Management of post-operative pancreatic fistulas following Longmire–Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy

Background Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. Methods We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. Results PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. Conclusions EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.

Insights of Outcome after Resection of Small Nonfunctioning Neuroendocrine Pancreatic Tumors

Background. The incidence of small nonfunctioning neuroendocrine pancreatic tumors (NF-PNETs) has been increasing systematically in the last few decades. Surgical resection was once considered the treatment of choice but has been questioned in the direction of a more conservative approach for selected patients. Our aim was to analyze the outcome of surgical resection of small (≤3cm) NF-PNETs. Methods. We retrospectively evaluated 14 patients with sporadic NF-PNETs who underwent pancreatic resection. Data were collected from patients’ medical records. Results. Of the 14 patients included, 35.71% were men, and the average age was 52.36 ± 20.36 years. Comorbidities were present in 92.86% of the cases. The incidence of postoperative complications was 42.86%, the 30-day mortality was zero, and the length of follow-up was 3.31 ± 3.0 years. The results of pathological evaluations revealed WHO grade I in 42.86% of cases, II in 21.43%, and neuroendocrine carcinoma in 35.71%. The median tumor size was 1.85cm (range, 0.5–3cm), and 2 cases had synchronous metastasis. The median TNM stage was IIa (range, I–IV). The disease-free and patient survival rates were 87.5% and 100% at 3 years and 43.75% and 75% at 10 years, respectively. The tumor pathological grade was significantly higher in head tumors than body-tail tumors, but there were no differences with respect to tumor size and TNM staging. Conclusion. A surgical approach to treat small sporadic NF-PNETs is safe with low mortality and high patient survival. Based on these data, small pancreatic head tumors can be more aggressive, suggesting that surgical resection is still the best option to treat small nonfunctioning PNETS. Thus, conservative treatment should be indicated very cautiously for only cases with absolute contraindications for surgery.

Meningioma-related subacute subdural hematoma: A case report

Background: Meningiomas are the most frequent benign head tumors, although spontaneous hemorrhage is a rare form of presentation of such lesions. Of all possible bleeding locations associated with them, the subdural space is one of the most uncommon, with very few cases reported worldwide. Case Description: A middle-aged woman presented with progressively worsening left-sided headache, initiated 2 weeks before, with no other complaints, denying any previous head trauma. Head computed tomography revealed a subacute left hemisphere subdural hematoma and left frontal, suggestive of meningioma on magnetic resonance imaging. Surgical treatment was performed with hematoma evacuation and lesion removal. Neuropathology showed a transitional meningioma with signs of hemorrhage. After surgery, no neurological deficits were registered, and headache abated. Conclusion: As we could not identify any other cause for the subacute subdural hematoma, hemorrhage from the meningioma was the most probable cause, and thus, we decided to remove it along with clot evacuation. Based on neuropathological findings, we propose an alternative mechanism for this spontaneous hemorrhage from the meningioma, involving the place where the periphery of the lesion insertion, the dura mater as the origin of the hemorrhage. Knowledge of this association could help define the best treatment in such cases.

Survival outcomes of pancreatic intraepithelial neoplasm (PanIN) versus intraductal papillary mucinous neoplasm (IPMN) associated pancreatic adenocarcinoma.

766 Background: Pancreatic intraepithelial neoplasms (PanINs) and intraductal papillary mucinous neoplasms (IPMNs) are common pancreatic adenocarcinoma precursor lesions. However, data regarding their respective associations with prognosis is lacking. Methods: We retrospectively evaluated 72 resected pancreatic adenocarcinoma cases at the KU Cancer Center between Aug 2009 and March 2019. Patients were divided into either one of two groups, PanIN or IPMN, based on the results of the surgical path report. We compared baseline characteristics, overall and progression free survival between the two groups, as well as OS and PFS based on local or distant tumor recurrence. Results: 52 patients had PanIN and 20 patients had IPMN. Demographic and baseline characteristics are as follows (PanIN/IPMN): Median age 62.5/69; Gender (male) 63%/65%; ECOG status (0-1) 98%/85%; pancreatic head tumors 87%/70%; pancreatic body tumors 6%/15%; pancreatic tail tumors 7%/15%; Abnormal CA19-9 at diagnosis 79%/67%; Comorbidity Index 5/5 respectively. Median PFS was 26.2 months (95% CI: 21.4-31.0) for PanIN and 74.3 months (95% CI: 15.7-132.9) for IPMN [p = 0.004]. Median OS was 70.3 months (95% CI: 35.4-105.2) for PanIN and 78.8 months (95% CI: 33.2-124.4) for IPMN [p = 0.013]. Within the PanIN group, median OS after recurrence was 71.3 months (95% CI: 68.8.-73.4) for local recurrence and 46.7 months (95% CI: 39.2-54.2) for distant recurrence [p = 0.330]. Conclusions: Patients who had a IPMN associated pancreatic cancer had better PFS and OS when compared to patients with PanIN associated pancreatic cancer. In patients with PanIN associated cancer that recurred, OS was better with local recurrence compared to distant recurrence but did not meet statistical significance. The results need to be validated in a larger cohort. [Table: see text]

Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent

The incidence of pancreatic cancer has increased and outcomes have been improving with a multidisciplinary treatment approach. Pancreatoduodenectomy is the surgical approach for pancreatic head tumors; however, postoperative cholestasis or cholangitis may require endoscopic or percutaneous intervention. Placement of a percutaneous transhepatic cholangiographic (PTC) drain is a safe approach; however, this requires routine maintenance. This case demonstrates placement of a palliative biliary stent by a rendezvous approach using an in situ PTC drain.

P03.14 New features of modern 3D conformal external radiotherapy (RT) of benign head tumors in children

BACKGROUND demonstrate the possibilities of radiation therapy (LT) in children with benign head tumors using IMRT, VMAT, IGRT techniques - high-precision modern 3D conformal radiation therapy MATERIAL AND METHODS From 1990 to 2007 for the first time in Russia, 88 children with juvenile angiofibromas were treated in Russian Scientific Center of Roentgenoradiology. The studies were carried out on the gamma-therapeutic apparatus “AGAT-P1” and on the linear accelerator “Phillips SL75” Total dose was 35–45 Gy. In 2014–2018 we treated 29 patients aged 3–17 years with benign tumors of the skull base and brain (angiofibromas, craniopharyngiomas, hemangiomas) using high-precision techniques (IMRT, VMAT, IGRT). 15 of 29 patients were repeatedly operated in various domestic and foreign clinics and were admitted to RT with the threat of bleeding, with recurrent growth of tumors, including after multiple selective angioembolization. RESULTS Up to 80% of patients had a 5-year stable remission, and the optimal total dose for radiation therapy of benign head tumors in children was scientifically substantiated. It was found that there is a high risk of continued growth after RT in children under 8 years of age, complications in 10% of patients in the coming years after RT and in 100% of those reirradiated. In all 29 cases of RT in children, we observed a positive clinical effect - stopping bleeding from the nasopharynx after 1–3 sessions of 3D conformal RT (Dose per fraction 1.8 Gy, total dose 45–54 Gy), positive clinical symptoms under the supervision of an Head and Neck surgeon. The effect of hardening and stopping the growth of tumors according to MRI data were followed up after 3 months, 6 months, 1 year. CONCLUSION The development of navigational, endosurgical and fibro-endoscopic minimally invasive technologies in the last 30 years has allowed to expand the indications for surgical methods of treatment for benign head tumors in children, which has reduced their flow to RT. However, after modern surgical interventions, 6–10% of these patients experience recurrences and bleeding, the number of which can be reduced with timely RT. New technologies in LT provide minimal impact on surrounding healthy tissues and allow wider use of RT in recurrent and difficult-to-reach benign skull base tumors in children