Opioid-free versus opioid-based anesthesia in pancreatic surgery

Background Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Methods Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results Compared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

Nutritional status of patients undergoing pancreatic resection

Changes in the exocrine function of the pancreas often develops after proximal and distal resections. Exocrine pancreatic insufficiency (EPI) is characterized by a reduced secretion of pancreatic enzymes, because of which the digestion and absorption of nutrients is impaired. Clinical manifestations of EPI and, as a consequence, changes in nutritional status significantly affect the quality of life of patients.

Prognostic Factors in Resected Pancreatic Ductal Adenocarcinoma: Is Neutrophil-Lymphocyte Ratio a Useful Marker?

Background: The aim of this study is to analyze the role of neutrophil-lymphocyte ratio and its variation pre and post-operatively (delta NLR) in overall survival after pancreatectomy for pancreatic ductal adenocarcinoma at a single centre and to identify factors associated with overall survival.Methods: A retrospective study of consecutive patients undergoing pancreatic resection due to PDAC or undifferentiated carcinoma from January 2010 to January 2020 was performed. Association between evaluated factors and overall survival were analyzed using a log-rank test and Cox proportional hazard regression model.Results: Overall, 242 patients underwent complete pancreatic resection for PDAC or undifferentiated carcinoma. OS was 22.8 months (95% CI: 19.5-29) and survival rates at 1, 3 and 5 years were 72%, 32.5% and 20.8% respectively. NLR and delta NLR were not significantly associated with survival (HR=1.14, 95%CI: 0.77-1.68, p=0.5). Lymph node ratio was significantly associated (HR=1.66, 95%CI: 1.21-2.26, p=0.001) in the bivariate analysis. In multivariable analysis the only factors that were significantly associated with survival were perineural invasion (HR=1.94, 95%CI: 1.21-3.14, p=0.006), surgical margin (HR=1.83, 95%CI: 1.10-3.02, p=0.019), tumor size (HR=1.01, 95%CI: 1.003-1.027, p=0.16), postoperative CA 19-9 level (HR=1.001, p<0.001), and completion of adjuvant treatment (HR=0.53, 95%CI: 0.35-0.8, p=0.002).Conclusion: Neutrophil-lymphocyte ratio and delta NLR were not associated with overall survival in this cohort. Risk factors such as perineural invasion, surgical margins, CA19-9 level and tumor size showed worse survival in this study, whereas completing adjuvant treatment was a protective factor.

P-P43 Lymph Node Negative Duodenal Adenocarcinoma Is Associated with Long-term Patient Survival following Pancreaticoduodenal Resection

Background Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy. Due to the low incidence of DA there is limited data reporting patient outcomes following radical pancreatic resection. Large retrospective single and multi-centre studies suggest that lymph node metastasis is an important factor for long-term patient survival following resection. The management of DA has tended to favour aggressive surgical resection with pancreaticoduodenectomy (PD), although a morbidity of up to 50% has been reported, mostly related to post-operative pancreatic fistulas. We assessed the disease-free (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy for DA in our institution. Methods We retrospectively analysed all patients undergoing pancreatic resection for DA at our institution between January 2009 – March 2020 inclusive. All DAs were cytologically or histologically proven prior to surgical resection following imaging review in a Hepato-pancreaticobiliary multidisciplinary team meeting. Patients underwent a Whipple’s with distal gastrectomy or pylorus preserving pancreaticoduodenectomy (PPPD) based on tumour size and location. Statistical analysis was performed by a Mann-Whitney U test using a p-value significance of 0.05 (SPSS, IBM, USA). DFS and OS curves were presented by Kaplan- Meier survival curves. Results 19 patients underwent pancreatic resection at our institution for DA during the study period. 12 patients underwent Whipple’s with distal gastrectomy and 9 patients underwent PPPD. The overall postoperative morbidity and mortality was 37% and 5% respectively. R0 resection was achieved in 18 patients (95%). 9 patients (47%) had no nodal involvement. Median follow up was 31 months (range 1-108 months). Median DFS was 17 months but was significantly higher in patients with no nodal metastasis [p &lt; 0.001]. Median OS was 9.5 months for the whole cohort but was significantly higher in the patients with no nodal vs nodal metastasis (60 vs 17.5 months respectively) p &lt; 0.003]. Conclusions DA can be resected by PD or segmental resection. PD is favoured due to improved resection margins and overall increased patient survival, despite an increased morbidity. Our series reports comparable morbidity and mortality to the published literature for DA resected by PD. This study reports a 95% R0 resection rate for DA with a 3- and 5-year survival of 50% and 30% respectively. DFS was found to be significantly higher in patients with no nodal disease, despite predominant T4 disease. This series has identified that lymph node metastasis is one of the most important prognostic determinants of long-term patient survival. Program permission yes

P-P20 ‘Fast Recovery’ A multidisciplinary approach to improving recovery after pancreatic resection and ultimately increasing uptake of adjuvant chemotherapy

Background Pancreatic cancer surgery has a multi-system impact on a potentially vulnerable population. Current rates of adjuvant chemotherapy uptake are low. Our group developed a multidisciplinary bundle of care with the aim of improving recovery after surgery. The primary aim was to improve uptake of adjuvant chemotherapy and the secondary aim was to prevent nutritional decline. Methods This prospective, observational, cohort study evaluated the effect of the ‘Fast Recovery’ programme. This programme, developed with input from dieticians, physiotherapists, surgeons, and geriatricians and comprising pre- and post-operative frailty assessments, nutritional support and physiotherapy was implemented for all within our unit undergoing pancreatic resection for cancer. (See Fig. 1) Results Over 1 year, patients enrolled in the Fast Recovery programme (N = 44) were compared to those treated prior to the pathway change (N = 409). The Fast Recovery programme was not associated with a significant increase of adjuvant chemotherapy uptake (80.5 vs. 74.3%, p = 0.452), but did lead to a significantly lower average weight loss (4.3 vs. 6.9kg, p = 0.013). Patients that did not receive adjuvant chemotherapy performed significantly worse on a pre-operative six minute walk test (mean distance: 277 vs. 454 metres, p = 0.001). Conclusions Feasibility of a multimodal package to improve patient care following pancreatic resection has been shown by this pilot study. No significant improvement in the chemotherapy uptake was observed, however, this was potentially a result of the study being underpowered. Pre-operative physical assessments were found to be predictive of adjuvant chemotherapy uptake and could potentially be used to identify those in need of additional support. Further work is needed to evaluate the routine use of such a programme.

P-P30 Outcomes from resection of pancreatic metastases and non-neuroendocrine, non-pancreatic tumours

Background Isolated metastatic disease within the pancreas is an uncommon finding. The potentially higher perioperative risk and low incidence of resectable metastases has limited the development of evidence based guidelines for pancreatic metastectomy. However, reports in the literature suggest a considered approach to resecting patients with limited disease, favourable tumour type and a significant disease free interval. The aim of this study was to examine the indications and outcomes of pancreatic resection for metastatic disease and non-pancreatic, non-neuroendocrine malignancy at a high-volume pancreatic surgery centre. Methods This is a retrospective analysis of a prospectively managed database of pancreatic resections for metastatic disease or primary non-pancreatic, non-neuroendocrine tumours at a single institution. Data collected and analysed included patient demographics, operative details and peri-operative outcomes, subsequent survival and mode of recurrence. Results Records of 711 patients who underwent pancreatic resection were examined. 21 consecutive patients met the inclusion criteria, representing 3% of the unit’s throughput. The perioperative morbidity and mortality were 33% and 0% respectively. Overall survival was 86months (95%CI 63-107) for renal cell carcinoma and 64months for other tumours. Conclusions When coupled with the low morbidity and mortality rates of a high-volume pancreatic surgery centre using careful patient selection, pancreatic metastectomy has the potential to result in good long-term survival. Recent improvement in the efficacy of systemic therapies, particularly for renal cell carcinoma and melanoma contribute to the utility of resection and to the improved survival of patients.