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Prognostic significance of lymph node involvement in periampullary cancer
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Electronic Poster Abstracts
EP02D-097 - Table 1
Pts Primary procedure
Sex Age, yr
Diagnosis
Means of diagnosis
Length of Type of stay, d operation
Outcome
1
Postsurgical complication
F
66
Duodenal perforation following laparoscopic cholecystectomy
Clinical decision, CT scan
59
EPD + PJ
Survival
2
Postsurgical complication
M
74
Dehiscence of duodenal suture postampullectomy
Clinical decision, CT scan
89
EPD + CPS Death
3
Postsurgical complication
M
44
Severe necrotizing pancreatitis post ERCP
Clinical decision, CT scan
75
EPD + CPS Death
4
Postsurgical complication
M
42
Dehiscense of cystojejunostomy for pancreatic pseudocyst
Clinical decision, CT scan
110
EPD + CPS Survival
5
Postsurgical complication
F
63
Delayed duodenal perforation by foreign Clinical body following cholecystectomy decision, CT scan
35
EPD + CPS Survival
Results: The emergency pancreaticoduodenectomy subgroup of patients showed an overall morbidity of 80%, and mortality of 40%. In 80% (4/5) of patients treated by emergency pancreaticoduodenectomy, the pancreatic stump was closed and not reconstructed (CPS), and in 20% (1/5) a pancreaticojejunostomy (PJ) was performed. Conclusion: Emergency pancreaticoduodenectomy is an effective life-saving operation reservable to pancreatoduodenal trauma, perforations, and bleeding, unmanageable by a less invasive approach. It should be preferentially approached by surgeons with a high level of experience in hepatobiliary and pancreatic surgery and in trauma centers too, but it should also be in the armamentarium of general surgeons performing hepatopancreato-biliary surgery.
EP02D-098 PERIOPERATIVE ANTIMICROBIAL THERAPY FOR PANCREATODUODENECTOMY S. G. Barreto1, M. K. Singh2, S. Sharma3 and A. Chaudhary1 1 Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, 2Clinical Research, and 3 Microbiology, Medanta,-The Medicity, India Objectives: Infectious complications occur in upto 45% of patients following pancreatoduodenectomy (PD) and are higher in patients undergoing preoperative endoscopic invasive procedures. Surgical morbidity adversely affects long-term outcomes and thus role of perioperative antimicrobials needs evaluation. The aim of the study was to compare the impact of Ertapenem administered as 3-once daily perioperative doses on infectious complications in patients at high-risk for complications (underwent preoperative invasive endoscopic procedures) versus those at low-risk (up-front surgery). Methods: A retrospective analysis of a prospectively maintained database of consecutive patients who underwent PD for pancreatic and periampullary lesions at a
tertiary referral centre, between June 2011 and May 2013 was performed. Based on an analysis of intraoperative bile cultures, all patients were administered 3-once daily doses of Ertapenem (1 gram) as follows: within 1 hour prior to induction, on post-operative day 1 and day 2. Antibiotics were ceased following post-operative day 2 until discharge unless patients developed infectious complications. Results: Patients were matched for factors known to affect outcomes following PD including demographic, nutritional (age, sex, BMI and serum albumin levels), surgical (pancreatic duct size and texture, intraoperative blood transfusions) and histopathological parameters. No significant difference between the two groups in terms of overall morbidity (P = .740), infectious complications (P = .334), mortality (P = .933) and post-operative hospital stay (P = .745) was noted. Conclusion: Perioperative Ertapenem resulted in a nonsignificant difference in infectious and overall complications in high-risk patients undergoing PD as compared to low-risk group. This intervention is promising and needs evaluation in a larger cohort of patients.
EP02D-099 PROGNOSTIC SIGNIFICANCE OF LYMPH NODE INVOLVEMENT IN PERIAMPULLARY CANCER P. Mishra1, S. Saluja1, H. Shah1, S. Chandrasekar1, A. Arora2 and P. Raj1 1 Gastrointestinal Surgery, GB Pant Institute of Postgraduate Medical Education & Research, and 2 Hepatopancreaticobiliary surgery, Institute of Liver & Biliary Sciences, India Introduction: Role of lymph node ratio (LNR) and lymph node positivity inperiampullary tumours remains controversial. We performed a study to evaluate these aspects in periampullary carcinoma. Patients and methods: All patients undergoing pancreatoduodenectomyfor periampullary carcinoma from 2004 to 2013 were reviewed. Pancreatic head tumours and margin positive resections were excluded. Demographic profile and histopathology were recorded.LNR was evaluated as both
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts categorical and continuous variable. Disease specific survival (DSS) and Recurrence free survival (RFS) were calculated. Results: 139 patients underwent pancreaticodudenectomy. Of 139 patients, 104 (74%) were alive at last follow-up. Forty-four (31.7%) patients developed recurrence. Median DSS and RFS were 74 and 72 months, respectively. Threeyear and 5-year DSS was 77% and 69%, while RFS were 67% and 55% respectively. Total number of retrieved lymph nodes (<12 or >12, <15 or >15) did not affect DSS or RFS. Univariate analysis showed that T-stage, lymph node positivity, LNR and perineural invasion significantly affected DSS and RFS. Multivariate analysis showed Lymph node positivity lost its significance for RFS and DSS. AUC for prediction of DSS and RFS by LNR was 0.66 (p = 0.005) and 0.7 (p < 0.001). The sensitivity and specificity of LNR for DSS was 57% and 76% and for RFS was 57% and 79% respectively. Conclusion: While Lymph node involvement loses significance on multivariate analysis, LNR remains a significant factor using categorical test for RFS only. It has low sensitivity, with AUC <70. Lymph node retrieval did not show any impact. Further studies would be required before one concludes that LNR is an important prognostic factor in periampullarytumours.
EP02D-100 PANCREATIC SURGERY IN A REFERAL CENTRE IN COLOMBIA. MULTIDISCIPLINARY TEAM WORK: EXPERIENCE OF 18 MONTHS. MEDERI HOSPITAL J. C. Sabogal, P. Torres and A. Isaza Mederi Hospital, Colombia Introduction: Pancreatic surgery has been experienced significant improvement in terms of mortality. Pancreaticoduodenectomy and distal pancreatectomy. The purpose of this study is to describe and analyze the experience of a multidisciplinary team on the HPB department in Bogota, Colombia. Method: Descriptive and retrospective study from January 2014 and July 2015 at Mederi Hospital. The article describes the positive impact of having multidisciplinary approach from the diagnosis until the postoperative care. Results: From January 2014 to July 2015 thirty-five patients underwent for a pancreatic surgery. Twenty-seven pancreaticoduodenectomies and eight distal pancreatectomy were done. Median age was 61,76 years-old (24e83). Operative time 3,5 h (3e6 h). Bleeding volume was 412,6 cc (100 e 1000 cc) Postoperative transfusion on 15 out of 35 patients. Biliary fistula 1 case. Pancretic fistula 28, 57 %. Peri operative surgical Morbidity 30 60 days was 34,2 %. Medical morbidity was 29, 62 %. Mortality was 14.2 % in the first year and 0 % in the second year. Analysis: Multidisciplinary approach has been developed to assess patients with pancreatic mass. Preoperative assessement is crucial to determine medical condition of patients. Intraoperative and Postoperative management has been improved. Conclusions: Preliminar report of thirty-five patients who underwent for a pancreatic surgery. Multidisciplinary approach has a positive impact on the positive results. There is a significant room for improvement.
HPB 2016, 18 (S1), e385ee601
e419
EP02D-101 PARTINGTON-ROCHELLE PANCREATICOJEJUNOSTOMY FOR CHRONIC PANCREATITIS: RESULTS AND FOLLOW UP C. Vallejo, M. Serradilla, J. R. Oliver, M. Del Campo, T. Gimenez-Maurel and A. Serrablo HPB Surgical Unit, Zaragoza University, Miguel Servet University Hospital, Spain Introduction: Drainage operations for chronic pancreatitis (CP) are based on the concept that obstruction of the main pancreatic duct(s) leads to an increased intraductal and intraparenchymal pressure, and that this gives rise to pain. Partington and Rochelle pancreaticojejunostomy (PRP) has been one of the techniques that have been used most often but there is little evidence concerning well-indicated surgery, pain control, pancreatic endocrine and exocrine insufficiency and postoperative complications. Material and methods: Between Febuary 2001 and September 2014, PRP was performed in 14 patients in whom have not control pain and the the main pancreatic duct’s diameter exceeded 7 mm and there was no inflammatory tumor in the pancreatic head. Perioperative morbidity and mortality were analyzed in all patients. Results: 12 were men and 2 were women, the age range was 39e72 years old. Alcohol consumption was known in 9 patients. Medical respective pain treatment for CP was in median 48 months (range 8e360) prior to surgery, with previous ERCP in 4 patients. Postoperative complications (IIeIIIa DindoeClavien) at 90 days occurred in 5 patients, 3 had intra-abdominal abscess and 2 gastrointestinal bleeding but there were not reoperations. Average hospital stay was 25 days. The median follow-up was 27 (range 1e 141) months. 7 patients were completely free of pain, 2 had occasional pain, 2 suffered from a new acute pancreatitis episode and 2 had complications which required surgery regarding to cephalic problems. Conclusion: Partington-Rochelle pancreaticojejunostomy is a safe procedure with a good pain control in patients after alcohol withdrawal.
EP02D-102 HAMBURG’S PREPARE SCORE FOR PANCREATIC RESECTIONS: PRELIMINARY RESULTS IN A SPANISH HPB SURGERY UNIT M. Rodriguez Lopez, M. Bailon Cuadrado, B. Pérez Saborido, R. Velasco Lopez, S. Mambrilla Herrero, K. T. Plua Muñiz, E. Asensio Diaz, L. M. Diez Gonzalez, D. Pacheco Sanchez, P. Pinto Fuentes and A. Barrera Rebollo General and Digestive Surgery, Rio-Hortega University Hospital, Spain Introduction: Many scores have been suggested to predict outcomes in pancreatic resections. The PREPARE was recently defined to stratify patient’s risk of postoperative complications according to Dindo-Clavien classification. Our aim is to preliminarily evaluate the use of PREPARE score using a short series in our HPB Surgery unit. Methods: Prospective analysis of 9 patients undergoing pancreatic resection at Rio-Hortega University Hospital
Electronic Poster Abstracts
EP02D-097 - Table 1
Pts Primary procedure
Sex Age, yr
Diagnosis
Means of diagnosis
Length of Type of stay, d operation
Outcome
1
Postsurgical complication
F
66
Duodenal perforation following laparoscopic cholecystectomy
Clinical decision, CT scan
59
EPD + PJ
Survival
2
Postsurgical complication
M
74
Dehiscence of duodenal suture postampullectomy
Clinical decision, CT scan
89
EPD + CPS Death
3
Postsurgical complication
M
44
Severe necrotizing pancreatitis post ERCP
Clinical decision, CT scan
75
EPD + CPS Death
4
Postsurgical complication
M
42
Dehiscense of cystojejunostomy for pancreatic pseudocyst
Clinical decision, CT scan
110
EPD + CPS Survival
5
Postsurgical complication
F
63
Delayed duodenal perforation by foreign Clinical body following cholecystectomy decision, CT scan
35
EPD + CPS Survival
Results: The emergency pancreaticoduodenectomy subgroup of patients showed an overall morbidity of 80%, and mortality of 40%. In 80% (4/5) of patients treated by emergency pancreaticoduodenectomy, the pancreatic stump was closed and not reconstructed (CPS), and in 20% (1/5) a pancreaticojejunostomy (PJ) was performed. Conclusion: Emergency pancreaticoduodenectomy is an effective life-saving operation reservable to pancreatoduodenal trauma, perforations, and bleeding, unmanageable by a less invasive approach. It should be preferentially approached by surgeons with a high level of experience in hepatobiliary and pancreatic surgery and in trauma centers too, but it should also be in the armamentarium of general surgeons performing hepatopancreato-biliary surgery.
EP02D-098 PERIOPERATIVE ANTIMICROBIAL THERAPY FOR PANCREATODUODENECTOMY S. G. Barreto1, M. K. Singh2, S. Sharma3 and A. Chaudhary1 1 Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, 2Clinical Research, and 3 Microbiology, Medanta,-The Medicity, India Objectives: Infectious complications occur in upto 45% of patients following pancreatoduodenectomy (PD) and are higher in patients undergoing preoperative endoscopic invasive procedures. Surgical morbidity adversely affects long-term outcomes and thus role of perioperative antimicrobials needs evaluation. The aim of the study was to compare the impact of Ertapenem administered as 3-once daily perioperative doses on infectious complications in patients at high-risk for complications (underwent preoperative invasive endoscopic procedures) versus those at low-risk (up-front surgery). Methods: A retrospective analysis of a prospectively maintained database of consecutive patients who underwent PD for pancreatic and periampullary lesions at a
tertiary referral centre, between June 2011 and May 2013 was performed. Based on an analysis of intraoperative bile cultures, all patients were administered 3-once daily doses of Ertapenem (1 gram) as follows: within 1 hour prior to induction, on post-operative day 1 and day 2. Antibiotics were ceased following post-operative day 2 until discharge unless patients developed infectious complications. Results: Patients were matched for factors known to affect outcomes following PD including demographic, nutritional (age, sex, BMI and serum albumin levels), surgical (pancreatic duct size and texture, intraoperative blood transfusions) and histopathological parameters. No significant difference between the two groups in terms of overall morbidity (P = .740), infectious complications (P = .334), mortality (P = .933) and post-operative hospital stay (P = .745) was noted. Conclusion: Perioperative Ertapenem resulted in a nonsignificant difference in infectious and overall complications in high-risk patients undergoing PD as compared to low-risk group. This intervention is promising and needs evaluation in a larger cohort of patients.
EP02D-099 PROGNOSTIC SIGNIFICANCE OF LYMPH NODE INVOLVEMENT IN PERIAMPULLARY CANCER P. Mishra1, S. Saluja1, H. Shah1, S. Chandrasekar1, A. Arora2 and P. Raj1 1 Gastrointestinal Surgery, GB Pant Institute of Postgraduate Medical Education & Research, and 2 Hepatopancreaticobiliary surgery, Institute of Liver & Biliary Sciences, India Introduction: Role of lymph node ratio (LNR) and lymph node positivity inperiampullary tumours remains controversial. We performed a study to evaluate these aspects in periampullary carcinoma. Patients and methods: All patients undergoing pancreatoduodenectomyfor periampullary carcinoma from 2004 to 2013 were reviewed. Pancreatic head tumours and margin positive resections were excluded. Demographic profile and histopathology were recorded.LNR was evaluated as both
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts categorical and continuous variable. Disease specific survival (DSS) and Recurrence free survival (RFS) were calculated. Results: 139 patients underwent pancreaticodudenectomy. Of 139 patients, 104 (74%) were alive at last follow-up. Forty-four (31.7%) patients developed recurrence. Median DSS and RFS were 74 and 72 months, respectively. Threeyear and 5-year DSS was 77% and 69%, while RFS were 67% and 55% respectively. Total number of retrieved lymph nodes (<12 or >12, <15 or >15) did not affect DSS or RFS. Univariate analysis showed that T-stage, lymph node positivity, LNR and perineural invasion significantly affected DSS and RFS. Multivariate analysis showed Lymph node positivity lost its significance for RFS and DSS. AUC for prediction of DSS and RFS by LNR was 0.66 (p = 0.005) and 0.7 (p < 0.001). The sensitivity and specificity of LNR for DSS was 57% and 76% and for RFS was 57% and 79% respectively. Conclusion: While Lymph node involvement loses significance on multivariate analysis, LNR remains a significant factor using categorical test for RFS only. It has low sensitivity, with AUC <70. Lymph node retrieval did not show any impact. Further studies would be required before one concludes that LNR is an important prognostic factor in periampullarytumours.
EP02D-100 PANCREATIC SURGERY IN A REFERAL CENTRE IN COLOMBIA. MULTIDISCIPLINARY TEAM WORK: EXPERIENCE OF 18 MONTHS. MEDERI HOSPITAL J. C. Sabogal, P. Torres and A. Isaza Mederi Hospital, Colombia Introduction: Pancreatic surgery has been experienced significant improvement in terms of mortality. Pancreaticoduodenectomy and distal pancreatectomy. The purpose of this study is to describe and analyze the experience of a multidisciplinary team on the HPB department in Bogota, Colombia. Method: Descriptive and retrospective study from January 2014 and July 2015 at Mederi Hospital. The article describes the positive impact of having multidisciplinary approach from the diagnosis until the postoperative care. Results: From January 2014 to July 2015 thirty-five patients underwent for a pancreatic surgery. Twenty-seven pancreaticoduodenectomies and eight distal pancreatectomy were done. Median age was 61,76 years-old (24e83). Operative time 3,5 h (3e6 h). Bleeding volume was 412,6 cc (100 e 1000 cc) Postoperative transfusion on 15 out of 35 patients. Biliary fistula 1 case. Pancretic fistula 28, 57 %. Peri operative surgical Morbidity 30 60 days was 34,2 %. Medical morbidity was 29, 62 %. Mortality was 14.2 % in the first year and 0 % in the second year. Analysis: Multidisciplinary approach has been developed to assess patients with pancreatic mass. Preoperative assessement is crucial to determine medical condition of patients. Intraoperative and Postoperative management has been improved. Conclusions: Preliminar report of thirty-five patients who underwent for a pancreatic surgery. Multidisciplinary approach has a positive impact on the positive results. There is a significant room for improvement.
HPB 2016, 18 (S1), e385ee601
e419
EP02D-101 PARTINGTON-ROCHELLE PANCREATICOJEJUNOSTOMY FOR CHRONIC PANCREATITIS: RESULTS AND FOLLOW UP C. Vallejo, M. Serradilla, J. R. Oliver, M. Del Campo, T. Gimenez-Maurel and A. Serrablo HPB Surgical Unit, Zaragoza University, Miguel Servet University Hospital, Spain Introduction: Drainage operations for chronic pancreatitis (CP) are based on the concept that obstruction of the main pancreatic duct(s) leads to an increased intraductal and intraparenchymal pressure, and that this gives rise to pain. Partington and Rochelle pancreaticojejunostomy (PRP) has been one of the techniques that have been used most often but there is little evidence concerning well-indicated surgery, pain control, pancreatic endocrine and exocrine insufficiency and postoperative complications. Material and methods: Between Febuary 2001 and September 2014, PRP was performed in 14 patients in whom have not control pain and the the main pancreatic duct’s diameter exceeded 7 mm and there was no inflammatory tumor in the pancreatic head. Perioperative morbidity and mortality were analyzed in all patients. Results: 12 were men and 2 were women, the age range was 39e72 years old. Alcohol consumption was known in 9 patients. Medical respective pain treatment for CP was in median 48 months (range 8e360) prior to surgery, with previous ERCP in 4 patients. Postoperative complications (IIeIIIa DindoeClavien) at 90 days occurred in 5 patients, 3 had intra-abdominal abscess and 2 gastrointestinal bleeding but there were not reoperations. Average hospital stay was 25 days. The median follow-up was 27 (range 1e 141) months. 7 patients were completely free of pain, 2 had occasional pain, 2 suffered from a new acute pancreatitis episode and 2 had complications which required surgery regarding to cephalic problems. Conclusion: Partington-Rochelle pancreaticojejunostomy is a safe procedure with a good pain control in patients after alcohol withdrawal.
EP02D-102 HAMBURG’S PREPARE SCORE FOR PANCREATIC RESECTIONS: PRELIMINARY RESULTS IN A SPANISH HPB SURGERY UNIT M. Rodriguez Lopez, M. Bailon Cuadrado, B. Pérez Saborido, R. Velasco Lopez, S. Mambrilla Herrero, K. T. Plua Muñiz, E. Asensio Diaz, L. M. Diez Gonzalez, D. Pacheco Sanchez, P. Pinto Fuentes and A. Barrera Rebollo General and Digestive Surgery, Rio-Hortega University Hospital, Spain Introduction: Many scores have been suggested to predict outcomes in pancreatic resections. The PREPARE was recently defined to stratify patient’s risk of postoperative complications according to Dindo-Clavien classification. Our aim is to preliminarily evaluate the use of PREPARE score using a short series in our HPB Surgery unit. Methods: Prospective analysis of 9 patients undergoing pancreatic resection at Rio-Hortega University Hospital