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Total laparoscopic pancreaticoduodenectomy: initial experience and short-term outcomes
e438
Electronic Poster Abstracts
EP02E-028 ARTERY FIRST TECHNIQUE FOR MANAGEMENT OF AN ABERRANT RIGHT HEPATIC ARTERY DURING PANCREATICODUODENECTOMY, OUR EXPERIENCE
EP02E-029 MINIMALLY INVASIVE VERSUS OPEN APPROACH FOR DISTAL PANCREATECTOMY: A RETROSPECTIVE COMPARATIVE STUDY
R. Sayyed, A. Muzaffar, M. T. Pirzada, A. A. Syed and F. Hanif Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan Introduction: Aberrant hepatic arterial anatomy poses a challenge for surgeon during pancreaticoduodenectomy (PD). These anomalies are best picked up on preoperative imaging in order to avoid inadvertent injury to the aberrant vasculature. Damage to aberrant vasculature may lead to liver ischaemia and also biliary-enteric anastomotic failure. We present our experience of dealing with aberrant hepatic vessels during PD.
K. -F. Lee, A. Fong, C. Chong, Y. -S. Cheung, J. Wong and P. Lai Department of Surgery, Chinese University Hong Kong, Hong Kong Introduction: Laparoscopic and robotic distal pancreatectomy have emerged as viable minimally invasive options for selected patients with pancreatic pathology at body and tail. This study aims to compare the operative outcomes of these approaches with classical open approach. Methods: All patients who underwent elective distal pancreatectomy with or without splenectomy from July 2003 to August 2015 were recruited. Patients with
EP02E-028 - Table 1
Robotic (n [ 18)
Laparoscopic (n [ 6)
Open (n [ 46)
p-Value
Age
58 (39–80)
54.5 (23–80)
55.5 (22–79)
0.392
Male gender
9 (50%)
3 (50%)
18 (39.1%)
0.689
Pathologies: CA pancreas/Cystic neoplasm/ Neuroendocrine tumor
3 (16.7%)/5(27.8%)/ 5(27.8%)
1 (16.7%)/2(33.3%)/ 3(50.0%)
4 (8.7%)/12(26.1%)/ 12(26.1%)
Operation time (min)
339 (113–600)
380 (195–403)
267 (110–510)
Blood loss (ml)
200 (10–1770)
450 (100–1000)
323 (20–2800)
0.201
Mortality
0 (0%)
0 (0%)
1 (2.2%)
>0.999
Morbidity/Pancreatic leak
2 (11.1%)/2(11.1%)
2 (33.3%)/1(16.7%)
17 (37.0%)/6(13.0%)
0.118/ >0.999
Splenectomy done
12 (66.7%)
4 (66.7%)
40 (87.0%)
0.090
Postoperative hospital stay (days)
5.5 (3–9)
7 (6–69)
9 (6–99)
<0.001*
Methods: All patients who underwent PD between September 2014 and August 2015 were studied and those with aberrant hepatic vascular anatomy identified on preoperative imaging or intraoperatively were included. We used artery first technique for dissection in expected cases and aberrations were classed according to Hiatt classification. Results: A total of 23 PD were performed between September 2014 and August 2015, of which 10 cases (43%) of aberrant arterial anatomy were identified (Table 1). These aberrant vessels were recognized and preserved in 9 cases. In one patient, the replaced right hepatic artery arising from SMA was coursing through pancreatic parenchyma needing resection and reconstruction of the vessel with uneventful postoperative recovery. We also identified one replaced right hepatic artery arising from SMA coursing lateral to CBD and entering liver parenchyma in gallbladder fossa. Conclusions: Aberrant hepatic arterial anomalies are common and should ideally be picked up by preoperative imaging. It is possible to preserve these vessels in most cases with careful surgical dissection using artery first technique. Surgeons performing pancreaticoduodenectomy should be well versed with the aberrant vascular anatomy to minimize any inadvertent damage.
0.006*
distal pancreatectomy as part of gastrectomy operation were excluded. A retrospective comparative study was performed based on a prospectively collected data base. Results: The result was summarized in the Table 1. In brief, the patient demographics and disease pathologies were comparable among the three groups. There was no difference in operative mortality, morbidity, blood loss, pancreatic leak rate or spleen preservation rate. The operation time was longer but postoperative stay was shorter in laparoscopic and robotic group. Conclusions: Robotic and laparoscopic distal pancreatectomy take longer time to complete but they shorten the hospital stay.
EP02E-030 TOTAL LAPAROSCOPIC PANCREATICODUODENECTOMY: INITIAL EXPERIENCE AND SHORTTERM OUTCOMES S. H. Choi1 and K. H. Kwon2 1 Surgery, CHA Bundang Medical Center, CHA University, and 2Surgery, National Health Insurance Corporation Ilsan Hospital, Republic of Korea
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts Background: Pancreaticoduodenectomy (PD) is one of the most formidable surgeries. Even such complicated procedures have been occupied by the minimally invasive approach in far advanced laparoscopic era. We would like to introduce our early experience of totally laparoscopic PD. Materials and methods: The patients were prepared in supine position and five trocars were used. Following resection, all of the reconstructions were accomplished by the laparoscopic approach intracorporeally. The specimen was retrieved through a small extension of skin incision of the umbilical camera port. Result: From March 2014 to August 2015, nine patients underwent laparoscopic PD. Pathology of resected lesions included 3 ampulla of Vater cancer, 2 bile duct cancer, 2 pancreatic cancer, 1 duodenal cancer, and 1 mucinous cystic tumor. Number of nodes harvested was 11.6 2.8. The mean total operative time was 486 84 min, and the mean estimated blood loss was 622 281 ml. One patient was converted to minilaparotomy because of difficult dissection of the uncinate process, which patient had grade B pancreatic leakage. There was no clinically significant complications except previous one patient. The mean length of stay after surgery was 12.8 4.6 days. Conclusion: Despite of worrisome potential risk and complications, laparoscopic PD could be performed safely with competent short-term outcomes. However, it is still a technically demanding and hardship operation during the initial learning curve. Further studies to evaluate long-term favorable outcomes and to develop proper training program for a steep learning curve are required.
EP02E-031 IS IT SAFE FOR ELDERLY PATIENTS UNDERGOING PD? J. Y. Park, J. S. Heo, S. Jung, J. Bu, W. Kwon, S. H. Choi and D. W. Choi Samsung Medical Center, Republic of Korea Introduction: Pancreaticoduodenectomy (PD) was very complex surgery and occurred high post-operative complication. The aim of this study was to evaluate the safe for elderly patients undergoing PD. Methods: This retrospective study included 470 patients who underwent PD for periampullary tumors between July 2012 and Oct 2014. The patients were grouped as group1 (less than 75 years old group, n = 406) and group 2(more than 75 years old, n = 64). Safe were assessed in patients characteristics, and postoperative outcomes. Results: ASA score 3 was higher rate group 2 than group1 (6.7% vs 23.4%; p < 0.001). There was not difference in the rates of overall morbidity (29.8% vs 37.5; p = 0.215), postoperative pancreatic fistula (POPF) (21.9% vs 28.1; p = 0.265), delayed gastric emptying (DGE)(6.7% vs 6.2%; p = 0.905) and postpancreatectomy hemorrhage (PPH) (3.5% vs 7.8%; p = 0.164) between the two groups. Length of stay was significantly difference between two groups (median 10 days vs 12 days, p = 0.017). Conclusion: Elderly patients was high perioperative risk and longer length of hospital stay, however, there was no difference with postoperative complications. Although
HPB 2016, 18 (S1), e385ee601
e439
elderly patients may take a long time to recovery from surgery, there is not concern an age for surgery.
EP02E-033 SINGLE LAYER ANASTOMOSIS FOR PANCREATICO JEJUNOSTOMIES (PJ) FOR CHRONIC CALCIFIC PANCREATITIS R. Vellaisamy1, S. Ramalingam Durai Rajan2, J. Jesudasan2, A. Anbalagan2, B. Duraisamy2, P. Raju2, C. Servarayan Murugesan1 and K. Devy Gounder2 1 Institute of Surgical Gastroenterology, and 2Sge, Madras Medical College, India Introduction: PJ is conventionally done in 2 layers. It can be safely done in single layer also. Different anastomotic techniques of pancreatico jejunostomies have been reported in the literature. These range from two to three layers. This study reports the experience with the single layer technique in 91 patients. Methods: This is a retrospective review from a prospective database. 91 patients underwent various PJ procedures from June 2011 to June 2015. The overall mean age was 35.6 years. The indication for surgery was chronic pancreatititis with and without head mass. Various morbidity and mortality data were analysed. PJ was done with Roux loop of jejunum with 2 0’ prolene in single layer in continuous manner. Results: Mean operating time was 2.9 hours or 2 hours 54 mts. Average blood loss was 181.5 ml. Mean Duration of stay was 7 days. LPJ was performed in 14% (13/91). Frey’s was performed in 86%. Wound infection was present in 8%. Pulmonary morbidity was 12%. Pain relief was excellent in 82%. One leak was observed which was managed conservatively. Mortality was nil. Discussion: Single layer anastomosis has been done successfully in 91 patients. The benefits are less operation time, less injury to adjacent organs, less cost due to minimal number of suture materials needed and no extra morbidity. This study clearly shows single layer anastomosis is no way inferior to the double layer anastomosis as for as the safety and other parameters are concerned.
EP02E-034 TOTAL LAPAROSCOPIC CENTRAL PANCREATECTOMY R. Jureidini1, T. Bacchella1, T. C. Ribeiro1, G. N. Namur1, E. R. Figueira1, L. M. Rios2 and I. Cecconello3 1 Gastroenterology - Pancreatic and Biliary Surgery Division, University of Sao Paulo, 2University of Sao Paulo/ Medical School, and 3Gastroenterology, University of Sao Paulo, Brazil Introduction: Central pancreatectomy is a parenchyma sparing resection technique developed for borderline and benign pancreatic tumours localized in pancreatic neck or proximal body when enucleation is not adviseble. This technique avoids subtotal distal pancreatectomy or pancreatoduodenectomy. Despite attractive rationale, less than 50 laparoscopic procedures were described till now mostly because complexity of pancreatic distal pancreas reconstructions. Results: Five patients who underwent totally laparoscopic central pancreatectomy where analysed from August 2011 to June 2014 in the University of Sao Paulo.
Electronic Poster Abstracts
EP02E-028 ARTERY FIRST TECHNIQUE FOR MANAGEMENT OF AN ABERRANT RIGHT HEPATIC ARTERY DURING PANCREATICODUODENECTOMY, OUR EXPERIENCE
EP02E-029 MINIMALLY INVASIVE VERSUS OPEN APPROACH FOR DISTAL PANCREATECTOMY: A RETROSPECTIVE COMPARATIVE STUDY
R. Sayyed, A. Muzaffar, M. T. Pirzada, A. A. Syed and F. Hanif Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan Introduction: Aberrant hepatic arterial anatomy poses a challenge for surgeon during pancreaticoduodenectomy (PD). These anomalies are best picked up on preoperative imaging in order to avoid inadvertent injury to the aberrant vasculature. Damage to aberrant vasculature may lead to liver ischaemia and also biliary-enteric anastomotic failure. We present our experience of dealing with aberrant hepatic vessels during PD.
K. -F. Lee, A. Fong, C. Chong, Y. -S. Cheung, J. Wong and P. Lai Department of Surgery, Chinese University Hong Kong, Hong Kong Introduction: Laparoscopic and robotic distal pancreatectomy have emerged as viable minimally invasive options for selected patients with pancreatic pathology at body and tail. This study aims to compare the operative outcomes of these approaches with classical open approach. Methods: All patients who underwent elective distal pancreatectomy with or without splenectomy from July 2003 to August 2015 were recruited. Patients with
EP02E-028 - Table 1
Robotic (n [ 18)
Laparoscopic (n [ 6)
Open (n [ 46)
p-Value
Age
58 (39–80)
54.5 (23–80)
55.5 (22–79)
0.392
Male gender
9 (50%)
3 (50%)
18 (39.1%)
0.689
Pathologies: CA pancreas/Cystic neoplasm/ Neuroendocrine tumor
3 (16.7%)/5(27.8%)/ 5(27.8%)
1 (16.7%)/2(33.3%)/ 3(50.0%)
4 (8.7%)/12(26.1%)/ 12(26.1%)
Operation time (min)
339 (113–600)
380 (195–403)
267 (110–510)
Blood loss (ml)
200 (10–1770)
450 (100–1000)
323 (20–2800)
0.201
Mortality
0 (0%)
0 (0%)
1 (2.2%)
>0.999
Morbidity/Pancreatic leak
2 (11.1%)/2(11.1%)
2 (33.3%)/1(16.7%)
17 (37.0%)/6(13.0%)
0.118/ >0.999
Splenectomy done
12 (66.7%)
4 (66.7%)
40 (87.0%)
0.090
Postoperative hospital stay (days)
5.5 (3–9)
7 (6–69)
9 (6–99)
<0.001*
Methods: All patients who underwent PD between September 2014 and August 2015 were studied and those with aberrant hepatic vascular anatomy identified on preoperative imaging or intraoperatively were included. We used artery first technique for dissection in expected cases and aberrations were classed according to Hiatt classification. Results: A total of 23 PD were performed between September 2014 and August 2015, of which 10 cases (43%) of aberrant arterial anatomy were identified (Table 1). These aberrant vessels were recognized and preserved in 9 cases. In one patient, the replaced right hepatic artery arising from SMA was coursing through pancreatic parenchyma needing resection and reconstruction of the vessel with uneventful postoperative recovery. We also identified one replaced right hepatic artery arising from SMA coursing lateral to CBD and entering liver parenchyma in gallbladder fossa. Conclusions: Aberrant hepatic arterial anomalies are common and should ideally be picked up by preoperative imaging. It is possible to preserve these vessels in most cases with careful surgical dissection using artery first technique. Surgeons performing pancreaticoduodenectomy should be well versed with the aberrant vascular anatomy to minimize any inadvertent damage.
0.006*
distal pancreatectomy as part of gastrectomy operation were excluded. A retrospective comparative study was performed based on a prospectively collected data base. Results: The result was summarized in the Table 1. In brief, the patient demographics and disease pathologies were comparable among the three groups. There was no difference in operative mortality, morbidity, blood loss, pancreatic leak rate or spleen preservation rate. The operation time was longer but postoperative stay was shorter in laparoscopic and robotic group. Conclusions: Robotic and laparoscopic distal pancreatectomy take longer time to complete but they shorten the hospital stay.
EP02E-030 TOTAL LAPAROSCOPIC PANCREATICODUODENECTOMY: INITIAL EXPERIENCE AND SHORTTERM OUTCOMES S. H. Choi1 and K. H. Kwon2 1 Surgery, CHA Bundang Medical Center, CHA University, and 2Surgery, National Health Insurance Corporation Ilsan Hospital, Republic of Korea
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts Background: Pancreaticoduodenectomy (PD) is one of the most formidable surgeries. Even such complicated procedures have been occupied by the minimally invasive approach in far advanced laparoscopic era. We would like to introduce our early experience of totally laparoscopic PD. Materials and methods: The patients were prepared in supine position and five trocars were used. Following resection, all of the reconstructions were accomplished by the laparoscopic approach intracorporeally. The specimen was retrieved through a small extension of skin incision of the umbilical camera port. Result: From March 2014 to August 2015, nine patients underwent laparoscopic PD. Pathology of resected lesions included 3 ampulla of Vater cancer, 2 bile duct cancer, 2 pancreatic cancer, 1 duodenal cancer, and 1 mucinous cystic tumor. Number of nodes harvested was 11.6 2.8. The mean total operative time was 486 84 min, and the mean estimated blood loss was 622 281 ml. One patient was converted to minilaparotomy because of difficult dissection of the uncinate process, which patient had grade B pancreatic leakage. There was no clinically significant complications except previous one patient. The mean length of stay after surgery was 12.8 4.6 days. Conclusion: Despite of worrisome potential risk and complications, laparoscopic PD could be performed safely with competent short-term outcomes. However, it is still a technically demanding and hardship operation during the initial learning curve. Further studies to evaluate long-term favorable outcomes and to develop proper training program for a steep learning curve are required.
EP02E-031 IS IT SAFE FOR ELDERLY PATIENTS UNDERGOING PD? J. Y. Park, J. S. Heo, S. Jung, J. Bu, W. Kwon, S. H. Choi and D. W. Choi Samsung Medical Center, Republic of Korea Introduction: Pancreaticoduodenectomy (PD) was very complex surgery and occurred high post-operative complication. The aim of this study was to evaluate the safe for elderly patients undergoing PD. Methods: This retrospective study included 470 patients who underwent PD for periampullary tumors between July 2012 and Oct 2014. The patients were grouped as group1 (less than 75 years old group, n = 406) and group 2(more than 75 years old, n = 64). Safe were assessed in patients characteristics, and postoperative outcomes. Results: ASA score 3 was higher rate group 2 than group1 (6.7% vs 23.4%; p < 0.001). There was not difference in the rates of overall morbidity (29.8% vs 37.5; p = 0.215), postoperative pancreatic fistula (POPF) (21.9% vs 28.1; p = 0.265), delayed gastric emptying (DGE)(6.7% vs 6.2%; p = 0.905) and postpancreatectomy hemorrhage (PPH) (3.5% vs 7.8%; p = 0.164) between the two groups. Length of stay was significantly difference between two groups (median 10 days vs 12 days, p = 0.017). Conclusion: Elderly patients was high perioperative risk and longer length of hospital stay, however, there was no difference with postoperative complications. Although
HPB 2016, 18 (S1), e385ee601
e439
elderly patients may take a long time to recovery from surgery, there is not concern an age for surgery.
EP02E-033 SINGLE LAYER ANASTOMOSIS FOR PANCREATICO JEJUNOSTOMIES (PJ) FOR CHRONIC CALCIFIC PANCREATITIS R. Vellaisamy1, S. Ramalingam Durai Rajan2, J. Jesudasan2, A. Anbalagan2, B. Duraisamy2, P. Raju2, C. Servarayan Murugesan1 and K. Devy Gounder2 1 Institute of Surgical Gastroenterology, and 2Sge, Madras Medical College, India Introduction: PJ is conventionally done in 2 layers. It can be safely done in single layer also. Different anastomotic techniques of pancreatico jejunostomies have been reported in the literature. These range from two to three layers. This study reports the experience with the single layer technique in 91 patients. Methods: This is a retrospective review from a prospective database. 91 patients underwent various PJ procedures from June 2011 to June 2015. The overall mean age was 35.6 years. The indication for surgery was chronic pancreatititis with and without head mass. Various morbidity and mortality data were analysed. PJ was done with Roux loop of jejunum with 2 0’ prolene in single layer in continuous manner. Results: Mean operating time was 2.9 hours or 2 hours 54 mts. Average blood loss was 181.5 ml. Mean Duration of stay was 7 days. LPJ was performed in 14% (13/91). Frey’s was performed in 86%. Wound infection was present in 8%. Pulmonary morbidity was 12%. Pain relief was excellent in 82%. One leak was observed which was managed conservatively. Mortality was nil. Discussion: Single layer anastomosis has been done successfully in 91 patients. The benefits are less operation time, less injury to adjacent organs, less cost due to minimal number of suture materials needed and no extra morbidity. This study clearly shows single layer anastomosis is no way inferior to the double layer anastomosis as for as the safety and other parameters are concerned.
EP02E-034 TOTAL LAPAROSCOPIC CENTRAL PANCREATECTOMY R. Jureidini1, T. Bacchella1, T. C. Ribeiro1, G. N. Namur1, E. R. Figueira1, L. M. Rios2 and I. Cecconello3 1 Gastroenterology - Pancreatic and Biliary Surgery Division, University of Sao Paulo, 2University of Sao Paulo/ Medical School, and 3Gastroenterology, University of Sao Paulo, Brazil Introduction: Central pancreatectomy is a parenchyma sparing resection technique developed for borderline and benign pancreatic tumours localized in pancreatic neck or proximal body when enucleation is not adviseble. This technique avoids subtotal distal pancreatectomy or pancreatoduodenectomy. Despite attractive rationale, less than 50 laparoscopic procedures were described till now mostly because complexity of pancreatic distal pancreas reconstructions. Results: Five patients who underwent totally laparoscopic central pancreatectomy where analysed from August 2011 to June 2014 in the University of Sao Paulo.