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Surgical duodenal ampullectomy in the treatment of ampullary neoplasm: 12 cases experience
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Abstracts / Pancreatology 13 (2013) S2–S98
Section of Pancreatic Surgery, Department of Surgery, University of Milan School of Medicine, Istituto Clinico Humanitas, Rozzano, Italy Introduction: Pancreatic surgery is associated with high morbidity; this is probably the reason why surgeons are still reluctant in applying fasttrack recovery programs. Identification of diagnostic criteria to early predict PICs development could be useful in tailoring perioperative management to patient personal risk. Aims: Assessment of diagnostic accuracy of RCP and WBC as early predictors of PICs in pancreatic surgery. Patients & methods: Between Jan-2010 and Feb-2013 we performed 319 pancreatic resections, of which 187 pancreaticoduodenectomies (PD). RCP (detected with an high-sensivity method) and WBC from POD1 to POD7 were analyzed searching for association with PICs (anastomotic leakage, sepsis, airways, urinary tract and wound infection, abdominal collection); using receiver-operating-characteristic method (ROC), diagnostic accuracy was evaluated by area-under-thecurve (AUC) analysis. Results: PICs incidence was 41,8% (PD:46,7%). Cancer diagnosis, chemotherapy, age, ASA, blood-loss didn’t influence PIC rates, contrary to increasing BMI (p<0,001). Mean RCP levels were higher in all patients who developed PIC each day from POD1 to POD7 (p<0,001), regardless of surgical procedure, while mean WBC levels were higher in this group only from POD4 to POD7 (p<0,001). The highest diagnostic accuracy was observed in PD for RCP levels on POD4 (AUC¼0,835; 95%C.I.): a 14,70 mg/L cut-off revealed 83% sensibility and 81% specificity for PICs. RCP from POD1 to POD7 associated with high grade PICs (Clavien-Dindo Grade IIV)(p<0,001). Conclusion: POD4 RCP level appears predictor for PICs in pancreatic surgery and could guide patient’s management (fast track recovery programs or diagnostic research for septic processes); WBC, more influenced by physiological postoperative inflammatory response, fail in decisively distinguishing patients developing PICs.
PII-79 Abstract id: 256. Surgical duodenal ampullectomy in the treatment of ampullary neoplasm: 12 cases experience Maria Rachele Angiolini 1, Francesca Gavazzi 1, Maria Carla Tinti 1, Cristina Ridolfi 1, Marco Madonini 1, Paola Spaggiari 2, Marco Montorsi 1, Alessandro Zerbi 1. 1 Section of Pancreatic Surgery, Department of Surgery, University of Milan School of Medicine, Istituto Clinico Humanitas, Rozzano, Italy 2 Department of Pathology, Istituto Clinico Humanitas, IRCCS Rozzano, Milan, Italy
Introduction: Duodenal ampullectomy is a technically demanding but effective surgical procedure for treatment of patients suffering from benign and malignant disease limited to Vater ampulla. Aims: Evaluation of outcomes after surgical duodenal ampullectomy in a referral centre for pancreatic surgery. Patients & methods: Between Jan-2010 and Feb-2013 we performed 196 consecutive surgical procedures for benign and malignant periampullary disease, of which 12 Vater ampullectomies. Indication to ampullectomy was made depending on mandatory preoperative endoscopic ultrasound (EUS) with evidence of disease limited to ampullary wall and on biopsy results. In two patients with ampullary carcinoma we performed a palliative ampullectomy because of comorbidities which contraindicated pancreaticoduodenectomy. Mean BMI was 25,272,7. Mean age was 6613. Three patients had preoperative jaundice and required biliary stenting. Results: Mean operative time was 28052,7 min and mean blood loss was 13799 ml. Overall morbidity was 25%, of which a case of pneumonia and two duodenal fistulas requiring radiological drainage. Median length of hospital stay was 10 days (range 8-24); one patient needed readmission. No patient experienced reintervention. Histological diagnosis revealed 6 ampullary carcinomas, 1 neuroendocrine neoplasm, 5 ampullary
adenomas. Two patients with ampullary carcinoma experienced local recurrence, of which one underwent pancreaticoduodenectomy, while the other received chemotherapy because of comorbidities. All patients are alive and in f-up, 11 are free from disease. Conclusion: In an high volume pancreatic surgical center duodenal ampullectomy is feasible and shows good postoperative results. In selected cases it could be considered a valid alternative to pancreaticoduodenectomy. Preoperative EUS is mandatory for proper surgical indication.
PII-80 Abstract id: 61. Laparoscopic distal pancreatectomy: What factors are related to the learning curve? Salvatore Buscemi, Claudio Ricci, Giovanni Taffurelli, Marielda D’Ambra, Nicola Antonacci, Carlo Alberto Pacilio, Riccardo Casadei, Francesco Minni. Surgical and Emergency Unit, Department of Internal Medicine and Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy Introduction: Factors related to the learning curve for laparoscopic distal pancreatectomy have rarely been evaluated. Aims: The primary endpoint was operative time. The secondary endpoints were conversion rate, reoperation rate, overall postoperative morbidity and mortality, postoperative pancreatic fistula, postpancreatectomy haemorrhage, length of hospital stay and unplanned splenectomy. Patients & methods: A retrospective study of 32 patients who underwent a laparoscopic distal pancreatectomy performed by a single high volume pancreatic surgeon experienced in advanced laparoscopic surgery. Pre-, intra- and postoperative data were collected. Results: The operative time and the cumulative sum of the procedures presented a significant logarithmic correlation (P¼0.048), but not a linear correlation (P¼0.091). The learning curve was said to have been completed after 17 procedures (AUC ¼0.714; P¼0.040). Multivariate analysis confirmed that the completion of the learning curve (a cut-off of 17 procedures) significantly reduced operative time by 18% (effect 0.82; C.I. 95 %-0.71-0.95; P¼0.009) but extended resection increased it (effect 1.24; C.I. 95 %-1.03-1.49; P¼0.023). Conversion rate, reoperation rate, overall postoperative morbidity and mortality, postoperative pancreatic fistula, postpancreatectomy haemorrhage, and length of hospital stay were not significantly related to completion of the learning curve. Unplanned splenectomy was significantly more frequent in the first 17 procedures. Conclusion: Operative time seems to be the main factor related to the completion of the learning curve for laparoscopic distal pancreatectomy. The learning curve could be considered completed after 17 procedures if performed by surgeons experienced in advanced laparoscopic techniques and in high volume centres for pancreatic surgery.
PII-81 Abstract id: 71. Pancreatic resections: Are there preoperative factors related to a “soft pancreas” and are they useful in predicting pancreatic fistulas? Marielda D’Ambra, Giovanni Taffurelli, Claudio Ricci, Salvatore Buscemi, Francesco Monari, Nicola Antonacci, Riccardo Casadei, Francesco Minni. Surgical and Emergency Unit, Department of Internal Medicine and Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy Introduction: Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistulas. Aims: Endpoints were: to recognize preoperative factors related to a soft pancreatic remnant and to establish if they are useful in predicting a pancreatic fistula. Patients & methods: Retrospective study of patients who underwent pancreaticoduodenectomy or left pancreatectomy. Factors considered
Abstracts / Pancreatology 13 (2013) S2–S98
Section of Pancreatic Surgery, Department of Surgery, University of Milan School of Medicine, Istituto Clinico Humanitas, Rozzano, Italy Introduction: Pancreatic surgery is associated with high morbidity; this is probably the reason why surgeons are still reluctant in applying fasttrack recovery programs. Identification of diagnostic criteria to early predict PICs development could be useful in tailoring perioperative management to patient personal risk. Aims: Assessment of diagnostic accuracy of RCP and WBC as early predictors of PICs in pancreatic surgery. Patients & methods: Between Jan-2010 and Feb-2013 we performed 319 pancreatic resections, of which 187 pancreaticoduodenectomies (PD). RCP (detected with an high-sensivity method) and WBC from POD1 to POD7 were analyzed searching for association with PICs (anastomotic leakage, sepsis, airways, urinary tract and wound infection, abdominal collection); using receiver-operating-characteristic method (ROC), diagnostic accuracy was evaluated by area-under-thecurve (AUC) analysis. Results: PICs incidence was 41,8% (PD:46,7%). Cancer diagnosis, chemotherapy, age, ASA, blood-loss didn’t influence PIC rates, contrary to increasing BMI (p<0,001). Mean RCP levels were higher in all patients who developed PIC each day from POD1 to POD7 (p<0,001), regardless of surgical procedure, while mean WBC levels were higher in this group only from POD4 to POD7 (p<0,001). The highest diagnostic accuracy was observed in PD for RCP levels on POD4 (AUC¼0,835; 95%C.I.): a 14,70 mg/L cut-off revealed 83% sensibility and 81% specificity for PICs. RCP from POD1 to POD7 associated with high grade PICs (Clavien-Dindo Grade IIV)(p<0,001). Conclusion: POD4 RCP level appears predictor for PICs in pancreatic surgery and could guide patient’s management (fast track recovery programs or diagnostic research for septic processes); WBC, more influenced by physiological postoperative inflammatory response, fail in decisively distinguishing patients developing PICs.
PII-79 Abstract id: 256. Surgical duodenal ampullectomy in the treatment of ampullary neoplasm: 12 cases experience Maria Rachele Angiolini 1, Francesca Gavazzi 1, Maria Carla Tinti 1, Cristina Ridolfi 1, Marco Madonini 1, Paola Spaggiari 2, Marco Montorsi 1, Alessandro Zerbi 1. 1 Section of Pancreatic Surgery, Department of Surgery, University of Milan School of Medicine, Istituto Clinico Humanitas, Rozzano, Italy 2 Department of Pathology, Istituto Clinico Humanitas, IRCCS Rozzano, Milan, Italy
Introduction: Duodenal ampullectomy is a technically demanding but effective surgical procedure for treatment of patients suffering from benign and malignant disease limited to Vater ampulla. Aims: Evaluation of outcomes after surgical duodenal ampullectomy in a referral centre for pancreatic surgery. Patients & methods: Between Jan-2010 and Feb-2013 we performed 196 consecutive surgical procedures for benign and malignant periampullary disease, of which 12 Vater ampullectomies. Indication to ampullectomy was made depending on mandatory preoperative endoscopic ultrasound (EUS) with evidence of disease limited to ampullary wall and on biopsy results. In two patients with ampullary carcinoma we performed a palliative ampullectomy because of comorbidities which contraindicated pancreaticoduodenectomy. Mean BMI was 25,272,7. Mean age was 6613. Three patients had preoperative jaundice and required biliary stenting. Results: Mean operative time was 28052,7 min and mean blood loss was 13799 ml. Overall morbidity was 25%, of which a case of pneumonia and two duodenal fistulas requiring radiological drainage. Median length of hospital stay was 10 days (range 8-24); one patient needed readmission. No patient experienced reintervention. Histological diagnosis revealed 6 ampullary carcinomas, 1 neuroendocrine neoplasm, 5 ampullary
adenomas. Two patients with ampullary carcinoma experienced local recurrence, of which one underwent pancreaticoduodenectomy, while the other received chemotherapy because of comorbidities. All patients are alive and in f-up, 11 are free from disease. Conclusion: In an high volume pancreatic surgical center duodenal ampullectomy is feasible and shows good postoperative results. In selected cases it could be considered a valid alternative to pancreaticoduodenectomy. Preoperative EUS is mandatory for proper surgical indication.
PII-80 Abstract id: 61. Laparoscopic distal pancreatectomy: What factors are related to the learning curve? Salvatore Buscemi, Claudio Ricci, Giovanni Taffurelli, Marielda D’Ambra, Nicola Antonacci, Carlo Alberto Pacilio, Riccardo Casadei, Francesco Minni. Surgical and Emergency Unit, Department of Internal Medicine and Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy Introduction: Factors related to the learning curve for laparoscopic distal pancreatectomy have rarely been evaluated. Aims: The primary endpoint was operative time. The secondary endpoints were conversion rate, reoperation rate, overall postoperative morbidity and mortality, postoperative pancreatic fistula, postpancreatectomy haemorrhage, length of hospital stay and unplanned splenectomy. Patients & methods: A retrospective study of 32 patients who underwent a laparoscopic distal pancreatectomy performed by a single high volume pancreatic surgeon experienced in advanced laparoscopic surgery. Pre-, intra- and postoperative data were collected. Results: The operative time and the cumulative sum of the procedures presented a significant logarithmic correlation (P¼0.048), but not a linear correlation (P¼0.091). The learning curve was said to have been completed after 17 procedures (AUC ¼0.714; P¼0.040). Multivariate analysis confirmed that the completion of the learning curve (a cut-off of 17 procedures) significantly reduced operative time by 18% (effect 0.82; C.I. 95 %-0.71-0.95; P¼0.009) but extended resection increased it (effect 1.24; C.I. 95 %-1.03-1.49; P¼0.023). Conversion rate, reoperation rate, overall postoperative morbidity and mortality, postoperative pancreatic fistula, postpancreatectomy haemorrhage, and length of hospital stay were not significantly related to completion of the learning curve. Unplanned splenectomy was significantly more frequent in the first 17 procedures. Conclusion: Operative time seems to be the main factor related to the completion of the learning curve for laparoscopic distal pancreatectomy. The learning curve could be considered completed after 17 procedures if performed by surgeons experienced in advanced laparoscopic techniques and in high volume centres for pancreatic surgery.
PII-81 Abstract id: 71. Pancreatic resections: Are there preoperative factors related to a “soft pancreas” and are they useful in predicting pancreatic fistulas? Marielda D’Ambra, Giovanni Taffurelli, Claudio Ricci, Salvatore Buscemi, Francesco Monari, Nicola Antonacci, Riccardo Casadei, Francesco Minni. Surgical and Emergency Unit, Department of Internal Medicine and Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy Introduction: Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistulas. Aims: Endpoints were: to recognize preoperative factors related to a soft pancreatic remnant and to establish if they are useful in predicting a pancreatic fistula. Patients & methods: Retrospective study of patients who underwent pancreaticoduodenectomy or left pancreatectomy. Factors considered