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Distal pancreatectomy with celiac axis resection for adenocarcinoma of the pancreatic body: The modified appleby procedure
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Abstracts / Pancreatology 15 (2015) e1ee17
Introduction: Pancreatic sphincteroplasty (PS) remains an unusual technique during ERCP. Literature review report scarce references of PE including the largest series 4 patients. Aims: Evaluate the indications of PS in our hospital, analyzing the outcomes as therapeutic technique of pancreatic ERCP (pERCP). Methods: All PS performed in our hospital during pERCP between august 2009 and December 2014 were retrospectively included in the study. Epidemiological data, pERCP indication, current pancreatic disease, EP dilation caliber, associated therapeutic endoscopic maneuvers, therapeutic success and complications were registered. IRB approval was obtained for this study. Results: During the study period 198 pERCP were performed in our hospital, 25 of which, corresponding to 15 patients, included a PS. Mean age of patients was 62.76±15.78 years. Mean caliber of PS was 8.08 mm (range: 5-10). pERCP was indicated for pancreatic duct stenosis (9 patients), proximal migration of pancreatic stents (2), pancreatic stones (16) and collection transpapillary drainage (1). Despite initial indication 21 pancreatic stones (mean diameter: 10 mm), 23 stenosis and 4 collections were found during pERCP. PS was completed immediately after pancreatic sphincterotomy in 8 out of the 15 patients and pancreatic stents were placed in all pERCPs (mean: 2.59, range: 1-6). PS was significantly associated to the presence of pancreatic stones and stenosis comparing with the other pancreatic disorders found on pERCP (48.8%vs2.6%; p<0,0000001 and 16.7%vs3.5%; p¼0.01). PS contributed to successful pancreatic stone extraction, pancreatic stenosis resolution and proximal migrated pancreatic stents extraction in 55.6%, 17.4% and 100% of patients respectively. After PS one patient each suffered pancreatitis and perforation, not significantly different from the global pERCP complication rate (8%vs8.6%;p>0.05). Conclusion: PS is accomplished mainly in association with pancreatic stones and stenosis, and provides safe pancreatic endoscopic therapy.
8. Differential cost of EUS-guided pancreatic collection drainage techniques ~ oz, A. SanchezA. Sanchez-Yague, A. Gonzalez-Canoniga, C. Lopez-Mun Cantos Hospital Costa del Sol, Marbella, Spain Introduction: Endoscopic ultrasound (EUS) guided drainage of symptomatic pancreatic collections has replaced other approaches. The classic approach requires access to the collection, tract dilatation and placement of several double-pigtail stents. A novel approach highlights a single-step procedure using a catheter featuring a cautery-tip and a lumen-apposing covered-metal-stent (LA-CMS) delivery system. This system decreases initial procedure time and facilitates necrosectomy sessions. Aims:We aimed to compare the differential cost of the classic strategy (CS) to this single-step procedure (SSP). Material and methods: We analyzed our database from 2008 to 2014. Informed consent was obtained in all cases. The differential cost covers the parts of the procedures that are different, excluding intubation times, study of the collections or removal of necrosis as those were performed in both strategies equally. Initial technique was considered from puncture of the collection to complete deployment of the last stent. Necrosectomy sessions were calculated adding time of removal of the plastic stents plus time from the insertion of the guidewire to deployment of the last stent. As the LA-CMS maintains a patent lumen no time was considered in SSP. Indirect costs were measured at 0.078V/second. Material costs for the initial procedure in the CS including 19G needle, guidewire, dilatation balloon, pushing catheter and 3 double-pigtail stents was 1.037V. Cost of the SSP catheter was 1.800V. For every necrosectomy session, materials costs including snare, dilatation balloon, guidewire, catheter and 2 or 3 doublepigtails were 816,8V or 914,8V. No material cost was associated to the use of the LA-CMS. Results: A total 25 procedures were included, 12 in the CS and 12 in the SSP groups. The SSP was fastest to complete the procedure
(55±13vs1772±468sec;p<0.0001). Mean differential cost of the initial procedure was significantly lower in the CS (1175Vvs1803V;p<0.0001) though the mean accumulated cost significantly increased in the CS group after necrosectomy (1-4 sessions; range 2181V-5032V) compared to the SSP group (1-4 sessions;1803V;p<0.0001). Conclusions: A single-step LA-CMS placement procedure significantly decreases initial procedure time and facilitates necrosectomy sessions.Although placement of a LA-CMS is initially more expensive this cost is significantly offset when at least one necrosectomy session is performed.
9. Distal pancreatectomy with celiac axis resection for adenocarcinoma of the pancreatic body: The modified appleby procedure ndez, F. Morera, M. Garc J.M. Gamez del Castillo, O. Ferro, M.C. Ferna es, E. ~ oz, L. Sabater, J. Ortega Mun Servicio de Cirugía General y Aparato Digestivo, Hospital Clínico Universitario de Valencia, Spain Introduction: Complete oncological resection is the only possibility for long-term survival in pancreatic cancer. Arterial infiltration of the hepatic artery or the celiac axis has been classically considered an absolute contraindication for surgery. Nevertheless the promising results of new oncological and surgical strategies in pancreatic cancer have led to reconsider these patients as border-line resectable. Aim: To report a clinical case of a patient with a pancreatic cancer infiltrating the celiac axis successfully treated by neoadjuvant chemotherapy, preoperative arterial embolization and surgical resection (VIDEO). Clinical case: A 61-year-old male, with the diagnosis of pancreatic cancer of the body-tail and infiltration of the celiac axis. Initially considered unresectable, neoadjuvant chemotherapy was performed and after 8 cycles of FOLFIRINOX the case was reevaluated. Since there was no metastasis nor progression of disease, surgical treatment was indicated. Preoperative hepatic arterial embolization was carried out 10 days before surgery and distal pancreatectomy with celiac axis resection was performed. After an uneventful recovery the patient was discharged 7 days after surgery. One week later the patient was readmitted with an intrabdominal abscess successfully treated by percutaneous drainage. Conclusions: The modified Appleby procedure is a feasible and useful treatment for the management of pancreatic cancer involving the celiac axis. The therapeutic approach to these patients should be performed within a multidisciplinary team involving oncologists, interventional radiologists and surgeons. As new oncological therapeutic advances develop, the availability of complex surgical techniques to resect such difficult cases will gain acceptance.
10. Neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma. Preliminary results ez, B. Laquente, H. Verdaguer, L. Secanella, A. Rafecas, J. J. Busquets, N. Pela Torras, T. Serrano, S. Ruiz, E. Ramos, J. Fabregat Hospital Universitario de Bellvitge, Barcelona, Spain Introduction: Borderline resectable pancreatic adenocarcinoma (ADKP-BR) may benefit from resection when preceded by neoadjuvant therapy. Aims & methods: Between 2010 and 2014, we evaluated 22 consecutive patients (pts) with cytology confirmed ADKP-BR. Borderline resectability was confirmed in the multidisciplinary team. Most pts received 6 cycles of gemcitabine 1 g/m2 ev on day 1 and oxaliplatin 100 mg/m2 day 2 (GEMOX) every two weeks. Six pts received the same chemotherapy (CT) schedule plus erlotinib in the context of a trial. After re-staging with multidetector computer tomography (MDTC), pts without progressive
Abstracts / Pancreatology 15 (2015) e1ee17
Introduction: Pancreatic sphincteroplasty (PS) remains an unusual technique during ERCP. Literature review report scarce references of PE including the largest series 4 patients. Aims: Evaluate the indications of PS in our hospital, analyzing the outcomes as therapeutic technique of pancreatic ERCP (pERCP). Methods: All PS performed in our hospital during pERCP between august 2009 and December 2014 were retrospectively included in the study. Epidemiological data, pERCP indication, current pancreatic disease, EP dilation caliber, associated therapeutic endoscopic maneuvers, therapeutic success and complications were registered. IRB approval was obtained for this study. Results: During the study period 198 pERCP were performed in our hospital, 25 of which, corresponding to 15 patients, included a PS. Mean age of patients was 62.76±15.78 years. Mean caliber of PS was 8.08 mm (range: 5-10). pERCP was indicated for pancreatic duct stenosis (9 patients), proximal migration of pancreatic stents (2), pancreatic stones (16) and collection transpapillary drainage (1). Despite initial indication 21 pancreatic stones (mean diameter: 10 mm), 23 stenosis and 4 collections were found during pERCP. PS was completed immediately after pancreatic sphincterotomy in 8 out of the 15 patients and pancreatic stents were placed in all pERCPs (mean: 2.59, range: 1-6). PS was significantly associated to the presence of pancreatic stones and stenosis comparing with the other pancreatic disorders found on pERCP (48.8%vs2.6%; p<0,0000001 and 16.7%vs3.5%; p¼0.01). PS contributed to successful pancreatic stone extraction, pancreatic stenosis resolution and proximal migrated pancreatic stents extraction in 55.6%, 17.4% and 100% of patients respectively. After PS one patient each suffered pancreatitis and perforation, not significantly different from the global pERCP complication rate (8%vs8.6%;p>0.05). Conclusion: PS is accomplished mainly in association with pancreatic stones and stenosis, and provides safe pancreatic endoscopic therapy.
8. Differential cost of EUS-guided pancreatic collection drainage techniques ~ oz, A. SanchezA. Sanchez-Yague, A. Gonzalez-Canoniga, C. Lopez-Mun Cantos Hospital Costa del Sol, Marbella, Spain Introduction: Endoscopic ultrasound (EUS) guided drainage of symptomatic pancreatic collections has replaced other approaches. The classic approach requires access to the collection, tract dilatation and placement of several double-pigtail stents. A novel approach highlights a single-step procedure using a catheter featuring a cautery-tip and a lumen-apposing covered-metal-stent (LA-CMS) delivery system. This system decreases initial procedure time and facilitates necrosectomy sessions. Aims:We aimed to compare the differential cost of the classic strategy (CS) to this single-step procedure (SSP). Material and methods: We analyzed our database from 2008 to 2014. Informed consent was obtained in all cases. The differential cost covers the parts of the procedures that are different, excluding intubation times, study of the collections or removal of necrosis as those were performed in both strategies equally. Initial technique was considered from puncture of the collection to complete deployment of the last stent. Necrosectomy sessions were calculated adding time of removal of the plastic stents plus time from the insertion of the guidewire to deployment of the last stent. As the LA-CMS maintains a patent lumen no time was considered in SSP. Indirect costs were measured at 0.078V/second. Material costs for the initial procedure in the CS including 19G needle, guidewire, dilatation balloon, pushing catheter and 3 double-pigtail stents was 1.037V. Cost of the SSP catheter was 1.800V. For every necrosectomy session, materials costs including snare, dilatation balloon, guidewire, catheter and 2 or 3 doublepigtails were 816,8V or 914,8V. No material cost was associated to the use of the LA-CMS. Results: A total 25 procedures were included, 12 in the CS and 12 in the SSP groups. The SSP was fastest to complete the procedure
(55±13vs1772±468sec;p<0.0001). Mean differential cost of the initial procedure was significantly lower in the CS (1175Vvs1803V;p<0.0001) though the mean accumulated cost significantly increased in the CS group after necrosectomy (1-4 sessions; range 2181V-5032V) compared to the SSP group (1-4 sessions;1803V;p<0.0001). Conclusions: A single-step LA-CMS placement procedure significantly decreases initial procedure time and facilitates necrosectomy sessions.Although placement of a LA-CMS is initially more expensive this cost is significantly offset when at least one necrosectomy session is performed.
9. Distal pancreatectomy with celiac axis resection for adenocarcinoma of the pancreatic body: The modified appleby procedure ndez, F. Morera, M. Garc J.M. Gamez del Castillo, O. Ferro, M.C. Ferna es, E. ~ oz, L. Sabater, J. Ortega Mun Servicio de Cirugía General y Aparato Digestivo, Hospital Clínico Universitario de Valencia, Spain Introduction: Complete oncological resection is the only possibility for long-term survival in pancreatic cancer. Arterial infiltration of the hepatic artery or the celiac axis has been classically considered an absolute contraindication for surgery. Nevertheless the promising results of new oncological and surgical strategies in pancreatic cancer have led to reconsider these patients as border-line resectable. Aim: To report a clinical case of a patient with a pancreatic cancer infiltrating the celiac axis successfully treated by neoadjuvant chemotherapy, preoperative arterial embolization and surgical resection (VIDEO). Clinical case: A 61-year-old male, with the diagnosis of pancreatic cancer of the body-tail and infiltration of the celiac axis. Initially considered unresectable, neoadjuvant chemotherapy was performed and after 8 cycles of FOLFIRINOX the case was reevaluated. Since there was no metastasis nor progression of disease, surgical treatment was indicated. Preoperative hepatic arterial embolization was carried out 10 days before surgery and distal pancreatectomy with celiac axis resection was performed. After an uneventful recovery the patient was discharged 7 days after surgery. One week later the patient was readmitted with an intrabdominal abscess successfully treated by percutaneous drainage. Conclusions: The modified Appleby procedure is a feasible and useful treatment for the management of pancreatic cancer involving the celiac axis. The therapeutic approach to these patients should be performed within a multidisciplinary team involving oncologists, interventional radiologists and surgeons. As new oncological therapeutic advances develop, the availability of complex surgical techniques to resect such difficult cases will gain acceptance.
10. Neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma. Preliminary results ez, B. Laquente, H. Verdaguer, L. Secanella, A. Rafecas, J. J. Busquets, N. Pela Torras, T. Serrano, S. Ruiz, E. Ramos, J. Fabregat Hospital Universitario de Bellvitge, Barcelona, Spain Introduction: Borderline resectable pancreatic adenocarcinoma (ADKP-BR) may benefit from resection when preceded by neoadjuvant therapy. Aims & methods: Between 2010 and 2014, we evaluated 22 consecutive patients (pts) with cytology confirmed ADKP-BR. Borderline resectability was confirmed in the multidisciplinary team. Most pts received 6 cycles of gemcitabine 1 g/m2 ev on day 1 and oxaliplatin 100 mg/m2 day 2 (GEMOX) every two weeks. Six pts received the same chemotherapy (CT) schedule plus erlotinib in the context of a trial. After re-staging with multidetector computer tomography (MDTC), pts without progressive