- Email: [email protected]
Randomized clinical trial comparing postoperative morbidity on two types of intestinal reconstruction after pancreaticoduodenectomy (PAUDA)
e14
Abstracts / Pancreatology 15 (2015) e1ee17
Introduction: Post-ERCP pancreatitis (PAP) occurs in 2-10% of cases, depending on settings and indications. PAP is more frequent in hi-risk groups ( i.e. women with Oddi’s sphincter dysfunction and in the absence of stones or biliary dilation). Prophylactic pancreatic duct stenting (PDS) is recommended in this setting. Aims: Prospective collection and description of PDS inserted in 182 consecutive ERCPs performed with biliary stone removal intention among €ive papilla in a 3rd level University Hospital. patients with na Material & methods: Prospective collection of 182 consecutive ERCPs €ive papilla (1st attempt). All pawith choledocolithiasis suspicion and na tients received endoscopist sedation with Propofol and periprocedural PAP prophylaxis (100 mg of rectal indomethacin). Demographic data, indication, endoscopist features, anatomical variants and endoscopic technical factors were collected, and presence of PAP was analysed. Results: A complete stone removal was achieved in 85% of the patients in spite of 50% of big stones. In 9 out of 182 (4.94%) patients a 3-5-french/35 cm prophylactic PDS were inserted and no PAP was observed in them. Six were men (66.6%) and age was not relevant. Main ERCP indications were choledocolithiasis and cholangitis. Biliary cannulation was not achieved in one patient and, additionally, in another two the stones could not be removed. Two patients suffered a sphincterotomy bleeding that was stopped by adrenaline injection. In 44% of the cases the procedure was started by a resident or a training fellow. Six of the patients had papillitis, 4 had small sized papillas, 2 had ectropion and 1 was intradiverticullar. Five out of 9 patients received a needle knife precut (NKP). Indications for prophylactic insertion were difficult cannulation with repeated guidewire pass to the MPD, Wirsung contrast injection, and precut. Conclusions: Insertion of a prophylactic PDS in difficult choledocholithiasis ERCP procedures might prevent PAP
39. Pancreatic stents for treatment of pancreatic duct dysruption syndrome: Analysis of outcomes and factors associated with therapeutic success C. Prieto, B. Gonzalez de la Higuera, D. Ruiz-Clavijo, J.M. Urman, F. Bolado, M. Casi, J.J. Vila Complejo Hospitalario de Navarra, Servicio de Digestivo, Pamplona, Spain Background: Treatment of pancreatic duct dysruptions (PDD) with pancreatic trasnpapillary stents (PTS) is effective in 44-92% of patients. Higher resolution rates are achieved when the PTS bridges the PDD, which is technically challenging. Aim: To analyze the results of PDD therapy with PTS and evaluate the influence of different factors on therapeutic success. Method: Retrospective analysis of a prospectively filled database including patients who underwent PDD endoscopic treatment between january/2009 and december/2014. Variables included: type of PDD (partial/complete), pancreatic disease (estenosis, pancreatolithiasis, collection), location of PTS (“bridging”, “intradysruption” and “distal” PTS when it was placed connecting the pancreatic duct proximally and distally to the PDD, into the PDD or below the PDD respectively) and treatment outcome. Approved by Institutional Review Board. Results: During the study period 33 patients underwent PDD endoscopic treatment with PTS and were included: 22 with partial and 11 with complete PDD. Associated pancreatic disease was: stenosis (18 patients), pancreatolithiasis (2 patients) and pancreatic collection (31 patients). The PTS was “bridging” in 15 patients (12 with partial and 3 with complete PDD); “intradysruption” in 9 patients (4 with partial and 5 with complete PDD); and “distal” in 9 patients (6 with partial and 3 with complete PDD). Major and minor papilla pancreatic sphincterotomy was performed in 10 and 4 patients respectively. Three patients underwent surgery after ERCP for complications of the acute pancreatitis process and they were not included in the treatment outcome analysis. In the remaining 30 patients r-
esolution of the PDD was achieved in 21 patients with PTS (70%): 13/19 in partial PDD and 8/11 in complete PDD. “Bridging” PTS achieved resolution in 92.8%, “intradysruption” in 66% and “distal” in 28% of patients. “Bridging” or “intradysruption” were significantly more effective than “distal” PTS (82.6%vs28%; p¼0,006). The other variables analysed did not show influence on treatment outcome. Conclusions: Endoscopic treatment of PDD with PTS is effective in 70% of patients. “Bridging” or “intradysruption” PTS are the best therapeutic options increasing therapeutic success to 82% of patients.
40. Treatment of infected pancreatic necrosis: Outcome in a 9-year, single-center, consecutive series (2006-2014) ~o n 1, V. Sanchiz 1, L. Sabater 2, N. Garcia 1, I. Pascual 1, O. Moreno 1, R. An 1 1 1 ~ A. Pena , J. Tosca , P. Lluch , M. Minguez 1, F. Mora 1 1
Servicio Medicina Digestiva, Hospital Clinico Universitario, Universitat de Valencia, Valencia, Spain 2 Servicio de Cirugia, Hospital Clinico Universitario.Universitat de Valencia, Valencia, Spain Introduction: Infected pancreatic necrosis (IPN) is a severe complication in acute pancreatitis (AP) which results in significant morbidity and mortality, specially when associated with organ failure. Management of IPN has changed in recent years towards a more conservative approach. Aims: To report the experience in management of IPN in a 9- year consecutive series, after implementing a more conservative approach. Material and methods: Between 2006 and 2014, 1162 patients with AP have been admitted at the Hospital Clinic University of Valencia. Among them, there were 28 cases of IPN. Conservative approach consisted of percutaneous and/or endoscopic drainage followed, if necessary, by open necrosectomy. Primary open surgery was indicated only in critical IPN with non-responsive MOF or acute abdomen with diagnostic uncertainty. Persistent organ failure (Marshall Index) was assessed at admission, during the first week and at diagnosis of IPN. Outcome measures were: mortality, morbidity, need for necrosectomy, hospital stay and ICU admission. Results: An initial conservative approach was carried out in 23 patients (percutaneous drainage in 13 patients, endoscopic drainage in 5 and percutaneous and endoscopic drainage in 4). 21.7 % and 8.7 % of patients had persistent MOF during the first week and at diagnosis of IPN, respectively. 10 patients were operated later on due to failure of initial conservative treatment. Median time from admission to surgical intervention was 41 days (19-123 days). Mortality occurred in 8 cases (34.8 %), 2 of them had not been operated. Primary open Surgery was performed in 5 patients: 2 cases due to acute abdomen and perforation suspicion and 3 with non-responsive MOF (2 abdominal compartment syndrome). MOF was present in 2 patients (40%) at diagnosis of IPN and in 4 (80%) during the first week. 4 patients died (80 %). Conclusions: Conservative management without necrosectomy is a successful management in 47.8 % of patients. Conservative management allows delaying surgery. Primary surgically treated patients had a more severe disease.
41. Randomized clinical trial comparing postoperative morbidity on two types of intestinal reconstruction after pancreaticoduodenectomy (PAUDA) ez, E. Ramos, L. Llado , J. Fabregat J. Busquets, S. Martin, L. Secanella, N. Pela Hospital Universitari de Bellvitge, Barcelona, Spain
Abstracts / Pancreatology 15 (2015) e1ee17
Purpose: The aim of the study is to compare the effect of Roux-en Y reconstruction (study group, DPCDA) versus classical Child reconstruction (DPCUN) in the incidence of delayed gastric emptying (DGE) in patients for pancreaticoduodenectomy (PD). The hypothesis of the study is that Roux-en Y reconstruction decreases incidence of DGE after pancreaticoduodenectomy. Background: The PD is the procedure of choice in the tumors of the head of the pancreas, periampullary tumors and intractable inflammatory pathology. The most common postoperative complication is DGE, defined as intolerance for solid oral intake by the 7th day postoperative. In some cases, oral intolerance can occur after the 21st postoperative day. Therefore, the patient requires parenteral nutrition and prolonged hospital stay. The aim of the study is to compare the effect of Roux-en Y reconstruction (study group, DPCDA) versus classical Child reconstruction (DPCUN) in the incidence of DGE in patients after PD. The hypothesis of the study is that Roux-en Y reconstruction decreases incidence of DGE after PD. Methods: A pilot randomized clinical trial was designed to compare the two surgical techniques reconstructing the digestive tract after PD in patients treated in our center. Patients were randomized after tumor resection and before the reconstruction through computer randomization numbers (using a sealed envelope technique). The primary endpoint is the incidence of DGE. Secondary endpoints are postoperative morbidity, the hospital stay, postoperative endocrine and exocrine function, and specific complications as pancreatic fistula. Results: Between 2013 and 2014, 46 PDs were randomized equally. The groups were similar in terms of age (mean age was 70 years old), sex, and pathology. Ductal pancreatic adenocarcinoma was the most frequent cause of surgery. A patient was excluded intraoperatively because of severe hemodynamic instability, after randomization. Global incidence of DGE was 40%, similar between the groups (48% vs 32%, n.s.). Mean postoperative stay was 15 days (7-49). Conclusions: Our analysis shows that Roux-en-Y reconstructions do not reduce the incidence of delayed gastric emptying; however, further study will be necessary to evaluate the utility of this method.
e15
42. Cholecystectomy in mild biliary acute pancreatitis. Are we conducting in our center the current clinical guidelines recommendations? C. Prieto, F. Bolado, M. Casi, D. Ruiz-Clavijo, B. Gonzalez de la Higuera, J. Urman, E. Valdivieso, J.J. Vila Complejo Hospitalario de Navarra, Servicio de Digestivo, Pamplona, Spain Introduction: The most common cause of acute pancreatitis in our environment is biliary. Current guidelines recommend cholecystectomy during admission or soon after. Aim: To analyze the compliance with these recommendations in our center. Material and methods: Retrospective study of admissions due to mild biliary acute pancreatitis (02/2014-11/2014). We analyzed age, gender, previous cholecystectomy and, if not, whether cholecystectomy was performed during or after admission. Besides this, until the end date of the study we studied the need for readmission due to gallstones-related symptoms and the time until surgery was performed. Descriptive statistics (SPSS 20.0) were used. Results: 67 patients, 50.7% women. Mean age: 69.35 (27-97). Three had undergone a previous cholecystectomy. Cholecystectomy was performed in 68.75% of cases (n¼44). 35.93% of them (n¼23) during initial admission or within 30 days after discharge. In the 32.81% of cases (n¼21) after 30 days. Cholecystectomy was not performed in 31,25 % of patients (n¼20): in ten of them due to comorbidity or advanced age, in eight, the family or the patient refused the surgery, one of them moved to another city, and in one case there were doubts about the presence of cholelithiasis. There were 14 complications in patients who had been excluded or were waiting for cholecystectomy: 6 pancreatitis (twice in two cases), 2 cholangitis, 3 cholecystitis and 1 biliary colic. Conclusions: In 32.81% of patients the clinical guidelines recommendations regarding cholecystectomy in mild biliary acute pancreatitis were not followed. 18.75% of cases presented with complications.
Abstracts / Pancreatology 15 (2015) e1ee17
Introduction: Post-ERCP pancreatitis (PAP) occurs in 2-10% of cases, depending on settings and indications. PAP is more frequent in hi-risk groups ( i.e. women with Oddi’s sphincter dysfunction and in the absence of stones or biliary dilation). Prophylactic pancreatic duct stenting (PDS) is recommended in this setting. Aims: Prospective collection and description of PDS inserted in 182 consecutive ERCPs performed with biliary stone removal intention among €ive papilla in a 3rd level University Hospital. patients with na Material & methods: Prospective collection of 182 consecutive ERCPs €ive papilla (1st attempt). All pawith choledocolithiasis suspicion and na tients received endoscopist sedation with Propofol and periprocedural PAP prophylaxis (100 mg of rectal indomethacin). Demographic data, indication, endoscopist features, anatomical variants and endoscopic technical factors were collected, and presence of PAP was analysed. Results: A complete stone removal was achieved in 85% of the patients in spite of 50% of big stones. In 9 out of 182 (4.94%) patients a 3-5-french/35 cm prophylactic PDS were inserted and no PAP was observed in them. Six were men (66.6%) and age was not relevant. Main ERCP indications were choledocolithiasis and cholangitis. Biliary cannulation was not achieved in one patient and, additionally, in another two the stones could not be removed. Two patients suffered a sphincterotomy bleeding that was stopped by adrenaline injection. In 44% of the cases the procedure was started by a resident or a training fellow. Six of the patients had papillitis, 4 had small sized papillas, 2 had ectropion and 1 was intradiverticullar. Five out of 9 patients received a needle knife precut (NKP). Indications for prophylactic insertion were difficult cannulation with repeated guidewire pass to the MPD, Wirsung contrast injection, and precut. Conclusions: Insertion of a prophylactic PDS in difficult choledocholithiasis ERCP procedures might prevent PAP
39. Pancreatic stents for treatment of pancreatic duct dysruption syndrome: Analysis of outcomes and factors associated with therapeutic success C. Prieto, B. Gonzalez de la Higuera, D. Ruiz-Clavijo, J.M. Urman, F. Bolado, M. Casi, J.J. Vila Complejo Hospitalario de Navarra, Servicio de Digestivo, Pamplona, Spain Background: Treatment of pancreatic duct dysruptions (PDD) with pancreatic trasnpapillary stents (PTS) is effective in 44-92% of patients. Higher resolution rates are achieved when the PTS bridges the PDD, which is technically challenging. Aim: To analyze the results of PDD therapy with PTS and evaluate the influence of different factors on therapeutic success. Method: Retrospective analysis of a prospectively filled database including patients who underwent PDD endoscopic treatment between january/2009 and december/2014. Variables included: type of PDD (partial/complete), pancreatic disease (estenosis, pancreatolithiasis, collection), location of PTS (“bridging”, “intradysruption” and “distal” PTS when it was placed connecting the pancreatic duct proximally and distally to the PDD, into the PDD or below the PDD respectively) and treatment outcome. Approved by Institutional Review Board. Results: During the study period 33 patients underwent PDD endoscopic treatment with PTS and were included: 22 with partial and 11 with complete PDD. Associated pancreatic disease was: stenosis (18 patients), pancreatolithiasis (2 patients) and pancreatic collection (31 patients). The PTS was “bridging” in 15 patients (12 with partial and 3 with complete PDD); “intradysruption” in 9 patients (4 with partial and 5 with complete PDD); and “distal” in 9 patients (6 with partial and 3 with complete PDD). Major and minor papilla pancreatic sphincterotomy was performed in 10 and 4 patients respectively. Three patients underwent surgery after ERCP for complications of the acute pancreatitis process and they were not included in the treatment outcome analysis. In the remaining 30 patients r-
esolution of the PDD was achieved in 21 patients with PTS (70%): 13/19 in partial PDD and 8/11 in complete PDD. “Bridging” PTS achieved resolution in 92.8%, “intradysruption” in 66% and “distal” in 28% of patients. “Bridging” or “intradysruption” were significantly more effective than “distal” PTS (82.6%vs28%; p¼0,006). The other variables analysed did not show influence on treatment outcome. Conclusions: Endoscopic treatment of PDD with PTS is effective in 70% of patients. “Bridging” or “intradysruption” PTS are the best therapeutic options increasing therapeutic success to 82% of patients.
40. Treatment of infected pancreatic necrosis: Outcome in a 9-year, single-center, consecutive series (2006-2014) ~o n 1, V. Sanchiz 1, L. Sabater 2, N. Garcia 1, I. Pascual 1, O. Moreno 1, R. An 1 1 1 ~ A. Pena , J. Tosca , P. Lluch , M. Minguez 1, F. Mora 1 1
Servicio Medicina Digestiva, Hospital Clinico Universitario, Universitat de Valencia, Valencia, Spain 2 Servicio de Cirugia, Hospital Clinico Universitario.Universitat de Valencia, Valencia, Spain Introduction: Infected pancreatic necrosis (IPN) is a severe complication in acute pancreatitis (AP) which results in significant morbidity and mortality, specially when associated with organ failure. Management of IPN has changed in recent years towards a more conservative approach. Aims: To report the experience in management of IPN in a 9- year consecutive series, after implementing a more conservative approach. Material and methods: Between 2006 and 2014, 1162 patients with AP have been admitted at the Hospital Clinic University of Valencia. Among them, there were 28 cases of IPN. Conservative approach consisted of percutaneous and/or endoscopic drainage followed, if necessary, by open necrosectomy. Primary open surgery was indicated only in critical IPN with non-responsive MOF or acute abdomen with diagnostic uncertainty. Persistent organ failure (Marshall Index) was assessed at admission, during the first week and at diagnosis of IPN. Outcome measures were: mortality, morbidity, need for necrosectomy, hospital stay and ICU admission. Results: An initial conservative approach was carried out in 23 patients (percutaneous drainage in 13 patients, endoscopic drainage in 5 and percutaneous and endoscopic drainage in 4). 21.7 % and 8.7 % of patients had persistent MOF during the first week and at diagnosis of IPN, respectively. 10 patients were operated later on due to failure of initial conservative treatment. Median time from admission to surgical intervention was 41 days (19-123 days). Mortality occurred in 8 cases (34.8 %), 2 of them had not been operated. Primary open Surgery was performed in 5 patients: 2 cases due to acute abdomen and perforation suspicion and 3 with non-responsive MOF (2 abdominal compartment syndrome). MOF was present in 2 patients (40%) at diagnosis of IPN and in 4 (80%) during the first week. 4 patients died (80 %). Conclusions: Conservative management without necrosectomy is a successful management in 47.8 % of patients. Conservative management allows delaying surgery. Primary surgically treated patients had a more severe disease.
41. Randomized clinical trial comparing postoperative morbidity on two types of intestinal reconstruction after pancreaticoduodenectomy (PAUDA) ez, E. Ramos, L. Llado , J. Fabregat J. Busquets, S. Martin, L. Secanella, N. Pela Hospital Universitari de Bellvitge, Barcelona, Spain
Abstracts / Pancreatology 15 (2015) e1ee17
Purpose: The aim of the study is to compare the effect of Roux-en Y reconstruction (study group, DPCDA) versus classical Child reconstruction (DPCUN) in the incidence of delayed gastric emptying (DGE) in patients for pancreaticoduodenectomy (PD). The hypothesis of the study is that Roux-en Y reconstruction decreases incidence of DGE after pancreaticoduodenectomy. Background: The PD is the procedure of choice in the tumors of the head of the pancreas, periampullary tumors and intractable inflammatory pathology. The most common postoperative complication is DGE, defined as intolerance for solid oral intake by the 7th day postoperative. In some cases, oral intolerance can occur after the 21st postoperative day. Therefore, the patient requires parenteral nutrition and prolonged hospital stay. The aim of the study is to compare the effect of Roux-en Y reconstruction (study group, DPCDA) versus classical Child reconstruction (DPCUN) in the incidence of DGE in patients after PD. The hypothesis of the study is that Roux-en Y reconstruction decreases incidence of DGE after PD. Methods: A pilot randomized clinical trial was designed to compare the two surgical techniques reconstructing the digestive tract after PD in patients treated in our center. Patients were randomized after tumor resection and before the reconstruction through computer randomization numbers (using a sealed envelope technique). The primary endpoint is the incidence of DGE. Secondary endpoints are postoperative morbidity, the hospital stay, postoperative endocrine and exocrine function, and specific complications as pancreatic fistula. Results: Between 2013 and 2014, 46 PDs were randomized equally. The groups were similar in terms of age (mean age was 70 years old), sex, and pathology. Ductal pancreatic adenocarcinoma was the most frequent cause of surgery. A patient was excluded intraoperatively because of severe hemodynamic instability, after randomization. Global incidence of DGE was 40%, similar between the groups (48% vs 32%, n.s.). Mean postoperative stay was 15 days (7-49). Conclusions: Our analysis shows that Roux-en-Y reconstructions do not reduce the incidence of delayed gastric emptying; however, further study will be necessary to evaluate the utility of this method.
e15
42. Cholecystectomy in mild biliary acute pancreatitis. Are we conducting in our center the current clinical guidelines recommendations? C. Prieto, F. Bolado, M. Casi, D. Ruiz-Clavijo, B. Gonzalez de la Higuera, J. Urman, E. Valdivieso, J.J. Vila Complejo Hospitalario de Navarra, Servicio de Digestivo, Pamplona, Spain Introduction: The most common cause of acute pancreatitis in our environment is biliary. Current guidelines recommend cholecystectomy during admission or soon after. Aim: To analyze the compliance with these recommendations in our center. Material and methods: Retrospective study of admissions due to mild biliary acute pancreatitis (02/2014-11/2014). We analyzed age, gender, previous cholecystectomy and, if not, whether cholecystectomy was performed during or after admission. Besides this, until the end date of the study we studied the need for readmission due to gallstones-related symptoms and the time until surgery was performed. Descriptive statistics (SPSS 20.0) were used. Results: 67 patients, 50.7% women. Mean age: 69.35 (27-97). Three had undergone a previous cholecystectomy. Cholecystectomy was performed in 68.75% of cases (n¼44). 35.93% of them (n¼23) during initial admission or within 30 days after discharge. In the 32.81% of cases (n¼21) after 30 days. Cholecystectomy was not performed in 31,25 % of patients (n¼20): in ten of them due to comorbidity or advanced age, in eight, the family or the patient refused the surgery, one of them moved to another city, and in one case there were doubts about the presence of cholelithiasis. There were 14 complications in patients who had been excluded or were waiting for cholecystectomy: 6 pancreatitis (twice in two cases), 2 cholangitis, 3 cholecystitis and 1 biliary colic. Conclusions: In 32.81% of patients the clinical guidelines recommendations regarding cholecystectomy in mild biliary acute pancreatitis were not followed. 18.75% of cases presented with complications.