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.

Initial Experience with Biodegradable Pancreatic Stents in the Prevention of Postoperative Pancreatic Fistula after Cephalic Pancreaticoduodenectomy

Background: Postoperative Pancreatic Fistula (POPF) remains the most important morbidity after pancreaticoduodenectomy. There is no consensual technique for pancreatic reconstruction and many surgeons use a transanastomotic drain. Currently, the stents used are not degradable and they can cause obstruction, stricture and pancreatitis. The use of biodegradable stents that disappear a few months after the intervention could have a role in the prevention of pancreaticojejunostomy complications. The aim of the study was to evaluate technical success of implantation and safety of newly available biodegradable stents in 16 patients undergoing cephalic duodenopancreatectomy. Materials and Methods: A single-center prospective non-randomized study was conducted with patients undergoing PD. A total of 16 patients were included. A duct-to-mucosa end-to-side anastomosis was performed for the pancreaticojejunal anastomosis and the biodegradable stent (Archimedes) was placed from the pancreatic duct to the jejunum. Results: One of the patients developed POPF, which was successfully treated with interventional radiology drainage and somatostatin analogues. Completed degradation occurred after 3 months in all cases. There was no mortality at 30 days after PD. Conclusion: Based on our experience, the use of resorbable internal pancreatic prostheses could be a valid alternative to prevent POPF after a pancreaticoduodenectomy, also avoiding the main complications related to the use of non-absorbable prostheses.

Risk Factors of Pancreatic leakage AfterWhipple’s Procedure

Background Pancreaticoduedenectomy is the operative of choice in cases of resectable tumors of the periampullary region. Critical step in pancreatic surgery is no longer the resection itself but the reconstruction of the pancreaticoenteric anastomosis. Different methods of pancreatic reconstruction have been proposed aiming to limit the rate of leakage of pancreatic anastomosis. Aim of the Work to evaluate the risk factors of pancreatic remnant leakage after Whipple’s procedure as regards risk factors of the diameter of the pancereatic duct and the texture of the pancereatic remnant during operation (soft or firm). Patients and Methods A prospective study conducted on 30 patients who underwent pancreaticoduodenectomy in Ain Shams University Hospitals during the period from June 2012 to June 2018 to evaluate the risk factors of pancreatic leakage after Whipple’s procedure regarding pancreatic duct diameter and pancreatic remnant texture. Results 60% of leakage group had soft pancreas and narrow pancreatic duct less than 3mm, while 40% of non leakage group had soft pancreas and narrow pancreatic duct less than 3mm. Conclusion strong correlation between postoperative pancreatic leakage and narrow pancreatic duct as well as soft pancreas. Statistics proved that correlation and also, the relation of high mortality rate among those who developed postoperative pancreatic fistula.

Delayed gastric emptying after pancreatoduodenectomy: comparison between invaginated pancreatogastrostomy and pancreatojejunostomy

Background: The association between delayed gastric emptying (DGE) after pancreatoduodenectomy (PD) and pancreatic reconstruction technique remain unclear. The aim of this study is to investigate whether the occurrence of DGE differs between pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) . Methods: A total of 83 patients who underwent subtotal stomach-preserving pancreatoduodenectomy was retrospectively analyzed, and the factors associated with clinically relevant DGE were explored. These patients were divided into a PG group and a PJ group according to the pancreatic reconstruction. DGE occurrence and its association with intra-abdominal complications was compared between the two types of pancreatic reconstruction. Results: The overall incidence of DGE was 27.7%. Intra-abdominal complications including pancreatic fistula were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. In addition, DGE with intra-abdominal complications tended to be more frequent in PG, despite the fact that intra-abdominal complications occurred at a similar frequency in both groups. Conclusions: Intra-abdominal complications were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. We speculate that intra-abdominal complications affected patients with PG more and resulted in frequent occurrence of DGE.

Delayed gastric emptying after pancreatoduodenectomy: comparison between invaginated pancreatogastrostomy and pancreatojejunostomy

Background: The association between delayed gastric emptying (DGE) after pancreatoduodenectomy (PD) and pancreatic reconstruction technique remain unclear. The aim of this study is to investigate whether the occurrence of DGE differs between pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) . Methods: A total of 83 patients who underwent subtotal stomach-preserving pancreatoduodenectomy was retrospectively analyzed, and the factors associated with clinically relevant DGE were explored. These patients were divided into a PG group and a PJ group according to the pancreatic reconstruction. DGE occurrence and its association with intra-abdominal complications was compared between the two types of pancreatic reconstruction. Results: The overall incidence of DGE was 27.7%. Intra-abdominal complications including pancreatic fistula were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. In addition, DGE with intra-abdominal complications tended to be more frequent in PG, despite the fact that intra-abdominal complications occurred at a similar frequency in both groups. Conclusions: Intra-abdominal complications were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. We speculate that intra-abdominal complications affected patients with PG more and resulted in frequent occurrence of DGE.

Delayed gastric emptying after pancreatoduodenectomy: comparison between two different pancreatic reconstruction techniques

Background The association between delayed gastric emptying (DGE) after pancreatoduodenectomy (PD) and pancreatic reconstruction technique remain unclear. The aim of this study is to investigate whether the occurrence of DGE differs between pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG). Methods A total of 83 patients who underwent subtotal stomach-preserving pancreatoduodenectomy was retrospectively analyzed, and the factors associated with clinically relevant DGE were explored. These patients were divided into a PG group and a PJ group according to the pancreatic reconstruction. DGE occurrence and its association with intra-abdominal complications was compared between the two types of pancreatic reconstruction. Results The overall incidence of DGE was 27.7%. Intra-abdominal complications including pancreatic fistula were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. In addition, DGE with intra-abdominal complications tended to be more frequent in PG, despite the fact that intra-abdominal complications occurred at a similar frequency in both groups. Conclusions Intra-abdominal complications were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. We speculate that intra-abdominal complications affected patients with PG more and resulted in frequent occurrence of DGE.

Modified Heidelberg technique of pancreatic anastomosis postpancreaticoduodenectomy – 10 years of experience

Context: Pancreatic fistula has forever been a dreaded complication after pancreatic anastomosis (PA). We present a retrospective analysis of 10 years of experience with the Modified Heidelberg technique (MHT) that has been recently described. Aim: The aim of the study is to establish postoperative pancreatic fistula (POPF) rates after MHT. Settings and Design: This is a retrospective observational study carried out at a tertiary cancer center in South India in the Department of Surgical Oncology. Subjects and Methods: Two hundred and eight consecutive patients who underwent pancreaticoduodenectomy (PD) and PA with MHT for a variety of proximal pancreatic lesions from January 2008 to February 2018 were included in this study. The incidence of POPF was recorded by the International Study Group on Pancreatic Fistula 2005 and 2016 definitions. Statistical Analysis Used: Epidemiological and clinical data are expressed in ratios and percentage and presented in table format. Results: Between January 2008 and March 2016, 186 patients underwent PD, and MHT was used for PA. Five (2.7%) patients developed Grade A POPF whereas Grades B and C were seen in three (1.6%) patients each with one death. Between April 2016 and February 2018, 22 patients underwent PD. Two patients (9%) had biochemical leak whereas none of them developed clinically relevant POPF. No deaths were recorded in this period. Overall, Grade B and Grade C POPF rates were 1.4% each, whereas 30-day mortality was 0.4%. Conclusions: Results of this study indicate that MHT is a safe, reliable, easy to learn, and adopt technique of pancreatic reconstruction after PD.