P-P54 Interpreting trends in post-operative drain fluid amylase according to type of anastomosis used to form a pancreaticojejunostomy

Background The formation of the pancreaticojejunostomy during pancreaticoduodenectomy is the most technically challenging aspect of the procedure, with its failure increasing rates of both morbidity and mortality significantly. Early identification and management of a clinically relevant post-operative pancreatic fistula (CR-POPF) can be critical in reducing the threat of potentially avoidable harm to the patient. The most used indicator for a CR-POPF is the level of drain fluid amylase. There are many different techniques for forming the anastomosis, with considerable analysis but no consensus on superiority. We aimed to look at our centres experience using different techniques and the trends we observed in drain amylases and clinical outcomes. Methods A prospective database of all patients in a single UK centre undergoing pancreatic or duodenal resection has been maintained. This includes patient demographics, diagnosis pre and post operatively, operative details and duration, complications, and outcomes. All patients undergoing a pancreaticoduodenectomy between 1st January 2020 and 31st July 2021 were identified and their data retrospectively analysed. Results Thirty-three patients underwent a pancreaticoduodenectomy during the study period. The pancreatojejunostomy was formed using a duct-to-mucosa anastomosis in twenty-eight patients and using a dunking technique in five patients. The mean of the highest drain fluid amylase on post-operative day one for the patients with a dunking anastomosis was 14804.8 (range 3643-43686), on day three 2376.12 (range 167-8008.6) and of the three patients whose drains were in situ at day 5 it was 522.2 (range 31 to 983. An 83.9% reduction in mean drain amylases was observed between Day One and Day Three, followed by a further 78% reduction between day 3 and day. One patient (20%) had a CR-POPF with a grade B fistula, two others had a biochemical leak. The mean Day One drain amylases for patients with a duct-to-mucosa anastomosis was 71% lower at 4274.5 (range 15.4 to 41755). However this increased by 11.5% by Day Three to 4766.4 (range 5 to 46300) before falling by 64.7% to 1681.9 (range 5 to 13015) on Day Five. Eight patients (28.6%) had a CR-POPF – 3 grade B and 5 grade C fistula - and three patients had a biochemical leak. Conclusions In our centre’s experience, the type of anastomosis used to perform the pancreatic reconstruction post pancreaticoduodenostomy significantly impacts the post-operative trend in drain fluid amylase. This is important for clinicians to appreciate in order to avoid premature suspicion of a CR-POPF and prevent potentially unnecessary intervention.

714 UTILITY, TECHNIQUES, AND OUTCOMES FOR THORACIC DRAINAGE AFTER OESOPHAGECTOMY: A SYSTEMATIC REVIEW

The routine use of post-operative drains in surgery continues to evolve as part of modern practices. Modern enhanced recovery protocols eschew using abdominal drains due to their impact on patient comfort, mobility, and recovery. This change in practice has not applied to thoracic drainage after oesophagectomy, where one or multiple drains are routinely placed. The aim of this study was to determine the evidence for, and how best to use drains during oesophageal surgery. Methods A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases until Jan 25th, 2021. All studies which compared outcomes for different types or uses of thoracic drainage, or reported outcomes directly related to chest drains in oesophageal surgery were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed by the Newcastle-Ottawa and Jadad Scores. Results 28 studies met the inclusion criteria. Four studies compared drain numbers, three showed similar outcomes and pain reduction using one. A single study showed that another, ‘anastomotic drain’ aided diagnosis and reduced leak mortality. Transhiatal drains had less pain and similar outcomes compared to intercostal drains. Drain fluid amylase aids leak diagnosis, however, accuracy requires drains to remain for 6 days. Removal of drains with daily volumes of less than 300 mL did not impact effusion rate. Complications can arise from drains with a 7% chance of drains migrating into the lumen of a leak and a risk of drain-site metastasis. Conclusion Drain use is a small facet of oesophageal surgery that can have a significant impact on outcomes. There is no evidence for non-drain use. A single transhiatal drain reduces pain without impacting on outcomes. Drains can have a role in diagnosing and managing anastomotic leaks, however, to be accurate drains have to stay in situ for longer. This extends patients discomfort and moves away from ERP trends and other surgical specialities.

1500 Chyle Leakage Following Laparoscopic Cholecystectomy: A Problematic Post-Operative Complication

Introduction Symptomatic choleliathiasis is a common surgical issue affecting 10% of the British population, of which laparoscopic cholecystectomy is the gold standard treatment. Asymptomatic chyle leakage post-laparoscopic cholecystectomy is an extremely rare complication. Case Report A 56-year-old man presents with right upper quadrant pain after recurrent episodes of acute cholecystitis. An MRCP showed small stones in the gallbladder and a stone in the distal common bile duct. The management was an urgent in-patient laparoscopic cholecystectomy. At operation, he was found to have significant gallbladder inflammation and a drain was left in-situ. On post-operative day 1, there was a triglyceride rich milky white drain fluid output, which was confirmed as chyle. Method The patient was asymptomatic and systematically well, so a conservative approach was taken. A strict low-fat diet resulted in resolution of the chyle leak, and the drain was removed on post-operative day 4. Follow-up at 8 weeks confirmed full recovery. Conclusions There are four recorded cases of such a phenomenon and is suggested it is caused by iatrogenic injury to the gallbladder fossa which may contain lymphatic vessels. The gold standard investigation is lymphoscintography, although drain fluid analysis and computed tomography imaging are more attainable investigations. Conservative management includes a fat-free diet, total parenteral nutrition and ocreotide whereas surgical management includes identifying the site of leakage and suturing it or applying fibrin glue. Lessons from this unexpected complication include treating the patient, cautiously monitoring the drain and considering surgical intervention if conservative management fails.

Lymphoedema and oedema of advanced disease

Lymphoedema is chronic swelling developing as a result of failure of the lymphatic system to drain fluid and other substances, such as proteins, from the tissues. This chapter focuses on oedema associated with advanced cancer and other diseases, encountered towards the end of life. It is often of multifactorial origin. Management involves an assessment of contributory factors, consideration of which may be reversible, and treatment, which takes into account the patient’s priorities and the balance of benefit versus burden. Modifications of the combined physical treatments used for chronic lymphoedema are often required in this setting.

Alternative Fistula Risk Score and First Postoperative Day Drain Fluid Amylase as Predictors of Pancreatic Fistula After Pancreatoduodenectomy

Objectives: The alternative fistula risk score (aFRS) and the first postoperative day drain fluid amylase (DFA) are predictors of the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To our knowledge, this association had not yet been studied.Methods: This study assessed the predictive effect of aFRS and/or DFA on CR-POPF in a retrospective cohort of 58 patients following PD. The Shapiro-Wilk and the Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics (ROC) curve and the confusion matrix were used to analyze the predictive models.Results: The aFRS values were not statistically different between patients in the CR-POPF and non-CR-POPF groups (Mann-Whitney U test: 59.5, p=0.12). The DFA values were statistically different between the CR-POPF and non-CR-POPF groups (Mann-Whitney U test: 27, p=0.004). The aFRS and DFA were independently less predictive for CR-POPF, compared to combined aFRS + DFA.Conclusions: The combined model involving aFRS>20% + DFA≥5,000 U/L was the most effective predictor of CR-POPF occurrence following PD.