Application Analysis of Omental Flap Isolation and Modified Pancreaticojejunostomy in Pancreaticoduodenectomy (175 Cases)

Background: To explore the application value of free omentum wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).Methods: The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analyzed. All patients were divided into 86 cases in group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases in group B (control group). The incidence of pancreatic fistula and other related complications, inflammatory factors and survival rate were compared between the two groups.Results: The incidences of B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in group A were lower than those in group B, and the difference was statistically significant (P <0.05). The free omentum wrapping isolation and the modified pancreaticojejunostomy group drainage tube extubation time, open diet time and postoperative hospital stay were earlier than the control group (P <0.05). There were also statistically significant differences in CRP, IL-6, PCT inflammatory factors 1, 3, and 7 days after surgery as well as in postoperative survival rate.Univariate analysis showed that BMI, pancreatic duct diameter, greater omental flap isolation and modified pancreaticojejunostomy were related to the occurrence of pancreatic fistula after PD. Multivariate analysis showed that BMI≥24, pancreatic duct diameter less than 3mm, no greater omental flap isolation method and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P<0.05).Conclusions: Wrapping and isolating with free greater omentum plus modified pancreaticojejunostomy can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and is conducive to the prognosis.

556 A Prospective Review of Risk Factors, Clinical Presentation and Management Outcomes for Chronic Pancreatitis

Aim and objectives: To identify the risk factors, symptoms, and severity of Chronic pancreatitis (CP) on admission. To determine the relationship between pancreatic duct diameter and severity of pain and to assess extent of pain relief achieved by medical, endoscopic, and surgical intervention. Method 75 patients with CP were admitted over 2 years. Data collected included etiology, symptoms, pain scores and CT/MRCP findings. Patients were classified into mild, moderate, and severe category according to Cambridge classification. Type and response to treatment was recorded. Statistical correlation of the pancreatic duct diameter and pain severity as well as the comparison of pain scores after medical, surgical and endoscopy was performed using Chi square test (p value &lt;0.05) Results Median age of presentation of CP was 43 years. Male: female ratio was 3:1. Alcohol was the etiology in 66 %, 99% presented with pain, 65 % belonged to severe category. There was no statistical correlation between pain severity and duct diameter. Pain relief following medical management was 66 %, endoscopic - 73% and surgical - 83 %. There was no correlation between Cambridge classification and pain severity. There was no statistical difference between pain relief offered by either of the three modalities. However, there was a statistically significant correlation between duct diameter and type of intervention. Conclusions There is no consensus on the best treatment modality for CP as pain relief was equivalent amongst all the modalities. Therefore, the choice of intervention for patients suffering from chronic pancreatitis should be based on imaging characteristics and symptomology.

Carbohydrate Antigen 19-9 Is an Invasive Malignancy Preoperative Prognostic Factor for Intraductal Papillary Mucinous Neoplasms

<b><i>Introduction:</i></b> This study aimed to determine the preoperative clinicophysiological and postoperative clinicopathological predictors of malignancy in patients with intraductal papillary mucinous neoplasm (IPMN). <b><i>Methods:</i></b> This was a retrospective observational study. We included 121 patients (73 men and 48 women; mean age: 68.7 years) who had undergone pancreatic resection for IPMN between 2007 and 2018. These patients were grouped into invasive carcinoma (IPMN-INV, <i>N</i> = 21) and low/high-grade IPMN (IPMN-LG/HG, <i>N</i> = 100) groups. Univariate and multivariate analyses of clinicophysiological parameters were carried out. These parameters were also compared between the IPMN-INV/HG (<i>N</i> = 53) and IPMN-LG (<i>N</i> = 68) groups. Survival analyses according to macroscopic type and IPMN subtypes were performed. <b><i>Results:</i></b> On univariate analysis, age (<i>p</i> = 0.038), carbohydrate antigen (CA) 19-9 (<i>p</i> &#x3c; 0.001), IPMN macroscopic type (<i>p</i> = 0.001), IPMN subtype (<i>p</i> &#x3c; 0.001), pancreatic duct diameter (<i>p</i> &#x3c; 0.001), and mural nodule (<i>p</i> = 0.042), between IPMN-INV and IPMN-LG/HG were found to be significant prognostic factors of malignancy. CA 19-9 was found to be an independent prognostic factor of IPMN malignancy on multivariate analysis (<i>p</i> = 0.035). The 1-, 3-, and 5-year overall survival (OS) rates of the IPMN-INV and IPMN-LG/HG groups were 94.4/100%, 94.4/100%, and 67.2/100%, respectively. The OS rate in the IPMN-LG/HG group was significantly higher than that in the IPMN-INV group (<i>p</i> &#x3c; 0.001). On univariate analysis, platelet (<i>p</i> = 0.043), CA 19-9 (<i>p</i> = 0.039), prognostic nutritional index (<i>p</i> = 0.034), platelet/lymphocyte ratio (<i>p</i> = 0.01), IPMN macroscopic type (<i>p</i> &#x3c; 0.001), IPMN subtype (<i>p</i> &#x3c; 0.001), pancreatic duct diameter (<i>p</i> = 0.036), and mural nodule (<i>p</i> = 0.032) between IPMN-INV/HG and IPMN-LG were found to be significant prognostic factors of malignancy. On multivariate analysis, CA 19-9 was found to be an independent prognostic factor (<i>p</i> = 0.042) between IPMN-INV/HG and IPMN-LG of malignancy. The 1-, 3-, and 5-year OS rates of the IPMN-INV/HG and IPMN-LG groups were 97.9/100%, 97.9/100%, and 82.6/100%, respectively. The OS rate was significantly higher in the IPMN-LG group than in the IPMN-INV/HG group (<i>p</i> = 0.03). No significant differences in survival were observed in patients with macroscopic tumors (<i>p</i>= 0.544). <b><i>Conclusion:</i></b> CA 19-9 is an independent invasive malignancy predictor of IPMN.

Risk Score for Prediction of Severe Postoperative Complications After Pancreaticoduodenectomy

Introduction Morbidity after pancreaticoduodenectomy (PD) still remains high. Postoperative pancreatic fistula (POPF) is the most common cause of increased morbidity after PD. Assessment of predictability of risk score for severe postoperative complications was the objective of this study. MethodsThis was a retrospective observational study. Patients undergoing pancreaticoduodenectomy at Tribhuvan University Teaching Hospital (TUTH) between January 2017 to December 2017 were included in the study. Variables were recorded from case sheets of the patients. The “Risk Score” was calculated using the pancreatic duct diameter and body mass index (BMI). Association of risk score and severe postoperative complications were analyzed. ResultsA total number of patients were 43, including 23 (53.5%) males and 20 (46.5%) females. The mean age was 57.09 ± 11.85 years ranges from 29 years to 76 years. The POPF and delayed gastric emptying (DGE) was 23.3% (10/43); and post-pancreaticoduodenectomy hemorrhage (PPH) was 11.6% (5/43). Severe postoperative complications were present in 13.9% (6/43) patients. In univariate analysis, pancreatic duct diameter (p=0.045) and Risk Score (p=0.02) were significantly associated with severe postoperative complications after PD. However none of them were significant in multivariate analysis. ConclusionRisk score failed to predict severe postoperative complication after pancreaticoduodenectomy.

Pancreatic fistula risk assessment after distal pancreatectomy: a retrospective controlled study

Background. Despite declining mortality, postoperative pancreatic fistula (PPF) remains a common complication of distal pancreatic resection surgery challenging to clinical prediction.Objectives. Prognostic analysis of the postoperative pancreatic fistula risk factors in patients with previous distal pancreatectomy.Methods. A retrospective controlled assay enrolled 107 patients, including 63 (58.9%) male and 44 (41.1%) female patients. All patients underwent distal pancreatectomy followed by a morphological examination of resected material. All patients had a general and biochemical blood panel profiling. Pancreatic tissue density at a putative resection zone was assessed with computed tomography. The patients were allocated to two cohorts: (1) not developing PPF (77 patients) and (2) having postoperative PPF complications (30 patients.Results. No statistically significant differences by age, gender, ASA and BMI scores were observed in study cohorts. Multivariate analysis revealed a statistically significant correlation of the PPF rate with the following factors: main pancreatic duct diameter <3 mm (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.01–1.05, p = 0.01), pancreatic density at putative resection zone <30 HU in CT (OR 3.18, 95% CI 1.38–7.74, p < 0.01) and differential albumin of postoperative day 1 vs. pre-surgery >14 g/L (OR 3.13, 95% CI 1.19–8.24, p < 0.01).Conclusion. A main pancreatic duct diameter <3 mm, pancreatic density at putative resection zone <30 HU in CT and differential albumin of postoperative day 1 vs. pre-surgery >14 g/L are independent risk factors of postoperative fistulae.

EXPRESS: Magnetic Resonance Lymphangiography in Group 1 Paediatric Pulmonary Arterial Hypertension

Pulmonary hypertension could have thoracic lymphatic abnormalities caused by right ventricular failure. Since there is no description of such abnormalities, the purpose of this study was to investigate them with magnetic resonance. Prospective review magnetic resonance T2-weighted lymphangiography was performed between January 2017 and October 2019 through quantitative thoracic duct diameter, diameter index and qualitative lymphatic abnomalities types: 1- little or none abnormalities, 2-abnormalities in supraclavicular region, 3-abnormalities extending into the mediastinum, and 4-abnormalities extending into the lung. Five patients group 1 pulmonary arterial hypertension participated in this study. The mean: age was 12.44±4.92 years old, three male and two female, The quantitative analysis yielded the following results: mean thoracic duct diameter of 2.92±0.16 mm, and thoracic duct index 2.28±1.03 mm/m2. Qualitative lymphangiography abnormalities were type 1 in three patients, type 2 in one, all with low risk determinants and type 3 in one with hight risk determinants and rigth ventricular faillure. Magnetic resonance T2-weighted lymphangiography in group 1 paediatric pulmonary arterial hypertension allowed for the identification of the thoracic duct, wich was used to perform both quantitative and qualitative analysis of thoracic lymphatic abnormalities, in particular when increased high risk determinants and rigth ventricular faillure were present, These features represents an extracardiac findings useful to understand systemic venous congestion impact on lymphatic system.

Ultrasound in the diagnosis of parotid duct obstruction not caused by sialolithiasis: diagnostic value in reference to direct visualization with sialendoscopy

Objectives: The aim of this study was to evaluate the diagnostic value of ultrasound in the obstructive pathology of the parotic gland not caused by sialolithiasis using sialendoscopy as reference standard. Methods: Retrospective analysis of all patients who presented with suspected diagnosis of obstructive ductal pathology of the parotid gland other than sialolithiasis between January 2011 and December 2017. 538 patients, for a total of 691 parotid glands were included in the study. Ultrasound was performed, followed by sialendoscopy in all cases. Duct diameter and parenchyma echogenicity were assessed. Direct sialendoscopic examination of the parotid duct was regarded as the reference standard. Results: Parotid glands with normal sialendoscopic findings (21.6%, n = 149) had a duct diameter of 0.3 mm (0–2.7 mm) and homogeneous hyperechoic parenchyma on ultrasound in 98.7%. Ductal inflammation/sialodochitis (32.9%, n = 227) on sialendoscopy had significantly larger ductal diameter of 0.7 mm (0–4.3 mm, p = 0.001) and hypoechoic parenchyma in 78.0% (p < 0.001). Parotid glands with stenosis (45.6%, n = 315) had hypoechoic parenchyma in 52.6% and a ductal diameter of 4.1 mm (0–19.0 mm; p = 0.001). The ductal diameter was ≥2.7 mm in 95.6% of the stenosis (AUC 0.886, p = 0.001). Using 5.1 mm as benchmark ductal diameter, stenosis with ductal anomaly (68/315) were identifiable with a sensitivity of 92.6% and a specificity of 96.8% (AUC 0.986, p = 0.001). Conclusion: Ultrasound parameters can be used to distinguish different types of obstructive ductal pathology of the parotid gland, supporting the use of this imaging modality as diagnostic tool of first choice.

Pancreatic Configuration Index in Predicting Postoperative Pancreatic Fistula in a Tertiary Care Center in Nepal

Background: Post-operative pancreatic fistula is the single most common and most significant cause of post-operative morbidity and perioperative mortality. Identification of at risk patient preoperatively help to take policy of extra vigilance to act on time. This study evaluated the predictive role and cut-off value of pancreatic configuration index to predict post-operative pancreatic fistula.Methods: This was a prospective observational study in patients who had undergone pancreaticoduodenectomy from March 2017 to June 2018 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. The patients with age <16 years, those who underwent re-exploration or mortality before 3rd postoperative day, additional surgery besides pancreaticoduodenectomy were excluded from the study. Pancreatic configuration index was calculated as a ratio of pancreatic parenchymal thickness and pancreatic duct diameter. Predictive value of pancreatic configuration index in predicting post-operative pancreatic fistula was evaluated.Results: Among 58 patients, 9 were excluded from study and 49 patients were included in the study. The mean age of the patients was 56.6 ± 13.9 years (21 to 79 years) and male to female ratio was 1.1:1 (26 vs 23). Post-operative pancreatic fistula developed in 13/49 (26.5%) patients. On both univariate and multivariate analysis, pancreatic texture (p = 0.022), main pancreatic duct diameter at neck (p = 0.002) and pancreatic configuration index (p = 0.001) were significantly associated with development of post-operative pancreatic fistula. The sensitivity and specificity of pancreatic configuration index to predict post-operative pancreatic fistula are 92.3% and 91.7% with positive predictive value of 80% and negative predictive value of 97.1%.Conclusions: Pancreatic configuration index is a useful preoperative predictor of post-operative pancreatic fistula after pancreaticoduodenectomy.Keywords: Pancreaticoduodenectomy; pancreatic configuration index; postoperative pancreatic fistula.

Investigation of Biliary Canal Variations as a Cause of Stone Formation in the Choledochal Canal

The present study aimed to investigate if there is an association between the diameter of the choledochal duct and choledochal duct stone formation. The present study consisted of 79 patients who had endoscopic interventions and MRCP procedure with surgery history. Some followed due to disorders of the liver, gall bladder, and biliary tract and some of whom presented hepatobiliary complaints between 2017 and 2019. The choledochal duct diameter measured from MRCP images and choledochal duct stone had examined; the type classified according to Huang classification. Among the cases classified, 29 patients, was Huang Type A1, 27 patients were Huang Type A2, 16 patients were Huang Type A3, and seven patients were Huang Type A4. There was not any statistically significant association in terms of choledochal diameter regarding the types. Choledochal duct diameter was statistically higher in female patients than male patients (p<0.05). According to the age group, a statistically significant difference detected for choledochal duct stone formation; individuals over 45 years of age present an increase for choledochal duct stone (p<0.05). The choledochal duct diameter was found higher in female patients compared with male patients; stone formation has found increased in both gender over 45 years of age. It should consider before surgical procedures and radiological tests.

Diagnostic criteria for a “soft” pancreas and their influence on the occurrence of pancreatic fistula after pancreatoduodenal

Purpose. Identification of the possibilities of contrast enhancement computed tomography in evaluated the number of the acinar structures in the pancreatic parenchyma at the preoperative stage to predict the development pancreatic fistula.Material and methods. In 2016–2019, 196 pancreatoduodenectomy were performed. 86 patients were retrospectively selected. Patients were divided into 2 groups: group 1 included 16 observations with the development of clinically significant pancreatic fistula, in 2 – 70 cases without complications. According to preoperative contrast enhancement computed tomography, structure of the pancreas, pancreatic parenchyma thickness, pancreatic duct diameter, the density of the pancreas in the native phase, relative parenchyma enhancement ratio, washout coefficient, pancreas stump volume were evaluated. According histological, the number of acinar and fat cells in the section of the removed pancreas was evaluated.Results. “Soft” structure of the pancreas (r = 0.374, p = 0.000), pancreatic parenchyma thickness (r = 0.549, p = 0.000), the density of the pancreas in the native phase of the scan (r = 0.568, p = 0.000), the values relative parenchyma enhancement ratio (r = 0.63, p = 0.000), pancreas stump volume (r = 0.508, p = 0.000) positively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic duct diameter (r = −0.339, p = 0.001) negatively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic fistula risk is 3.09 times higher with the number of acini more than 72.5%, sensitivity 75%, specificity 75.71%. Pancreatic fistula risk is 1.8 times higher with the density of the pancreas in the native phase over 35.5 HU sensitivity 62%, specificity 65%. Pancreatic fistula risk is 2.76 times higher with values parenchyma accumulation coefficient more than 1, sensitivity 75%, specificity 73%.Conclusions. Contrast enhancement computed tomography allows evaluating acinar index in the preoperative period to pick out the high-risk patient group to development of pancreatic fistula.