P-P07 The incidence of Malignancy in Patients with Suspected Periampullary Tumours Who Underwent Blind Whipple Resections: A Single Institution Cross Sectional Review at King Hussein Medical Centre, Amman, Jordan

Background In this study, we evaluated the incidence of malignant and benign histopathological findings in patients undergoing blind pancreaticoduedenectomy (PD) for presumed periampullary cancer based on clinical, radiological and endoscopic findings. Methods Medical records of 29 patients who underwent pancreaticoduedenectomy at King Hussein Medical Centre were reviewed. Demographics, clinical presentation, preoperative imaging and postoperative histopathological results were analysed Results The percentage of malignancy was 82.8% and that of a benign lesion was 17.2%.All patients with benign results on final histopathology had chronic pancreatitis (100%), and all of them (100%) had abdominal pain on initial presentation. Out of all patients with periampullary malignancy, 21 (87.5%) had jaundice on initial presentation. The most important radiological correlate of malignancy is dilatation of the common bile duct greater than 6mm. Conclusions The finding of chronic pancreatitis in pancreaticoduedenectomy specimens of patients with suspected periampullary malignancy is justifiable, because none of the differences in clinical presentation or available diagnostic modalities can be reliably used to distinguish between benign versus malignant disease. Moreover, Pancreaticoduedenectomy in these patients offers the best chance for long term survival with acceptable mortality and morbidity.

‘It’s always in the back of my mind’: understanding the psychological impact of recovery following pancreaticoduodenectomy for cancer: a qualitative study

ObjectivesTen per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. There is limited previous research focusing on psychological well-being; unmet support needs impact negatively on quality of life. This paper reports the psychological impact of a pancreatic cancer diagnosis and subsequent pancreaticoduodenectomy, exploring how patients’ lives alter following surgery and how they seek support.DesignInductive qualitative study involving in-depth semistructured interviews with 20 participants who had undergone pancreaticoduodenectomy for pancreatic or distal biliary duct cancer. Interviews were audiorecorded, transcribed and anonymised, and thematic analysis used principles of constant comparison.SettingSingle National Health Service Trust in Northwest England.ParticipantsPatients were eligible for inclusion if they had had pancreaticoduodenectomy for head of pancreas cancer, periampullary cancer or distal cholangiocarcinoma between 6 months and 6 years previously, and had completed adjuvant chemotherapy.ResultsAnalysis identified the following main themes: diagnosis and decision making around surgery; recovery from surgery and chemotherapy; burden of monitoring and ongoing symptoms; adjusting to ‘a new normal’; understanding around prognosis; support-seeking. Participants seized the chance to have surgery, often without seeming to absorb the risks or their prognosis. They perceived that they were unable to control their life trajectory and, although they valued close monitoring, experienced anxiety around their appointments. Participants expressed uncertainty about whether they would be able to return to their former activities. There were tensions in their comments about support-seeking, but most felt that emotional support should be offered proactively.ConclusionsPatients should be made aware of potential psychological sequelae, and that treatment completion may trigger the need for more support. Clinical nurse specialists (CNSs) were identified as key members of the team in proactively offering support; further training for CNSs should be encouraged. Understanding patients’ experience of living with cancer and the impact of treatment is crucial in enabling the development of improved support interventions.

P-L06 Establishing minimum datasets and disease specific forms for cancer patients in multidisciplinary team meetings

Background Multidisciplinary team (MDT) meetings aim to ensure standardised access to cancer pathways and treatment. It is thus important that minimum datasets are established and provided to the MDT clinicians to facilitate thorough discussion and encourage shared decision making. To determine the effectiveness of pre-established minimum dataset proformas for periampullary tumours, hepatocellular carcinoma (HCC), colorectal cancer with liver metastases (CRLM) and hilar cholangiocarcinoma in cancer MDT meetings. Methods Cancer specific minimum dataset forms were developed by consultants to be implemented in MDTs for the four types of hepatobiliary pancreatic cancers: HCC, periampullary cancer, hilar cholangiocarcinoma and CRLM. 189 MDT reports and 184 referral letters were analysed from three weekly MDT meetings to determine the outcomes reported against those outlined in the proformas. The proformas were then implemented by consultants leading the weekly MDT meetings for three consecutive weeks. 128 MDT reports and 126 referral letters were re-audited from these MDT meetings to determine if there was a change in the outcomes reported. Results In this quality improvement project, 21.25% (11/52) of outcomes in MDT and 19.23% (10/52) of outcomes in the referral letters had a statistically significant difference in the reporting of outcomes from Cycle 1 to Cycle 2 across all four cancers. Greater changes in reporting were observed for outcomes that may carry higher prognostic value, such as tumour size and vascular invasion. Despite the notable difference in reporting seen for datasets consisting of smaller cohorts, the change was not statistically significant due to the insufficient statistical power proving the need for trialling such proformas in a wider population. Conclusions The minimum dataset proformas were associated with a limited gain in compliance with data reporting. Further work, with particular focus on user acceptability and attitudes is required to improve use of minimum dataset proformas in MDT.

The Relationship between Nutritional Status and Body Composition with Clinical Parameters, Tumor Stage, CA19-9, CEA Levels in Patients with Pancreatic and Periampullary Tumors

Recent studies have obtained inadequate data on the association between nutritional status, body composition, clinical parameters and tumor stage in patients withpancreatic and periampullary tumors. The purpose of this study was to assess the relationship between nutritional status (NS), body composition (BC) and selected clinical parameters in patients with pancreatic and periampullary cancer, as well as describe the differences between resection and non-resection groups. This is a prospective study of 76 patients with pancreatic and periampullary tumors. We evaluated NS, BMI, body mass loss (BML) and albumin, total protein, CRP, CEA, CA19-9, lipase, amylase, tumor stage, and BC using bioelectrical impedance (BIA). All subjects were divided into resection (n = 59) and non-resection (n = 17) groups. The non-resection group had a worse NS, as well as increased amylase and WBC, compared to the resection. The selected parameters of BC corresponded to BML albumin, TP, NS, age, BMI, Karnofsky, RBC, HCT and HGB. No associations were found between BC with tumor size, CRP, CA19-9, and CEA. We recorded the relationship between metastasis and NRS, as well as tumor size with SGA. The percentage of BML was positively correlated with age and CRP but negatively correlated with RBC, HGB, HCT and anthropometric measurements. We found many statistical correlations with NS and selected parameters, as well as differences between the resection and non-resection group. The detection of early prognostic factors of nutritional impairments would improve the quality of life and reduce the rate of postoperative complications.

Endoscopic Ultrasound versus Conventional Ultrasonography as A Diagnostic Tool for Patients with Obstructive Jaundice

Background Patient presented with jaundice, initial evaluation should be ultrasonography for evaluation of liver parenchymal changes, cirrhosis and assessment of hepatic vascularity and evaluation of intrahepatic, extrahepatic biliary system. Aim of the Work to compare between the Conventional US and Endoscopic Ultrasound in diagnosis of obstructive jaundice and other diagnostic modality including CT/MRI, ERCP for diagnosis and evaluation of the cause of OJ. Patients and Methods This study was conducted on 60 patients with obstructed jaundice as evident by ultrasonography in the form of dilated CBD with IHBRDs, with visualization of Gall bladder content and pancreas if can be well visualized, all patients had clinically apparent jaundice with disturbance of liver biochemical profile, all patient underwent EUS and compare finding with US including CBD diameter and IHBRDs degree. Results EUS provide better visualization of CBD and IHBRDs with diagnosis of pathological lesion including stones, malignancy. EUS also has better visualization of pancreatic pathology including inflammation and malignancy and extent of the tumor including local extent, lymphatic spread with vascular invasion. Conclusion EUS is better than US and other modality CT&MRI and ERCP in diagnosis of distal CBD stricture including malignant obstruction especially in cases of early malignancy and small tumors, and calculary distal obstruction. CT is insensitive in diagnosis of periampullary cancer, EUS provide early diagnosis of Pancreaticobiliary malignancy and give better advandage for early resectability .

Endoscopic Double Stenting for the Management of Combined Malignant Biliary and Duodenal Obstruction

Periampullary cancers are often diagnosed at advanced stages and can cause both biliary and duodenal obstruction. As these two obstructions reduce patients’ performance status and quality of life, appropriate management of the disease is important. Combined malignant biliary and duodenal obstruction is classified according to the location and timing of the duodenal obstruction, which also affect treatment options. Traditionally, surgical bypass (gastrojejunostomy and hepaticojejunostomy) has been performed for the treatment of unresectable periampullary cancer. However, it has recently been substituted by less invasive endoscopic procedures due to its high morbidity and mortality. Thus, endoscopic double stenting (transpapillary stenting and enteral stenting) has become the current standard of care. Limitations of transpapillary stenting include its technical difficulty and the risk of duodenal-biliary reflux. Recently, endoscopic ultrasound-guided procedures have emerged as a novel platform and have been increasingly utilized in the management of biliary and duodenal obstruction. As the prognosis of periampullary cancer has improved due to recent advances in chemotherapy, treatment strategies for biliary and duodenal obstruction are becoming more important. In this article, we review the treatment strategies for combined malignant biliary and duodenal obstruction based on the latest evidence.

More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis

Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection.