Results of complex treatment of patients with operable pancreatic head cancer using preoperative intra-arterial chemotherapy in combination with radiation therapy in multifractionation mode

The aim of this study was to assess the safety and efficacy of treating patients with operable pancreatic cancer after preoperative intra-arterial infusion of chemotherapy combined with conformal radiation therapy in a multi-fractionation mode. Patients (n = 40) were randomized into two groups: the main one – intra-arterial infusion of chemotherapy + radiation therapy + surgery (n = 20), and control – intra-arterial infusion of chemotherapy + surgery (n = 20). Neoadjuvant therapy consisted of intra-arterial infusion of chemotherapy (chemoembolization of a pancreatic head tumor with oxaliplatin 85 mg/m2) followed by intra-arterial chemo infusion with gemcitabine 1000 mg/m2. In the main group, radiation therapy was also carried out in two fractions per day, 2 Gy with an interval of 4–6 hours, 5 days a week, up to a total dose of 50 Gy. In the main group, the lower incidence of postoperative pancreatitis and the pancreatic fistulas were statistically confirmed, the incidence of grade 2 therapeutic pathomorphisis increased, as well as the median life expectancy.

P-P45 Prognostic Value of CRP in Post-PPPD and Whipple’s Re-Intervention

Background Several studies have aimed to use different biochemical and haematological markers to predict relevant post-operatively pancreatic fistulas after hepatobiliary operations, however none has been defined as the gold-standard. This study aimed to evaluate the sensitivity and specificity of day 3 C-reactive protein (CRP) and drain amylase values in predicting re-intervention in patients who have undergone pancreatico-duodenectomy (PPPD) or Whipple’s procedure. Methods Retrospective collection of data from a prospective database of patients who underwent PPPD or Whipple’s procedure between January 2017 and February 2021. Serum CRP was collected from day one to day five post-operatively, and day three or the closest available result of post-surgery drain amylase values were considered. Cutoff values were determined as follows: day three CRP optimal level was determined by the median (175 mg/L), and drain amylase was determined by three times the upper limit of normal serum amylase level (330 U/L). Post-operative pancreatic fistulas (POPF) were classified as per the 2016 International Study Group for Pancreatic Surgery (ISGPS). Re-intervention was defined as any deviation from the normal post-surgical care – including interventional radiology procedures, embolisation, re-look laparotomies and re-admission to Intensive Care. Results A total of 217 patients were included in this study – 182 underwent pylorus preserving pancreaticoduodenectomy as opposed to those who had Whipple procedure. 55 (25%) patients required re-intervention post-operatively. A day three CRP above 175 showed a sensitivity of 78% and specificity of 66% in predicting re-intervention in these patients. The combination of this and elevated drain amylase proved to be more sensitive (85%) and specific (87%) than the CRP alone. Conclusions Day 3 CRP and drain amylase are accurate predictors of post-PPPD and Whipple’s re-interventions. We aim to include this as part of the local Enhanced Recovery Pathway to help identify patients that will potentially develop complications requiring further surgical management.

Method of forming a pancreatogastric anastomosis after pancreatoduodenal resection

Aim. To evaluate the reproducibility and safety of the developed pancreatogastric anastomosis with various surgical approaches during pancreatoduodenectomy.Materials and methods. The experience of surgical treatment of 47 patients with malignant tumours of the periampullary zone, who underwent pancreatoduodenectomy, was considered. The proposed variant of anastomose was performed to 14 (29.8%) patients: in 7 cases with a minimally invasive approach to perform pancreatoduodenectomy; and in 7 cases with an open approach. To compare retrospectively 33 (70.2%) patients who underwent pancreatogastric anastomosis according to the Bassi technique: 9 – with minimally invasive surgery, 24 – with open surgery. The frequency of pancreatic fistulas, the number of repeated interferences, and hospital mortality were taken into account.Results. A significant advantage of the new method of forming an anastomosis in the duration of the operation was noted in comparison with the Bassi technique. There were no statistically significant differences in blood loss while various types of anastomoses (p > 0.05). When using the proposed technique, the formation of pancreatic fistulas was not revealed. The development of pancreatic fistula was observed in 4 (16.7%) patients after open surgery and in 7 (77.8%) patients after minimally invasive Bassi anastomose formation. Reoperations were performed after open surgery in 3 (12.5%) cases and in 4 (44.4%) cases of minimally invasive surgery according to the Bassi technique. There were 2 (22.2%) deaths in the minimally invasive group.Conclusion. The proposed pancreatogastric anastomosis is applicable in clinical practice. This method allows to create relatively fast and less challenging anastomosis, including with a minimally invasive approach. The use of this technique makes it possible to reduce mortality and postoperative complications in patients with a “complex” pancreas.

Abstract 17237: A Pair Of Diaphragm-Crossed Organs: A Pancreatico-Pericardial Fistula

Introduction: Pseudocysts are a known complication of chronic pancreatitis, occurring in 30-40% of patients. They form when disruption of the pancreatic duct system creates fluid-filled pockets with high concentrations of digestive enzymes. Leakage of these enzymes can create pancreatic fistulas. Here, we present a case of an unusual fistula that occurred in an immunocompromised individual. Case Description: A 34-year-old man with a history of Acquired Immunodeficiency Syndrome, alcohol use disorder, and chronic pancreatitis who had recently recovered from acute pancreatitis complicated by pericardial effusion was readmitted with worsening pleuritic chest pain and shortness of breath. He was hemodynamically stable with a normal cardiopulmonary exam without jugular venous distention or pulsus paradoxus. Labs were at his baseline other than an elevated d-dimer level. Computed tomography scan revealed a large, loculated pericardial effusion with a fistula extending through the diaphragm to a large peripancreatic pseudocyst. Gastroenterology performed pancreatic ductal stenting via endoscopic retrograde cholangiopancreatography and Interventional Radiology placed a percutaneous drainage catheter to facilitate resolution of the pseudocyst. Discussion: A pancreatico-pericardial fistula is a very rare complication of chronic pancreatitis. A 2016 review detailed only fifteen cases over a 40-year span with surgical management providing the best outcomes. Given this patient’s immunocompromise and malnutrition surgery was not offered, but endoscopic stenting and percutaneous drainage allowed for successful resolution of his fistula.

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.

Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology

Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

Optimal management of peripancreatic fluid collection with postoperative pancreatic fistula after distal pancreatectomy: Significance of computed tomography values for predicting fluid infection

Peripancreatic fluid collections have been observed in most patients with postoperative pancreatic fistula after distal pancreatectomy; however, optimal management remains unclear. This study aimed to evaluate the management and outcomes of patients with postoperative pancreatic fistula and verify the significance of computed tomography values for predicting peripancreatic fluid infections after distal pancreatectomy. We retrospectively investigated 259 consecutive patients who underwent distal pancreatectomy. Grade B postoperative pancreatic fistula patients were divided into two subgroups (B-antibiotics group and B-intervention group) and outcomes were compared. Predictive factor analysis of peripancreatic fluid infection was performed. Clinically relevant postoperative pancreatic fistulas developed in 88 (34.0%) patients. The duration of hospitalization was significantly longer in the B-intervention (n = 54) group than in the B-antibiotics group (n = 31; 41 vs. 17 days, p < 0.001). Computed tomography values of the infected peripancreatic fluid collections were significantly higher than those of the non-infected peripancreatic fluid collections (26.3 vs. 16.1 Hounsfield units, respectively; p < 0.001). The outcomes of the patients with grade B postoperative pancreatic fistulas who received therapeutic antibiotics only were considerably better than those who underwent interventions. Computed tomography values may be useful in predicting peripancreatic fluid collection infection after distal pancreatectomy.

Postoperative pancreatic fistulas after pancreaticoduodenectomy using pair-watch suturing and duct-to-mucosa pancreaticojejunostomy anastomosis techniques

Background: Morbidity and mortality after pancreaticoduodenectomy (PD) have been associated with postoperative pancreatic fistula (POPF). Pancreatic anastomosis is challenging for most surgeons, and there is no universal or standardized technique. This study compared the incidence of POPF between the pair-watch suturing technique (PWST) and duct-to-mucosa pancreaticojejunostomy (PJ) anastomosis technique. Methods: This retrospective cohort analysis included 71 patients who underwent a PD between January 2009 and October 2018. The incidence and risk factors of complications after PWST and duct-to-mucosa PJ anastomoses were compared. Results: There was no significant difference in the incidence of POPF between the PWST (n = 7; 30.4%) and duct-to-mucosa PJ (n = 9; 18.7%) groups. The tumor site (p = 0.001) and pancreas density on computed tomography without contrast (p = 0.002) were significantly different between the groups. Age ≥ 60 years (odds ratio (OR): 11.07; 95% confidence interval (CI): 1.14–107.36; p = 0.038) and pancreatic body mass/duct size (B/W) ratio (OR: 1.41; 95% CI: 1.04–1.91; p = 0.029) were identified as significant risk factors for POPF. International Study Group for Pancreatic Fistula grade B POPF, wound infections, and pneumonia occurred more frequently in patients who underwent a duct-to-mucosa PJ anastomosis. However, the postoperative complications were not significantly different between the groups. Conclusions: The incidence of clinically relevant POPF was similar between patients who underwent the PWST and those who underwent a duct-to-mucosa PJ anastomosis. However, a preoperative risk factor assessment for the evaluation of tumor site, patient age, and B/W ratio could help determine which surgical technique should be used in individual patients.

138 Endovascular Hepatic Artery Stents in The Modern Management of Post-Pancreatectomy Haemorrhage

Aim Post-operative haemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on endovascular hepatic artery stents in the management of post-pancreatectomy haemorrhage. Method This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcome, contextualized by the clinical course of the denominator population. International Study Group for Pancreas Surgery (ISGPS) terminology was used for post-pancreatectomy haemorrhage. Results Sixty-seven (15%) had post-operative haemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; two-proportions test). Post-operative pancreatic fistulas were more frequent in the post-operative haemorrhage group (P = 0.029; two-proportions test). The median (IQR) delay between surgery and haemorrhage was 5 (2-14) days. Twenty-six required intervention comprising re-operation alone in 12, embolization alone in 5 and endovascular hepatic artery stent deployment in 5. Four further patients underwent multiple interventions with two having stents. Endovascular stent placement achieved initial haemostasis in 5 (72%). Follow-up was for a median (IQR) of 199 (145-400) days post-stent placement. In two patients the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 (8-22) days. Conclusions This study shows that in the specific setting of post-pancreatoduodenectomy haemorrhage with either a short remnant GDA bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important haemostatic option but is associated with a high risk of subsequent graft occlusion.