VP01 Video Pancreas: Open Pancreas Surgery 
Selection of Video Presentations from Abstract Submissions
VP01-01 Parenchyma-sparing Pancreatic Resection for a Small Neuroendocrine Tumor: Dealing with a Difficult Postoperative Pancreatic Fistula
Lucas McCormack, Argentina

F. Laxague, D. Ramallo, A. Angeramo, N. Dreifuss, M. Lendoire, L. McCormack
Hospital Aleman of Buenos Aires, Argentina

Introduction: In pancreatic surgery, the preservation of healthy parenchyma has become one of the goals to be achieved. Numerous operative approaches are depending on their size, location, pathology, and surgical experience. In this context, the use of central pancreatectomy for benign or low-grade malignant lesions has been expanded.
Content description: A 67-year-old male patient presented with an incidental solid pancreatic tumor. Initially, he was under follow-up for isolated and asymptomatic 10 mm nodule in the pancreas neck without connection with the pancreatic duct. After 1 year, an MRI detected an increment of size to 18 mm. Serum tumors markers including cancer antigen 19-9, carcinoembryonic antigen and chromogranin A were within normal values. With a presumed diagnosis of neuroendocrine tumor, a central pancreatectomy was performed with Roux-en-Y pancreaticojejunostomy of the left pancreas and pancreatic stump closure on the head side. Frozen section biopsies of both margins were negative for malignancy. After surgery, a pancreatic fistula grade B was diagnosed and treated with a long-acting analog of somatostatin, percutaneous drainages and endoscopic sent of the Wirsung duct. After 6 months of follow-up, no pancreatic endocrine or exocrine dysfunction was diagnosed. Histologic assessment of pancreas specimen demonstrated neuroendocrine tumors grade G1 with negatives margins.
Conclusion: Central pancreatic lesions can be safely treated with a parenchyma-sparing pancreatic resection. Although this technique could be associated with a higher risk of pancreatic fistula, lower rates of endocrine and exocrine pancreatic insufficiency make this resection technique very attractive to avoid long-term complications.
VP01-02 Standardized Technique of Distal Pancreatectomy with Celiac Axis Resection - Tricks to Achieve Zero Mortality over 53 Cases
Yosuke Inoue, Japan

Y. Inoue, A. Oba, Y. Ono, T. Sato, H. Ito, Y. Takahashi
Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japan

Background: Distal pancreatectomy with celiac axis resection (DP-CAR) is one promising option for advanced pancreatic body cancers. However, it contains difficulty in dissection of the celiac axis, risk of massive bleeding, and potential risk of gastric ischemia due to defect of the left gastric artery, leading to high incidence of mortality.
Methods: We present the standardized technique of DP-CAR with 4 technical tips. The first: Celiac first approach and clamping to minimize the blood loss. The second: Left kidney mobilization to obtain opened view during retroperitoneal dissection. The third: Left gastric artery reconstruction to avoid ischemic gastropathy. The last: Confirmation of blood flow of left gastric artery using ICG fluorescence imaging.
Results: Patients comprised 26 locally advanced, 17 borderline resectable, and 10 resectable according to NCCN guideline. Twenty-six patients underwent DP-CAR with high ligation of CA, and 27 underwent DP-CAR with CA ligation at distal of LGA origin (mDP-CAR). When compared between DP-CAR and mDP-CAR, operation duration (498 vs. 406 min, P=0.0018) was longer in DP-CAR and blood loss (664 vs. 520 ml, P=0.27) was comparable. Transfusion was needed in only one patient (2%) in DP-CAR group. Postoperative complication included ischemic gastropathy in 2, pancreatic fistula (B/C) in 19(36%), and delayed gastric emptying in 15(28%). Complication ≥ C-D grade 3 occurred in 17 patients (32%) without mortality. R0 resection was achieved in 21(81%) vs. 24 patients (89%, P=0.47, 0mm rule).
Conclusion: DP-CAR is promising procedure to resect advanced pancreatic body cancers and safely performed with the standardized technique.
VP01-03 Total Pancreatectomy for Multifocal Pancreatic Cancers
Hiromichi Ito, Japan

H. Ito, Y. Ushida, Y. Ono, T. Sato, Y. Inoue, Y. Takahashi
Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japan

Introduction: It is not uncommon that intraductal neoplasm of the pancreas including intraductal papillary mucinous neoplasm (IPMN) and intraductal tubulopapillary neoplasm (ITPN) involves entire pancreas, and total pancreatectomy is necessary for patients with such tumors to achieve cure. Herein, we illustrate the case of the patient with multifocal pancreatic cancers who underwent total pancreatectomy. The disease turned out to be derived from IPMC by histologic examination in the resected specimen.
Case: The patient was an 82-year-old woman who presented with epigastric pain and CT showed large pancreatic body mass. The staging work-up revealed at least 5 PET-avid lesions throughout the entire pancreas without extra-pancreatic metastasis, and EUS-FNA confirmed them as adenocarcinoma. Thus, total pancreatectomy was recommended.
The video describes the technical detail of our total pancreatectomy and some useful tricks including SMA-first approach and left kidney mobilization to minimize blood loss and to maintain good exposure for retroperitoneal dissection in the left side.
VP01-04 Whipple Procedure Combined with Autologous Small Intestine Transplantation for Radical Resection of Pancreatic Cancer
Tingbo Liang, China

X. Bai, W. Chen, Q. Zhang, C. Guo, T. Liang
The First Affiliated Hospital Zhejiang University School of Medicine, China

SMA/SMV invasion may hamper resection of pancreatic cancer because it is extremely difficult to achieve R0 resection. Taking advantage of autologous small intestine technique, R0 resection is possible. We have performed four cases of such condition after responded chemotherapy. Here we reported one case.
A 70-year-old male patient was referred to our department due to epigastric pain for seven months, and pancreatic adenocarcinoma was confirmed by biopsy. Imaging showed a 4-cm tumor with SMA contact > 180° and SMV contact < 180°, without other vessels or organs involved (locally advanced disease, cT4NxM0). He received eight cycles of modified FOLFIRNOX chemotherapy, and CA19-9 level reduced from 343.2 to 43.1 U/ml. Partial response was recorded since the tumor shrined to 2.1 cm, and SMA tumor invasion was significantly improved. Whipple procedure combined with autologous small intestine transplantation was planned. After the transection of common bile duct, replaced right hepatic artery, gastroduodenal artery, stomach, small intestine was removed. Following removal of the Whipple specimen, small intestine was implanted by anastomoses of SMA-abdominal aorta and SMV-inferior vena cava. The operation took 640 min, with blood loss of 800 ml. The conventional pathology demonstrated negative surgical margins, chemotherapy response of CAP score 2 (pT4N0M0, IB). The patient was discharged on postoperative day 20.
VP01-05 Pancreaticoduodenectomy in a Patient Without a Celiac Axis
Morgan Bonds, United States

M. Bonds, W.S. Helton
Virginia Mason Medical Center, United States

This video presents the surgical planning and technical aspects of performing a pancreaticoduodenectomy in a patient without a celiac axis. A patient with a pancreatic head adenocarcinoma was found to be lacking a celiac axis origin off of the aorta. This complicates proceeding with resection of his cancer as the gastroduodenal artery and peripancreatic collateral arteries would require ligation, thus abolishing arterial flow to the liver and stomach. Two collaterals, the inferior transverse pancreatic artery and inferior pancreaticoduodenal artery, were identified on preoperative imaging as appropriate conduits for reconstruction. The video demonstrates the steps for isolating these arteries and restoring arterial flow to the proper hepatic and left gastric arteries after removal of the pancreaticoduodenectomy specimen.
VP01-06 Pancreaticoduodenectomy after Esophagogastric Resection for Antireflux Plastic Complicated by Gastric Fundus Rupture
Emanuele Kauffman, Italy

E. Kauffman, N. Napili, U. Boggi
Università di Pisa, Italy

Pancreatoduodenectomy (PD) in patients already undergoing to esophagectomy is very rare. In 2002, a 64-years old woman underwent esophagogastric plastic for gastroesophageal reflux disease and jatal hernia, following perforation of the gastric fundus and mediastinitis, solved by esophagectomy with anastomosis on tubulized stomach. One year later was diagnosed adenoma of the Vaterian papilla, the patient refused treatment. In Febbruary 2019 she referres to our unit for jaundice. The patient performed EGDS and biopsy of the ampulloma, the istologic revealed high grade of dysplasia. The CT-scan confirmed marked dilatation of main bile duct, and solid nodular formation of the mayor papilla. The presence of the gastric tube in the retrosternal side was also detected. The patient was scheduled for PD after multidisciplinary discussion. This video presented our surgical approach.
VP01-07 A Case of Successful SSPPD with Resection and Reconstruction of Right Hepatic Artery for Pancreatic Head Cancer with Hepatic Arterial Variation
Takeomi Hamada, Japan

T. Hamada, A. Nanashima, M. Nishimuta, T. Wada, N. Imamura, M. Hiyoshi
Department of Surgery, Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Miyazaki, Japan

Major arterial resection and reconstruction is a useful option for locally advanced resectable pancreas cancers with arterial invasion. Especially, in cases with right hepatic artery (RHA) branching from superior mesenteric artery. In this case, invasion to the RHA is often observed on the dorsal side of the pancreas. We herein succeeded subtotal stomach preserving pancreatoduodenectomy combined RHA resection and reconstruction. A 51-year-old man admitted with obstructive jaundice was found CT to have a mass in the pancreatic head invading the duodenum. Preoperative imaging showed that the RHA bifurcated from the SMA was close to the tumor. He underwent RHA resection and reconstruction combined with SSPPD and his postoperative course was uneventful. Intraoperative findings, after resection of the hepatic artery, it has been reported that non-reconstruction is acceptable. However, RHA was reconstructed because a decrease in intrahepatic blood flow was observed after the test clamp. Arterial reconstruction was performed by cardiovascular surgeons. On histopathological examination, the tumor was closely attached to the RHA without the histopathological evidence of involvement of the vessel and R0 resection was accomplished.
Surgical resection with major artery resection for locally advanced pancreatic cancer needs further discussion is required concerning surgical indications and significance. Arterial resection and reconstruction combined with PD is an alternative option to achieve the safe and R0 resection in highly selected patients.Furthermore, cooperation with other fields is important.
VP01-08 Pancreaticoduodenectomy with the Use of Temporary Gore-Tex Mesenterico Venous Shunt and Intermittent Mesenteric Arterial Clamping for Complex Venous Resection and Reconstruction in Locally Advanced NET
Mohammed Ghallab, United Kingdom

M. Ghallab1, C. Maulat2, M. Tedeschi2, A. Sa Cunha2, D. Cherqui2
1HPB Liver Transplant, Queen Elizabeth Hospital University Hospitals Birmingham NHS Foundation Trust, United Kingdom, 2HPB, Paul Brousse Hospital - Paris South University, France

Introduction: This video presents a 38-year-old gentleman with a 10x8.5x9.3 cm hypervascular pancreatic mass in head and neck of pancreas with invasion of superior mesenteric pedicle and malignant lymphadenopathy. EUS and biopsy confirmed Pancreatic Neuroendocrine tumour.
Method: The video demonstrates the use of a combination of superior mesenteric artery clamping (Pringle-like) combined with a temporary veno-venous shunt to allow for extensive dissection of the pancreatic head mass without interruption of portal venous flow.
- Right hemicolectomy
- Opening of lesser sac and division of the stomach
- Division of the pancreas to the left of the neck
- Dissection of the splenic vein and SMV confluence
- Supra-pancreatic dissection of the caelica axis vessels
- Identification and division of the suprapancreatic portal vein.
- Dissection and ligation of infra-pancreatic SMV
- End to End anastomosis of ringed Gore-tex graft to the SMV and end to side to the portal vein.
- Finishing the pancreatic resection under veno-venous shunt and intermittent SMA clamping
- Dissection of SMA off the tumour and neighbouring lympadenopathies.
- Replacement of the Gore-tex graft with cryopreserved iliac vein allogenic cadaveric graft.
- Reconstruction pancreaticojejunostomy, hepaticojejunostomy and gastrojejunostomy.
Conclusions: With more extensive venous involvement, resection can be problematic and is associated with major bleeding, may induce intestinal congestion and or hepatic ischemia by interruption of portal inflow
We propose the use of temporary meseterico venous shunt is a safe technique that should be used more often in Borderline resectable or locally advanced pancreatic resection with vascular reconstruction.
VP01-09 Appleby Procedure for Pancreatic Body Adenocarcinoma
Amy Li, United States

A. Li1, E. Lee2, B. Visser1
1Stanford University, United States, 2Inova Fairfax Hospital, United States

The Appleby procedure is performed for pancreatic body and tail masses with local involvement of the celiac axis and its branches, traditionally considered locally advanced and unresectable. This is the case of a 73-year-old female who presented with abdominal pain and weight loss. She was diagnosed with a 4 cm pancreatic body adenocarcinoma with abutment of the celiac axis and splenic vein occlusion. She underwent five cycles of neoadjuvant FOLFIRINOX with good response. Tumor size decreased to 3 cm. CA19-9 dropped from 612 to 197. Preoperative common hepatic artery angioembolization was performed, with demonstration of retrograde flow through the gastroduodenal artery. She underwent Appleby procedure with distal pancreatectomy and splenectomy with en bloc resection of the celiac axis. This video combines the use of an overhead camera as well as a head mounted camera on the operating surgeon to present our approach and operative technique. Due to tumor thrombosis of the splenic vein, the short gastric vessels were initially preserved. FThen, hepatic artery lymphadenectomy was performed and common hepatic artery identified and divided. Prior to division, retrograde flow through the gastroduodenal artery was confirmed. The pancreas was divided with a stapler. Next, the splenic vein was divided at its insertion into the SMV, followed by the left gastric pedicle. Posterior dissection was performed superiorly along the SMA to identify and divide the celiac axis at its origin. At this point, outflow via the short gastrics were divided. A right-to-left posterior dissection of the distal pancreas and splenectomy were then completed.
VP01-10 Distal Pancreatectmy with en Bloc Celiac Axis Resection
Xueli Bai, China

X. Bai1, B. Wang2, Y. Chen1, D. Huang2, T. Liang1
1HBP Department, Zhejiang University, School of Medicine, the First Affiliated Hospital, China, 2Zhejiang University, School of Medicine, the First Affiliated Hospital, China

A 64 year old male patient was diagnosed as pancreatic cancer with multiple lung metastasis half a year ago. In image studies, it showed a tumor in the neck of pancreas. Common hepatic artery (CHA) and splenic artery were invaded. After confirmation of biopsy, the regime of modified FOLFIRINOX combined with PD-1 antibody was recommended. The patient received 12 cycles of modified FOLFIRINOX and 10 cycles of anti-PD-1. During the treatment, the tumor markers decreased consistently. The evaluation showed the tumor in pancreatic neck shrinked a lot (the diameter decreased from 3.0 cm to 2.1 cm) and metastatic lesions in lung almost disappeared. Evaluation according to RECIST 1.1 was partial response (PR). The CHA and splenic artery was still invaded, while gastroduodenal artery (GDA) was not invaded. Multiple disciplinary team discussed about this case and recommended distal pancreatectmy with en bloc celiac axis resection for this patient. The surgery went well. CHA, left gastric artery, and celiac axis (CA) were dissected. Lesion in pancreas together with pancreatic body and tail, spleen, and left adrenal gland were removed. The pathological result showed that 1. low differentiation adenocarcinoma in pancreatic neck; 2. the surgical margins of pancreas, CA and CHA were negative; 3. the lymph nodes were negative. By implementation of enhanced recovery after surgery, the patient recovered smoothly. He has Stage A pancreatic fistula with 1378 U/L Amy in abdominal drainage on POD 3 and abdominal drainage tube was removed on POD6. The patient was discharged on POD7.
VP01-11 Total Pancreatectomy and Portal Vein Resection with Iliac Vein Allograft
Ruelan Furtado, Australia

R. Furtado, G. Starkey
Department of Surgery, Austin Health, Australia

The patient is a 51 year old with a locally advanced pancreatic cancer. Following treatment with FOLFIRINOX chemotherapy, staging CT shows the a mass in the neck of the pancreas, which encroaches upon the common hepatic artery, the splenic artery, the portal vein and the proximal superior mesenteric vein. The dissection and vein reconstruction with an iliac allograft is demonstrated and narrated. Highlights include posterior and left-sided approaches to the superior mesenteric artery.
VP01-12 Posterior RAMPS for Distal Pancreatic Cancer (Video Presentation)
Aamir Parray, India

A. Parray, M. Bhandare, V. Chaudhari, S. Shrikhande
Surgical Oncology, Tata Memorial Hospital, India

Objective: To present a systematic approach and operative technique to Posterior RAMPS.
Methods: We present a case of a 60-year-old lady with no comorbidities who presented with abdominal pain.After initial ultrasound of abdomen, triphasicCT Scan of the abdomen (pancreas probocol) revealed pancreatic tail mass infiltrating Gerota' fascia and colon. CA19-9 was 9.8 and there was no evidence of distant metastasis. We performed a posterior radical ante grade modular pancreatico-splenectomy with celiac axis resection.
Results: The procedure was performed in 150 minutes with a blood loss of 300ml. Postoperative course was uneventful. Histopathology report showed MDAC, pT3N1, all margins were free of tumor (R0 resection).
Conclusions: RAMPS remains preferred option for distal pancreatic tumours to obtain adequate posterior margins and lymph node clearance.
VP01-13 Autologous Falciform Ligament Graft for Venous Reconstruction during Pancreaticoduodenectomy
Eric Herrero, Spain

E. Herrero1, M. Galofré1, J. Camps1, M.I. García-Domingo1, L. Martinez1, S. Sentí2, A. Rodríguez3, E. Cugat1,2
1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2HPB Surgery Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain, 3Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain

Introduction: Complete oncological resection (R0) is the main determinant of survival in pancreatic carcinoma and, for this, occasionally a vascular reconstruction is required.
Method: Borderline resectable tumor in a 52 year old woman who underwent neoadjuvant therapy prior to surgery. Involvement of the lateral aspect of the portal vein was confirmed during surgery. A pancreaticoduodenectomy and lateral resection of the portal vein was performed. Vascular reconstruction was carried out with an autologous lateral graft of the falciform ligament using continuous 5/0 absorbable monofilament suture.
Results: In our experience, the use of the falciform ligament as a graft allowed the reconstruction of the venous defect in a simple, economical way, with excellent functional results and free of complications.
In thos case, a CT scan performed 3 months after surgery showed correct patency of the graft.
Conclusions: Autologous peritoneal grafts are non-thrombogenic and have some advantages, such as the ease of obtaining them and their low cost.
An alternative is the use of the falciform ligament, which adds an advantage to the peritoneal graft as it is a double membrane structure that gives it greater strength, and can be used on both sides.
VP01-14 Radical Antegrade Modular Pancreato-Splenectomy (RAMPS) for Locally Advanced Pancreatic Tail Cancer
Arindam Mondal, India

A. Mondal, M. Bhandare, V. Chaudhari, S. Shrikhande
Surgical Oncology, GI Services, Tata Memorial Hospital, India

Objective: To present a systematic approach and operative technique of RAMPS.
Methods: We present a case of a 60-year-old gentleman with no comorbidities who presented with abdominal pain. After initial ultrasound of abdomen, triphasic CT Scan of the abdomen (pancreas protocol) revealed pancreatic tail mass, encasing splenic artery, abutting splenic flexure of colon and involving Gerota's fascia and renal capsule (locally advanced pancreatic cancer). There were few enlarged regional lymph nodes, but no evidence of distant metastasis. The biopsy was confirmed it to be adenocarcinoma. In order to achieve an adequate posterior margin, he was planned for a posterior RAMPS surgery. We performed a posterior RAMPS procedure along with excision of anterior renal capsule and en-bloc segmental colonic resection. A colo-colic anastomosis was done to re-establish colonic continuity.
Results: The procedure was performed in 260 minutes with a blood loss of 400ml. Postoperatively, the patient developed a pancreatic collection which was treated with pigtail catheter drainage. Histopathology report showed MDAC of pancreas involving adrenal gland and renal capsule, but not involving the colon (pT4N0), with all margins free of tumor (R0 resection).
Conclusions: RAMPS procedure is a valuable option for achieving adequate posterior resection margins in selected locally advanced pancreatic body and tail cancers. The procedure can be safely and effectively performed at high volume centers.
VP01-16 Standard Open Pancreaticoduodenectomy
Zipeng Lu, China

Z. Lu, K. Jiang, J. Wu, W. Gao, Y. Miao
Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, China

Nowadays, the pancreaticoduodenectomy is widely performed by HPB surgeons worldwide. However, the clinical outcomes after pancreaticoduodenectomy varies between different centers, and it has been demonstrated that high-volume center had significantly lower morbidity and mortality rate than the low- or median-volume. Many factors may contribute to this disparity in surgical safety profile from different centers in terms of patient volume, in which the optimized surgical techniques in high-volume center may contribute. However, the quality of surgical manipulations is difficult to demonstrate and evaluate in clinical studies. In this video, we aim to introduce the whole procedure of a standard pancreaticoduodenectomy with all technical modifications from a high-volume center with annual volume of over 450 pancreaticoduodenectomies from China. Technical modifications were introduced in pancreatic uncinate dissection, pancreaticojejunostomy, hepatojejunostomy, and gastrojejunostomy, etc. We believe that good surgical outcomes can be guaranteed through exquisite and optimized technical manipulations during the surgery.
VP01-17 Pylorus Preserving Pancreaticoduodenectomy for Mirror People - a Rare Case
Jiang Kuirong, China

J. Kuirong, M. Yi, W. Jishu
The First Affiliated Hospital with Nanjing Medical University, China

A 66 years old female patient presented with upper abdominal discomfort for 2 months. The preoperative CT showed visceral inversion and duodenal papilla mass. So we performed pylorus preserving pancreaticoduodenectomy for this patient. During the procedure, we found replaced hepatic artery originating from SMA. This is a rare and interesting case.
VP01-18 Total Pancreatectomy for Multifocal Pancreatic PNETs Using the ´Artery First´ Approach
Sujoy Pal, India

S. Pal, B. Singh, R. Jayapal, V. Moond, L. Aggarwal, R. Panwar
GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, India

Total pancreatectomy (TP) is indicated in patients with multifocal PNETs associated with MEN1 syndrome. After a multidisciplinary work up these patients are taken up for surgery. Following a roof-top incision, laparotomy is done, lesser sac is opened and intraoperative ultrasound done to confirm the presence of multifocal PNETs. En bloc removal of the pancreas with or without the spleen is facilitated by using the 'SMA first' approach. The technique allows for mobilization of the head, neck and uncinate process off the SMV and SP-SMV junction without transection of the neck. After securing the GDA and splenic vessels, the pancreatic body and tail along with the spleen is mobilized off its retroperitoneal attachments and entire pancreas along with C-loop of duodenum is removed after dividing the distal stomach, hepatic duct and proximal jejunum. The spleen can be preserved if the short gastrics are maintained as per the Warshaw technique. But our philosophy is to remove it whenever we are dealing with potentially malignant PNEts (such as gastrinomas, non-functioning tumors). Following the specimen removal, a hepaticojejunostomy is done first and the distal stomach is anastomosed about 30 cms downstream on the same or isolated loop of jejunum. Postoperative recovery is prolonged because of the complex glycemic control regimen. Over the last 2 years we have performed TP in 3 patients with MEN 1 using the 'artery first" technique demonstrated in the video and all have done well without recurrence.