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Early morbidity and mortality of laparoscopic versus open distal pancreatectomy, a single centre experience
S38
Abstracts / Pancreatology 14 (2014) S1eS129
Aims: To report our experience in implementing the centralisation and discuss changes observed in terms of team’s building, practice and results Patients & methods: Retrospective review of prospectively collected data. Data was reviewed and compared before centralisation and over seven years after that main outcomes are peri-operative mortality and morbidity. Secondary outcomes are MDT activities, number of procedures, IT/HDU stay and total hospital stay and the development of new surgical techniques Results: Our covered population has increased from 700.000 before centralization to 3.7 millions after, with subsequent increase in the number of patients discussed in MDT and patients undergoing surgery. Despite the increase in numbers, mortality and morbidity rates were well below international standard with a significant reduction in ITU/HDU and overall hospital stay. Conclusion: Centralisation improved outcomes and increased number of patients offered surgery and neoadjuvant treatment for borderline resectable tumours. Finance was a key element in the process and should be given priority in planning.
Materials & methods: Surgical specimens of human pancreatic necrosis was sourced with ethical approval. Control tissue was normal porcine pancreas. Both were incubated with irrigation fluids: H2O2 (0.5% and 1%) and NS for 30 mins at 37 C. Samples cut into fresh frozen sections were evaluated using histology and immunohistochemistry and larger samples 1 cm3 were imaged by CT (Skyscan83kV, 120vA) and MRI (varian, 4.7T) before and after incubation. Results: Histology revealed gross swelling of necrosis in response to NS while H2O2 reduced the overall mass of necrosis. H2O2 at 1% cause mild dissolution of healthy porcine pancreas. CT volume calculations showed increase in volume of necrosis with NS and reduction with H2O2. MRI showed reduction in the amount of fat within necrosis samples with H2O2 on T2. Conclusion: This study has demonstrated that H2O2 is more effective than NS in reducing the mass of necrosis and should augment the efficacy of drainage by reducing the risk of blockage.
W-063. W-061. Is Roux-Y binding pancreatico-jejunal anastomosis feasible for patients undergoing distal pancreatectomy? €ty, Isto Nordback, Johanna Laukkarinen Anne Antila, Juhani Sand, Sari Ra Tampere university Hospital, dept. of gastroenterology and alimentary tract surgery, Finland Background: After pancreatico-duodenectomy, the Finnish binding pancreatico-jejunal anastomosis (FBPJ) technique reduces the risk for pancreatic fistula. Aims: Our aim was to investigate 1) whether FBPJ is a feasible technique even after distal pancreatectomy (DP) and 2) whether it prevents the risk for POPF after DP. Patients & methods: 47 patients underwent DP in Tampere University Hospital between 10/2009 and 07/2013. Patients were recruited based on CT and randomized (RPT) based on operation findings (transection line has to be left side to portal vein, as pancreatic mobilization is required for FBPJ) to receive either Roux-Y FBPJ or hand-sewn closure of pancreatic remnant. Patients outside the RPT were included in a prospective follow-up. Results: 27/47 patients met the criteria for recruitment but only 16/27 for RPT. Moreover, in the RPT FBPJ arm, only 5/8 patients were fit for the FBPJ anastomosis. Clinically significant POPF rate was significantly higher in the FBPJ group (3/5; 60%) compared to the RPT hand-sewn closure group (1/8; 13%; p<0.05) and to all patients with hand-sewn closure (5/41; 37%; p<0.05). 30 day mortality was zero. Overall, FBPJ was technically feasible only for 28% of operable patients. Conclusion: Even though FBPJ works nicely and reduces the amount of POPD after pancreatico-duodenectomy, it can not be recommended for the routine closure of pancreatic remnant in patients undergoing DP as it was not technically achievable in 72% of the cases. Moreover, the technique does not seem to reduce the risk for POPF compared to the hand-sewn closure.
W-062. Liquefaction of pancreatic necrosis using hydrogen peroxide. Lisa Brown a, Anthony Phillips a, Richard Flint b, Max Petrov a, John Windsor a a
University of Auckland, New Zealand b University of Otago, New Zealand Background: The current first-line treatment for walled off necrosis (WON) is percutaneous drainage (PD), but it succeeds in only 35% of patients. The commonest cause of failure is PD blockage. Flusing with hydrogen peroxide (H2O2) has been used anecdotely as an alternative to normal saline (NS) on the pretext that it accelerates the liquefaction of necrosum and decreases PD blocakge, but this not been experimentally validated. Aims: The aim was to evaluated the effect of H2O2 on human WON using microscopic and imaging techniques.
Early morbidity and mortality of laparoscopic versus open distal pancreatectomy, a single centre experience Rowland Storey, Mitul Patel, Alastair Young, Amer Aldouri, Andrew Smith St James's Leeds, United Kingdom Background: Laparoscopic distal pancreatectomy (LDP) is now the procedure of choice for distal pancreatic resection in our institution. Potential benefits such as shorter hospital stay, reduced blood loss, morbidity and comparable oncological outcomes have been stated. Aims: To review our experience of LDP versus open distal pancreatectomy (ODP) over a 10-year period. Patients & methods: All distal pancreatectomy cases performed in our institution between May 2004 and February 2014 were identified from a prospectively collected database. Morbidity for LDP versus OPD was compared. Results: 106 distal pancreas resections were performed during the study period. One patient who underwent simultaneous liver transplantation was excluded from analysis. Excluding multivisceral resections (n¼27), 41 LDP and 37 ODP were performed. Multivisceral resection was classed as visceral resection above pancreatectomy and splenectomy.
Splenectomy Mean operative time (min) Blood transfusion Pancreatic fistula Gd B or above Complication IIIa or above 30-day mortality Median length of stay (days)
LDP n¼41 (%)
ODP n¼37 (%)
p
33 (80.5) 204 2 (4.9) 8 (19.5) 6 (14.6) 0 9
28 (75.7) 230 11 (29.7) 7 (18.9) 10 (27) 0 9
NS NS 0.005 NS NS NS
Conclusion: Among our cohort blood loss was the only discriminating factor for the laparoscopic versus open procedure. Among the 11 patients who received a blood transfusion in the ODP cohort, 7 (63.6%) were laparoscopic converted to open cases. Through excluding LDP converted to open, blood transfusion requirement for LDP versus ODP failed to reach statistical significance (p ¼ 0.171).
W-064. Laparoscopic distal pancreactectomy, does lesion size matter? John Richardson, Francesco Di Fabio, Aawad Shamali, Thomas Armstrong, Arjun Takhar, Colin Johnson, Neil Pearce, Mohammed Abu-Hilal University Hospital Southampton, United Kingdom Background: Laparoscopic distal pancreatectomy (LDP) has been shown to be feasible and safe, for a wide variety of indications and pathologies. The impact of size on adapting a laparoscopic approach to the management of lesions of the left pancreas remains unclear. Aims: To assess our results in LDP for lesions larger than 5cm.
Abstracts / Pancreatology 14 (2014) S1eS129
Aims: To report our experience in implementing the centralisation and discuss changes observed in terms of team’s building, practice and results Patients & methods: Retrospective review of prospectively collected data. Data was reviewed and compared before centralisation and over seven years after that main outcomes are peri-operative mortality and morbidity. Secondary outcomes are MDT activities, number of procedures, IT/HDU stay and total hospital stay and the development of new surgical techniques Results: Our covered population has increased from 700.000 before centralization to 3.7 millions after, with subsequent increase in the number of patients discussed in MDT and patients undergoing surgery. Despite the increase in numbers, mortality and morbidity rates were well below international standard with a significant reduction in ITU/HDU and overall hospital stay. Conclusion: Centralisation improved outcomes and increased number of patients offered surgery and neoadjuvant treatment for borderline resectable tumours. Finance was a key element in the process and should be given priority in planning.
Materials & methods: Surgical specimens of human pancreatic necrosis was sourced with ethical approval. Control tissue was normal porcine pancreas. Both were incubated with irrigation fluids: H2O2 (0.5% and 1%) and NS for 30 mins at 37 C. Samples cut into fresh frozen sections were evaluated using histology and immunohistochemistry and larger samples 1 cm3 were imaged by CT (Skyscan83kV, 120vA) and MRI (varian, 4.7T) before and after incubation. Results: Histology revealed gross swelling of necrosis in response to NS while H2O2 reduced the overall mass of necrosis. H2O2 at 1% cause mild dissolution of healthy porcine pancreas. CT volume calculations showed increase in volume of necrosis with NS and reduction with H2O2. MRI showed reduction in the amount of fat within necrosis samples with H2O2 on T2. Conclusion: This study has demonstrated that H2O2 is more effective than NS in reducing the mass of necrosis and should augment the efficacy of drainage by reducing the risk of blockage.
W-063. W-061. Is Roux-Y binding pancreatico-jejunal anastomosis feasible for patients undergoing distal pancreatectomy? €ty, Isto Nordback, Johanna Laukkarinen Anne Antila, Juhani Sand, Sari Ra Tampere university Hospital, dept. of gastroenterology and alimentary tract surgery, Finland Background: After pancreatico-duodenectomy, the Finnish binding pancreatico-jejunal anastomosis (FBPJ) technique reduces the risk for pancreatic fistula. Aims: Our aim was to investigate 1) whether FBPJ is a feasible technique even after distal pancreatectomy (DP) and 2) whether it prevents the risk for POPF after DP. Patients & methods: 47 patients underwent DP in Tampere University Hospital between 10/2009 and 07/2013. Patients were recruited based on CT and randomized (RPT) based on operation findings (transection line has to be left side to portal vein, as pancreatic mobilization is required for FBPJ) to receive either Roux-Y FBPJ or hand-sewn closure of pancreatic remnant. Patients outside the RPT were included in a prospective follow-up. Results: 27/47 patients met the criteria for recruitment but only 16/27 for RPT. Moreover, in the RPT FBPJ arm, only 5/8 patients were fit for the FBPJ anastomosis. Clinically significant POPF rate was significantly higher in the FBPJ group (3/5; 60%) compared to the RPT hand-sewn closure group (1/8; 13%; p<0.05) and to all patients with hand-sewn closure (5/41; 37%; p<0.05). 30 day mortality was zero. Overall, FBPJ was technically feasible only for 28% of operable patients. Conclusion: Even though FBPJ works nicely and reduces the amount of POPD after pancreatico-duodenectomy, it can not be recommended for the routine closure of pancreatic remnant in patients undergoing DP as it was not technically achievable in 72% of the cases. Moreover, the technique does not seem to reduce the risk for POPF compared to the hand-sewn closure.
W-062. Liquefaction of pancreatic necrosis using hydrogen peroxide. Lisa Brown a, Anthony Phillips a, Richard Flint b, Max Petrov a, John Windsor a a
University of Auckland, New Zealand b University of Otago, New Zealand Background: The current first-line treatment for walled off necrosis (WON) is percutaneous drainage (PD), but it succeeds in only 35% of patients. The commonest cause of failure is PD blockage. Flusing with hydrogen peroxide (H2O2) has been used anecdotely as an alternative to normal saline (NS) on the pretext that it accelerates the liquefaction of necrosum and decreases PD blocakge, but this not been experimentally validated. Aims: The aim was to evaluated the effect of H2O2 on human WON using microscopic and imaging techniques.
Early morbidity and mortality of laparoscopic versus open distal pancreatectomy, a single centre experience Rowland Storey, Mitul Patel, Alastair Young, Amer Aldouri, Andrew Smith St James's Leeds, United Kingdom Background: Laparoscopic distal pancreatectomy (LDP) is now the procedure of choice for distal pancreatic resection in our institution. Potential benefits such as shorter hospital stay, reduced blood loss, morbidity and comparable oncological outcomes have been stated. Aims: To review our experience of LDP versus open distal pancreatectomy (ODP) over a 10-year period. Patients & methods: All distal pancreatectomy cases performed in our institution between May 2004 and February 2014 were identified from a prospectively collected database. Morbidity for LDP versus OPD was compared. Results: 106 distal pancreas resections were performed during the study period. One patient who underwent simultaneous liver transplantation was excluded from analysis. Excluding multivisceral resections (n¼27), 41 LDP and 37 ODP were performed. Multivisceral resection was classed as visceral resection above pancreatectomy and splenectomy.
Splenectomy Mean operative time (min) Blood transfusion Pancreatic fistula Gd B or above Complication IIIa or above 30-day mortality Median length of stay (days)
LDP n¼41 (%)
ODP n¼37 (%)
p
33 (80.5) 204 2 (4.9) 8 (19.5) 6 (14.6) 0 9
28 (75.7) 230 11 (29.7) 7 (18.9) 10 (27) 0 9
NS NS 0.005 NS NS NS
Conclusion: Among our cohort blood loss was the only discriminating factor for the laparoscopic versus open procedure. Among the 11 patients who received a blood transfusion in the ODP cohort, 7 (63.6%) were laparoscopic converted to open cases. Through excluding LDP converted to open, blood transfusion requirement for LDP versus ODP failed to reach statistical significance (p ¼ 0.171).
W-064. Laparoscopic distal pancreactectomy, does lesion size matter? John Richardson, Francesco Di Fabio, Aawad Shamali, Thomas Armstrong, Arjun Takhar, Colin Johnson, Neil Pearce, Mohammed Abu-Hilal University Hospital Southampton, United Kingdom Background: Laparoscopic distal pancreatectomy (LDP) has been shown to be feasible and safe, for a wide variety of indications and pathologies. The impact of size on adapting a laparoscopic approach to the management of lesions of the left pancreas remains unclear. Aims: To assess our results in LDP for lesions larger than 5cm.