomography (MDCT).
Methods: We investigated 112 patients who underwent contrast-enhancement MDCT before surgical resection of the pancreas between January 2015 and July 2018. The pancreatic branch from the AMCA was divided into the dorsal pancreatic artery (DPA) and the inferior pancreaticoduodenal artery (IPDA). The branching level and angle of the AMCA from the SMA were also evaluated.
Results: The AMCA was present in 27.7% of patients (n = 31/112). The AMCA branching pattern was classified into four types: type A, no branch from the AMCA (n = 20); type B, a common trunk with the DPA (n = 6); type C, a common trunk with the IPDA (n = 3); and type D, a common trunk with the DPA and IPDA (n = 2). The AMCA with the IPDA (types C and D) branched more proximally compared to the AMCA without the IPDA (P = 0.04). The AMCA branched vertically from the SMA in most cases (n = 24/31, 77.4%).
Conclusions: The AMCA had a pancreatic branch in 8.9% (10/112) of cases. Special attention should be paid to its branching pattern in pancreatic and colon surgery.
PP06-04 Impact of Antithrombotic Therapy on the Perioperative Outcomes with Focus on Bleeding and Thromboembolic Complications in Patients Undergoing Pancreticoduodenectomy
Teruo Komokata, Japan

T. Komokata, B. Aryal, N. Tada, K. Yoshikawa, M. Kaieda, K. Nuruki
Department of Surgery, National Hospital Organization Kagoshima Medical Center, Japan

Introduction: We assessed perioperative outcomes of pancreaticoduodenectomy (PD) in patients receiving antithrombotic therapy (ATT).
Methods: Seventy-seven patients who underwent PD at our institution between 2013 and 2019 were retrospectively reviewed. Clinical findings and surgical outcomes including hemorrhagic and thromboembolic events were compared in patients with or without ATT. Interruption of ATT and preoperative heparin bridging were based on our hospital protocol.
Results: Among ATT (30) and non-ATT (47) groups, patients receiving ATT had a significantly higher age (p=0.019) and history of (H/O) cardio-cerebrovasucular diseases (p< 0.001). Operative time and surgical blood loss were not significantly different between the groups. ATT group was associated with significantly higher rate of postoperative complications, Clavien-Dindo (CD) classification≥II （66.7 vs. 40.4%, p=0.025） and thromboembolic events (13.3 vs. 0%, p=0.020). Operative mortality in ATT and non-ATT groups was 2 (6.7%) and 1 (2.1%), respectively. Multivariate analysis showed that the increased 1) surgical blood loss (≥1,000 mL), 2) post-pancreatectomy hemorrhage (≥grade B), 3) thromboembolic events, and 4) postoperative major complications (CD≥III) were independently associated with 1) diabetes mellitus (p=0.001) and H/O percutaneous coronary intervention (PCI) (p=0.037), 2) H/O upper abdominal surgery (p=0.019) and coronary arterial bypass grafting (p=0.033), 3) age≥80 years (p=0.035) and H/O PCI (p=0.011), and 4) American Society of Anesthesiologists Physical Status (ASA-PS) class 3 (p=0.010).
Conclusions: In patients with ATT under thromboembolic risks, PD is still a feasible procedure. ATT group appears to have higher age with cardio-cerebrovascular diseases and low level of ASA-PS warranting optimization of management to prevent hemorrhagic and thromboembolic complications.
PP06-06 Prognostic Significance of CA 19-9
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

Introduction: Pancreatic adenocarcinoma (PDAC) remains a lethal disease despite improvements in surgical technique and adjuvant therapies. CA19-9 is a useful tumor marker for monitoring recurrent disease. We sought evaluate the prognostic significance of CA 19-9.
Methods: Utilizing the National Cancer Database we identified patients who were diagnosed with PDAC. We then stratified based upon CA 19-9 levels < 250, 251-500, 501-979, and >980. Patient characteristics and survival were compared with Mann-Whitney U, Pearson's Chi-square, and the Kaplan-Meier method.
Results: We identified 15,378 (< 250 n=4829, 251-500 n=1517, 501-979 n=1698, and >980 n=7334) patients with median age of 67 (18-90) years. Elevated levels of CA 19-9 correlated to more advanced T stage, p< 0.001, and N stage, p< 0.001. Additionally, CA 19-9 correlated to LN+, p< 0.001 and lower R0 resections >980 (73.1%), 501-979 (76.9%), 251-500 (77.8%) and < 250 (79.7%), p< 0.001. Median and overall 5-year survival correlated to CA 19-9 levels: < 250 (28.2mo and 27%), 251-500 (27.7mo and 27%), 251-979 (23mo and 20%), and >980 (19.5mo and 15%),
p< 0.001. We identified CA19-9 >500 as predictor of median and overall 5- year survival: < 500 (28.1mo and 27%) and >500 (20.1mo and 16%), p< 0.001. CA 19-9 correlated to progression of disease (15.3mo vs 11.3mo).
Conclusions: CA 19-9 levels correlates to more advanced disease in patients with PDAC. Patients with levels >500 will have larger tumors, increased LN+, and lower R0 resections. These patients will have shorter time to progression of disease.
PP06-07 Effect of Intramuscular Electrical Stimulation on Postsurgical Nociceptive Pain in Pancreaticobilliary Cancer Patients: A Randomized Double-Blind Controlled Trial
Hyung Sun Kim, Korea, Republic of

H.S. Kim1, J. Park2, S. Shin3, J.E. Park3, S. Hwang3, J.B. Lim4, S.Y. Jun5, J.S. Park5
1Department of Surgery, Pancreatobiliary Cancer Clinic, Gangnam Severance Hospital, Yonsei University, Korea, Republic of, 2Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Korea, Republic of, 3Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Korea, Republic of, 4Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Korea, Republic of, 5Department of surgery, Pancreatobiliary Cancer Clinic, Gangnam Severance Hospital, Yonsei University, Korea, Republic of

Introduction: This study aimed to determine the effectiveness of electrical twitch obtaining stimulation (ETOIMS) as a new modality for managing postoperative somatic pain in patients undergoing open pylorus-preserving pancreaticoduodenectomy (PPPD).
Method: Among 48 patients who consecutively underwent PPPD, a total of 44 eligible patients were registered and randomly assigned to a control group and ETOIMS group. The ETOIMS group received ETOIMS in the bilateral rectus abdominis muscles at 14 stimulation points under ultrasound guidance immediately after surgery.Pain score (visual analog scale, VAS), peak cough flow (PCF), and gait speed were repetitively measured between a day before surgery and 4 weeks after surgery. Data were analyzed using the linear mixed model and repeated measures analysis of variance.
Results: Data of 38 patients (ETOIMS, 18; control, 20) were finally analyzed. The VAS scores at operation day (mean [SD], ETOIMS, 5.50 [1.95]; control, 6.45 [2.19], P = .02) and at postoperative day (POD) 3 (ETOIMS, 3.22 [1.48]; control, 4.05 [1.57], P = .04) were significantly lower in the ETOIMS group. The improvement of proportional PCF from POD2 to POD7 was greater in the ETOIMS group (mean [SD], ETOIMS, 25.33% [12.19%]; control, 17.13% [9.67%], P = .03). Gait speed recovered to the preoperative level at POD14 in the ETOIMS group (mean [SD], 93.30% [13.91%], P = .20), while gait speed was still lower in the control group (84.64% [16.03%], P < .01).
Conclusions: ETOIMS helps in rapid reduction of postoperative somatic pain developed after PPPD and improves PCF and gait speed.
PP06-08 Upper Digestive Hemorrage of Uncertain Origin: Hemosuccus Pancreaticus
Leandro Pierini, Argentina

V. Cardona1, L. Pierini2, P. Angel1, G. Hevia Alejandro1, R. Alejandro1
1Hospital J. B. Iturraspe, Argentina, 2General Surgery, Hospital J. B. Iturraspe, Argentina

Introduction: Upper gastrointestinal bleeding is a common cause of hospitalization, having multiples possible etiologies, being well known his mains origins, but losing sensibility in front of infrequent entities. Therefore, this article's objective is to introduce a rare, and hence, not considered differential diagnosis that should not be excluded, the Hemossucus Pancreaticus.
Methods: A patient's case with upper gastrointestinal bleeding of unknow origin is presented, who has been studied through a six months lapse, in which, during his evolution he develops a hemodynamic instability state.
Results: The case of a patient with a rare etiology of gastrointestinal bleeding, in which the diagnosis is reached after multiple procedures, given the ignorance of the underlying pathology, and therefore not expected.
Conclusion: This entity is seen, mainly, in patient whit a history of alcoholism, chronic pancreatitis or aneurysm peripancreatic arteries. It's shown as an acute bleeding's case or, most commonly, as intermittent episodes whit the presence of melena. The current literature recommends multiple invasive and non-invasive diagnostic methods, and two therapeutic options: embolization or surgery.
[Segmental Arterial Mediolysis. RM sequence T2 in the axial plane.The pancreatic canal is dilated.]
PP06-09 Deviations from a Clinical Pathway Post-Pancreatoduodenectomy predict 90-Day Unplanned Readmission
Savio George Barreto, Australia

M. Karunakaran Nair1, S.G. Barreto1,2, M.K. Singh3, D. Kapoor1, A. Chaudhary1
1Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta - The Medicity, India, 2Surgery, Flinders University, Australia, 3Clinical Research, Medanta - The Medicity, India

Background: Post-pancreatoduodenectomy (PD) clinical care pathways result in reduced hospital stay, complications and decreased costs. This study aimed to determine frequency of deviations from a post-PD clinical care pathway to understand how deviations influenced post-operative length of stay and the risk of 90-day unplanned readmissions.
Methods: A prospective analysis of a post-PD clinical care pathway at a tertiary referral centre was carried out between May 2016 and March 2018. Patients were divided based on the number of factors deviating from the clinical care pathway (Group I: No Deviation; Group II: deviation in 1-4 factors; Group III: deviation in 5-8 factors). The analysis included profiling of patients on different demographic and clinical as well as medical and surgical outcome parameters (discharge by postoperative day 8 and 90-day unplanned readmission rate).
Results: Post-PD clinical care pathways are feasible but deviations from the pathway are frequent (91%). Patients with a higher BMI, low serum albumin and cardiac co-morbidities are amongst the cohorts more likely to be associated with deviations. An increase in frequency of deviations from the pathway was significantly associated with increased risk of POPF (p< 0.025) and DGE (p< 0.0001), delayed discharge (p< 0.0001), risk of mortality (p< 0.003) and 90-day unplanned readmission rate (p< 0.001).
Conclusions: Deviations from a post-PD clinical care pathway are common. Poor nutrition and cardiac co-morbidities are associated with an increased likelihood of deviation. As the number of deviations increase, so does the risk of significant complications and interventions, delayed discharge and 90-day readmission rate.
PP06-11 Adult Non-Obstructive Megaduodenum: A Case Report and Review of Literatures
Yusheng Du, China

Y. Du
Department of Pancreatic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China

Objective: To introduce the clinical manifestation，imaging characteristics，diagnosis and treatment of adult non-obstructive megaduodenum.
Methods: We reported a case of adult non-obstructive megaduodenum.Meanwhile,related literature was reviewed and the clinical manifestation，imaging characteristics，diagnosis and treatment of the disease were introduced.
Results: The patient had duodenal down part obvious dilatation and distal non-stenosis,which had been confirmed by air-barium sulfate double contrast roenotgenography,and underwent duodenal shunt procedures and roux-en-Y gastrojejunostomy. The patient was followed-up for five months，without recurrence or complication.
Conclusions: Adult non-obstructive megaduodenum is a specific congenital malformation with no obvious clinical symptoms.X-ray examination is very important. Duodenal shunt procedures and roux-en-Y gastrojejunostomy is the optimal approach for treatment of the disease．
PP06-12 Hepatopancreatobiliary Surgery in Lubaga Hospital, Kampala, Uganda
Michael Okello, Uganda

M. Okello1,2, M. Kiconco2, W. Atala2, U. Mutekoba2, F.X. Baseka2, A.T. Ainembabazi2, E. Kyomugisha2, W. Buwembo1, P. Ocama3
1Anatomy, Makerere University College of Health Sciences, Uganda, 2Surgery, Lubaga Hospital, Uganda, 3Medicine, Makerere University College of Health Sciences, Uganda

Introduction: Hepatopancreatobiliary surgeries were not routinely being done in Uganda thus these patients had to be referred abroad. We, therefore, report the first in country series of patients who underwent these complex surgeries and their outcomes. These pioneer complex surgeries currently are the highest done in a single centre in Uganda.
Method: Records of 42 patients who underwent surgery for hepatopancreatobiliary diseases in Lubaga hospital between February 2019 and January 2020 were analyzed. Four (4) patients with incomplete data, 3 with choledocholithiasis and 2 with peritoneal carcinomatosis were excluded. Thirty three (33) patients with complete data were included in the study.
Results: There were 18(54.5%) females and 15 (45.5%) males. 10 patients had liver surgery (30.3%), 12 underwent roux en y hepaticojejunostomy (36.4%) among which 8 (66.7%) were due to unresectable tumors. 11 patients underwent Whipple's procedure (33.3%). Average Length of hospital stay was 10.5days for liver surgery group, 11.9 days for hepaticojejunostomy group and 15 days for the Whipple's procedure group. There was 1 in-hospital death in the liver surgery group, 2 in the hepaticojejunostomy group and 1 in the Whipple's procedure group.
Discussion: Morbidity and mortality that was associated with hepatopancreatobiliary surgeries has reduced due to improvement in techniques and skills. Sixty percent (66.7%) of patients who underwent hepaticojejunostomy in our institution had unresectable tumors hence showing late presentation. Despite the advanced disease, over all in-hospital mortality was 4 (12%) for this heterogeneous group of patients.
Conclusion: We are doing hepatopancreatobiliary surgeries in Uganda with comparably good outcomes.
PP06-14 Alterations in Portal Flow Dynamics Following Total Pancreatectomy and Autologous Islet Cell Transplant
Brittney M. Williams, United States

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

Introduction: The aim of this study is to evaluate doppler ultrasonography (DUS) flow dynamics following total pancreatectomy and autologous islet cell transplant (TPAIT).
Methods: Retrospective analysis of prospectively collected data was done from February 2018 to September 2019. DUS measuring portal vein (PV) branch velocity (PVV) was performed on post-operative day (POD) 1, 2, and 5, and as applicable due to abnormal liver function tests (LFT).
Results: Fifteen cases of TPAIT were performed. The mean change in PV pressure at infusion was 5.4 cm H2O [1.5 -26 (SD 6.3)]. The lowest mean flow was observed on POD 1 in the main and right posterior PV; on POD 2 in the right anterior and left PV. Correlation analysis showed weak correlation between LFTs and PVV, not significant until POD 5 (r = 0.55, p = 0.04). In the post-discharge period LFTs and PVV correlation was strongly statistically significant (r = 1.0, p-value < 0.001). There was a strong negative correlation between islet cell volume infused and right anterior PVV on POD 2 (r = -0.88, p = 0.02). Islet cell mass and PVV did not significantly correlate until POD 5 (r = 0.80, p = 0.03). No patients had PVT. Two patients had post-operative bleeding, both of which had extremely low velocities (main PVV 0.181).
Conclusion: The correlation between PVV and LFTs is not significant until the post-discharge period when US is performed due to clinical concern rather than protocol. The value of scheduled post-operative velocity measurement may be overstated.
PP06-15 Association between Metformin and Clinical Outcomes Following Pancreaticoduodenectomy in Patients with Type 2 Diabetes and Pancreatic Ductal Adenocarcinoma: Retrospective Study with Systematic Review and Meta-Analysis
Daegwang Yoo, Korea, Republic of

D. Yoo1, N. Kim2, D.W. Hwang1, K.B. Song1, J.H. Lee1, W. Lee1, J. Kwon1, Y. Park1, S.C. Kim1
1Hepatobiliary Pancreatic Surgery, Asan Medical Center, Korea, Republic of, 2Clinical Epidemiology and Biostatistics, Asan Medical Center, Korea, Republic of

Background: Retrospective studies on the association between metformin and clinical outcomes may be affected by time-related bias. Recent studies used time-varying analysis to avoid time-related bias, but only considered the start date of metformin and not the stop date. We aimed to determine the clinical benefits of metformin in patients with type 2 diabetes and pancreatic ductal adenocarcinoma following pancreaticoduodenectomy.
Methods: Analysis using a Cox model with time-varying covariates was performed while considering both the start and stop dates of metformin use. Also, a systematic review and meta-analysis with previous studies on the effect of metformin in pancreatic cancer patients was performed.
Results: A total of 283 patients were included in the retrospective analysis. The overall survival was significantly different according to metformin use, as shown in the adjusted analysis by Cox models with time-varying covariates reflecting both the start and stop dates of postoperative metformin use (HR, 0.747; 95% CI, 0.562-0.993; P = 0.045). The results of the meta-analysis differed according to the analytic method used in each study. Notably, we found that our current study was the first to incorporate both the start and stop dates, and that there are no randomized clinical trials for operable pancreatic cancer as well.
Conclusions: Metformin use was associated with a higher overall survival following pancreaticoduodenectomy in patients with type 2 diabetes and PDAC in time-varying analysis incorporating both the start and stop dates. More studies with this analytic method and randomized clinical trials for operable pancreatic cancer are needed.
PP06-17 The Top 100. Review of the Most Cited Articles on Pancreas and Laparoscopy
José Manuel Ramia Ángel, Spain

A. Manuel Vázquez1, J.R. Oliver Guillén2, R. Latorre Fragua3, A. Palomares Cano2, M. Serradilla Matín2, J.M. Ramia Ángel4
1Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Spain, 2Department of General and Digestive Surgery, Hospital Universitario Miguel Servet, Spain, 3Hospital Universitario de Guadalajara, Spain, 4Department of General and Digestive Surgery, Hospital Universitario de Alicante, Spain

Introduction: The number of citations is considered as an indirect indicator of the merit of a paper, journal or researcher, although it is not an infallible method to determine scientific quality. The bibliography referring to the pancreas and laparoscopy is very scarce. Our goal is to determine the characteristics of the most cited paper about pancreas and laparoscopy.
Methods: We performed a search of all articles published in any journal about pancreas and laparoscopy until September 2019 using the Web of Science application and selected the 100 most cited papers in all databases. We evaluated number of citations, journal, year, quartile, impact factor, institution, country, authors, type of paper, type of surgery, topic and area.
Results: The top-100 citations account 10,970 citations.
The journal with the most articles is Surgical Endoscopy and 2007 is the year with the highest number of papers in the top-100 citations. The papers from America and Europe are 39% versus 36% respectively.
Case series is the most frequently type of study; outcomes/morbidity is the most frequently discussed topic, and distal pancreatectomy is the most frequently type of surgery.
Conclusion: This bibliometric study on the pancreas and laparoscopy is conditioned by the time factor, since laparoscopy has come later to pancreas surgery and this topic has begun to be studied recently. This fact is related probably due to the morbidity and mortality associated with pancreatic surgery and the need for high specialization in this field. This means that the information you have is recent and scarce.
PP06-18 Exploring the Psychological Impact of Living with and after Cancer Following Major Pancreatic Surgery: A Qualitative Study
Anna Taylor, United Kingdom

A. Taylor1, D. Chang2, C. Chew-Graham3, A. Kausar2
1East Lancashire Hospitals NHS Trust, United Kingdom, 2Hepato-Pancreatic-Biliary Service, Department of General Surgery, East Lancashire Hospitals NHS Trust, United Kingdom, 3School of Primary, Community and Social Care, University of Keele, United Kingdom

Introduction: Pancreatic cancer is the 11th most common cancer in the UK. Most patients are diagnosed after metastasis but around 10% undergo a pancreaticoduodenectomy. There is limited research focusing on the psychological wellbeing of patients diagnosed with pancreatic cancer, and unmet support needs will impact negatively on quality of life. Our study aimed to explore patients' experiences of surgery and living with pancreatic cancer, as well as identifying opportunities to optimize psychological wellbeing.
Methods: Semi-structured interviews were conducted with patients from an NHS Trust in Northwest England who had undergone a pancreaticoduodenectomy for pancreatic or biliary duct cancer. Interviews explored their experience of the diagnostic process and surgery, the impact of cancer on their life, and sources of support. Data were analysed using a thematic approach.
Results: Initial analysis has yielded several themes, including: reactions to diagnosis; self-identity and 'redefinement of self' following diagnosis or recurrence; and life being considered a trajectory measured by scans. Participants also described difficulties navigating the healthcare system and being unclear on when and from whom to ask for help. They expressed a desire for a proactive approach from healthcare professionals for both physical and emotional problems. A sense of stoicism was alluded to throughout interviews.
Conclusion: An awareness of the impact of treatment on identity, and recognition of psychological sequelae following diagnosis, is vital in order to offer emotional support proactively. Understanding patients' experience of living with cancer and the impact of treatment is crucial in enabling the development of improved support interventions.
PP06-20 Improving the Standard of Care for All - A Practical Guide to Developing a Center of Excellence
Vichin Puri, United States

E. Vivian, V. Puri, A. Mejia, R. Dickerman, P. Kedia, V. Moparty, J. Mallow, L. Lundberg, A. Vo
Methodist Dallas Medical Center, United States

Introduction: The incidence of and pancreatic disorders has increased significantly in last decade. With the evolution of minimally invasive pancreas surgery in 1994 and robotic surgery in 2001 surgeons have been able to push the envelope in this field. These operations are technically complex and have historically been accompanied by substantial risk for mortality and morbidity. The number of pancreatic resections performed in the US increased by 75% between 1993 and 2014, which has mandated the need for more specialized surgeons and centers that can maintain low operative risk and good patient outcomes. The strong link between hospital and provider volume and improved patient outcomes has prompted centralization of pancreatic disease management and with that the need for well-designed Centers of Excellence (CoE). This article provides a basic guideline to establishing such a center at a community hospital willing to improve patient outcomes related to pancreatic pathology.
Methods:
1. Establishing the foundation with leadership buy-in, structure and purpose; mission statement; determining market share; and budgeting.
2. Formalizing the program by providing clinical education and competency training; establishing nurse navigation and multidisciplinary involvement; developing clinical information systems for a value-based healthcare structure and establishing quality and performance improvement initiatives.
3. Solidifying the CoE status through certification/accreditation from external institutions such as the Joint Commission and maintain marketing and outreach in the service area.  
Conclusions: The steps outlined in this article are meant to provide a guide to facilities looking to build a disease or procedure-specific CoE.
[Figure 1: Timeline of CoE Development; Figure 2: Example CoE Dashboard]
PP06-23 An Effectiveness of Partial Splenic Embolization for Hemorrhage from Anastomotic Varices after Choledochojejunostmy: A Case Report
Takahiro Haruna, Japan

T. Haruna1, T. Yokoyama1, H. Makino1, A. Hirakata1, H. Takata1, N. Taniai2, Y. Kawano3, J. Ueda3, H. Yoshida4
1Nippon Medical School Tamanagayama Hospital, Japan, 2Nippon Medical School Musashikosugi Hospital, Japan, 3Nippon Medical School Chibahokusou Hospital, Japan, 4Nippon Medical School, Japan

Introduction: Hemorrhage from anastomotic varices after choledochojejunostmy is one of a rare complication after pancreatodudenectomy. We report a case of an effectiveness of partial splenic embolization for hemorrhage from anastomotic varices after choledochojejunostmy.
Case presentation: An 85-year-old woman was diagnosed locally advanced pancreatic carcinoma contact with superior mesenteric artery and portal vein. She underwent subtotal stomach-preserving pancreatodudenectomy (SSPPD) with portal vein resection and anastomosis after chemoradiotherapy. Her postoperative course was uneventful, however, she was admitted to our hospital with anemia and melena on postoperative 3 month. Computed tomography showed an obstructed portal vein anastomosis and a formation of collaterals adjacent to the choledochojejunostomy. Double balloon endoscopy showed varices around the choledochojejunostomy site, we diagnosed hemorrhage from the varices. We could not perform endoscopic therapy because it was a difficult procedure. Therefore, we performed partial splenic embolization (PSE) to reduce portal hypertension and control the hemorrhage. After the PSE, she had no anemia and melena.
Conclusion: Ectopic varices hemorrhage caused by extrahepatic portal vein obstruction after an intraperitoneal surgery is one of a lethal complication, early detection of the hemorrhage source and its treatment could be difficult. No guideline for varices hemorrhage around choledochojejunostomy site is established. It is worth considering that PSE might be one of a treatment for the varices hemorrhage.
PP06-26 Preduodenal Portal Vein (PDPV) with Preduodenal Common Bile Duct (PDCBD) and Whipple Procedure. A Case-report
Francisco Carriel, Chile

F. Carriel1,2,3, A. Paredes1,3, F. Oppliger1,2,3, M. Vivanco2,3, G. Rencoret1,2,3
1Universidad del Desarrollo, Chile, 2Clinica Alemana de Santiago, Chile, 3Hospital Padre Hurtado, Chile

Introduction: Various anatomic disorders of the Portal Vein (PV) like PDPV have been described, but they are rare. Associated PDCBD is an extremely rare event. We report a patient with PDPV and PDCBD who underwent a pancreaticoduodenectomy.
Presentation of the case: A 69-year-old woman presented with a tumor of the papilla of Vater was scheduled for surgery. Preoperative imaging showed a PDPV anterior to a PDCBD, arising from a pre-pancreatic confluence of the splenic and superior mesenteric vein. During pancreaticoduodenectomy, a choledochoduodenal fistula was encountered and repaired. Complete dissection and isolation of structures was possible, and there was no need for a PV reconstruction, as presented in other case reports. No postoperative complications of importance presented. Pathology confirmed a R0 resection of a non-invasive intra-ampullary papillary-tubular neoplasm (IAPN). At one-month follow-up the patient was clinically asymptomatic.
Discussion: Such a discovery is often incidental and of little importance, but it takes on major importance for HPB surgeons because accidental damage of PDPV and PDCBD can lead to serious consequences. These rare disorders do not contradict Whipple procedures but should be performed by experienced surgeons with adequate preoperative imaging. Skills in PV reconstruction and its peri-operative might be beneficial for successful outcomes in some cases.
Conclusion: Extended surgical procedures like a pancreaticoduodenectomy are realisable in patients with PV disorders, but require awareness, adequate radiological interpretation and specific surgical experience for secure treatment.
PP06-27 Quality of Life after Pancreatic Resection for Malignant and Benign Disease - A Cross-sectional Study
Clare Toms, Australia

C. Toms1,2, D. Steffens1,2, D. Yeo2,3,4, C. Pulitano2,3,4, C. Sandroussi2,3,4
1Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Australia, 2The University of Sydney, Australia, 3Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Australia, 4Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Australia

Introduction: To investigate QOL trajectories following pancreatic resection for malignant or benign disease.
Methods: Consecutive patients of six upper gastrointestinal surgeons who underwent pancreatic resection at one of six hospitals in Sydney, Australia between Apr-2014 and Apr-2019 were invited to participate. The main outcome was self-reported QOL using the Short Form 36 (SF-36v2) expressed as mental (MCS) and physical component scores (PCS) with values ranging from 0-100 and the Functional Assessment of Cancer Therapy - Hepatobiliary (FACT-Hep) expressed as a total score, with values ranging from 0-180. Higher scores indicate better QOL. QOL outcomes were measured at < 12, 12-23, 24-35, 36-47 and ≥48 months post-surgery. Differences at each timepoint were compared with ANOVA and multiple pairwise comparisons were made using the Bonferroni correction.
Results: Of 224 invited patients, 121 (54%) responded. Mean (SD) age was 68.0 (11.9) years and 52% (n=63) were male. Malignancy was the indication for surgery in 78% (n=94), 63% (n=74) of participants underwent pancreaticoduodenectomy and 57% (n=69) were between 12 and 35 months from surgery.
No difference in the PCS and total FACT-Hep score was observed for the studied period. A significant increase on the MCS was observed from < 12 month to 12-23 months postoperatively (mean difference: 9.4; 95%CI: 1.1to17.1); No difference on MCS was noted on any other time points (Figure 1).
Conclusions: MCS improved significantly from < 12 months to 12-23 months. No further significant changes were observed in MCS, PCS and total FACT-Hep scores over time compared to baseline.
[Figure 1. Quality of Life trajectories following pancreatic resection]
PP06-28 Post Traumatic Pancreatic Fistula. When One Surgery Is Not Enough
Carlos Miguel Gomez Vela, Mexico

S.A. Pimentel Melendez1, Y.A. Nacud Bezies2, C.M. Gomez Vela2, M.F. Paez Arteaga2, M.A. Medina Medrano2, C. Contreras Rojas2
1Digestive and Endocrine Surgery, IMSS High Specialty Medical Unit No 25. CMNN, Mexico, 2DIgestive and Endocrine Surgery, IMSS High Specialty Medical Unit No 25. CMNN, Mexico

In the setting of abdominal blunt trauma, damage to the pancreas is a infrequent complication(0.2 / 3.1%), although when the spleen is damage the lesion to the tail of the pancreas is not as infrequent as the single pancreatic trauma alone. primary closure and repair in an unstable patient can be applied trying to prevent excessive surgical time, but with the risk of developing a pancreatic fistula in the post operative period. in the following case report, we present the case of a young male with splenic and pancreatic trauma, who developed a pancreatic fistula and that required multiple surgeries in order to control this serious complication.
26 yo male who under went emergency laparotomy secondary to blunt abdominal trauma, with splenic and distal pancreatic injury, who after multiple surgeries developed type b pancreatic fistulae with impossibility to perform ercp with stent placement as a treatment, so he was referred to our service for surgical evaluation.
Patient with adequate surgical evolution discharged 4 days after surgery without biochemical leak evidence, currently on 2nd month of followp as out patient with good clinical evolution.
Surgical resection is a feasible as a secondary treatment for non endoscopicaly fitpatients for treatment pancreatic fistulae with good results in third level high volume centers.
PP06-30 Liquid Biopsies in Pancreatic Adenocarcinoma: Evaluation of DNA Damage Repair Pathway Alterations
Rachael Galvin, United States

R. Galvin1, C. Chung1, E. Achenbach2, S. Sen2
1Department of Surgery, Swedish Medical Center, United States, 2Sarah Cannon Research Institute at HealthONE, United States

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with few effective standard of care therapeutic options. However, molecular profiling in PDAC patients has identified many potentially actionable gene alterations in these cancers and the FDA recently approved the first BRCA-targeted therapy for patients with PDAC. These drugs are also known to work on patients with somatic alterations in DNA damage response and repair (DDR) genes. Given this new treatment option, patients will require molecular profiling to determine drug eligibility. This study examines the incidence of BRCA and other DDR gene alterations in our PDAC patient population.
Methods: All patients with refractory or metastatic PDAC, referred to a single tertiary cancer center (from 2014-2019) were retrospectively reviewed for molecular profiling results and BRCA/DDR gene alterations.
Results: We identified 57 patients with PDAC that underwent molecular profiling. Thirty-nine of the 57 patients (68.4%) underwent tissue-based molecular profiling, while 42 patients (73.6%) underwent blood-based sequencing. Two of the 57 patients had BRCA1 mutations (3.5%) and 10 patients had BRCA2 mutations (17.5%). There were 7 patients (12.3%) with other DDR gene alterations identified, including ATM (7.0%), CHEK2 (1.8%), FANCC (1.8%), and MLH1 (1.8%).
Conclusion: This study demonstrates the utility of molecular profiling in PDAC patients and identifies a broad subset of patients that may benefit from new targeted treatment options available for BRCA-mutated tumors.
PP06-32 Effect of Preoperative Malnutrition Using Global Leadership Initiative on Malnutrition (GLIM) Criteria on Short- and Long-term Outcomes of Patients with Pancreatic Head Cancer
Boram Lee, Korea, Republic of

B. Lee, H.-S. Han, Y.-S. Yoon, J.Y. Cho, Y. Choi
Department of Surgery, Seoul National University Bundang Hospital, Korea, Republic of

Background: Although malnutrition is a global concern, there has been a lack of consensus on diagnostic criteria for application in clinical settings. Therefore, the Global Leadership Initiative in Malnutrition (GLIM) criteria has recently developed for assessing the malnutrition. The aim of study is to assess the effect of preoperative malnutrition, by means of GLIM criteria for predicting short- and long-term outcomes in patients who underwent curative pancreatoduodenectomy (PD).
Methods: From 2004 to 2018, 228 consecutive patients who underwent curative PD in our center for pancreatic ductal adenocarcinoma. The definition of malnutrition is based on both phenotypic criteria (weight loss, low body mass index [BMI] and reduced muscle mass), and etiologic criteria (reduced intake or assimilation and inflammation) in GLIM criteria.
Results: 75 (32.9%) of 228 patients were classified as with malnutrition. Preoperative malnutrition associated with an increased risk of estimated blood loss (816.7±875.2 vs. 593.1±489.9, P=0.015) and total hospital stay (27.3±15.7 vs. 22.9±17.7, P=0.045). The mediam follow-up period was 9.5months. The malnourished patients had inferior median 1-/3-/5-year overall survival, when compared to well-nourished patients (66.3%, 18.0% and 12.0% vs. 81.3%, 51.8% and 39.3%, P< 0.001). On multivariate analysis, malnutrition (Hazard Ratio 1.81, P=0.002) correlated independently with poor survival.
Conclusion: The GLIM criteria is a simple and useful tool for predicting the short- and long-term outcomes of pancreatic head cancer patients who underwent PD.
PP06-33 Postoperative Management of Clinically Relevant Pancreatic Fistula in our Institute
Hiroyuki Matsukawa, Japan

H. Matsukawa1, H. Suto2, Y. Andou2, M. Oshima2, K. Okano2, Y. Suzuki2
1Gastroenterological Surgery, Kagawa University, Japan, 2Gastroenterological surgery, Kagawa University, Japan

Introduction: Drain amylase levels are determined and drain bacterial culture results are obtained on days 1 and 3 postoperatively. In cases that drain fluid is aseptic, all drains are basically removed early regardless of fluid volume and amylase level. In contrast, in cases with drain fluid infection, the target drain is replaced with an 18-22Fr silicone drain once a stable fistula formation is confirmed. When intraabdominal abscess is detected after the drain removal, a 10-12Fr polyethylene percutaneous pigtail catheter is introduced under CT guidance. Enhanced CT is performed routinely on day 7 and as needed in patients with pancreatic fistula (PF) to evaluate fluid collection with or without pseudoaneurysm.
Method: Among 122 patients who underwent pancreatectomy (99 pancreatoduodenectomy (PD) and 23 distal pancreatectomy (DP)) between April 2015 and March 2018, 40 patients (30 PD and 10 DP) complicated with ISGPS PF were reviewed from the hospital records.
Result: Grade B and grade C PF developed in 37 and 3 patients, respectively. In patients with grade B PF, 27 were successfully managed only with repeated drain replacement; the first replacement was performed on day 11 (6-25), the median length of drainage was 35 days (17-88), and the median length of postoperative stay was 42 days (25-146). Two patients who underwent reoperation for insufficient drainage and 1 who died of rapture pseudoaneurysm were categorized into grade C.
Conclusions: Our postoperative managements of intraoperatively placed drains and PF resulted in relatively favorable outcomes except for considerably long hospital stay.
PP06-34 Coil Embolization of Common Hepatic Artery Pseudoaneurysm after Pylorous Preserving Pancreaticoduodenectomy: A Case Report
Jae Uk Chong, Korea, Republic of

J.U. Chong, J.H. Lee, H.S. Lee, K.H. Kwon
Surgery, National Health Insurance Service Ilsan Hospital, Korea, Republic of

Introduction: Pseudoaneurysm from pancreatic leakage after pancreaticoduodenectomy can result in fatal intra-abdominal bleeding. Here, we present a case of coil embolization of common hepatic artery pseudoaneurysm after pylorous preserving pancreaticoduodenectomy (PPPD).
Case report: A 70 year-old male underwent PPPD for common bile duct cancer (T2N0). Prior to the operation, endoscopic retrograde biliary drainage was inserted and resulted in acute interstitial pancreatitis. The operation was uneventful and patient was discharged on postoperative day #14. On postoperative day #25, patient came to the emergency room with abdominal pain and fever. Computed tomography showed aggravated acute interstitial pancreatitis, common hepatic artery pseudoaneurysm with adjacent small hematoma and segmental narrowing of portal vein resulting from localized fluid collection. Emergency abdominal angiography was performed to insert a stent into stenotic part of the portal vein for better portal flow to the liver. Coil embolization from proximal right and left hepatic artery to the common hepatic artery was done. During angiography, arterial flow to the liver from inferior phrenic artery was observed. Additional percutaneous drain was also placed for intra-abdominal fluid collection. Following the embolization, AST/ALT elevated to 456/263IU/L then decreased to 48/57IU/L after four days. Total bilirubin level was also elevated to 5.3mg/dL then decreased to normal range after 20 days. Patient was discharged on 30 days after the embolization without further complications.
Conclusion: Coil embolization for pseudoaneurysm of common hepatic artery may be safely considered when portal flow is intact and collateral arterial flow to the liver from inferior phrenic artery is present.
[Figures: A)preop CT, B)POD#25, C)Narrowing of SMV,PV, D) CHA pseudoaneurysm, E)POD#60]
PP06-35 Lack of Association between Postoperative Acute Pancreatitis and Postoperative Complications Following Pancreaticoduodenectomy: A Secondary Analysis from a Randomized Trial
Daegwang Yoo, Korea, Republic of

D. Yoo1, S.Y. Park2, D.W. Hwang1, J.H. Lee1, K.B. Song1, W. Lee1, J. Kwon1, Y. Park1, S.C. Kim1
1Hepatobiliary Pancreatic Surgery, Asan Medical Center, Korea, Republic of, 2Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Korea, Republic of

Objective: To evaluate the association between postoperative acute pancreatitis (POAP) and postoperative complications including postoperative pancreatic fistula (POPF) in patients undergoing PD.
Summary background data: Prediction of post-PD morbidity is difficult especially in the early postoperative period when CT scans are not available. Elevated serum amylase and lipase in postoperative day 0 or 1 may be used to define POAP, but existing literature do not agree on whether POAP is significantly associated with POPF.
Methods: We analyzed the data obtained from a previously published randomized controlled trial. POAP was defined as elevations in serum amylase above 110 U/L on postoperative day 0 or 1. Clinically relevant POAP (CR-POAP) was defined as elevations in CRP on postoperative day 2 in those with POAP. Postoperative complications including severe complications (Clavien-Dindo ≥ IIIa), POPF, and clinically relevant POPF (CR-POPF; grades B or C) were analyzed. For a robust selection of variables for multivariable analysis, 500 bootstrap samples were drawn from the original data and backward elimination was performed while forcing POAP to be included.
Results: In 246 patients, POAP did not show significant associations with total postoperative complications (odds ratio [OR] 0.697; 95% CI, 0.360-1.313; P = 0.271), severe complications (OR 0.647; 95% CI, 0.258-1.747; P = 0.367), and CR-POPF (OR 0.998; 95% CI, 0.310-3.886; P = 0.998) in multivariable analysis.
Conclusions: In patients undergoing PD, POAP was not significantly associated with postoperative complications including POPF. Caution should be taken when using POAP as a predictor of POPF.
PP06-36 Improving Accessibility to Pancreatic Cancer with Circulating Tumour Cell Technologies for Targeted Molecular Therapeutics
Claire Alexandra Zhen Chew, Singapore

C. Chew1, S.L. Chan2, E.S.H. Cheow3, A.W.C. Kow2, K. Madhavan1,2, S.G. Iyer1, C.E. Chee4, G.K. Bonney1
1Surgery, National University Hospital, Singapore, 2Surgery, National University of Singapore, Singapore, 3iHealthTech, National University of Singapore, Singapore, 4Haematology-Oncology, National University Hospital, Singapore

Pancreatic adenocarcinoma is one of the most lethal malignancies with majority of patients having already developed metastases at presentation. Diagnosis is typically made by endoscopic ultrasound guided biopsy which remains a procedure where often samples are insufficient for diagnosis.
Particularly in pancreas cancer where tissue access is limited, circulating tumour cells (CTC) is an attractive target for non-invasive therapeutic monitoring as they can reflect the evolving mutational profile of the disease. Unfortunately, the isolation of CTCs is technically challenging and to date only enumeration assays of limited clinical utility have been described in pancreatic cancer. The ex-vivo expansion of CTCs would greatly increase the amount of data that can be obtained from a single liquid biopsy.
In this proof-of-concept study, we established CTC cultures from the peripheral blood of patients with pancreatic cancer at various stages of disease progression. CTC isolation and culture conditions were optimised, and tumour status was confirmed by identification of KRAS mutation with demonstration of tumourigenicity in mice. CTC lines were characterised with proteomics and compared against profiles of paired biopsy derived organoids and primary tumour samples where available.
Our study has established CTC lines that provide the opportunity to personalize therapy in real-time by taking into account the temporal evolution of disease. Based on this proof-of-concept study, we have expanded the clinical utility of CTC cultures for drug sensitivity screening and therapeutic biomarker discovery.
PP06-37 Intraductal Papillary Mucinous Neoplasms (IPMN): Long Term Management and Results at Single HPB Center
Gabriel Gondolesi, Argentina

M.F. Fernandez, F. Pattin, S. Almanzo, L. Montes, P. Farinelli, P. Barros Schelotto, G. Gondolesi
Cirugia HPB y Trasplante Multiorganico, Hospital Universitario Fundacion Favaloro, Argentina

Introduction: IPMN origins within the cells of the pancreatic duct. Accepted as lesions that can progress to pancreatic cancer, TC, MRI and EUS should be used to identify risk factors to decide whether the patient should benefit from a surgical approach.
Methods: Retrospective analysis of patients diagnosed of IPMN between 2015 and 2019. Variables analyzed include demographics, symptoms, images, surgical indication, type of lesion, presence of malignant disease and survival. The statistical studies performed will be described in each of the results reports and were performed using SPSS version 17.
Results: 58 patients were diagnosed with IPMN: 48 were found pre-operatively (Group 1) while 10 post-resection (Group 2, 9.7%). G1: 73% were fem., 71% asymptomatic, 23 (48%) multifocal, 13 (27%) located the head of the pancreas, 8 (17%) in the body and 4 (8%) in the tail. Table 1 summarizes the analyzed. The average time to surgery was 22.4 +/- 29.4 months. In G2: 6 were associated to invasive AdenoCa, 2 to an Ampuloma, 1 to a NET and 1 in a pancreas divisum. Long term survival: 100% for G1 at 10 years, while in G2 is 100% and 86% at 1 and 10 years respectively. Recurrence rate: 22%.
Conclusions: Those results highlight the value of following stablished guidelines in order to be successful with a conservative approach when an IPMN is diagnosed. In patients with IPMN I or III, surgery is recommended. Newly diagnosed IPMN II should be strictly followed due to an increased risk of malignancy.
 Preo-operative DiagnosisGenderAgeSurgery or Follow upSurgical indicationPathology reportSurvival (month)AliveRecurrency
Patients with indication of surgeryIPMN I
IPMN I
IPMN I
IPMN I
IPMN I
M
F
M
F
F
88
69
72
36
60
Distal Pancreatectomy
Cephalic duodenopancreatectomy
Distal Pancreatectomy
Distal Pancreatectomy
Pending Surgery		Type of IPMN
Type of IPMN
Type of IPMN
Type of IPMN
High CA19.9 in EUS. Size >4cm		IPMN I with LGD
IPMN I with MGD
Mixed type IPMN with LGD
Microcystic Serous Cystadenoma
-		22
29
27
14
24		Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
-
Patients with indication of surgeryIPMN II
IPMN II
IPMN II
IPMN II
F
F
M
F
74
73
71
66
Cephalic duodenopancreatectomy
Cephalic duodenopancreatectomy
Distal Pancreatectomy
Pending Surgery		Mural tumor with contrast enhacement
Mural tumor with contrast enhacement
Mural nodule >5mm
Size >4cm. Atrofic pancreas		IPMN I with MGD
IPMN II
IPMN II with MGD
-		38
108
87
1		Yes
Yes
Yes
Yes
No
Yes
No
-
Patients with indication of surgeryIPMN III
IPMN III
IPMN III
F
F
M
70
68
71
Total Duodenopancreatectomy
Total Duodenopancreatectomy
Pending Surgery		High CEA in EUS
Growth >5mm/2 years
Dilatated Wirsung		Mixed type IPMN with LGD
Mixed type IPMN with HGD
-		58
45
3		Yes
Yes
Yes
No
No
-
Follow upIPMN I
N=1		F63Follow up--72Yes-
Follow upIPMN II
N=30		M=7
F= 23		63+/-13Follow up--12+/-13All-
Follow upIPMN III
N=5		F=4
M=1		60+/-14Follow up--20+/-8All-
[Patients that underwent surgery with preo-operative diagnosis of IPMN.]
PP06-38 Doudenal Stenosis from Spontaneous Heterotopic Mesenteric Ossification Around Pancreas: A Case Report
Dong Hee Ryu, Korea, Republic of

D.H. Ryu, J.-W. Choi, H. Choi
Chungbuk National University College of Medicine, Korea, Republic of

Background: Heterotopic mesenteric ossification is a very rare disease. In most of cases, the patients had a history of an abdominal surgery or trauma. However, spontaneous heterotopic mesenteric ossification is extremely rare.
Case presentation: A 60-year-old man presented with recurrent nausea and vomiting. On gastroduodenoscopy, luminal stenosis and edematous change at 2 nd ~3 rd portion of duodenum without complete obstruction was seen. On abdomino-pelvis computerized tomography, slightly less prominent enhancing wall thickening at 2nd and 3rd portion of duodenum was found. We performed a pylorus-preserving pancreaticoduodenectomy. The pathologic report confirmed heterotopic ossification with extensive fibrosis in peripancreastic soft tissue.
Conclusions: Herein, we described a case of duodenal stenosis from spontaneous heterotopic mesenteric ossification around pancreas that has never been reported.
PP06-40 ZIP Codes Influences Staging of Pancreatic Cancer at Diagnosis
Cataldo Doria, United States

C. Doria, E. Schwartz, S. Ranieri Dolan, K. Yatcilla, J. Chung, P. De Deyne
Capital Health, Cancer Center, United States

Introduction: The purpose of this study was to determine if pancreatic cancer stage at diagnosis is associated with the patient's zip code. Our hypothesis was that low socio economic status (SES) is associated with late diagnosis of pancreatic cancer.
Methods: We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer between 2010-2018. We selected subjects (328) by zip code, representing the plurality of the cases in our catchment area. Outcome variables were overall survival and socio-economic status; predictor variables were recurrence, insurance, type of treatment, gender, cancer stage, age, and gender. We converted zip code to municipality and culled data using Adjusted Gross Income (AGI, FY 2017) We then created groups using a cutoff at filings of >$100,000 of AGI; Low SES = municipalities where ≤5% of the filings were over $100,000, Mid SES = municipalities where between 5%-40% of the filings were over $100,000, High SES = municipalities where ≥40% of returns were over $100,000. Comparative statistical analysis was performed using Chi-square for nominal and ordinal variables, a two-way ANOVA test was used for continuous variables, p- value was set at 0.05.
Results: Although it was not statistically significant different, we found a trend where patients with low SES had a higher stage pancreatic cancer at diagnosis (Tab. 1).
Conclusion: Our study shows that the subjects who live in a municipality with low SES are at disadvantage when diagnosed with pancreatic cancer.
[Table 1]
PP06-41 Robotic Assisted Roux En Y Hepaticojejunostomy, after Failed Cholecystojejunostomy for the Treatment of a Choledocal Cyst. Case Report
Samuel Arnulfo Pimentel Melendez, Mexico

E. Jimenez Chavarria1, S.A. Pimentel Melendez1,2, H.F. Noyola Villalobos1, I. Fernandez Alvarado1, J. Hernandez Hurtado1
1HPB Surgery, Hospital Central Militar, Mexico, 2Digestive and Endocrine Surgery, IMSS High Specialty Medical Unit No 25. CMNN, Mexico

The cysts of the biliary tree are congenital entities, which can occur not only in bile duct, but throughout the biliary tree, often accompanied by an anomalous pancreatobiliary union. With an incidence of 1 case per 100,000 inhabitants, with a preponderance of 4: 1 women-men. They may be asymptomatic in childhood and have symptoms in adulthood, such as abdominal pain or jaundice. We present the case of a a 19-year-old female patient, with history of diffuse abdominal pain, accompanied by jaundice, with an ultrasound with diagnosis pf choledocholithiasis, with failed ERCP with suspicion ofa choledochal cyst, a 2nd ercp was performed where stents were placed, and subsequently undergoes an unspecified biliodigestive bypass.At 24 hours with acute abdominal pain, significant distension, re-entering the operating room where a large biliary leak is identified, requiring UCI care for 1 month. With multiple abdominal reinterventions during that period. The patient was discharged with the biliary leak present, arriving at our center with severe dehydration and malnutrition . improvement of her condition was required, placing a trans hepatic stent and Staging the lesion as a choledocal cyst still IC. Robotic assisted roux en y hepaticojejunostomy was perfomerd, identifying the previous attempt as a cholecystojejunostomy, completing the resection of the remanent cyst and the biliary bypass. Patient continued with favorable post operative follow up, discharged 7 days post op, and is dong well after a year of follow up, avoiding the risk of cholangiocarcinoma in the long term.
[ctst]
PP06-42 Anticoagulation Practices in Total Pancreatectomy with Autoislet Transplantation Patients: An International Survey of Clinical Programs
Chirag Desai, United States

K.R. Szempruch1, C.S. Desai2
1University fo North Carolina, United States, 2University of North Carolina, United States

Introduction: Anticoagulants are used in order to prevent thrombosis and assist with the islet engraftment during TPAIT (Total Pancreatectomy with Autoislet Transplantation) at the risk of bleeding complications. There appears no consensus guideline on anticoagulation protocol used. We aim to describe current practices by centers internationally.
Methods: An online survey was sent via email communication to TPAIT programs enrolled in the Collaborative Islet Transplant Registry (45 email domains may be suggestive of equal number of program). Three reminder emails were sent over the course of six weeks. 49 questions assessing demographics, patient related risk factors, and intra- and post-operative anticoagulation and aspirin use were formulated.
Results: Fifteen programs across 6 countries, 3 continents responded. 10(66.6%) classified patients into high or low risk. Responses to anticoagulation and antiplatelet practices are in Table 1. Intra-operatively, programs gave one (n=9), two (n=3), or no (n=3) heparin boluses with 10(66.6%) giving based on units/kg(0-50) and 5(33.4%) using a fixed dose. 14(93.3%) used heparin in the islet product. Post-operatively, heparin drips were initially used (n=10) and most commonly were started based on unit/kg/hr (n=8) with aPTT goal monitoring. [40-50 seconds (n=4) or >50 seconds (n=4)]. 8 programs (53.3%) used set duration of heparin, 25-48 hours being most common. 12(80%) used low molecular weight heparin (LMWH) post-operatively at some point of time. Aspirin was used by 10 programs (66.7%). Rate of thrombosis and bleeding wasn't clarified.
Conclusion: Very high practice variability among programs providing this specialized treatment warrants further studies and a consensus guideline.
QuestionYes, n (%)No, n (%)
Intra-operative heparin bolus(es) given12 (80)3 (20)
Heparin drip started initially post-operatively10 (66.7)5 (33.3)
Use portal pressure to decide rate of heparin drip0 (0)13 (100)
Monitoring of heparin drip9 (75)3 (25)
Set duration of heparin drip8 (61.5)5 (38.5)
Monitoring of anti-Xa levels if LMWH used post-operatively5 (35.7)9 (64.3)
Use of liver function test or liver doppler to consider stopping LMWH2 (22.2)7 (77.8)
Goal anti-Xa level changes throughout the duration of use0 (0)7 (100)
Patient risk factors change anti-Xa goal after start3 (75)1 (25)
[Table 1. TPAIT program responses to anticoagulation practices]
PP06-43 A Rare Case of Malignant Polycystic Pancreas Involving the Whole Pancreas Treated Surgically - Case Report
Atiya Lambe, India

A. Lambe1, R. Yadav2, K. Adyanthaya2
1General Surgery, Bombay Hospital Institute of Medical Sciences, India, 2HPBI and General Surgery, Bombay Hospital Institute of Medical Sciences, India

Polycystic pancreas is a rare disease with an unknown incidence. Very few cases have been reported in the literature. Polycystic pancreas is often found in association with autosomal dominant polycystic kidney disease or Von Hippel Lindau syndrome. The differential diagnosis include congenital cysts, simple cysts, pseudocyst, cystic neoplasms, hydatid cyst. This is a case report of a 54 year old male presenting with obstructive jaundice, loss of appetite, weight loss. Computed tomography scan of the abdomen and magnetic resonance imaging showed multiple cysts of varying sizes involving the entire pancreas. Patient underwent a battery of investigations however there was no conclusive evidence regarding the presence of an underlying malignancy. In view of persistent symptoms the patient was surgically treated. Total pancreatectomy with splenectomy was performed. Histopathology report was suggestive of intraductal papillary mucinous neoplasm, high grade, with associated invasive carcinoma involving pancreatic head, body and tail. The patient required intensive post operative care with management of diabetes mellitus, with repeated intensive care unit stay in view of diabetic ketoacidosis. The patient received 6 cycles of adjuvant chemotherapy. He is doing well so far and is on routine follow up.
PP06-44 Study of a Rare Benign Gangliocytic Paraganglioma within the Ampulla of Vater
Minahi Ilyas, United Kingdom

M. Ilyas1, K. Stasinos2, M. Zardab3, A. Taha4, A. Banerjee4, H. Kocher5
1Royal London Hospital (Barts NHS Foundation Trust), United Kingdom, 2Royal London Hospital, Barts NHS Foundation Trust, United Arab Emirates, 3Royal London Hospital, Barts NHS Foundation Trust, United Kingdom, 4Hepatobiliary Team, Royal London Hospital, Barts NHS Foundation Trust, United Kingdom, 5Hepatobiliary Team, Barts NHS Foundation Trust, United Kingdom

Method: Gangliocytic paraganglioma (GP) is an extremely rare benign tumor with embryological origin commonly from the hindgut.
Retrospective study of this rare presentation in a 64year old male done.
4/ 2016, Our patient had presented with malaena, vomiting and abdominal pain.
Multiple investigations conducted (OGD, ERCP, CT abdomen and pelvis) demonstrated: A 2.4 by 3 cm, non-obstructing, hypodense, polypoidal enhancing tumour arising from the mesenteric aspect of the 3rd segment of the duodenum, with 2-3areas of ulceration alongwith a segment VII/VI liver lesion which an MRI liver pointed towards a haemangioma.
Multi-Disciplinary Team Meeting conclusion: Likely Gastrointestinal Stromal Tumor.
9/2016 Serial scans: Stable duodenum mass and liver lesion with no retroperitoneal lymphadenopathy.
09/2016 Trans-duodenal ampulla excision with re-implantation of bile and pancreatic duct completed. Clearance Margin 0.2mm.
Intra- op findings: 2.5-3cm ovoid mass in second part of duodenum prolapsing to 3rd part of duodenum.
The lesion was excised and stalk revealed pancreatic and bile duct opening separately.
Frozen section: negative for malignancy
Results: Gangliocytic Paraganglioma is characterized by its triphasic cellular differentiation (epithelioid neuroendocrine cells, spindle cells with Schwann cell differentiation, ganglion cells) alongwith characteristic immunoprofiling.
Known clinical Features:
- Age 15 - 84 years.
- M > F (1.5:1)
- Approximately only7% metastasize to lymph nodes.
(Only 23cases such cases reported by 2014.
Conclusion: Here we describe a rare condition managed with a limited resection and reconstruction with no recurrence in 4years. Meta analyses of the known GP cases to identify differentiating features may be helpful in understanding this disease better.