Pancreas transection at last procedure in pancreatoduodenectomy

S82

Abstracts / Pancreatology 16 (2016) S1eS192

Methods: From September 2014 to December 2015, 24 consecutive patients who underwent DP using the method were enrolled in this study. The pancreatic stump was wrapped with this strip of the mesh after dissection of the pancreas and ligation of the main pancreatic duct. A transpancreatic mattress suture with the strip of mesh was made using a 30 monofilament polypropylene thread. The suture was passed from the dorsal to the ventral surface at a point 5 mm cranial from the cut end to straddle the main pancreatic duct. Two pancreas-transfixing sutures with the strip of mesh were then made at the same points of the mattress suture. Finally, the sutures were ligated to accomplish pancreatic stump closure. Results: Overall morbidity (Clavien classification
grade II) was observed in 5 (21%) patients, and there was no mortality. Although 16 patients (67%) developed POPF grade A according to the International Study Group on Pancreatic Fistula, no clinically-relevant POPF grade B or C was observed. Conclusion: The method described here is a simple, safe, and effective technique for preventing POPF development after DP.

Methods: A total of 69 patients underwent DP at Yamanashi University between December 2010 and March 2015. The risk factor of POPF were retrospectively investigated between hand-sewn suture (n¼35) and a triplerow stapler closure (n¼34). The amylase levels of serum and drainage fluid were measured on postoperative days (POD) 1, 3. POPF was defined using the international Study Group on Pancreatic Fistula (ISGPF) definition. Results: Triple-row closure significantly decreases POPF Grade B/C (p¼0.007). 14 of 35 patients (40.0%) with hand-sewn closure had POPF Grade B/C. On the other hand, 4 of 34 patients (11.8%) with triple-row stapler had POPF Grade B/C. In hand-sewn closure. Age, thickness of the stump were significant risk factors for POPF in univariate analysis. In multivariate analysis, age was the only risk factor. In triple-row closure. BMI was significant risk factors for POPF in univariate and multivariate analysis. In all patients, drainage data of amylase level of more than 1067.5 on POD 3 was cut off value for prediction of POPF Grade B and C after DP (p<0.001). Conclusions: A triple-row stapler closure decreases POPF after DP. Drainage data of amylase level of more than 1067.5 on POD 3 was the risk for POPF Grade B and C after DP.

F-126. Optimal stapler cartridge selection according to the thickness of the pancreas in distal pancreatectomy Hongbeom Kim, Jin-Young Jang, Jae Ri Kim, Youngmin Han, Eun Jeong Kim, Wooil Kwon, Sun-Whe Kim Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, South Korea Objective: To identify optimal stapler cartridge choice in distal pancreatectomy (DP) according to pancreatic thickness. Background: Stapling is a popular method for stump closure in DP. However, research on which cartridges are suitable for different pancreatic thickness is lacking. Methods: From November 2011 to April 2015, data was prospectively collected from 217 consecutive patients underwent DP with 3-layer endoscopic staple closure in Seoul National University Hospital, Korea. Post-operative pancreatic fistula (POPF) was graded according to ISPFG definitions. Staplers were grouped based on closed-length (CL) (Group I: CL1.5 mm, II: 1.5 mm17 mm. With pancreatic thickness <12 mm, the POPF rate was lowest with group II (I: 50%, II: 27.6%, III: 69.2%, p¼0.035). Conclusion: The optimal stapler cartridges with pancreatic thickness less than 12 mm were those in group II (Gold, CL:1.8 mm). There was no suitable cartridge for thicker pancreases. Further studies are necessary to reduce POPF in thick pancreases.

F-127.

F-128. A branch-closing technique to reduce postoperative pancreatic fistula after pancreatectomy Yasunari Kawabata, Hikota Hayashi, Kazunori Mizutani, Yoshitsugu Tajima Department of General and Digestive Surgery, Shimane University, Japan Background: Pancreatic anastomosis after pancreaticoduodenectomy (PD) and pancreatic stump closure after pancreatosplenectomy (DP) are the most critical step. To prevent postoperative pancreatic fistula (POPF), we employed a suture closure technique for small cut side branches of the pancreatic duct system (PDS) exposed on the pancreatic stump (branchclosing technique:BCt). Methods: The pancreas was cut with a scalpel in either PD or DP, and the BCt was performed at 6 to 12 points by 6-0 nonabsorbable sutures. In a DP, the main pancreatic duct was closed with 5-0 nonabsorbable sutures. In a PD, pancreatic anastomosis was performed in a fashion of duct-to-mucosa pancreaticojejunostomy (PJ). While in the conventional pancreatectomies (cPx), either a duct-to-mucosa PJ or a stump closure with stapler was performed without BCt. Histologically, the anatomical structure of the cut side branches of the PDS was evaluated on the pancreatic stump. Results: Histologically, small branches of the PDS run parallel to a pair of small arteries and veins. This finding visually facilitates the BCt. A total of 225 patients underwent a Px between April 2006 and December 2015 at our hospital. Ninety-five patients received the BCt, including 65 cases with PD and 30 with DP, while 130 patients underwent a cPx, including 100 cases with PD and 30 with DP. The two study groups were similar in patient's background. Morbidity (Grade III to IV according to Clavien-Dindo classification) was recognized in 7 patients (7.4%) in the BCt group and 19 patients (14.6%) in the cPx group (p¼0.08). The occurrence of clinically relevant POPF (grade B/C) was 2.1% in the BCt and 20.0% in the cPx (p<0.01). Multivariate analysis showed that the BCt was an independent predictor of non-occurrence of POPF (HR, 0.10; 95% CI, 0.01-0.46; p<0.01). Conclusion: The branch-closing technique is effective to reduce POPF after pancreatectomy.

Using a triple-row stapler for stump closure of a pancreas decreases incidence of pancreatic fistula after distal pancreatectomy Hiromichi Kawaida, Hiroshi Kouno, Mitsuaki Watanabe, Naohiro Hosomura, Hidetake Amemiya, Masanori Matsuda, Hideki Fujii First Department of Surgery, Faculty of Medicine, Yamanashi University, Japan Introduction: Postoperative pancreatic fistula (POPF) is a major complication in patients undergoing distal pancreatectomy (DP). The aim of this study is to investigate the risk factors of hand-sewn suture and a triple-row stapler closure in DP.

F-129. Pancreas transection at last procedure in pancreatoduodenectomy Tatsuya Oda, Shinji Hashimoto, Osamu Shimomura, Masanao Kurata, Yukio Ohshiro, Keisuke Kohno, Nobuhiro Ohkohchi Dpt. of Surgery, University of Tsukuba, Japan Though pancreaticoduodenectomy (PD) is still a dangerous surgical procedure which associate with 20-50% morbidity and 3-8% mortality

Abstracts / Pancreatology 16 (2016) S1eS192

rate, procedural steps have regarded as almost established one, and similar standardize process are employed in world-wide institutions. This standard procedure includes i) common bile duct resection -> ii) stomach transection -> iii) pancreas tunneling and transection -> iv) jejunum transection -> v) SMA nerve plexus transection, resulting specimen removal. Our unique procedure in PD resection phase is so we call “pancreas transection at last method”, which involves approaching SMA-nerve plexus, SMA and SMV from back, without tunneling the pancreas-PV space. Sequentially, pancreatic head was mobilized by a right-caudal site approach, and pancreas head was totally freed from SMA and SMV with keeping continuity to pancreas body. Transecting pancreas was carried out just prior to specimen removal. This procedure confer several merit that can not be obtain with conventional approach includes tunneling the pancreas-PV space and transect pancreas at early stage of operation. In conventional approach, especially with cases of direct invasion by a cancer and/or severe adhesion by inflammations, a possible damage of PV system, causing massive bleeding may occurs in tunneling process. Moreover, two pancreatic cut surfaces could be a source of continuous bleeding and pancreatic juice leakage during the procedure, causing auto digestion of surgical field. Transecting pancreas just prior to specimen removal become realistic by mobilization of pancreatic head from SMA/SMV by a right-caudal site approach followed Kocherization. We have been providing Zero mortality for a series of 280 PD, and the original methods may contribute to the prominent result. Clinically relevant PF (grade B+C) and median hospital stay at former half of recent decade was 31.8% and 20.5 days, and they have improved to 13.8% and 15.5 days at these 5 years by standardizing these two unique procedure.

F-130. Intraductal tubulopapillary neoplasms of the pancreato-biliary system (ITPN, ITNB): Report of three cases and review of the literature

S83

F-131. The efficacy of EUS-FNA for the metastatic tumors of the pancreas Keiichi Hatamaru, Yoshito Uenoyama, Yukitaka Yamashita Department of Hepatology and Gastroenterology, Japan Red Cross Society Wakayama Medical Center Introduction: Metastatic tumors of the pancreas is rare, and determining whether a pancreatic mass is a primary or metastatic neoplasm is often difficult. We studied cases of diagnosed metastatic tumors of the pancreas using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Object: During the period from January 2011 to September 2015, we performed 244 cases of EUS-FNA for the pancreatic tumors, 5 cases diagnosed of metastatic tumors of the pancreas. Results: The mean age 63.8±19.0 years old, man four, woman one. The lesion part was two pancreas heads, pancreas body one, frequent occurrence two in the pancreas. The mean tumor diameter was 31.2±14.1mm, mean puncture number of times was 4±2.7 times, and the FNA puncture needle, 21G was three cases, 22G was two. It was 80% (4/5) to have been diagnosable in EUS-FNA, there is no accidental occurrence symptom in all cases. The primary lesion is cecal cancer, lung small cell carcinoma, renal cell carcinoma, thymic carcinoid, chronic lymphocytic leukemia (CLL), of these, a case of CLL was not able to be diagnosed. Lung small cell carcinoma was pancytokeratinpositive, CD56-positive, chromogranin-negative. As for renal cell carcinoma, clear cell was recognized, and each pancytokeratin, vimentin, CD10, p504s was positive. Thymic carcinoid was with positive chromogranin, synaptophysin, NSE, CD56. As for the case of CLL, the last diagnosis was provided by the percutaneous needle biopsy. In this case, it was difficult to collect FNA specimen in EUS-FNA and was not given a diagnosis. Discussion: The immunohistological findings were the most important to the EUS-FNA diagnosis in metastatic pancreas tumor, and it was necessary to collect FNA specimen of enough quantity. In addition, to using a 21G needle in the FNA and to increasing the number of puncture times led to obtain a satisfactory diagnostic result.

Balazs Tihanyi 1, Laszlo Nehez 1, Katalin Borka 2, Tamas Szekely 2, Tibor Frigyes Tihanyi 1, Laszlo Harsanyi 1 1 2

1st. Department of Surgery, Semmelweis University, Hungary 2nd. Department of Pathology, Semmelweis University, Hungary

Aim: of our study to demonstrate our findings of intraductal tubulopapillary neoplasm of the pancreas and of the bile duct (ITPN and ITNB) as rare entities of the hepato-pancreato-biliary tract. ITPN and ITNB are rare and not a well characterized lesions. The first description of ITPN was published in 2009. Patients and methods: During the last 6 years we found two cases of ITPN (1:grade II, T2N0;2:grade I, T1N0 stage ITPN) and one case of ITNB (grade III, T4Nx). Macroscopically solid nodules without visible mucin secretion were seen. The histological morphology with hematoxylin eosin staining showed special tubulopapillary growth. Polymorph and highgrade atypical cells were seen. The neoplastic cells showed no visible mucin secretion. Special immunohistochemical examinations were performed as well. Results: Immunohistochemically the tumor cells showed strong positivity of CK7, CK19 and MUC6. MUC1 positivity was proved in 10-30%, but they were for MUC2 and MUC5AC negative. The CEA, Tripsin, Synaptophysin, EMA, Chromogranine, Vimentin and NSE reactions were negative, too. KRAS was negative, while the Ki67 labeling index was in 30% of the tumor cells positive and p53 was found to be positive in one ITPN case in 10%. The ITPN cases could have radical resection (1:PPPD, 2:total pancreato-duodenectomy), but the ITNB patient was found inoperable due to local invasion of the portal region. Conclusions: ITPNs are distinct from other intraductal tumors of the pancreas. To distinguish this specific intraductal tumor from IPMNs histological and immunohistochemical examinations, such as MUC1, MUC2, MUC5AC and MUC6 are obligatory. We did not find any low-grade atypia beside the tubulopapillary tumors, while beside invasive IPMNs low or high grade dysplasia could be detected.

F-132. Pancreatectomy for neoplasms originated from other organs Hiromune Shimamura 1, Hideaki Kodama 1, Ayako Endo 1, Youichi Narushima 2, Shuichi Ishiyama 3, Kazunori Takeda 1 1

Department of Surgery, Sendai Medical Center, Japan Department of Surgery, Towada City Central Hospital, Japan 3 Department of Surgery, Sendai Kosei Hospital, Japan 2

Introduction: Pancreatectomies are operative procedures that accompany great difficulties in terms of high morbidity rate. When tumors originated from organs other than pancreas directly invade or metastasize to the pancreas, pancreatectomy will be necessary to obtain radical resection of the tumor. Here we review our cases of pancreatectomy for neoplasms originated from other organs. Patients and methods: Patients, with tumors originated from organs other than pancreas, underwent pancreatectomy in our hospital between September 1999 and October 2015, were retrospectively reviewed. Results: Seventeen patients were recruited. Original organs of neoplasm were as follows:stomach (cancer, lymphoma, GIST; n¼5), colon (cancer; n¼5), kidney (cancer; n¼3), and others (brain, adrenal gland, mesocolon, retroperitoneum; each n¼1). Pancreaticoduodenectomy (PD) was performed for 9 patients, whereas 8 patients underwent distal pancreatectomy (DP). Postoperative pancreatic fistula (ISGPF grade B, C) occurred in 3 cases of PD, whereas in one case of DP. All patients discharged hospital (median postoperative hospital stay:29days) in good status, except for one renal cancer case, which renal cancer recurred so early. Conclusion: When neoplasms, originated from organs other than pancreas, directly invade or metastasize to pancreas, and radical pancreatic resection may lead to long term survival, pancreatectomy should aggressively be performed.