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Is pylorus preserving pancreatoduodenectomy responsible for delayed gastric emptying?
Abstracts / Pancreatology 17 (2017) S1eS68
papilla, inadvertent guidewire pancreatic duct cannulation on three occasions and inability to achieve deep biliary cannulation within 3 minutes. Main outcome measures were PEP and successful biliary cannulation. Results: A PF was performed in 49 cases (31 women, 18 men, 25 under 60 years) Success rate of biliary cannulation using PF were 96% (47/49). Thirty eight (77.5%) patients had risk factors for PEP 20 had 1 risk, 13 had 2 and 5 had 3. Conditions of DBC were: impacted stone in the papilla 4 cases, longer bulging of papilla 6 cases, lower location of papilla orifice 15 cases, partial location of papilla orifice 16 and stricture of papillary orifice 8 cases. Five patients had periampullary diverticulum, 4 patients had normal common bile duct (under 9 mm) and one patient was pregnant. None of the patients experienced PEP. Two patients had minor bleeding, no needed blood transfusion, just endoscopic treatment. One patient (2%) had fever and was hospitalized for medical treatment. Discussion: There are studies suggesting that early institution of the precut is safe and effective strategy. Althought several autors classify precut as a risk factor for post-ERCP pancreatitis, the reason for this findings is a reluctance or inability to use it early, when repeated manipulation of the papilla induce trauma and edema to the papillary bed causing obstruction of pancreatic duct. Conclusion: The use of Precut Fistulotomy for difficult biliary cannulation is safe and effective. Therefore, in experience hands “ultra” early use of PF is recommended.
0119. Usefulness of K-ras mutational analysis as a routine method to increase diagnostic sensitivity of EUS-guided FNA nchez del Monte, Jos Cesar Ricardo Ortega Espinosa, Julio Sa e Guillermo de la Mora Levy, Octavio Alonso Larraga, Mauro Eduardo Ramírez Solís, ndez Guerrero Ang elica Herna Instituto Nacional de Cancerologia, Mexico Introduction: Some studies have suggested that the presence of Krasmutations can increase the diagnostic sensitivity of this procedure. Aim: To explore if routine analysis for K-ras mutations increases sensitivity of EUS-guided FNA aspirates and determine the group of patients in which this could be useful. Background: K-ras mutations have been detected in pancreatic cancer. Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-guided FNA) cytology has become the gold standard for histologic diagnosis, with sensitivities around 90%. Method: Consecutive patients with a diagnosis of solid pancreatic mass undergoing EUS-guided FNA at our institution were included. After each needle pass the material obtained was placed on glass slides, Carbowax as fixative for cell block and sterile pellets for K-ras mutation analysis. PCR Therascreen (Qialgen. Ltd) was used. Wild type K-ras was considered negative while the presence of mutations in codons 12,13 were considered positive for malignancy. Specifically atypical or indeterminate cytology was considered negative. Malignant cytology and/or compatible imagingþclinical follow-up was considered the standard for a diagnosis of malignancy. Results: 67 patients were included but 10 samples were not adequate for mutational analysis, so data on 57 patients is presented, of which 28 were female with a mean age of 61 years (28-85). Diagnostic values for Cytology were: S:92.3%, E:71.5%, PPV:100% & NPV:92%. The addition of Kras increased sensitivity by 3.5% percent to 95.8%. Only two cases with inadequate cytology were further diagnosed as malignant with a positive K-ras mutation, while 10 cases with definite malignancy by cytology had no mutation identified. Conclusion: K-ras mutation analysis is not clinically useful and increases sensitivity marginally, even in patients with indeterminate cytology. Our study suggests that routine analysis is not warranted in all patients and could be useful for only a small group of patients with equivocal cytology results.
S25
0120. Is pylorus preserving pancreatoduodenectomy responsible for delayed gastric emptying? Ricardo Tadashi Nishio, Andre de Moricz, Rodrigo Altenfelder Silva, Adhemar Monteiro Pacheco Jr ^ncias Me dicas da Santa Casa de S~ Faculdade de Cie ao Paulo, Brazil Introduction: In the late 70's, Traverso and Longmire proposed pylorus preserving pancreatoduodenectomy (PPPD) as an alternative surgery for chronic pancreatitis. PPPD has been used for adenocarcinoma and other tumors located in the pancreatic head. Both Whipple and PPPD have similar results concerning morbidity and mortality rates, quality of life and long time survival rates. Delayed gastric emptying (DGE) is a common complication of PPPD. The mechanism of DGE is not completely understood but some surgeons believe that PPPD technique is responsible for DGE. Aim: The aim of this article is to demonstrate that DGE is secondary to other complications and it is not related to the PPPD technique. Background: DGE is present in 12 to 42% of all cases. It is responsible for prolonged hospitalization and considerable elevation of hospital and treatment costs. Method: The studied was performed in the ambulatory of Biliary Tract and Pancreas Group of the Department of Surgery of Santa Casa de S~ ao Paulo. All patients treated with PPPD, for both benign and malign diseases, with DGE with prolonged hospitalization (more than 10 days) between the period of 2001 and 2016 were included in this study and the causes of DGE were investigated. Results: Between 2001 and 2016, 105 PPPDs were performed. of all patients, 72 patients had prolonged hospitalization and 12 patients had no cause for prolonged hospitalization and 15 patients were not fit for this study. Twelve patients did not present DGE. Twenty six patients presented DGE related to pancreatic fistulae, biliary fistulae and abdominal fluid collections. Seven cases presented DGE with no apparent cause. However, later investigation revealed that two cases presented anastomotic ulcer in the endoscopic study. Discussion: Although DGE is a frequent complication, it is secondary to other complications like pancreatic fistula. DGE is also a complication of the Whipple technique. It seems that DGE is not related to the technique it self. Several studies have been conducted to study if the form of reconstruction is responsible for DGE. However, the results presented do not allow any conclusion so far. Studies have shown that DGE is commonly related to other complications in the abdominal cavity like pancreatic fistulae, biliary fistulae, abdominal fluid collections, vascular irrigation problems after reconstruction and anastomotic dehiscence. It seems the best way to prevent DGE i stop prevent other complications. Conclusion: Although DGE is a frequent complication o PPPD, our analysis revealed that DGE is often associated with other complications.
0121. Artery divestment for artery involved pancreatic cancer: A retrospective study Miao Yi, Jiang Kuirong, Cai Baobao, Yin Lingdi, Lu Zipeng, Wu Junli, Gao Wentao, Dai Cuncai Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, China Introduction: The treatment of artery involved locally advanced pancreatic cancer (ai-LAPC) are now under robust discussion. Aim: The safety and oncology efficiency of artery divestment for aiLAPC is estimated in this study. Method: Between June 2014 and June 2016, a series of ai-LAPC patients received curative pancreatectomy with artery divestment (Ad.) was compared retrospectively with concurrent control group (Ctl.) of 87 no major artery involved cases received radical operations.
papilla, inadvertent guidewire pancreatic duct cannulation on three occasions and inability to achieve deep biliary cannulation within 3 minutes. Main outcome measures were PEP and successful biliary cannulation. Results: A PF was performed in 49 cases (31 women, 18 men, 25 under 60 years) Success rate of biliary cannulation using PF were 96% (47/49). Thirty eight (77.5%) patients had risk factors for PEP 20 had 1 risk, 13 had 2 and 5 had 3. Conditions of DBC were: impacted stone in the papilla 4 cases, longer bulging of papilla 6 cases, lower location of papilla orifice 15 cases, partial location of papilla orifice 16 and stricture of papillary orifice 8 cases. Five patients had periampullary diverticulum, 4 patients had normal common bile duct (under 9 mm) and one patient was pregnant. None of the patients experienced PEP. Two patients had minor bleeding, no needed blood transfusion, just endoscopic treatment. One patient (2%) had fever and was hospitalized for medical treatment. Discussion: There are studies suggesting that early institution of the precut is safe and effective strategy. Althought several autors classify precut as a risk factor for post-ERCP pancreatitis, the reason for this findings is a reluctance or inability to use it early, when repeated manipulation of the papilla induce trauma and edema to the papillary bed causing obstruction of pancreatic duct. Conclusion: The use of Precut Fistulotomy for difficult biliary cannulation is safe and effective. Therefore, in experience hands “ultra” early use of PF is recommended.
0119. Usefulness of K-ras mutational analysis as a routine method to increase diagnostic sensitivity of EUS-guided FNA nchez del Monte, Jos Cesar Ricardo Ortega Espinosa, Julio Sa e Guillermo de la Mora Levy, Octavio Alonso Larraga, Mauro Eduardo Ramírez Solís, ndez Guerrero Ang elica Herna Instituto Nacional de Cancerologia, Mexico Introduction: Some studies have suggested that the presence of Krasmutations can increase the diagnostic sensitivity of this procedure. Aim: To explore if routine analysis for K-ras mutations increases sensitivity of EUS-guided FNA aspirates and determine the group of patients in which this could be useful. Background: K-ras mutations have been detected in pancreatic cancer. Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-guided FNA) cytology has become the gold standard for histologic diagnosis, with sensitivities around 90%. Method: Consecutive patients with a diagnosis of solid pancreatic mass undergoing EUS-guided FNA at our institution were included. After each needle pass the material obtained was placed on glass slides, Carbowax as fixative for cell block and sterile pellets for K-ras mutation analysis. PCR Therascreen (Qialgen. Ltd) was used. Wild type K-ras was considered negative while the presence of mutations in codons 12,13 were considered positive for malignancy. Specifically atypical or indeterminate cytology was considered negative. Malignant cytology and/or compatible imagingþclinical follow-up was considered the standard for a diagnosis of malignancy. Results: 67 patients were included but 10 samples were not adequate for mutational analysis, so data on 57 patients is presented, of which 28 were female with a mean age of 61 years (28-85). Diagnostic values for Cytology were: S:92.3%, E:71.5%, PPV:100% & NPV:92%. The addition of Kras increased sensitivity by 3.5% percent to 95.8%. Only two cases with inadequate cytology were further diagnosed as malignant with a positive K-ras mutation, while 10 cases with definite malignancy by cytology had no mutation identified. Conclusion: K-ras mutation analysis is not clinically useful and increases sensitivity marginally, even in patients with indeterminate cytology. Our study suggests that routine analysis is not warranted in all patients and could be useful for only a small group of patients with equivocal cytology results.
S25
0120. Is pylorus preserving pancreatoduodenectomy responsible for delayed gastric emptying? Ricardo Tadashi Nishio, Andre de Moricz, Rodrigo Altenfelder Silva, Adhemar Monteiro Pacheco Jr ^ncias Me dicas da Santa Casa de S~ Faculdade de Cie ao Paulo, Brazil Introduction: In the late 70's, Traverso and Longmire proposed pylorus preserving pancreatoduodenectomy (PPPD) as an alternative surgery for chronic pancreatitis. PPPD has been used for adenocarcinoma and other tumors located in the pancreatic head. Both Whipple and PPPD have similar results concerning morbidity and mortality rates, quality of life and long time survival rates. Delayed gastric emptying (DGE) is a common complication of PPPD. The mechanism of DGE is not completely understood but some surgeons believe that PPPD technique is responsible for DGE. Aim: The aim of this article is to demonstrate that DGE is secondary to other complications and it is not related to the PPPD technique. Background: DGE is present in 12 to 42% of all cases. It is responsible for prolonged hospitalization and considerable elevation of hospital and treatment costs. Method: The studied was performed in the ambulatory of Biliary Tract and Pancreas Group of the Department of Surgery of Santa Casa de S~ ao Paulo. All patients treated with PPPD, for both benign and malign diseases, with DGE with prolonged hospitalization (more than 10 days) between the period of 2001 and 2016 were included in this study and the causes of DGE were investigated. Results: Between 2001 and 2016, 105 PPPDs were performed. of all patients, 72 patients had prolonged hospitalization and 12 patients had no cause for prolonged hospitalization and 15 patients were not fit for this study. Twelve patients did not present DGE. Twenty six patients presented DGE related to pancreatic fistulae, biliary fistulae and abdominal fluid collections. Seven cases presented DGE with no apparent cause. However, later investigation revealed that two cases presented anastomotic ulcer in the endoscopic study. Discussion: Although DGE is a frequent complication, it is secondary to other complications like pancreatic fistula. DGE is also a complication of the Whipple technique. It seems that DGE is not related to the technique it self. Several studies have been conducted to study if the form of reconstruction is responsible for DGE. However, the results presented do not allow any conclusion so far. Studies have shown that DGE is commonly related to other complications in the abdominal cavity like pancreatic fistulae, biliary fistulae, abdominal fluid collections, vascular irrigation problems after reconstruction and anastomotic dehiscence. It seems the best way to prevent DGE i stop prevent other complications. Conclusion: Although DGE is a frequent complication o PPPD, our analysis revealed that DGE is often associated with other complications.
0121. Artery divestment for artery involved pancreatic cancer: A retrospective study Miao Yi, Jiang Kuirong, Cai Baobao, Yin Lingdi, Lu Zipeng, Wu Junli, Gao Wentao, Dai Cuncai Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, China Introduction: The treatment of artery involved locally advanced pancreatic cancer (ai-LAPC) are now under robust discussion. Aim: The safety and oncology efficiency of artery divestment for aiLAPC is estimated in this study. Method: Between June 2014 and June 2016, a series of ai-LAPC patients received curative pancreatectomy with artery divestment (Ad.) was compared retrospectively with concurrent control group (Ctl.) of 87 no major artery involved cases received radical operations.