ELECTRONIC POSTERS (EP02A-EP02F) – PANCREAS

EP02A e Electronic Poster: 2A e Pancreatitis Surgical intervention is very important yet the result is devastating. EP02A-003 Method: We reported a case of severe acute pancreatitis GROOVE PANCREATITIS e SERIES OF with massive retroperitoneal necrosis in a 40 years old male 9 CASES with a history of endoscopic retrograde cholangio Y. Bang, S. Patil, P. Rabella and G. V. Rao pancreaticography (ERCP). Surgical Gastroenterology, Asian Institute of Gastroen- Result: After a series of surgical debridement and a close terology, India follow up in intensive care unit, the patient has survived with a intermittent increase in blood amylase and lipase Introduction: Groove pancreatitis also known as para- level, but without any significant clinical symptoms. duodenal pancreatitis is a rare but well-defined type of focal Conclusion: Early recognition and intervention with a pancreatitis seen in duodeno-pancreatic groove. It presents good perioperative critical care is necessary in the man- with recurrent episodes of pancreatitis, gastric outlet agement of severe acute pancreatitis with retroperitoneal obstruction or jaundice. necrosis. Aims and objectives: Study clinicopathological charac- teristics of Groove pancreatitis and evaluate role of various diagnostic modalities and surgery in management of it. Material and methods: 9 cases of Groove Pancreatitis EP02A-005 diagnosed and operated from September 2009 to EARLY VERSUS DELAYED August 2017 are studied. Data including demographic LAPAROSCOPIC CHOLECYSTECTOMY information, presenting symptoms and signs, radiolog- IN ACUTE GALL STONE INDUCED ical investigations, extent of surgery, histology were evaluated. PANCREATITIS Results: 7 patients were male and 2 females. Median age of B. Devkaran presentation was 50 years. Most common presentation was General and Laproscopic Surgery, Indira Gandhi Medical recurrent epigastric pain followed by Gastric outlet College, India obstruction. 1 Patient presented only with Gastric outlet Introduction: Cholecystectomy is mandatory to prevent obstruction without any epigastric pain. Contrast enhanced further biliary events in patients with biliary acute CT was diagnostic in all patients which demonstrated pancreatitis, but timing of cholecystectomy remains thickening of duodeno-pancreatic groove with normal controversial. pancreas. EUS guided FNAC was done in 7 patients which Material and methods: The prospective study included showed characteristics of Pancreatitis. 8 patients underwent 400 patients of acute mild biliary pancreatitis. Whipples pancreaticoduodenectomy and 1 patient with Group A comprised of 200 patients who underwent only gastric outlet obstruction underwent Gastro-jejunos- laparoscopic cholecystectomy in the same admission tomy. Post operative recovery was normal in all patients (within 10 days) and and all patients are symptom free. Group B comprised 200 patients operated after 6 weeks. Discussion: Groove pancreatitis affects the groove which Operative time, blood loss, unclear Calots antomy, con- contains dorso-cranial portion of the pancreatic head, du- version to open cholecystectomy, need for drains, intra- odenum, and CBD. It generally presents with symptoms of operative/postoperative complications, hospital stay after abdominal pain, nausea, postprandial vomiting. CECT is surgery were compared. diagnostic of Groove pancreatitis. Pancreaticoduodenec- Results: The mean operative time was 28.2 minutes in tomy is the surgical treatment of choice for it. In patients Group A and 26.8 minutes in Group B, the mean blood with outlet obstruction without any pain, Gastro- loss was 22.6 ml in Group A and 18 ml in Group B, jejunostomy is acceptable treatment. Calot’s triangle anatomy was unclear in 40 (20%) cases in Group A and 32 (16%) cases in Group B, conversion to open cholecystectomy was done in 24 (12%) cases in EP02A-004 Group A and 16 (8%) cases in Group B.48 (24%) cases in SEVERE ACUTE PANCREATITIS WITH Group A and 24 (12%) in Group B had a need for drain. Mean hospital stay was 3.04 days in Group A and 3.02 RETROPERITONEAL NECROSIS: A days in Group B. 96 (48%) of cases in Group B had CASE REPORT recurrent attacks ranging from 1 to 5 episodes during the A. Nugroho and T. Poniman waiting period for surgery. Digestive Surgery, Fatmawati General Hospital, Conclusion: From the study it is clear that early laparo- Indonesia scopic cholecystectomy is safe, effective feasible in pa- Background: Retroperitoneal necrosis in acute pancreatitis tients of acute mild biliary pancreatitis, preventing recurrent fi is a rare form of disease, but very lethal once it happened. attacks which otherwise cause signi cant morbidity in those undergoing delayed cholecystectomy.

HPB 2018, 20 (S2), S505eS684 S506 Electronic Posters (EP02A-EP02F) e Pancreas

EP02A-006 Results: Preoperative diagnosis was correct in all the cases except one, when cystic tumor of the pancreatic head was THE EFFECT OF NAFAMOSTAT suspected (1,8%). Patients were presented with abdominal MESILATE INFUSION INTO MAIN pain(100%), weight loss(76%), vomiting(30%) and jaun- PANCREATIC DUCT ON THE dice(18%). CT, MRI and endoUS were the most useful PREVENTION OF POST-ERCP diagnostic modalities. Ten patients were treated conserva- PANCREATITIS IN PORCINE MODEL tively, 35 underwent pancreaticoduodenectomies(PD), pancreatico- and cystoenterostomies(8), Nakao proced- J. -S. Park, S. Jeong and D. H. Lee ures(4), duodenum-preserving pancreatic head (DPPH) Inha University School of Medicine, Republic of Korea resections(5), and 15 pancreas-preserving duodenal resec- Background and aim: Post endoscopic retrograde chol- tions(PPDR). No mortality. Full pain control was achieved angiopancreatography (ERCP) pancreatitis (PEP) is not an after PPRDs in 93%, PDs in 83%, and after PPPH re- uncommon adverse event but may be an avoidable sections and draining procedures in 18% of cases. New complication. For prevention of PEP, various pharmaco- diabetes mellitus(3) and exocrine insufficiency(3) devel- logical or endoscopic attempts were conducted. However, oped after PD, Fig 1. Weight gain after 1 year was much most preventive options were usually ineffective. The aim more significant after PD and PPDR, Fig 2. of this study was to evaluate the effect of intra pancreatic Conclusions: duct injection of Nafamostat Mesilate (NM) for the pre- 1. The diagnosis of DD can be confidently determined vention of PEP in in vivo swine models. preoperatively; Methods: The experiment was conducted on 8 mini pigs. 2. Early diagnosis of DD saves pancreas Animals were randomly allocated to contrast media (CM) 3. Late diagnosis converts DD in PP and leaves patient group (n=4) and NM group (n=4). Pancreatitis was induced only PD; with high pressure of infusing CM into the main pancreatic 4. The efficacy of PPDR proves that DD is an entity of duct by ERCP. After CM injection, NM dissolution fluid duodenal, but not paraduodenal origin. (50 mg/5 ml) was infused in NM group and the same amount of 5% dextrose solution was infused with same manner in CM group, respectively. Twenty four hours after EP02A-009 the endoscopic procedures, pancreatic injuries were eval- uated histologically including inflammation, edema, SPONTANEOUS GASTRIC vacuolization, necrosis and hemorrhage. FISTULATION DURING THE COURSE Results: No technical difficulty or adverse event occurred OF ACUTE NECROTIZING during the procedures. Acute pancreatitis was observed in all PANCREATITIS: A CASE REPORT animals on histologic examinations. Degrees of pancreatitis S. Gunasekaran in the NM group (as assessed using mean histologic acute Khoo Teck Puat Hospital, Singapore pancreatitis scores, 6.5Æ1.29) tended to be mild than in the CM group (8.5Æ1.29), but this difference was not significant Introduction: Acute pancreatitis is a common surgical fi (p=0.114). However, NM group (1.0) scored lower on the condition with signi cant morbidity and mortality. development of necrosis than CM group (1.75, P=0.024). Pancreatic pseudocysts and walled off pancreatic necrosis Conclusion: The intra pancreatic duct injection of NM (WOPN) are late sequele of pancreatitis. Spontaneous fi showed a promising result on prevention of developing perforation or stulation of such collections into a hollow PEP, especially in prevention of necrosis. viscus is a rare complication of pancreatitis. The most commonly reported site is the transverse colon, though fi EP02A-008 such stulation can involve all levels of the alimentary tract. WHICH SURGERY TO CHOOSE FOR Method: We describe a rare case of spontaneous gastric DUODENAL DYSTROPHY, GROOVE OR fistulation of a WOPN with subsequent improvement in the PARADUODENAL PANCREATITIS? patient’s clinical condition and successful conservative EXPERIENCE OF 77 CASES management. V. Egorov and R. Petrov Case report: A 52 year old Chinese male presented on day Surgical Oncology, Bakhrushin Brothers Moscow City 29 after a bout of severe necrotizing alcoholic pancreatitis fi Hospital, Russian Federation with worsening pain and sepsis. Imaging con rmed the presence of an infected walled off pancreatic necrosis Background: The term “paraduodenal pancreatitis“(PP) abutting and inseperable from the posterior gastric wall and was proposed as an umbrella for cystic dystrophy in het- duodenum. The patient was treated initially with percuta- erotopic pancreas (duodenal dystrophy,DD), paraduodenal neous drainage and a step wise approach with an aim for cyst and groove pancreatitis, by reasoning that these condi- VARDS. On day 38 of pancreatitis, there was a sudden tions mimic pancreatic head tumors and share certain histo- change in drain fluid character to copious amounts of clear logical evidences. The reasons for amalgamation of these gastric fluid. CT and fluoroscopic imaging confirmed the terms are unclear. presence of spontaneous fistulation into the stomach. Pa- Objective: To assess the results of different types of DD tient was treated conservatively for as a controlled fistula treatment. with rapid clinical improvement, hence avoiding any Method: 1.Prospective analysis of 77 cases of DD (2004- further surgical intervention. 2017), comparing 77 pretreatment and 59 histopathological Conclusion: Though prompt surgical intervention may be findings; 2.Assessment of clinical presentation and the re- required in cases of infected necrotic collections, the rare sults of DD treatment. instances of spontaneous perforation into the duodenum or

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S507 stomach results in transient drainage of the infected considered the treatment of choice for SVT, however, collection and subsequent clinical improvement. surgical procedure in necrotizing pancreatitis is difficult and risky because of severe inflammation, adhesion, and bleeding tendency. Herein, we report a case of GVB sec- EP02A-010 ondary to SVT complicated by necrotizing pancreatitis ACUTE LUNG AND RENAL INJURY IN which was successfully treated with splenic artery embo- lization (SAE). SEVERE ACUTE PANCREATITIS: Methods: A 42-year-old man was referred to our hospital CROSSTALK BETWEEN for treatment of a necrotizing pancreatitis. Initial intensive INFLAMMATION AND COAGULATION medical treatment was performed and following operative S. Chuklin, S. Chooklin and G. Shershen necrosectomy was done after 8 weeks from admission. On Lviv Regional Clinical Hospital, Ukraine postoperative day 13, hematemesis developed and abdom- inal CT scan revealed extravasation of contrast media at Introduction: Acute pancreatitis (AP) is a complex in- gastric cardia and fundus. Emergency EGD was fail to flammatory syndrome with unpredictable progression to control the bleeding due to ongoing active bleeding. Emer- systemic inflammation and multiple organ dysfunction gency angiography was performed and celiac arteriography syndrome. Multiple organ system failure (MOSF) is a revealed no active bleeding from arterial system. Under severe clinical process that causes progressive renal and suspicion of GVB SAE was performed. pulmonary failure. The pathogenesis of organ failure in AP Results: After SAE, splenic blood flow was remarkably is complicated. decreased and bleeding stopped immediately, and no more Materials and methods: We examined 155 patients with episode of gastrointestinal bleeding was observed. An AP. According to the international classification in 98 pa- abdominal CT scan 2 days following the SAE showed no tients we diagnosed the moderate severe AP, and in 57 more active bleeding and small splenic infarction less than patients the severe AP. Disorders of kidney function were only 10% of total splenic volume was observed. in 48 patients. Disorders of lung function were in 60 pa- Conclusion: SAE could be the best treatment option for tients. We determined the blood gases, creatinine level, gastric variceal bleeding when splenectomy is difficult such indicators of hemostasis and inflammation. as in case associated with severe acute pancreatitis or Results: Analysis of the relationship of inflammation and associated with severe adhesion, or when in patients with hemostasis in patients with AP and respiratory dysfunction, high operation risk. and renal failure is accompanied by decreased of activated partial thromboplastin time, increased of thrombin time, fibrinogen concentration, D-dimers level, and level of sol- uble fibrin-monomer complexes, lack of activity of anti- EP02A-012 thrombin III, increased synthesis of C-reactive protein, INTRAHEPATIC PANCREATIC excessive production of proinflammatory cytokines IL-2, PSEUDOCYST; A RARE IL-6, and TNF-a. In acute pancreatitis patients with renal COMPLICATION OF PANCREATITIS dysfunction was shown a direct correlation between severity of renal failure (SOFA score) and concentrations of C. K. Cho and H. J. Kim IL-6, CRP, D-dimers, soluble fibrin-monomer complexes, Surgery, Chonnam National University Medical School, and duration of thrombin time. Republic of Korea Conclusion: The inflammatory cascades and hyper- Introduction: Pancreatic pseudocyst is located usually in coagulative state are initiated the acute renal injury and acute lesser sac and peripancreatic space and is rarely developed lung injury in acute necrotizing pancreatitis. It is important in the liver. The intrahepatic pancreatic pseudocyst(IHPP) to understanding the pathophysiological mechanisms of following acute pancreatitis is extremely rare with very severe AP to reduce morbidity and mortality through the limited number of clinical reports about IHPP. early detection the patients who are at risk for developing Methods: A 70-year-old woman was referred because of organ failure. upper abdominal pain of 3 days’ duration. An abdominal CT scan revealed 11x10 cm sized cystic mass in the left lateral section of liver. On EUS findings, a huge hypoechoic lesion EP02A-011 with internal echogenicity was noted in the lesser sac. EUS- guided gastrocystostomy was performed and analysis of THE ROLE OF SPLENIC ARTERY cystic fluid showed a high level of amylase (21,200 U/L). EMBOLIZATION FOR GASTRIC After the endoscopic procedure, severe abdominal pain VARICEAL BLEEDING ASSOCIATED developed and physical examination showed peritoneal WITH SPLENIC VEIN THROMBOSIS IN irritation sign. An emergency operation was performed. fi NECROTIZING PANCREATITIS: Results: On operation ndings, a huge cystic tumor was located in the left lateral section of liver without direct REPORT OF A CASE communication with pancreas. However, mass-like necrotic C. K. Cho and H. J. Kim tissue was filled with in the hepatoduodenal ligament, Surgery, Chonnam National University Medical School, hepatogastric ligament, and Glisson sheath of the left hepatic Republic of Korea lobe. Left lateral sectionectomy was performed. Pathologic Introduction: Splenic vein thrombosis (SVT) is a rela- examination confirmed the pseudocyst with findings of non- tively common finding in pancreatitis and SVT associated epithelialized granulation tissue of the cystic wall. gastric variceal bleeding (GVB) could be sometimes a life- Conclusion: IHPP should be considered when a huge threatening complication. Traditionally splenectomy is intrahepatic cystic lesion is found in patients with recent

HPB 2018, 20 (S2), S505eS684 S508 Electronic Posters (EP02A-EP02F) e Pancreas episodes of pancreatitis. The high level of amylase on Methods: We performed retrospective study of step-up sur- cystic fluid analysis plays a key role in the diagnosis of gical ttreatment of 173 patients with ANP. As a first step VE IHPP. Drainage procedure or surgical resection can be were used in 69, TI - 99 cases. In 31 patients with extended considered, if necessary, for the treatment of IHPP. necrosis their multimodal application were performed. Dura- tion of in-hospital treatment, complications, amount of pro- cedures and necessarily for open necrosectomy were studied. EP02A-013 Results: From 52 patients with acute necrotizing collections fi LONG TERM OUTCOMES OF SURGERY (ANC) separate application of VE or TI was nal method of treatment in 74.0% patients, video-assisted retroperitoneal IN CHRONIC PANCREATITIS debridement (VARD) we performed in 13.5%, mini-lapa- V. Shetty, S. Nagral and N. Doctor rotomic necrosectomies - 5.8%, open necrosectomies Department of Surgical Gastroenterology, Jaslok Hospital -19.2% observations. Their application in 102 patients with and Research Centre, India walled off pancreatic necrosis (WOPN) was followed by Introduction: Chronic Pancreatitis(CP) has high prevalence VARD in 10.8%, mini-laparotomic necrosectomies - 3.9%, in India and is mostly idiopathic(ICP). The onset is at a open necrosectomies - 16.8% cases. Total number of inva- young age and presents with recurrent abdominal pain and sive procedures reached 2.5Æ0.24, complication rate - progressive pancreatic endocrine and exocrine dysfunction. 12.3% (pancreatic fistula -7.2%), overall mortality - 2%. Various surgical procedures for CP show good short term Multimodal VE and PTI approach was applied in 9 ANC and results, but the long term outcomes remain unclear. 32 WOPN observations with no mortality cases. Necessary Methods: 75patients who underwent various surgeries for of additional intervention occurred in 12.9% (p<0.05), open CP were analysed retrospectively. Patients operated more necrosectomies - 6.4% (p<0.05), there were no procedure- than 2years prior were included. They were followed-up related immediate and long-term complications. with a questionnaire to assess their pain relief (Izbicki pain Conclusions: Multimodal application of video-endoscopic score), exocrine and endocrine function and quality of life and transcutaneous interventions is effective approach as (QOL) (using EORTC QLQ-30 questionnaire). first step for surgical treatment of patients with extended Results: 75patients underwent surgeries for CP over infected ANP. 12years. During follow-up 17 patients had expired. 21 were lost to follow-up. Remaining 37patients were included in the analysis. EP02A-015 Tropical pancreatitis was the etiology in 54%. 59.5% UTILITY OF PROACTIVE patients were of age 21 to 40 years. Pain was the indication PERCUTANEOUS INTERVENTIONS IN for surgery in 97%. 51% had pancreatic duct diameter more than 6mm. 78%(29/37) underwent resectional procedures. STEP-UP APPROACH OF SURGICAL Mean duration of follow-up was 80months. 75% patients TREATMENT OF INFECTED ACUTE complained of persistent pain but at lower intensity. NECROTIZING PANCREATITIS fi Asigni cant percentage of patients developed diabetes or I. Khomiak1, O. Rotar2, A. Khomiak1 and V. Rotar2 had worsening sugar control 49-70 months after surgery. Of 17 1Department of Pancreas Surgery and Bile Ducts Recon- patients who had expired at follow-up, 3 developed pancreatic struction Surgery, O.O. Shalimov National Institute of malignancy. The cause of death in 8 patients was unknown. Surgery and Transplantology, and 2General Surgery, Conclusion: In spite of good early results, majority of Bukovinian State Medical University, Ukraine patients of CP have pain recurrence in the long run. The Background: Percutaneous puncture/drainage is recom- high long term mortality we noticed in our study is mended as the first invasive step for surgical treatment of disturbing and needs to be studied in a larger patient cohort. infected acute necrotizing pancreatitis (IANP). A proactive percutaneous interventions (PPI) is a new strategy which could reduce the need for surgical necrosectomy and EP02A-014 improve outcomes, but data are lacking. MULTIMODAL VIDEO-ENDOSCOPIC Methods: We performed retrospective study of 210 pa- AND TRANSCUTANEOUS tients in whom step-up approach for surgical treatment of INTERVENTIONS IN SURGICAL IANP was applied during 2013-2017. PPI were performed TREATMENT OF INFECTED ACUTE in 99 cases. In all patients interventions were performed only after failure of conservative treatment. Duration of in- NECROTIZING PANCREATITIS hospital treatment, complications and mortality rates as I. Khomiak1, O. Rotar2, V. Rotar2 and A. Khomiak1 well as necessarily for open necrosectomy were studied. 1Department of Pancreas Surgery and Bile Ducts Recon- Results: PPI considered frequent and early drain revision struction Surgery, O.O. Shalimov National Institute of and upsizing, so total number of invasive procedures Surgery and Transplantology, and 2General Surgery, reached 2.9Æ0.24. From 43 patients with acute necrotizing Bukovinian State Medical University, Ukraine collections (ANC) PPI were final method of treatment in 34 Background: Recent researches improves understanding (79.0%) patients, video-assisted retroperitoneal debridement of natural course of acute necrotizing pancreatitis (ANP). (VARD) we performed in 6 (13.9%), mini-laparotomic Today there are no disagreements on timing and indications necrosectomies - 2 (4.7%), open necrosectomies - 7 (16.3%) for surgical treatment, but different approaches still exist. observations. In 56 patients with walled off pancreatic ne- Our aim was to establish the efficacy of multimodal video- crosis (WOPN) after application of PPI necessary of VARD endoscopic (VE) and transcutaneous interventions (TI) in occurred in 8 (14.3%), mini-laparotomic necrosectomies - 3 surgical treatment of infected ANP. (5.4%), open necrosectomies - 15 (26.8%) cases. All open

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S509 necrosectomies were postponed on terms after 4th week from Introduction: Raised raised transaminase was believed to onset; there were 1 death (1.0%) due to massive hemorrhage be associated with gallstone pancreatitis (GP), though the from pancreatic pseudoaneurism. high quality evidence is lacking. This study assesses the Conclusions: PTI is effective technique of first line of step- role of ALT (alanine aminostransferase), ALP (alkaline up approach of surgical treatment of patients with IANP phosphatase), bilirubin and C-reactive protein (CRP) at both with ANC and WOPN. admission on predicting GP. Methods: All patients presented with acute pancreatitis EP02A-016 between October 2016 to October 2017 were included in MORTALITY PREDICTION MODEL FOR this study and relevant parameters were collected from SURGERY IN SEVERE ACUTE electronic patient documents. Total of 140 patients were analysed in this study. PANCREATITIS Results: Among 140 patients with acute pancreatitis, 33 1 2 1 1 J. Pereira , T. Campos , C. Daniel , C. Casimiro , patients were of GP and remaining of 107 patients suffered 3 3,4 A. Matos and C. Henriques non-biliary pancreatitis (NGP). Mean ALT level was 1 General Surgery, Centro Hospitalar Tondela-Viseu, significantly higher in gallstone pancreatitis (237Æ 351 IU 2 Portugal, Cirurgia, Hospital de Santa Casa de São versus 107Æ162 IU; P=.005) compared to non-biliary 3 Paulo, Brazil, School of Technology and Management, pancreatitis. But ALP (151.5Æ 186 versus 138Æ105 IU; 4 Instituto Politécnico de Viseu, and Centre for Mathe- P=0.64) bilirubin (35.5Æ24.5 versus 20.7Æ79.6; P= 0.09) matics, University of Coimbra, Portugal and CRP (30Æ73 versus 47.6Æ79; P=0.25) showed no Introduction: Acute pancreatitis is a usually benign dis- difference. ease with a low mortality rate. However, complications Conclusion: Raised ALT level above 200 IU in patients develop in some patients, resulting in a life-threatening with acute pancreatitis was associated with gallstone condition. Complicated cases require significantly greater pancreatitis. ALP, bilirubin, CRP levels at admission were resources, including surgery. In this study, the authors not different between GP and non-biliary pancreatitis. evaluate the surgical treatment for severe acute pancreatitis by analyzing clinical outcomes from 3 different Surgical departments, to identify parameters that could predict EP02A-019 mortality early on the course. PREDICTIVE VALUE OF RAISED Methods: This retrospective study included the analysis of medical records of 66 patients diagnosed with severe acute SERUM LIPASE ON DIAGNOSING pancreatitis operated between 2000 and 2014 in the ACUTE PANCREATITIS e A SINGLE Department of Cirurgia 1 and Department of Cirurgia 2 of the CENTRE EXPERIENCE Centro Hospitalar Tondela-Viseu, Portugal and the Depart- U. Mathuram Thiyagarajan1, E. Coote2, E. Foley2, ment of Surgery of Hospital da Santa Casa de São Paulo, M. Gallanagh2 and R. Thomas2 Ò Ò Brasil. Data were analyzed using SPSS Version 22 IBM . 1Royal Surrey County Hospital, and 2Croydon University Results: The patients included were mostly men with a Hospital, United Kingdom median age of 52,5 years. The most common etiology was Introduction: Significantly raised serum lipase level in a gallstones. The following variables showed an independent patient with abdominal pain was considered diagnostic of relationship with mortality: age, length of stay, Ranson acute pancreatitis (AP). Hence it was considered more score, APACHE II scores at admission and surgery and specific on diagnosing AP compared to serum amylase. renal, respiratory and cardiovascular failures. Multivariate Here with we share our experience on role of serum lipase analysis showed that the combination of Ranson or in AP. APACHE II at admission with renal and respiratory failure Methods: All patients presented with acute abdominal pain were strongly associated with mortality. who had significantly raised serum lipase between October Conclusion: Despite APACHE II at surgery appears to be a 2016 to October 2017 were included in this study and good predictor of mortality it is important to find an early relevant parameters were collected from an electronic pa- prognostic model. The combination of Ransom or tient notes. Total of 201 patients were analysed in this APACHE II at admission with the early development of study. renal and respiratory failure showed, in this series, to be the Results: Among the 201 patients, only140 (69.65%) have best predictor of mortality. been diagnosed with acute pancreatitis and remaining 61 (30.34%) had been found to be caused by other causes including small bowel obstruction, gallstones. Hence the EP02A-018 raised serum lipase (three times the normal value) not ROLE OF ALT, BILIRUBIN, ALKALINE diagnostic of acute pancreatitis. PHOSPHATASE AND CRP ON Further analysis showed higher the value of lipase was PREDICTING GALLSTONE associated with biliary pancreatitis compared to non- e pancreatitis causes (1427.4Æ2497 versus 364.6Æ393; PANCREATITIS A SINGLE CENTRE P=0.002). EXPERIENCE Conclusion: High serum lipase in a patient with acute U. Mathuram Thiyagarajan1, A. Ponnuswamy2, E. Foley3, abdominal pain not always associated with AP. But M. Gallanagh3, E. Coote3 and R. Thomas3 lipase higher than 1400 IU is aasociated with gallstone 1Royal Surrey County Hospital, 2Dept of General Medi- pancreatitis. Hence this study raises the question pre- cine, Conquest Hospital, Hastings, and 3London Road, dictive value of lipase in patients with acute abdominal Croydon University Hospital, United Kingdom pain.

HPB 2018, 20 (S2), S505eS684 S510 Electronic Posters (EP02A-EP02F) e Pancreas

EP02A-020 Results: All patients were tried conservative management before being taken up for surgery. Surgery was offered to VARYING INFLAMMATORY those patients who had VAS score >8. CCP with tail dis- RESPONSES IN GALLSTONE eases in our series were tail mass e 12, infected tail cyst e PANCREATITIS VERSUS NON-BILIARY 7, pseudocyst e 7, ductal disruption e 1, isolated tail PANCREATITIS e AN INTERESTING calcification e 4, sinistral portal hypertensione1, splenic e FINDING artery pseudoaneurysm 1. Surgeries performed for tail 1 2 2 diseases were Freys procedure with distal pancreatectomy U. Mathuram Thiyagarajan , E. Foley , M. Gallanagh , e e 2 2 14, Distal pancreatectomy with splenectomy 4, Freys E. Coote and R. Thomas e e 1 2 procedure 11, completion distal pancreatectomy 1, Royal Surrey County Hospital, and Croydon University completion Freys procedure e 1. Statistical analysis Hospital, United Kingdom showed significant improvement of pain score. Introduction: Acute pancreatitis (AP) is known to cause Conclusions: Chronic pancreatitis with tail disease is a cascade of complex inflammatory response following an specific group of diseases which are rare when comparing initial insult. Hence the scoring systems includes white with head mass and is least discussed. They need to be blood cell count (WBC). This study analyse the inflam- addressed failing which they may recur even with Freys matory responses between gallstone pancreatitis (GP) procedure. Hence tail resection may be a good option in versus non-galltone pancreatitis (NGP). isolated or predominant tail disease with good pain control. Methods: All patients presented with AP between October 2016 to October 2017 were included in this study and relevant parameters were collected from an electronic pa- EP02A-022 tient documents. Total of 140 patients were analysed in this study. We have collected the WBC count and C-reactive POST-ENDOSCOPIC RETROGRADE protein (CRP) at admission, 24 hours and 72 hours to assess CHOLANGIOPANCREATOGRAPHY their response to AP. PANCREATITIS: MORBIDITY AND RISK Results: Among 140 patients with acute pancreatitis, 33 FACTORS patients had GP and remaining of 107 patients suffered E. El Hanafy1 and E. Atef2 NGP. The WBC count at admission, 24 hours and 72 hours 1Gastroenterology Surgical and Transplantation Center, in GP versus NGP were (11.6Æ 5 versus 13.7Æ17; P=.24), Faculty of Medicine e Mansoura University, and (12.6Æ20 versus 10.1Æ17;P=0.21) and (13.2Æ22 versus 2mansoura university, Egypt 9.2Æ4.7;P=0.15) respectively. But the CRP levels at admission, 24 hours and 72 hours were (30.4Æ 73 versus Introduction: Post-ERCP pancreatitis (PEP) remains the fi 47.6Æ79; P=0.25), (71.9Æ20 versus 92.2Æ97; P=0.35) and most serious complication after ERCP . PEP was de ned (89Æ106 versus 122.7Æ107; P=0.05) respectively. as new or worsened abdominal pain together with a Conclusion: There was a significantly high CRP level was serum amylase level at least three times normal at more associated with non-biliary pancreatitis. Further investiga- than 24 h after ERCP and necessitating hospitalization tion is needed to assess this response and perhaps this could for more than one night. The aim of this study is to shed on evolution of AP. detect risk factors for (PEP) and investigate the predictors of its severity. Methods: This is a prospective cohort study of all patients who underwent ERCP between August 2012 and EP02A-021 September 2014. Pre-ERCP data, intraoperative data, and MANAGEMENT OF CHRONIC post-ERCP data were collected. PANCREATITIS WITH TAIL Results: The study population consisted of 996 patients. PREDOMINANT DISEASE e SINGLE Their mean age at presentation was 58.42 (Æ 14.72) years, CENTRE EXPERIENCE (MADRAS and there were 454 male and 442 female patients. PEP occurred in 102 (10.2%) patients; eighty (78.4%) MEDICAL COLLEGE, CHENNAI, INDIA) cases were of mild to moderate degree, while severe N. B. Obla, D. R. Balamurugan, pancreatitis occurred in 22 (21.6%) patients. No hospital D. R. Benet Duraisamy and D. R. Prasanna mortality was reported for any of PEP patients during the Surgical Gastroenterology, Madras Medical College, study duration. Age less than 35 years (P = 0.001, OR = India 0.035), narrower common bile duct (CBD) diameter (P = Introduction: Pain in chronic pancreatitis is usually due to 0.0001) and increased number of pancreatic cannulations head mass, ductal hypertension, and parenchymal disease. (P = 0.0001) were independent risk factors for the occur- But tail disease also contribute to pain in certain group of rence of PEP. patients. In our centre we address the tail disease with Conclusion: PEP is the most frequent and devastating surgical interventions with the aim of improving pain and complication after ERCP. PEP is associated with higher quality of life. morbidity and mortality beside its effect in increasing the Methods: This is the retrospective study of 31 patients who consumption of hospital resources. Age less than 35 years, underwent surgical management for tail disease over the narrower median CBD diameter and increased number of period of 3 years (2014 - 2017) with a mean postoperative pancreatic cannulations are independent risk factors for the follow-up of 6 months. Using VAS score, pain was occurrence of PEP. analyzed both preoperatively and postoperatively.

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EP02A-023 Results: 518 articles were obtained, only 8 focused on pancreatic surgery in patients with CP and vascular ab- CHRONIC CALCIFIC PANCREATITIS: normalities (two case report, six series of cases). COMPLICATIONS AND MANAGEMENT The existence of EPH in patients with CP undergoing e A SINGLE CENTRE EXPERIENCE surgery increases intraoperative blood loss, postoperative FROM SOUTH INDIA morbidity and mortality. The results are shown in Figure 1. L. Soundara Rajan, A. Amudhan, S. Rajendran and O. L. Naganath Babu Surgical Gastroenterology, Institute of Surgical Gastroen- terology, Rajivgandhi Government General Hospital, India Introduction: Chronic calcific pancreatitis is a commonly encountered problem in south india. Surgical intervention is contemplated when there is intractable pain, local and vascular complications. We have analysed complications that have occurred in the background of chronic calcific pancreatitis in our institute and their management outcomes. Methodology: This is an observational study from the maintained database in our institute, of patients who were admitted with chronic calcific pancreatitis and its compli- cations from 2010 to 2017. Figure 1 Results: A total 318 patients were admitted with diagnosis of chronic calcific pancreatitis during this period. Intractable pain was the most common complication followed by pseudocyst, Pancreatic surgery in patients with CP has good results in biliary stricture and jaundice, ascites, vascular complications terms of pain reduction and improvement of disability, but including pseudoaneurysms, malignancy and duodenal it leads to high morbidity and mortality in those patients obstruction. Freys procedure was the most commonly done who associate EPH. procedure. In addition to Freys a number of other procedures Conclusions: Literature on surgery for CP and EPH is are needed depending on the complications encountered. scarce and confusing. Studies are limited series which mix fi Conclusion: Complications of CCP account for signi cant different types of surgery and different vascular affecta- subset of patients with CCP. They have a protracted course tions. So, it would be necessary more studies to know if and are usually symptomatic. Patients with complications there is any technique of choice in these patients or if some of CCP may need additional procedures done in addition to of them should not be candidates for surgical treatment. Frey’s procedure which can be done in high volume centre with acceptable morbidity and mortality. EP02A-027 TYPE 2 AUTOIMMUNE PANCREATITIS EP02A-024 (OR IDCP): AN AUSTRALIAN PANCREATIC SURGERY IN PATIENTS RETROSPECTIVE EPIDEMIOLOGICAL WITH CHRONIC PANCREATITIS AND ANALYSIS AND REVIEW OF THE EXTRAHEPATIC PORTAL CURRENT ICDC CRITERIA HYPERTENSION: A SYSTEMATIC K. Pattabathula1,N.O’Rourke2, P. Kerlin3 and REVIEW M. Bettington4 1 2 A. Manuel, R. Latorre Fragua, A. Lopez Marcano, Royal Brisbane and Women’s Hospital, HPB Surgery, 3 4 A. Medina Velasco, C. Garcia Amador, C. Ramiro Perez, Wesley Hospital, Gastroenterology, and Envoi Pathol- L. Diego Garcia, V. Arteaga Peralta, ogy, Royal Brisbane and Women’s Hospital, Australia R. de la Plaza Llamas and J. M. Ramia Angel Introduction: Type 2 autoimmune pancreatitis (or idio- General and Digestive Surgery, University Hospital of pathic duct-centric chronic pancreatitis) is a rare, benign Guadalajara, Spain disease with inherent challenges in diagnosis. The objective Introduction: Chronic pancreatitis (CP) is a progressive of this study was to analyse the clinical epidemiology of and permanent destruction of pancreas, resulting in this disease and to assess validity of diagnostic criteria. disabling pain and loss of endocrine/exocrine function. The Method: Five patients, retrospectively collected over 5- indications for surgery include intractable pain, suspected years, that met the ‘probable’ or ‘definitive’ current Inter- malignancy or complications/combinations of the previous. national Consensus Diagnostic Criteria (ICDC), for type 2 Certain conditions can increase morbidity-mortality risk, autoimmune pancreatitis were included. such as extrahepatic portal hypertension (EPH). This Results: Two patients, both female aged 16 and 19, met the complication of CP represents a surgical risk that must be definitive criteria. Three patients, two male and one female, accounted for in the design of a surgery. aged 26-61, met the probable criteria. Four patients had pre- Method: This study is a systematic review on the existence existing inflammatory bowel disease. Four patients had focal of EPH in patients undergoing surgery for CP. changes or demonstrable mass on endoscopic ultrasound Adhering to PRIMSA guidelines (PRISMA12NL), a (EUS)orcross-sectionalimaging(CTorMRCP).Ofthis systematic search was performed in PubMed/Embase, for group, one patient underwent surgery (laparoscopic distal articles on EPH and pancreatic surgery for CP. pancreatectomy and splenectomy) for a malignant-appearing

HPB 2018, 20 (S2), S505eS684 S512 Electronic Posters (EP02A-EP02F) e Pancreas lesion in the pancreatic body with specimen histology Background: Disconnected left pancreatic remnant confirming type 2 AIP. A total of three patients began and (DLPR)da viable tail disconnected by necrosis–following responded well to steroid and/or other immunosuppressant severe acute necrotizing pancreatitis has been an indication therapy. None of the patients have experienced relapse in their for completion distal pancreatectomy, a highly morbid pro- disease post-medical or surgical management at 6-24 months cedure. Surgical transgastric necrosectomy (TGN) is novel follow-up. alternative to other debridement strategies because it Conclusions: The epidemiology of type 2 autoimmune explicitly creates an internal fistula (cystgastrostomy). We pancreatitis is distinctly different to the more sinister pa- sought to characterize the natural history of DLPR after TGN. thologies that it may mimic. Clinicians must be aware of this Methods: Using data from a multicenter, international fact in their approach to the serum IgG4-negative patient database, we evaluated 121 patients (31% female, median with recurrent pancreatitis, particularly in the young, female age 51yrs) who underwent TGN for walled-off pancreatic demographic and in the presence of co-existing IBD. There necrosis between (2002-18). All clinicopathologic data is value in diagnostic rubrics in distinguishing this disease. were abstracted from medical records. The location of ne- crosis was identified based on preoperative imaging and those with subset of patients were analyzed. EP02A-028 Results: Of the 121 patients, 52 had DLPR prior to BILIARY COMPLICATIONS IN necrosectomy. PANCREATIC NECROSECTOMY S. R. V. Gunturi, V. Thumma, N. Kunduru, J. R. Bathalapalli, N. R. Rakesh, K. K. Bishnoi, D. Sarma, G. Gondu and B. Nagari Surgical Gastroenterology, Nizams Institute of Medical Sciences, India Introduction: Necrotising Pancreatitis is a challenging problem and pancreatic necrosectomy is associated with significant morbidity and mortality even in high volume centres.Following Necrosectomy intra operative and im- mediate postoperative bile leak is a rare complication and associated with high mortality.The aim of this study is to present our experience in general and to highlight the Table 1 biliary complications in particular. Methods: The clinical outcome of patients who underwent pancreatic necrosecctomy with emphasis on biliary com- The etiologies in this subset were etiologies were biliary plications in the last 7 years in our institute was studied. (40%), alcohol-related (40%), iatrogenic (8%), hyper- Results: Six Patients had bile leak and four of them were triglyceridemia (4%), and idiopathic (8%). Median ASA detected on table and in two patients in immediate post op was 3. Indication for TGN was infected necrosis in 27% period. In three subjects the cause of bile leak was identified and persistent illness (73%). While most (94%) had lesser- and rescued without mortality.(Two from small bowel fis- sac necrosis, 32% involved the root-of-mesentery and 17% tula and one from previous cysto gastrostomy stent) four the paracolic-gutter. Fourteen cases (27%) were performed out of six in whom there was bile leak were salvaged. laparoscopically, one required conversion-to-open. Median Conclusion: Management of Necrotising Pancreatitis re- follow-up was 11 months (1-60 mo). Morbidity (any quires Multidisciplinary team approach. Early detection of complication) was 30% with one mortality; 12 patients complications and timely intervention by experienced team is required readmission. There was one reoperation and one fi the key. Bile leak patients will have very high morbidity and postop pancreatic stulae per group. There were no sig- fi mortality. In patients with bile leak, identifying the cause and ni cant differences between transgastric necrosectomies appropriate management resulted in better outcomes. with or without DLPRs. Conclusions: Necrotizing pancreatitis with DLPR may be successfully managed with a single-stage transgastric necrosectomy, avoiding persistent fistulas, drains, or need EP02A-029 for reoperation to address the DLPR. DISCONNECTED LEFT PANCREATIC REMNANT FOLLOWING NECROSECTOMY FOR SEVERE EP02A-031 PANCREATITIS CAN BE MANAGED MANAGEMENT OF SEVERE ACUTE WITHOUT PANCREATECTOMY: AN PANCREATITIS: A 17-YEAR INTERNATIONAL, MULTICENTER EXPERIENCE IN A SINGLE ANALYSIS INSTITUTION 1 1 1 2 2 P. Worth , T. Rafeeqi , M. Dua , C. Ball , F. Sutherland , G. Pupelis1,2, K. Zeiza1,2, M. Pavlovics1,2, R. Starinskis2, 2 1 E. Dixon and B. Visser V. Fokins1,2, K. Atstupens1 and H. Plaudis1,2 1 Department of Surgery, Stanford University, United 1General and Emergency Surgery, Riga East University States, and 2Department of Surgery, University of Calga- Hospital, and 2Rigas Stradins University, Latvia ry, Canada

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Introduction: Severe acute pancreatitis (SAP) is associated (18.7Æ3.7 vs. 9.1Æ0.5, p=0.028), day 1 (18.8Æ11.2 vs. with persistent organ failure lasting longer than 48 hours 12.6Æ10.2, p=0.013) and day 3 (17.4Æ13.1 vs. 9.0Æ7.2, and requiring ICU treatment. p=0.012) were significant elevated in patients who Aim: Retrospective review of a 17-year experience of SAP developed pancreatic necrosis. Receiver operator curve treatment in a single institution. analysis revealed that day 3 NLR had the largest area Materials and methods: Retrospective analysis of medical under curve of 0.778. A D3 NLR of more than 9 was charts, evaluation of complication rate and the main determined to be the optimal cut off value in predicting outcomes. the development of pancreatitis, with a sensitivity of Results: In total, 392 patients with SAP according to the 78.95% and a specificity of 65.47%. revised Atlanta classification were treated in our institution Conclusion: Ratios derived from standard haemato- from January 2000 till February 2017. The mean age in the logical indices may be able to predict the development cohort was 49.5Æ16.2 years, predominantly males with of pancreatic necrosis in acute pancreatitis. The day 3 alcohol etiology. The mean APACHE II score at admission NLR seems to be the best test, but further validation is was 7.8Æ5.2, necrotizing SAP was proved in 76.5%, needed. MODS developed in 94%, including development of renal dysfunction in 52.7% and pulmonary dysfunction in 38.2% of patients. The majority of patients (65%) underwent EP02A-033 fi continuous veno-venouse hemo ltration leading to a low FOCUSED OPEN NECROSECTOMY IN incidence of abdominal compartment syndrome. Prophy- lactic antibiotic treatment, early oral low-volume feeding THE TREATMENT OF NECROTIZING and percutaneous drainage of symptomatic inflammatory PANCREATITIS: A 12-YEAR fluid collections or infected necrotic collections were used, EXPERIENCE IN A SINGLE resulting in a 76% infection rate considering all study INSTITUTION period and decreasing with the implementation of the V. Fokins, K. Atstupens, K. Zeiza, H. Plaudis and combined treatment strategy. Surgical intervention was G. Pupelis performed in 271 patients (69.3%) using the open approach General and Emergency Surgery, Riga Stradins Univer- in the early period and combined focused necrosectomy in sity/Riga East University Hospital, Latvia the last 12 years. The mean hospital stay was 25Æ9.3 days, ICU stay 12Æ5.9 days, mortality reached 12.7%. Introduction: Minimally invasive surgery plays an Conclusion: Our treatment strategy has changed from important role in the treatment of acute necrotic pancreatitis aggressive open surgical to combined percutaneous (ANP). drainage and focused necrosectomy in the late phase, The aim of the study is to analyze our 12-year experience leading to a shorter hospital stay and lower mortality. of ultrasound-assisted Focused Open necrosectomy (FON) in the treatment of ANP. Materials and methods: Patients were allocated to two groups: conventional open necrosectomy (CON) and EP02A-032 ultrasound-assisted (FON) - patients were operated PREDICTING PANCREATIC NECROSIS through minimal direct subcostal and/or lumbo-retro- AFTER ACUTE PANCREATITIS USING peritoneal approach. Before surgery symptomatic in- RATIOS DERIVED FROM STANDARD flammatory fluid collections were drained percutaneously HAEMATOLOGICAL INDICES under ultrasound control. The success of surgical pro- cedure was analysed comparing both methods consid- J. J. Ng, J. Windsor, A. W. C. Kow, I. S. Ganpathi, ering the time of intervention: if before 4 weeks from K. Madhavan and G. K. Bonney onset - intervention in acute necrotic collection (ANC) National University Hospital, Singapore phase;ifafter4weeks-interventioninwalledofne- Introduction: Pancreatic necrosis is the leading cause of crosis (WON) phase. secondary infection in patients with acute pancreatitis. Results: In total, 182 patients underwent necrosectomy There is currently no reliable haematological marker of during the study period. CON group consisted of 50 pa- prediction for the development of pancreatic necrosis. The tients operated in ANC phase and 48 patients operated in aim of this study is to evaluate the use of ratios derived WON phase compared to 35 patients and 49 who under- from haematological indices in predicting the development went FON. Operating time was significantly shorter in FON of pancreatic necrosis in patients with acute pancreatitis. patients, p< 0.001. Significantly fewer repeated in- Method: A retrospective study involving all patients terventions were done in WON phase in FON patients, p< admitted to the National University Hospital in Singapore 0.003. ICU and hospital stay was significantly shorter in for acute pancreatitis between May 2011 and June 2014 both phases in FON group, p< 0.046, p< 0.001. Compli- (N=383) was conducted. Patient data was collected from cation rate was 23% vs. 30% and mortality reached 6% vs. review of electronic medical records. Neutrophil-to- 7% in FON and CON groups accordingly. lymphocyte, neutrophil-to-monocyte, platelet-to-lympho- Conclusion: Percutaneous drainage of the symptomatic cyte and red cell distribution width-to-platelet ratios were fluid collections under ultrasound control and focused in- generated for each patient. Data analysis was performed terventions using intraoperative ultrasound navigation using SPSS version 23. called FON is associated with a shorter operative time and Results: Initial bivariate analysis showed that the hospital stay, lower complication rate and mortality. neutrophil-to-lymphocyte ratio (NLR) on admission

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EP02A-034 rates to them have been mixed. This study aims to review the clinical management of patients with acute pancreatitis CLINICAL EXPERIENCE OF in a tertiary institute in Singapore, and to identify areas that ENDOSCOPIC TRANSLUMINAL can be improved upon. PANCREATIC NECROSECTOMY Methodology: Patients admitted with the diagnosis of PERFORMED IN CASES OF INFECTED acute pancreatitis at the National University Hospital NECROTIZING PANCREATITIS AT THE (NUH) between 2011 and 2014 were included. Hardcopy and electronic records were reviewed retrospectively and STAGE OF SEQUESTRATION data was collected on patients’ demographics, cause of A. Shabunin, V. Bedin, I. Korzheva, A. Nechipay, acute pancreatitis, severity of disease, blood tests and im- M. Tavobilov, D. Komissarov, V. Vengerov and aging results, procedure and operative notes, and clinical A. Kolotilshchikov outcome. Results were analysed to look for compliance and City Clinical Hospital named by Botkin S.P., Russian adherence to the International Association of Pancreatology Federation (IAP) / American Pancreatic Association (APA) guidelines Introduction: Severe acute pancreatitis complicated by (2013). infected necrotizing pancreatitis is associated with signifi- Results: Of the 391 patients, 266 (68%), 83 (21%) and cant morbidity and mortality. Modern surgery in patients 42 (11%) had mild, moderate and severe pancreatitis with necrotizing pancreatitis consists of open-surgery and respectively. However, only 145 patients (37%) had minimally invasive approaches: percutaneous drain place- prognostication using SIRS as a criteria. 33% of patients ment, VARD, endoscopic transluminal necrosectomy. had ultrasonography of the right upper quadrant done Materials and methods: Throughout 2011-2017 Botkin within 24Hrs of admission. With regards to antibiotics Clinical hospital admitted 246 patients with infected use, only 159 (63.9%) of patients had appropriate use of necrotizing pancreatitis for surgical treatment. The antibiotics. Index admission cholecystectomy was method’s choice was made considering results of clinical performed for 21% of patients diagnosed with mild examination, localization of acute collectors and necrotized pancreatitis. tissues. Endosonography helps to evaluate chances for Conclusion: The compliance to existing IAP/APA endoscopic drainage placement, visualize acute liquid guidelines for management of acute pancreatitis is vari- collectors, earlier found on CT, determine the type of acute able even in a tertiary institute, and there are many collectors, evaluate length of necrotizing tissues. 12 mm reasons causing this discrepancy. Identifying these gaps Self-expanding metal stents were placed and direct and implementing measures to address them allows for necrosectomy was performed. continued improvement in the management of patients Results: In 14 cases we used endoscopic transluminal with acute pancreatitis. necrosectomy (patients with diagnosed «walled-off necro- sis» and acute collectors). 8 Patients were completely cured only by this method and without any further need for open EP02A-036 surgery. In 6 patients we added adjunctive percutaneous A BINATIONAL ANALYSIS OF 252 drains for better irrigation and debridement. The trans- luminal necrosectomy was repeated 2-7 times in case of no PANCREATIC RESECTIONS FOR clinical improvement or if necrotized tissues couldn’tbe CHRONIC PANCREATITIS WITH fully removed. The average frequency of procedures was REGARD TO INCIDENTAL 3.6. One complication occurred (arrosive bleeding which CARCINOMA SEQUENCE AND was stopped by endoscopic hemostasis). There was no OVERALL POSTOPERATIVE OUTCOME mortality in this patients. F. Klein1, T. Le Thu1, C. S. Rösch2, H. Wundsam2, Conclusion: Endoscopic transluminal necrosectomy is an 1 1 1 1 effective minimally invasive method of debridement in T. Malinka , M. Biebl , J. Pratschke , M. Bahra and R. Függer2 patients with infected necrotizing pancreatitis with walled- 1 off necrosis (especially if acute collectors and necrotized Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, tissues located in the center of pancreas and peripancreatic 2 space). Germany, and Department of Surgery, Ordensklinikum Linz, Krankenhaus der Elisabethinen Linz GmbH, Austria Introduction: Therapeutic treatment algorithms for pa- EP02A-035 tients with chronic pancreatitis remain to be debated controversially until today. Especially surgical therapy is A REVIEW OF CLINICAL often only considered after long-term conservative treat- MANAGEMENT IN PATIENTS WITH ment. The aim of this study was a binational analysis of ACUTE PANCREATITIS: HOW patients who underwent pancreatic resections for suspected COMPLIANT ARE WE WITH chronic pancreatitis at an austrian and german high-volume GUIDELINES, AND HOW CAN WE center with regard to incidental carcinoma sequence and overall postoperative outcome. IMPROVE Patients and methods: An overall of 252 consecutive Y. Gao, G. Bonney, K. Madhavan, W. C. A. Kow, pancreatic resections for suspected chronic pancreatitis S. G. Iyer and J. W. Tan were performed at both institutions between 2005 and National University Hospital, Singapore 2015. In a binational retrospective analysis both post- Aim: Various guidelines on the management of acute operative results as well as histopathological findings were pancreatitis are available in literature, and the compliance analyzed.

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Results: Pancreatic resections were performed in 193 male EP02A-038 (76.6%) and 59 female patients (23.4%) with a median age of 53.2 years. A total of 175 pancreatic head resections PANCREATIC COLONIC FISTULAE, AN (69.4%), 37 distal pancreatectomies (14.7%), 23 total INCIDENTAL FINDING IN A PATIENT pancreatectomies (9.1%) and 18 other pancreatic resections WITH NEWLY DIAGNOSED CHRONIC (7.1%) were performed within our study period. Post- PANCREATITIS operative complications > Clavien II occurred in 94 pa- M. Achalandabaso Boira, L. Ferreira and K. Conlon tients (37.3%). 21 patients (8.3%) developed clinically St. Vincents University Hospital, Ireland relevant postoperative pancreatic fistula (grade B and C), fi while postoperative mortality occurred in 5 patients (2.0%). Pancreatic colonic stulae (PCF) are an uncommon Final histological examination of the operation specimen complication of severe acute pancreatitis (SAP). They revealed an incidental pancreatic adenocarcinoma in 18 out usually present in the setting of acute necrosis and may be of the 252 patients (7.1%). associated with interventional drainage. Presentation Conclusion: The results of our study demonstrate that without a prior history of pancreatitis has not been reported. fi pancreatic resections for chronic pancreatitis may nowa- We present a case of an incidental nding. days be considered as technically feasible and safe. Espe- A 67-year-old man presented with weight loss and non- fi cially the high incidence of incidental pancreatic productive cough. There was a signi cant tobacco and adenocarcinoma underlines the necessity for an early sur- alcohol history. CXR showed left pulmonary lesion. CT gical therapy approach in these patients. TAP showed a mass in the left upper lobe consistent with primary neoplasm. The pancreas was noted to have extensive calcification in HOP, ductal calculi and pancre- atic duct dilatation. Gas was seen along body and tail EP02A-037 tracking back towards the transverse colon. A gastrografin PERIPANCREATIC ABSCESS enema confirmed the diagnosis of a PCF. Colonoscopy SECONDARY TO BILIARY ruled out any colonic pathology. The patient denied any SALMONELLA SEPSIS history of abdominal pain or prior admisions to hospital with pancreatitis. As the patient was asymptomatic, deci- A. O. Hairol1, S. M. Ikhwan2, O. Iqtidaar2, sion was made to avoid further intervention. M. F. Azem2 and V. M. Leow3 PCF associated with SAP has a low incidence but carries 1Department of Surgery, Universiti Kebangsaan Malaysia, an increased risk of mortality. PCF is most commonly Malaysia, 2Department of Surgery, Universiti Sains associated with walled-off pancreatic necrosis or abscess Malaysia, and 3Advance Medical and Dental Institute formation. The diagnosis requires CT and contrast enema. The most common causes of pancreatitis are gall- PCF may require endoscopic or surgical closure although stones and alcohol but Salmonella sp infection with when appears after percutaneous drainage might close peripancreatic collection is quite rare. This atypical spontaneously. SAP should be treated in multidisciplinary presentation needs to be kept in mind when dealing with units. In our case due to the stability of the patient a watch a case of fever with abdominal pain in our local setting and wait approach was chosen. Exocrine and endocrine in Malaysia especially if additional biochemical tests function is monitored. To our knowledge, this is the first are suggestive. asymptomatic case of pancreatic colonic fistulae described. We presented a case of a 46-year-old lady with recurrent admissions for pancreatitis. The first admission ultrasound revealed presence of multiple small gallstones and thus she was treated as gallstone pancreatitis in view of high serum EP02A-039 amylase level. During the third admission of similar REFERRAL PATTERN IN ACUTE complaint within one month, Computed Tomography scan PANCREATITIS TO SURGICAL UNIT (CT scan) was performed and showed presence of peri- AND OUTCOME pancreatic fluid collection which suggestive of necrotic G. Sharma1, R. Gupta1, S. Rana2, M. Kang3, debris and pus. In view of persisting symptoms and raised V. Sharma2 and A. Kulkarni1 infective blood parameters, she was submitted to ultra- 1General Surgery, 2Gastroenterology, and 3Radio- sound guided drainage of the collection. The drainage diagnosis, PGIMER, India content culture was Salmonella typhii .Intravenous ceftri- axone was started as per sensitivity and the patient Background: Patients have been routinely referred to surgi- improved clinically and biochemically. The repeated drain cal services once diagnosis of infected pancreatic necrosis was culture after 8 days of intravenous (IV) antibiotics was made. However with the increasing use of step-up approach at negative and CT reassessment of collection showed many centers, referral pattern for these patients has changed resolved collection. Laparoscopic cholecystectomy was with very sick patients getting referred to surgical services. performed within one month. Methods: In this prospective observational study, 90 pa- This case highlights the importance of keeping in mind tients were referred to surgical services. 24 patients were the possibility of Salmonella sp infection in cases of referred for interval cholecystectomy following acute phase peripancreatic fluid collection because early diagnosis of pancreatitis and 66 were referred for further management and treatment can lead to resolution of the potentially in the acute phase of disease from January 2016 to June 2017. fatal condition. Once the etiology is identified, prompt Results: In this study, of the 66 patients, 4 patients were treatment with antibiotics as per sensitivity, percutaneous excluded from the study. 55 patients had severe disease and drainage and followed by cholecystectomy yield very 7 had moderately severe disease. 40 patients were managed good results. with PCD only, 1 patient was referred after endoscopic

HPB 2018, 20 (S2), S505eS684 S516 Electronic Posters (EP02A-EP02F) e Pancreas necrosectomy, and 16 patients required surgery of which 15 Introduction: The purpose of our study was to determine were being managed with PCD. Overall Sepsis reversal with the effect of mutation in the cationic trypsinogen gene PCD was seen in 55.3% patients. Curative efficacy of PCD (PRSS1) on the severity of acute pancreatitis. was 46.4%. Patients referred within one week of PCD Methods: The study included 54 patients (mean age placement had better survival (20.8% vs. 54.8%, P=0.011), 41.8 Æ 12.9 years) with necrotising pancreatitis (n=34; higher sepsis reversal with PCD (75% vs. 42%, P=0.014) 62.9%) and interstitial oedematous pancreatitis (n=20; and lower surgical mortality (16.6% vs. 77.7%) as compared 37.1%). to patients referred after one week of PCD insertion. Genomic DNA was extracted from peripheral blood Conclusions: In the step-up era, there has been change in mononuclear cells using the GeneJet Whole Blood referral pattern in acute pancreatitis with patients being Genomic DNA Purification Mini Kit (ThermoScientific, referred in the later part of the disease process. In this study, USA). For identification of Arg122Hi polymorphic al- early referral to the surgical unit with respect to PCD leles of the PRSS1 gene amplification of the corre- placement has shown better outcomes. sponding gene site on the iCycler IQ5 device (BioRad, USA) was performed. Amplification mode: 93oC, 1 min; EP02A-040 35 cycles: 93oC, 10 seconds; 64oC, 10 seconds; 72oC, 20 EARLY CT SCAN IS NOT USEFUL IN seconds. PREDICTING SEVERITY OF ACUTE Results: Polymorphic allele Arg122His of the PRSS1 gene was detected in 46.3% of patients with necrotising PANCREATITIS: ANALYSIS OF 1412 pancreatitis. CONSECUTIVE PATIENTS IN A There was a strong statistically significant association TERTIARY CARE ITALIAN HOSPITAL between the mutation in the PRSS1 gene and the formation M. Massani1,G.Marte2,B.Pauletti2,A.Veltri2 and N. Bassi2 of pancreatic necrosis (r=0.651). 1Signor, and 2IV Dpt of Surgery, Regional Hospital, Italy The chance of pancreatic necrosis in patients with mu- Objective: The aim of our study is to verify the prognostic tations in the PRSS1 gene was 11.11 times higher than in e role of Computer Tomography (CT) in early and delayed patients without this mutation [95%, 2.93 42.2]. phase of moderately severe and severe acute pancreatitis (AP). The relative risk indicator demonstrated that there was Methods: We retrospectively reviewed 1412 patient’s data a direct relationship between the mutation of the PRSS1 from January 2006 to December 2015 in our Surgical gene and the pancreatic necrosis. In patients with mu- tation in the PRSS1 gene, the pancreatic necrosis was Department of Treviso Hospital. We then analyzed 248 patients following RAC criteria. Early and delayed CTSI observed 2.4 times more often than without it [95%, e were compared with bedside index for severity in acute 1.4 4.12]. Conclusion: pancreatitis (BISAP) and serum C-reactive protein levels. The presence of mutation in the gene of fi Results: Concerning all 1412 patients, the 17.5% had cationic trypsinogen (PRSS1) signi cantly increases the moderately severe and severe AP. Of the 248 patients, 133 risk of severe forms of acute pancreatitis. were male and 115 female. Biliary aetiology was the most common seen in 47.6% of the cases. Early and delayed CTSI score showed a statistical significant correlation (p- EP02A-042 value < 0.05); while no statistical correlation was found SALVAGE MINIMALLY INVASIVE between CTSI and BISAP score. CRP-48h strongly SURGERY AFTER FAILED INITIAL correlate with SIRS criteria. PERCUTANEOUS DRAINAGE AS STEP- Discussion: Both early and delayed CTSI do not correlate with organ failure and the severity of pancreatitis. UP APPROACH IN PANCREATIC Furthermore, repeating CT scan after few days does not add NECROSIS: RESULTS OF A any significant information. BISAP showed a good pre- PROSPECTIVE STUDY dictive accuracy for moderately severe and severe AP but A. Kulkarni1, R. Gupta1, S. Rana2, M. Kang3, H. Singh1, fi no correlation was found with local imaging ndings. V. Sharma2, M. Khullar4 and G. Sharma5 Conclusions: Our study demonstrate that CTSI does not 1Division of Surgical Gastroenterology, 2Department of provide essential information in early phase, both regarding Gastroenterology, 3Department of Radiology, 4Depart- systemic and local complications. BISAP, should be used in ment of Experimental Medicine, and 5Department of early phase for a prognostic evaluation. Therefore our atti- General Surgery, PGIMER, CHANDIGARH, India tude nowadays is to delay CT scan or consider MRI as late as Introduction: Prolonged use of PCD has a possibility of possible even in moderately severe and severe pancreatitis. developing simmering sepsis and late-onset organ fail- ure.Timing of switching from PCD to surgical interven- EP02A-041 tion becomes important. We aimed to ascertain optimal THE EFFECT OF MUTATION IN THE timing of intervention mortality and morbidity with VARD. GENE OF CATIONIC TRYPSINOGEN Method: Study was conducted from July 2016 to December PRSS1 ON THE SEVERITY OF ACUTE 2017. Patients with moderately severe and severe acute PANCREATITIS pancreatitis (revised Atlanta) who failed to improve or V. Petrushenko, D. Grebeniuk, A. Levanchuk, K. Pankiv, deteriorated within 7 days after PCD were included. Patients I. Radoga, V. Stoika and S. Khytruk who did not respond to aggressive PCD management Department of Endoscopic and Cardiovascular Surgery, received minimally invasive surgical intervention. National Pirogov Memorial Medical University, Ukraine Results: 55 patients were assessed and 36 were inclu- ded.Severe acute pancreatitis was present in 88.9% (n=32).

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S517 fi Mean APACHE and modi ed Marshall Score at presenta- EP02A-045 tion were 10.3Æ 5.5 and 3.69Æ2.6 respectively. MCTSI at time of presentation was 8.72Æ1.66. Overall, 63% (35/55) EARLY SURGICAL INTERVENTION patients were successfully managed with PCDs alone. In FOR CHRONIC PANCREATITIS those who failed initial PCD drainage, the PCD success rate IMPROVES PATIENT OUTCOME e A was 44% (16/36). Indications for surgery included unre- RETROSPECTIVE, SINGLE-CENTER solved sepsis in 7 patients and colonic ischemia, bowel STUDY obstruction and flank abscess in one each. 8 surgical in- terventions were performed in 7 patients (VARD-6, mini- M. J. Reichert, M. Schernhammer, D. Hartmann, C. Jäger, mal incision-2). Patients were operated at a mean of 48.2 H. Friess and G. O. Ceyhan Æ6.6 days from onset of pain. Incidence of positive blood Department of Surgery, Klinikum rechts der Isar, Tech- culture(p=0.03) and requirement of TPN(p< 0.01) were nical University of Munich, Germany significantly more in patients who were operated. Overall Introduction: Chronic pancreatitis (CP) is a non-infectious mortality for whole group was 25.4%(14/55),mortality in inflammation of the pancreas, usually associated with re- PCD only group was 34.5 %(10/29) and in PCD+VARD lapsing pain attacks. The treatment of CP is initially a was 57.1%(4/7). domain of conservative therapy. In the case of complicating Conclusion: 63% patients were managed with PCD and symptoms, endoscopic therapy with repeated interventional irrigation alone. Mortality remained high in patients stenting is usually performed, often leading to a delay of requiring surgery after extended PCD drainage. surgical treatment options. Method: Our primary hypothesis is that early surgical treat- ment of patients with CP results in an improved patient EP02A-043 outcome. For this purpose, we performed a retrospective, single-center analysis of 150 patients, who underwent surgery CORRELATION BETWEEN THE LEVEL due to chronic pancreatitis at the Klinikum rechts der Isar OF PROINFLAMMATORY CYTOKINES Munich between 2007 and 2017. In addition to demographic AND THE SEVERITY OF NECROTISING and disease-relevant data, the onset of symptoms, the number PANCREATITIS of interventions, the time of surgical treatment, and associated endoscopic and surgical complications were analyzed. V. Petrushenko, D. Grebeniuk, N. Liakhovchenko, Results: According to our retrospective analysis of 150 CP O. Zatserkovna, O. Levadnyi and V. Sobko patients (32% female, 68% male) of different etiology a Department of Endoscopic and Cardiovascular Surgery, significant reduction of endoscopic interventions after National Pirogov Memorial Medical University, Ukraine surgical therapy is shown. The time span from the first Introduction: The purpose of the study was to estimate presentation after onset of symptoms to the first operative fl the correlation between the level of proin ammatory intervention was < 5 months to > 72 months. Patients who cytokines (PCs) and the severity of necrotising pancrea- underwent early surgical intervention had fewer total titis (NP). endoscopic interventions and less morbidity. Methods: The study included 108 patients with diagnosis Conclusions: Frequent endoscopic stenting and associated of NP. IL-8, IL-6, IL-1b and TNF-a levels in serum and in complications often result in a lengthy and stressful situa- fl the peritoneal uid were determined. tion for the patient. An endoscopic therapy should therefore fl Results: Levels of PCs in peritoneal uid (near the in- be performed only as a bridging measure until surgical fl fi ammatory site) were signi cantly higher than the corre- therapy or acute intervention in the septic or non-operable < sponding values in serum (p 0.01). patient. Apart from such situations, early treatment of pa- In patients with high levels of PCs in the blood serum, tients with CP should be sought. fluid accumulation in parapancreatic areas and in the abdominal cavity, as well as multiple organ failure, were more common. At IL-1b values 12.0 pg/ml and TNF-a 20.0 pg/ml, EP02A-046 we observed the most severe course of NP - with hyper- ACUTE PANCREATITIS IN THE leukocytosis, hyperthermia, marked signs of multiple organ ELDERLY failure and common necrosis in the pancreas and para- J. Almeida, C. Soares, T. M. Rocha, J. Pinto-de-Sousa and pancreatic sites. Body temperature indices depended on the M. Oliveira concentration of PCs in serum, primarily on the level of Centro Hospitalar Tâmega e Sousa, Portugal TNF-a (r=0.57, p< 0.01). A direct correlation between the Introduction: Acute pancreatitis (AC) is a common pa- concentration of IL-8, IL-6, IL-1b and TNF-a and the thology. However, associated morbidity and mortality in number of neutrophils and lymphocytes (p< 0.05) was very old patients remains unclear. The objective of this found. study was to evaluate the morbidity and mortality associ- The direct correlation between the concentrations of all ated with AP in patients aged  85 years. PCs and the values of the hematocrit number - IL-1b Methods: Retrospective cohort study of hospitalized pa- (r=0.92; p< 0.001), IL-6 (r=0.49; p< 0.05), IL-8 (r=0.62; tients diagnosed with AC between May 2013 and May p< 0.001) and TNF-a (r=0.62; p< 0.01). 2016, aged  85 years. Conclusion: PCs stimulate the development of hypo- Results: In the indicated period, 907 patients with AC were volemia and inflammatory reactions by deepening micro- hospitalized; 81 with  85 years (8.9%). Fifty-two patients circulation disorders, which are a hallmark of early stages (64%) were female. Biliary etiology was the most frequent (58 of severe NP. patients, 71.6%). Seven patients had been cholecystectomized

HPB 2018, 20 (S2), S505eS684 S518 Electronic Posters (EP02A-EP02F) e Pancreas and in 15 patients (18.5%) there was at least one previous Methods: “I, II, III and IV” mean multiple persistent, hospitalization for PA. The mean hospitalization time was 11 single persistent, transient or no OF while “a, b and o” for days (min 3, maximum 67), the morbidity rate was 49%, and infective, aseptic and no complications respectively. By the the in-hospital mortality rate was 6%. Thirty patients under- mean of “Roman letters + English letters” we evaluated AP went cholecystectomy with intra-operative cholangiography. patients who survived the early OF period into the local Surgery was rejected by 23 (76.7%). Of these, 12 were complications period (see figure A), “X” represented death readmitted (52%). Of the patients operated, 2 presented grade in early stage due to OF. Mortality, surgical rates and ICU IIIb complications of the Clavien-Dindo classification. stay were retrospectively analyzed in 313 AP patients, Conclusion: AP in the very elderly patient seems to be asso- compared with RAC and DBC. ciated with prolonged hospitalization times, high morbidity Result: Survival analysis between “I, II, III, IV” and “a, b, o” rates and not negligible mortality rates. Prospective studies validated the division of AP in two stages by OF and local specifically designed to assess the role of cholecystectomy in complications (see figure C). ICU stay, surgical rates were this particular subgroup of patients are needed. significantly different between 13 levels (see figureB).X,Ia, IIa, Ib, IIb, Io and IIo all belonged to SAP with 2012RAC, with EP02A-047 different mortality. With 2012DBC, group X was under- estimated as SAP due to without infection (see figure D). DOES RADICALITY OF FREY Conclusion: “13 levels” was easy for memory and application PROCEDURE FOR CHRONIC by two letters for critical factors in two stages of pancreatitis. PANCREATITIS INFLUENCE THE LATE With the help of subdividing and bug removing the homoge- RE-INTERVENTION RATE AFTER neity and accurity of classification both increased. SURGERY? Keywords: Severe/Critical acute pancreatitis (SAP/CAP); organ failure (OF); Revision of Atlanta classification in 2012 H. Ramesh and J. Mathew (RAC); Determinant-based classification in 2012 (DBC). Surgical Gastroenterology & Liver Transplantation, Lakeshore Hospital & Research Center, India Background: There is a paucity of data on late re-in- terventions after Frey Procedure for chronic pancreatitis. Aim: To determine if extent of head coring influences rates of re-intervention after Frey procedure. Study design: Retrospective analysis. Patients and methods: The data of 500 patients in 3 groups (A=105, B=192 and C-203) treated over different time periods and increasing radicality of head coring were analysed to determine re-intervention rates and outcomes after re-intervention. Results: 70 re-interventions were required in 53 patients. 56 of these occurred in the first 4 years after surgery. Reinterventions were significantly more frequent in group A (30/105; 29%), and B (18/192 patients; 9%) than in C (5/ 203; 2%). Reinterventions were endoscopic in 45 and surgical in 25 cases. Reinterventions included endoscopic biliary stenting (n=27), pancreatic stenting (n=8), chol- edochoduodenostomy (n=3), repeat Frey procedure (n=8), Whipple resection (n=6), endoscopic pseudocyst drainage (n=12), and tail abscess drainage (n=2). There was no mortality. Overall, 51 out of 53 patients are well after reintervention over long-term follow up. Conclusion: Increased radicality of head coring decreased the 13 grades for AP severity classification. number of re-interventions after Frey procedure. Outcomes after such reintervention were good in most cases. The ma- jority of interventions occurred within 4 years after surgery. EP02A-049 EP02A-048 SEVERE PANCREATITIS IN A CHILEAN A NEW CLASSIFICATION OF THE COHORT: DOES BILIARY SEVERITY OF ACUTE PANCREATITIS PANCREATITIS HAVE A MORE BENIGN Y. Zhang and T. -B. Liang COURSE? The Second Affiliated Hospital of Medical College, F. Castillo1, P. Fluxá1, J. Reyes1, S. Cabrera2 and Zhejiang University, China R. Abularach1 Introduction: A good assessment system of acute 1Digestive Surgery, University of Chile / Barros Luco pancreatitis is important for clinical studies. RAC is widely Hospital, and 2University of Santiago of Chile, Chile used but neglects the role of necrotic infection, as well DBC The purpose of this study was to assess the mortality of underestimates the early death patients. So we developed severe pancreatitis, according to the origin of the disease. “13 grades”.

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Methods: Between 2009 to 2017, a retrospective cohort of retrospectively through medical notes. AP severity grade 53 patients was recruited, and data was grouped by the was classified according to the revised Atlanta classification. origin of the pancreatitis, surgical procedure requirement as Results: 1665 Spanish patients and 260 Swedish pa- management strategy for severe pancreatitis, and relevant tients with AP were included. Gender, etiology, BMI, clinical data. Results were associated with patient survival. age, smoking, time from onset of disease to admission For statistical analyses, p values < 0.05 were considered and SIRS upon admission were overall almost equal significant in all analyses. between the two cohorts. Also, development of transient Results: 62% of the patients were male, with a median age and persistent organ failure as well as ICU admission, of 59 years. The median Marshall score was 8. In 25 pa- invasive intervention and mortality was similar. How- tients (47%), the origin of pancreatitis was biliary. 8 pa- ever, previous comorbidities (diabetes, lung, heart and tients were admitted for hypertrigliceridemic pancreatitis. kidney disease) differed significantly between the The survival proportion at 8 years was 53.4%. 19 patients countries. died, 3 were excluded from the analysis (cause of death not Conclusions: Herein we describe the clinical characteris- related to pancreatitis). Patients were grouped according to tics of AP in two large European cohorts. In this study origin in Biliary Pancreatitis and Non Biliary Pancreatitis. previous comorbidities did not seem to have any impact on When overall survival of both groups was compared, no the outcomes of the patients. statistically differences were found (p = 0.3).

EP02A-051 SERUM TRIGLYCERIDE LEVEL AS A PREDICTOR OF LOCAL COMPLICATIONS AND SEVERITY IN ACUTE PANCREATITIS M. Adell Trape, J. N. Hidalgo, E. Pando, P. Alberti, L. Vidal, C. Dopazo, C. Gomez, M. Caralt, J. Balsells and R. Charco Hepato-Pancreato-Biliary and Transplant Surgery, Hos- ’ Survival comparation. pital Universitario Vall d Hebron, Universidad Autónoma de Barcelona, Spain Background: A multitude of predictive models have been When cause related deathswere analysed, 8 (47%) were developed to predict the severity of acute pancreatitis (AP). from biliary origin. 13 patients required a surgical pro- Nevertheless, the impact of different levels of hyper- cedure (including ERCP, biliary drainage or necrosec- triglyceridemia on local complications and severity of AP tomy), 6 of which died (46%). has not been clearly defined. In this study, we aimed to Conclusions: In severe pancreatitis, the global mortality analyze the influence of elevated triglyceride (TG) level in remains high (32%), with no differences according to the AP and its prognosis. origin of the disease (32% of mortality in the biliary group). Methods: Clinical data of 118 patients enroled pro- Necrosectomy procedure was required in 6 patients, 4 from spectively at our institution were analysed, serum tri- the biliary group. Biliary does not seem to have a more glyceride levels was measured within the first 24 hours. benign outcome. We excluded patients with hypertrigliceridemia as an ethiology of AP. According to the highest triglyceride level, the patients were divided into a normal TG group EP02A-050 (< 200mg/dL) and an elevated TG group (200mg/dL). CLINICAL FEATURES UPON Parameters evaluated were: local complications (pancre- ADMISSION AND OUTCOMES OF atic necrosis infection, need for invasive procedures PATIENTS WITH ACUTE against necrosis) and AP severity; persistent organ failure e (POF), admission to intensive vare unit (ICU), PA PANCREATITIS COMPARISON severity according to the Atlanta Classification) and BETWEEN TWO EUROPEAN COHORTS mortality and persistent systemic inflammatory response H. Sternby1, S. Regnér1, E. de Madaria2 and Spanish syndrome (PSIRS). Pancreatitis Group Results: The TG elevation at the early stage of AP was 1Department of Surgery, Institution of Clinical Sciences associated with higher incidence of pancreatic necrosis Malmö, Lund University, Sweden, and 2Department of (69.6%versus 38.3%, P=0.007), need for invasive proced- Gastroenterology, Alicante University Hospital, Spain ure against necrosis (30.4% versus 6.3%, P =0.001), hos- > Introduction: There is still a lack of conclusion on the pital stay 20 days (52.2% vs. 24.2%, P = 0.008) and impact of early characteristics of acute pancreatitis (AP) higher mortality (17.4% versus 5.3%, p=0.049). Incidence patients with regard to disease severity. The aim of this of POF, admission to ICU, Atlanta severity score, PSIRS, study was to describe the clinical features of patients with pancreatic necrosis infection were higher in elevated TG fi AP in two European cohorts. group but without statistically signi cant. Methods: Adults with AP were consecutively enrolled at 23 Conclusions: We have found that increased TG levels following Spanish centers and one Swedish center. Clinical data the onset of AP are associated with local pancreatic complications, regarding the patients were obtained upon inclusion and longer hospital stay and higher mortality.

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EP02A-052 PCR levels were dosed and APACHE-II index followed during the first 72 hours since symptomatic onset and pa- EVALUATION OF THE MODIFIED CT tients underwent contrast-enhanced CT within the first SEVERITY INDEX (MCTSI) AND CT week of symptom onset. Patients were divided in two SEVERITY INDEX (CTSI) IN ASSESSING groups: PCT  2ng/ml and PCT< 2ng/ml. Chi-square and SEVERITY AND CLINICAL OUTCOMES area-under-the-curve receiver-operating characteristics IN ACUTE PANCREATITIS (AUC) were applied. Parameters evaluated were: local complications (pancreatic necrosis infection, need for P. Alberti, E. Pando, L. Vidal, J. N. Hidalgo, C. Gomez, invasive procedures against necrosis) and AP severity; C. Dopazo, L. Blanco, M. Caralt, J. Balsells and R. Charco persistent organ and multiorgan failure (PO, PMOF), Hepato-Pancreato-Biliary and Transplant Surgery, Hos- admission to intensive care unit (ICU), PA severity ac- ’ pital Universitario Vall d Hebron, Universidad Autónoma cording to the Atlanta Classification) and mortality. de Barcelona, Spain Results: PCT levels  2ng/ml outperformed CRP 15mg/ Background: The aim of our study was to compare the dl and APACHE-II for transient organ failure (AUC 0.757, MCTSI, CTSI and APACHE II indices for predicting local p=0.04) and infected necrosis (AUC 0.806, p=0.043). For complications and severity in acute pancreatitis (AP). POF, MOF, mortality, need of intensive care unit, Methods: Clinical data of 137 patients enrolled prospec- prolonged hospital stay, and need for an invasive proced- tively at our institution were analyzed. They underwent ure, none of the biological markers nor the physiological contrast-enhanced CT within the first week of symptom index showed a decent area under the curve and statistical onset. Parameters evaluated were: local complications significance. (pancreatic necrosis infection, need for invasive procedures Conclusion: Procalcitonin levels greater or equal than 2ng/ against necrosis) and AP severity (persistent organ failure, ml more accurately predicts organic failure and necrotic admission to intensive care unit (ICU), PA severity ac- pancreatic infection. cording to the Atlanta Classification) and mortality. Chi- square and area-under-the-curve receiver-operating char- acteristics (AUC) were applied. EP02A-054 Results: For local complications, the CTSI index showed little superiority over the MCTSI and APACHE II index in RISING IN BUN OVER 24H AND predicting an invasive procedure (AUC 0.824, CI: 0.71e HAEMATOCRIT ‡44% PREDICTS 0.94) and pancreatic necrosis infection (AUC 0.823, CI: SEVERITY AND LOCAL 0.70e0.95). For AP severity prediction, the MCTSI COMPLICATIONS IN ACUTE showed superiority over CTSI and APACHE II for every PANCREATITIS single criteria evaluated: persistent organ failure (AUC 0.747, CI: 0.64e0.85) AP severity (AUC 0.758, CI: 0.65e E. Pando, P. Alberti, L. Vidal, J. N. Hidalgo, C. Dopazo, 0.87), need for ICU (AUC 0.736, CI: 0.61e0.86) and L. Blanco, M. Caralt, C. Gomez, J. Balsells and R. Charco mortality (AUC 0.826, CI: 0.72e0.94). Hepato-Pancreato-Biliary and Transplant Surgery, Hos- ’ Conclusion: The MCTSI index more accurately predicts pital Universitario Vall d Hebron, Universidad Autónoma acute pancreatitis severity than CTSI and APACHE II. de Barcelona, Spain MTCSI is also a good local complications predictor such as Background: The aim of our study was to compare need of intervention and pancreatic necrosis infection. admission haematocrit  44%, blood urea nitrogen (BUN) and variations in their levels over 24 h with acute physi- ology and chronic health evaluation II score (APACHE II)  EP02A-053 and C-reactive protein levels 15mg/dl, in order to determine the most accurate laboratory test for predicting PROCALCITONIN LEVELS AT pancreatic necrosis and severity in acute pancreatitis (AP). ADMISSION AS A PREDICTOR OF Methods: Clinical data of 212 AP patients, prospectively INFECTED PANCREATIC NECROSIS IN enroled for study at our institution, were analysed. The ACUTE PANCREATITIS predictive accuracy of the laboratory test was measured using area-under-thecurve receiver-operating characteris- L. Vidal, E. Pando, P. Alberti, J. N. Hidalgo, L. Blanco, tics (AUC) analysis and sensitivity and specificity tests. M. Caralt, C. Gomez, N. Puertolas, J. Balsells and Results: Rising in BUN over 24h outperform other labo- R. Charco ratory parameters and APACHE II, for severity of AP; Hepato-Pancreato-Biliary and Transplant Surgery, Hos- persistent organ failure (AUC: 0.716, p=0.000), persisting pital Universitario Vall d’Hebron, Universidad Autónoma multiorgan failure (AUC: 0.786, p=0.000), mortality de Barcelona, Spain (AUC:0.826,p=0.000), intensive care unit admission Background: Recognizing a priori potential critical pa- (AUC: 0.789, p=0.000) also for local complications as; tients that could develop local complications (need of infected pancreatic necrosis (AUC: 0.680, p=0.025) and invasive procedures and necrosis infection) during acute needed for intervention procedures against necrosis (AUC: pancreatitis (AP) onset is determinant for morbimortality 0.737, p=0.001). Haematocrit  44% on admission was the and healthcare costs. The aim of the study was to determine only siignificant test predicting intrapancreatic necrosis  whether higher procalcitonin levels, PCR levels 15mg/dL (AUC: 0.64 CI: 0.547e0.732). In a composite analysis of  and APACHE-II index 8 at admission could predict patients with haematocrit  44% on admission and/or severity of AP and local complications. Rising BUN over 24 h, the rate of persistent organ failure Methods: Clinical data of 55 AP patients, prospectively rose compared with patients without this characteristics enrolled for study at our institution were analyzed. PCT and (20.4% vs 5.1%, OR: 4.8 CI: 1.75e13.1).

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Conclusion: Rising in BUN over 24h plays a role in the after symptoms onset) could relate with acute pancreatitis prediction of severity and local complications in acute (AP) severity and local complications (need for an invasive pancreatitis. Haematocrit  44% on admission plays a role procedure against necrosis/infected necrosis). in the prediction of pancreatic necrosis. Methods: Clinical data of 57 AP patients, enrolled pro- spectively at our institution were analyzed. PCT levels were dosed during the first 72 hours since symptomatic onset and EP02A-055 patients underwent contrast-enhanced CT within the first THE ROLE OF EXTRA-PANCREATIC week of symptom onset. Parameters evaluated were: local INFECTIONS IN THE PREDICTION OF complications (pancreatic necrosis infection, need for SEVERITY AND LOCAL invasive procedures against necrosis) and AP severity: persistent organ and multiorgan failure (POF, PMOF), COMPLICATIONS IN ACUTE admission to intensive care unit (ICU), PA severity ac- PANCREATITIS cording to the Atlanta Classification (AC) and mortality. In E. Pando, P. Alberti, L. Vidal, M. Adell Trape, C. Gomez, order to determine statistical significance, Pearson’s chi- M. Caralt, L. Blanco, C. Dopazo, J. Balsells and R. Charco squared test and Fisher’s exact test were used. Hepato-Pancreato-biliary and Transplant Surgery, Hos- Results: There was no significant relation between PCT pital Universitario Vall d’Hebron, Universidad Autónoma levels 2ng/ml and mortality, POF, PMOF, ICU, prolonged de Barcelona, Spain hospitalization, AP severity according AC and the presence  fi Background: The aim of our study was to determine the of pancreatic necrosis. PCT 2ng/ml had a signi cant < predictive power of extra-pancreatic infections (EPI) for statistical association for transient OF (72.7% vs 13%, p assessing severity and local complications in AP including 0,0005), antibiotics use (81.8% vs. 28.9%, p=0,001), need infected pancreatic necrosis (IPN). for an invasive procedures against necrosis (27.3% vs. 4.3% Methods: Clinical data of 280 AP patients prospectively , p=0,045) and infected pancreatic necrosis (27.3% vs 2.2%, enroled were analysed. EPI analysed were bacteraemia, p=0.014). pneumonia, urinary tract infection and catheter line infec- Conclusion: At admission, dosing PCT levels could help tion. Severity outcomes assessed were persistent organ determine acute pancreatitis clinical course and the pres- failure (POF), persistent multi-organ failure (PMOF), ence of local complications, especially the need of invasive mortality, hospital stay and intensive care unit (ICU) procedures against local complications. admission. A comparison using APACHE-II>8 points was made. For local complications, 37 consecutive patients with acute necrotising pancreatitis (ANP) were enroled. IPN was EP02A-057 defined as a positive culture after necrosectomy. The pre- EXTRAPANCREATIC NECROSIS WITH dictive accuracy of EPI was measured using area-under- PANCREATIC (EXPN) the-curve (AUC) reciever-operating characteristics. INTRAPANCREATIC NECROSIS (INPN) Results: Fifty one cases of EPI were found (18.2%). Bacteraemia showed the best accuracy in predicting PREDICTS SEVERITY AND LOCAL significantly POF, ICU admission and hospital stay > 20 COMPLICATIONS IN ACUTE days (AUC 0.686, AUC 0.749, AUC 0.628 respectively) PANCREATITIS BETTER THAN and also for local complications including IPN and need for ISOLATED EXPN OR INPN an interventinal procedure against necrosis (AUC 0.77, L. Vidal, E. Pando, C. Dopazo, P. Alberti, J. N. Hidalgo, AUC 0.763 respectively) compared with pneumonia or C. Gomez, L. Blanco, M. Caralt, J. Balsells and R. Charco APACHE-II>8 points. Bacteraemia was present in 9/15 Hepato-Pancreato-Biliary and Transplant Surgery, Hos- cases of IPN, and preceded IPN in 6 cases. On the other pital Universitario Vall d’Hebron, Universidad Autónoma hand pneumonia shows a good accuracy for dead and de Barcelona, Spain PMOF (AUC: 0.674 and AUC: 0.680). Conclusion: In our study, EPI, particularly bacteraemia, Background: In the course of acute necrotizing pancrea- played a role in predicting severity and local complications titis the presence of extrapancreatic necrosis (EXPN) and fl fi in AP. its in uence over the clinical course is not well de ne. Methods: Clinical data of 237 patients enrolled prospec- EP02A-056 tively at our institution were analyzed. They underwent fi ARE PROCALCITONIN LEVELS ON contrast-enhanced CT or RMN within the rst week of symptom onset. Parameters evaluated were: local compli- ADMISSION RELATED TO ACUTE cations (pancreatic necrosis infection, need for invasive PANCREATITIS SEVERITY AND LOCAL procedures against necrosis) and AP severity (persistent COMPLICATIONS? organ and multiorgan failure (POF, MOF), admission to M. Adell Trape, P. Alberti, C. Dopazo, E. Pando, L. Vidal, intensive care unit (ICU), PA severity according to the fi J. N. Hidalgo, L. Blanco, M. Caralt, J. Balsells and Atlanta Classi cation) and mortality. EXPN and its asso- R. Charco ciation with intrapancreatic necrosis (INPN) were analysed. Hepato-Pancreato-Biliary and Transplant Surgery, Hos- Area-under-the-curve receiver-operating characteristics pital Universitario Vall d’Hebron, Universidad Autónoma (AUC) were applied. de Barcelona, Spain Results: The ocurrence of EXPN with INPN showed su- periority over the isolated presentation of EXPN or INP for Background: The aim of our study was to determine POF (AUC:0.648, p=0.004), MOF (AUC:0.69, p=0.003) whether a cut-off level of procalcitonin (PCT) greater or mortality (AUC: 0.682, p=0.022), ICU (AUC:0.656, equal than 2ng/ml at admission (during the first 72 hours

HPB 2018, 20 (S2), S505eS684 S522 Electronic Posters (EP02A-EP02F) e Pancreas p=0.028), infected pancreatic necrosis (AUC:0.808, with intraperitoneal or retroperitoneal videoscope- p=0.000) and need for an intervention against pancreatic assisted debridement for left-sided infected WON. This necrosis (AUC:0.816, p=0.000). is an original gasless technique, in contradistinction to Conclusions: The association of EXPN and INPN more videoscopic assisted retroperitoneal debridement accurately predicts severity and local complications in (VARD). acute pancreatitis than isolated EXPN or INPN. We defined predominant infected WON as right or left-sided according to the location on CT scan. In pa- tients with predominantly left-sided WON consisting EP02A-058 mostly of fluid, we perform endoscopic drainage up to CHRONIC PANCREATITIS e SURGICAL three times. If there is mainly necrotic tissue, we perform videoscope-assisted necrosectomy as the first step. While STRATEGIES AND ITS planning the approach, we consider the distance from the MANAGEMENT’S skin to the WON and interposed organs. If expansion of S. Vyas1 and C. Vyas2 the WON spreads to the omental bursa ventrally, we 1Surgery Plastic, and 2Radiology, Mahatma Gandhi select an intraabdominal approach. If the necrosis spreads Medical College and Hospital, India from the retroperitoneum anteriorly to the pararenal Aims: Worldwide Chronic pancreatitis (CP) is most extraperitoneal space, debridement is performed retro- venareble disease all over the world having highest inci- peritoneally. In patients with predominately right-sided dence of 150 to 200 cases per 100,000 persons in our infected WON, we perform conventional open country. The aim of our study was to describe our experi- necrosectomy for safety. ence in the surgical strategies of chronic pancreatitis and This new videoscope-assisted debridement is performed it’s further managment. with a 5cm skin incision. A metallic tube (Ootsuki fukukyo Methods: A retrospective study of 29 patients who un- tube (TKZ-F1338), Takasago Medical Industry, Tokyo, derwent different surgical procedures, inclusive of modi- Japan) is initially placed from the skin to inside the WON. fl fied Frey’s and modified Puestow’s procedure between A exible videoscope, suction, or laparoscopic forceps are 2015-17and with at least 6 months follow-up. De- easily inserted and removed through this tube under direct mographics, indications for surgery specific to the proce- vision. This new technique allows adequate debridement in fl dure,peri-operative and post-operative complications and a safe manner without using CO2 insuf ation. The post- late outcomes were analysed. operative course in all four patients was favorable after a Results: The median age was 35years. 22 out of the 29 single procedure. patients (58.6%) were male. Symptoms includes chronic severe abdominal pain, with 1 patient having an associated complaint of respiratory distress due to pancreatico-pleural EP02A-061 fistula. The etiology was secondary to alcohol in 12 out of DISTAL PANCREATECTOMY FOR 17 male patients(70%), i.e. 41% of total patients. Final PANCREATITIS: ARE OUTCOMES decision of operative procedure was made intra-operatively DIFFERENT BASED ON DISEASE with 55.2% patients undergoing modified Frey’s and 44.8%, puestow’s (with or without splenectomy). Com- PATTERN? plications occurred were hemorrhage, anastomotic leak, W. Lancaster, D. Adams and K. Morgan lymphatic injury. No mortality was reported. At a minimum Surgery, Medical University of South Carolina, United of 6 months follow-up 24 out of 29 patients (82.7%) had a States complete pain relief. Background: Distal pancreatectomy is performed infre- Conclusions: The purpose of surgical therapy for the disease quently for pancreatitis and reported outcomes vary.This is to relieve sever symptom that is intractable pain; to improve heterogeneous patient group has not been well-examined in the patient’s quality of life; and to treat other complications. the modern era to guide patient selection and optimal Decompression(drainage), resection (combined or separate) management. and neuroablation are commonly used methods. Methods: A prospective database of patients undergoing distal pancreatectomy at a single institution from August 2012 to August 2017 are evaluated.Preoperative, periop- EP02A-060 erative, postoperative data as well as postoperative endo- VIDEOSCOPE-ASSISTED scopic intervention were assessed. NECROSECTOMY OF LEFT-SIDED Results: A total of 96 patients underwent distal pancrea- tectomy during the study period(60 men, 61%,mean age 49 INFECTED PANCREATIC WALLED-OFF years). Thirty(30%) had post-acute pancreatitis discon- NECROSIS (WON): REPORT OF FOUR nected left pancreatic remnant(DLPR), 30% chronic PATIENTS pancreatitis with mid-body stricture or inflammatory H. Sasanuma, N. Sata, M. Taguchi, A. Miki, K. Endo, pseudotumor, 20% had chronic distal pseudocyst, and 20% M. Koizumi, Y. Sakuma, L. Alan and Y. Yasuda had distal necrosis. Seven patients(7%)underwent laparo- Surgery, Jichi Medical University, Japan scopic pancreatectomy.Thirty-day readmission rate was high,but lower in patients with DLPR compared to the Videoscope-assisted debridement of infected pancre- remainder of the study population (35% vs. 46%, p< atic walled-off necrosis (WON) is a minimally invasive 0.05).Significant postoperative complications(grade 3,4) technique. We report four patients successfully treated

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S523 were seen in 37% of patients with the incidence in EP02A-063 patients with DLPR(27%) similar to chronic pancreatitis (37%).Clinically relevant postoperative pancreatic fistula EVALUATION OF THE BEDSIDE INDEX occurred in 19% of patients and was most frequent in pa- FOR SEVERITY IN ACUTE tients with distal pseudocyst (53%).25% of patients with PANCREATITIS SCORE (BISAPS) IN distal pseudocyst required postoperative ERCP(median 2 PREDICTING DISEASE SEVERITY, fi procedures) for management of stula compared to 3% of ORGAN FAILURE AND MORTALITY IN patients with DLPR(p=0.05).Among patients with 6 months of follow-up,35% developed new onset diabetes ACUTE PANCREATITIS 1 2 1 and 55% had persistent opioid use. V. Sanmugachandran , H. Othman , M. Y. Abdul Wahab , 2 3 Conclusions: Distal pancreatectomy is undertaken in R. Jarmin and Z. Zuhdi 1 2 pancreatitis with high perioperative morbidity and is not Surgery, Hospital Tengku Ampuan Rahimah, Surgery, 3 often accomplished laparoscopically.Preoperative in- Universiti Kebangsaan Malaysia, and Surgery, Universiti dications are heterogeneous and have similar postoperative Kebangsaan Malaysia Medical Centre, Malaysia morbidity.Postoperative ERCP is useful in managing Introduction: Severity assessment in acute pancreatitis persistent pancreatic fistulae,which are more common in (AP) is important for early identification of patients at patients with pseudocyst. increased risk of complications and mortality and also to improve outcome.Several prognostic markers have been developed for severity stratification in acute pancreatitis, all EP02A-062 of which has its limitations. BISAP is a simple and clini- SEVERE PANCREATITIS WITH cally oriented severity scoring system that can predict the morbidity and mortality of acute pancreatitis within 24 h of COLONIC PERFORATION presentation.This early recognition of severe disease would SUCCESSFULLY MANAGED USING enable the clinician to consider more aggressive in- VIDEO-ASSISTED RETROPERITONEAL terventions within a time frame that could potentially pre- DEBRIDEMENT: A CASE REPORT vent adverse outcomes. Methods: This is a cross sectional study that was con- Y. Hozaka1, H. Kurahara1, Y. Kawasaki1, Y. Mataki1, ducted in HTAR and HCTM from January 2015 till August S. Iino1, M. Sakoda1, S. Mori1, H. Shinchi2, 2016. The BISAP and Imrie’s score was calculated using K. Maemura1 and S. Natsugoe1 data from the first 24h of admission.Severity of AP was 1Department of Digestive Surgery, Breast and Thyroid determined according to the most recently revised Atlanta Surgery, and 2Kagoshima University Graduate School of Classification. Health Sciences, Kagoshima University, Japan Results: 159 cases were recruited,there were 5(3%) deaths. Background: Colorectal complications including pene- There was a statistically significant trend for increasing tration and perforation in acute pancreatitis often become mortality (P< 0.0001) with increasing BISAP score.The severe and fatal. Effective drainage is pivotal for suc- area under the ROC for mortality by BISAP score was cessful treatment. We present a case of large retroperi- 0.945 (95% CI:-0.898 to 0.975) and 0.922 (95% CI:-0.869 toneal abscess with colonic necrotizing perforation due to to 0.959).BISAP score 2 was associated with increased severe acute pancreatitis treated with video-assisted risk of developing severe pancreatitis (odds ratio=63 (95 % retroperitoneal debridement (VARD) using a step-up CI:13.592-295).BISAP score also showed a positive cor- approach. relation with Glasgow score and CRP(P< 0.01). Case presentation: A 31-year-old man was admitted to a Conclusion: The BISAP score represents a simple way to general hospital with a diagnosis of severe acute pancre- identify patients at risk of increased mortality and the atitis due to fallen gallstones. At 10 days after onset, he development of disease severity within 24h of presentation. was referred to our hospital for more intensive treatment. This risk stratification capability can be utilized to improve On day 16, he experienced melena and shock. Therefore, clinical care and patient outcome. embolization of the three straight arteries of the descending colon was performed. On day 30, because computed to- mography showed retroperitoneal abscess, percutaneous drainage using the retroperitoneal route was performed. On EP02A-064 day 36, ileostomy was performed because the appearance RISK FACTORS OF RECURRENT of drained pus from the retroperitoneal abscess became ACUTE PANCREATITIS AND feces-like. On day 58, VARD was performed to treat the PROGRESSION TO CHRONIC fl refractory retroperitoneal abscess causing highly in am- PANCREATITIS AFTER THE FIRST matory state due to insufficient drainage. On day 85, fluoroscopic imaging showed disappearance of the abscess ATTACK OF ACUTE PANCREATITIS cavity. He was transferred to the previous hospital on J. H. Cho, E. J. Kim, Y. J. Kim and Y. S. Kim day 89. Internal Medicine, Gachon University Gil Medical Center, Conclusions: VARD enabled less invasive treatment for Republic of Korea patients with colonic necrotizing perforation due to severe Background/aims: Estimation of recurrent acute pancre- pancreatitis. atitis (RAP) and progression to chronic pancreatitis (CP) in

HPB 2018, 20 (S2), S505eS684 S524 Electronic Posters (EP02A-EP02F) e Pancreas patients with the first attack of AP is still a huge clinical 3) identification of proteins in supernatant by Proteomics challenge. We aim to elucidate risk factors for the RAP and analysis. progression to CP. Results: Of the 12 irrigation solutions, gastric juice was the Methods: Medical records of patients with the first attack most effective (and normal saline the least effective) in of AP between 2007 and 2016 were retrospectively accelerating liquefaction, as evidence by protein break- reviewed. Total of 60 patients with RAP and randomly down (P < 0.05 T-test). Histochemistry confirmed the selected 120 patients with single episode AP were included. highest breakdown of collagen and fat by gastric juice. Results: On the comparison between single episode AP and Proteomics analysis showed that gastric juice caused RAP, younger age(42.8Æ11.9 vs 57.6Æ17.2), male(76.7 vs breakdown of both the structural proteins of PN. All other 56.7%), alcohol(88.3 vs 55.0%), smoking(71.7 vs 37.5%), irrigation solutions were less effective. moderately severe/severe grade of Atlanta classification(58.3 Conclusion: Gastric juice accelerates liquefaction of PN, vs 32.5%), higher CT severity index(CTSI)(3.37Æ2.31 vs and more effectively than other enzyme solutions or normal 2.62Æ1.89), higher Triglyceride(TG)(480 vs 245 mg/dL) saline. Autologous gastric juice irrigation is worthy of were related to RAP. On the multivariate analysis, younger further study, and may increase the efficacy of both percu- age(OR 0.975; 95%CI 0.953-0.997), alcohol(OR 2.817; taneous and endoscopic drainage. 95%CI 2.010-6.561), CTSI(OR 1.196; 95%CI 1.063-1.345) were significant risk factors of recurrence of AP after first attack. In addition, among 60 patients with RAP, 24 patients EP02A-067 showed CP feature and the median time to progression to CP CLINICAL MANAGEMENT OF ACUTE was estimated to be 1247 days.(range 879-1614). Cox regression analysis presented that higher CTSI(OR 1.390; IDIOPATHIC PANCREATITIS: 95%CI 1.156-1.167), short interval to recurrence(< 1yr)(OR IDENTIFYING AREAS OF 2.872; 95%CI 1.193-6.914) and two or more recurrence(OR IMPROVEMENT AND COMPARATIVE 4.198; 95%CI 1.611-10.937) were significant risk factors of RESULTS OF OUTCOMES progression to CP after first attack of AP. T. R. X. Gan1, Y. Gao2, J. Tan3, G. Bonney1,2, Conclusions: Younger age, higher CTSI, alcohol con- K. Madhavan1,2, A. W. Kow1,2 and I. G. Shridhar1,2 sumption were significantly related to RAP. Higher CTSI 1Department of Surgery, University Surgical Cluster, Di- and short interval to recurrence, two or more recurrence were vision of Hepatopancreatobiliary Surgery and Liver associated with progression to CP after recurrent episodes. Transplantation, 2Department of Surgery, Yong Loo Lin School of Medicine, and 3Yong Loo Lin School of Medi- cine, National University of Singapore, Singapore EP02A-066 Idiopathic Pancreatitis is defined when initial evaluation IMPROVING THE EFFICACY OF with history, physical examination, focused laboratory DRAINAGE FOR INFECTED testing, and routine ultrasound does not reveal an underlying PANCREATIC NECROSIS BY etiology. While IAP-APA recommends endoscopic ultra- ENZYMATIC ACCELERATED sound (EUS), magnetic resonance cholangiopancreatog- LIQUEFACTION raphy (MRCP) and computed tomography (CT) as further investigations, adherence varies according to institutional 1 2 3 4 L. Brown , J. Hong , N. Zyromski , S. Connor , practices and preferences. Idiopathic pancreatitis outcomes 1,2 1 A. Phillips and J. Windsor are also not well-established. Our study aims to determine 1 2 Department of Surgery, University of Auckland, Uni- the extent of work-up after initial evaluation and compare versity of Auckland, Applied Surgery and Metabolism idiopathic and non-idiopathic pancreatitis outcomes in a 3 Laboratory, Indiana University Health University Hos- tertiary institution in Singapore. 4 pital, and Department of Surgery, Christchurch Public A review of acute pancreatitis cases between 2011-2014 Hospital, New Zealand was performed. Data about further investigations including Introduction: Drainage of infected fluid collections associ- EUS, MRCP, CT was collected. Outcomes including cho- ated with pancreatic necrosis (PN) commonly fail because lecystectomy, severity, recurrence, pancreatic necrosis and solid necrosum causes drain occlusion. In an attempt to pancreatitis-related mortality were compared between maintain patency and ensure drain efficacy it is common idiopathic and non-idiopathic pancreatitis. practice to flush or irrigate drains, often with Normal Saline. Of the 391 patients with acute pancreatitis, 84 were initially Alternatives to saline, including proteolytic enzymes, have identified as idiopathic. 20 had missing information and 64 been reported. The aim of this study was to investigate the were truly idiopathic. The mean age was 58.4 years (Æ 14.1). efficacy of enzymes to accelerate the liquefaction of human Of the 64, 12 (18.8%) had EUS, 7 (10.9%) had MRCP, 39 PN. (60.9%) had CTAP. Overall, 16 (25%) had none, 39 (60.9%) Methods: Ethical approval was obtained for biobanking had one, 8 (12.5%) had two and only 1 (1.6%) had all three. human PN following open necrosectomy in Auckland and Table 1 demonstrates a comparison of their outcomes. Cho- Indianapolis. Twelve different irrigating solution were lecystectomy rate was low at 7.8% for idiopathic. The severity tested, including: normal saline (control), human gastric was significantly lower (p=0.017) and recurrence higher in juice (collected from patient on proton pump inhibitor), idiopathic (18.7%) vs biliary group (10%). hydrogen peroxide and collagenase. Representative sam- Extensive specialized investigations beyond initial ples of PN were incubated with each irrigating solution. evaluation may be unnecessary in idiopathic pancreatitis, Liquefaction was measured by which is milder and associated with higher recurrence rates. 1) protein breakdown with Direct Detect protein assay, A standardized work-up algorithm would be useful given 2) fat and collagen breakdown by histochemistry and the variability in the extent of work-up.

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EP02A-067 Table 1 Outcome Idiopathic Non-Idiopathic/Non Biliary Pancreatitis p-value Pancreatitis (64) Biliary Pancreatitis (89) (238) Underwent Cholecystectomy 5 (7.8%) 12 (13.4%) 142 (59.6%) 0.000 Severity Mild 53 Moderate Mild 51 Moderate Mild 162 Moderate 0.017 9 Severe 2 24 Severe 14 50 Severe 26 Recurrence 12 (18.7%) 24 (27%) 26 (10%) 0.000

EP02B e Electronic Poster: 2B e Pancreatic Cysts EP02A-068 EP02B-001 SPONTANEOUS PERFORATION OF SYSTEMATIC REVIEW OF THE e ASCENDING COLON A LATE CLINICAL UTILITY AND VALIDITY OF IATROGENIC COMPLICATION IN THE SENDAI AND FUKUOKA NECROTIZING PANCREATITIS. CONSENSUS GUIDELINES FOR REPORT OF A CASE MANAGEMENT OF INTRADUCTAL G. Konstantoudakis1, P. Kokoropoulos1, N. Danias1, PAPILLARY MUCINOUS NEOPLASMS 2 1 C. Kontopoulou and I. Papadopoulos OF THE PANCREAS 14th Surgical Department, and 22nd Radiology Depart- 1,2 1 3 3 ment, Attikon University Hospital, Greece N. Srinivasan , J. Y. Teo , Y. -K. Chin , D. M. Tan , C. H. Thng4,5 and B. Goh Kim Poh1,5 Background: Among patients with acute necrotizing 1Department of Hepatopancreatobiliary and Transplant pancreatitis, those with infected necrosis have higher mor- Surgery, 2Yong Loo Lin School of Medicine, 3Department of tality and present various local and systematic complications. Gastroenterology and Hepatology, 4Department of Onco- We report a case of spontaneous perforation of the ascending logic Imaging, and 5Duke-NUS Medical School colon, two weeks after operation for necrosectomy. Patient: A 66-year old female patient was admitted in the Unit Introduction: The Sendai consensus guidelines (SCG) in with gallstone pancreatitis. She had Ranson criteria in 48hrs 2006 and the Fukuoka consensus guidelines (FCG) in 2012 >5 and a CT Severity index of 9 at 72hrs post admission. Two were developed to guide the management of intraductal weeks later patient condition worsened due to ascites, sepsis papillary mucinous neoplasms (IPMNs) of the pancreas. and pleural effusions. CT imaging showed two large collec- This systematic review was performed to assess the clinical tions, one in lesser sac and the other at the right retroperitoneal utility and validity of the SCG and FCG. space. The latter was drained under CT guidance and cultures Methods: A computerized search of PubMed was indicated the need for initiation of antibiotics. performed to identify all the studies which evaluated either/ Results: The patient showed some improvement but one or both the SCG and FCG in surgically resected, histo- fi month post admission she was intubated because of severe logically con rmed IPMNs of the pancreas. desaturation due to ARDS. She was underwent surgical Results: A total of 22 studies were included in this sys- necrosectomy and was transferred post-op in ICU. There tematic review out of which 10 studies evaluated the FCG, was improvement during the first days and two weeks later 8 studies evaluated the SCG and 4 studies evaluated both. intestinal content was noted from the right drain tube. She In the 14 studies evaluating the FCG, of a total of 2498 underwent laparotomy, where a perforation was found to neoplasms, 849 (34%) were malignant and 1649 (66%) the ascending colon due to errosion from the drain tube and were benign neoplasms. Pooled analysis showed that 751 a right hemicolectomy plus ileostomy was performed, of 1801 (41.7%) FCG+ve neoplasms were malignant and along with further necrosectomy. 599 neoplasms of 697 (85.5%) FCG-ve neoplasms were Conclusions: Different complications in necrotizing benign. PPV of the high-risk and worrisome-risk groups pancreatitis can be treated in various ways, from conser- were 465/986 (47.2%) and 239/520 (46%) respectively. vative management, to percutaneous drainage, video- In the 12 studies evaluating the SCG, a total of 1234 neo- assisted retroperitoneal debridement and open surgery. plasms were evaluated of which 388 (31.4%) were malignant There is no universally accepted treatment algorithm, but a and 846 (68.6%) were benign. Pooled analysis showed that step-up approach according to patient’s clinical condition is 265 of 802 (33%) SCG+ve neoplasms were malignant and the most appropriate management of this complex disease. 238 of 266 SCG-ve (89.5%) neoplasms were benign.

EP02B-001 Comparisons of results between the FCG and SCG. SCG FCG Number of studies 12 14 Number of patients 1234 2498 Malignant, n (%) 388 (31.4) 849 (34.0) Benign, n (%) 846 (68.6) 1649 (66.0) Consensus +ve, n (%) 958 (77.6) 1801 (72.1) Range of PPVs of consensus +ve 11%-52% 27%-100% Range of NPVs of consensus -ve 71%-100% 72%-100% Overall PPV, n (%) 265/802 (33.0) 751/1801 (41.7) Overall NPV, n (%) 238/266 (89.5) 599/697 (85.9)

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Conclusion: The FCG had a higher PPV compared to the Methods: We performed a retrospective analysis of 1369 SCG. However, the NPV of the FCG was slightly lower patients with BD-IPMN seen the Seoul National University than that of the SCG. Malignant and even invasive IPMNs Hospital in Korea from January 2001 through December may be missed according to both guidelines. 2016. We included only patients whose imaging studies showed classical features of BD-IPMN, and collected data from each patient over time periods of at least 3 years. EP02B-002 Results: The median annual growth rate of the cyst was 0.8 INTRADUCTAL PAPILLARY mm over a median follow-up time of 61 months. During surveillance, 46 patients (3.4%) underwent surgery due to MUCINOUS NEOPLASMS: A MODEL disease progression after a median follow-up time of 62 FOR INSTITUTING POPULATION- months. Worrisome features were observed in 210 patients BASED SCREENING PANCREAS MRI (15.3%) during surveillance, including cyst size of 3 cm or C. Ball, D. Ng, A. Bressan, E. Dixon and G. Kaplan more (n=112, 8.2%), cyst wall thickening (n=51, 3.7%), University of Calgary, Canada main pancreatic duct dilatation (n=77, 5.6%), and mural nodule (n=43, 3.1%). Along with annual rate of cyst Introduction: Intraductal papillary mucinous neoplasms growth, incidences of main pancreatic duct dilatation and (IPMN) represent an occasional precursor to pancreatic mural nodules associated with the sizes of cysts at detection adenocarcinoma. Widespread screening for IPMNs has not (P< .001). been pursued due to perceived cost and an unpredictable Conclusion: In a retrospective analysis of patients with natural history of the lesions themselves. The purpose of BD-IPMN followed for more than 5 years, we found most this study was to develop a model for population-based, cysts to be indolent, but some rapidly grew and progressed. low cost screening for IPMNs. Surveillance protocols should therefore be individualized, Methods: Economic and statistical modelling was based on initial cyst size and rate of growth. employed to create a plausible screening guideline for identifying IPMNs in an aging population. Results: Over 5,780,900 (16.1%) Canadians are 65 years old or older (10.1 seniors for every child under 15 years). EP02B-004 This cohort is also growing faster than all other segments MUCINOUS NON-NEOPLASTIC CYST (3.5% growth per year; 4 times faster than the population). OF THE PANCREAS: IS SURGICAL The diagnosis of IPMNs cluster at age 63 years. A limited RESECTION AVOIDABLE? pancreatic screening magnetic resonance imaging (MRI) S. Agrawal1, M. Bal2 and S. Jain3 study (coronal and thin-slice T2 axial image acquisition) 1 requires less than 1 minute to complete. The cost per scan is Hepatobiliary and Pancreatic Surgery, Department of $398.64 (CAN) in the public payer system. This compares to Surgical Oncology, Indraprastha Apollo Hospitals, 2Department of Pathology, Tata Memorial Hospital, and $157.44 for a screening colonoscopy and $88.65 for 3 screening mammography. The initial pancreas MRI Surgical Gastroenterology, Sakra world Hospital, India screening image acquisition cost for all Canadians between Introduction: Mucinous non-neoplastic cyst (MNNC) is ages 60 and 64 would approximate 946.12 million dollars an emerging subset of pancreatic cysts and its preoperative (QALY=$99,341 compared to no screening). This compares differentiation from mucinous cystic neoplasm (MCN) or to 4.13 million dollars (lifetime cost) for annual mammog- intraductal papillary mucinous neoplasm (IPMN) with raphy per 1000 woman aged 50 to 69 (total cost is 20.18 innate dysplasia and a high malignant potential presents a billion dollars; QALY=$95,313 compared to no screening). diagnostic challenge due to several overlapping clinical, Conclusion: A population-based MRI screening strategy radiological and biochemical features including a mucin- for detecting IPMNs in patients over 60 years of age is producing lining and elevated cyst fluid CEA. reasonable when compared to other established oncologic Method: A 66-year-old female presented with postprandial screening programs. epigastric pain radiating to the back. Laboratory data were unremarkable. Abdominal ultrasound and contrast- enhanced computed tomography scan revealed a hypo- EP02B-003 dense area in the tail of the pancreas consistent with a simple cyst. An endoscopic ultrasonography and FNA PROGRESSION OF PANCREATIC demonstrated a thin-walled unilocular cyst consistent with BRANCH DUCT INTRADUCTAL a mucinous cyst.The patient underwent a distal pancrea- PAPILLARY MUCINOUS NEOPLASMS tectomy and surgical pathology demonstrated a mucinous ASSOCIATES WITH CYST SIZE non-neoplastic cyst (MNNC) of the pancreas. Result: MNNC has no malignant potential and does not Y. Han, H. Lee, J. S. Kang, J. R. Kim, H. S. Kim, require surgical resection or surveillance; however, as it W. Kwon, S. -W. Kim and J. -Y. Jang mimics MCN and IPMN improved preoperative charac- Surgery, Seoul National University Hospital, Republic of terization of the cyst on computed tomography scan and Korea magnetic resonance imaging, endoscopic ultrasonography Backgrounds: Most guidelines for management of patients with cyst fluid analysis are required to avoid unnecessary with intraductal papillary mucinous neoplasms (IPMN) vary pancreatic resection. d in proposed surveillance intervals and durations these are Conclusion: The data suggest that novel molecular usually determined based on expert opinions rather than techniques are required for the accurate preoperative substantial evidence. We evaluated the progression of branch identification of MNNC to avoid unnecessary pancreatic duct (BD)-IPMN under surveillance at a single center, and resection. determined optimal follow-up intervals and duration.

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EP02B-006 Preoperative diagnosis was correct in two cases. None of the cysts were aspirated preoperatively. LYMPHOEPITHELIAL CYST OF Results: Cysts were located in the body and tail of pancreas PANCREAS: A CASE REPORT and their sizes were 3, 7 and 12 cm. Surgeries performed C. K. Cho1, E. K. Park1 and H. J. Kim2 were distal pancreatectomy with splenectomy in two cases, 1Surgery, Chonnam National University Medical School, and one of them laparoscopically. The third case was managed 2Surgery, Suhgwang General Hospital, Republic of Korea with partial cystectomy after protecting the surgical field Introduction: A lymphoepithelial cyst (LEC) of the and using hypertonic sodium chloride as a scolicide sub- pancreas is very rare benign cystic lesion of pancreas and is stance. Two patients received albendazole preoperatively not associated with malignant potential. The differential and all of them in the postoperative period. The post- diagnosis of LEC with other cystic tumor of pancreas by operative recovery was satisfactory and up to date there is pre-operative imaging study is almost impossible. no evidence of recurrence in any of three patients. Methods: A 55 years old man was referred to our hospital Conclusion: Hydatid cysts should be included in the dif- presenting incidentally detected cystic mass in retro- ferential diagnosis of pancreas cystic lesions, mainly in pancreatic space on abdominal computed tomography. He endemic areas. was treated with endoscopic submucosal dissection for gastric high grade dysplasia a month ago. Abdominal computed tomography showed about 6 cm sized septated cystic lesion with septal enhancement in pancreas head. Laboratory findings including tumor marker were all within normal range. Pancreas magnetic resonance imaging showed about 6 cm sized multiloculated and septated cystic mass along hepatoduodenal ligament abutting to hepatic Pancreas hydatid disease. caudate lobe and pancreas head. Preoperative diagnosis was thought to be extrapancreatic retroperitoneal tumor such as lymphangioma or neurogenic tumor, or exophytic pancreatic cystic tumor, less likely. Results: In operative findings, 6x5 cm sized conglomerated EP02B-010 cystic mass in retropancreatic space abutting to pancreas MANAGEMENT OF DRASTICALLY head was observed and was filled with caseous material. INCREASED AND RUPTURED WALLED- Mass excision with wedge resection of pancreas was OFF PANCREATIC NECROSIS: A CASE performed. In histopathologic examination of the spec- imen, the cystic mass was confirmed by LEC of pancreas. REPORT Conclusion: Here in, we present a case of LEC of pancreas. K. Yogo, K. Hiramatsu, S. Saeki, T. Amemiya, H. Goto, It is difficult to diagnose LEC of pancreas preoperatively T. Seki, D. Kuga, H. Fujieda, K. Tabata and T. Arai because of the limitation of specific findings of LEC in Surgery, Anjo Kosei Hospital, Japan imaging modality. Introduction: Walled-off necrosis of the pancreas occurs as a late complication of severe acute pancreatitis. Drainage and necrosectomy are required when infected, but when EP02B-007 and how to treat sterile and asymptomatic cases is PRIMARY HYDATID CYST OF THE controversial. Case presentation: Sixty-six year old male was treated for PANCREAS: A REPORT OF THREE acute pancreatitis 2 months prior to presenting to our CASES emergency department with acute abdominal pain. Physical J. De Vinatea1,2, F. Revoredo2, G. Reaño2, P. Polanco3, examination showed mild tenderness on upper abdomen, L. Villanueva2, F. Kometter2, J. Arenas4, J. Tang2 and with elevated levels of white blood cells, CRP and M. Uribe2 pancreatic enzymes in the blood examinations. Contrast 1Surgery, Universidad Nacional Mayor de San Marcos, enhanced CT showed pancreatic pseudo-cyst, which had 2Surgery, Guillermo Almenara Hospital, Peru, 3Surgery, increased in size, compared to the CT taken 2 months UT Southwestern Medical Center, United States, and earlier. He returned home after examinations, as the 4Pathology, Guillermo Almenara Hospital, Peru abdominal pain had relieved. But he returned to our Introduction: Hydatid disease is a parasitic infestation emergency room 10 hours later, with worsened abdominal caused by Echinococcus granulosus and very rarely affects pain. Physical examination showed severe tenderness on the pancreas. upper abdomen. CT showed abdominal free air and Methods: All cases of pancreatic involvement by hydatid necrotized pancreas, with ruptured pseudo-cyst. We had disease from 2003 to 2017 at the Guillermo Almenara diagnosed it as ruptured walled-off necrosis, and went on Hospital, Lima, Peru were reviewed. We excluded cases an emergency operation. Open drainage and necrosectomy with massive abdominal infestation and those with doubtful were done. Though it required a long term postoperative pancreatic location even after the surgical. Three cases management, he was discharged well. underwent surgery and diagnosis was confirmed by histo- Discussion: Infected or symptomatic walled-off necrosis is pathology. All patients had a complete clinical records with a good indication for intervention: necrosectomy and detailed epidemiological aspects, abdominal tomography drainage, but when and how to treat sterile and asymp- and / or MRI, ELISA test and / or Western Blot test for tomatic walled-off necrosis is controversial. Our case was hydatidosis. Two of them had positive serology. symptomatic only temporarily, and did not show distinct

HPB 2018, 20 (S2), S505eS684 S528 Electronic Posters (EP02A-EP02F) e Pancreas signs of infection. However, it exacerbated drastically in Introduction: Little is known regarding the natural history short period of time to rupture. of Intraductal Papillary Mucinous Neoplasms (IPMNs) of Conclusion: Watchful waiting and early intervention the pancreas diagnosed in younger individuals, as current should be considered in symptomatic walled-off necrosis, guidelines only suggest surgery in younger patients. The even if the symptoms do not persist. aim of this study was to evaluate whether clinical features and malignancy risk of IPMNs are influenced by patient’s age at diagnosis. EP02B-011 Methods: A total of 2189 progressively observed IPMNs EXAMINATION OF PANCREATIC were retrieved and dichotomized, according to a 50-year- CYSTIC NEOPLASM EXCEPT IPMN old cut-off. Surgically resected IPMNs were compared in WHO UNDERWENT SURGICAL terms of pathological features. Both surgically resected and RESECTION IN OUR DEPARTMENT follow-up patients were compared in terms of cumulative 1 1 1 1 risk of developing high-risk stigmata (HRS), overall sur- Y. Mataki , K. Maemura , H. Kurahara , Y. Kawasaki , vival (OS) and disease-free survival (DSS), considering the M. Hashiguchi1, K. Tanoue1, M. Sakoda1, S. Iino1, 2 1 occurrence of pancreatic cancer (PC). H. Shinchi and S. Natsugoe < 1 Results: Patients 50 years old had more frequent Department of Digestive, Breast and Thyroid Surgery, < 2 abdominal pain (38.5 vs. 22.4%; p 0.01) and acute and Department of Health Science, Kagoshima Univer- pancreatitis (20.4 vs. 9.3%; p< 0.01) at presentation. Pa- sity, Japan tients 350 years old had more multifocal IPMNs (50 vs Background: These days, detection of cystic neoplasm of 36.9%; p< 0.01) and more frequent HRS (8.5% vs 4.3%; p the pancreas has been increasing because of improvement 0.04). Among resected patients, those 350 years had more for image-diagnosis and substantiality for health examina- invasive IPMNs (26.6% vs 17.3%; p 0.03). Patients 350 tion. We retrospectively analyzed the disease except IPMN years had a significantly higher cumulative risk of devel- in our department. oping HRS during that time, a significantly lower OS, but 32 cases were enrolled in this study. Age: 51 years in median similar DSS when compared with those < 50 years old. (24-80), Gender: 8 men, 23 females, Main lesions in the Conclusions: The natural history of IPMNs in terms of pancreas were located in head / body / tail; 9 / 10 / 12, The size cancer-related death does not seem to be affected by age. of tumor: 55 mm in median (8-140). Distant metastases (yes/ Younger patients can be followed-up as their elderly no) were (3/28). Follow-up period was 55 months (7-130). counterparts, however they have significantly more time to Results: progress towards malignancy. 1. Symptom were examined in 13 cases, abdominal pain in 11, abdominal discomfort in 2, no symptom in 19. 2. The preoperative diagnosis was pathologically ob- EP02B-013 tained in 4 cases by EUS-FNA, all of those were SPN. 3. Distal pancreatectomy was performed in 18 cases INTRADUCTAL PAPILLARY (laparoscopic surgery in 15), pancreaticoduodenectomy in MUCINOUS NEOPLASMS: THE 8, central pancreatectomy in 4, total pancreatectomy in 1. BOLOGNA EXPERIENCE. LESSONS 4. Bleeding volume was 640 ml (0-1510) and operation LEARNED FROM 357 CASES OBSERVED time was 465 minutes (224 - 844). IN A TERTIARY CARE CENTER fi 5. Discrepancy between preoperative and nal diagnosis 1 1 1 1 fi C. A. Pacilio , C. Ricci , G. Taffurelli , M. Di Marco , occurred in 8 cases (26%) Among them, nal diagnosis was 2 2 2 2 MCN in 3, epidermoid cyst in 2, SCN, squamoid cyst, L. Calculli , C. Serra , N. Pagano , M. Migliori , F. Minni1 and R. Casadei1 hamartoma in 1, respectively. 1 2 6. Recurrence and metastasis: LN metastasis occurred in University of Bologna, Italy, and S. Orsola Malpighi 2 cases (simultaneous in 1 SPN, 3 years after 1 ITN sur- Hospital, Italy gery), multiple liver metastasis in 2 (simultaneous and 1 Background: In the last decades, the attention to Intra- year after operation in SPN). ductal Papillary Mucinous Neoplasms (IPMNs) has raised Conclusion: Exact diagnosis for pancreatic cystic disease due to the increase of their incidental diagnosis. The aim of except IPMN is very important because of that with ma- our study was to evaluate which factors influenced survival lignant potential. in our population affected by IPMN. Methods: A retrospective study on a prospective database of 357 patients observed at our institution from January EP02B-012 2004 until January 2016 was conducted. Pre-, intra- and postoperative data were collected. Patients managed THE ROLE OF AGE IN THE conservatively were compared with those who underwent MANAGEMENT OF IPMNS OF THE surgery as regards demographic, clinical data, radiological PANCREAS: SAME RISK OF CANCER- work up, features of the cysts and overall survival (OS). RELATED DEATH BUT DIFFERENT Multivariate analyses were carried out in order to assess ’ IMPLICATIONS FOR THE factors related to patients management as well as those related to OS. MANAGEMENT Results: Multivariate analysis showed that the factors 1 2 2 2 G. Marchegiani , G. Perri , S. Andrianello , G. Malleo , stronglyrelatedtosurgerywere:locationinthetailofthe 2 2 2 T. Pollini , C. Bassi and R. Salvia pancreas (OR 4.48; P=0.011), presence of mural nodules (OR 1 2 Surgery, University of Verona, Italy, and Verona Uni- 15.39; P< 0.001), Wirsung size > 5 mm (OR 8.55; P< versity, Italy 0.001), Wirsung size  10mm (OR 133.75; P< 0.001), a

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S529 positive citology (OR 19.81; P=0.008) and acute pancreatitis nomogramIPMN) were retrospectively analyzed in pa- (OR 16.7; P< 0.001); conversely, age was independently tients who underwent pancreatectomy due to branch duct relatedtothefollowupstrategy(OR0.93;P=0.001). type IPMNs at Severance Hospital between December Furthermore, parameters that significantly influenced OS 2005 and December 2014. were: age (HR 1.07; P< 0.001), jaundice (HR 7.67; P< Results: A total of 94 patients were enrolled. Low and in- 0.001) and the presence of mural nodules (HR 2.03; P=0.019). termediate dysplasia were defined as benign IPMN. Malig- Conclusions: Despite the limitations of the study, the main nant IPMN was defined as those with high grade dysplasia factors related to OS in our experience were ageing, jaun- and associated invasive carcinoma. 52 (55.3%) patients were dice and the presence of mural nodules within the cyst. benign and 42 (44.7%) patients were malignant IPMN. Main duct size (5.4 vs. 8.4mm, p=0.004), tumor size (26.9 vs. 43. mm, p< 0.001), malignancy values (35.4 vs. 57.0, p< EP02B-014 0.001) and invasiveness values (16.8 vs. 37.7, p< 0.001) < MUCINOUS NON-NEOPLASTIC CYST calculating by nomogram, and SUVmax (2.1 vs. 4.9, p 0.001) were significantly higher in malignant IPMNs. OF PANCREAS SUVmax was significantly correlated with malignancy D. -E. Park values (p=0.009) and invasiveness values (p=0.002) calcu- Surgery, Wonkwang University Hospital, Republic of lating by nomogram in simple linear regression analysis. Korea Conclusion: When SUVmax value in PET is combined Pancreas cystic lesions consist of a wide range of path- with nomogram, the malignancy predictability in pancre- ological entities. Recently pancreatic cysts incidence has atic IPMN can be increased. been increasing and incidentally identified because of regular medical check up. Almost of all the pancreas cystic neoplasm is widely known Intraductal Papillary mucinous EP02B-017 neoplasm(IPMN). However, currently, rare cases unknown PANCREATIC LITHIASIS AND histologically are newly described as Mucinous Non- PANCREATIC PSEUDOCYST IN A 27- neoplastic cyst of pancreas(MNCP). Despite the using of e high technological Imaging systems as MRI or CT, YEAR-OLD WOMAN A CASE REPORT distinguishing non-neoplastic from neoplastic cysts is still D. Paramythiotis1, T. Boutsiadou2, P. Bangeas1, difficult with differentiation appropriately. S. Netta1 and A. Michalopoulos1 We report a 65-year-old male admitted for evaluation of 11st Propedeutic Surgical Department, and 2Aristotle abnormal findings in upper gastrointestinal(UGI) endoscopy. University of Thessaloniki, Greece The initial CT demonstrated not only a single round low Introduction: Pancreatic cysts manifest as a common attenuated cystic lesion about 2.5cm sized but also no evi- complication of acute and chronic pancreatitis. Drainage or dence of an enhanced solid portion in borderline of pancreas resection of the pseudocysts is performed under specific body and tail portion. The diameter of main pancreatic duct indications, including stenosis of the common bile duct, was mild dilatation. 3-dimensional magnetic resonance infection of the cyst, compression of major vessels, cholangio-pancreatography imaging demonstrated about compression of the stomach or duodenum or pancreatico- 2.5cm sized a single cystic nodule without solid portion at pleural fistula. borderline of pancreas body or tail portion and also multiple Methods: We report the rare case of a 27-year-old- female small cystic nodules around it as daughter cysts. The patient patient with a 2-year history of asymptomatic pancreatic underwent distal pancreatectomy without splenectomy and pseudocyst and no clinical evidence of prior incidence of final histology demonstrated a single cyst lined by mucinous pancreatitis. Her medical history included diabetes mellitus epithelium. The final diagnosis was MNCP. type I, appendicectomy and C-section and there was no The MNCP clinical course is known as benign. The reference of alcohol abuse. Cyst was revealed randomly purpose of this report is all surgeons to cognize these cystic with Computed Tomography of the abdomen 2 years ago lesions pre-operatively and to avoid ‘unnecessary’ surgery. due to gynecological examination. She was admitted to our clinic due to constant pain located in the left upper abdomen radiating in the lumbar region for the last 7 days. EP02B-016 A new Abdomen CT and MRCP was conducted, which AUGMENTING NOMOGRAM TO revealed a large pancreatic pseudocyst with uneven mar- PREDICT MALIGNANCY IN gins, pancreatic duct dilatation, various pancreatic stones and several splenic infarcts. PANCREATIC IPMN BY USING SUVMAX Results: Left-sided pancreatectomy and splenectomy was H. K. Hwang, C. M. Kang, D. S. Yoon and W. J. Lee performed due to high suspicion of cystadenoma or Yonsei University College of Medicine, Republic of Korea cystadenocarcinoma. No post-operative complications Introduction: It is still unclear to predict malignancy of were observed, and patient was discharged in good condi- branch duct type intraductal papillary mucinous neoplasm tion in 6th PO day. (IPMN) of pancreas. The maximum standard uptake value Conclusion: Pancreatic lithiasis appear more often to men (SUVmax) in PET (positron emission tomography) was than women, at the age of 40-60 years old, and in patients investigated to increase predictability of the malignancy in with acute-on-chronic pancreatitis. Implication of genetic IPMNs. factors should not be underestimated. Differential diagnosis Method: Clinicopathologic factors, SUVmax, and must always include cystadenoma or cystadenocarcinoma predicting values of malignancy and invasiveness calcu- to avoid serious preoperative misjudgment of draining lating by nomogram (http://statgen.snu.ac.kr/software/ rather than eradication of the cyst.

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EP02B-018 and all are doing well without any recurrence at followup. Mean followup was 51.1 months. NEUROENDOCRINE TUMOR OF THE Conclusion: Primary pancreatic hydatid cyst is very rare. PANCREAS ACCOMPANIED BY A Preoperative identification is helpful in preventing unnec- CYSTIC LESION essary radical operations (especially for hydatid cyst of the H. J. Jang and C. S. Park pancreatic head) for this benign disease. Surgery, University of Ulsan College of Medicine / Gangneung Asan Hospital, Republic of Korea e e We have reported a case of pancreatic neuroendocrine EP02C Electronic Poster: 2C Pancreas tumor with dilated distal pancreatic duct and the cyst for- Tumours mation. A 47-year old man without previous history of the EP02C-001 pancreatitis was admitted to our hospital with upper PRE-OPERATIVE ELEVATED TUMOR abdominal cystic mass, which was formed in the pancreatic M2-PYRUVATE KINASE IS A PLASMA tail by ultrasonogram and computed tomography. The pre- operative diagnosis was a pancreatic cyst or pancreatic MARKER OF ADVERSE PROGNOSIS IN pseudocyst. The tumor, which was measured about 13 cm in PANCREATIC CANCER length and 6 cm in diameter, arouse from the pancreatic body I. Bandara, M. Baltatzis, S. Sanyal and A. Siriwardena and was well capsulated. The examination of the surgical Regional Hepato-Pancreato-Biliary Unit, Manchester specimen resulted in the incidental discovery of an Royal Infirmary, United Kingdom obstructive nodule of endocrine tumor, mesuring 7 mm in Introduction: A wide range of human tumours express the diameter and located immediately at the contact of the cyst. enzyme pyruvate kinase, a component of the aerobic The tumor was ill limited and neural invasion are present. glycolysis pathway. We have previously demonstrated that Immunohistochemical studies showed that the tumor cells plasma levels of the M2 isoenzyme measured as Tumor expressed chromogranin and synaptohysin. Pseudocysts M2-PK are elevated in patients with pancreatic cancer. This accompanying pancreatic ductal carcinoma were sometimes study examines the role of Tumor M2-PK as a marker of reported but endocrine tumors accompanied by cyst were prognosis in pancreatic cancer. very rare. This case report underlines that the diagnosis of a Methods: 73 consecutive patients with a clinical diagnosis cystic lesion of the pancreas must be done much cautiously of pancreatic or peri-ampullary cancer were enrolled. Their in patient without a clinical history of pancreatitis. Median (range) age was 66 (23-83) years. Pre-operative samples of venous blood were taken for analysis of Tumor M2-PK. Clinical outcomes were recorded on a case report EP02B-019 form. The full study protocol was approved by the North PRIMARY HYDATID OF THE West Research Ethics Committee (protocol number 06/ PANCREAS: AN UNCOMMON MRE08/69). All patients gave their written informed con- sent for participation. DIFFERENTIAL FOR CYSTIC LESIONS Results: The mean plasma Tumor M2-PK level for patients OF THE PANCREAS with malignancy was 60.3 U/ml (SD: 106.5 U/ml) A. Javed1, P. Aravinda1, B. Shashikiran2 and A. Agarwal1 compared to 22 U/ml (SD: 12 U/ml) for patients with 1G.I Surgery and Liver Transplant, and 2GB Pant Institute benign disease (p< 0.001). Multivariate Cox regression of Post Graduate Medical Education and Research, India analysis showed that Tumor M2-PK (>27 U/mL), Ca19-9 > Introduction: Primary hydatid cyst of pancreas is very ( 39 U/ml), resection status and disease stage were asso- rare. In endemic areas, differentiating pancreatic hydatid ciated with poorer survival. Tumor M2-PK dichotomized at fi from other cystic lesions may be difficult but has important the optimal cut-off value of 27 U/ml tted as a binary management implications. model: patients with Tumor M2-PK higher than 27 U/ml Methods: Retrospective analysis of patients with intra- had worse prognosis than those with lower values (hazard fi abdominal hydatid between January 2000 to December 2017. ratio: 2.049, signi cantly increased risk of death, p=0.042). Results: Of 310 patients with intra abdominal hydatid Conclusion: An elevated level of Tumor M2-PK (with a cut- cysts, 6 had primary pancreatic hydatid cysts. Male:female off threshold of 27 U/mL) measured pre-operatively is a ratio was 1:5 with an age range between 14 and 45 years. marker of adverse prognosis in patients with pancreatic cancer. Pain was the predominant symptom in 5 patients, 4 presented with abdominal lump. One patient developed intracystic bleeding. Cyst were located in the head of EP02C-002 pancreas in 1 patient(16.6%), body in 2 patients(33.3%), IS INTEGER-BASED RISK SCORE TO body and tail in 1 patient(16.6%) and tail of the pancreas in PREDICT IN-HOSPITAL MORTALITY 2 patients (33.3%) respectively. The average size of the cyst FOLLOWING PANCREATECTOMY was 7.8 (range 4-10) cm.Hydatid serology was positive in 3 RELIABLE? patients. An accurate preoperative diagnosis was estab- 1 2 3 4 lished in only 3 patients(50%). All patients were treated by S. Badar , M. Zhou , T. W. Tan , A. Annamalai , H. Shokouh- Amiri1,5, G. B. Zibari1,5, P. Peddi6 and surgery (open surgery in 3 patients and laparoscopic sur- 1 gery in 2 patients). Surgical procedures included distal Q. Chu 1Surgery, 2Public Health and Epidemiology, Louisiana pancreatico-splenectomy(emergency),cysto-peri- 3 cystectomy, deroofing and Roux En Y cysto jejunostomy State University Health New Orleans, Vascular Surgery, University of Arizona Health Science, 4Surgery, Cedars- (laparoscopic),distal pancreatectomy(laparoscopic) and 5 deroofing. Albendozole therapy was given to all patients Sinai Medical Center, Transplant Surgery, Willis

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Knighton Health Shreveport, and 6Hematology and and the distinction between stage I, II and III disease of the Oncology, Louisiana State University Health Shreveport, survival curves was more apparent. United States Conclusion: LNR can be considered as a useful indepen- Introduction: An integer-based risk score predicting in- dent prognostic indicator for PC patients following curative hospital mortality following pancreatectomy was published resection regardless of the surgical procedures. Compared in 2010 by Hill et al using the Nationwide Inpatient Sample with the AJCC 8th staging system, the formulated nomo- database. We attempt to externally validate this study using gram showed superior predictive accuracy for OS and its National Cancer Database (NCDB). novel staging system revealed better risk stratification. Methods: Using NCDB a cohort of 14,971 pancreatic adenocarcinoma patients who underwent curative pancrea- tectomy during 2003-2011 was evaluated. In this cohort 80% EP02C-004 of the patients were in training set and remaining belong to EFFICACY OF INTEGRATED IMMUNE validation set. Clinicopathologic and demographic data were RATIO ASSOCIATED WITH TUMOR collected and, multivariable logistic regression to model the risk of in-hospital mortality was generated. Bootstrap methods GROWTH AND PROGNOSIS IN were used to create integer based risk score. PANCREATIC CANCER Results: Four independent variables were significantly N. Pu, G. Zhao, W. Lou and W. Wu predictive of in-hospital mortality; age, annual hospital Zhongshan Hospital, Fudan University, China volume, comorbidity index and type of resection. Integer Introduction: The prognosis of pancreatic ductal adeno- values were assigned to each and were used for calculating carcinoma (PDAC) remains poor owing to its difficulty in the additive score. The estimated in-hospital mortality was diagnosis and therapy. Immunotherapy has revealed its fi strati ed to low, medium and high-risk groups (1.46%, robust performance in several malignancies. fi 3.31%, and 7.34%) with a ve-fold difference between the Methods: The tissue microarray was stained and analyzed low and high-risk groups. Our C-index for our training set associated with clinicopathological characteristics. The and validation set was 0.65 and 0.66, respectively, preclinical murine models administrated with various im- suggesting that the model may not be a reliable one. munotherapies were analyzed by growth inhibitor, flow Conclusion: Our study fails to validate the integer-based cytometry, ELISA and immunohistochemistry. risk scoring system to predict in-hospital mortality after Results: The infiltrating FoxP3+ regulatory T cells (Tregs) pancreatectomy as previously published. and PD-1 expression in tumor tissues were associated with survival, while CD8+ infiltrating T cells (TILs) was lack of evidence. Then, CD8, FoxP3 and PD-1 expression were EP02C-003 merged together to create a new estimated valuedintegrated COMPARISON OF PROGNOSTIC immune ratio (IIR) comprehensively considering their PREDICTION BETWEEN NOMOGRAM drawbacks, which showed excellent distinction in risk fi fi BASED ON LYMPH NODE RATIO AND strati cation of survival. IIR was veri ed as an independent prognostic factor according to multivariate analysis, so did T AJCC 8TH STAGING SYSTEM FOR and N classification. In the preclinical murine model, CD25 PATIENTS WITH RESECTED and TGF-b combinational blockade revealed higher tumor PANCREATIC CARCINOMA: A SEER growth inhibitor value. Under overall consideration, the ANALYSIS combinational therapy significantly depleted periphery and intratumoral FoxP3+ Tregs and enhanced intratumoral CD8+ N. Pu, G. Zhao, W. Wu and W. Lou T cells compared to control or anti-TGF-b monotherapy (all Zhongshan Hospital, Fudan University, China P< 0.05). The intratumoral IL-10, TGF-b was notably lower Introduction: The prognosis of pancreatic carcinoma (PC) associated with higher IFN-g excretion with the combina- remains poor and the AJCC 8th staging system for survival tional immunotherapy. Such combinational immunotherapy prediction in PC patients after curative resection is still limited. was further verified to synergize with anti-PD-1 mono- Methods: The data of 3,458 patients used in this study were therapy to promote the tumor growth inhibitor and cure rate. retrieved from the Surveillance, Epidemiology, and End Conclusion: The combination of CD25, TGF-b and PD-1 Results (SEER) database. The prognostic value of lymph blockade has a potentially effective role in inhibiting tumor node ratio (LNR) was analyzed in the primary cohort and formation and progression, and provides a strong rational prognostic nomogram based on LNR was established to strategy in clinical trials on the basis of IIR. create a novel staging system. Then, analyses were con- ducted to evaluate the application of the formulated nomo- gram staging system and AJCC 8th staging system. Results: Significant positive correlations were found between EP02C-005 LNR and all factors except for surgical procedures. The re- EPIDERMAL INCLUSION CYST IN AN sults of univariate and multivariate analysis showed, LNR was INTRA-PANCREATIC ACCESSORY identified as an independent prognostic indicator for OS in SPLEEN: A CASE SERIES AND REVIEW both primary and validation cohorts (all P< 0.001). A prog- OF THE LITERATURE nostic nomogram based on LNR was formulated to obtain 1 1 2 2 superior discriminatory abilities. Compared with the AJCC H. J. Tan , W. L. Neo , B. Goh , S. Y. Lee and J. H. Kam2 8th staging system, the formulated nomogram staying system 1 2 showed higher HRs of stage II, III and IV disease (reference to Department of General Surgery, and Department of stage I disease) by univariate analyses in the primary cohort Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore

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Introduction: An epidermoid cyst in an intra-pancreatic complications in patients treated with surgery. These data accessory spleen (ECIPAS) is a rare lesion. A review of the suggest that manage appropriate patient selection may English literature showed that very few cases were reported improve outcome after PD. worldwide. Most of the cases are diagnosed post-opera- tively after surgical resection based on a pre-operative diagnosis of a possible pancreatic malignancy. EP02C-007 Methods: A MEDLINE database review of the relevant MEASUREMENT OF INDICATOR medical literature published and identified all reported cases of ECIPAS were conducted with the following key GENES USING CDNA AMPLIFICATION words: epithelial cyst, pancreas and intra-pancreatic BY POLYADENYLIC ACID RT-PCR accessory spleen. Relevant publications were evaluated and (POLY A RT-PCR) USING PAIRED demographic data, imaging findings as well as management SAMPLES FROM TISSUE AND DUCTAL options were collected. JUICE DURING Results: We found 39 articles describing this clinical condition, with the largest series described containing 3 PANCREATICODUODENECTOMY cases. In this series, we present 2 cases of epidermoid cysts S. Sanyal and A. Siriwardena arising from an intra-pancreatic accessory spleen. Regional Hepato-Pancreato-Biliary Unit, Manchester Conclusion: It is important to consider the differential Royal Infirmary, United Kingdom diagnosis of epidermoid cyst in an intra-pancreatic accessory Objectives: Assessment of genetic material from pauci- spleen in management of cystic neoplasms of the pancreas. cellular pancreatic fluid aspirates may be facilitated by the technique of Poly A PCR (polyadenylic acid reverse tran- scriptase polymerase chain reaction) which allows creation EP02C-006 of complementary DNA (cDNA) from RNA isolated from fl EFFECT OF RISK FACTORS ON EARLY uid. This is a proof-of-principle study using matched samples of juice and tissue from patients undergoing COMPLICATIONS AFTER pancreaticoduodenectomy. PANCREATICODUODENECTOMY FOR Methods: Intra-operative sampling of pancreatic juice and PERIAMPULLARY CANCER collection of matched tissue samples was undertaken in P. Minhtri1,2 and V. Truongquoc3,4,5 patients undergoing pancreaticoduodenectomy for clini- 1Surgery, University of Medicine and Pharmacy, 2Surgery, cally suspected pancreatic cancer or main-duct intraductal Cho Ray Hospital, 3University of Medicine and Pharmacy, papillary mucinous neoplasm. RNA was isolated and Poly 4Cho Ray Hospital, and 5Hepato-Biliary and Pancreatic A PCR was used to globally amplify the RNA. Real-time Surgery, Cho Ray Hospital, Viet Nam polymerase chain reaction (RT-PCR) was used to measure expression levels of 17 genes selected from microarray Introduction: Pancreaticoduodenectomy (PD) is one of the studies. Spearman’s rank correlation test was used to standard treatments for periampullary cancers. Although examine the relationship of gene expression between the mortality has significantly dropped to below 2%, pancreatic juice and tissue. The study was approved by complications after PD remain high in the range of 30% to Regional Ethics Committee. 50%. The primary aim of this study was to evaluate the Results: Mesothelin (MSLN) showed significant correla- impact of risk factors on post-pancreaticoduodenectomy tion (p< 0.008) in expression levels between paired complications. pancreatic juice and tissue samples in pancreas cancer. In Methods: Prospective cohort study. Patients undergoing IPMN Matrix Metalloproteinase 7 (MMP7), showed sig- PD for periampullary cancers at a single institute were nificant correlation (p< 0.01) in the expression levels be- evaluated. Early complications was defined as those tween paired pancreatic juice and tissue samples. occurring within 30 days after surgery. Records were using Conclusion: This study confirms that RNA analysis of the administrative database of Cho Ray Hospital between paired pancreatic juice and tissue samples and establish- January 2012 and December 2016. Benign pathology was ment of cDNA using poly A PCR is technically feasible. not considered in the outcome of this study. Risk factors Application of the technique to non-invasively obtained affecting on early complications were evaluated. pancreatic juice during endoscopic assessment of tumors Results: Postoperative pathology confirmed malignant and the use of gene arrays of cancer indicator genes are the tumors in 230 patients between the time period. The next steps in development of this technique. complication rate was 25.65%, included pancreatic fistula (10.43%), surgical site’s infection (4.38%), intra-abdominal abscess (0.87%), postoperative bleeding (2.61%), cardio- pulmonary complications (0.43%), hepaticojejunostomy EP02C-008 leak (0.8%), chyle fistula (3.48%), re-operation (6.09%). The DOES BLOOD GROUP AFFECT size of pancreatic duct less than 3 mm, soft pancreatic texture SURVIVAL FOLLOWING fi have been implicated as major predictors of pancreatic stula PANCREATODUODENECTOMY FOR (p< 0.0001). Concentration of hemoglobin less than 10 g/dl had been considered as predictive factor for surgical site’s PERIAMPULLARY MALIGNANCY? 1 1 2 1 1 infection (p< 0.02). Soft pancreatic texture had also been K. Khalil , S. Bansal , S. Ayaani , J. Hodson , J. Isaac , 1 1 2 shown to correlate with postoperative bleeding (p< 0.001). B. Dasari , R. Marudanayagam , G. Marangoni , 1 1 Conclusions: Early complications after PD remains R. Sutcliffe and K. Roberts 1 2 high. Independent of pancreatic duct’s size, pancreatic University Hospitals Birmingham, and University Hos- texture and hemoglobin factors, negatively impacted pitals Coventry and Warwickshire, United Kingdom

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Background: Blood group is reported to have an effect Results: We identified 7,210 patients diagnosed with upon survival following pancreatoduodenectomy for PDAC during the study period. Median age was 68.8 years pancreatic ductal adenocarcinoma. The effect of blood (inter-quartile range: 62.1-75.2 years), and 51.5% were group is not known, however, among patients with other men. The majority (61.7%) lived in an urban area at the periampullary cancers. This study sought to review this. time of diagnosis. During the latest calendar period, we Methods: Data were collected for a range of factors and observed an improved survival among PDAC patients survival outcomes from patients treated at two centres. residing in urban areas compared with patients living in Those with blood groups B and AB were excluded, due to rural areas (adjusted HR: 0.89; 95% CI: 0.82-0.97), even small numbers. Patient survival was compared between after adjustment for cancer-directed treatment (adjusted patients with blood groups O and A using multivariable HR: 0.88; 95% CI: 0.76-1.01). analysis which accounted for confounding factors. Conclusions: Patients with PDAC residing in urban areas Results: Among 431 patients, 235 (54.5%) and 196 have a better survival compared with patients living in rural (45.5%) were of blood groups A and O respectively. areas in the later years. Baseline comparisons found a significant difference in the distribution of tumour types (p=0.011), with blood group O patients having more ampullary carcinomas (33.2% vs EP02C-011 23.4%) and less pancreatic ductal adenocarcinomas (45.4 INTRAOPERATIVE vs 61.3%) than group A. On multivariable analysis, after accounting for confounding factors including pathologic RADIOFREQUENCY ABLATION variables, survival was found to be significantly shorter in OF FUNCTIONING INSULINOMA: those with blood group A than group O (p=0.047, HR 1.30 A CASE REPORT AND LITERATURE [95%CI: 1.00-1.69]). REVIEW Conclusions: Blood group appears to affect the distri- G. Unenbat1, A. Yerbolat1, V. Gantulga1, bution of periampullary cancer type. It also appears to N. Javzandolgor2, E. Taivanbaatar1, M. Gillet3 and affect long term survival among patients, regardless of J. Chinburen1 tumour type. 1Hepato-Pancreato-Biliary Surgery, National Cancer Center of Mongolia, 2LuxMed Hospital, Mongolia, and 3Chirurgie Digestive, Centre Hopitalier Universitaire de EP02C-010 Vaudois, Switzerland GEOGRAPHICAL RESIDENCY Introduction: Insulinomas are rare neoplasm with a re- INFLUENCES PANCREATIC ported incidence of 1-4 cases per million patient- year. CANCER SURVIVAL: A DANISH Insulinoma is the most common form of the pancreas islet NATIONWIDE POPULATION-BASED cells producing excessive amounts of insulin. It can be seen COHORT STUDY at every age but mostly seen between 30 and 60 yr of age, with women accounting for 59%. 1 2 3 J. Kirkegård , M. Ladekarl , C. W. Fristrup , Case report: A 38-years-old young man was seen in 4 5 1 C. Palnæs-Hansen , M. Sall and F. V. Mortensen the outpatient room of Hepato-Pancreato-Biliary 1 2 Department of Surgery, Department of Oncology, department of our institution with the anxiety, dizziness, 3 Aarhus University Hospital, Department of Surgery, lightheadedness, personality changes and unusual 4 Odense University Hospital, Department of Surgical behavior, which were relieved with eating something or Gastroenterology and Transplantation, Rigshospitalet, taking glucose water orally. He had many times of 5 and Department of Surgery, Aalborg University Hospital, unconscious situations in last 10 years. He thus had Denmark Whipple triad. Introduction: It is unknown if geographical residency af- Methods: Midline incision was created with scalpel and fects pancreatic cancer survival in a tax-financed health- electrocautery. The duodenum and pancreatic head were care system. mobilized. 18g semi-automatic biopsy-needle in tumor Method: We conducted a population-based cohort study of target central placement than take a one of filar tissue by all patients diagnosed with histologically verified pancre- under ultrasound guided. Intraoperative RFA was atic ductal adenocarcinoma (PDAC) in Denmark during performed under direct vision of the duodenum to avoid 2004-2015. We used nationwide registries to assemble our burn damage. Simultaneously infusion/perfusion with cold cohort and collect information on demographic character- normal saline of the areas around the tumors was done istics, comorbidity, cancer-directed treatment, and vital during ablation. Ultrasound guided biopsy was performed status. We followed patients from the date of PDAC before RFA. The surgery was successfully finished without diagnosis until death, emigration, or October 1, 2017. We a perioperative complication but needed to reoperate 2 stratified patients into three calendar periods according to weeks later to drain pancreatic leakage and it was suc- year of diagnosis (2004-2007, 2008-2011, and 2012-2015). cessfully managed. We used Cox proportional hazards model to compute Results: Histology shows a solid pseudo-encapsulated hazard ratios (HRs) with associated 95% confidence in- insulinoma of the pancreas but needed to perform immu- tervals (CIs) of death, comparing patients in rural and urban nohistochemical assay to confirm the diagnosis. areas. HRs were adjusted for age, sex, comorbidity, tumor Conclusions: Intra-operative RFA is safe and feasible in stage, and localization. In a sub-analysis, we also adjusted patients with quotidian life difficulties in order to avoid for cancer-directed treatment. surgerical approaches.

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EP02C-012 through surgical resection and endoscopic ultrasound- guided fine-needle aspiration (EUS-FNA) of the primary IS SUTURELESS tumor prior to any treatment. PANCREATICOGASTROSTOMY MORE Results: This study included 100 patients who underwent EFFECTIVE THAN SINGLE-LAYER upfront surgery, and 97 who received CRT. CRT was DUCT-TO-MUCOSA mainly performed in the case of locally advanced PDAC. PANCREATICOJEJUNOSTOMY IN Of the 97 patients who received CRT, 21 later underwent surgical resection. In patients who underwent upfront sur- PANCREATICODUODENECTOMY? gery, low GLUT-1 expression was an independent pre- D. Kostov and V. Kostov dictor of longer overall survival. The MST of patients with Surgery, Naval Hospital, Bulgaria high and low GLUT-1 expression was 19.0 and 35.1 Introduction: The present study aimed to assess the safety months respectively (P = 0.008). Low GLUT-1 expression of pancreatic anastomosis after pancreaticoduodenectomy was significantly associated with higher rate of CR/PR and (PD) and to compare the results of sutureless pancreato- resection, and better prognosis. The MST in patients with gastrostomy (PG) with those of single-layer duct-to- high and low GLUT-1 expression was 17.0 and 26.6 mucosa pancreatojejunostomy (PJ) after PD in patients months, respectively (P = 0.008). Furthermore, in patients with malignant disease of the pancreatic head and of the who underwent surgical resection after CRT, high GLUT-1 periampullary region. expression was a significant factor for shorter recurrence- Methods: The study included 173 consecutive patients un- free survival (P = 0.043). dergoing PD from May 2009 to December 2015 at a single Conclusions: Among patients with pancreatic cancer, those surgical center. Single-layer duct-to-mucosa PJ was with low GLUT-1 expression in the primary tumor had a performed in 52 patients and sutureless PG in the remaining better prognosis compared to those with high GLUT-1 123. The primary endpoint was the safety of the procedures, expression. Moreover, patients with low GLUT-1 expres- which was assessed as the occurrence of complications during sion displayed better therapeutic response to CRT. hospitalization. Postoperative pancreatic fistula (POPF) was classified as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. EP02C-014 Results: We found that the incidence of POPF was POTENTIAL PROGNOSTIC 11.52%. With regard to POPF, the present study showed no significant difference in the two groups (p=0.043). The BIOMARKERS IN PANCREATIC JUICE incidence of Grade C POPF was significantly higher in the OF RESECTABLE PANCREATIC PJ group than in the PG group (p=0.001), which was been DUCTAL ADENOCARCINOMA fl re ected in the form of a higher rate of postoperative S. Agrawal1 and S. Jain2 hemorrhage (p=0.001), intra-abdominal abscess (p=0.012), 1Hepatobiliary and Pancreatic Surgery, Department of and septic shock (p=0.012) events in the PJ group. Surgical Oncology, Indraprastha Apollo Hospitals, and Conclusions: The evaluation of short-term outcomes 2Surgical Gastroenterology, Sakra World Hospital, India demonstrates that suturelessPG is a feasible and safe tech- Introduction: Despite potentially curative surgery nique, associated with lower life-threatening complications pancreatic cancer has a dismal prognosis. Serum cancer than single-layer duct-to-mucosa PJ. If longterm functional antigen 19-9 (CA 19-9) correlates with tumor burden, outcomes confirm similar results, sutureless PG could resectability and survival in patients with pancreatic ductal become a valid alternative for pancreatic anastomosis after adenocarcinoma. Identification of novel biomarkers may PD in patients with soft pancreas and high morbidity. facilitate early diagnosis of pancreatic cancer and improve survival. Method: Pancreatic juice is a rich source of cancer-specific EP02C-013 proteins rendering it a promising tool for identifying bio- SIGNIFICANCE OF NEOADJUVANT markers.Recent proteomic and microRNA expression ana- CHEMORADIOTHERAPY FOR lyses have identified several biomarkers of potential LOCALLY ADVANCED PANCREATIC diagnostic and prognostic value. Tumor markers CA 19-9 and carcinoembryonic antigen (CEA) are widely used in the CANCER characterization of premalignant and malignant lesions of the 1 1 1 1 H. Kurahara , K. Maemura , Y. Mataki , M. Sakoda , pancreas. Elevated level of CEA in bile is a marker for ma- 1 1 1 2 S. Iino , Y. Kawasaki , M. Hashiguchi , S. Ueno , lignancy and a predictor of hepatic recurrence. The potential 3 1 H. Shinchi and S. Natsugoe value of CA 19-9, CEA and lactate dehydrogenase as prog- 1 2 Digestive Surgery, Breast and Thyroid Surgery, Clinical nostic biomarkers in pancreatic juice and bile is unknown. 3 Oncology, and Health Sciences, Kagoshima University, Result: In contrast to the recently identified biomarkers Japan requiring further investigation prior to recommendation for Introduction: Metabolic shift to glycolysis has been re- clinical use, CA 19-9 and CEA are widely used and vali- ported to involved in radioresistance. The aim of this study dated markers of diagnostic and prognostic value in PDAC was to examine the utility of glucose transporter type 1 and pre-neoplastic lesions of the pancreas. (GLUT-1), which is a key regulator of the glucose meta- Conclusion: Specimens of pancreatic juice and bile can be bolism, as a predictor of the therapeutic effect of chemo- readily collected during surgical resection of the tumor and radiotherapy (CRT) in pancreatic cancer. analyzed according to well-established laboratory protocols Methods: Patients with PDAC were enrolled. Specimens for assays of CA 19-9, CEA and LDH to evaluate their for immunohistochemical evaluations were obtained prognostic value. Profiling of pancreatic juice and bile to

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S535 identify biomarkers may improve early diagnosis and se- Introduction: Intraductal tubulo-papillary neoplasm lection of patients for the optimal adjuvant therapeutic (ITPN) is the rarest pancreatic tumor. Invasive ITPC is even modality. more rare and its biology is unknown. Aim: To discuss biology of invasive metastatic and nonmetastatic ITPC and appropriate tactics by the example EP02C-015 of two cases. COMMON HEPATIC ARTERY Patients and results: 1.A 36-year old woman with jaundice and anemia after profuse GI bleeding was OCCLUSION FOR ASSESSMENT OF operated on 5 day for the pancreatic tumor invading the LIVER BLOOD SUPPLY DURING 111 whole pancreas. Uneventful postoperative period. ITPC PROCEDURES INCLUDING 22 DP CARS was diagnosed at pathology and genetic examination. V. Egorov1, R. Petrov1 and J. Zhurina2 Four years later there is no relapse, ECOG -0, well 1Surgical Oncology, and 2Radiology, Bakhrushin Brothers monitoring of diabetes mellitus, fully functional. Six Moscow City Hospital, Russian Federation months ago she has given to the healthy child and both do well by the moment. 2.In 2015, April in 29- year old Aim: To study stomach and liver collateral arterial supply lady the mass was found in the pancreas which was after common(CHA and celiac artery(CA) temporary observed as a cyst. In 2016, March tumor was found in occlusion. the pancreatic head and body and two focuses in the Background: Distal pancreatectomy with celiac artery right liver. CNB - adenocarcinoma. DS-Ductal adeno- resection (DPCAR) is in use for borderline-resectable carcinoma, T3NoM1, 6 courses of gemcitabine + 2 pancreatic cancer. It is believed that considerable reduction LACE. Multiple consultations of multiple byopcies in of the liver arterial supply after DPCAR may cause severe different institutions and countries: adenocarcinoma of liver ischemia. Decision to reconstruct СHA or left gastric unknown origin in the liver and pancreas. Four courses has to be justified. of FOLFIRINOX with quick progression of tumor. Patients and methods: Arterial anatomy, diameters of After intensive discussion 26 months after the disease CHA, proper hepatic, gastroduodenal and pancreatoduo- beginning total pancreatectomy and extended right denal arcades(PDA) were registered before surgery in 111 hemihepatectomy was performed for 32- year old lady. consecutive patients with pancreatic body/tail cancer(n36), Complicated postoperative period, stabilization but gastric cancer with pancreatic involvement(n30) and liver sudden death a day before discharge. tumors(n45) by CT. For DPCAR(n22) patients IOUS and Conclusion: Natural history and tactics for Invasive met- CT were performed during and after surgery. Arterial blood astatic ITPC is unknown. The efficacy of surgery and flow in the liver and mean systolic velocity in hepatic ar- conventional chemotherapy has to be discussed. teries before and after clamping were measured intra- operatively by US. Results: Classical arterial anatomy was identified in 67%. Pulse disappeared in 9(8%) cases after clamping of CHA, EP02C-017 RGEA and aLHA/rLPA. Collateral arterial blood flow in DISCORDANT NONFUNCTIONAL the liver parenchyma was preserved in all cases. DPCAR PANCREATIC NEUROENDOCRINE led to increase of GDA, PDA and RGEA blood flow in 1-12 TUMOR, WHAT’S NEXT? times; PDA were detected only once before DPCAR. 1 2 2 3 Gastric ischemia was revealed in four and liver ischemia in G. Molina , F. Serpa , A. Herrera and D. Barzallo 1 fi 0 cases. Department of Surgery, Ponti cia Universidad Catolica del Ecuador, 2Department of Surgery, Hospital Metro- Conclusion: 3 1. IOUS is a reliable modality for intraoperative assess- politano, and Department of Surgery, Hospital Monte ment of liver arterial blood supply during DPCAR. Sinaí, Ecuador 2. Gastric ischemia is much more frequent event than Background: Surgery is the treatment of choice for liver ischemia after CA occlusion. IO ICG gastroscopy can pancreatic neuroendocrine neoplasms, we report a case be the option for the reconstruction of left gastric artery. of a patient with a suspected low grade nonfunctional 3. CHA occlusion before DPCAR is unnecessary pancreatic neuroendocrine tumor confirmed by biopsy, procedure. however, after successful surgery, pathology revealed a discordant grade 3 nonfunctional neuroendocrine tumor. EP02C-016 Summary: Patient is a 43-year-old woman, she complained of abdominal discomfort, physical examination INVASIVE METASTATIC AND showed a mass in the pancreatic neck, labs reports NONMETASTATIC INTRADUCTAL including complete blood count, urinary 5-HIAA, chro- TUBULO-PAPILLARY CARCINOMA. mogranin A, pancreatic polypeptide and octreotide scan NATURAL HISTORY AND were normal. Biopsy confirmed a low-grade neuroendo- APPROPRIATE TACTICS BY THE crine tumor. Surgery was planned, and a distal pancreatectomy was EXAMPLE OF TWO CASES performed without showing any lymph nodes or liver 1 1 2 2 V. Egorov , R. Petrov , N. Ratnikova and D. Kalinin masses. 1Surgical Oncology, Bakhrushin Brothers Moscow City Hospital, and 2Pathology, Vishnevsky Institute of Surgery, Russian Federation

HPB 2018, 20 (S2), S505eS684 S536 Electronic Posters (EP02A-EP02F) e Pancreas

and calibration curves from data obtained in 3 institutions and validated in the cohort of patients coming from the fourth institution. Results: The nomogram was constructed using data from 178 patients while the validation cohort consisted of 61 patients. Seven imaging features on computed tomography showing peripancreatic venous abnormalities were identified and they were classified into 4 types. Age, length of tumor contact, peripancreatic venous abnormalities and Lymph node staging were independent factors of overall survival. The nomogram showed good probabilities of survival on calibration curves. The C-index of the model in predicting overall survival (OS) was 0.824 for the validation cohort. The correlation between the radiographic and pathologic findings was high. Conclusions: The nomogram accurately predicted OS in patients with pancreatic head cancer with suspected peri- pancreatic venous invasion after attempted curative pancreatic resectional surgery.

Pancreatic Tumor with Spleen. EP02C-020 The patient successfully recovered after surgery, how- CD11B HYPERACTIVATION IMPROVES ever, pathology revealed a discordant grade 3 nonfunc- RESPONSE TO IMMUNOTHERAPY IN tional neuroendocrine tumor with lymph nodes invasion. Conclusions: Surgery is the treatment of choice for PANCREATIC CANCER pancreatic neuroendocrine neoplasms, however, when they R. Panni1, J. Herndon1, B. Knolhoff1, G. Hogg1, are advanced, clinical treatment is usually given before V. Gupta2, R. Fields3, W. Hawkins3 and D. DeNardo4 planning surgery. In this case, we suspected of a low-grade 1Washington University School of Medicine, 2Adhaere tumor that could be cured by surgery. However final pa- Pharmaceuticals, Inc, 3Hepatobiliary Surgery, and thology showed us a completely different scenario, making 4Medicine, Washington University School of Medicine, us involved in a dark zone in the literature, of how to United States manage these patients after the procedure. Introduction: Survival in pancreatic cancer (PC) remains low This case enlights us since it is unclear, on whether the and development of effective clinical approaches is critical. primary tumor should have been removed in this clinical Modern strategies including immunotherapy show minimal scenario, however, we couldn’t have known this if we efficacy in human PC. One way to improve response to hadn’t done the surgery, and teaches us that even in a immunotherapy is to reprogram the tumor microenvironment successful recovery, surgery should not have been the best which includes desmoplastic-stroma and abundant immuno- choice for this kind of tumors. suppressive myeloid-infiltrate. We utilize a novel strategy of hyper-activating CD11b-receptor using a small molecule agonist, ADH-503. ADH-503 binds to CD11b-receptor, EP02C-019 preventing its binding to ligand ICAM-1 which prevents A PREOPERATIVE NOMOGRAM leukocyte trans-endothelial migration. We hypothesize that CD11b hyper-activation will reprogram myeloid response PREDICTS PROGNOSIS OF UP FRONT and improve immunotherapeutic efficacy in PC. RESECTABLE PATIENTS WITH Methods: We utilized genetic (KPC: p48-Cre; LSL- PANCREATIC HEAD CANCER AND KrasG12D; Trp53flox/flox) and orthotopic models of murine SUSPECTED VENOUS INVASION PC models to evaluate the effect of ADH-503 on tumor- fi fl Y. Shen1, X. Bai2 and T. Liang2 growth and immune-in ltrates by ow-cytometry and 1Department of Hepatobiliary and Pancreatic Surgery, immunohistochemistry. Zhejiang University, and 2Zhejiang University, China Results: To determine the effect of CD11b hyper-activa- tion in PC, we treated tumor bearing mice with ADH-503 Background: Pancreatic head adenocarcinoma is for 10 days and observed significant reduction in tumor- commonly diagnosed at an advanced stage when adjacent weight. Analysis of myeloid cells showed that monocytes, vascular invasion is present. This study aimed to establish a granulocytes and macrophages were significantly reduced preoperative prognostic nomogram for patients who under- by ADH-503. Simultaneously there was a decrease in went attempted curative resectional surgery for pancreatic regulatory T-cells and increase in CD8+ T-cell numbers, head cancer with suspected peripancreatic venous invasion. activation and proliferation. We observed a significant Methods: The data on all consecutive patients who un- change in gene expression profiles of tumor infiltrating derwent attempted curative resectional surgery for pancre- macrophages with ADH-503-therapy, suggesting macro- atic head cancer with suspected peripancreatic venous phage re-polarization. In orthotopic models, which are invasion were retrospectively collected from 2012 to 2016 extremely resistant to immunotherapy, combination of at 4 academic institutions in China. The demographic and ADH-503+/-anti-PD1 and ADH-503+/-41BB, showed radiological parameters were analyzed using univariate and significant regression of tumor-growth, suggesting multivariate Cox regression analyses. The final nomogram improved efficacy in combination with immunotherapy. was established using the concordance Harrell’s C-indices

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S537

Conclusions: Our data suggest that combination of CD11b Lipids essential to cellular functions and survival are hyper-activation and immunotherapy has the potential to strong candidates for biomarkers in pancreatic ductal overcome the barrier to T-cell infiltration and may be a adenocarcinoma (PDAC). We postulated that lipid useful strategy in the treatment of PC. profiling of the portal venous circulation may offer unique insight into the molecular characterization of PDAC patients. EP02C-021 Method: Portal vein plasma samples from 29 PDAC pa- PANCREATOBLASTOMA IN ADULTS: A tients were collected intraoperatively during pancreatico- duodenectomy and analyzed by multi-dimensional mass CASE REPORT AND REVIEW OF spectrometry-based shotgun Lipidomics to profile lipid LITERATURE changes. S. M. Yin1, Y. -W. Liu1, F. -Y. Kuo2 and L. -C. Tsang3 Results: Unique profiles from 20 lipid classes and 235 1General Surgery, 2Anatomic Pathology, and 3Radiology, lipid species analyzed reliably discriminated PDAC Kaohsiung Chang Gung Memorial Hospital, Taiwan, Re- (stages I-IV), Intraductal papillary mucinous neoplasm public of China (IPMN), and non-malignant pancreatitis (Figure 1). A Introduction: Pancreatoblastoma is a rare neoplasm panel of 14 lipid species was selected as biomarkers for mostly in pediatric patients between 1 to 8-year-old. Here differential diagnosis. Biomarker discovery analyses we reported a rare treatment experience for adult pancrea- including receiver operating characteristic (ROC) curves fi toblastoma with relatively good prognosis. for sensitivity and speci city and support vector ma- Method: Case Report. chine (SVM) suggest that the biomarker panel may have A 27-year-old female presented with postprandial full- high potential for clinical application in early detection ness, anorexia and weight loss for 3 months. Laboratory tests of resectable pancreatic cancers. Multivariate analyses identified elevated serum AST(143 IU/L), ALT (201 IU/L), indicated lipids changes important in cell signaling and Alk-p (567 IU/L), amylase(186 IU/L) and lipase(239.1 IU/ function allowed for segregation of IPMN from non- L). All tumor maker levels were within the normal ranges. malignant pancreatic pathologies and from different Liver CTA confirmed huge right abdomen heterogenous stages of PDAC (Stages I-IV). Pathway analysis sug- mass about 12x14x19cm with mass effect to MPV, HA and gests that at the earliest stage of pancreatic tumorigen- biliary ducts, as well as P-duct and biliary duct dilatation. esis (i.e., IPMN), cellular membrane lipids MRI showed retroperitoneum tumor arising from pancreatic (glycerophospholipid and sphingolipid) and their head, mixed cystic/hemorrhage and solid component, downstream signaling (phosphatidyl inositol anchors fi compatible with solid and pseudopapillary neoplasm of critical for signal transduction) were signi cantly pancreas. Ultrasound-guide tumor biopsy was done and changed. fi revealed solid pseudopapillary neoplasm of pancreas. Conclusions: Shotgun Lipidomics pro ling of portal The patient underwent en-bloc Whipple procedure and venous blood may have high potential as biomarker lymph nodes dissection without vascular or adjacent struc- for PDAC early detection and accurate stage tures resection. Pathology revealed the tumor cells with acinar discrimination. differentiation are polarized around small lumina. Squamoid corpuscles are demonstrated and immunohistochemical staining showed positivity of CD10 in squamoid nests, diffuse positive for CK7, trypsin and chymotrypsin, which confirmed the diagnosis of pancreatoblastoma. Result: The post-operative course was uneventful and the patient was discharged on the fourteenth post-operative day. The patient did not undergo adjuvant therapy and was alive and disease-free after 9 months until the time of submission of this manuscript. Figure 1 Conclusion: Pancreatoblastoma without invasion to adja- cent structures or metastasis might have acceptable survival by en-bloc Whipple procedure without adjuvant therapy. EP02C-024 EP02C-023 PANCREATODUODENECTOMY WITH LIPIDOMICS ANALYSIS OF VASCULAR RESECTION FOR ALTERATIONS IN PORTAL VEIN PANCREATIC HEAD CANCER: SINGLE PLASMA LIPIDS IN PANCREATIC CENTER EXPERIENCE CANCER PATIENTS M. Vozdvizhenskiy1, A. Orlov2, V. Savinkov2, S. Frolov2 and A. Tyurin2 P. Arnoletti1, J. Wang2, S. Litherland3 and X. Han2 1Samara State Medical University, and 2Samara State 1Surgical Oncology, Florida Hospital Cancer Institute, Oncology Center, Russian Federation 2University of Texas Health Science Center, and 3Florida Hospital Cancer Institute, United States Objectives: The problem of vascular resection during pancreaticoduodenectomy for local advanced pancreatic Introduction: Lipidomics is emerging as a novel head cancer is still remains controversial. approach for cancer diagnosis and characterization.

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The aim of the study was to evaluate safety and long- EP02C-026 term outcomes of pancreaticoduodenectomy (PD) with vascular resection. PHASE I STUDY OF Materials and methods: 29 patients with local advanced CHEMORADIOTHERAPY USING pancreatic head cancer underwent PD with major vascular GEMCITABINE PLUS NAB-PACLITAXEL resection (VR). 21 patient had resection of SMV, 4 FOR UNRESECTABLE LOCALLY resection of PV, 2 resection of mesenterico-portal ADVANCED PANCREATIC CANCER segment with graft interposition, 1 resection of SMA, 1 S. Yamada1, T. Fujii2, N. Takano3, H. Takami4, resection of common hepatic artery. 76% of patients had 4 4 4 4 adjuvant chemotherapy. To estimate short-term outcomes M. Suenaga , M. Hayashi , Y. Niwa and Y. Kodera 1Gastroenterological Surgery (Surgery II), Nagoya Uni- 50 patients with PD without VR were included in this 2 study. We included in this study 50 patients with versity Graduate School of Medicine, Department of pancreatic carcinoma with vessel involvement, who un- Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences University of Toyama, 3Surgery, derwent palliative therapy including surgical bypass and/ 4 or chemotherapy. Overall survival was estimated using Tokai Chuo Hospital, and Nagoya University Graduate the method of Kaplan-Meier. School of Medicine, Japan Results: PD with VR compared with PD without VR Purpose: In unresectable locally advanced (UR-LA) did not demonstrate higher postoperative complication pancreatic cancer, chemoradiotherapy has been pervading rate (37,9% and 32%), reoperation rate (2 and 3 cases) view in the clinics. We designed the chemoradiotherapy and hospital stay (20Æ7and18Æ4 days). Postoperative using nab-paclitaxel combined with gemcitabine (GnP) in mortality was 3,4% and 4%. Patients undergoing palli- the UR-LA disease. The purpose of this phase I study was ative therapy had overall morbidity 2% and 30 days to determine a recommended dose for this novel regimen. mortality 0%. The median survival time for patients Methods: Patients with the UR-LA disease were eligible, undergoing PD with VR and palliative therapy group and frequency of dose-limiting toxicities (DLTs) were was 14 and 12 months. Palliative therapy had compa- evaluated and recommended dose (RD) was determined. rable with VR group 2-years survival 17.2% and 16%. Patients were registered according to the designated dose Patients undergoing PD with VR showed 5-year sur- levels of chemoradiotherapy using the GnP. After addi- vival 10.3%. tional 6 cycles of the GnP were continued, surgical Conclusion: Pancreaticoduodenectomy with VR for local exploration is considered if the tumor maintained the stable advanced pancreatic head carcinoma is safe and offer 5- disease and tumor marker was normalized. years survival 10.3%. Results: The DLT (grade 4 thrombocytopenia) was solely observed in 1 of 12 patients, and recommended doze was set to be at level 3. Grade 3-4 leukopenia was observed in 9 EP02C-025 (75.0%) patients and neutropenia in 7 (58.3%). Response ’ rate was 41.7% and disease control rate was 100%. Con- SIMULTANEOUS COURVOISIER S AND version surgery was performed in 6 (50%) patients. Evans DOUBLE DUCT SIGNS classification was 1 patient in grade 1b, 1 in grade 2, 2 in S. Agrawal1, S. Vohra2 and S. Jain3 grade 3 and 2 in grade 4. Median progression-free survival 1Hepatobiliary and Pancreatic Surgery, Department of and overall survival were not reached (3.7-16.8 months and Surgical Oncology, 2Department of Radiology, Indrap- 5.6-16.8 months, respectively). rastha Apollo Hospitals, and 3Surgical Gastroenterology, Conclusion: Recommended doses for chemoradiotherapy Sakra World Hospital, India using the GnP in UR-LA pancreatic cancer were deter- fi Introduction: Presence of Courvoisier’s or double duct mined. This therapy showed a favorable ef cacy with high signs in a jaundiced patient is suggestive of malignant ratio of conversion surgery. Now, phase II trial is underway fi obstruction of the pancreaticobiliary ductal system. to investigate the safety and ef cacy. The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown. EP02C-027 Method: We report a case of obstructive jaundice sec- PREDICTORS OF LONG TERM ondary to an ampullary cancer demonstrating the Cour- SURVIVAL AFTER voisier’s sign on clinical examination and a double duct sign on imaging. The patient underwent a pancreatico- PANCREATICODUODENECTOMY FOR duodenectomy which confirmed an ampullary PERI-AMPULLARY adenocarcinoma. ADENOCARCINOMA: A Result: Biductal obstruction of the CBD and MPD may RETROSPECTIVE STUDY OF 5-YEAR result in the Courvoisier’s and/or double duct signs and the SURVIVORS diagnostic value of these signs in the evaluation of a patient M. El Sorogy and A. El Nakeeb with obstructive jaundice is widely accepted. Surgery, Mansoura University, Gastrointestinal Surgery Conclusion: The impact of the simultaneous occur- Center, Egypt rence of the Courvoisier’s and double duct signs on fi survival outcome is unknown and an area for future Introduction: Despite the recent re nements in the surgi- investigation. cal techniques and advances in the postoperative adjuvant

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S539 protocols, the median survival for patients who underwent presence of premalignant lesions in the ligatured distal surgical resection is reported to be around 20 months. pancreas. Several factors have been identified as predictors for sur- vival as tumor size and differentiation, lymph node ratio and resection margins. EP02C-029 Patients and methods: This study included patients who TWO CASES OF underwent PD for pathologically proven periampullary adencarcinomas at Gastrointestinal Surgery Center, PANCREATICODUODENECTOMY FOR Mansoura University, Egypt in the period between March CHILDREN WITH SOLID 2006 and April 2012. Patients were divided into 2 groups; PSEUDOPAPILLARY NEOPLASM OF patients who survived less than 5 years and those who THE PANCREAS HEAD survived more than 5 years. Y. Kageyama, R. Yamaguchi, M. Furuta, S. Watanabe, Results: During the study period 228 patients underwent K. Aizu, F. Sato, A. Arimoto, M. Yamada, Y. Toyoda and PD for periampullary adenocarcinoma. Of those patients, Y. Mitake 181 were short-term survivors (< 5 years) and 47 were long Surgery, Kasugai Municipal Hospital, Japan -term survivors (> 5 years). The median 5-year survival was 34 months (20 %). Pancreatic adenocarcinoma showed Solid pseudopapillary neoplasm (SPN) of the pancreas the worst 5-year survival (27 months) while ampullary has low grade malignant potential and can be cured by adenocarcinoma showed the best 5-year survival (54 complete surgical resection. We herein report the 2 children months). Short-term survivors significantly demonstrated patients underwent subtotal stomach-preserving pancreati- high levels of CA 19-9 (P = 0.04). Regarding the tumor coduodenectomy (SSPPD) for SPN. size, the tumor was significantly smaller in size in the long- One patient was a 14-year-old girl with manifesting term survivors group (P < 0.001). R0 resections had better intraperitoneal hemorrhage due to traumatic tumor rupture. prognosis and survival. The tumor, 5.4cm in diameter, located at the pancreas head. Conclusion: Predictors for long-term survival were tumor The other patient was a 14-year-old girl with complaining size less than 2 cm in diameter, negative resection margins of nausea and diagnosed as having pancreas head tumor and pre-operative CA 19-9 levels of less than 37 U/ml. measured 3.6 cm in diameter. Both patients underwent Nodal status was not found to affect the long-term EUS-FNA and pathologically diagnosed with SPN, and survival. had surgery a few months after initial diagnosis because they prioritized their school life. The postoperative convalescence was uneventful in both cases. During 3 and 2 years follow-up periods respectively, they are in good EP02C-028 health without recurrence. PANCREATIC DUCT LIGATION IN A SPN of the pancreas typically affects young females in KRAS MODEL OF PANCREATIC their second or third decades, and considered especially ADENOCARCINOMA REDUCES THE rare in children. The most common symptoms are NUMBER AND THE RISK OF abdominal pain and a palpable mass. Some patients are APPARITION OF PREMALIGNANT asymptomatic, and the tumors are detected incidentally as the former case. LESIONS OVER TIME Surgical resection offers a long-term survival with 5-year F. Burdio1, R. Quesada2, L. Grande2 and M. Cáceres2 survival rates as high as 95-97%. On the other hand, 1Surgery, and 2Hospital del Mar, Spain regardless of its benign pathological features, SPN has a Introduction: Pancreatic duct ligation (PDL) in murine latent ability to recur, including hepatic metastasis, local model has been described as an exocrine pancreatic atro- recurrence, and peritoneal dissemination. Although inci- phy-inducing procedure. However, its influence has not dence of lymph node metastasis is rare, some reports been described on premalignant lesions. This study de- indicate a relationship between lymph node positivity and scribes the histological changes of premalignant lesions in a recurrence. transgenic murine PDL model. Pancreatic resection and long-term follow-up are Methods: Selective ligation of the splenic lobe of the considered a reasonable treatment for SPN of the pancreas. pancreas was performed, including its main pancreatic duct, in Ptf1a-Cre (+/ki); K-ras LSLG12Vgeo (+/ki) mice (PDL-Kras mice).Three experimental groups have been EP02C-030 considered: PDL group, controls and shams. We analyzed GEMCITABINE-BASED NEOADJUVANT the presence and number of premalignant lesions (PanIN 1, TREATMENT IN BORDERLINE 2, 3 and Atypical Flat Lesions) in Proximal (PP) and distal (DP) pancreas for each group at different postoperative RESECTABLE PANCREATIC DUCTAL periods. ADENOCARCINOMA: A SYSTEMATIC Results: Controls and shams have a 7 and 9-time increase REVIEW AND META-ANALYSIS OF of risk of presenting PanIN 2, 3 and AFL in their distal INDIVIDUAL PATIENT DATA pancreas (High Grade Pancreatic lesions -HGPL-), than F. Giovinazzo1, F. Soggiu2, C. M. Kang3, PDL-Kras mice. Furthermore, PDL-Kras mice have M. M. Zalupski4, S. Yentz4, S. Helton5, J. B. Rose6, significantly less PanIN 1, 2 and AFL lesions in DP C. Takishita7, Y. Nagakawa7 and M. Abu-Hilal8 compared to PP. 1Department of Surgery, Southampton University Hospital Conclusions: Pancreatic duct ligation in Ptf1a-Cre (+/ki); NHS Foundation Trust, 2HPB, Royal Free Hospital, K-ras LSLG12Vgeo (+/ki) mice induces a decrease in the

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United Kingdom, 3HPB Surgery, Yonsei University Col- invasion ability of PDAC both in vivo and in vitro. lege of Medicine, Republic of Korea, 4University of Compared with non-tumor tissues, PDAC tissues showed Michigan, 5General Thoracic and Vascular Surgery, Vir- down-regulation of OGDHL and up-regulation of miR-214 ginia Mason Medical Center, 6Section of Surgical and TWIST1. The results showed that OGDHL was a target Oncology, University of Alabama, United States, gene of miR-214 and always negatively regulated by miR- 7Department of Gastrointestinal and Pediatric Surgery, 214 and the decreased expression level of OGDHL was on Tokyo Medical University, Japan, and 8Department of account of the increased expression level of miR-214 in Surgery, Southampton University Hospital NHS Founda- PDAC. In addition, TWIST1 was frequently up-regulated tion Trust, United Kingdom in PDAC and induces miR-214 expression. However Introduction: Several non-randomized studies investi- OGDHL could inhibit TWIST1 expression via both pro- gated gemcitabine-based neo-adjuvant therapies (NAT) in moting ubiquitin-mediated proteasomal degradation of borderline resectable pancreatic ductal adenocarcinoma HIF1a and regulating AKT pathways. The effect of (BR-PDAC). The aim of this study was to assess the OGDHL/HIF1a/TWIST1/miR-214 signaling pathway in effectiveness of NAT on overall survival (OS) in resected pancreatic carcinogenesis and metastasis was also deter- and non-resected patients. mined both in vivo and in vitro. A combination of down- Methods: A systematic review of all published articles on regulation OGDHL and over-expression miR-214 and NAT for BR-PDAC was performed. The definition of TWIST1 predicts a poorer overall survival in PDAC pa- borderline resectable was according to NCCN (v2.2016). A tients. Finally, we demonstrated that the relationship of meta-analysis of individual participant data (IPD) was expression among OGDHL, miR-214 and TWIST1 may be performed. Patients were divided in two groups: resected a significant predictor of prognosis in PDAC patients. It is a and non-resected. The primary outcome was OS. Second- novel pathway in OGDHL-regulated inhibition of PDAC ary outcomes were disease-free survival (DFS), toxicity, tumorgenesis and metastasis. It may be a brand new resection rate and complete resection (R0). targeted therapy in PDAC through OGDHL, TWIST1, Results: Seven studies were included. Median OS was 22.9 miR-214, and HIF1a for prevention, treatment and - 41.2 and 9.3 - 15.4 months in resected and non-resected prognosis. groups, respectively. Four centers provided IDP of 170 (68%) patients: all received gemcitabine-based neoadjuvant chemotherapy with additional radiotherapy in 121 (71%). EP02C-032 Pooled median patient-level OS was 27.2 (95%CI 23 - FEASIBILITY OF PORTAL VEIN 31.3) and 20.4 (95%CI 12.7 - 28) months in resected and RESECTION ONLY WHEN NECESSARY non-resected groups (p=0.03). There was no significant difference in OS in patients treated with different protocols. DURING DFS after resection was 17.9 (95%CI 14.3 - 21.5) months. PANCREATICODUODENECTOMY FOR Eighty-two (48.2%) patients experienced Grade III-IV PANCREATIC CANCER toxicity. Resection and R0 rates were 62% and 88%, Y. Kishi1, S. Nara1, T. Iwasaki1, K. Fukuoka1, M. Esaki1, respectively. N. Hiraoka2 and K. Shimada1 Conclusion: Gemcitabine-based NAT is effective in pa- 1Hepatobiliary and Pancreatic Surgery, National Cancer tients with BR-PDAC. Resected patients reached a signif- Center Hospital, and 2Division of Molecular Pathology, icantly longer OS than non-resected. Compared to upfront National Cancer Center Research Institute, Japan surgery, NAT may achieve longer median OS both in Introduction: Efficiency of pancreaticoduodenectomy resected and non-resected patients. Treatment sequencing (PD) with portal vein (PV) resection (PVR) for pancreas and specific elements of NAT should be further investi- cancer (PC) have been reported. Whether PVR should be gated with RCTs. indicated based on preoperative CT or intraoperative find- ings is controversial. Methods: Patients who underwent PD for PC between EP02C-031 2002 and 2016 were classified based on the degree of PV OGDHL INHIBITS HUMAN contacting with tumor by CT as: A, no contact, B; PV of PANCREATIC DUCTAL &180;C,PVof>180. Pathological PV invasion (pPV) ADENOCARCINOMA PROGRESSION to tunica adventitia, media, and intima was defined as pv1, AND IS REGULATED BY MICRORNA- pv2, and pv3, respectively. First, pPV was compared among the groups A, B, and C. Second, among the patients 214/TWIST1 NEGATIVE FEEDBACK without pPV (pv0) in group B/C, prognosis of those who PATHWAY underwent PD without PVR (PVR(-)pv0) were compared Y. Liu, J. Wang, F. Meng and L. Liu with the matched patients with PVR (PVR(+)pv0). General Surgery, The First Affiliated Hospical of Harbin Results: Totally 518 patients (A, 236; B, 244; C, 38) Medical University, China including 18 patients with preoperative chemotherapy un- Oxoglutarate dehydrogenase like (OGDHL) is involved derwent PD. PVR was performed in 11%, 73%, and 95% of < in tricarboxylic acid cycle and has been reported as a group A, B, and C patients, respectively (P 0.01). pPV candidate tumor suppressor in some other tumors. We first distribution (Figure) and R0 rate (A, 81%; B, 66%; C, 58%; < fi explored the role of OGDHL in human pancreatic ductal P 0.01) were different. Totally 67 patients were classi ed adenocarcinoma (PDAC) progression. OGDHL was as PVR(-)pv0. Other 67 patients were selected as PVR(+) frequently down-regulated in human PDAC and predicted pv0. Preoperative CA19-9 value, R0 rate, and tumor stages poor prognosis. OGDHL suppressed PDAC growth though were comparable. Postoperative survival was comparable G1 cell cycle arrest and also inhibited migration and (5-year, 33% vs. 33%, P =0.79).

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EP02C-036 AN ECTOPIC PANCREATIC CANCER AT THE SECOND PORTION OF THE DUODENUM MIMICKING DUODENAL CANCER: A CASE REPORT H. Choi1,2, J. -W. Choi1,2,D.H.Ryu1,2 and Y. Xu2 1Surgery, Chungbuk National University Hospital, and 2Surgery, Chungbuk National University College of Med- icine, Republic of Korea A 43-year-old male presented to our hospital with weight loss, chronic nausea and vomiting. Endoscopy and imaging studies showed severe duodenal stenosis. And histologic Figure examination by endoscopic duodenal biopsy was high grade dysplasia. We performed pancreaticoduodenectomy. The fi Conclusions: PVR based on the intraoperative findings nal diagnosis was heterotropic pancreatic cancer in the is feasible. However, group C definedbyCTwasasso- second duodenum by immunohistochemical staining. The ciated with high pPV degree and R1 rate, therefore, patient was discharged on postoperative day 15. Ectopic fi preoperative treatment would be recommended in these pancreas is commonly an incidental nding at surgery or patients. autopsy and has been frequently reported in the gastroin- testinal tract, especially in the stomach. However, malig- nancy of ectopic pancreas in the duodenum is a very rare disease. We describe an ectopic pancreatic cancer in the EP02C-034 second portion of duodenum with managed successfully. IS FOLFIRINOX SUITABLE FOR CHINESE PATIENTS WITH LOCALLY ADVANCED PANCREATIC CANCER? EP02C-037 T. Liang, X. Bai, X. Li, C. Guo, Q. Li and S. Wei IMPACT OF THE CONTROLLING The Second Affiliated Hospital, Zhejiang University School NUTRITIONAL STATUS (CONUT) of Medicine, China SCORE ON THE PROGNOSIS AFTER For locally advanced pancreatic cancer (LAPC), pre- CURATIVE RESECTION OF operative neoadjuvant treatment (NAT) is strongly recommended and FOLFIRINOX regimens may be the PANCREATIC ADENOCARCINOMA first choice. However, the promotion of NAT for LAPC Y. Kato1, S. Yamada2, F. Sonohara2, M. Suenaga2, patients in China is a hard work because patients fear to H. Takami2, M. Hayashi2, Y. Niwa2 and Y. Kodera2 1 2 experience severe adverse events. In this study, we Surgery, Nishio Municipal Hospital, and Nagoya Uni- evaluate the safety and efficacy of modified-FOLFIR- versity Graduate School of Medicine, Japan INOX (mFOILFIRINOX) in Chinese LAPC patients and Introduction: The controlling nutritional status (CONUT) compare the survival between LAPC patients with score has been established as a useful tool to evaluate mFOLFIRINOX-based NAT (LAPC-N) and LAPC pa- immune-nutritional status. This study aimed to retrospec- tients with upfront surgery (LAPC-S). 74 resectable tively investigate the impact of the CONUT score on short- (RPC), 19 LAPC-S and 41 LAPC-N patients from 2012 and long-term outcomes in patients undergoing pancrea- to 2017 were included. 35 of 41 LAPC patients were tectomy for pancreatic ductal adenocarcinoma (PDAC). treatedwithmFOLFIRINOXandfurtherrestaged,with Methods: Between April 2002 and April 2016, 344 a response rate of 37.1%. The most common grade 3/4 consecutive patients who underwent curative resection of adverse events are neutropenia (24.4%), anemia (22.0%) PDAC without neoadjuvant therapy were analysed. After the and thrombocytopenia (12.2%). MFOLFIRINOX best predictive value of the CONUT score for survival was contributed to a remarkable decrease in both CA19-9 explored, predictors of overall survival (OS) were identified level and tumor size. 14 of 41 LAPC-N patients un- using Kaplan-Meier analyses, the log-rank test and Cox derwent operation (LAPC-N-S) after downstaging. multivariable analysis. Correlations between the CONUT Compared to LAPC-N-S, LAPC-S patients suffered score and postoperative complications were analysed using longer surgery time, more blood loss and higer risk of the Mann-Whitney U test and Spearman`s rank correlation. postoperative complications. The median OS and PFS of Results: The median survival times of patients with high and LAPC-N-S patients with tumor resection was 27.7m and low CONUT scores were 18.0 and 26.8 months, respec- 19.3m which is similar to RPC patients (30.0m and tively. The high CONUT score group showed significantly 23.0m) and much longer than LAPC-S patients (9.2m lower OS than that of the low CONUT score group in the and 8.8m). The modification of FOLFIRINOX had univariate analysis (P = 0.002). In contrast, no significant significantly improved tolerance with similar efficacy to difference in recurrence-free survival was found (P = 0.43). full dose. Downstaging patients with tumor resection The multivariate analysis demonstrated that a high CONUT and regular adjuvant therapy experience a similar long- score was an independent prognostic risk factor for OS term survival of RPC patients. MFOLFIRINOX-based (hazard ratio: 1.64, P = 0.003). The CONUT score showed NAT may be the best choice for Chinese patients with no association with postoperative pancreatic fistula, the LAPC. Clavien-Dindo grade or the postoperative hospital stay.

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Conclusion: The CONUT score, which is a measure of Materials and method: 55 year male presented with immune-nutritional status, was an independent prognostic jaundice for three months, frequent attacks of pain, fever. risk factor for OS in patients with PDAC after pancrea- Haemogram was normal except raised ESR 93. Serum tectomy and was not associated with RFS or postoperative bilirubin level like 2.2mg/dl to 3.7mg/dl, alkaline phos- complications. phatase level elevated 449 U/L,SGPT level raised 88U/ L.Kidney function test, X-ray chest, ECG normal.Viral profile negative.CA19-9 16.4 U/ml. EP02C-038 USG of whole abdomen revealed dilated common bile PROGNOSTIC IMPACT OF PORTAL duct of 15.8mm diameter and soft tissue mass of 1.5*3.1cm size at distal CBD.MRCP revealed grossly dilated common SYSTEM INVASION BASED ON TUMOR bile duct of 35mm diameter,main pancreatic duct diameter LOCATION IN PANCREATIC CANCER 12mm , soft tissue mass of 4.5cm*3.5cm at periampullary D. Morimoto1,S.Yamada1,K.Murotani2,H.Takami1, region with extension into the lumen of distal CBD. M. Suenaga1,M.Hayashi1,Y.Niwa1,T.Fujii3 and Y. Kodera1 CECT abdomen showed focal lesion of about 3 cm at the 1Department of Gastroenterological Surgery (Surgery II), head of pancreas is resectable. Nagoya University Graduate School of Medicine, 2Division The case diagnosed preoperatively as carcinoma peri- of Biostatistics, Clinical Research Center, Aichi Medical ampullary region.Patient underwent pylorous preserving University, and 3Graduate School of Medicine and Phar- whipples operation.Patient recovered well in postoperative maceutical Sciences, University of Toyama, Japan period. fi Objective: The aim of this study was to clarify the corre- Histopathological report benign tumor ndings is lation between image classification and degree of patho- ampullary adenomyoma.Resection margin free of tumour. logical invasion of portal system, and evaluate the Lymph nodes free of metastasis. prognostic impact in pancreatic cancer. Discussion: Adenomyoma rare lesion. Endoscopic biopsy Methods: Between January 2003 and June 2017, a total of and histological examination not conclude diagnosis in 324 resected pancreatic cancer patients (head; 244, body endoscopically invisible lesion.Pathologist mistakes with well and tail; 80) were enrolled. As image findings, portal vein differentiated adenocarcinoma .Adenomyoma mimicking (PV) invasion was classified into type A (absent), B (uni- with carcinoma clinically and radio logically.tissue diagnosis lateral narrowing), C (bilateral narrowing), and D (stenosis not done before surgery .Did whipples operation. or obstruction with collaterals), whereas, splenic vein Conclusion: Proper tissue diagnosis essential to avoid (SPV) invasion was classified as type a (absent), b (ste- whipples operation. nosis), and g (obstruction). Pathological grade of portal system invasion was classified into: grade 0 (no invasion), 1 (tunica adventitia), 2 (tunica media), and 3 (tunica intima). EP02C-040 Results: Both in PV and SPV invasions, there was a sig- SOLID PSEUDOPAPILLARY TUMOUR nificant correlation between image classification and path- OF PANGREAS: A RARE < < ological grade (PV; P 0.0001, SPV; P 0.0001, PRESENTATION respectively). In head cancer, type A had a significant better survival than type  B(P< 0.0001). Whereas in body and S. Rahman tail cancer, there was no difference among type a, b and g.In Hepatobiliary Pancreatic and Liver Transplant Division, multivariate analysis, type B (P = 0.0003), C (P = 0.007) in Bangobandhu Sheikh Mujib Medical University, head cancer and lymph node metastases (P = 0.0003) in body Bangladesh and tail cancer were the independent prognostic factors. Introduction: Pseudopapillary tumour (SPT).First described Conclusion: Image classification was correlated with in 1959 as “papillary tumour of pancreas, Benign or malig- pathological grade in portal system invasion in pancreatic nant” Location varies either head or tail.Gradually become cancer. Image classification in PV invasion can be used for larger before giving any symptoms.Metastasis rarely to liver. prognostic prediction, but not in SPV. Materials and methods: Abdominal mass for one and half month,experience pain in abdomen. Initially dull ache and continuous suddenly severe and colicky, lasted few hours EP02C-039 following meal and movement.vomiting of same duration. OBSTRUCTIVE JAUNDICE DUE TO Apetite good but early satiety, Physical condition was good but anxious looks. ADENOMYOMA OF THE AMPULLARY Ultrasonography finding. A large mixed echogenic mass REGION, A RARE CASE 6.6 cm *6.2 cm on medial aspect of left kidney attached to S. Rahman the tail of pancreas. Hepatobiliary Pancreatic and Liver Transplant Division, CT scan shows: Large rounded mixed density mass Bangobandhu Sheikh Mujib Medical University, lesion is noted adjacent to posterior wall of stomach Bangladesh measuring 7.5*7.4cm and inseparable from tail of pancreas. Introduction: A rare case, benign in nature. Causing Operative procedure: By midline incision abdomen biliary obstruction leads to jaundice. Usual common site is opened .Large well capsulated mass detected along the stomach, small intestine is the second common sites usually lesser curvature of the stomach. Through opening at the fi in the periampullry area or ileum. Preoperative diagnosis is gastrocolic omentum the swelling indenti ed attached to extremely difficult, that’s why extensive surgery was body of pancreas. The growth dissected upto neck , trans- performed because of confusion about diagnosis with ected, closed by 3-0 PDS hand sewing in two layers. The periampullary carcinoma. growth mobilized upto tail transected 1 cm away from the

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S543 margin of swelling closed by 3-O PDS in two layers. The Introduction: Pancreatic adenocarcinoma (PDAC) remains operative time two hours thirty minutes.Blood loss a disease with a poor prognosis despite advances in surgery 50ml.Keeping two drains abdomen closed. On 10th post- and systemic therapies. Neoadjuvant treatment strategies operative patient discharged. have been given increased attention and is a promising Discussion: The central pancreatectomy a non standard alternative to adjuvant chemotherapy. However, their role operation for unusual lesion. The technique is safe. remains controversial. This meta-analysis aims to clarify the Conclusion: Central pancreatectomy effectively preserve benefits of neoadjuvant therapy in resectable PDAC. longtime endocrine function. It gives benefit in only benign Methods: Eligible studies were identified from MEDLINE, and low grade malignant neoplasm.it is only done when EMBASE, Cochrane and PubMed. Studies comparing enucleation is difficult. neoadjuvant therapy with a surgery first approach (with or without adjuvant therapy) in resectable PDAC were included. The primary outcome assessed was overall sur- EP02C-041 vival (OS). Random-effects meta-analysis was performed, A CASE REPORT OF RESECTION FOR as well as pooling of unadjusted Kaplan-Meier curve data. Results: A total of 533 studies were identified that analysed POSTOPERATIVE LUNG METASTASIS the effect of NAT in PDAC. 27 studies were included in the OF PANCREATIC CANCER AFTER final data synthesis. Meta-analysis suggested beneficial SYSTEMIC CHEMOTHERAPY effects of NAT with prolonged survival for NAT compared S. Takamatsu, T. Irie, S. Kato, H. Nagano, to no NAT, HR (95% CI): 0.72 (0.69, 0.76). In addition, R1 fi S. Ootsukasa and Y. Kawachi resection rates were signi cantly less for patients receiving Surgery, Musashino Red Cross Hospital, Japan NAT: RR 0.51 (0.47, 0.55). Conclusions: Current evidence suggests neoadjuvant We often encounter recurrence after surgery for pancreatic chemotherapy has a benefit in OS in resectable PC in com- cancer. Systemic chemotherapy is usually undergone for such parison to upfront surgery and adjuvant therapy. Further recurrence, however, prognosis is very poor. We reported a trials are needed to address the need for practice change. case whose postoperative lung metastasis of pancreatic cancer was able to resect after systemic chemotherapy. The patient was a 56-year-old female who underwent distal pancreatectomy for invasive ductal carcinoma of the EP02C-043 pancreatic body in 2012. Pathological examination of the PRESSURIZED INTRAPERITONEAL resected specimen demonstrated that moderately differen- AEROSOL CHEMOTHERAPY (PIPAC) IN tiated tubular adenocarcinoma invaded into splenic vein PANCREATIC CANCER PATIENTS and diagnosed as Stage IIA (pT3 pN0 M0) according to the WITH PERITONEAL METASTASIS seventh edition of TNM classification. Postoperative course 1,2 1,2 2,3 was uneventful and she received standard adjuvant M. Ploug , M. Graversen , S. Detlefsen , 2,4 1,2 chemotherapy with gemcitabine for six months. One year P. Pfeiffer and M. Bau Mortensen 1 after operation, bilateral and multiple lung metastases were HPB Section, Department of Surgery, Odense University 2 shown on computed tomography. Consequently, we started Hospital, Odense PIPAC Center (OPC) and Odense 3 systemic chemotherapy with S-1 and continued for 2 years Pancreas Center (OPAC), Department of Clinical Pa- 4 and 6 months. No other distant metastases than lung thology, and Department of Clinical Oncology, Odense presented and the number of lung metastases decreased by University Hospital, Denmark chemotherapy. Finally, only one nodule remained in right Introduction: The median survival in pancreatic cancer lung on computed tomography, therefore, we considered to (PC) patients with synchronous peritoneal metastasis (PM) be resectable. She underwent surgery for lung metastasis is six weeks, and the effect of palliative systemic chemo- after four years of the operation for primary pancreatic therapy is limited. Pressurized IntraPeritoneal Aerosol cancer, and pathological examination confirmed lung Chemotherapy (PIPAC) has shown promising results in metastasis of pancreatic cancer. Now, one year has passed patients with PM of different origin, but data in patients since lung metastasis was resected, there was no evidence with PM from PC are sparse. We present prospective data of recurrence. on PIPAC treatment in nine PC patients with PM. In conclusion, we reported a case that postoperative lung Methods: Between January 2016 and January 2018, PC metastasis of pancreatic cancer became resectable by sys- patients with isolated PM were included. Objective temic chemotherapy and successfully treated by surgery. response evaluation was based on the Peritoneal Regression Grading Score (PRGS) in repeated biopsies from PM. Survival data, prior chemotherapy, number and complica- EP02C-042 tions of PIPAC procedures were collected. SYSTEMIC ADJUVANT AND Results: Nine patients (5M/4F, median age 62 years (range 46-72)) were included. Six patients had synchronous PM, NEOADJUVANT CHEMOTHERAPY IN whereas three patients developed PM after initial resection. MODERN PANCREATIC CANCER Patients had received between 2 and 12 (median 9) cycles of TREATMENT: A SYSTEMATIC REVIEW systemic chemotherapy prior to inclusion. Twenty-four AND META-ANALYSIS PIPAC procedures (median 2, range 1-5) were performed, without significant complications. The median survival was 11 K. Rangarajan, P. Pucher, J. Primrose, A. Bateman, months (range 8-25) after diagnosis of PM and 6 months Z. Hamady and N. Evans Harding (range 2-16) after the first PIPAC. Based on the PRGS score in Department of Surgery, University Hospital Southampton, six patients who received > 1 PIPAC, four patients responded United Kingdom

HPB 2018, 20 (S2), S505eS684 S544 Electronic Posters (EP02A-EP02F) e Pancreas and two had stable disease. One patient died before the second University, 5University of Missouri, 6Mayo Clinic, 7City of PIPAC (disease progression), two patients received no further Hope Medical Center, and 8Virginia Mason Medical PIPAC since PM could not be bioptically verified. Center, United States Conclusions: PIPAC is safe in pancreatic cancer patients Background: Optimal treatment of pancreatic ductal with peritoneal metastasis, and PIPAC may induce an adenocarcinoma of the neck, body and tail (PDAC-NBT) is objectively measureable treatment response. predicated upon complete surgical resection with negative (R0) margins. However, preoperative identification of pa- tients who may achieve successful resection is difficult. EP02C-044 Thus study seeks to identify preoperative imaging charac- PANCREATIC MASS WITH AORTIC teristics that may serve as prognostic markers associated THICKENING AND RENAL LESIONS: with non-R0 resection and subsequent poor survival. Methods: Patients at five high-volume pancreatic centers AN UNUSUAL CAUSE with PDAC-NBT who underwent surgical resection with I. Sulieman1, A. Mahfouz2, E. Al-Kuwari3, L. Szabados4, curative intent were retrospectively analyzed. The most W. Elmoghazi1, A. Elaffandi1 and H. Khalaf1 immediate preoperative cross-sectional computed tomog- 1Department of Surgery, 2Department of Radiology, raphy scan was assessed and correlated with the primary 3Department of Pathology, and 4Department of Radiology outcome measures of overall survival and surgical margins. & Nuclear Medicine, Hamad Medical Corporation, Qatar Results: 330 patients were surgically treated between 2001 Introduction: Most patients with pancreatic masses pose a and 2016. Of these, 247 underwent R0 (78.2%), 67 R1 diagnostic challenge when a benign lesion is suspected, and (21.2%), and 2 R2 resection (0.6%). A non-R0 resection often, resection is needed before a benign diagnosis is was significantly associated with worse survival confirmed. (p=0.0002). On preoperative imaging, patients with tumors Case: A 57 years old male patient presented with a greater than 20 mm, tumor attenuation greater than 70 pancreatic head mass with obstructive jaundice and a history Hounsfield units, or who demonstrated pancreatic atrophy of submandibular lymph node enlargement of unknown or calcifications had significantly worse overall survival etiology for two years. He also had a history of recurrent eye (p=0.010, p=0.036, p=0.025 respectively). Tumors with pain and redness, skin lesions, and prostatic enlargement. any vascular interface with the splenic artery, splenic vein, MRI showed a pancreatic head mass with double duct sign, or both were significantly more likely to undergo non-R0 aortic thickening and inflammation, bilateral renal lesions, resection (p=0.0006, p=0.0004, p=0.020, respectively). diffuse lymph node enlargement, and prostatic enlargement. Posterior extension of the tumor was also associated with FDG-PET/CT demonstrated abnormal uptake correspond- non-R0 resection (p=0.001). ing to the MRI lesions. Biopsy of an inguinal lymph node Conclusions: Preoperative cross-sectional imaging can revealed infiltrates with IgG4 plasma cells, consistent with identify tumor characteristics which are associated with poor the diagnosis of IgG4 disease. The patient was treated with survival and non-R0 resections. These data suggest PDAC- IV steroids and showed significant improvement. NBT patients with vascular involvement may benefit from Discussion: IgG4 related disease is a rare entity that is aggressive, en-bloc surgical resection, preoperative medical characterized by lesions that show heavy infiltration with therapy, and regionally directed margin-enhancement IgG4 positive plasma cells, storiform fibrosis, and oblitera- techniques. tive phlebitis. The pancreas is the most commonly involved organ, but several other organ systems are involved, and this helps in clinical suspicion of the diagnosis. A biopsy from EP02C-046 any easily accessible site that shows the characteristic his- PROGNOSTIC SIGNIFICANCE OF fi tological features is suf cient for diagnosis. Patients respond PERITONEAL WASHING CYTOLOGY IN quickly to steroids, but recurrence is frequent. Conclusion: IgG4 related disease is a rare cause of RESECTABLE PANCREATIC pancreatic tumorous lesions that need a high index of CARCINOMA suspicion for diagnosis and should be differentiated from D. Takahashi1,2, M. Konishi1, S. Okubo1, M. Sugimoto1, pancreatic neoplastic lesions, and medical treatment is S. Kobayashi1, S. Takahashi1 and N. Gotohda1 effective. 1Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, and 2Department of Surgery, Shizuoka Saiseikai General Hospital, Japan EP02C-045 Introduction: Prognostic significance of peritoneal PREOPERATIVE IMAGING washing cytology in pancreatic carcinoma is still contro- CHARACTERISTICS PREDICT POOR versial, and the treatment strategy for the patients with SURVIVAL AND INADEQUATE positive cytology(CY+) has not been established. The aim of this study is to evaluate the clinical significance of CY+ RESECTION FOR LEFT-SIDED in resectable pancreatic carcinoma. PANCREATIC ADENOCARCINOMA: A Methods: This study included a retrospective cohort of 450 MULTI-INSTITUTIONAL ANALYSIS patients who underwent curative resection for pancreatic F. Alemi1, Z. Jutric2, J. Grendar3, A. M. Roch4, carcinoma with positive or negative cytology between A. L. Cheng5, P. D. Hansen3, E. P. Ceppa4, H. J. Asbun6, January 2000 and December 2015. CY+ patients under- S. Warner7 and A. A. Alseidi8 went surgical resection only when they had no other poor 1St Vincent Medical Center, 2University of California, prognostic factor such as portal vein invasion. Intra- Irvine, 3Providence Portland Cancer Center, 4Indiana operative washing cytology was performed according to the

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Japanese General Rules for the Study of Pancreatic Cancer. EP02C-048 All slides were stained with Papanicolaou method, and examined by experienced cytoscreeners and pathologists. TENASCIN C IS UPREGULATED AROUND Results: Overall, 13 patients were CY+, and 437 patients PERINEURAL INVASION OF were CY-. Lymph node metastasis was significantly more PANCREATIC DUCTAL common in the CY+ group than in the CY- ADENOCARCINOMA AND CORRELATES group(p=0.040). The median recurrence-free survival was WITH LOCOREGIONAL RECURRENCE 6.9 months for the CY+ group and 13.9 months for the CY- group(p=0.044). The median overall survival was 18.7 S. Furuhashi, T. Sakaguchi, R. Kitajima, R. Kiuchi, months for the CY+ group and 32.5 months for the CY- M. Takeda, T. Hiraide, Y. Shibasaki, Y. Morita, group(p=0.295). 10 of 13 CY+ patients were recurred (3 H. Kikuchi and H. Takeuchi peritoneum, 3 loco-regional, 4 liver, 1 lymph node, 2 lung, Second Department of Surgery, Hamamatsu University 1 remnant pancreas). One CY+ patient survived more than School of Medicine, Japan 5 years after surgery without evidence of recurrence, and Introduction: Pancreatic ductal adenocarcinoma (PDAC) another one patient survived more than 5 years with the is characterized by stromal desmoplasia and perineural in- recurrence of remnant pancreas. vasion. However, mechanisms which drive stromal change Conclusion: Some CY+ patients without other poor and neural tropism in cancer progression remain unclear. prognostic factors may survive long by curative resection. Tenascin C (TNC), an extracellular matrix glycoprotein, has been reported to be expressed mainly in cancer stroma and associated with metastasis and poor prognosis in EP02C-047 PDAC. The aim of this study is to evaluate relationships between TNC expressions around nerves and clinicopath- PATIENTS WITH PANCREATIC CYSTIC ological features in resected PDAC. NEOPLASMS CAN BENEFIT FROM Method: A total of 79 PDAC patients without receiving MANAGEMENT OF any preoperative treatment who underwent surgical resec- MULTIDISCIPLINARY TEAM tion between January 2000 and May 2017 were enrolled in this study. TNC expression was examined immunohis- T. Liang1, X. Bai1, Y. Chen1, C. Guo1, Q. Zhang1, tochemically on paraffin-embedded sections from resected Y. Shen1,Y.Li2 and X. Li1 specimen. The perineural staining intensity of TNC in 1The Second Affiliated Hospital, and 2Zhejiang University invasive front of pancreatic cancer was defined as high or School of Medicine, China low (Image), by comparing with that in adjacent non- Background: Pancreatic cystic neoplasms (PCNs) are a cancerous tissue in the same section. The relationships spectrum of neoplasms that can be benign or malignant. between TNC expression and clinicopathological features The accuracy of diagnosis is critical for this disease since were retrospectively analyzed. different types of PCNs are treated using various modal- Results: High TNC perineural expression in invasive front ities. Multidisciplinary team (MDT) has been proposed to was seen in 30 (38%) patients, and associated with peri- participate in the management of various diseases. We neural invasion (p=0.006), pT3  (p=0.01), lymph node aimed to determine the performance of MDT in the man- metastasis (p=0.038) and postoperative locoregional agement of PCNs. recurrence (p=0.039). High perineural TNC expression was Methods: We retrospectively reviewed 167 pathologically significantly associated with worse recurrence free survival proved PCN patients and set three groups according to their rates by univariate analysis. surgical date and treatment modalities: 1) historical control Conclusions: Perineural TNC expression is a potential group; 2) concurrent control group; and 3) MDT group. predictable marker for locoregional recurrence. The composition of subtypes of PCNs, preoperative diag- nostic accuracy, postoperative complications, and post- operative hospital stay were compared among the three groups. EP02C-049 Results: The incidence of SCN reduced in the MDT INVERSE PROBABILITY OF group, while the incidence of IPMN was much higher. TREATMENT WEIGHTING ANALYSIS MDT management significantly elevated the accuracy of OF UPFRONT SURGERY VERSUS preoperative diagnosis (71.7%) and also increased the NEOADJUVANT diagnostic accuracies of ultrasound, CT, and MRI/MRCP in patients with PCNs. The morbidity of pancreatic fis- CHEMORADIOTHERAPY FOLLOWED tula, the most common complication, was significantly BY SURGERY FOR PANCREATIC reduced in the MDT group (28.3%). Furthermore, the ADENOCARCINOMA WITH ARTERIAL mean hospital stay after surgery in the MDT group was ABUTMENT much shorter than those of the other two groups (10.73 T. Fujii1, S. Yamada2, K. Murotani3, H. Takami2, days). N. Tanaka1, I. Yoshioka1, K. Shibuya1, T. Okumura1 and Conclusion: For PCN patients, MDT management im- Y. Kodera2 proves the overall accuracy of preoperative diagnosis, 1University of Toyama, 2Nagoya University Graduate lowers postoperative complication morbidity, and School of Medicine, and 3Aichi Medical University, Japan shortens postoperative hospital stay. Additionally, MDT Background: Combined arterial resection during pancre- is beneficial for surgeons and radiologists to gain more atectomy can be a challenging treatment, and outcome experience and make better preoperative diagnoses for would be more favorable if the tumor becomes technically PCNs.

HPB 2018, 20 (S2), S505eS684 S546 Electronic Posters (EP02A-EP02F) e Pancreas removable from the artery. Neoadjuvant chemo- in twelve (85.7%) patients. Median follow up: 62 months radiotherapy (NACRT) is expected to achieve locoregional (range; 0-215), overall survival:142 months (range; 60-264). control and enable margin-negative resection. Conclusion: Minimal Invasive surgery became the standard Aim: To investigate the effects of NACRT in patients with treatment for most patients with insulinoma with high pancreatic adenocarcinoma (PDAC) which were deemed curability rate since 2000. Malignant insulinomas may have borderline resectable through preoperative imaging due to favorable long-term outcomes with multimodality treatment. abutment of the major artery, including the superior mesenteric artery (SMA) or common hepatic artery (CHA), but were still considered to be technically removable. EP02C-051 Patients and methods: Comparisons were make between GENERALISED LYMPHADENOPATHY 71 patients who underwent upfront surgery and 21 patients ’ who underwent NACRT followed by surgery in the strategy IN A LONG TERM WHIPPLE S to preserve the artery, using unmatched and inverse proba- SURVIVOR e NOT ALWAYS bility of treatment weighting analysis (UMIN000017115). DISSEMINATED METASTASIS Results: Fifty patients in the upfront surgery group and 18 N. Shivathirthan, K. Patel and Y. Kumar in the NACRT group underwent curative resection (70% vs Dept of Gastro Surgery, India 86%, respectively; P = 0.1609). The results of the pro- Introduction: In periampullary carcinoma, metastasis pensity score weighted logistic regressions indicated that through haematogenous and lymphatic routes is not un- the incidences of pathological lymph node metastasis and a common occuring not only at the time of diagnosis, but also pathological positive resection margin were significantly after treatment. Intra-abdominal recurrence post Whipple’s lower in the NACRT group (odds ratio, 0.006; P < 0.0001 procedure ranges from 38-86%, while spread to distant and odds ratio, 0.007; P = 0.0005, respectively). Among the lymph nodes is rarely seen. So generalised lymphadenop- propensity-score matched patients, the estimated 1- and 2- athy post Whipple’s surgery should raise suspicion for non- year survival rates in the upfront surgery group were 66.7% malignant differentials. and 16.0%, respectively, and those in the NACRT group Case report: A 50 year old female presented with com- were 80.0% and 65.2%, respectively. plaints of multiple swellings in axillae, iliac, inguinal and Conclusion: It was suggested that chemoradiotherapy supraclavicular region with past history of Whipple’s followed by surgery provided clinical benefits in patients pancreaticoduodenectomy done 6 years back for peri- with PDACs in contact with the SMA or CHA. ampullary carcinoma (adenocarcinoma- grade II). PET scan showed metabolically active multiple lymphadenopathy suggestive of metastasis. Excision biopsy of axillary lymph EP02C-050 node and FNAC of Iliac nodes done revealed non-necrot- INSULINOMAS: CLINICAL FEATURES, ising granulomatous inflammation consistent with TREATMENT AND OUTCOMES AT THE sarcoidosis. Diagnosis of lymph nodal sarcoid like reaction NATIONAL CANCER INSTITUTE IN was made and she was treated with NSAIDs. PERU Results: The presence of non-caseating granulomas in cancer patients with no symptoms or signs suggestive of A. Guevara, R. Fernandez, E. Payet, E. Ruiz and F. Berrospi systemic sarcoidosis is typically referred to as sarcoid-like INEN, Peru reaction. Due to high degree of overlap on SUV max after Introduction: Insulinomas are rare functional pancreatic PET-CT, for benign and malignant conditions, a patholog- tumors with good prognosis when small and benign but ical diagnosis is often mandatory to differentiate between dismal results if larger or harbor malignant features. the two. Identifying sarcoid-like reactions as metastasis re- Objective: Analyze clinical features, treatment and clinical sults in disease upstaging leading to over/under treatment. outcomes of insulinomas treated in the period 1992 - 2017 Conclusion: Generalised Lymphadenopathy in long term at The National Cancer Institute (INEN) of Peru. Whipple’s survivor is less likely to be disseminated metas- Methods: All patients with biochemical / histopathological tasis. In developing countries like India, where granuloma- criteria for insulinoma were included and retrospectively tous pathologies are highly prevalent, differential diagnosis analyzed. of sarcoid-like reaction, tuberculosis and lymphoma should Results: Fourteen patients were included, [9 women be thought of. Therefore a comprehensive pathologic ex- (64.3%); mean age 41.1 Æ 17.1 years (range, 11e74)]. amination is necessary to avoid potential pitfalls. Thirteen patients (92.9%) had sporadic tumors. Twelve (85.7%) had solitary tumors. Eleven (78.6%) had fasting hypoglycemia. Mean glucose nadir was 32.4 Æ 9.8 mg/dL EP02C-052 e with a median insulin value of 42 uU/mL (range,14.6 285). INTRODUCING “K-SHAPED SIGN”,A The lesion was identified by CT or MRI before surgery in twelve patients. Four (28.6%) were found in the tail and four NEW FINDING ON CT TO DETECT A in the pancreas body. Mean size of lesion 3.75 cm (range; PANCREATIC CANCER AT THE EARLY 1.2e14 cm). Nine (64.3%) patients were treated with STATE enucleation and seven of them with laparoscopy (77.8%). No Y. Kobashi1, J. Matsui2, Y. Seto1, A. Baba1, fi mortality recorded. Two patients had clinically signi cant S. Yamazoe1 and T. Mogami1 fi pancreatic stula (ISGPF type B). Three patients (21.4%) 1Radiology, and 2Surgery, Tokyo Dental College Ichikawa had malignant insulinomas, two of them developed meta- General Hospital, Japan static disease after 94 and 156 months and surgery + Introduction: We found and evaluated a specific change of chemotherapy was offered. Surgery alone achieved curability the pancreas on CT just before a pancreatic cancer appears.

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Methods: We selected 32 patients among 241 patients with Cryodestruction modulate long term antitumor immune advanced pancreatic cancer. All 32 patients took abdominal response it may be promising in multidisciplinary approach CT more than one time, before their pancreatic cancers in the treatment of LAPC. were diagnosed. Eight of the 32 patients underwent pancreatic resection.We reviewed all patients’ abdominal CT and checked how abnormal findings appeared in the EP02C-054 fi pancreas before nding their pancreatic cancer. ROOT OF MESENTERY AND SMALL Results: Twenty-three (71.8%) of the 32 patients had a localized constriction of the pancreatic parenchyma before BOWEL TUMOURS ALSO THE DOMAIN appearing the pancreatic cancer. We named it “K-shaped OF HPB SURGEONS: A SINGLE UK sign” based on the figure. All of the 23 patients showed CENTRE OUTCOME focal fatty changes around the area the K-shaped sign D. Gumaa, A. Gordon-Weeks and M. Silva appeared. Four (17.3%) of the 23 patients had both K-shape Oxford University Hospitals NHS Foundation Trust, sign and a partial main pancreatic duct dilatation. United Kingdom Nineteen of the 32 patients had a normal pancreas Background: Primary malignant tumours of the small without focal fatty change on CT before the K-shaped sign bowel represent 1-3% of all malignant gastrointestinal tu- occurred. Thirteen of the 32 patients had detected the K- mours. Neuroendocrine tumours (NET) are the predomi- shaped sign since the initial abdominal CT. All the 32 pa- nant histological subtype with adenocarcinoma and tients had the pancreatic cancer in the K-shaped sign’s area. gastrointestinal stromal tumours (GIST) also recognised. Conclusion: We introduced new CT finding before pancre- Method: Retrospective cohort study of patients with histo- atic cancer could be found, and named it “K-shaped sign” on logically confirmed small bowel tumours operated at Oxford CT. Although the “K-shaped sign” phenomenon has to be university hospitals from January 2012 to the present day. associated with early pancreatic cancer, it is unclear what the Results: 87 patients underwent surgery for small bowel cause of the phenomenon is. When the K-shaped sign is malignancy. 24 patients required emergency surgery, pri- observed on CT, the onset of a pancreatic cancer should be marily due to bowel obstruction. NET was the most considered and determined by using more precise modalities. common subtype (41 patients) followed by adenocarci- noma (28) and GIST (18). Ileal tumours were more frequently NET than adenocarcinoma or GIST (24.3%, EP02C-053 10.7% and 5.6%, p< 0.0001) and patients with adenocar- CRYODESTRUCTION IN LOCALLY cinoma were more frequently anaemic pre-operatively (Hb аDVANCED PANCREATIC CANCER 110.7Æ4.7g/dL, 129.9Æ3.4 and 117.6Æ5.9 for adenocar- cinoma, NET and GIST, p< 0.0005). NETs were signifi- D. Ionkin1, A. Chzhao1, O. Zhavoronkova2, cantly smaller than adenocarcinoma or GIST Y. Stepanova2 and N. Karelskaya2 (21.8Æ2.0mm, 42.6Æ6.2 and 82.6 Æ17.7, p< 0.0001) 1General Surgery, and 2Radiology, A.V. Vishnevsky Insti- however, a greater proportion had metastatic disease tute of Surgery, Russian Federation (39.0%, 3.6% and 11.1%, p=0.0004), perineural invasion Purpose: Improving the life quality, and increase life ex- (73.2% for NET, 21.4% for adenocarcinoma, p=0.0002) pectancy (in combination of chemotherapeutic treatment) in and R1 resection status (22.0% for NET, 3.6% for adeno- patients with locally advanced pancreatic cancer (LAPC). о carcinoma, p=0.047). Tumour grade, nodal status and his- Materials and methods: Since January 2012, pen cryo- topathological subtype were independent predictors of destruction has been performed in 36 patients with LAPC outcome on multivariate analysis, with NET demonstrating (male-14(38.9%), female-22(61.1%). The mean age was significantly longer overall survival compared with Æ 58 6.8 years. Tumor size was 2.5-10 cm. Local destruction adenocarcinoma or GIST (HR2.9 95%CI 1.5-5.3). was supplemented by bypass anastomoses in 18(50%) cases. Conclusion: Despite the relatively advanced stage of NETs ” ” "CRYO-MT and "CRYO-01 were used, as well as porous- at presentation, these tumours demonstrated better overall sponge applicators made of titanium nickelide. The target survival than adenocarcinomas of the small bowel. De С temperature: -186o . Exposure time: 3-5 min. All patients bulking procedures with R1 resection is an acceptable subsequently underwent adjuvant chemotherapy, supple- approach for NET as compared to adenocarcinoma or GIST. mented with regional chemoembolization in 10 cases. Results: There were no lethal outcomes during the inter- vention and in the nearest postoperative period. Intraperi- toneal bleeding was in 2(5.5%) cases (due to cracks EP02C-055 appearing on the border of the pancreatic tissue and "iceball” QUANTITATIVE PERFUSION ANALYSIS -1, the artery was damaged in the process of biopsy after AND TIME INTENSITY CURVE cryodestruction - 1). Acute pancreatitis was in 5 (13.8%) ANALYSIS IN DIFFERENTIAL cases. Suppuration in the manipulation zone - in 2(5.5%). DIAGNOSIS OF SOLID PANCREATIC Ascite was in 9(25%) patients (stopped conservatively for 5- 8 days). After cryodestruction: the complete disappearance TUMORS BY CONTRAST-ENHANCED of the pain syndrome - 42.2%, a significant decrease in its ULTRASOUND. A PILOT STUDY intensity - 41.6%. Survival in Kaplan-Meier: 6 months-92%, Y. Stepanova, N. Askerova and I. Timina 12-84%, 24-48%, 36-14%. Mediana-18.2 months. Radiology, А.V. Vishnevsky Institute of Surgery, Russian Conclusion: Cryodestruction in patients with LAPC im- Federation proves the quality of life due to pain relief. Cryodestruction Aim: To assess the clinical value of the TIC-analysis in the in combination with chemotherapy increases survival rate. differential diagnosis of pancreatic adenocarcinoma and

HPB 2018, 20 (S2), S505eS684 S548 Electronic Posters (EP02A-EP02F) e Pancreas chronic pseudotumoral pancreatitis by contrast-enhanced seen in 19 of CA19-9 2 group and 22 cases of CA19-9 >2 ultrasound. group, showing significant difference (p< 0.0001). Disease Materials and methods: Contrast-enhanced ultrasound specific survival (DSS) was significantly poorer in CA19-9 with TIC-analysis was performed on 23 patients with focal 2 group (MST 16.9 mo) than in CA19-9 >2 group (MST pancreas lesions. The indicators were evaluated by phases: 31.6 mo) (p=0.0162). Also, DSS of elevated DUPAN-2 arterial e 13 sec, pancreatic e 17 sec, venous e 37 sec, was significantly lower than that of normal DUPAN-2 delayed e 120 sec. Valuation options: the intensity and the (MST 21.7 mo vs. 42.7 mo, p=0.0011). time at which the maximum accumulation of contrast Conclusion: CA19-9 2 group shows poorer prognosis substance (time to peak) was achieved in the zone of and higher DUPAN-2 than CA19-9 >2 group. DUPAN-2 detected focal changes and the pancreas parenchyma. All should be measured in PC cases with normal level of serum patients were operated on, tumors were verified morpho- CA19-9. logically: adenocarcinoma of the pancreas in 18(78%) pa- tients, chronic pseudotumoral pancreatitis e in 5(22%) patients. EP02C-057 Results: The results about intensity of the tumors obtained RESSECTION OF PANCREATIC by the TIC-analysis do not allow to differentiate these pathological processes statistically significant (p>0,05), CARCINOMA IN THE REMNANT which, in all probability, due to the fact that pancreatic PANCREAS AFTER AN R0 adenocarcinoma and chronic pseudotumoral pancreatitis PANCREATICODUODENECTOMY FOR have similar morphological characteristics in the form of PAPILLARY CANCER: A CASE REPORT pronounced desmoplastic stromal response and fibrosis- R. A. Fuziy1,2, O. D. Campos2, A. K. S. Alves3, E. Lobo1, hyalinosis, respectively. The "Time to peak” parameter A. Goldenberg1, G. D. J. L. Filho1, B. B. Benini1, allowed us to determine statistically significant that N. S. Liboni4, R. A. Neto5 and F. R. A. Torrez1 pancreatic adenocarcinoma had an early accumulation of 1Surgery, UNIFESP, 2Oncologia, Beneficiencia Portu- contrast agent (average 16 sec) and early washout (from an guesa, 3Surgery, Hospital Alemao Osvaldo Cruz, 4Sur- average of 17 sec); the chronic pseudotumoral pancreatitis gery, Beneficência Portuguesa de São Paulo (BP), and had the slow accumulation of contrast agent (average 85 5Pathology, UNIFESP, Brazil sec) and slow washout (from an average of 86 seconds) (p< 0,05). Introduction: We report a rare case of a repeated pancre- Conclusion: The “Time to peak” parameter at ultrasound atic resection in the remnant distal pancreas 18 months after fi examination with echocontrast allows statistically signifi- a laparoscopic Whipple R0 procedure. In this case, the rst cantly differentiate adenocarcinoma of the pancreas and surgery was for papillary cancer. chronic pseudotumoral pancreatitis. Method: In February 2014, a 73-year-old woman under- went a laparoscopic Pancreatoduodenectomy procedure with lymphadenectomy for papillary cancer. In August 2015, in follow up segment MR revealed a tumor in the EP02C-056 remnant pancreas. There were no findings of invasion of the CLINICOPATHOLOGICAL surrounding tissue or distant metastasis. After radiological CHARACTERISTICS OF PANCREATIC reevaluation (PET and CT) in October 2015, we removed CANCER WITH NORMAL LEVEL OF the remnant pancreas and spleen also by laparoscopic SERUM CA19-9 surgery. M. Mizuma, F. Motoi, K. Fukase, H. Ohtsuka, K. Nakagawa, T. Morikawa, H. Hayashi, T. Naitoh, T. Kamei and M. Unno Department of Surgery, Tohoku University, Japan Introduction: We need to pay attention to Lewis negative patients in PC with normal level of serum CA19-9. The aim of this study was to evaluate clinicopathological charac- teristics of PC with normal level of serum CA19-9. Methods: Between 2001 and 2016, 135 consecutive PC cases with normal level of serum CA19-9 before start of treatment, who underwent surgical resection at our insti- tute, were retrospectively reviewed. These cases were divided into two groups. One is cases within 2.0 U/mL of serum CA19-9 (CA19-9 2 group), which includes pa- tients with negative Lewis antigen. The other is cases more Pet than 2.0 U/mL of serum CA19-9 (CA19-9 >2 group). Clinicopathological features were investigated between the Results: Histopathologically, the tumor was classified as a groups. Also, according to value of the serum DUPAN-2, ductal adenocarcinoma, not the same tumor which had been the cases divided into the two groups (normal DUPAN-2 removed during the first operation, with infiltration of and elevated DUPAN-2), which were compared in peripancreatic adipose tissue and without lymph node prognosis. metastasis. She was using Capecitabin after the surgery and Results: CA19-9 2 and CA19-9 >2 group had 22 and in august 2016 peritoneal metastasis apears and died in 113 cases, respectively. Elevated serum DUPAN-2 was

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S549 september 2017. We compare the two histophatological Hôpital Rangueil, 7CHU Caen, 8Hôpital Beaujon, and diagnoses. 9Hôpital Paul Brousse, France Conclusions: There are very few reports of pancreatic Rational: Biliary self-expandable metallic stents carcinoma in the remnant pancreas after a pancreatico- (bSEMSs) have been proven to have longer stent patency duodenectomy in the literature. In most of these cases, it is than plastic stents (bPS) in malignant biliary obstruction for adenocarcinoma and even so difficult to assess whether and is now advise as a standard practice. The risk of tumor the remnant pancreatic cancer is a recurrence or a second dislocation following bSEMS placement and associated primary cancer. In our patient, the first hypothesis seems to pathological pattern has never been evaluated. This study be a new tumor. aimed to evaluate the impact of insertion of bSEMS on pathological pattern and long-term survival of patients who underwent pancreaticoduodenectomy (PD) for resectable EP02C-058 pancreatic ductal adenocarcinoma (PDAC). SOLITARY METASTATIC MELANOMA Methods: A multicenter observational study was OF THE PANCREAS WITH AN performed using a common database of patients with opereted resectable PDAC from sixteen high-volume cen- UNKNOWN PRIMARY SITE ters in France between 2009 and 2015. Y. N. Lee, W. Y. Kim and E. Y. Kim Results: Of 597 patients who underwent PD for PDAC, Department of Surgery, Presbyterian Medical Center, 197(62%) underwent preoperative endoscopic biliary Korea, Republic of drainage, including 105(51%) with SEMS and 92(49%) Solitary metastatic melanoma of the pancreas is very with PS. rare. Clinical experience and the literature of surgical The patients without biliary drainage had a significantly resection of pancreatic metastasis is also limited. We report better median overall survival (34,9 vs 29,5 months; a case of isolated metastatic melanoma with an unknown p=0.004) and recurrence free survival (24,6 vs 189, primary site. months; p=0.002) than those with bSEMS. Patients with A 64-year-old male with epigastric pain was admitted to bPS had intermediate survivals without any difference with the emergency room. He had no medical history except the 2 other groups. hypertension and right wrist fracture. CT showed 7.5 x 4.5 Perineural (p=0.001) and lymphovascular (p=0.029) in- cm mass on pancreas body. Laboratory findings showed vasion were significantly more frequent in patients with only slightly elevated amylase levels of 109 U/L (28< bSEMS, but lymph node involvement and ratio were not. normal range < 100 U/L). Intraoperative frozen section Multivariate analysis showed that biliary drainage, biopsy revealed that the mass is melanoma. A distal lymph node involvement and the absence of adjuvant pancreatectomy and splenectomy was performed. All treatment were independently associated with poorer resection margins and lymph nodes were negative for overall survival. tumor. Immunohistochemistry detected the expression of Conclusions: Use of SEMS, but not PS, was associated protein S100, HMB45. A physical examination by a with a poorer prognosis among patients who underwent PD dermatologist and ophthalmologic examination by an for PDAC, possibly related to tumor dislocation following ophthalmologist failed to find any evidence of a primary SEMS placement. Neoadjuvant therapy in that setting site. The postoperative course was uneventful. At 8 month should be discussed systematically. follow-up there were no signs of recurrence. Metastatic melanoma has a poor prognosis. There is no consensus of treatment of solitary metastatic melanoma of EP02C-060 the pancreas. Complete surgical resection of isolated met- THE MEDULLARY CARCINOMA OF astatic melanoma of the pancreas with an unknown primary THE PANCREAS site may improve the prognosis. M. F. Anduaga Peña, J. Quiñones Sampedro, M. D. J. Rodriguez Perdomo, L. M. Gonzalez Fernandez, EP02C-059 M. J. Iglesias Iglesias, M. D. C. Esteban Velasco and L. Muñoz Bellvis RISK OF TUMOR DISLOCATION Complejo Asistencial Universitario de Salamanca, Spain FOLLOWING SELF-EXPANDABLE Introduction: The medullary carcinoma of the pancreas METALLIC STENTS PLACEMENT, (MCP) is a new variety of adenocarcinoma of the pancreas. ASSOCIATED PATHOLOGICAL It has been recently described and there are very few cases PATTERN AND SURVIVAL FOR report in the literature. MCP usually have K-ras wild-type PANCREATIC ADENOCARCINOMA. genes and sometimes are microsatellite unstable. Case report: We report the case of an 80-year-old woman RESULTS OF A FRENCH with arterial hypertension and hypercholesterolemia. The MULTICENTER STUDY patient was admitted in the gastroenterology department. L. Schwarz1, P. Tortajada1, J. Perinel2, R. Souche3, The abdominal CT showed a homogeny mass in the head of L. Barbier4, R. Kianmanesh5, F. Muscari6, A. Mulliri7, the pancreas and another mass in the cecum. The technique E. Ragot8, A. Sa Cunha9 and FRENCH Working Groups used was a total pancreatectomy, splenectomy, cholecys- (Fédération de Recherche en Chirurgie) tectomy and a right hemicolectomy. 1Digestive Surgery, Rouen University Hospital, 2Hopital The histological examination showed a MCP. Twenty- Edouard Herriot, Hospices Civils de Lyon, 3CHU Mont- two lymph nodes were not affected, and margins of pellier, 4CHU Tours, 5CHU Reims, 6CHU Toulouse, resection were not affected. Frequent PanIn Foci in

HPB 2018, 20 (S2), S505eS684 S550 Electronic Posters (EP02A-EP02F) e Pancreas surrounding pancreatic tissue was described, and also the EP02C-062 histological examination of the right hemicolectomy showed an appendicular mucocele tumor with twenty- UNDIFFERENTIATED CARCINOMA OF seven lymph nodes not affected. PANCREAS WITH OSTEOCLASTIC Discussion: Pancreatic medullary carcinomas have a GIANT CELLS: A CASE REPORT fi genetic pro le different from that of conventional M. Ahuja1, S. Shah1 and R. Deshpande2 pancreatic ductal adenocarcinomas. Usually have K-ras 1GI Surgery, and 2Histopathology, PD Hinduja Hospital wild-type genes and sometimes are microsatellite Mahim, India unstable. Undifferentiated carcinoma of pancreas with osteoclastic The importance to identify MCP, is that it can be a giant cells (UCPOGC) is an extremely rare and aggressive clinical key clue to the presence of a potential occult cancer neoplasm comprising < 1% of non-endocrine pancreatic syndrome, including HNPCC. tumors. Very few cases have been reported till date and, The prognosis seems to be better than infiltrating ductal histogenesis and biological behavior of the tumor stay adenocarcinoma of the pancreas, and there are not special controversial. recommendations about treatment. In general, the treatment We report the case of UCPOGC in a 49-year-old female, of this tumor is similar to infiltrating ductal adenocarci- who presented with insidious onset left upper abdominal pain noma of the pancreas (surgery, chemotherapy and for 3 months, not relieved with any medication. Abdominal radiotherapy). CECT and MRI imaging revealed a large 9.8cm x 5.5cm multicystic, centripetally enhancing lesion involving the tail of pancreas and lower pole of the spleen. CA19-9 was EP02C-061 normal. The patient underwent a distal pancreatico-sple- NEOADJUVANT nectomy resection and UCPOGC was established on the HYPOFRACTIONATED histopathological and immunohistochemical stains. CHEMORADIOTHERAPY WITH S-1 Due to the rarity of the cancer, there is a lack of pro- FOR PATIENTS WITH RESECTABLE spective studies on treatment options. Surgical en-bloc resection is currently considered first line treatment. The AND BORDERLINE RESECTABLE role of adjuvant therapy with radiotherapy or chemotherapy PANCREATIC CANCER has not been established. K. Okano, H. Suto, M. Oshima, Y. Ando and Y. Suzuki Gastroenterological Surgery, Kagawa University, Japan The ideal neoadjuvant treatment protocol for patients EP02C-063 with pancreatic cancer (PDAC) remains unclear. We PERIAMPULLARY CANCER AND evaluated the efficacy and safety of neoadjuvant hypo- PARAAORTIC LYMPH NODES fractionated chemoradiotherapy with S-1 (NACRT) for METASTASES: A CALL TO patients with resectable (R) and borderline resectable (BR) PDAC. SYSTEMATIC INTRAOPERATIVE Methods: Eligibility criteria included patients with R FROZEN SECTION and BR PDAC, performance status 0-1, and age 20-85 A. Doussot, A. Bouvier, N. Santucci, J. B. Lequeu, years. Hypofractionated external-beam radiotherapy (30 N. Cheynel, P. Ortega Deballon, P. Rat and O. Facy 2 Gy in 10 fractions) with concurrent S-1 (60 mg/m )was Digestive Surgical Oncology, University Hospital of delivered 5 days/week for 2 weeks prior to Dijon, France pancreatectomy. Introduction: Pancreatoduodenectomy for periampullary Results: Fifty-seven patients were enrolled, including 33 cancer (PAC) with paraaortic lymph nodes metastases R and 24 BR patients. The total rates of protocol treat- (PALN +) is associated with poor survival. Still, there are ment completion and resection were 91% (50/57) and no current guidelines advocating systematic detection of 96% (55/57). No patient experienced grade 4 toxicity. CT PALN+ before PAC resection. showed 52 (91%) with a SD, 4 (7%) with a PR, and 1 Methods: All consecutive patients who underwent surgical patient (2%) with PD. Pathologically negative margins exploration/resection with concurrent paraaortic (group 16) (R0) were achieved in 54 of 55 patients (98%) who lymphadenectomy for a suspected PAC between 2008 and underwent pancreatectomy. Pathological response was 2016 were considered for inclusion. Resection was sys- fi classi ed as Evans grade I in 8 patients (15%), IIa in 31 tematically aborted in case of intraoperative PALN+ (56%), IIb in 14 (25%), III in 1 (2%), and IV in 1 (2%). detection. Diagnostic performance of preoperative imaging The 1-, 3- and 5-year overall survival (OS) rates were upon blind review and intraoperative PALN dissection with 93%, 73% and 49% in R and 75%, 47% and ND in BR frozen section (FS) for PALN detection were evaluated. patients, respectively (p=0.025). Additionally, the prognostic significance of PALN+ on Conclusion: Present study demonstrated that hypo- overall survival (OS) was analyzed. fractionated NACRT with S-1 is well tolerated and safe. Results: Over the study period, among 193 patients under- Our protocol allowed a high rate of subsequent resection, going surgery for PAC, 156 had intraoperative PALN fi with encouraging survival data. This is the rst and dissection of which 145 had FS analysis. Median number of fi largest study to evaluate the safety and ef cacy of resected PALN was 3 (range, 1-15). Overall, PALN+ was hypofractionated NACRT with S-1 in patients with R and found in 21 patients (13.5%). Upon blind review, preoper- BR PDAC. ative imaging performed poorly for PALN+ detection with a low agreement between imaging and final pathology

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(Kappa-Cohen index< 0.2). In contrast, PALN FS showed Introduction: Carcinogenesis has been closely associated high detection performances and almost perfect agreement with systematic inflammatory response. Several studies with final pathology (Kappa-Cohen index=0.810, 95%CI have demonstrated the relationship between the white 0.736-0.884, p< 0.001). Regarding survival outcomes, there blood cell (WBC) and platelet (PLT) indices and tumors as was no difference between patients with PALN+ and pa- a prognostic factor. The aim of our study was to investigate tients not resected in the setting of liver metastases or locally the role of WBC and PLT indices in the differential diag- unresectable disease found at exploration (p=0.615). nosis of pancreatic lesions as well as prediction of disease Discussion: During PD for PAC, intraoperative PALN stage. dissection with FS analysis yields accurate PALN assess- Methods: Patients treated for pancreatic lesions in our ment and might help adequate patient selection. This Institution during a 6-year were prospectively sampled and should be particularly advocated for PDAC and resection retrospectively analyzed for the purposes of this study. should be aborted in case of PALN+. WBC and PLT indices as well as tumor marker values were examined and potential links with the type of pancreatic pathology as well as clinicopathological parameters were EP02C-064 investigated. MAJOR MUTATIONS ANALYSIS IN EUS- Results: A total of 131 patients (69 male) with a mean age of 66.6 Æ 10.7 years who were treated for pancreatic lesions GUIDED FNA SPECIMENS FROM PDAC were included in our study and comprised 94 adenocarci- FOR PRECISION MEDICINE nomas, 12 neuroendocrine tumors (NET) and 23 cystic M. Oshima, Y. Ando, H. Suto, K. Okano and Y. Suzuki neoplasms (PCN). Adenocarcinomas had significantly lower Gastroenterological Surgery, Kagawa University, Japan lymphocyte count (p=0.005) and lymphocyte to monocyte Introduction: Pancreatic ductal adenocarcinoma (PDAC) is ratio (LMR)(p=0.015), and higher platelet to lymphocyte devastating diseases and some cases recur early after surgery ratio (PLR)(p=0.007) compared to PCNs. Non operable even it seemed to be resectable or borderline resectable at adenocarcinomas had increased monocyte count (p=0.023) preoperative diagnosis. EUS-FNA is performed as diagnostic and LMR decreased (p=0.01) compared to operable disease. examination in patients with PDAC and major mutations Patients with metastatic disease showed lower lymphocyte analysis in EUS-guided FNA specimens in our institution. percentage (p=0.014) and LMR (p=0.03) and higher Aim: Three major mutations (p16, p53, Smad4) were analyzed neutrophil (p=0.034), monocyte count (p0.032) and in EUS-guided FNA specimens from PDAC and the re- neutrophil to lymphocyte ratio (NLR)(p=0.013) compared lationships were evaluated between mutation status and clin- to non-metastatic adenocarcinomas. fi ical characteristics in order to introduce precision medicine. Conclusion: According to the ndings of our study, Method: The immunohistochemically status of 3 major lymphocyte count and LMR can help distinguish adeno- mutations were evaluated in EUS-FNA specimens, in 120 carcinomas from PCNs as well as predict the metastatic patients diagnosed in our institution from 2014 to 2017. status of the disease. Result: The number of resected cases were 43 and unre- sected cases were 77. Abnormal immunolabeling of p16, p53 and Smad4 were identified in 80.8%, 71.7% and EP02C-068 49.2%, respectively in the whole patients with PDAC. INCIDENTAL HISTOLOGICAL Abnormal immunolabeling of p53 was detected in larger DIAGNOSIS OF SMALL PANCREATIC amounts in unresected cases (78.4% p=0.039) and cases NEUROENDOCRINE TUMORS: ARE WE with abnormal immunolabeling of p53 included more UR- M cases (47.4%) without significant differences (p=0.069). UNDERESTIMATING THEIR Loss of Smad4 immunolabeling was significantly associ- INCIDENCE? ated with shorter overall survival (p=0.0124). S. Partelli1, F. Giannone1, F. Muffatti1, S. Crippa1, Conclusion: The assessment of major 3 mutations evalu- V. Andreasi1, G. Zamboni2, C. Rubini3, C. Doglioni1 and ated in EUS-guided FNA specimens from PDAC can M. Falconi1 provide investigation of biological malignancy. Major 1Vita e Salute University-San Raffaele Hospital, 2Ospedale mutations analysis in EUS-guided FNA specimens at Sacro Cuore - Don Calabria, Italy, and 3Ospedali Riuniti diagnosis could provide an additional prognostic tool, Ancona, Italy useful for decision of treatment and introduction of preci- Background: The annual incidence of pancreatic neuro- sion medicine in PDAC. endocrine tumors (PanNET) has been estimated to be around 0.8/100,000 inhabitants. Aim of the study was to determine the frequency of incidental histological diagnosis EP02C-065 of PanNET during pancreatic specimen evaluation for other WHITE BLOOD CELL AND PLATELET neoplasms. INDICES AS INDICATORS OF Method: We retrospectively reviewed 1023 histopatho- PANCREATIC TUMOR TYPE AND logical examinations of pancreatic specimens performed by three different pathologists in 3 high-volume centers in DISEASE STAGE Italy. Preoperative evaluations and surgical procedures N. Machairas, I. D. Kostakis, D. Papaconstantinou, were performed directly or under the supervision of a single A. Paspala, N. Koliakos, V. Ntomi, N. Zavras, surgeon. All the cases with a main pathological diagnosis of E. P. Misiakos, P. Patapis and A. Machairas PanNET were excluded. 3rd Department of Surgery, National and Kapodistrian Results: An incidental associated diagnosis of PanNET University of Athens, Medical School, Greece was made in 38 specimens (4%). NET was the most

HPB 2018, 20 (S2), S505eS684 S552 Electronic Posters (EP02A-EP02F) e Pancreas frequent (57%) type of associated neoplasm followed by benign nature of most tumors was consistent with reported intraductal mucinous neoplasm (IPMN) (16%). Among world experience. However, incidence of IPMN is lower those 38 cases, 29 (76%) had a largest diameter < 5mm and that of SPEN appears higher in Indian centers. (microadenoma). 16 out of 38 incidental PanNET were classified as nonfunctioning (42%) whereas other 7 cases (18%) were classified as glucagonomas. A median value EP02C-070 Ki67 of 1% was measured in 9 incidental PanNET. Patients FACTORS OF IMPROVING ONCOLOGIC with incidental PanNET were significantly older (median age: 69 years versus 65.5 years, P=0.003). There was no OUTCOMES IN RESECTED LEFT-SIDED association between incidental diagnosis of PanNET and PANCREATIC CANCER: gender, operation, and main histological diagnosis. When CHRONOLOGICAL ANALYSIS excluding microadenomas, the median age between pa- S. Y. Rho, J. W. Jung, H. K. Hwang, C. M. Kang and tients with incidental PanNET (n=9) and the remaining W. J. Lee patients was no statistically different (median age 64 years Department of Surgery, Yonsei University College of > versus 65.5 years, P 0.05). Medicine, Republic of Korea Conclusion: The frequency of incidental histological Introduction: Minimally invasive approach for curative diagnosis of PanNETs is considerably high suggesting that resection of pancreatic ductal adenocarcinoma (PDAC) has their real incidence is probably underestimated. become no loner a rarity. Thus, at this point, analyzing the oncologic outcomes of left-sided PDAC according to chronological changes and understanding what factors have EP02C-069 affected to treating the left-sided PDAC will be important SURGERY FOR CYSTIC TUMORS OF in the future. PANCREAS: REPORT OF HIGH Methods and material: Between January 1992 and VOLUME MULTI INSTITUTIONAL December 2017, 149 patients underwent curative distal fi INDIAN EXPERIENCE OVER A DECADE pancreatectomy. Phase I was de ned from 1992 to 2005, phase II from 2006 to 2010, and phase III from 2011 to 2017. 1 1 2 3 M. Bhandare , V. Chaudhari , R. Pradeep , H. Ramesh , Results: In overall survival analysis, there was statistically 4 5 6 7 P. Dhar , S. Pal , P. Senthilnathan , S. Jeswanth and significance between phase I (median 13 months , 95% CI 1 S. Shrikhande [9.169-16.831]) and phase II (median 23 months 95% CI 1 2 Tata Memorial Hospital, Surgical Gastroenterology, Asian [14.541-31.459]) (p=0.017). There was also statistically 3 Institute of Gastroenterology, Surgical Gastroenterology, difference between phase I and phase III (median 33 4 Lakeshore Hospital, Surgical Gastroenterology, Amrita months , 95% CI [18.885-47.115]) (p-value = 0.009). In 5 Institute of Medical Sciences, Surgical Gastroenterology, cox regression analysis of phase I, patient selection criteria 6 All India Institute of Medical Sciences, Surgical Gastroen- (p = 0.016, Hazard ratio (HR) 5.950) was the affecting 7 terology, Gem Hospital & Research Centre, and Surgical factor for overall survival. In phase II, pathologic tumor Gastroenterology, Stanley Medical College Chennai size affected oncologic outcome. (overall survival : HR Introduction: Pancreatic cystic lesions are recently being 1.318, p=0.022, disease-free survival : HR 5.530, p=0.010) detected with increasing frequency, however, they remain . In Phase III, adjuvant chemotherapy was associated with largely uncommon and Indian data on this topic is sparse. overall survival (HR 0.366, p=0.018), and disease-free Material and methods: Prospectively maintained data- survival (HR 0.294, p=0.004). bases of operated patients of cystic tumors of pancreas for a Conclusion: Chronologically, oncologic outcome tended period of 10 years from January 2007 to December 2016 at to improve In PDAC treatment, we confirmed that factors seven high volume academic centers across India were related to not only tumor biology such as tumor size and N collated to gain insights about nationwide scenario of pre- stage, but also factor involved in postoperative treatment sentation and management of these tumors. Demographic, such as adjuvant chemotherapy were important. imaging and relevant perioperative variables along with pathological data were analyzed. Results: 433 patients were reported from 7 centers. Median EP02C-071 age at presentation was 42 years. Female to male ratio was MICROVESSEL DENSITY (MVD) IN 3.4:1. 70% patients presented with abdominal pain and 17 % lesions were incidentally detected. CECT remained PATIENTS WITH PANCREATIC modality of choice and EUS was additionally performed in ADENOCARCINOMA: A SYSTEMATIC 72(16.5%) patients. Preoperative diagnosis was established REVIEW AND META-ANALYSIS in 56% patients. 66.7% of the lesions were located in the P. Ntellas1, K. Perivoliotis2, K. Dadouli3, M. Ioannou1 and body and tail of the pancreas. Median tumor size was 6 cm. K. Tepetes2 411 patients underwent curative intent surgeries. 76 1Department of Pathology, 2Department of Surgery, Uni- (18.5%) resections were performed laparoscopically. Peri- versity Hospital of Larissa, and 3Postgraduate operative mortality was 0.9%. Final histology revealed 97 Programme (MSc): Research Methodology in Biomedi- (22.4%) Serous neoplasms, 113 (26.1%) mucinous neo- cine, Biostatistics and Clinical Bioinformatics at Univer- plasms, 34 (8%) IPMNs and 120 (27.7%) SPENs. Malig- sity of Thessaly, Greece nancy was reported in 9% (39) patients. Introduction: A meta-analysis was conducted, for the Conclusion: This is the largest and first multi institutional effect of microvessel density (MVD) on the survival of report of operated patients of cystic neoplasms of pancreas patients with Pancreatic Adenocarcinoma to be appraised. form India. Female preponderance, young age presentation,

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Methods: This meta-analysis was performed on the basis EP02C-073 of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic data- SYNCHRONOUS PANCREATIC bases (MEDLINE, Web of Science and Cochrane Central INTRADUCTAL PAPILLARY Register of Controlled Clinical Trials) were systematically MUCINOUS NEOPLASM AND screened. Fixed Effects or Random Effects model was NEUROENDOCRINE MICROADENOMA used, according to the Cochran Q test. WITH CONCOMITTENT DOUBLE Results: In total 23 eligible studies were found. Pooled HR for overall survival (OS) and disease free survival (DFS) COLON ADENOCARCINOMA: A CASE was 1.67 (95%CI: 1.39-2.01, p< 0.001) and 1.34 (95%CI: REPORT 1.04-1.74, p=0.03), respectively. Due to the high levels of A. Ioannidis1, K. Kofina1, M. Grigoriou2, M. Lazaridis1, between studies heterogeneity, further sub-analyses were C. Cosmidis3 and C. Efthimiadis1 performed. Odds ratios of overall survival between high 1Department of Surgery, Euromedica General Clinic, and low MVD groups, validated a significant superiority of 2Department of Surgery, Interbalkan Medical Center, and low MVD tumors, at 12 (OR: 3.58, p< 0.001), 24 (OR: 33rd Department of Surgery, A.H.E.P.A. University Hos- 2.66, p=0.01, 36 (OR: 2.90, p=0.003, and 60 (OR: 2.53, p< pital, Greece 0.0001) months. Introduction: Intraductal papillary mucinous neoplasms of Conclusion: MVD significantly correlates with the HR of the pancreas are rare epithelial tumors that account for 1- OS and DFS. Further prospective studies of higher meth- 3% of exocrine pancreatic neoplasms, whereas pancreatic odological and quality level are required. neuroendocrine tumors represent 1-2% of all pancreatic neoplasms. We present a case of synchronous occurence of these rare tumors, in combination with double colon EP02C-072 adenocarcinoma. PATTERNS OF RECURRENCE AFTER Case report: A 72-year-old male patient was admitted to RESECTION FOR PANCREATIC our Surgical Department for treatment of a tumor located in the pancreatic tale, as well as two tumors of the right colon, NEUROENDOCRINE TUMORS: WHO, diagnosed through computed tomography and coloscopy, WHEN AND HOW? during the investigation of symptoms of diffuse abdominal G. Marchegiani1, L. Landoni2, S. Andrianello2, pain. The patient underwent distal pancreatectomy, sple- G. Masini2, B. Bianchi2, A. Scarpa2, R. Salvia2 and nectomy, cholecystectomy and right hemicolectomy and C. Bassi2 was discharged on the tenth postoperative day in good 1Surgery, University of Verona, and 2Verona University, Italy health condition. Histologic examination of the excised Introduction: Pancreatic Neuroendocrine Tumors specimens showed the presence of intraductal papillary (pNETs) represent an increasing indication for pancreatic mucinous neoplasm and neuroendocrine microadenoma resection, but there are only few data about their possible (NET-G1) of the pancreas, as well as double colon recurrence after surgery. Aim of this study is to describe the adenocarcinoma pT3(2), N0, of good differentiation. frequency, timing, and patterns of recurrence after resection Discussion: Intraductal papillary mucinous neoplasms and for pNETs with implications for postoperative follow-up. neuroendocrine tumors of the pancreas are considered rare, Methods: Retrospective analysis of pathologically but their concomitant presence, in combination with confirmed pNET treated between 1990 and 2015 at the extrapancreatic tumors, has been reported by certain Verona Hospital Trust. Predictors of recurrence and sur- studies. Therefore, it is necessary that patients with intra- vival analysis were performed. ductal papillary mucinous neoplasms are thoroughly Results: The cohort consisted of 487 patients with a examined preoperatively in order to detect other synchro- median follow-up of 71 months. Recurrence developed in nous malignancies. 12.3% of cases: 54 (11.1%) developed liver metastases, 11 (2.3%) local recurrence, 10 (2.1%) nodal recurrence and 8 (1.6%) metastases in other solid organs. Thirty-one (6.4%) EP02C-074 died due to disease recurrence. Size > 20 mm, G3 grade, OUTCOMES OF NEOADJUVANT fi nodal metastasis and vascular in ltration were independent THERAPY FOR LOCALLY ADVANCED predictors of overall recurrence. Tumor recurrence occurred either in the first year after surgery (n= 9), and PANCREATIC ADENOCARCINOMA: AN after ten years of follow-up (n= 4). Conditional survival INTENTION TO TREAT ANALYSIS analysis revealed that in case of a non-functioning G1 WITH COMPARISON TO PATIENTS pNET < 20mm without nodal metastasis and vascular in- WITH RESECTABLE AND BORDERLINE vasion the risk of developing recurrence over time is RESECTABLE DISEASE negligible. After 5 years without developing recurrence, S. K. Kamarajah, J. Hodson, F. Marcon, M. Kalisvaart, this occurs only with liver metastases. R. Marudanayagam, R. P. Sutcliffe, P. Muiesan, Conclusions: Recurrence of pNETs is rare and predicted D. F. Mirza, J. Isaac and K. Roberts by tumor size, nodal metastasis, grading and vascular in- Department of Hepatobiliary Surgery, Queen Elizabeth vasion. Patients with G1 pNET without nodal metastasis or Hospital Birmingham, United Kingdom vascular invasion could be considered as cured by the surgery. After 5 years without recurrence, the follow-up Background: Neoadjuvant therapy (NAT) for pancreatic should be focused in excluding the development of liver ductal adenocarcinoma (PDAC) has gained popularity. metastases. However, results of NAT are rarely compared to other

HPB 2018, 20 (S2), S505eS684 S554 Electronic Posters (EP02A-EP02F) e Pancreas cohorts or on an intention-to-treat basis. This study provision of chemotherapy between hospitals, with the presented outcomes from a centre where NAT was standard majority providing chemotherapy to between 71 and 82% of care for patients with locally advanced (LA) disease and of their patients. However, there were two hospitals with up-front resection was standard of care for patients with low provision of chemotherapy (54 and 30% respectively), borderline resectable (BR) venous disease or resectable resulting in a statistically significant difference between the disease. hospitals (p=0.015). Methods: Patients with PDAC between 2013 and 2017 Conclusion: In spite of current level 1A evidence (n=345) were classified as resectable, BR and LA, ac- supporting the use of adjuvant chemotherapy after resection cording to NCCN criteria. for PDAC, there is significant variability between hospitals Results: Some 16% (54/345) were BR and 20% (70/345) who provide this therapy. Though centralisation may not be were LA. Patients with LA disease were younger than those needed to the same extent as surgery, individual hospitals with BR or resectable disease (64vs65vs68 years, p< practice should be audited. Ensuring equality of provision 0.001). NAT was used 79% of LA disease, 4% of BR, and of chemotherapy may be a simple way to improve out- none of the resectable patients (p< 0.001). There were no comes after PD for PDAC. differences in survival between resectable, BR and LA disease (19vs15vs19 months; p=0.585). Resection rates were higher in resectable disease followed by BR and LA EP02C-076 < (78%vs65%vs30%; p 0.001). Among those with LA ADJUVANT CHEMOTHERAPY disease 44% (31/70) did not receive any surgery. Among those that did the median survival was 31 months (HR: FOLLOWING 0.29, 95% CI: 0.11 - 0.79, p=0.015). PANCREATICODUODENECTOMY FOR Conclusion: Survival between patients with resectable, BR PANCREATIC DUCTAL or LA disease is equivalent. A large proportion of patients ADENOCARCINOMA e FACTORS with LA disease never undergo surgery. If this can be AFFECTING RECEIPT AND improved, then NAT is likely to be associated with increased survival. However, studies of quality of life and COMPLETION OF CHEMOTHERAPY 1 2 1 1 patient preference are urgently required, as these are almost A. Sultana , J. Hodson , R. Marudanayagam , B. Dasari , 1 1 1 1 certainly affected by NAT. P. Muiesan , D. Mirza , J. Isaac , R. Sutcliffe , Y. T. Ma3 and K. Roberts1 1HPB Surgery and Liver Transplant, 2Medical Statistics, 3 EP02C-075 and Oncology, University Hospitals Birmingham NHS Foundation Trust, United Kingdom ADJUVANT CHEMOTHERAPY Introduction: Adjuvant chemotherapy has a major impact FOLLOWING upon survival after resection of pancreatic ductal adeno- PANCREATICODUODENECTOMY FOR carcinoma (PDAC). However, not all patients receive PANCREATIC DUCTAL adjuvant chemotherapy, and in those who do, there exists a ADENOCARCINOMA e INTER- subset who are unable to complete treatment. This study HOSPITAL VARIABILITY IN UPTAKE evaluated the factors that impacted on both the usage and 1 2 1 1 completion of adjuvant chemotherapy following pancrea- A. Sultana , J. Hodson , R. Marudanayagam , B. Dasari , ticoduodenectomy (PD) for PDAC. P. Muiesan1, D. Mirza1, J. Isaac1, R. Sutcliffe1, 3 1 Methods: Patients undergoing PD for PDAC between Y. T. Ma and K. Roberts January 2007 and December 2015 were included in the 1HPB Surgery and Liver Transplant, 2Medical Statistics, 3 study. Demographic, perioperative and histopathology data and Oncology, University Hospitals Birmingham NHS were extracted from a prospectively maintained database. Foundation Trust, United Kingdom Data was obtained on whether adjuvant chemotherapy was Introduction: Evidence from randomised controlled trials given, and reasons for either non-administration or non- supports adjuvant chemotherapy following resection for completion of chemotherapy. pancreatic ductal adenocarcinoma (PDAC), showing clear Results: Among two hundred and seventy-two patients, survival benefit. Though pancreatic surgery in the United just 48.5% of patients received and completed adjuvant Kingdom is centralised, provision of chemotherapy is not, chemotherapy (130/268) with a further 50 (18.7%) being given in the local hospital. This study assessed the starting but not completing chemotherapy. On univari- administration of adjuvant chemotherapy following able analysis, the strongest predictors of adjuvant pancreaticoduodenectomy (PD) for PDAC, focusing on chemotherapy usage were patient age (mean: 65 vs. 69 rates of administration and how these differed between the years in chemotherapy vs. no chemotherapy, p< 0.001) 14 hospitals that delivered this service. and T-stage (72% uptake in T3 vs. 40% in other T- Methods: A prospectively maintained database was stages, p=0.041). reviewed, and patients undergoing PD for PDAC between Of the patients who started adjuvant chemotherapy, those January 2007 and December 2015 were identified for in- who completed all cycles were significantly more likely to clusion (N=272), although data were missing for 4 patients have N0 compared to N1 disease (93% vs. 75%, p=0.028). (1.5%). Data were collected on whether adjuvant chemo- Conclusion: Despite the clear benefits of adjuvant therapy was given and the hospital where chemotherapy chemotherapy, less than half of patients actually complete was administered. Chemotherapy uptake rates were this treatment after PD for PDAC. Strategies to increase this compared between sites using Fisher’s exact test. are urgently needed, as this may provide a relatively simple Results: Adjuvant chemotherapy was administered to 67% way to improve outcomes. (N=180/268) of patients. There was generally similar

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EP02C-077 hospitals around Jakarta during 1993-2016 were reported retrospectively. PREOPERATIVE ENDOSCOPIC Results: Resection was performed in 202 patients at Cipto SPHINCTEROTOMY IN EARLY Mangunkusumo as main Hospital and 8 networking hos- AMPULLARY CANCER (T1-2N0M0) pitals surround. There were 111 males, mean age of 50.73 FOLLOWED BY PANCREATICO- years. Jaundice (68.3%) and abdominal pain (15%) were DUODENECTOMY e THE CASE FOR predominant, with hypoalbuminemia of 3,5 mg/dL in 51.1% subjects, average time to operation is 3.4 months. ADJUVANT CHEMOTHERAPY Biliary decompressions performed in 112 subjects. There 1 2 3 R. Saxena , S. Kumar and M. Jain were 80 PD, 120 PPPD and 2 total pancreatectomies 1 2 3 Surgical Gastroenterology, Radiotherapy, and Pathol- performed, include 7.4% benign cases. Resection rate ogy, Sanjay Gandhi Post-Graduate Institute of Medical increased from 2 to 13,6 per year. Relaparotomy were Sciences, India performed in 29 subjects, with 44,8% lead to operative Introduction: Pancreaticoduodenectomy (PD) for early death. The overall mortality decreased from 33.3% to 4.1% ampullary tumors (T1-2N0M0) should be curative. Those in the last 3 years. Overall morbidity was 65.1% in 168 requiring preoperative endoscopic biliary decompression survivors, with 52.5% SSI and pancreatic fistula (24.2%) as behaved differently from naïve tumors on follow up. They fatal complication. There were 83.2% survivors; with < were studied to uncover factors for different survival, and 10% survived after 5 years, 50% < 18 months, and < 20% redefine management protocols. after 2 years. Actual 29 survivor live > 5 years, included 3 Methods: 300 node negative ampullary tumors treated with patients > 10 years. PD, collected prospectively, were classified into two groups Conclusion: Mobile single-team method and decentrali- - those undergoing preoperative endoscopic sphincter- sation approach is an excellent and well-accepted strategy. otomy (ES) (ES group, n=210) and those with no preop- erative ES (Naive group, n=90). 67 patients developing recurrence were analyzed specifically. EP02C-079 Results: PD was performed at a median of 37 days VALIDATION OF AJCC 8TH EDITION following ES. The demographics, preoperative parameters and tumor histology were evenly matched in the two PANCREATIC CANCER STAGING groups. Wound infection (p=0.012) and delayed gastric SYSTEM USING A LARGE emptying (p=0.035) were higher in the ES group. At a MULTINATIONAL DATA median time of 20 months post-PD, recurrence of disease W. Kwon1,J.He2, R. Higuchi3, S. Y. Lee4, J. Kim1, was observed in 67 (22.3%) patients. The ES group had S. -W. Kim1, C. Wolfgang2, J. Cameron2, fi earlier recurrence, and a signi cantly higher incidence of M. Yamamoto3 and J. -Y. Jang1 liver metastases (p=0.046), particularly in the second year 1Department of Surgery, Seoul National University Col- post PD (p=0.035). The Naive group had an overall sur- lege of Medicine, Republic of Korea, 2Department of vival advantage of 6.3 months. None received any neoad- Surgery, Johns Hopkins University School of Medicine, juvant or adjuvant treatment. United States, 3Department of Surgery, Tokyo Women’s Conclusions: ES, cutting through the ampullary tumor, Medical University, Japan, and 4Department of Mathe- predisposing to dissemination in the portal circulation may matics and Statistics, Sejong University College of Natural be responsible for the high incidence of liver metastases in Sciences, Republic of Korea early ampullary tumors. A higher incidence in the second Introduction: AJCC released the 8th edition of pancreatic year post-PD is explained by the tumor doubling time of the cancer staging to be applied from 2018. The aim was to ampullary cancer cells, and makes a case for the use of compare the 7th and 8th edition AJCC staging system for adjuvant chemotherapy even in these early tumors, pancreatic cancer and to validate the 8th edition using a warranting a randomized controlled trial to address the large multinational data. issue. Method: Data of 2,864 patients with pancreatic ductal adenocarcinoma at the pancreas head were collected from Korea (571), Japan (824), and the USA (1,469). A survival EP02C-078 analysis was performed to compare the 7th and the 8th DECENTRALISATION OF MOBILE editions. Validation of both editions was performed by log- SINGLE-TEAM APPROACH FOR rank tests and test for trend repeated 1,000 times with SUPERIOR OUTCOMES ON random validation sets. Results: In the 7th edition, 4.1%, 3.1%, 18.6%, 67.5%, PANCREATICODUODENAL 3.6%, and 3.1% of the patients were staged as IA, IB, IIA, RESECTION IN INDONESIA IIB, III, and IV. In the 8th edition, 8.8% were IA, 13.9% IB, T. Lalisang1,2, W. Jeo1,2 and Y. Mazni1,2 3.1% IIA, 38.2% IIB, 32.9% III, and 3.1% IV. Down- 1Digestive Surgery Division, Department of Surgery, staging of 459 patients occurred from IIA to the new IA and Universitas Indonesia, and 2Cipto Mangunkusumo Hos- IB due to changes in the T classification. Upstaging of 856 pital, Indonesia patients occurred from the former IIB to III due to the new Introduction: Nowadays, there is no published study from N2. The 7th edition mis-stratified IA and IB - IB showing Indonesia regarding pancreaticoduodenectomy (PD). better survival than IA. The 8th edition correctly stratifies Method: Morbidity, mortality, and survival of PD the stages, but lacks discriminatory power between IB and performed by mobile single-team approach in several IIA (p=0.271). Validation revealed that the 8th edition had a more correct and better stratification.

HPB 2018, 20 (S2), S505eS684 S556 Electronic Posters (EP02A-EP02F) e Pancreas

Conclusions: The 8th edition AJCC staging system pro- irresectability of pancreatic cancer. However, optimal cut- vides more even distribution of patients with a more off values for CEA and CA19-9 are still disputable. This powerful discrimination compared to the 7th edition for study aimed to assess the value of preoperative CEA and pancreas head cancer. CA19-9 blood levels as predictors for irresectability in Survival curves... patients with pancreatic adenocarcinoma discussed at the pancreatic multidisciplinary team (MDT) meetings in a tertiary referral center. EP02C-081 Methods: Patients with pancreatic adenocarcinoma CIRCULATING MIR-107 COULD BE A discussed at the MDT meetings from 2013 through 2017 were reviewed. The optimal cut-off values of both CEA and POTENTIAL BIOMARKER FOR CA19-9 for the prediction of irresectable disease were PANCREATIC DUCTAL determined using receiver operating characteristic curves, ADENOCARCINOMA followed by a multivariable analysis. N. R. Dash1, A. Saraya2, S. Rashid3 and S. Rashid3 Results: In total, 376 patients were included. The 1Department of Gastrosurgery and Liver Transplantation, optimal cut-off values for predicting irresectability were 2Department of Gastroenterology and Human Nutrition, 7.0 ng/ml for CEA and 304.8 U/ml for CA19-9, and 3Department of Gastroenterology, AIIMS, India resulting in a positive predictive value of 85% for CEA>7.0 ng/ml and 75% for CA19-9>304.8 U/ml Introduction: It is challenging to diagnose the pancreatic (Figure 1: percentages indicate number of patients ductal adenocarcinoma early. Circulating miRNAs have above and under the optimal cut-off values). Both tumor evolved as important non-invasive biomarkers for detection markers were independent predictors of irresectability, of various cancers. The purpose of this study was to check demonstrated by an odds ratio of 4.25 (95%CI: 1.88- the expression of circulating miR-107 in patients with 9.64; P< 0.001) for CEA and 2.64 for CA19-9 (95%CI: PDAC, chronic pancreatitis (CP) and healthy controls 1.32-5.26; P=0.006). (HC). Materials and methods: miRNA enriched total RNA was extracted from serum of patients with PDAC (n=105), CP (n=31) and HC (n=36) using Exiqon’s miRNA isolation kit. miR-107 was selected using different miRNA data- bases and on the basis of existing literature showing its role in different cancers. Relative miR-107 expression was analyzed using q-PCR (SYBR green chemistry). Fold change was calculated using 2-DCt method. Appropriate statistical tests were used. A p-value of < 0.05 was considered statistically significant. Results: Mean age of patients with PDAC, CP & healthy controls was 55.9Æ12.0, 37.3Æ11.9 and 38.9Æ14.8, respec- tively. The median levels of miR-107 were found to be 1.21, 6.40 and 91.75 respectively. The differences were highly Fig. 1 Distribution of CEA and CA19-9 blood levels. significant between PDAC,CP and the HC (p-value=0.0001). miR-107 levels in PDAC patients were correlated with clin- Conclusion: The results of this study show that the pre- ical parameters, survival and response to chemotherapy, dictive value of preoperative CEA for irresectability is however no statistical significance was observed. better than CA19-9 in pancreatic adenocarcinoma patients, Conclusion: miR-107 circulating levels can differentiate which demonstrates that implementing CEA serum levels PDAC or CP from healthy volunteers but not between during MDT meetings as an additional tool for establishing PDAC and CP. Since miRNA can be measured in serum, it tumor resectability is worthwhile. could be a potential non-invasive biomarker for detection of PDAC in selected group of patients. EP02C-083 EP02C-082 PSYCHOMETRIC PERFORMANCE OF THE VALUE OF PREOPERATIVE THE PANCREATIC CANCER DISEASE CARCINOEMBRYONIC ANTIGEN AND IMPACT (PACADI) SCORE T. Heiberg1, B. Baekelandt2, T. K. Kvien3 and T. Buanes4 CANCER ANTIGEN 19-9 BLOOD 1 LEVELS AS PREDICTIVE FACTORS Department for Regional Research Support, Oslo Uni- versity Hospital, 2Institute of Clinical Medicine, University FOR IRRESECTABILITY IN of Oslo, 3Department of Rheumatology, Diakonhjemmet PANCREATIC CANCER PATIENTS Hospital, and 4Department of Hepato-Pancreato-Biliary L. van Manen, J. Groen, A. Vahrmeijer, R. J. Swijnenburg, Surgery, Oslo University Hospital, Norway B. Bonsing and S. Mieog Introduction: Access to patient reported outcome mea- Surgery, Leiden University Medical Center, Netherlands sures that are brief, disease specific, and emphasizing the Introduction: In addition to preoperative imaging, the patient perspective is limited. We have earlier developed tumor markers carcinoembryonic antigen (CEA) and car- and suggested the use of the PACADI score.(1) The bohydrate antigen 19-9 (CA19-9) are used to predict

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S557 purpose of this study was to perform a full psychometric Introduction: The new T1 pancreatic cancer by the 8th edi- testing of this instrument. tion AJCC staging system discards the concept of “extension Methods: Patients (n=363) with suspected pancreatic beyond the pancreas” and focuses on size. Also, the new T1 is cancer (PC) were referred to a tertiary hepato-pancreatic- divided into T1a, T1b, and T1c based on size. As T1 biliary center. The PACADI score was computed after pancreatic cancer is very rare, the feasibility of these changes completion of numeric rating scales (NRS) 0-10 for each of has not been evaluated. We aimed to evaluate the feasibility of the eight dimensions included in the score. The patients the new T1 definition in a pancreas head cancer cohort. also completed EQ-5D and the Edmonton Symptom Method: Data of 540 patients with T1 pancreatic ductal Assessment System (ESAS). Data were collected at base- adenocarcinoma defined by the 8th edition were collected line and after 1, 2 and 3 months follow-up. We examined from Korea, Japan, and the USA. Invasive IPMNs were correlations between instruments, test-retest reliability by excluded. Survival analyses were performed. Intra Class Correlation (ICC) after one month in patients Results: Of the 540 patients, 181 patients were T1 by the who reported stable condition, and Standardized response 7th edition and 359 were down-staged to T1 from the mean (SRM) was computed based on changes between former T3 because the concept of “extension beyond the assessments in patients who reported improved health. pancreas” was discarded. The 5-year survival rate and the Results: Table shows differences between patients with median survival of T1 patients were 30.6% and 27 months. confirmed PC, other malignancies and patients without Comparing tumors that extend beyond the pancreas (new malignancy. PACADI was overall higher in patients with T1) and those confined within the pancreas (original T1), PC (p=0.03), and PACADI was significantly higher in the latter showed significantly longer median survival (43 patients with PC than patients with other malignancies vs. 24 months, p< 0.001). In terms of T1a/b/c, there were (p=0.02). Cross-sectional correlations between PACADI , no significant differences in survival. Using maxstat, EQ-5D and ESAS overall at baseline and 3 months were subdividing into 2 groups using 1.1 cm as cut-off value strong (r=-0.62 to -0.80, all p< 0.001). ICC for PACADI yielded significantly discrete prognostic groups (p< 0.001). was 0.87 and SRM was 0.63 to 0.81, all in patients with PC. Conclusions: The new T1 definition may be more prac- Conclusion: PACADI had a satisfactory psychometric tical, but the implication of the concept of “extension performance, which was comparable to EQ-5D and ESAS beyond the pancreas” should be re-investigated. Further, overall, supporting its use in clinical and scientific settings. the subcategorization of T1a/b/c may not be adequate and http://www.pacadi.com/. may require revision or deletion.

EP02C-085 Baseline characteristics. A CASE OF INTRA ABDOMINAL Pancreatic Other n[104 Without p-value cancer malignancies cancer (Chisquare DESMOID TUMOR INVADING TO n[213 n[46 /ANOVA) PANCREASE TAIL WITH THE Age 68.1 (10.4) 66.5 (10.9) 66.3 0.36 REPEATED EPISODES OF INTRA (11.5) ABDOMINAL RUPTURE, MIMICKING Females 49.5 39.2 37.8 0.13 THE NEOPLASTIC PANCREATIC CYSTS (%) A. Nakazawa, Y. Miyata and Y. Beck Pacadi 3.45 (2.11) 2.79 (2.03) 3.02 0.03 score (2.13) Hepato-Biliary-Pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Japan EQ-5D 0.61 (0.30) 0.70 (0.26) 0.66 0.06 (0.31) Background: The intra abdominal desmoid tumor is rare ESAS 10 3.65 (2.86) 2.99 (2.70) 3.16 0.13 disease and accounts for 8% of the total desmoid tumors. It (overall) (2.55) is difficult to diagnose as desmoid tumor because there’sno typical imaging findings. Case: The patient was 28-year-old female. She was presented with epigastric pain. CT revealed cyst of the EP02C-084 pancreas tail, 12cm in diameter, and acute pancreatitis with IS THE NEW T1 CATEGORY DEFINED BY ascites. So she was referred to our hospital for further ex- THE 8TH EDITION AJCC PANCREATIC amination. CT and MRI were examined again and revealed CANCER STAGING SYSTEM AN the multilocular cysts in the pancreas tail. EUS revealed multilocular cysts with protuberance lesion. Also pancreatic IMPROVEMENT? AN EVALUATION BY amylase elevated to 1547U/L, so we diagnosed neoplastic MULTINATIONAL DATA pancreatic cysts with pancreatitis and treated her as pancre- W. Kwon1,J.He2, R. Higuchi3, S. Y. Lee4, J. Kim1, atitis. However, she had abdominal pain again, we suspected S. -W. Kim1, C. Wolfgang2, J. Cameron2, rupture of neoplastic pancreatic cysts because of shrinking of M. Yamamoto3 and J. -Y. Jang1 cysts in its size. 3 weeks later, she had another attack of 1Department of Surgery, Seoul National University Col- abdominal pain. She had three episodes of abdominal pain lege of Medicine, Republic of Korea, 2Department of due to rupture of the pancreatic cyst within one month, and Surgery, Johns Hopkins University School of Medicine, was considered to be an indication for surgical treatment. She United States, 3Department of Surgery, Tokyo Women’s underwent spleen preserving distal pancreatectomy. As for Medical University, Japan, and 4Department of Mathe- intraoperative findings, the cystic lesion of pancreas tail was matics and Statistics, Sejong University College of Natural distant from the spleen and adhered to the posterior wall of Sciences, Republic of Korea the gastric body. We found a capsule rupture in part of the

HPB 2018, 20 (S2), S505eS684 S558 Electronic Posters (EP02A-EP02F) e Pancreas cysts. As for specimen, the tumor was white solid nodule, Physiology and Pathophysiology, and 6Department of Sur- 6.7cm in diameter, and invaded to the pancreas. Immuno- gery, Paracelsus Medical University, Austria histochemical diagnosis was desmoid tumor. The post- Introduction: Tumor cells need to maintain telomere ends operative course was uneventful. The patient survives for unlimited growth potential. Two telomere maintenance without recurrence for 14 months after surgery. mechanisms (TMMs) are known: reactivation of telome- rase activity (TA) and alternative lengthening of telomeres EP02C-086 (ALT) in association with favorable patient outcome. IS SURGERY THE BEST TREATMENT Exploring TMMs of PanNETs could lead to progress in FOR REDUCING YEARS OF LIFE LOST prognosis and therapy. But it is not known if TMMs in fi fi DUE TO SPORADIC SMALL (£2 CM) PanNETs can be detected from formalin- xed paraf n- embedded (FFPE) tissue. NON-FUNCTIONING PANCREATIC Methods: FFPE tissue samples from 58 patients diagnosed NEUROENDOCRINE TUMOURS? with PanNET were studied. Relative telomere length C. A. Pacilio1, C. Ricci1, N. Brighi2, V. Ambrosini1, (relTL) was analyzed as telomeric content (TC) related to a G. Taffurelli1, D. Santini2, D. Campana1, F. Minni1 and single copy reference gene (S) by qPCR and ALT by C- R. Casadei1 circle Assay (CCA). TA was studied by pyrosequencing of 1University of Bologna, and 2S. Orsola Malpighi Hospital, TERT promoter mutations (TPMs) C250T and C228T. Italy Results: T/S ratios of relTL were normalized to U2OS control Background: There is still controversy about the best cells, which show ALT activity and long telomeres. Relative management of non-functioning pancreatic neuroendocrine quantity (RQ) values ranged from 0.013 to 0.604. One third of tumours (NF-PNETs) 2cm. the samples show comparable values regarding relTL of other Methods: Retrospective study involving 102 surgically ALT positive cell lines and are ALT candidates. Results of treated patients affected NF-PNETs. Patients having small CCA by qPCR and radiolabel demonstrated that DNA was fi tumours (2 CM) and those having large tumours (>2cm) successfully isolated but none of the FFPE samples ful lls the were compared regarding demographics, clinical and conditions for being declared ALT. First pilot experiments pathological factors evaluating the risk of malignancy and analyzing TA by TPMs from 5 of 58 samples with either high fi relation to survival times such as overall survival (OS), or low TC identi ed no activating TPMs. disease free survival (DFS), years of life lost (YLL), years Conclusion: Absence of any TMM activity in the studied lost due to disability (YLD) and disability adjusted life PanNET cohort is surprising and should be validated on years (DALY). fresh material and by alternative methods, such as detection Results: Small tumours were T3-4 in 11% and G2-3 in 36.6% of mutations in the histone-chaperon ATRX, strongly of cases; lymph node and distant metastases were present in associated with PanNET and ALT. 31% and 8% of cases, respectively. When small and large tumours were compared, significant differences were found in relation to the presence of symptoms (P=0.012), tumour status EP02C-089 (P>0.001), grading (P>0.001) and YLD (P=0.002). Multi- CLINICAL OUTCOMES OF variate analysis predicting malignancy and survival times CHEMORADIOTHERAPY FOR showed that tumour size was related only to grading (P< 0.001). The YLL and DALY were influenced by age at UNRESECTABLE LOCALLY diagnosis (P< 0.001) and presence of symptoms (P=0.039), ADVANCED PANCREATIC CANCER while YLD was only related to grading (P=0.036). H. Ishida, Y. Homma, M. Doi, J. Yamamoto, Y. Ome and Conclusions: Tumour size did not seem to be reliable in G. Honda predicting malignancy. In fact, small tumours could present Department of Surgery, Tokyo Metropolitan Cancer and nodal or distant metastases and could be G2-3 in a non- Infectious Diseases Center Komagome Hospital, Japan negligible percentage of cases. Secondly, their risk of ma- Introduction: We evaluated the clinical outcomes of pa- lignancy and survival time are similar to larger tumours. tients with unresectable locally advanced (UR-LA) pancre- Additional parameters should be considered in order to atic cancer following chemoradiotherapy (CRT) using S-1 reduce YLL of patients with small tumors, such as age at (per oral anticancer drug) with or without gemcitabine. diagnosis, presence of symptoms and grading. Methods: Between January 2009 and December 2016, 53 patients with UR-LA pancreatic cancer underwent CRT at our institution. All patients received a total of 50.4 Gy of EP02C-087 radiation (1.8 Gy  28 days) and S-1 (80 mg/m2/day TELOMERE MAINTENANCE administered on the same day as the radiation therapy). In 2 MECHANISM OF PANCREATIC addition, a weekly dose of gemcitabine (200 mg/m ) was administered to the GS-RT group alone. NEUROENDOCRINE TUMORS Results: Of the 53 patients, 27 and 26 were divided into the S1- 1 2 3 2 S. Hofer-Zeni , D. Neureiter , S. Stättner , E. Klieser , RT (without gemcitabine) and GS-RT groups, respectively. 4,5 3 6 6 T. Kiesslich , F. Primavesi , T. Jäger , S. Swierczynski , Compared to the S1-RT group, the patients in the GS-RT 1 1 E. Naderlinger and K. Holzmann group were younger and demonstrated better performance 1 Department of Medicine I, Medical University of Vienna, status before treatment. However, the incidence of hemato- 2 Institute of Pathology, Paracelsus Medical University, logic adverse events (59.3% vs 7.7%, p=0.0001) and inter- 3 Department of Visceral-, Transplant- and Thoracic Sur- ruption of CRT (78.8% vs 46.1%, p=0.0244) were higher in 4 gery, Medical University Innsbruck, Department of Internal the GS-RT group than in the S1-RT group. The completion 5 Medicine I, Paracelsus Medical University, Institute of rate of CRT was more than 90% in both groups. Two patients

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S559 of the GS-RT group underwent conversion surgery. More Pathology, Cantonal Hospital Winterthur, 4General and patients in the GS-RT group required maintenance chemo- Visceral Surgery, University Clinic Ulm, 5Visceral and therapy than those in the S1-RT group (92.6% vs 65%, Transplantation Surgery, University Hospital Zurich, p=0.0194). The median survival time of the GS-RT and S1-RT 6Surgery, Cantonal Hospital Winterthur, 7Ludwig Institute groups were 18.5 and 16.8 months, respectively (p=0.134). for Cancer Research, University of Oxford, and 8Univer- Conclusion: CRT using S-1 with or without gemcitabine is a sity of Zurich, Switzerland promising therapeutic option for UR-LA pancreatic cancer, Introduction: Although pancreatic ductal adenocarci- because of its high completion rate and better prognosis. noma (PDAC) is an aggressive tumour, it displays a wide range of biology. However, at present, there are no reliable tests to predict patients’ cancer-specificoutcomesand EP02C-091 personalise therapy. Therefore, we aim to identify such PANCREATICODUODENAL biomarkers that can serve to individualise treatment of RESECTION FOR CARCINOMA HEAD resectable PDAC by performing a genome-wide survival e screen for single nucleotide polymorphisms (SNPs) that OF PANCREAS THE INFLUENCE OF reside in druggable and functional coding genomic MARGIN STATUS ON SURVIVAL regions. P. Varshney, R. Saxena, V. V. Reddy Ch, N. Gupta, Methods: Two prospective independent training/validation V. K. Kapoor and R. K. Singh datasets with a total of 331 consecutive patients who un- Surgical Gastroenterology, Sanjay Gandhi Post Graduate derwent pancreatic resection for PDAC were utilised, Institute of Medical Sciences, India including a multicentre European cohort (Switzerland and Aim: To evaluate the influence of margin status on survival Germany) and The Cancer Genome Atlas (TCGA) data- following resection for carcinoma head of pancreas (CaHOP). base. The genotypes were determined with SNP micro- Methods: A retrospective analysis of prospectively main- arrays. Cox multivariate analysis was used to screen for tained database of patients undergoing a Pancreaticoduo- SNPs that associate with allelic differences in tumour- denal resection (PDR) for CaHOP. 547 patients underwent a related survival. OncoKB, PolyPhen-2 and Provean algo- PDR at a tertiary care center from Jan 2001 till Dec 2013. Of rithms were utilised to search for SNPs in genes these, 24 patients (4.4%) operated for CaHOP form the study (i) with reported therapeutic implications, and material. Margins were defined as macroscopically positive (ii) that change the protein structure and function. Results: We identify and validate SNPs, such as PTEN (R2), microscopically positive (R1), negative margins (R0) rs644205 and close margins which were less than 1mm (Rc). (SNP A/G), that robustly associate with allelic dif- Results: 13/24 (54.2%) patients were R0, 6/24 (25%) were ferences in tumour-related survival in both study cohorts R1, 3/24 (12.5%) were Rc. 2 (8.3%) patients had positive (up-to p=0.0004; HR=2.64). We report on the alterations of margins on intra-operative frozen section and underwent a the protein sequence and the regulatory changes introduced fi total pancreaticoduodenectomy (TPD). 1 (4.2%) patient by the identi ed SNPs, and describe the resulting potential expired postoperatively following a classical PD . The post- therapeutic implications. fi operative morbidity included post pancreaticoduodenectomy Conclusion: The identi ed polymorphisms can serve as hemorrhage (PPH)(n=3, 12.5%), pancreaticojejunostomy (PJ) non-invasive, potentially predictive biomarkers readily leak (n=5, 22.7%), bile leak (n=2,8.3%) and DGE available at the time of PDAC diagnosis. These SNPs could (n=4,16.7%) The overall survival of these patients was 15.3 help guide personalise therapeutic strategies, such as the treatment with PI3K inhibitors of patients who carry the A- months. The survival following R0 resection was 15.5 rs644205 months, 13.9 months for R1 and Rc resection and 20 months allele of PTEN SNP . for TPD. Patients undergoing TPD for positive intraoperative margin on frozen section had better survival than those with R1 or close surgical (Rc) margins (20 months vs 13.9 months) EP02C-093 though there was no statistically significant difference based SMAD4 LOSS: A PREDICTOR OF on margin status of the patients because of small group size. WORSE TUMOR DIFFERENTIATION, Conclusion: R1 and Rc resections fare similarly. TPD for EARLY METASTASIS AND SHORTER positive resection margins provides better overall survival with acceptable morbidity. Larger prospective trials are SURVIVAL IN PANCREATIC DUCTAL required to validate these results. ADENOCARCINOMA S. Sabnis, P. Senthilnathan, S. B. Naidu, S. Srivatsan Gurumurthy, N. Anand Vijai, EP02C-092 V. P. Nalankilli and C. Palanivelu A GENOME-WIDE SCREEN FOR Surgical Gastroenterology & HPB Surgery, Gem Hospital INHERITED GENETIC VARIANTS THAT and Research Center, India AFFECT SURVIVAL AND THERAPY OF Background: Among the various biomarkers available in pancreatic cancer, this study aimed to analyzes whether the RESECTABLE PANCREATIC DUCTAL expression patterns of SMAD4 are correlated with meta- ADENOCARCINOMA static potential and are predictive of clinical outcome and C. Dimitrakopoulos1, B. Vrugt2, R. Flury3, U. Knippschild4, survival in patients with pancreatic cancer. D. Henne-Bruns4, R. Graf5, S. Breitenstein6, Methods: This is a prospective study conducted from N. Beerenwinkel1, G. Bond7 and L. F. Grochola6,8 March 2014 till February 2017, includes patients of 1Computational Biology Group, ETH Zurich, 2Institute for pancreatic ductal adenocarcinoma who underwent surgical Pathology, University Hospital Zurich, 3Institute for excision or tru-cut biopsy.

HPB 2018, 20 (S2), S505eS684 S560 Electronic Posters (EP02A-EP02F) e Pancreas

Results: Among forty-five patients, 33 had loss while 12 Results: In 10 cases ductal adenocarcinoma was found in had intact SMAD4. Loss of SMAD4 carries a 1.3 times histological or cytological examination. In 3 cases neuro- increased risk of vascular and 1.6 times risk of nodal endocrine tumor was found. In another 3 cases pancreas spread. Deletion of SMAD4 was associated with poor cystadenoma was confirmed. Central and peripheral blood differentiation (p=0.04,OR=5.6,C.I=0.9-34.4), and samples of 10 ductal adenocarcinoma cases were further increased the risk of perineural invasion by two times analysed by InCell and NGS methods. In all cases positive (OR=2,C.I=0.1-34.8). liquid biopsy was verified. 9 out of 10 patients have died in Thirty-three, eighteen, and five patients survived at the 6 months after the surgery. end of 6, 12 and 24 months respectively. Analysis revealed statistically significant association between SMAD4 loss and survival at six months (p=0.04), 12 months (p=0.01) EP02C-095 and 24 months (p=0.007). Among the operated patients 18FDG PET/CT IMPROVES STAGING OF (n=19), eleven patients developed recurrence during £ follow-up, period. all had loss of SMAD4 (p=0.03). SMALL 2 CM PANCREATIC TUMOURS The hazard ratios for poor tumor differentiation and E. Mohamed1, B. Sanghera2, W. Wong2, C. Halloran1 and SMAD4 loss were 5.8 (95%C.I=1.2-28.4,p=0.02) and 6.7 P. Ghaneh1 (HR=6.7,95%C.I=1.9-23.3,p=0.002) respectively. The 1Department of Molecular and Clinical Cancer Medicine, SMAD4 intact and loss group had median survival of University of Liverpool, United Kingdom, and 2East and 19.5+2.1 months (95%C.I=15.4-23.7) and 9.3+1.0 months North Hertfordshire NHS Trust, United Kingdom (95%C.I=7.3-11.4) respectively, confers a survival advan- Introduction: Pancreatic cancer is a devastating disease tage of 10 months (p=0.002,C.I.=-4.1to-0.9). with the highest survival figures currently achieved in pa- Conclusion: Loss of SMAD4 is strongly associated with tients with T1N0M0 disease. The aim of this study was to poor tumor differentiation with risk of metastasis at pre- investigate whether 18FDG PET/CT have an additional sentation. The overall survival is significantly influenced by value for nodal and metastatic staging of small T1 tumours. the loss of SMAD4 and poor tumor differentiation. Methods: We retrospectively screened the database of a clinical trial investigating the value of 18FDG PET/CT in patients with suspected pancreatic cancer (PETPANC trial- EP02C-094 ISRCTN73852054). Patients with small  2cm tumours 18 CIRCULATORY TUMOR CELLS OF were identified. Positive and negative influences of FDG PORTAL VENOUS SYSTEM IN CASE OF PET/CT acquisition over standardised staging with CT scan +/- MRCP +/- EUS on disease nodal and metastatic staging PANCREATIC CANCER AS A was gauged against a reference diagnosis after review of PREDICTIVE AND PROGNOSTIC available histopathological findings and follow up data for INDICATOR OF METASTATIC up to 12 months following enrolment into the trial. PROGRESSION AND OVERALL Results: 65 patients with small tumours were identified. SURVIVAL The median tumour size was 18mm with MRCP + EUS being employed in 18% and 17% of the cases respectively. 1,2 1,2 3,4 S. Sapovalovs , E. Miklasevics , A. Pukitis , For nodal staging, 18FDG PET/CT had a positive influence 1 1,2 M. Pavars and J. Gardovskis in 14 patients (21.5%) with 10 patients correctly upstaged 1 Surgery, Pauls Stradins Clinical University Hospital, and 4 patients correctly down-staged while it had a negative 2 3 Rigas Stradins University, Pauls Stradins Clinical Uni- influence in 3 patients (2 patients wrongly upstaged,1 4 versity Hospital, and University of Latvia, Latvia wrongly down-staged) . As for the M stage, it influenced Background: Pancreatic cancer (PC) is one of most the management decisions of 5 patients (7.7%) with three common, aggressive and potentially lethal oncological of them identified to have occult distant metastasis not disease. PC builds up w3% of oncological burden and is identified on CT while the other two had confirmed benign a cause of mortality in 7% of cancer cases. Standard lesions rather than malignant on 18FDG PET/CT. diagnostics of PC is CT, although in the last years Conclusions: 18FDG PET/CT holds an additional value endoscopic ultrasonography (EUS) is a helpful tool in and improves the accuracy of small pancreatic tumours management of small and borderline tumors. In situation staging. of borderline cases more information should be acquired before the appropriate treatment is chosen. Nowadays ” "liquid biopsy of the venous system can assist in cir- EP02C-096 culatory tumor cell (CTC) verification in case of PC. The prognostic value of CTC is still investigated. Central LONG-TERM AND SHORT-TERM blood samples are proved to be more informative and RESULTS EN BLOC specific than peripheral. PANCREATICODUODENECTOMY FOR Methods: In a single-center cohort study 16 patients with SURGICAL TREATMENT PATIENTS suspected PC were evaluated. In all cases CT scan was WITH NON-PANCREATIC AND NON- done. Open laparotomy with or without pancreaticoduo- BILIARY MALIGNANT TUMORS denal resection was performed in 14 patients with acqui- 1 1 2 3 sition of liquid biopsy from portal system. EUS guided K. Shostka , A. Sakharov , I. Gotsadze , G. Poryvaev , 3 3 1 1 transhepatic needle aspiration of portal vein was performed A. Kirshin , R. Tarasov , K. Ilyin , K. Arutyunyan and 1 in 2 cases. Peripheral blood samples were obtained in both L. Roman 1 groups, sizes of the both samples were 10 mL. Leningrad Regional Oncological Center, Russian Federation, 2Institute of Clinical Medicine (F.Todua

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S561

Clinic), Georgia, and 3Izhevsk Republican Clinical mGPS, group A is normal pattern. Group B is usually Oncology Center, Russian Federation malnourished. Group C is a cancer cachexia preliminary Introduction: Our purpose was to examine long-term and group. Group D was cancer cachexia. short-term results en bloc pancreaticoduodenectomy for Result: In CONUT score, Nomal:8, Mild:30, Moderate:19, tumors adjacent to the pancreas organs. High:1. mGPS Method: These data were collected by the Leningrad Group A 19, Group B 15, Group C 11, Group D 13. Regional Oncological Center (Saint Petersburg, Russian In relation to the prognosis, a significant difference was Federation), the Republican Clinical Oncology Center found between CONUT (Nomal / Mild vs Moderate / High) (Izhevsk, Russian Federation) and the Institute of Clinical and mGPS (Group A vs. BCD group) in the low NLR Medicine (F.Todua Clinic, Tbilisi, Georgia). Between group (p< 0.05). No significant difference was observed in January 2004 and May 2017 41 patients were operated on the high NLR group. for locally advanced cancer and for metastatic disease to the Conclusion: It was suggested that NLR, mGPS and head of the pancreas. There were 13 (32%) patients with CONUT Score are important factors regulating prognosis. colon cancer, 12 (29%) - gastric cancer, 8 (20%) - malig- nant tumor of the duodenum, 3 (7%) - lymphoma, 3 (7%) - kidney cancer and 2 (5%) - retroperitoneal sarcoma. EP02C-098 Results: All combined resections were successfully NEOADJUVANT TREATMENT WITH performed. Resection margins in all patients were tumor-free. GEMCITABINE PLUS NAB- Morbidity was 44% (18 patients), including 8 patients with grade I - IIIa complications by Clavien-Dindo and 9 - with PACLITAXEL VERSUS SURGERY FIRST grade IIIb. 17 of these complications were successfully cured FOR PANCREATIC by operative or conservative treatment. There was 1 death in ADENOCARCINOMA fi patient who developed a pancreatic stula type C. 5-year B. Ielpo, E. Vicente, Y. Quijano, R. Caruso, H. Duran, overall survival was reached for 2 largest patient groups with L. Malave, V. Ferri, E. Barzola, R. Isernia and C. Plaza colon and gastric cancer, which was 40 and 16%, respectively. Sanchinarro University Hospital, Spain Conclusions: Combined resections can improve overall Introduction: Neoadjuvant treatment has been reported to survival for patients with non-pancreatic and non-biliary prolong survival in patients with potentially resectable malignant tumors spreading to pancreas. Invasion of the pancreatic adenocarcinoma (PA). However, there are malignant tumor to the head of the pancreas should not be currently limited clinical results available using nab-pacli- contraindication to performing a combined surgery with PD taxel and gemcitabine in PA. This paper compares the if other non-resectable signs are absent. oncological results of patients affected by potentially resectable PA who underwent surgery first (SF) versus surgery following neoadjuvant treatment (NAT). EP02C-097 Methods: This is an observational, comparative study COMPARISON OF INFLAMMATION whereby data were abstracted from a prospective database NUTRITION-RELATED SCORES AS of patients affected by PA from 2007 to 2017. PREDICTORS IN PATIENTS WITH Results: We included a total of 90 patients (40 SF and 50 UNRESECTABLE ADVANCED NAT) which resulted in being preoperatively similar. Among the NAT patients, treatment was well tolerated and PANCREATIC CANCER the resection rate was 70% (35/50 patients). There was a S. Sekine, H. Baba, K. Hirano, K. Shibuya, I. Hashimoto, trend towards a higher R1 resection rate in the SF group S. Hojo, I. Yoshioka, T. Okumura, T. Nagata and T. Fujii compared with the NAT (14% vs 4 %; p = 0.1). Median Department of Surgery and Science, University of Toyama, overall survival in the resected NAT group was higher Japan (30.6 vs 22.1 months; p = 0.04). In the borderline resectable Background: Neutrophil to lymphocyte ratio (NLR) and group, overall survival was found to be four times higher mGPS (modified Glasgow Prognostic Score) are known as compared with SF (43.6 versus 13.5 months; p = 0.001). indices reflecting the inflammatory state. In addition, utility Conclusions: These data suggest that neoadjuvant treat- as prognostic predictors for various carcinomas has been ment with gemcitabine/nab-paclitaxel is a safe and effective reported.We examined the relationship of these inflamma- option for potentially resectable PA compared with the SF tion/nutrition-related prognostic scores in unresectable approach. advanced pancreatic cancer and examined its usefulness. Method: Patient (n=58) who had undergone treatment in our department for unresectable pancreatic cancer from EP02C-099 2003 to 2017(male:female = 38:20, average age 69.7 years EMERGENCY old). Gastro-jejnostomy was 27 cases, open laparotomy PANCREATODUODENECTOMY FOR wsa 6 cases, Colostomy was 3 cases, and 4 other cases. 18 GASTRINOMA WITH SEVERE cases were non-surgical treatment. 58cases were divided HEMORRHAGE e A CASE REPORT into two groups. ① high NLR group with NLRS 3.0 and O. Radulova-Mauersberger and H. Witzigmann ② low NLR group with NLR<3.0. Städtisches Klinikum Dresden Friedrichstadt, Germany As the evaluation of the general condition, we used Gastrinomas are the most common functional pancreatic nutritional risk index (NRI=10.7xAlb(g/dL)+0.0039ÂTLC endocrine tumors, presenting in 75-98% with duodenal (/mm3)+0.11ÂZn (mg/dL)-0.044Âage), Onodera’s prog- ulcers and their complications due to gastric acid nostic nutrition index (PNI), CONUT and mGPS. For hypersecretion.

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A 70-year-old man was admitted to our hospital with Results recurring severe upper gastrointestinal hemorrhage and no significant comorbidity. Emergency gastroscopy was performed, showing prominent gastric body folds, deep ulcers in the duodenum and oozing hemorrhage Forrest Ib. Hypergastrinemia (556 ng/L) was found during PPI ther- apy. The CT scan didn’t detect any active bleeding or a primary tumor, showing a thickened wall of duodenum, suspicious lymph nodes and a high-grade stenosis of the coeliac trunk. The applied primary therapy was repeated endoscopic hemostasis. Considering the recurring hemorrhage epi- sodes a stenting of the coeliac trunk was performed to ensure the vascularization of the liver in case of surgery. Due to sudden-onset massive hemorrhage a surgical approach, followed by a coil embolization of the gastro- duodenal artery were performed. A lymph node biopsy It should be noted that in the seven patients with pre- taken during the operation showed a neuroendocrine tumor, operative diagnosis of IPMN + PNET histology study which confirmed the diagnosis of Zollinger-Ellison-Syn- indicated the presence of concurrent but independent drome. Because of a repeated event of rapidly escalating lesions. hemorrhage, an emergency Whipple procedure was Discussion: Available literature involving IPMN-PNET is performed to remove the gastrinoma trinagle. After surgical very limited. Most accounts are case reports, from which it intervention hemostasis was achieved, but the patient suf- is not possible to extract recommendations. Data available fered severe postoperative complications. The histological do not allow differentiation between the radiological result showed a gastrinoma in the duodenum pT1 pN1 (2/ characteristics of the two entities, nor a description of the 15 LK) G2 R0. factors that may contribute to their coexistence; nor do they Radical surgery is an important part of the therapeutic allow any conclusions to be drawn about whether the approach to gastrinomas. An emergency Whipple proced- diagnostic-therapeutic strategy should be altered in these ure may be required for reccurent gastrointestinal bleeding. patients. In this situation a stenosis of the coeliac trunk is an addi- Further studies are needed to investigate this scenario tional challenge. and should aim to define the distinction between mixed and concurrent tumors more concisely.

EP02C-100 PANCREATIC NEUROENDOCRINE EP02C-101 TUMORS AND INTRADUCTAL MINIMALLY INVASIVE PAPILLARY MUCINOUS NEOPLASM OF PANCREATECTOMY FOR THE PANCREAS: A SYSTEMATIC ADENOCARCINOMA: A SINGLE REVIEW CENTER EXPERIENCE WITH 100 R. Latorre Fragua1, A. Manuel Vazquez2, RESECTIONS 1 1 2 2 C. Ramiro Pérez2, C. Garcia Amador2, M. Passeri , W. Lyman , A. Sastry , A. Cochran , 2 2 1 1 B. Gonzalez Sierra2, D. Diaz Candelas2, L. Diego García2, D. Iannitti , D. Vrochides , E. Baker and J. Martinie 1 2 V. Arteaga Peralta2, R. De La Plaza Llamas2 and HPB Surgery, Carolinas Medical Center, and Carolinas J. M. Ramia Ángel2 Medical Center, United States 1Hospital Universitario de Guadalajara, and 2General Background: Employing a minimally invasive Surgery, Hospital Universitario de Guadalajara, Spain approach in the resection of pancreatic adenocarcinoma Introduction: Intraductal papillary mucinous neoplasms is evolving as a viable strategy in select patients. The (IPMNs) of the pancreas account for 1-3% of exocrine aim of this study was to evaluate the outcomes of those pancreatic neoplasms and pancreatic neuroendocrine minimally invasive left pancreatectomies (MILP) and tumors (PNETs), for only 1-2% of all pancreatic neo- minimally invasive pancreaticoduodenectomies (MIPD) plasms. IPMNs and PNETs may co-occur as independent performed at our institution for adenocarcinoma since lesions, as mixed endocrine-exocrine tumors or PNETs the procedures were implemented in 2008 and 2012, with an intraductal growth pattern. respectively. Literature on the first two scenarios is scarce and Methods: We used a REDCap data repository, to compile confusing. This study is a systematic review on the coex- a list of all patients who had undergone either MILP or istence of IPMNs and PNETs. MIDP for pancreatic adenocarcinoma at our institution Methods: Adhering to PRIMSA guidelines (PRIS- starting in 2008. This totaled 100 cases. All 100 opera- MA12NL), a systematic search was performed in PubMed, tions were initiated in a minimally invasive fashion (either Embase, for articles on concurrent IPMN-PNET, mixed robotically or laparoscopically). The 15% that were endocrine-exocrine pancreatic tumors, and/or PNET with converted to open were also included in the subsequent an intraductal growth. 158 articles were obtained, only 15 analysis. focused on IPMN-PNET. Results: A total of 57 MILPs were attempted. Of those, 6 Results: The results are shown in Table 1. (10.5%) were converted to open. A total of 43 MIPDs were

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S563 attempted. Of those, 9 (20.9%) were converted to open. Results: We found that the CLDN1, 2, 4, 7, 12, 23 genes Patient demographics, perioperative data, and oncological were significantly over-expressed in pancreatic cancer factors are summarized in figure 1. R0 resection was samples compared to healthy tissue (p < 0.05). In contrast, attainable in 72.1% of MIPD cases and in 70.2% of MILP CLDN5, 6, 8, 16, 17, 20 genes were under-expressed in cases. Grade B/C pancreatic fistulas were seen in 9.3% of tumor. Gene expression of CLDN 3, 9-11, 14, 15, 18, 19 MIPD cases and in 10.5% Of MILP cases. was not influenced by tumor state. Discussion: This study reinforces the idea that at a high Conclusions: These results are suggestive of the epigenetic volume center, pancreatic resections can be approached effect of pancreatic cancer in the transcriptional level of in a minimally invasive fashion with a low conversion certain members of the CLDN gene family and provide rate and acceptable postoperative outcomes. Of note, we indications for their potential utility as biomarkers of risk favored robotic platform for MIPD, while MILPs were for pancreatic cancer. approached with both robotic and laparoscopic techniques. EP02C-103 DIFFERENTIAL GENE EXPRESSION PROFILE OF THE AQUAPORIN (AQP) GENE FAMILY COMPONENTS IN PANCREATIC CANCER D. Magouliotis1,2, V. Tasiopoulou3, K. Dimas2, N. Sakellaridis2 and D. Zacharoulis4 1Department of Surgery, University Hospital of Larissa, 2Pharmacology, 3Faculty of Medicine, University of Thessaly, and 4University Hospital of Larissa, Greece Background: Pancreatic cancer is a highly aggressive tumor mainly associated with poor prognosis. Aim: In this study we aimed to investigate the gene expression profile of aquaporins (AQPs) in patients with pancreatic cancer. Figure 1 Materials and methods: Gene expression data of AQP1-6 were analyzed from a study (Pei H, et al. Cancer Cell 2009 Sep 8;16(3):259-66) comprising of n=52 pancreatic cancer specimens and normal specimens. The gene expression data were log-transformed, median centered per array and EP02C-102 the standard deviation was normalized to one per array. All TRANSCRIPTOMIC ANALYSIS OF THE values from the transformed data were downloaded from CLAUDIN (CLDN) GENE FAMILY IN the PubMed GEO database (https://www.ncbi.nlm.nih.gov/ PANCREATIC CANCER gds). Genes were considered differentially expressed when their fold change was significantly higher or lower between D. Magouliotis1,2, V. Tasiopoulou3, K. Dimas2, groups (p< 0.05). N. Sakellaridis2 and D. Zacharoulis4 Results: We found that the AQP1,2,4 genes were 1Department of Surgery, University Hospital of Larissa, significantly under-expressed in pancreatic cancer sam- 2Pharmacology, 3Faculty of Medicine, University of ples compared to healthy tissue (p< 0.05). However, Thessaly, and 4University Hospital of Larissa, Greece AQP5 was over-expressed in tumor. The expression Background: Pancreatic cancer is a highly aggressive level of AQP3,6 was not significantly different between tumor mainly associated with poor prognosis. the two groups. We found significant negative correla- Aim: In this study we aimed to investigate the gene tion between the gene expression of AQP1 and AQP2 fi expression pro le of claudins in patients with pancreatic (p=0.0003; Spearman’s r=-0.38) and positive correlation cancer. between AQP2 and AQP4 (p=0.0283; Spearman’s Materials and methods: Gene expression data of claudins r=0.0379). Deming regression analysis revealed nega- (CLDN) 1-12, 14-20, 23 were analyzed from a study (Pei tive association (p=0.0003) between the gene expression H, Li L, Fridley BL, Jenkins GD et al. Cancer Cell 2009 of AQP1 and CLIC4 and positive association Sep 8;16(3):259-66) comprising of n=52 pancreatic cancer (p=0.0283) between AQP2 and AQP4 given by the specimens and normal specimens. The gene expression following equations: AQP2=-0.1896*AQP1+5.35 and data were log-transformed, median centered per array and AQP4= 0,1972*AQP2+2,022, respectively. the standard deviation was normalized to one per array. All Conclusions: These results are suggestive of the epigenetic values from the transformed data were downloaded from effect of pancreatic cancer in the transcriptional level of the PubMed GEO database (https://www.ncbi.nlm.nih.gov/ certain members of the AQP gene family and provide in- gds). Genes were considered differentially expressed when dications for their potential utility as biomarkers for fi their fold change was signi cantly higher or lower between pancreatic cancer. groups (p< 0.05).

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EP02C-104 Method: We report a case of a 17-year-old female patient with non-specific abdominal pain, initially of weak in- GENE EXPRESSION PROFILE OF tensity located in the left hypochondrium, radiating to the SIGMA-1 (S1R) AND SIGMA-2 (S2R) dorsal region and worsening in the last three months. RECEPTORS IN PANCREATIC CANCER Computed tomography evidenced two well-defined for- D. Magouliotis1,2, V. Tasiopoulou3, K. Dimas2, mations in the topography of the pancreas, one of solid N. Sakellaridis2 and D. Zacharoulis1 feature in the neck and the other solid with cystic areas in 1Department of Surgery, University Hospital of Larissa, the body. Laboratory tests and tumor markers did not show 2Pharmacology, and 3Faculty of Medicine, University of any type of alteration. Thessaly, Greece Results: Indicated an open surgical approach. Two well- defined formations separated by normal-looking pancreatic Background: Pancreatic cancer is a highly aggressive tissue were evidenced intraoperatively. Left hemi- tumor mainly associated with poor prognosis. pancreatectomy with splenectomy was performed. Patient Aim: The main goal of our study was to assess the evolved without complications and was discharged on the expression levels of the genes SIGMAR1 and TMEM97 6th postoperative day. The histopathological and immuni- encoding s1R and s2R, respectively, in pancreatic cancer as histochemical results confirmed the diagnosis of pseudo- compared to healthy controls. papillary cystic solid neoplasm in the two tumor formations Materials and methods: Gene expression data of with normal pancreatic parenchyma between them. SIGMAR1 and TMEM97 were analyzed from a database Conclusion: Solid pseudopapillary neoplasm of the (Pei H, et al. Cancer Cell 2009 Sep 8;16(3):259-66) pancreas mostly described as an unicentric lesion, with comprising of n=52 pancreatic cancer specimens and similar distribution in head, body and tail of the pancreas. normal specimens. The gene expression data were log- Some biomolecular aspects of the disease are still unknown transformed, median centered per array and the standard and may have a multicentric presentation, as in this patient. deviation was normalized to one per array. All values from the transformed data were downloaded from the PubMed GEO dataset (https://www.ncbi.nlm.nih.gov/gds). Gene expression was considered to be significantly over- or EP02C-106 under-expressed when p< 0.05 comparing pancreatic IMPACT OF THE BRCA GENE cancer vs. healthy controls. MUTATIONS ON THE SURVIVAL IN Results: The gene expression of SIGMAR1 was similar PATIENTS WITH PANCREATIC between pancreatic cancer and healthy controls. On the contrary, the TMEM97 was significantly under-expressed CANCER: A CASE SERIES ANALYSIS 1 2 in pancreatic cancer compared to healthy controls (p = E. J. Barzola Navarro , E. Vicente López , 1 1 1 1 0.0001). We also found a negative correlation between Y. Quijano Collazo , R. Caruso , B. Ielpo , H. Duran , 1 1 1 1 the gene expression of SIGMAR1 and TMEM97 (p = V. Ferri , E. Diaz , I. Fabra and C. Plaza 1 2 0.0132 and Spearman’s r= -0.2423). Deming regression HM Hospital Sanchinarro, and General surgery, HM analysis revealed significant negative association (p = Hospital Sanchinarro, Spain 0.0132) between the gene expression of SIGMAR1 and Introduction: The BRCA gene mutations are found in up TMEM97 given by the following equation: TMEM97 to 10% of pancreatic adenocarcinoma cases. Furthermore, =À10,66*SIGMAR1 + 76,62. this is a description of 5 cases of BRCA mutations with Conclusions: Our results indicate that TMEM97 that en- large response after neoadyuvancy, 2 cases with complete codes s2R is significantly under-expressed in human pathological response was obtained after resection. We will pancreatic cancer. The prognostic value of s2R along with show pancreatic cancer and the potential role of BRCA its possible utility as biomarker for pancreatic cancer re- mutations regarding therapeutic implications, complete quires further investigation. pathological response and survival benefits. Case report: We present 5 cases of pancreatic adenocar- cinoma in 3 of these the BRCA2 mutation was identified, in EP02C-105 one the BRCA1 gene alteration. Two patients following the neoadjuvant treatment with FOLFIRINOX and radio- MULTICENTRIC PANCREATIC SOLID fi e therapy underwent surgery; in the rst case a distal PSEUDOPAPILLARY TUMOR A CASE pancreatectomy with splenectomy was performed and in REPORT the second one the Whipple’s procedure. In both cases, a F. Apodaca-Torrez, R. Fuziy, A. Goldenberg, complete pathological response was reported (figure 1). R. Artigiani Neto and E. J. Lobo Other 3 patients were treated with FOLFIRINOX after Surgical Pancreato-Biliary Division, Universidade Fed- BRCA mutation identification and acceptable life expec- eral de São Paulo, Brazil tancy was obtained. Introduction: Solid pseudopapillary neoplasm of the Discussion: The association between complete patholog- pancreas is a neoplasm that since its original description by ical response, lower rates of local recurrence and better Frantz in 1959 has received several denominations. It is a survival in patients with various types of adenocarcinomas fi very rare neoplasm with an incidence of approximately 1% is well known. Identi cation of such patients with BRCA of all pancreatic neoplasms and is characterized by pre- mutations could help to perform a personalized treatment. dominantly reaching young female patients, having low Conclusion: In some patients with pancreatic cancer, aggressiviness and that almost always its treatment consists especially when there is clinical or demographic reason to fi of a complete surgical resection. Its etiopathogenic aspects suspect a genetic predisposition, a con rmation of the still generate discussions. presence of BRCA mutations could provide an opportunity

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S565 to use a target treatment with beneficial outcomes regarding 3year survival rate 0/33.3/68.6/92.3% 5year survival rate 0/ survival. 0/68.6/71.8%, p< 0.001). Conclusion: Concise prognostic score in the combination of post-treatment albumin, CA19-9 and NLR is likely to be useful.

EP02C-108 A SUCCESSFUL CASE OF BORDERLINE RESECTABLE PANCREATIC CANCER UNDERGOING CURATIVE SUBTOTAL PANCREATECTOMY WITH EN BLOC CELIAC AXIS RESECTION AFTER COMBINATION GEMCITABINE AND CAPECITABINE WITH TERTOMOTIDE H. C. Yu, S. W. Ahn and J. D. Yang Surgery, Chonbuk National University Medical School, Republic of Korea Complete pathological response after neodjuvant tr. Pancreatic cancer patients have a poor prognosis because of a low rate of resection that results from distant metastases or local advancement. We report a successful case of borderline resectable pancreatic cancer in a patient EP02C-107 who was curatively resected after combination gemcita- bine and capecitabine with tertomotide (RIAVAXÒ). A THE PROGNOSTIC EFFICACY OF 58-year-old woman was referred for treatment of a 20- ALBUMIN, CA19-9 AND NLR FOR mm pancreatic proximal body tumor involving the celiac PANCREATIC CANCER PATIENTS WHO axis, superior mesenteric artery and retropancreatic soft UNDERWENT NEOADJUVANT tissue infiltration as on imaging. Therefore, the combined CHEMORADIOTHERAPY chemoimmunotherapy regimen was initiated to allow for possible resection later. After six cycles of chemo- Y. Endo, M. Kitago, M. Shinoda, H. Yagi, Y. Abe, immunotherapy, a CT scan revealed that the soft-density G. Ohshima, Y. Nakano, T. Yokose and Y. Kitagawa mass around the celiac axis had dramatically disappeared, Surgery, Keio University, Japan and the tumor was then determined to be a resectable Introduction: Numerous studies examined the prognostic lesion. Thus, subtotal pancreatectomy with en bloc celiac factors for pancreatic cancer, but in neoadjuvant setting, the axis resection and splenectomy was performed and utilities of these markers are fully unknown. We hypothesis curability was achieved. that the combination of post-treatment serum albumin, The resected pancreas has revealed pathological no CA19-9 and NLR will be a reliable prognostic score for remnant tumor (complete response). There has been no patients with pancreatic cancer through neoadjuvant tumor recurrence or distant metastasis at more than 5 chemoradiotherapy. months after surgery, and the patient remains alive at 10 Method: Sixty-one patients who managed in our hos- months after initial chemoimmonotherapy. pital during 2003 to 2017 were reviewed in this anal- ysis. In our institute, NACRT usually comprises 5-FU (300 mg/body/day) or TS-1 60mg/m2/d, cisplatin EP02C-109 (10mg/body), mitomycin C (4mg/body/day,), heparin (6000 IU/body/day, and radiation (total 40 Gy). Cut-off THE ASSOCIATION OF KRAS value was set as 3.9g/dL for ALB, 40IU/mL for CA19-9 MUTATION IN CIRCULATING-TUMOR and 5.0 for NLR, respectively. We examined whether DNA AND SURVIVAL IN PATIENTS these makers and score are associated with overall WITH PANCREATIC CANCER survival(OS) in all patients and patients with subsequent M. K. Kim1, S. M. Woo2, B. Park3, K. -A. Yoon4,5, surgery. Y. H. Kim6, J. Joo3, H. M. Park2, S. -S. Han2, Result: The mean age was 66.7Æ8.0, 75.4% were male S. -Y. Kong1,7,8 and S. -J. Park2 patients. Forty-three patients underwent subsequent surgery 1Translational Cancer Research Branch, Division of with curative intent and 81.3% of patients had R0 re- Translational Science, 2Center for Liver Cancer, 3Bio- sections. In case that low ALB, high CA19-9 and high NLR metric Research Branch, Division of Cancer Epidemiology were assigned a value of 1, a log-rank test showed statis- and Prevention, 4Cancer Genomics Branch, Division of tically significant difference in OS between each score in in Convergence Technology, National Cancer Center, 5Col- both all patients and resected patients (all patients; lege of Veterinary Medicine, Konkuk University, 6Molec- 3vs2vs1vs0 3year survival rate 0/34.9/58.1/92.3%, 5year ular Imaging & Therapy Branch, Division of Convergence survival rate 0/0/50.9/71.8%, p< 0.001, resected patients; Technology, 7Center for Hematologic Malignancy, and 8Department of Laboratory Medicine, Center for

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Diagnostic Oncology, Research Institute and Hospital, cystadenoma 3 cases ,intraductal papillary mucinous tumor National Cancer Center, Republic of Korea 1 case. Circulating-tumor DNA (ctDNA) has been known to be Conclusion: Solid pseudopapillary tumor was the pre- released from tumor cells and investigated potential bio- dominant type encountered with females being commonly markers for therapeutic responses. However, the role of affected by cystic neoplasm of pancreas. Most common ctDNA in pancreatic cancer has not been well studied. Here presentation was abdominal pain in our series. we selected KRAS mutation which has been known common over 95% of pancreatic ductal adenocarcinoma (PDA) and evaluated applicability as a prognostic marker EP02C-113 through the quantitative analysis of ctDNA and KRAS ESTABLISHMENT OF PATIENT- mutation in the patients with PDA. Total of 147 PDA pa- DERIVED ORTHOTOPIC XENOGRAFT tients were enrolled in the study. The concentration and fraction of KRAS mutation were measured by KRAS (PDOX) MODELS TO REPRESENT screening multiplex droplet digital PCR kit (Biorad, USA) ENTIRE OF PANCREATIC CANCER in plasma. Median of ctDNA concentration, KRAS mutant PATIENTS concentration and fractional abundance were 425 ng/mL, S. I. Choi1,2, A. -R. Jeon1, H. M. Park3, S. -J. Park3,4, 0.11 copies/uL and 0.35 %, respectively. KRAS mutant S. -Y. Kong5,6, S. -S. Han3, E. K. Hong3,7, Y. -H. Koh3, concentration and fractional abundance showed the asso- S. M. Woo1,8 and Y. -H. Kim1,8 < ciation with poor survival in OS (P =0.007 and P .001). 1Molecular Imaging Branch, Research Institute, National When we analyzed the receiver operating characteristic Cancer Center, 2Department of Life Science, Ewha (ROC) curve to determine whether KRAS mutation in Womans University, 3Center for Liver Cancer, 4Carcino- fi ctDNA have additive bene ts with well-known tumor genesis and Metastasis Research Branch, Research Insti- markers CA19-9, combined with KRAS mutation concen- tute, 5Translational Cancer Research Branch, Division of tration or KRAS fractional abundance, the value of area Translational Science, 6Center for Hematologic Malig- fi under the curve (AUC) was signi cantly higher than the nancy, Department of Laboratory Medicine, Center for value calculated as CA19-9 alone. This study represents Diagnostic Oncology, 7Department of Pathology, and that KRAS mutant concentration and fractional abundance 8Department of System Cancer Science, Graduate School in ctDNA could be prognostic marker in pancreatic cancer. of Cancer Science and Policy, National Cancer Center, Republic of Korea Introduction: Patient derived xenograft (PDX) models as EP02C-112 the alternative that reflect pathological and molecular fea- CYSTIC NEOPLASMS OF PANCREAS e tures of the original disease have been generated by TERTIARY CARE CENTRE implanting tumor fragments from primary surgical resec- EXPERIENCE FROM INDIA tion into immune deficient mice subcutaneously. However, PDX studies in pancreatic cancer are scarce since only a O. K. Prakashen, A. Amudhan, S. Rajendran and small minority of patient-derived sample is resected tissue. O. L. Naganath Babu Methods: Here, we pioneered the patient derived ortho- Institute of Surgical Gastroenterology, Rajiv Gandhi topic xenograft (PDOX) model from especially non-surgi- Government General Hospital and Madras Medical Col- cal tumor tissues such as 1) endoscopic ultrasonography- lege, India guided/fine-needle aspiration (EUS/FNA) for primary Introduction: To report the type of cystic neoplastic le- tumor and 2) percutaneous liver biopsy for metastatic tumor sions of pancreas and its clinicopathological variables that as well as surgically resected tissue, with a technique of has been encountered in our centre. directly surgical orthotopic implantation into the pancreatic Methods: Retrospective observational study of the cystic tail. neoplastic lesions of pancreas operated in our centre from Results: Of 134 patients with pancreatic cancer, only 35 2011-2017 (26%) engrafted and could be propagated beyond pas- Results: Total number of cystic Lesions of pancreas sage one. The histopathological characteristics of the operated during 2011-2017 was 124. Total number of PDOX tumors are similar with those of the patient’s cystic neoplasm of pancreas operated during the same original tissues. Additionally, genetic alterations were period was 15.Our Incidence of cystic neoplasm of retained between patient tissues (F0) and PDOX tumors pancreas- 12% .All age groups were affected. Of 15 cases (F1wF3) from the mutation analysis using a compre- 13 were females & 2 were males. Females were more hensive cancer panel. Moreover, we developed the stable commonly affected. Most common symptom was abdom- storage method of freezing-thawing-implantation proto- inal pain. Mean size of the lesion was 7cm. Based on the col and overcame temporal and economic limit to location of the lesions whipples /distal pancreaticosple- establish PDOX models. nectomy was done. The most common postoperative Conclusion: We have demonstrated success in using sur- complication was grade B pancreatic leak. One patient died gical and nonsurgical specimen to build PDX models that in the postoperative period .The type of cystic neoplasm recapitulate tumor complexity and tumor environment,. was established after the histopathological examination of Because itmight be the valuable drug screening system or the resected specimen. The most common type of cystic development system for targeted therapeutics, we are now lesion encountered was solid pseudopapillary tumor- 6 using this approach to develop a rich resource of PDOX cases, followed by serous cystadenoma 5 cases,mucinous models for the investigation of therapeutic resistance.

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S567 EP02C-115 between PDAC diagnosis and surgery (TI) had worse IMPACT OF HISTOLOGICAL TUMOR overall survival (OS) compared to early operation after POSITIVE RESECTION AFTER diagnosis. Methods: All PDAC patients who underwent pancrea- PANCREATODUODENECTOMY IN toduodenectomy were retrospectively collected (2000- PATIENTS WITH DUCTAL 2015). Diagnosis date was defined as the CT-scan date ADENOCARCINOMA AND LYMPH where suspicious pancreatic lesion was observed. Sur- NODE INVASION vival analyses were performed using Kaplan-Meier method and Cox model was used to find predictive G. -R. Joliat, P. Allemann, I. Labgaa, N. Halkic, factors for OS. N. Demartines and M. Schäfer Results: In total, 192 consecutive patients underwent Lausanne University Hospital CHUV, Switzerland pancreatoduodenectomy for PDAC without neoadjuvant Introduction: In patients with pancreatic ductal adeno- treatment. Overall complication rate was 124/192 (65%) carcinoma (PDAC), complete tumor resection (R0) has and median comprehensive complication index was 20.9 been proven to improve overall survival (OS). The present (IQR 0-33.5). Mortality rate was 10/192 (5%). Nine study aimed to compare OS after R0 and R1 resections patients were lost to follow-up (5%). Median TI was 27 among patients with PDAC and lymph node invasion who days (17-40) and best threshold for 24-month OS was 30 underwent pancreatoduodenectomy. days. Median OS was similar between the groups with Methods: All consecutive PDAC patients of our prospec- TI30 and TI>30 days (28 vs. 24 months, p=0.184). tively-maintained pancreas database who underwent Recurrence rates were similar between both groups pancreatoduodenectomy were retrospectively analyzed (56% both, p=0.991). In patients with R0 resection (2000-2015). Only patients without neoadjuvant treatment (n=103), patients with TI30 days had better median fi were included. R0 resection was de ned as absence of OS (37 vs. 17 months, p=0.04). Recurrence rate was 31/ microscopic cancer cells at resection margin (1-mm clear- 66=47% for the TI30 days group and 22/37=60% for ance requirement). OS was calculated using Kaplan-Meier the TI>30 days group (p=0.224). On multivariate Cox method. regressions, TI>30 days was the only factor signifi- Results: During the study period, 192 consecutive patients cantly associated with shorter OS (HR 1.8, p=0.033) in underwent upfront pancreatoduodenectomy. On histopa- the R0 subgroup. thology, 165 patients had lymph node invasion (86%), Conclusion: In this cohort, delaying surgery>30 days after while 27 had no lymph node invasion (14%). Among pa- initial CT-scan was associated with poorer OS when tients with lymph node invasion (n=165), 92 had R0 complete resection (R0) was achieved. resection (56%), 61 R1 resection (37%), and 12 R2 resec- tion (7%). The 12 R2 resections were excluded (median OS: 14 months). Preoperative characteristics and de- mographics of R0 and R1 groups were similar. Overall EP02C-117 complication rates (Clavien II-V) were similar in both A CASE OF PANCREATIC DUCTAL groups (53/92=58% vs. 41/61=67%, p=0.232). Median OS ADENOCARCINOMA WITH PORTAL was 24 months for the R0 and R1 groups (p=0.725). VEIN TUMOR THROMBUS Recurrence rate was 59% for the R0 group and 64% for the CONTINUOUSLY INVADING THROUGH R1 group (p=0.533). Multivariate Cox proportional hazards THE POSTERIOR SUPERIOR model did not identify the R status or any other item as predictive factor for OS in patients with lymph node PANCREATICO-DUODENAL VEIN invasion. H. Nakano1, Y. Onishi2, Y. Yoshida2, T. Matsushita1, Conclusion: In PDAC patients who underwent upfront S. Kobayashi3 and T. Otsubo3 pancreatoduodenectomy without neoadjuvant treatment, 1Surgery, 2Gastroenterology, Shizuoka Medical Center, the R status did not influence OS in case of lymph node and 3Gastroenterological Surgery, St. Marianna Univer- invasion. sity, Japan Pancreatic ductal adenocarcinoma associated with portal vein tumor thrombus (PVTT) seems rare. Here, we report a EP02C-116 case of PVTT caused by pancreatic ductal adenocarcinoma DELAY OF UPFRONT (PDAC) of the head. In the present case of 71 y.o. male, PANCREATODUODENECTOMY IN preoperative images showed a ductal adenocarcinoma of the pancreatic head, and showed a thrombus of the main PATIENTS WITH DUCTAL portal trunk which had a distance with 4 cm from the main ADENOCARCINOMA DECREASES tumor. The continuity between the main pancreatic tumor OVERALL SURVIVAL IN CASE OF and the portal thrombus was not proved by preoperative COMPLETE RESECTION enhanced computed tomography (CT) or endoscopic ul- trasonography. Because lymph node swelling around the G. -R. Joliat, I. Labgaa, J. Gilgien, N. Halkic and common bile duct was detected, preoperative diagnosis was N. Demartines tumor thrombus originated from the lymph node metas- Lausanne University Hospital CHUV, Switzerland tasis. Pancreaticoduodenectomy with superior mesenteric- Introduction: Some studies suggested the importance of portal vein resection was then performed. Post-operative not delaying pancreatoduodenectomy when complete pathologic finding showed that the portal thrombus resection of ductal adenocarcinoma (PDAC) can be continuously invaded through posterior superior pancrea- achieved. This study aimed to assess if long time interval tico-duodenal vein (PSPDV) from the main pancreatic

HPB 2018, 20 (S2), S505eS684 S568 Electronic Posters (EP02A-EP02F) e Pancreas tumor. PDAC with PVTT presenting with long distance Conclusion: Cancers detected in the pancreatic body or tail from the main tumor was not previously reported and are less common, larger, more often metastasized and less seemed very rare. In addition, recurrence of intrahepatic often resectable than pancreatic head cancers. If resected, portal vein tumor thrombus was detected 8 months after the however, survival was similar. Only in patients with surgery. Therefore, PVTT of PDCA is not defined as metastasized disease, survival of patients with body or tail borderline resectable PDCA but may be considered as cancer was significantly worse than of patients with a head borderline disease and neoadjuvant therapy should be tumor. considered before resection.

EP02C-118 INFLUENCE OF THE LOCATION (HEAD, BODY, TAIL) OF PANCREATIC DUCTAL ADENOCARCINOMA ON TUMOR STAGE, TREATMENT AND SURVIVAL: Image 1 Logistic regressions regarding treatment. POPULATION-BASED ANALYSIS T. M. Mackay1, F. N. van Erning2, L. G. van der Geest2, B. Groot Koerkamp3, H. W. van Laarhoven4, J. de Vos-Geelen5, C. H. van Eijck3, O. R. C. Busch1, EP02C-120 V. E. Lemmens2,6, M. G. Besselink1 and for the Dutch DUODENOPANCREATECTOMY FOR Pancreatic Cancer Group 1 NEUROFIBROMATOSIS ASSOCIATED Surgery, University of Amsterdam, Cancer Center e Amsterdam, Academic Medical Center, 2Research, GIST CASE REPORT Netherlands Comprehensive Cancer Organisation (IKNL), A. M. Cosma1, V. Nechita2, M. Dragota1, F. Graur1 and 3Surgery, Erasmus MC e University Medical Center N. Al Hajjar1 Rotterdam, 4Medical Oncology, University of Amsterdam, 1General Surgery, Institute of Gastroenterology and Cancer Center Amsterdam, Academic Medical Center, Hepatology ’Dr. O. Fodor’, Cluj Napoca, and 2General 5Internal Medicine, Division of Medical Oncology, GROW Medicine, University of Medicine and Pharmacy, ’Iuliu - School for Oncology and Developmental Biology, Hatieganu’, Romania Maastricht UMC+, and 6Public Health, Erasmus Medical Introduction: Neurofibromatosis is a genetic autosomal Center, Netherlands dominant disease characterized by multiple skin nodules Introduction: The influence of the location (head, body, and hyperpigmentation. This condition is frequently asso- tail) of pancreatic ductal adenocarcinoma (PDAC) on ciated with a large variety of neoplasia, including GIST tumor stage, treatment and survival is unclear and investi- tumors in about 6% of cases. We present a case of neuro- gated sporadically. fibromatosis associated GIST. Methods: Adult patients with PDAC (all stages) diag- Method: A 57 year-old male patient with Von Reck- nosed between 2005-2015 from the population-based linghausen disease was referred into our service after he Netherlands Cancer Registry were included. Multivari- was discovered with a 7 mm nodular structure in contact able logistic and Cox regression analyses were used to with the pancreatic head, during a routine abdominal determine independent influence of tumor location on ultrasonography. Ultrasound examination performed in the likelihood of receiving treatment and survival, our service reveals a nodular tumor with hypoechoic respectively. circumference, central translucency, central necrosis, Results: Among 19,098 included patients, locations with medium contrast uptake and dimensions at about were 13,502 (71%) head, 2,435 (13%) body and 3,161 78/49/77 mm, without peritoneal fluid content. Trans- (16%) tail. Differences were found regarding tumor gastric biopsy specimen shows mesenchymal prolifera- stage (M1: head 42%, body 69%, tail 84%, p< 0.001), tion with spindle cells and elongated nuclei and c-kit size (>4 cm: head 21%, body 40%, tail 51%, p< 0.001) intensely positive. The diagnosis was gastrointestinal and resectability (resected: head 18%, body 5%, tail 7%, stromal tumor. A cephalic duodenopacreatectomy was p< 0.001), see Table 1. Median overall survival after performed. resection was 16.8, 15.0 and 17.3 months for location Results: Morphopathology confirmed a multifocal GIST of head, body and tail, respectively (p=0.156). In multi- low grade (G1), in the second stage. variable analyses, after adjustment for tumor and treat- Conclusion: GIST is sometimes associated with neurofi- ment characteristics, overall survival was similar for bromatosis type 1. In those cases the tumors are multifocal (non-)resected M0 subgroups, but was lower for M1 and have very often particular localization. We present a patients with body or tail cancer compared to head rare case of neurofibromatosis associated GIST surgically cancer (adjusted HR 1.13, 95% CI 1.07-1.19 and 1.25, treated by cephalic duodenopancreatectomy. 95% CI 1.19-1.31, respectively).

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survival, respectively (p < 0,05, 95% Cl). All treatment methods were well tolerated by all patients, with few adverse effects and no serious complications. There was no association between outcomes, variations in tumor characteristics, marker concentrations and therapeutic response. Conclusions: Good 3-year OS for resected PDAC was achieved by using novel PeriCRT treatment method.

EP02C-122 MYC ABERRATIONS IN AC AND PDA O. Paklina, M. Tavobilov, A. Karpov and G. Setdikova City Clinical Hospital named by Botkin S.P., Russian Federation Introduction: The aim of our study was investigation of the presence of MYC amplification in PDA and carcinoma of the vater. Method: 74 cases of PDA, 15 cases of cancer of the vater and seven cases of control pancreatic tissue were included in the study. We examined the expression of MUC1, 2 and 5AC types by immunohistochemical analyses in PDA and carcinoma of the vater. Dual-color interphase fluorescent in situ hybridization (FISH) was performed on 4-mm thick Intraoperative photo before resection. sections of formalin-fixed paraffin-embedded (FFPE) tumors. Results: Most of the PDA have been reported as - MUC1 + / MUC5AC + and accounted for 42% (31/74), the smallest EP02C-121 was a group with the intestinal mucin phenotype (MUC2 +) COMBINATION OF PERIOPERATIVE and only 7% (5/74). The group with the gastric phenotype CHEMOTHERAPY AND (MUC5AC +) was - 15% (11/74). Carcinoma of the vater in most cases have been reported as MUC2 + and accounted INTRAOPERATIVE RADIOTHERAPY for 80% (12/15), 20% (3/15) of cases the tumor presented FOR THE TREATMENT OF as MUC1 + /MUC5AC +. In normal ducts of all 7 control RESECTABLE PANCREATIC HEAD cases the tested loci had balanced (diploid) profile. FISH CANCER analysis of PDA revealed of MYC gene copy number in 21/ 74 (28%) cases. Eight of the 74 pancreatic tumors (10,8%) A. Shabunin, M. Tavobilov, V. Bedin, A. Karpov, revealed MYC gain in association with an increased chro- O. Paklina and G. Setdikova mosome 8 copy number. City Clinical Hospital named by Botkin S.P., Russian Conclusion: MYC gene amplification should be consid- Federation ered as a marker of a more aggressive behavior in cancers Introduction: A new treatment method involving neoad- biliary pancreaticduodenal region. Diploid profile MYC juvant chemoembolization of tumor vessels 5 days prior to gene in carcinomas of the vater indicates a more favorable surgery combined with intraoperative radiotherapy (IORT) prognosis compared with ductal adenocarcinomas of the followed by adjuvant chemotherapy was established for pancreas. patients with resectable pancreatic cancer. The aim of the present study was to assess the safety and efficacy of this treatment scheme. Method: Records of 161 patients with resectable PDAC EP02C-123 treated in Botkin Hospital between 2013e2017 were LOCOREGIONAL PROGRESSION IN reviewed. In 49 cases was used perioperative chemo- PATIENTS WITH PANCREATIC radiotherapy (PeriCRT). IORT was performed using Carl DUCTAL ADENOCARCINOMA Zeiss Intrabeam PRS 500 system. After resection stage, a O. Paklina, A. Shabunin, M. Tavobilov, G. Setdikova and single dose of 20 Gy IORT boost was delivered using 50- A. Karpov kV x-rays to a depth of 1 mm from the applicator surface. City Clinical Hospital named by Botkin S.P., Russian Afterward a histological examination and electron micro- Federation scopy of irradiated resection margin were performed. Results: All 161 patients with PDAC underwent gross Introduction: It is well recognized that pancreatic ductal total resection (R0) with lymphadenectomy D2. The adenocarcinoma (PDAC) is associated with very poor estimated median survival was 338, 358, 372 and 337 prognosis, early locoregional invasion and distant metas- days. Long-term survival was 70,2% (NACE), 75,1% tases. One reason for this is the proliferation of tumor (IORT), 80,7% (PeriCRT), 61,3% (control) for 3-year growth through perineural spaces.

HPB 2018, 20 (S2), S505eS684 S570 Electronic Posters (EP02A-EP02F) e Pancreas fi Methods: To evaluate the ef cacy of intraoperative radi- EP02C-125 ation therapy (IORT) for the extrapancreatic perineural invasion (EPPI) in the development of locoregional recur- THE SEVERITY OF NEURAL INVASION rence in patients with PDAC. DECREASES OVERALL SURVIVAL AND Results: In 14.5% (22/152) the tumor was pT1-2, pN0, TIME UNTIL TUMOR RECURRENCE IN EPPI 0, R0. R1 detected in 32.1% (49/152). EPPI was PATIENTS WITH PANCREATIC detected in 36.8% of cases (56/152). Metastases in regional DUCTAL ADENOCARCINOMA lymph nodes was found in 62.5% (95/152) of cases. In the study of autopsy basic morphological parameters speakers A. Brock, S. Schorn, E. I. Demir, C. Jäger, F. Scheufele, include locoregional tumor progression and / or a distant H. Friess and G. O. Ceyhan progression. Locoregional recurrence was found in 85% of Department of Surgery, Klinikum rechts der Isar, Tech- cases (29/34), which is manifested by the presence of nical University of Munich, Germany perineural invasion. The mean time from surgery until Introduction: Neural invasion/Pn is recognized as an un- locoregional recurrence without EPPI - 14 months, with the favorable factor decreasing overall survival/OS in patients presence of EPPI - 9 months. with pancreatic ductal adenocarcinoma/PDAC. Recently, Conclusion: Thus, the absence of regional lymph nodes we could clearly show that Pn is an omnipresent, histo- and/or with positive surgical margin does not preclude pathological feature of PDAC reaching up to nearly 100% the development of locoregional recurrence in patients of all tumor specimens and that Pn decreases OS and dis- with PDAC. This is what necessitates a combined ease-free surviva/DFSl. Yet, the impact of severity of Pn on approach to the treatment of these patients, including OS and DFS has not been systematically evaluated. surgery, supplemented by conducting IORT that effec- Methods: Therefore, 225 PDAC specimens of patients tively influences on tissues and reduces the number of resected between 07/2007 and 10/2014 were systematically local recurrence. revaluated and our Neural Invasion Severity Score”/NI-SSc was assessed. Afterwards, NI-SSc was correlated with clinical follow-up data focusing on OS and time to tumor recurrence. EP02C-124 Results: Overall incidence of Pn was 96%. Strikingly, a high Ò NI-SSc was not even associated with a diminished OS in RINTATOLIMOD (AMPLIGEN ) PDAC patients (median survival: 17.2 months vs. 27.6 MAINTENANCE THERAPY IN months, p = 0.001) but also a strongly decreased DSF (27.7 PANCREATIC CANCER PATIENTS: months vs. 10.5 months, p < 0.001). Moreover, time to local RESULTS FROM A SINGLE CENTER recurrence/LR (10.5 months vs. 27.7 months, p=0.001) and PILOT COHORT STUDY time to distant metastases/DM (12.9 months vs. 27.2 months, p = 0.01) was unfavorably affected by a high NI- fi1 1 2 D. Lati , M. Moskie , D. Mustafa and SSc in PDAC. Accordingly, NI-SSc was the strongest in- C. H. J. van Eijck1 1 2 dependent predictor for OS (HR = 1.02; p = 0.01), for LR Surgery, and Pathology, Erasmus MC, Netherlands (HR = 1.05; p < 0.0001) and for DM (HR = 1.01; p = 0.04) Introduction: In pancreatic cancer, elevated neutrophil-to- by the Multiple Cox proportional hazard model. lymphocyte ratio (NLR) and elevated systemic inflamma- Conclusion: In PDAC, the severity of Pn is an unfavorable tion index (SII) are related to poor survival. The aim of this predictor of a crucially shortened OS and time to LR and pilot study was to assess whether Rintatolimod DM. Therefore, the NI-SSc should gain increased consid- (AmpligenÒ) could stimulate changes in the NLR and SII eration in the planning of individual postoperative treat- in pancreatic cancer patients. In addition, we aimed to study ment for patients with PDAC. the systemic immune profile changes in depth. Method: Patients diagnosed with any stage of pancreatic cancer received Ampligen maintenance therapy in a named EP02C-126 patient program after completing the standard of care. The NLR ratios, SII’s and disease progression were assessed HISTOPATHOLOGICAL STUDY: A KEY during treatment. The blood samples were also analyzed by POINT IN PANCREATIC CANCER flow cytometry (FCM) and a broad panel of immune cells M. I. García Domingo1, E. Herrero1, J. Camps Lasa1, related to the TLR3 were measured. J. Tur Martinez1, M. Galofré Recasens1, Results: Since February 2016 a total of 26 patients have L. Martinez de la Maza1, C. Baez Leal2 and been included. The majority was male (65.4%) and the E. Cugat Andorra1 mean age was 62.3 years (SD 7.4 years). After 6 weeks 1Hospital Universitari Mutua Terrassa, and 2Pathological treatment, the NLR was significantly elevated (p=0.029) in Department, Hospital Universitari Mutua Terrassa, patients with progressive disease (n=8) compared to pa- Universitat de Barcelona, Spain tients without progressive disease (N=11). Over the time Introduction: R1 resection in pancreatoduodenectomy frame of 18 week treatment there was a drop in NLR and (PD) is a negative prognostic factor. Development of SII in patients without progression and an increase in NLR standardised pathologic protocols increased R1 rate and this and SII in patients with progressive disease (NS). can have implications in postoperative treatment strategy. fi Conclusion: Our data con rm that higher NLR values are Patients and methods: From 2000 we performed 243 PD. associated with poor outcome. During treatment, the NLR A total of 156 were due to pancreatic ductal adenocarci- could be valuable as a predictive marker for therapy noma. In May 2004 a new standardised anatomopatho- response. According to the data of this pilot study, logical protocol (SP) was introduced to evaluate resection’s Ampligen could induce an immune response and in addi- specimens (Verbeke Histopathology 2008). R1 was defined fi tion a bene cial shift in the NLR and SII. as presence of tumour cells at< 1mm from margin

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S571 resection. Our series was divided in two groups: specimens We identified 73 patients with RES and BR pancreas studied with the old pathological protocol (NSP) with 93 cancer who received neoadjuvant chemotherapy. There cases) and SP group with72cases. There were no differ- were no differences in baseline characteristics between ences demographic data, tumour size, TNM staging, groups (Table 1). 50.7% received single agent Gemcitabine lymphadenectomy and positive lymph nodes. and 49.3% received multi-agent chemotherapy (Gemcita- Results: There were no statistical differences in number of bine/Abraxane (27.4%) and FOLFIRINOX (21.9%)). R1 pancreatic margins SP 7% vs NSP 3% or in R1 retro- Forty-five patients (61.6%) underwent therapeutic resec- peritoneal margins (11% in both groups). More positive tion. No patients with RES had radiologic progression of vascular margins were identified in SP group 25% vs 4% in disease during neoadjuvant treatment. Five (6.9%) patients NPS, P = 0.001. R1 circumferential margin was higher in SP with BR tumors who received multi-agent chemotherapy group 32% vs 10% in NSP group, P = 0.001. 54% of patients had local progression, while 0 patients in the Gemcitabine in NSP received adjuvant chemotherapy vs 71% in SP group, group progressed (p = 0.03). Five (6.9%) patients devel- P < 0.001 and 37% of patients in SP group received radiation oped metastatic disease while receiving chemotherapy, as part of the adjuvant treatment vs 20% in NSP, P < 0.001. which was similar among groups (p = 0.67). No other Survival rates at 2/ 5 years in SP were 91/39% respectively differences in progression were identified between groups. and in NSP group: 71/32% without statistical difference. Poor performance status precluded surgery in 7 (9.6%) Conclusions: Standardised pathologic study of PD speci- cases. (Table 1). R0 resection was achieved in 93.3% of mens increased the rate of R1 margins and select patients cases. Median overall survival (OS) was 29.4 months. suitable to more specific postoperative treatments. Median OS for patients treated with neoadjuvant Gemci- tabine was 29.9 months compared to those treated with multi-agent chemotherapy 23.5 months (p = 0.66). EP02C-127 Progression of RES pancreas cancer is rare during NEOADJUVANT CHEMOTHERAPY FOR neoadjuvant chemotherapy. Single agent Gemcitabine may not be inferior to multi-agent chemotherapy. BORDERLINE RESECTABLE AND RESECTABLE PANCREATIC ADENOCARCINOMA: SINGLE AGENT EP02C-129 GEMCITABINE MAY NOT BE INFERIOR THE CLINICAL FEATURES AND EARLY TO MULTI-AGENT CHEMOTHERAPY DETECTION OF TS1 PANCREATIC S. Kizy1, A. Altman1, J. Y. C. Hui1, T. Tuttle1, CANCER INVESTIGATIONS ON 1 2 2 2 S. Marmor , E. Lou , E. Greeno , K. Chang , CLINICAL FEATURES AND EARLY- J. W. Denbo1 and E. Jensen1 1 2 STAGE DETECTION OF PTS1 Department of Surgery, and Department of Medicine, University of Minnesota, United States PANCREATIC CANCER

EP02C-127 Table 1 Characteristic Whole group Gemcitabine Multi-agent p value (comparing Gemcitabine n[73 n[37 Chemotherapy to Multi-agent Chemotherapy) n[36 Median Age, years (IQR) 67.1 (12.8) 68.4 (11.9) 66.4 (15.5) 0.24 Tumor Location, Head (%) 61 (83.56%) 34 (91.89%) 25 (69.44%) 0.06 Tumor size, cm (IQR) 2.7 (1.3) 2.4 (1.2) 2.2 (1.2) 0.96 Resectable (%) 37 (50.68%) 17 (45.95%) 20 (55.56%) 0.49 Proceed to surgery, resection (%) 45 (61.64%) 23 (62.16%) 22 (61.11%) 1 Proceed to surgery, no resection (%) 8 (10.96%) 6 (16.22%) 2 (5.56%) 0.26 Radiographic Local Progression (%) 5 (6.85%) 0 (0%) 5 (13.89%) 0.03 Radiographic Distant Progression (%) 5 (6.85%) 2 (5.41%) 3 (8.33%) 0.67 Poor performance status (%) 7 (9.59%) 4 (10.81%) 3 (8.33%) 1

Neoadjuvant therapy for borderline resectable (BR) and H. Yoshii and H. Izumi resectable (RES) pancreas cancer has become widely uti- Surgery, Tokai University Hachioji Hospital, Japan lized. We determined clinical outcomes for patients who Background: Among gastrointestinal cancers, pancreatic receive neoadjuvant chemotherapy alone for BR and RES cancer is highly malignant, and has poor prognosis. How- pancreas cancers. ever, in patients who undergo resection for tumors of less We identified patients who received neoadjuvant than 10 mm in diameter, the five-year survival rate is high chemotherapy for RES and BR pancreas cancer between at 80.4 %, and thus early detection is important for the 2010 and 2017. RES and BR was defined per NCCN treatment of pancreatic cancer. guidelines. Patients who received chemoradiation were Objectives: To detect TS1 pancreatic cancer early, we excluded. Patients received Gemcitabine alone or multi- examined the rate of TS1 pancreatic cancer visualization on agent chemotherapy (Gemcitabine/Abraxane or 5FU/ preoperative imaging. Oxaliplatin/leucovorin/irinotecan (FOLFIRINOX)). Inten- tion-to-treat analysis was performed.

HPB 2018, 20 (S2), S505eS684 S572 Electronic Posters (EP02A-EP02F) e Pancreas

Subjects: Among 102 patients who underwent resection of from patients and controls are currently analysed together normal pancreatic cancer at our hospital during the 15-year with ctDNA. period from May 2002 to December 2017, we included 10 Conclusion: CellSearchÓ had a good specificity especially patients (9.8 %) with TS1 pancreatic cancer. with the portal samples but a low sensivity for the diagnosis Results: The rates of tumor detection were 89 % on ul- of early PDAC. trasonography (US) (8/9 patients, with US not performed in one patient), 60 % (6/10 patients) on computed tomography (CT), 37.5 % on diffuse-weighted magnetic resonance EP02C-131 imaging (MRI) (3/8 patients, with MRI not performed in 2 DEVELOPMENT OF PANCREATIC patients), and 100 % on EUS (2/2 patients, EUS not performed in 8 patients). The rate of tumor visualization on DUCTAL ADENOCARCINOMA (PDAC) imaging was highest at 89 % on US. For EUS, the tumor PATIENT DERIVED XENOGRAFTS AS visualization rate was 100 %. Furthermore, on magnetic PLATFORMS FOR NOVEL resonance cholangiopancreatography (MRCP) the rate of THERAPEUTIC APPROACHES visualizing abnormal findings of the pancreatic duct was 86 E. Sereti1, D. Magouliotis1,2, T. Karagianellou1, % (6/7 patients, with MRCP not performed in 3 patients). N. Sakellaridis1, D. Zacharoulis2 and K. Dimas1 Conclusion: For the visualization of TS1 pancreatic 1Pharmacology, Faculty of Medicine, University of cancer, we believe that US is the most simple and useful Thessaly, Greece, and 2Department of Surgery, University examination. MRCP can delineate the pancreatic duct Hospital of Larissa, Greece noninvasively, and is thus useful to help with screening. Introduction: Pancreatic cancer is a frequent malignancy of devastating prognosis. Patient-derived xenografts (PDX) represent the cutting edge of cancer research in the field of EP02C-130 personalized medicine. Here, we report the establishment COMPARATIVE ANALYSIS OF of PDX models of pancreatic cancer for the development of CIRCULATING TUMOUR CELLS novel therapeutic approaches. DETECTION AND CIRCULATING Materials and methods: Tumor samples were collected TUMOR DNA IN LIQUID BIOPSY FOR upon surgery and inoculated into immunocompromised THE DIAGNOSIS OF EARLY STAGE mice. After xenograft development, tumors were compared to patient’s original tumor by immunochemistry, cultured PANCREATIC ADENOCARCINOMA and serially transplanted into mice for the determination of E. Buscail1,2, C. Caumont1, C. Alix-Panabières3, tumor growth characteristics. Protein expression was J. -P. Merlio1,4, A. Bedel1,2, F. Moreau-Gaudry1,2, studied using Western Blot. Stem cell characteristics were V. Vendrely1,2, C. Laurent1, S. Dabernat1,2 and L. Chiche1,2 examined by flow cytometry and limited dilution method. 1CHU Bordeaux, 2INSERM 1035, Université Bordeaux, Moreover, activity of selected compounds was studied both 3CHU Montpellier, and 4INSERM 1053, Université in vitro and in vivo. Bordeaux, France Results: 11 out of 26 engraftments were successful. Aim: Pancreatic ductal adenocarcinoma (PDAC) survival Immunohistochemical analysis of representative tumors rarely exceed 20% except if the tumor is small (< 20mm or revealed that they represent the most aggressive and less pT1). A way to improve survival is to perform early differentiated population of the patient’s tumor. In vitro diagnosis and find simple diagnosis tool. Searching for studies to characterize the expression of proteins such as tumour elements in body fluids might provide diagnosis sigma receptors showed that sigma receptors are overex- assistance. The aim of this study was to test liquid biopsy pressed in pancreatic cancer. Further in vivo studies to method in patient with early stage PDAC. evaluate the activity of compounds (sigma ligands) as single Methods: First, we tested 2 CTC enrichment methods agents or in combination with established drugs are ongoing. (density gradient OncoQuickÒ and negative selection Conclusion: These findings uncover the potential role of RosetteSepÔ) to estimate the sensitivity of CTC detection PDX for precision medicine and drug discovery. with cell spiking experiments of two pancreatic tumour cell lines in blood samples from 24 healthy volunteers. Addi- tionally, KRAS mutations were quantified in genomic DNA EP02C-132 by digital droplet Q-PCR (dd-PCR). Next, we designed a THE ACCURACY OF THE PROGNOSTIC prospective clinical trial (PANC-CTC, # NCT03032913) INDEX FOR PREOPERATIVE OUTCOME aimed at detecting/counting CTCs in resectable PDAC pa- tients and non-cancer patients using different methods ESTIMATION IN PATIENTS (CellSearchÓ, RosetteSepÔ, OncoQuickÒ, circulating UNDERGOING SURGERY FOR tumor DNA (ctDNA) quantification by dd-PCR, KRAS PANCREATIC DUCTAL mutation status of the primary tumors). Both peripheral and ADENOCARCINOMA portal (PDAC patients only) blood were analysed. E. S. Gruber, G. Jomrich, K. Sahora, M. Gnant, Results: OncoQuickÒ is more reliable in terms of recovery M. Schindl and Pancreatic Cancer Unit (PCU) efficiency and KRAS mutant detection than Rosette- Department of General Surgery, Division of Surgery, SepÔ.From February to November 2017, 21 resectable Comprehensive Cancer Center, Medical University of PDAC patients and 28 non-cancer patients (included 8 Vienna, Austria IPMN and 2 chronic pancreatitis) were included. fl CellSearchÓ detected 7/21 (2 peripheral and 5 portal Introduction: Cancer-related in ammation has a profound detection) patients with CTCs. CTC enrichment extracts impact on survival. We aimed to examine the feasibility of

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S573 the preoperative inflammatory biomarkers C-reactive pro- stromal fibrosis in PC, suggesting a novel anticancer mecha- tein (CRP) and white blood count (WBC) subsumed in the nism that reduces the number of cancer-associated fibroblasts. Prognostic Index (PI) and analyze the influence of other factors on prognostic strength. Methods: Medical records from patients operated on for EP02C-134 pancreatic ductal adenocarcinoma (PDAC) between 1995 and COMPARISON OF NEOADJUVANT 2014 were collected retrospectively. PI groups were defined as follows: PI-0: CRP 10mg/dL and WBC 11G/L, PI-1: GEMCITABINE VERSUS 5- CRP 10mg/dL or WBC 11G/L, PI-2: CRP 310mg/dL FLUOROURACIL/CAPECITABINE and WBC 311G/L. Survival analysis (Kaplan Meier, Cox- CHEMORADIATION FOR BORDERLINE Regression and interaction model) was performed and the RESECTABLE PANCREATIC CANCER influence of CA 19-9, smoking history and age >65 years on J. S. Peng, V. C. Vilchez, R. M. Walsh and G. Morris-Stiff the strength of survival prediction by the PI was evaluated. Department of General Surgery, Cleveland Clinic Foun- Results: PI was determined in 304 patients (163 men, 144 dation, United States women, mean age 65.6 years. 194 (54.8%) patients had score 0, 98 (27.7%) score 1 and 15 (4.2%) score 2. Both patients Introduction: Neoadjuvant therapy (NAT) is commonly with score 0 and 1 had a mean overall survival of 22.5 (+-1.5 utilized for borderline resectable pancreatic cancer (BRPC) SD) and 20.3 months (+-2.4 SD), respectively, compared to and is increasingly offered for resectable pancreatic 10.8 months (+-1.9 SD) in patients with score 2 (p = 0.004). adenocarcinoma. Patients at our institution undergo con- The PI proved as a superior independent prognostic factor (p current chemoradiation for BRPC, typically with gemcita- fl =0.02) for overall survival compared to the other preopera- bine, capecitabine, or 5- uorouracil (5-FU) as a tive available factors. The strength of survival estimation by radiosensitizing agent. We compared the pathologic, clin- the PI was influenced by CA 19-9 (p = 0.006), age >65 years ical, and oncologic outcomes for patients who underwent (p = 0.024) and smoking history (p = 0.034). pancreatic resection after NAT using these regimens. Conclusion: The PI is an accurate tool for prognosis esti- Methods: All patients with BPRC who underwent neoadju- mation in patients with PDAC undergoing surgery. vant chemoradiation and pancreatic resection between January 2012 and June 2017 were included. All patients received concurrent chemoradiation with the selection of chemotherapy at the discretion of the medical oncologist. Peri-operative, EP02C-133 pathologic, and long-term outcomes were compared. HISTOPATHOLOGICAL IMPACT IN Results: A total of 57 patients were included for analysis. PANCREATIC CANCER STROMA Thirty patients received gemcitabine, 23 received capecita- INDUCED BY NAB-PACLITAXEL bine, and 4 received 5-FU infusion. Full results are detailed in Table 1. The 5-FU/capecitabine and gemcitabine groups K. Ishido, D. Kudo, N. Kimura, S. Sakuraba, W. Taiichi, were comparable with regard to age, gender, and carbohy- C. Uchida and K. Hakamada drate antigen 19-9 levels. There were no significant differ- Department of Gastroenterological Surgery, Hirosaki ences in peri-operative complication or readmission rates. University School of Medicine, Japan There were more node positive resections in the 5FU/cape- Introduction: The aim of this study was to clarify the citabine group (59 vs 20%, p = 0.006), while other patho- histopathological changes in pancreatic cancer (PC) logic outcomes were comparable. Median disease-free induced by nab-Paclitaxel (NP). survival was 15.5 months in the 5-FU/capecitabine group Methods: This was a retrospective study of 25 patients versus 14.3 months in the gemcitabine group (p = 0.61); with PC who underwent curative resection after chemo- overall survival was 29.2 versus 26.5 months (p = 0.61). therapy between 2010 and 2017 at our institution. Ten of Conclusions: Neoadjuvant chemoradiation with gemcita- the patients received NP plus gemcitabine (GnP group) and bine demonstrated an advantage over 5-FU/capecitabine in 15 received S-1 plus gemcitabine (GS group) as preoper- BRPC, with more node negative resections. This ative treatment. Pathological evaluation of nuclear, cyto- improvement in pathology did not translate to a survival plasmic and stromal features was conducted, and scored benefit in this study. from -1 to +3. The clinical and pathological features in the two groups were then compared. Results: The serum CA19-9 levels in the GnP and GS groups were reduced to 10.1% and 44.7% after chemo- EP02C-135 therapy, respectively (p=0.01). With regard to changes in RADIOFREQUENCY ABLATION AND tumor size, the median tumor reduction rates in the GnP and IRREVERSIBLE ELECTROPORATION GS groups were 28.6% and 68.2%, respectively (p=0.005). IN LOCALLY ADVANCED PANCREATIC With regard to pathological changes, the cytoplasmic vac- CANCER: COMPETITIVE OR uole score and the intensity of Masson trichrome (MT) staining were significantly higher in the GnP group than in COMPLEMENTARY TREATMENT the GS group (2.0 vs 0.93, p=0.001; 1.57 vs -0.44, p< 0.001, MODALITIES? respectively). Additionally, the inflammatory infiltration M. Walma1,2, J. Vogel3, E. van Veldhuisen3, O. Busch3, score and the degree of fibroblast immaturity were signifi- H. Wilmink4, H. van Santvoort1,5, M. Besselink3, cantly lower in the GnP group than in the GS group (-0.21 vs Q. Molenaar1 and K. van Lienden6 1.88, p< 0.001; 0.29 vs 1.88, p< 0.001, respectively). 1Surgery, University Medical Center Utrecht, 2Academic Conclusion: GnP/GEM had a strong anticancer effect on PC. Medical Center Amsterdam, 3Surgery, 4Medical Oncology, It was considered that NP markedly enhanced the degree of Academic Medical Center Amsterdam, 5Surgery, St.

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Antonius Ziekenhuis Nieuwegein, and 6Interventional xenografts were developed using PaTu8902 cell line and Radiology, Academic Medical Center Amsterdam, treated by 10mg/kg. Netherlands For PC cells MiaPaCa-2, BcPx-3 and PaTu8902, Purpose: Radiofrequency ablation (RFA) and irrevers- paclitaxel IC50 ranged from 15 to 42nM; SBT-1214 and ible electroporation (IRE) are both local ablative strate- SBT-1216 IC50 range was from 18 to 83nM and 20 to gies for the treatment of locally advanced pancreatic 65nM, respectively. Concentrations close to IC50 (10 or cancer (LAPC) which are currently being studied in 30nM) of paclitaxel or SBT-1214/1216 induced apoptosis randomized controlled trials. It remains unclear to what and 100nM concentrations produced complete G2/M cell extent IRE and RFA are competitive or complementary cycle block in PaTu8902 cells. On the other side, pacli- modalities. taxel but not SBT 1214/1216 induced apoptosis in Methods: A post-hoc analysis in patients with RECIST- MiaPaCa-2 cells. In BxPc-3 cells, paclitaxel and SBT- stable LAPC after induction chemotherapy from the pro- 1214 but not 1216 produced G2/M block at 100nM spective IMPALA cohort (09-2013 to 03-2015). A litera- concentration. Moreover, solely SBT-1216 induced ture search identified original articles reporting on apoptosis at this concentration and G2/M block at 300nM. eligibility criteria for RFA and IRE. These criteria were Tumor xenograft model based on PaTu8902 retained the used to reassess the treatment eligibility for both parent cell line pattern of expression of drug transporters techniques. but SBT-1216 treatment caused induction of expres- Results: A total of 58 patients were included of which 53 sion of ABCB1, ABCB2 and SLC22A1 and concomi- (91%) were considered eligible for local ablative therapy. tant dowregulation of ABCC1, SLC29A1, SLC29A2 Of these, 36 patients (62%) were eligible for RFA and 44 and KRAS transcript in tumor xenografts collected (76%) for IRE with 27 patients (47%) eligible for both 24h after last dose. techniques and thus 26 patients (45%) eligible for one of Our data show that both classical taxane paclitaxel and both strategies. The main reason for ineligibility for RFA second generation derivatives are highly cytotoxic in model was a small tumor with perivascular growth in 13/22 cell lines but mechanisms of their action substantially differ ineligible patients (59%) and for IRE large size of tumors in most probably due to the differential expression of 9/14 ineligible patients (60%). Mean tumor diameter was apoptotic pathways. significantly different between groups eligible for solely RFA, eligible for both and eligible for solely IRE (58mm (SD = 8mm), 43mm (SD = 12mm) and 33mm (SD = 15) EP02C-137 respectively; p< 0.001). PANCREATIC NEUROENDOCRINE Conclusion: The vast majority of patients with LAPC are TUMOR MIMICKING eligible for either IRE or RFA. IRE and RFA are equally complementary as they are competitive for LAPC. For PREOPERATIVELY A MAIN DUCT larger tumors RFA appears to be more suitable, where for INTRADUCTAL PAPILLARY smaller perivascular tumors IRE seems more appropriate. MUCINOUS NEOPLASM A. Martínez Gómez, R. Memba Ikuga, E. Llàcer-Millán, L. Estalella Mercadé, J. Vadillo Bargallo, A. Díaz Padillo, EP02C-136 M. Franco Chacón, E. D. Padilla Zegarra and EVALUATION OF TAXANE EFFECTS IN R. Jorba Martín PANCREATIC CANCER MODELS Hospital Universitari Joan XXIII, Spain Introduction: Intraductal papillary mucinous neoplasms M. Oliverius1,2, M. Ehrlichova3, V. Brynychová4, (IPMN) are cystic tumor of the pancreas that usually adopt I. Ojima5, P. Soucek4 and B. Mohelnikova-Duchonova6 a predominantly intraductal growth. Pancreatic neuroen- 1Department of Surgery, 3.Faculty of Medicine Charles docrine tumors (P-NET) are uncommon and represent 1- University and Kralovske Vinohrady Hospital, 2This work 2% of all pancreatic neoplasms. Treatment of IPMN, ac- was supported by the Czech Science Foundation no. P301/ cording to the guidelines can be surveillance or surgical 12/1734, and by Ministry of Health of the Czech Republic resection. no. 16-28375A, 3Department of Toxicogenomics, National We report the case of a P-NET with intraductal growth Institute of Public Health, 4Department of Toxicoge- mimicking a malignant main duct IPMN. nomics, National Institute of Public Health, Department of Presentation: A 79-year-old-man with an incidental Toxicogenomics, National Institute of Public Health, pancreatic tumor. Abdominal TC and MRI revealed a Czech Republic, 5Institute of Chemical Biology and Drug diffuse pancreatic ductal dilatation of the main pancreatic Discovery, State University of New York at Stony Brook, duct (20 mm). An small hypercaptant lesion (15 mm) was Institute of Chemical Biology and Drug Discovery, State seen at the head of the pancreas compatible with malignant University of New York at Stony Brook, United States, and main duct IPMN. The patient was discussed in the multi- 6Department of Oncology, Faculty of Medicine and disciplinary meeting and surgery was decided because of Dentristry, Palacký University Olomouc, Czech Republic the high risk stigmata. Pancreaticoduodenectomy was Taxanes are alternative to gemcitabine treatment of performed. Intraoperative pathology showed an epithelium pancreatic cancer (PC). We investigated taxane action in of the wirsung denuded and well-differentiated non-func- PC in vitro and mouse xenografts in vivo. tioning NET Grade 1 of 2.1 cm, with intraductal growth ( PC cell lines MiaPaCa-2, BcPx-3 and PaTu8902 were pT2N0). used for in vitro analyses of effects of classical taxane Results: P-NETs with intraductal growth are unusual. Most paclitaxel and experimental second generation taxanes of these cases are located in the distal pancreas and in the SBT-1214 and 1216. Subcutaneous mouse tumor vast majority of cases the intraductal component, although

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S575 prominent, is associated with a parenchymal component. Introduction: This study aimed to evaluate clinicopatho- The prognosis of these tumors is unknown. logic outcome of WHO grade 2 and 3 Pancreas NET and It is occassionaly difficult to differentiate based on im- clarify the risk factor for survival and recurrence of WHO aging between pancreatic lesions with prominent intra- grade 2 and 3 pancreas NET. ductal growth pattern. Methods: We retrospectively reviewed database of Conclusion: Preoperative diagnosis of P-NET with intra- 126patients who underwent curtive intent surgery for ductal growth remains difficult. NET should be kept in pancreas NET at a single institute from January 2000 mind in the differential diagnosis of intraductal lesions through december 2016. WHO grade 2(n = 29) and grade because its therapeutical implications. 3(n = 30) patients were included in this study. Clinico- pathologic characteristics and overal survival, disease free survival rates were analyzed. EP02C-138 Results: There were no significant difference in clinical DPC4, P53 AND MTAP EXPRESSION IN characteristics between WHO grade 2 and 3 groups except age(p = 0.023). There was no significant differ- PATIENTS WITH LOCALLY ADVANCED ence in overall survival(p = 0.078), but there was sig- AND METASTASTIC PANCREATIC nificant difference in disease free survival(p = 0.012). CANCER Tumor location was the prognostic factor for overall M. Walma1, L. Deguerre1, H. van Santvoort1,2, survival in multivariate analysis(P=0.022). Poorly < J. Offerhaus3, Q. Molenaar1 and L. Brosens3 differentiation(P 0.001), Positive resection margin(P < 1Surgery, University Medical Center Utrecht, 2Surgery, St. = 0.007), Metastasis(P 0.001) were risk factor for Antonius Ziekenhuis Nieuwegein, and 3Pathology, Uni- recurrence. versity Medical Center Utrecht, Netherlands Conclusions: Tumor location, differentiation, resection margin, metastasis are better prognostic factor than WHO Introduction: Whole-genome sequencing studies have grade for grade 2,3 Pancreas NET. given extensive insight in the genetic landscape of resect- able pancreatic cancer. However, little is known about the molecular features of locally advanced (LAPC) and meta- static pancreatic cancer. This study aims to describe the EP02C-140 incidences of DPC4, P53 and MTAP mutations in WHIPPLE’S PROCEDURE: A REVIEW advanced pancreatic cancer. OF A 5-YEAR CLINICAL EXPERIENCE Methods: Patients diagnosed with LAPC or metastastic AT A TERTIARY CARE CENTER pancreatic cancer between January 2007 and July 2016 were identified. All patients with available biopsy material K. Sutariya and M. Vikani and a tumorload above 10% were included. Immunohis- Cigis Gastrosurgery Centre, India tochemical staining was performed using DPC4, P53 and Background: Pancreaticoduodenectomy seems to be the MTAP antibodies. Loss of expression, wild type or over- only way in resolving resectable periampullary tumors. expression were scored by an experienced pathologist and a This article is a case series with respect to the 5-year second pathologist was consulted in case of doubt. Dif- experience of the Whipple’s procedure at CIGIS gastro- ferences between LAPC and metastatic tumors were tested surgery center, Rajkot, India. with the chi-square test. Methods: Patient surgery details were gathered from the Results: A total of 63 patients were included, 42 (67%) surgical records of the hospital. Data was analyzed and with LAPC and 21 (33%) with metastatic pancreatic results were derived. cancer. Forty samples (64%) showed loss of DPC4 Results: From 2012 till 2017, 105 whipple’ssurgery expression and 49 (78%) a P53 mutation: loss of expression were performed. Mean age of cases was 55 years, mean in 16 cases (25%) and overexpression in 33 cases (52%). hospital stay length was 9 days and mean operation time MTAP loss was seen in 20 tumors (32%). Except for a trend was 360 minutes. Most common presenting symptom in DPC4, no differences in frequencies were seen between was jaundice (80 %). Feeding jejunostomy was done in LAPC and metastatic pancreatic cancer. DPC4 loss was all patients and hence no patients suffered delayed gastric seen in 30 LAPC patients (71%) versus 10 metastatic pa- emptying. Rate of pancreatic fistula was 15%. Five pa- tients (48%)(p = 0.064). tients developed post-operative bleeding for which angio- Conclusion: Locally advanced and metastatic pancreatic embolisation had to be done. Three patients developed cancer do not differ in DPC4, P53 and MTAP expression. post-operative intra-abdominal collection for which The loss in expression described in this study correspond drainage of collection was done. One patient had to be to those in resectable pancreatic cancer described in re-operated because of intestinal obstruction secondary to literature. kink of FJ tube. There was mortality in one patient due to pulmonary embolism. Conclusions: It is true that hospital setting, socioeconomic EP02C-139 level of the patients including their compliance, and the expertise of the surgical team can have an influence on the CLINICAL FEATURE OF WHO GRADE 2 result of this operation, but it is not mandatory that this AND 3 PANCREAS NEUROENDOCRINE surgery can only be done at a high volume centre. If the TUMOR operating surgeons are well trained in a high volume centre Y. J. Kim, D. J. Park and J. S. Heo under a good surgeon, the procedure can be carried out Samsung Medical Center, Sungkyunkwan University safely and similar results can be reproduced even at a ter- School of Medicine, Korea, Republic of tiary care centre.

HPB 2018, 20 (S2), S505eS684 S576 Electronic Posters (EP02A-EP02F) e Pancreas

EP02C-141 Methods: A review was carried out of a prospectively maintained database with consecutive patients who un- CAN THE RESECTABILITY OF derwent radical surgery for PDAC from January 2007 to PANCREATIC ADENOCARCINOMA BE December 2016. We analysed variables related to the PREDICTED? ANALYSIS OF 1001 appearance of recurrence and prognosis. Univariate anal- PATIENTS INCLUDED IN THE ysis of interval from recurrence to death (IRD) was NATIONAL ANATOMO-CLINICAL performed for each location. Results: 67 patients underwent pancreatectomy, with a DATABASE ON PANCREATIC median follow-up of 24.7 months. Recurrence appeared in ADENOCARCINOMA (BACAP) 48 patients (71.6%) with a mean disease-free survival and C. Maulat1, S. Gourgou2, B. Napoleon3, L. Palazzo4, overall survival rate of 21.5 and 10.5 months, respectively. N. Flori5, A. Hantoush Al Ali1, G. Piessen6, L. Buscail7, The mean IRD was 9.2 months. A Whipple procedure was B. Bournet7, F. Muscari1 and Consortium BACAP performed in 91.6% of patients, with venous resection in 1Chirurgie Digestive et de Transplantation, CHU Toulouse - 37.5%. Adjuvant chemotherapy was given to 72.9% of Hôpital Rangueil, 2Centre de Traitement des Données patients. A positive microscopic margin was present in Institut du Cancer, 3Hôpital Privé Jean Mermoz, 4Clinique 43.8% and poor differentiation in 27.1%. There was du Trocadéro, 5Institut du Cancer de Montpellier Val lymphovascular and perineural invasion in 47.9% and d’Aurelle, 6CHRU Lille, and 7Gastro-entérologie et 70.8%, respectively. The recurrence locations were: liver Pancréatologie, CHU Toulouse, Hôpital Rangueil, France (39.6%), local (31.3%), lung (10.4%), bone (6.3%) and Introduction: Surgery remains the only treatment in peritoneum (4.2%); 8.3% of recurrences occurred as pancreatic cancer with a chance for cure, but it is only disseminated disease (2 locations). IRD related to bone possible in 10 to 20%. The purpose of this study is to recurrences was significantly shorter when compared to the research the early clinical and biological criteria which will other locations (9.6 vs. 3.7 months; p = 0.004), while he- predict the profile of patients with resectable tumor. patic recurrences showed a longer IRD (7.6 vs. 12.0 Methods: 1001 patients were included by 15 centers in months; p = 0.045). BACAP between May 2014 and July 2017. Three groups Conclusion: Bone recurrences in PDAC present shorter were defined: Resectable (Res), Locally advanced (LA) and IRD, while hepatic recurrences show a longer interval. Metastatic (Met). 71 variables were analyzed in univariable and 21 in multivariable tests in each group. Results: Of the 1001 patients included in BACAP, 703 EP02C-143 were analyzed. The Res group included 164 patients, the LAPAROSCOPIC DISTAL LA group 266 patients and the Met group 273 patients. The PANCREATECTOMY: OUR median ages were 69, 71 and 69 respectively. The patients were correctly classified by the initial assessment in 72% of EXPERIENCE IN TERTIARY CARE the Res, 85% of the LA, and 87% of the Met. The median CENTER survival rate of the Res, LA and Met were 21, 15 and 9 K. Sutariya and M. Vikani months, respectively. We found 6 criteria which reduced Cigis Gastrosurgery Centre, India the probability of resectable tumor: a cruoric thrombosis, an Introduction: With advances in minimal access surgery,  OMS 2, pain, characteristic symptoms (jaundice, weight laparoscopic DP with or without splenectomy is slowly loss and acute pancreatitis), the body topography and the gaining acceptance as an alternative to open surgery in size of the tumor. Two biological criteria increased the selected cases. probability of having a resectable lesion: elevated bilirubin Methods and materials: A retrospective review of our < and an ACE rate 10 ng/ml. data was carried out. From 2010-2016, we performed eight Conclusion: This study carried out on a large national DP by the laparoscopic approach. A 5 port approach was fi cohort allowing us to de ne the predictive clinical and used. The specimen was divided using endo-GIA stapler fi biological pro le of tumor resectability at the time of (purple/green cartridge). The decision of spleen preserving diagnosis. was made if the splenic vessels and the splenic hilum were free. The specimen was retrieved in endobag using Pfan- nenstiel incision. The perioperative parameters, morbidity, EP02C-142 and follow-up results were analyzed. INFLUENCE OF RECURRENCE’S Results: From 2010e2016, eight patients underwent LOCATIONS OF PANCREATIC laparoscopic DP. All eight were females. Two patients underwent spleen preserving DP. None of the cases were ADENOCARCINOMA ON PATIENT converted to open surgery. The mean operative time was 4 SURVIVAL hours (5e6 hours). The mean diameter of tumor was 4 cm J. L. Muñoz de Nova, M. Di Martino, C. Marín Campos, (3e5 cm). Two patients developed post operative pancre- I. Mora Guzmán and E. Martín-Pérez atic fistula ISGPF grade 1e2 which was managed conser- Department of General and Digestive Surgery, University vatively. The mean hospital stay was 7 days (6e8 days). Hospital La Princesa, Spain The final diagnosis was serous cystadenoma in one patient, Introduction: The recurrence of invasive pancreatic ductal mucinous cystadenoma in four patients, NET in one patient adenocarcinomas (PDAC) is related to a poor prognosis. and solid pseudopapillary tumor in two patients. The mean The aim of this study is to compare patient survival rates follow up period was 3 years (2e4 years) with no with different recurrence’s locations. recurrence.

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Conclusion: Laparoscopic distal pancreatectomy is safe Results: 11 out of 12 patients had pre-operative biopsy and technically feasible for selected patients with benign and only 2 were diagnosed MiNEN. As Fig. 1 depicts, 4 and low grade malignant pancreatic tumor with acceptable patients (33.34%) received 5-Fluorouracil (5-FU) based morbidity and clinical outcomes. neoadjuvant chemotherapy as biopsy showed adenocar- cinoma/adenocarcinoma-dominant MiNEN and inoper- able/metastatic disease. All responded and underwent EP02C-144 curative surgery with adjuvant Cisplatin+Etoposide (Cis- EXTENDED SURGERY IN TREATMENT Eto) to control the viable grade-3 NEN. Out of these, 2 patients (16.6%) developed metastasis and were shifted OF PATIENTS WITH PANCREATIC to Capecitabine+Temozolomide (Cap-Tem). Six patients CANCER (50%) with neuroendocrine-dominant MiNEN/neuroen- L. Pererva1, V. Kopchak1, K. Kopchak2, I. Khomyak1, docrine differentiation received adjuvant Cis-Eto, 2 O. Duvalko1, S. Andronik1 and N. Davydenko3 (16.6%) of whom developed metastases for which Cap- 1Department of Pancreatic Surgery, State Institution «A.A. Tem was started. Of 2 patients on adjuvant Cap-Tem, Shalimov National Institute of Surgery and Trans- one (8.3%) developed locoregional and liver metastasis. plantology», 2Department of Abdominal Tumors, National Three patients (25%) have succumbed to progressive Cancer Institute, and 3Department of Anesthesiology, disease, 3 (25%) are on treatment for stable or progres- State Institution «A.A. Shalimov National Institute of sive disease, and 6 (50%) are disease-free at 4e30 Surgery and Transplantology», Ukraine months. Introduction: Extended pancreatectomy (EP) is the only Conclusion: MiNENs need quality histopathological potential cure for patients with pancreatic cancer with local examination and immunohistochemistry for diagnosis, invasion of surrounding vessels and organs. and dominant component in the lesion decides chemo- Methods: In the period 2010-2017 we performed 618 re- therapy. Neoadjuvant 5-FU based regimens may down- sections in patients with pancreatic adenocarcinoma. stage adenocarcinoma-dominant tumors, but there are no Standard resections were performed in 476 (77.0%) pa- guidelines on adjuvant Cis-Eto. Poor survival is reported tients. Extended pancreatectomy was performed in 142 irrespective of site of origin and adjuvant therapy. Dis- (23.0%) patients: pancreaticoduodenectomy - in 77 ease-free survival is better in neuroendocrine-dominant (54.2%), distal resections - in 54 (38.0%), total pancrea- tumors. Cap-Tem can be considered as alternative tectomy - in 11 (7.8%). EP with arterial resections was chemotherapy. performed in 11 patients, with venous resections - in 89. Results: Postoperetive complications occurred in 182 (38.2%) patients in the standard resection group and in 58 (40.8%) in the group with extended resections, (c2 = 0.3 p = 0.57). Mortality was 2.3% (14 patients): 5 (3.5%) - after extended resections and 9 (1.9%) - after standard pancre- atectomy, (c2 = 1.3, p = 0.25). Median survival and 5-year overall survival rate were reduced in patients after EP compared with those undergoing a standard resection (21 months 26.0% and 28 months 29.0%, c2 = 0.15, p = 0.69). Conclusion: Present results suggest that morbidity and mortality after EP are comparable with standard pancrea- tectomy. Long term results of the EP are worse, comparable with standard.

EP02C-145 DILEMMAS IN THE MANAGEMENT OF fl MIXED NEUROENDOCRINE- MiNEN owchart NONNEUROENDOCRINE NEOPLASMS P. Pande, G. Desai, R. Shah and P. Jagannath Department of Surgical Oncology, Lilavati Hospital and EP02C-148 Research Centre, India INSULIN ENHANCED KRAS- Introduction: Mixed neuroendocrine-nonneuroendocrine neoplasm (MiNEN) is rare tumor comprising exocrine and DEPENDENT MIGRATION AND neuroendocrine elements, each representing 30% of INVASION VIA SSTR2/AKT AXIS lesion. It is commonly misdiagnosed as adenocarinoma or Z. Lu, G. Wang, L. Yin, Y. Peng, N. Lv and Y. Miao grade-3 neuroendocrine neoplasm. Management is not well Pancreas Center, The First Affiliated Hospital of Nanjing defined. Medical University, China Methods: Retrospective analysis of prospectively Hyperinsulinemia has been reported to be a risk factor of entered data at our center from 2013-2017 revealed 12 pancreatic cancer, but the role and mechanism of insulin in MiNENs. These were analyzed for demographics, clini- carcinogenesis still remained unclarified. This study is to copathological characteristics, management strategies elucidate the synergistic effect of insulin in Kras-dependent and prognosis. tumorgenesis. 20nM was chosen as optimal concentration

HPB 2018, 20 (S2), S505eS684 S578 Electronic Posters (EP02A-EP02F) e Pancreas for insulin treatment after examining the effect of different islet invasion on the pathogenesis and progression of concentrations of insulin in HPNE-mut-Kras and HPNE- PDAC. E6E7 cell lines. Transwell, CCK8 and EDU assays showed that migration, invasion and proliferation capability of the two cell lines were significantly enhanced after insulin co- EP02C-150 incubation. Digital gene expression (DGE) sequencing PANCREATIC RESECTION FOR revealed that SSTR2 were downregulated in HPNE-mut- Kras but not in HPNE-E6E7, indicating that this gene might METASTATIC RENAL CELL be inhibited by KRAS. Then, the expression of SSTR2, CARCINOMA insulin receptor and downstream regulators (AKT , B. Anderson1, G. Williams1, L. Dageforde2, D. Sanford1, GSK3b, cyclin D1) was evaluated by qRT-PCR and R. Fields1, C. Hammill1, S. Strasberg1, M. Doyle2, Western blot, and the results were consistent with DGE. W. Chapman2 and A. Khan2 The effect of insulin on the HPNE-mut-Kras was 1HPB Surgery, and 2Transplant Surgery, Washington suppressed with additional AKT inhibitor MK2206, the University in St Louis, United States expression of downstream regulators was also suppressed. Introduction: The pancreas is a common site of metastasis Upregulating SSTR2 restored insulin-reduced invasion and from renal cell carcinoma (mRCC). Pancreatectomy has proliferation. Similarly, knock-down of mut-Kras been described in selected patients with localized metas- suppressed insulin-induced AKT phosphorylation. Our tasis, but long-term benefit remains poorly defined. study suggested that insulin might enhance the migration, Methods: Retrospective single center review of patients invasion and proliferation of pancreatic ductal epithelial undergoing pancreatectomy for mRCC at a tertiary care cells. This effect might be Kras-independent and mediated center from 1995-2017. Pre-treatment, treatment, and by SSTR2/AKT axis. follow-up data were reviewed. Results: 29 patients underwent pancreatectomy for mRCC: 15 distal pancreatectomies (DP), 10 pancreaticoduodenec- EP02C-149 tomies (PD) and 4 total-pancreatectomies (TP). The mean THE CHARACTERIZATION OF “ISLET age was 67+/-8 yrs, and 52% were male. mRCC was INVASION” IN PANCREATIC DUCTAL asymptomatic and diagnosed on surveillance imaging in ADENOCARCINOMA 40% while the remaining were symptomatic with abdom- inal pain (21%) and weight loss (17%) being the most I. E. Demir, A. C. Mutgan, H. Friess and G. O. Ceyhan common symptoms. The median time from index ne- Department of Surgery, Klinikum rechts der Isar, Tech- phrectomy to pancreatectomy was 8 years and 93% (27) nische Universität München, Germany had pancreatic resection with curative intent. 14 (48%) had Introduction: Insulin and insulin-like growth factor (IGF) multi-focal (2) pancreatic metastases, the average number signaling axis prompts pancreatic ductal adenocarcinoma/ of pancreatic tumors per patient was 1.8 with mean largest PDAC into an advanced stage by enhancing tumor tumor size of 2.4 cm. Preoperative biopsy was performed in growth,metastasis and therapy resistance. In the pancreas 65% and 76% (22/29) had clear-cell RCC subtype on final tissue, the main source of insulin is the Langerhans’ islets. pathology. Median survival post-pancreatectomy was 5.5 Importantly, PDAC cells also invade islets during carci- years with 42% of patients being alive at last followup. nogenesis and distort their structure, but this “islet inva- 55% had RCC recurrence after a mean of 2.7 years post- sion” has never been systematically characterized. pancreatectomy. . There was no significant difference in Method: To classify the islet invasion and structure in post pancreatectomy survival between choice of surgery PDAC, pancreatic tissues from 75 PDAC patients, with or (DP, PD or TP), unifocal and multifocal pancreatic tumors without diabetes mellitus, have been double-immuno- and laterality of index nephrectomy on univariate analysis stained with the ductal and cancer cell marker Cytokeratin (p > 0.05). 19 and with insulin. Accordingly, pancreatic islet structure Conclusions: Pancreatic resection can be performed in and invasion pattern has been characterized. select patients with mRCC with favorable long-term Results: PDAC tissues showed five different pancreatic outcomes. “islet invasion patterns”: 1) Presence of cancer cells around the borders of intact pancreatic islets termed ‘peri-insular invasion’, EP02C-151 2) presence of cancer cells within pancreatic islets termed FACTORS INFLUENCING SUCCESSFUL ‘endo-insular invasion’, 3) Distortion of the pancreatic islet structure due to COMPLETION OF CURATIVE- destructive growth of cancer cells (‘distorted islet INTENDED SURGERY FOR PATIENTS structure’), WITH PANCREATIC MALIGNANCY IN 4) Insulin-expressing CK19-positive cancer cells’,5) SOUTH AFRICA adjacence of small clusters of endocrine cells to cancer P. Tinguely, M. M. Bernon, O. Chihaka, R. Nashidengo, (‘adjacent cancer & islet’). Moreover, we found that a U. K. Kotze, J. C. Kloppers, J. E. Krige and E. Jonas portion of insulin-expressing cells co-expressed mutant K- Surgical Gastroenterology/Hepatopancreatobiliary Unit, Ras(G12D). Division of General Surgery, University of Cape Town and Conclusion: PDAC tissues frequently harbour “islet inva- Groote Schuur Hospital, Cape Town, South Africa sion” and, in addition, insulin expression in KrasG12D- mutated cells. Due to the pivotal role of insulin- and IGF-1- Introduction: Despite advances in resource availability for signaling in PDAC, it is essential to elucidate the impact of major hepatobiliary surgery in South Africa, a large number of patients operated with curative intent are found to be

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S579 irresectable at surgery. The aim of the study was to identify between the years 2011 and 2017. Patient, surgical and factors associated with non-completion of curative-inten- histopatological characteristics were collected and ded resection for pancreatic malignancy. analysed. Cases were the pancreatic resection surface Methods: All patients with suspected pancreatic malig- was closed by suture closure and pancreatic duct ligation nancy deemed primarily resectable at a weekly MDT alone were compared with cases where the resection conference and scheduled for curative-intended surgery surface was additionally covered by hemostatic agents. between January and December 2017, were identified from The outcome measure was the incidence of postoperative a prospective database. Parameters analyzed and compared complications. for patients that were explored and resected and explored Results: In total 73 patients were included into the study. and not resected are depicted in the table. Postoperative complications consisted of pancreatic fis- Results: Ninety patients were discussed at the MDT con- tula (n = 17), postoperative hemorrhage (n = 3) and ference. Forty-three patients were considered primarily organ/space surgical site infection (n = 7). According to resectable and scheduled for surgery. Five (12%) did not the classification of the International Study Group of undergo surgery due to death, disease progression or clinical Pancreatic Surgery ten fistulae were grade A and seven deterioration. Of the 38 patients who underwent an operation, were grade C. no resection was performed in 8 (21%) due to metastases (n = Conclusion: Our study shows a lower incidence of 4) or locally advanced disease (n = 4). Thirty patients were pancreatic fistula in cases where the pancreatic duct was resected (27 pancreatico-duodenectomies, 1 central and 2 ligated and the resection surface was covered by the he- total pancreatectomies). Of all the parameters compared be- mostatic patch Veriset. tween resected and not resected patients, time from the MDT conference to surgery was the only parameter that was significantly different (11 versus 31 days, p < 0.01).

EP02C-151Resected versus non-resected patients Explored and resected Explored and not resected p-value patients (n[30) patients (n[8) Age [years] 58 (35–73) 60 (27–69) 0.85 Gender [male] 13 (43%) 4 (50%) >0.99 Duration of symptoms [days] 30 (4–120) 60 (14–90) 0.35 Preoperative biliary drainage [y/n] 14 (47%) 5 (63%) 0.93 Total bilirubin [mmol/L] 177 (3–723) 164 (32–324) 0.24 CA 19-9 [kU/L] 292 (1–1463) 173 (1–8678) 0.64 Time from first visit to MDT [days] 13 (0–121) 5 (1–34) 0.21 Time from MDT conference to surgery [days] 11 (1–53) 31 (20–116) < 0.01 Time from last imaging to surgery [days] 25 (4–106) 39 (3–57) 0.27

Conclusions: In this pilot study conducted in a patient EP02C-155 cohort treated in a resource-constrained environment, non-completion of curative-intended pancreatic surgery SUCCESSFUL SURGICAL TREATMENT was strongly associated with a longer waiting time for OF INVASIVE PANCREATIC DUCTAL surgery. This has important implications when priori- ADENOCARCINOMA DURING tizing resources. PREGNANCY C. Ibis1, N. Nuamah2, F. Ekiz1, B. Celik1, A. Poyanli3 and B. Acunas3 1General Surgery Division of HPB Surgery & Liver EP02C-154 Transplantation, Istanbul University Istanbul Medical POSTOPERATIVE COMPLICATIONS OF Faculty, Turkey, 2General Surgery, 37 Military Hospital, DISTAL PANCREATECTOMY IN A Ghana, and 3Department of Radiology, Istanbul Univer- HIGH VOLUME CENTRE FOR sity Istanbul Medical Faculty, Turkey PANCREATIC RESECTIONS IN THE The treatment of pancreatic cancer is demanding. Sur- gical resection is the sine qua non for prolonged survival. CZECH REPUBLIC Pregnancy can sometimes be an obstacle to offer the patient L. Havlůj, A. Whitley, M. Oliverius and R. Gürlich the required treatment options who is suffering from a Department of Surgery, Royal Vinohrady University concomitant malignancy. We are presenting a successful Hospital, Czech Republic management of a pregnant women with pancreatic cancer. Introduction: The goal of this study was to investigate A 40-year-old woman suspected of pancreatic mass whether the method of closure of the pancreatic remnant during the 20th week of her pregnancy was admitted to our effects the incidence of postoperative complications in clinics. Detailed work-up revealed pancreatic cystic mass distal pancreatectomy. of 9cm with 3.5cm solid component which was interpreted Methods: Hospital records of the department of surgery to be a malignant pancreatic tumor by radiology. No distant of the Royal Vinohrady University Hospital were metastasis was detected. The tumor was determined reviewed for all open distal pancreatectomies performed resectable. Surgical intervention was allowed by the

HPB 2018, 20 (S2), S505eS684 S580 Electronic Posters (EP02A-EP02F) e Pancreas gynecology and obstetrics department without need of a EP02C-159 medical abortion according to the decision of the patient who was in the second trimester of her pregnancy. Distal USING 3D INDIVIDUAL MODELS FOR pancreatectomy with splenectomy and omentectomy was MINIMIZING VASCULAR RISK IN performed. She was discharged in the 6th day after an PANCREATIC CANCER SURGERY uneventful postoperative period with her healthy fetus. The F. Govsa1, A. Coker2, M. A. Ozer1, A. Uguz2 and histopathologic examination revealed invasive ductal O. V. Unalp2 adenocarcinoma originating from mucinous cystic 1Anatomy, and 2Surgery, Ege University, Turkey neoplasia of high grade dysplasia without any lymphatic Introduction: Pancreatic tumoral surgery has fatal com- metastasis. Medical oncology decided to delay the adjuvant plications such as injuries of abdominal aortae, celiac trunk, chemotheraphy just after forthcoming birth. She gave a portal vein and superior mesenteric artery. The aim of study birth to a healthy baby afterwards. The patient is in a good was to describe the application of the life-size 3D patient- condition without any recurrence after app. 2 years of specific models with its vascular details which are used for follow-up. minimizing vascular risks of intraoperative pancreatic Pregnancy with concomitant malignancy can be a chal- tumor patients. lenging clinical situation. Prompt decision-making, good Methods: CT scan of 20 patients with pancreatic cancer timing and, meticulous surgery followed by adequate were transformed into 3D personalized-specific model. adjuvant therapy can be live-saving for the patient and the These models were analyzed to obtain detailed information fetus as well. of each tumor, its location, nourishing branches, and its neighborhood structures and the probability of variational anatomical possibilities were used as an intraoperative EP02C-156 reference. ENVIRONMENTAL CADMIUM AND THE Results: They allowed the localization of tumoral tissues RISK OF PANCREATIC CANCER together with vascular details and topographical relation- DEVELOPMENT ships of pancreatic cancer. Tumoral elements including the dimensions, the location, the characteristics, and the neigh- V. Djordjevic1, D. Knezevic1, S. Kmezic1, 2 3 boring arteries and the surgical strategy were demostrated D. Wallace and A. Buha with the 3D models. Vascular elements like the arterial 1Clinic for Digestive Surgery-first Surgical Clinic, Clinical 2 structure of the intervention area, possible arterial vari- Center of Serbia, Serbia, Department of Pharmacology & ability, course of the arteries and arterial diameter and its Toxicology, Oklahoma State University Center for Health 3 pattern were determined and secure intervention areas were Sciences, United States, and Department of Toxicology, defined. Besides, the cases did not include infection, University of Belgrade-Faculty of Pharmacy, Serbia bleeding, and complications. Etiology of human pancreatic cancer (PC) is still rather Conclusion: Life-size 3D model is effective and reli- scant. Exposure to environmental cadmium (Cd), a ubiq- able in achieving an accurate and safety procedure uitous metal with well-established toxic and carcinogenic during pancreatic surgery, especially in surgically properties, has been hypothesized to be one of putative complex cases. 3D model provides an accurate repre- cause of PC. sentation of the tumor location, its vascular pedicle and The aim of this case-control prospective study was to vascular neighboring structures. It is therefore useful in determined Cd levels in pancreatic tissue. The cases surgical planning as it maximizes the possibility of ideal were a consecutive series of pancreatic tissue excised minimal invasive and targeted cancer surgery, as well as from 31 patients with PC, while controls pancreatic- providing individualized information concerning tissue samples were taken during routine postmortem vascular anatomy. examinations from subjects who died from a nonmalig- nant illness. Tissue samples were wet digested and Cd content was assessed using graphite furnace atomic ab- EP02C-160 sorption spectrometry. Higher concentrations of Cd were found in cancerous SURGICAL TREATMENT OF SOLITARY tissue when compared to control levels. Cadmium content MALIGNANT MELANOMA in cancerous tissue was also higher than in surrounding METASTASIS TO THE PANCREAS e non-cancerous tissue. The association between pancreatic CASE REPORT AND LITERATURE cancer risk and Cd levels in pancreatic tissue is indicated by e REVIEW the ORs and ORs were 2.79 (95% CL 0.91 8.50) and 3.44 1 1 2 (95% CL 1.19e9.95) in the third and fourth quartiles of the L. Ferreira , M. Achalandabaso , H. Alexandrino , J. Geoghegan1 and K. Conlon1 distribution of Cd concentrations in the study population, 1 2 respectively. The chances to develop cancer if not exposed St. Vincents University Hospital, Ireland, and Coimbra to Cd are between 35%-37.5% while in persons exposed to University Hospital, Portugal Cd these chances are higher 56.8%-65.6% depending on Solitary malignant melanoma (MM) metastasis to the chosen quartile cutoffs used to determine the level of Cd pancreas are rare and occur in approximately 1% of exposure. patients with metastatic MM. Historically, most patients Results of this study indicated a significant association are considered unresectable. However, resection of between PC development and Cd tissue levels. However, isolated metastasis could extend disease free survival further investigations are needed to confirm or infirm the benefit, particularly in the absence of effective systemic environmental Cd involvement in PC development. therapies.

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S581

We present a case of pancreatic resection for isolated EP02C-162 MM metastasis along with a review of the English published literature. Patients with extra-pancreatic dis- PREOPERATIVE TUMOUR SIZE ease and patients who did not undergo surgery were PREDICTS THE RISK OF RECURRENCE excluded. FOLLOWING PANCREATECTOMY FOR We report a case of a 46-year-old woman, with a right G1eG2 NEUROENDOCRINE TUMOURS: arm MM excised nine years ago, who presented with an A MULTIINSTITUTIONAL SPANISH isolated tail of the pancreas mass on routine follow-up. Laparoscopic distal pancreatectomy and splenectomy STUDY 1 1 2 was preformed and revealed a 28mm metastatic MM, with F. Ausania , P. Senra , D. Dorcaratto , 3 4 5 negative resection margins. M. A. Gomez-Bravo , T. González-Nicolás , E. Martín , 2 4 6 The patient is asymptomatic with no recurrence 10 L. Sabater , A. Serrablo and S. Sánchez-Cabus 1 2 months after the resection. No adjuvant treatment was HPB Unit, Hospital Alvaro Cunqueiro de Vigo, HPB 3 given. Unit, Hospital Clínico Universitario de Valencia, HPB 4 The literature review revealed 3 case series and 21 case Unit, Hospital Virgen del Rocío, HPB Unit, Hospital 5 reports with a total of 37 patients. The follow-up ranged Miguel Servet de Zaragoza, HPB Unit, Hospital de la 6 from 1-264 months with a 5 year survival of 37,5% Princesa, and HPB Unit, Hospital Clínic de Barcelona, reported. Spain It appears that in carefully selected patients surgery may Introduction: Pancreatic neuroendocrine tumour (PNET) offer an overall survival benefit. are rare tumours and well differentiated PNET are associ- Resection of isolated pancreatic metastases should be ated with relatively indolent physiological behavior. considered as it may provide a significant survival benefit However, G1-2 PNET correlate with a non-negligible risk for a disease with high mortality and lack of effective of recurrence and the most important risk factors can only systemic therapies. Multidisciplinary decision and treat- be detected postoperatively. The aim of this study is to ment in high volume centres is mandatory. explore which preoperative factors are associated with poorer disease-free survival (DFS). Methods: This is a retrospective multiinstitutional study. EP02C-161 Patients submitted to pancreatic resection from 6 Spanish EFFECTS OF ORAL NUTRITION centers were reviewed. Only patients with well differenti- ated tumours (G1eG2) were included. Demographic and SUPPORT ON QUALITY OF LIFE IN clinopathological variables were analysed. CACHECTIC PANCREATIC CANCER Results: Data from 126 patients were reviewed. Median PATIENTS age was 59 (25e84) years . Ninety-six patients (76.2%) had A. Coker1, D. B. Hopanci2, A. Uguz3, O. V. Unalp3, a non-functioning tumour and G2 was observed in 12 R. Uslu2 and E. Goker2 (9.5%) patients. Lymphadenectomy was performed in 78 1G Surgery HPB Unit, 2Medical Oncology, and 3Surgery, cases (61.9%). Recurrence occurred in 18 (14.3) patients. Ege University, Turkey Median DFS was 4.5 years. At univariate analysis, male gender, tumour size and vascular involvement were asso- Aim: We report here the results of a study for the ciated with shorter DFS. At multivariate analysis, preop- evaluation of the pancreatic cancer patients at a single erative tumour size was the only factor associated with surgeon’s experience in terms of QoL and cachexia and poorer DFS (p = 0.003, OR 1.2). Optimal cut- off value of survival. 20 mm was determined using ROC curve analysis. When Methods: 152 pancreatic cancer(PanCa) patients with matched with postoperative factors associated to poorer severe weight loss preoperatively and 73 patients with DFS (grade, perineural invasion and lymphnode metas- ampullary tumor patients evaluated retrospectively. The tasis), preoperative tumour size >20 mm was still statisti- study was conducted retrospectively between 2012e2016. cally significant (p = 0.04, OR 8). Criteria for inclusion were age >35 years, weight loss more Conclusion: Tumours size >20 mm on preoperative im- than 10% when surgical treatment decided, Stage III pa- aging was the only preoperative factor associated with tients with no distant metastases for pancreatic cancer, no poorer DFS in G1 and G2 pancreatic neuroendocrine tu- known psychiatric disorder Papillary tumors were included mours and therefore it should be considered an important as a control group, since they have been undergone tha information before planning surgical treatment. same operation by the same surgeon and they do not need any adjuvant treatment. Results and conclusion: QLQ-C30 improvement values were higher in cachectic pancreatic cancer patients EP02C-163 compared with the ampullary tumors. Baseline QoL was GASTRINOMAS ASSOCIATED WITH measured as median of 61 Æ 2.61 in PanCa. Overall MEN-1 SYNDROME Quality of Life was 74 Æ 3.05 after ONS (p < 0.05), in H. J. Jang and C. S. Park pancreas cancer.Fatigue symptom score was 47 Æ 3.81 Surgery, University of Ulsan College of Medicine, Gang- after operation and 31 Æ 4.69 and 24 Æ 7.85 after ONS for neung Asan Hospital, Republic of Korea 2 months and before starting adjuvant therapy respectively (p < 0,05). Anastomotic leak rate and readmission rate and Zollinger-Ellison syndrome (ZES) is a clinical syndrome survival were all better in ONS groups.ONS has a positive caused by excessive gastric acid secretion by gastrinoma, effect of pancreas cancer patients in terms of complications characteristically causing peptic disease and/or gastro- fl and survival. esophageal re ux disease. Approximately one third of

HPB 2018, 20 (S2), S505eS684 S582 Electronic Posters (EP02A-EP02F) e Pancreas patients with gastrinoma have multiple endocrine neoplasia Conclusions: In this large series of pancreatectomy pa- type 1 (MEN-1). tients, 36% and 20% developed post-operative exocrine We experienced two cases of gastrinomas associated and endocrine insufficiency, respectively. Patients should with MEN-1 syndrome. be educated regarding post-resection insufficiencies and 42 and 56-year-old man was admitted for abdominal pain providers should have heightened awareness for onset and diarrhea. The endoscopic findings revealed severe within the first four months after surgery. reflux esophagitis and multiple ulcers at the bulb and second portion of the duodenum. They were diagnosed as ZES based on typical clinical features such as markedly EP02C-165  fi elevated fasting gastrin level ( 1,000 pg/mL) and ndings CLINICAL EXPERIENCE OF NAB- from a CT scan and somatostatin receptor scan. Pathologic findings after the operation revealed malignant gastrinoma. PACLITAXEL PLUS GEMCITABINE He was confirmed to have parathyroid adenoma and MEN- TREATMENT IN RECURRENT CASES 1. We diagnosed this patient using immunohistochemical WITH PANCREATIC CANCER IN OUR studies and treated the patients by tumor resection with INSTITUTION distal pancreatectomy. The patients are alive and in a good Y. Wakasa, N. Kimura, K. Ishido, D. Kudo, H. Nagase and condition without recurrence for 10 months and 9 years. K. Hakamada MEN-1 syndrome should always be considered in pts Gastroenterological Surgery, Hirosaki University Grad- with ZES. A precise preoperative localization of all uate School of Medicine, Japan pancreaticoduodenal lesions, in combination with a surgi- fi cal exploration and management by experienced surgeons, Background: This analysis aimed to demonstrate ef cacy seems to be curative in patients. of nab-P+GEM and we analyzed the treatment outcomes of nab-P+GEM for patients with postoperative recurrent pancreatic cancer in our institution. Patients and methods: From January 2015 to December EP02C-164 2017, patients with recurrent pancreatic cancer in our LONG TERM EXOCRINE AND institution received nab-P+GEM (GEM 1000 mg/m2 + nab- ENDOCRINE FUNCTION AFTER PTX 125 mg/m2 on days 1,8,15 every 4 weeks) and treat- PANCREATECTOMY ment outcomes were evaluated. Results: A total of 7 patients received nab-P+GEM. Patient B. Anderson1, J. Kusakabe2, G. Williams1, characteristics were as follows: age (ranged between 54 to W. C. Chapman1, M. M. Doyle1, A. S. Khan1, 76 years, median 67 years), sex (4 males and 3 females), C. W. Hammill1, S. M. Strasberg1, W. G. Hawkins1 and primary location (4 cases of head, 2 cases of body and 1 R. C. Fields1 case of tail), recurrent site (3 cases of liver, 2 cases of lung, 1Washington University in St. Louis, United States, and 3 cases of local recurrence and / or lymph node), period 2Kyoto University Graduate School of Medicine, Japan from operation to recurrence (ranged between 2.5 to 13.5 Introduction: Long-term pancreatic function after months, median 8.4 months). The evaluation of the pancreatectomy is not well described, but is important for response to initial treatment were 1 case of Partial Response both pre-operative risk assessment and counseling having (PR), 5 cases of Stable Disease (SD) and 1 case of Pro- both short- and long-term health consequences. The gressive Disease (PD). The Response Rate (RR) and Dis- objective of this study was to identify risk factors for ease Control Rate (DCR) were 14.3% and 85.7%, fi pancreatic exocrine and endocrine insuf ciency after respectively. The median progression-free survival and pancreatectomy. overall survival were 5.6 months (range 2.3e8.3) and 7.3 Method: We retrospectively analyzed a single institutional months (range 6.2e10.8), respectively. The grade 3 or series of patients who underwent pancreaticoduodenec- higher adverse events were observed in 3 cases (neutro- tomy (PD) or distal pancreatectomy (DP) from 2000 - 2017. penia), and only 1 patient had to interrupt the treatment fi fi Exocrine and endocrine insuf ciency were de ned as the because of serious adverse events. need for new pharmacologic intervention. Cox proportional Conclusions: This analysis suggests that nab-P+GEM may modeling was used to identify peri-operative variables to be useful for patients with postoperative recurrent pancre- determine their impact on post-operative exocrine and atic cancer because of good tolerance. endocrine insufficiency. Results: 1,716 patient records were analyzed (75% PD, 25% DP). Average age was 63 years, 52% were male, and surgery was for malignancy in 74% of patients. Median EP02C-166 follow-up was 18 months. Post-operative exocrine insuffi- IS THERE A ROLE OF FROZEN ciency was present in 36% of patients. Race, body mass SECTION ANALYSIS OF DISTAL index (BMI), family history of diabetes, elevated pre- PANCREATIC MARGIN IN ALL FOR operative bilirubin, steatorrhea, and PD were correlated WHIPPLES PROCEDURE IN with increased risk of exocrine insufficiency. Post-opera- tive endocrine insufficiency was present in 20% of patients. MALIGNANCY? Male gender, BMI, tobacco use, family history of diabetes, S. R. V. Gunturi, V. Thumma, N. Kunduru, personal history of diabetes, and PD were correlated with J. R. Bathalapalli, G. R. Gondu, R. Kamineni, D. Sarma, increased risk of endocrine insufficiency. Median time to A. Chincholi and B. Nagari onset of exocrine and endocrine insufficiency were 69 and Surgical Gastroenterology, Nizams Institute of Medical 130 days, respectively. Sciences, India

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S583

Introduction: In Whipples Pancreaticoduodenectomy the EP02C-168 Frozen analysis of distal pancreatic margin is done routinely for main duct IPMN and head of pancreas ma- AN UNUSUAL CASE OF CHRONIC lignancies. The Frozen analysis of pancreatic margin is not PANCREATITIS done routinely in all centres when the indication of surgery R. Kilambi1,2, A. N. Singh1, S. Pal1, P. Das3 and is for lower end cholangiocarcinoma or ampullary K. S. Madhusudhan4 malignancy 1Gastrointestinal Surgery and Liver Transplantation, All Method and results: We are presenting a case report of 50 India Institute of Medical Sciences, 2Department of year lady with imaging features suggestive of dilated Hepato-Pancreato-Biliary Surgery, Institute of Liver and pancreatic duct with periampullary lesion.Intraoperatively Biliary Sciences, 3Department of Pathology, and frozen analysis of the distal pancreatic margin is positive 4Department of Radiology, All India Institute of Medical for malignancy and revision resection followed by Total Sciences, India pancreatectomy was done during the same time. Introduction: Chronic pancreatitis(CP) typically presents Conclusions: Even though the yield of pancreatic margin with pain abdomen along with endocrine and exocrine positivity is less in periampullary lesions when compared insufficiency. The inflammatory process can also involve with Pancreatic head malignancies and IPMN,it is a adjacent organs producing biliary strictures, duodenal reasonable approach to do frozen analysis of distal obstruction or venous thrombosis. Somatostatinoma is a pancreatic margin routinely in all cases to avoid any post rare neuroendocrine tumour characterized by the triad of operative surprise. diabetes, steatorrhea and gall-stones. It is interesting that the first two of its symptoms are classically associated with CP, and one may easily confuse a periampullary somatos- EP02C-167 tatinoma with a double duct sign for a case of CP with PANCREATOGASTROSTOMY AFTER biliary stricture. We present one such case where a peri- PANCREATICODUODENECTOMY IN ampullary-somatostatinoma was misdiagnosed as CP. Case: A 24-year-old male presented with history of CIRRHOTIC PATIENT WITH PORTAL obstructive jaundice 4 years back when he was diagnosed HYPERTENSION A CASE REPORT as choledocholithiasis with cholelithiasis and underwent A. E. Padilla Rosciano, A. Salazar Alvarez, endoscopic stenting. He was asymptomatic for an year G. Miranda Devora, H. N. Lopez Basave and thereafter and gradual developed epigastric pain and ste- M. G. Serna Thome atorrhea. He was evaluated with imaging which was sug- HPB Tumor Department, National Cancer Institute gestive of atrophic pancreas with dilated duct and Mexico, Mexico calcification and biliary dilation and was diagnosed as a Introduction: In pancreatic head tumors pancreaticoduo- case of CP with biliary stricture. He was referred to us for denectomy (PD) is the procedure of choice. There are few surgical management. A review of his imaging revealed a published studies that analyze patients with pancreas cancer small, arterially enhancing periampullary mass resulting in and liver disease . Patients with well-compensated chronic biliary and pancreatic ductal dilation. Side-viewing liver disease should be considered for PD at high volume endoscopy and biopsy showed a tumour with presence of centers. There is a few evidence in literature about psamomma bodies and immunohistochemistry positive for pancreaticoduodenectomy and pancreaticogastrostomy somatostatinoma. He underwent a pancreaticoduodenec- reconstruction in cirrhotic patients. tomy. His postoperative course was uneventful. Histopa- Case: We present 63 years old male patient with cirrosis thology showed a somatostatinoma arising in the and mild portal hypertension in Child-Pugh A who un- periampullary region with lymph nodal metastases. He is derwent pancreatoduodenectomy with pancreaticogas- doing well and pain-free at 24 months postoperatively. trostomy reconstruction for pancreatic head cancer, in early Conclusion: Periampullary-somatostatinoma can mimic postoperative evolution, present upper digestive tract CP and can lead to a missed diagnosis. bleeding episodes, two endoscopic interventions showed clots and the pancreaticogastrostomy without active bleeding.. A new episode of hematemesis with hypo- EP02C-169 volemic shock was the setting of reintervention at fourteen PHASE II STUDY OF day a laparotomy was realized, without evidence of CHEMORADIOTHERAPY COMBINED bleeding in abdominal cavity. The patient required 7 days at ICU to fully recover from surgery. WITH GEMCITABINE PLUS NAB- Discussion: Cirrhosis should not be considered as absolute PACLITAXEL FOR UNRESECTABLE contraindications to PD for pancreatic cancer, particularly LOCALLY ADVANCED PANCREATIC in patients with Child-Pugh A. The patient had complica- ADENOCARCINOMA (NUPAT 05 TRIAL) tion relative to cirrhosis but we think it was increased by the N. Takano1, S. Yamada1, T. Fujii2, H. Takami1, reconstruction of pancreatogastrostomy, because this sur- M. Suenaga1, M. Hayashi1, G. Nakayama1, M. Koike1, gical reconstruction modified the gastric mucosal’s pH and M. Fujiwara1 and Y. Kodera1 may be related with bleeding 1Gastroenterological Surgery, Nagoya University Grad- Conclusion: There is no contraindication to perform PD in uate School, and 2University of Toyama, Japan cirrhotic patients in Child Pugh A including patients with mild portal hypertension in specialized centers, we don’t Background: For patients with metastatic pancreatic recommend the reconstruction with pancreatogastrostomy adenocarcinoma (PDAC), gemcitabine plus nab-paclitaxel in this cases. (GnP) has shown improved survival and become one of the

HPB 2018, 20 (S2), S505eS684 S584 Electronic Posters (EP02A-EP02F) e Pancreas standard regimens worldwide. However, the efficacy of Conclusions: The risk of recurrence after resection for GnP for unresectable locally advanced (UR-LA) PDAC is Grade 2 WD-pNET is at least 4 times concerning Grade 1 still unclear, and also chemoradiotherapy for UR-LA tumors in this cohort of patients and most of them are in the PDAC is controversial. Therefore, we conducted phase I first 18 months. So, research have to look how to reduce study of chemoradiotherapy using GnP to assess the recurrence (adjuvant therapy in Grade 2?). toxicity and determined the recommended dose based on dose limited toxicity. From these results, we designed phase II trial to evaluate efficacy and toxicity of chemo- EP02C-171 ratiotherapy combined with GnP for UR-LA PDAC. PULMONARY EMBOLISM AFTER Method: Eligible requirements include chemotherapy- naïve patients diagnosed as UR-LA PDAC defined by PANCREATIC RESECTION FOR NCCN guidelines. The patients will be administrated 100 PANCREATIC CANCER 2 2 mg/m nab-paclitaxel followed 800 mg/m gemcitabine on T. Taniai day 1, 8, 15, every 4 weeks. Radiation therapy is planned to The Jikei University School of Medicine, Japan deliver as a total dose of 50.4 Gy in 28 fractions, 1.8 Gy per Introduction: The incidence of pulmonary embolism (PE) day from day 1. Treatment will be continued until disease has been increasing. Pancreatic resection for pancreatic progression or surgery if the disease is well controlled. The cancer has been reported as at high risk for PE. However, estimated enrollment is 25 patients started recruiting from the routine use of venous thromboembolism chemopro- December 2017. The primary endpoint is 2-year overall phylaxis after pancreatic resection remains controversial. survival rate. With two-sided alpha error of 0.05, this study We investigated the safety and efficacy of postoperative is estimated to have 81.7% power to detect a 30% increase chemoprophylaxis after pancreatic surgery. of the 2-year overall survival rate. Secondary endpoints are Methods: Between Jan 2008 and Aug 2017, 157 patients resection rate, OS, PFS, time to treatment failure, response underwent pancreatic resection for pancreatic cancer. The rate, disease control rate, early tumor shrinkage, deepness clinical diagnosis of PE was established by enhanced CT. of response, SUV-max on PET-CT, serum tumor markers, The CT was performed when patients developed dyspnea, relative dose intensity, safety, and QoL. Clinical trials in- hypoxemia, or the blood D-dimer levels over 20 ng/ml. formation: UMIN 000028116 Since Jan 2013, low-molecular-weight heparin (LMWH) subcutaneous injection was started 24 h after the surgery and continued for 7 to 14 days. Patients with bleeding risk, EP02C-170 impaired renal function, and aged over 80 years were THE RISK OF RECURRENCE IN GRADE excluded from LMWH. 2 PANCREATIC NEUROENDOCRINE Results: The overall incidence of PE was 1.9% (n = 3); TUMORS 2.5% (n = 2) from 2008 to 2012 and 1.3% (n = 1) from 2013 to 2017. LMWH was used in 62% of patients from 1 2 1 2 O. Guevara , H. Facundo , R. Pinilla and R. Oliveros 2013 to 2017. No patient developed PE with LMWH. All 1 Surgery, Universidad Nacional de Colombia -Instituto the patients with PE were asymptomatic but with high 2 Nacional de Cancerologia, Colombia, and Gastrointes- blood levels of D-dimer. All three patients with PE were tinal Surgery, Instituto Nacional de Cancerologia, successfully treated with anticoagulant therapy and fully Colombia recovered. One patient on LMWH developed post- Introduction: Although Well Differentiated Pancreatic operative intraabdominal bleeding that required Neuroendocrine Tumors (WD-pNET) are considered as reoperation. good prognosis tumors, some patients will die after recur- Conclusion: The use of LMWH seems to be effective for rence in resected cases. We studied the risk of recurrence PE prophylaxis after pancreatic resection for pancreatic after resection in patients with WD-pNET regarding the cancer. However, the use of LMWH after surgery could Grade (WHO 2010 classification). increase the risk of bleeding. Method: A cohort study in patients undergoing to complete resection of WD-pNET between 2010-2016. Most of pa- tients were discussed in a Multidisciplinary Neuroendo- EP02C-172 crine Tumors Board. Perioperative variables are registered CLINICAL FEATURES OF REMNANT as well as the follow up. We compare the risk of recurrence in tumors Grade 1 and 2. PANCREATIC CANCER FOLLOWING Results: Thirty four patients were included. Median age CURATIVE PANCREAS RESECTION was 46 years (IQR 38-62), 58.8% were women and 38.2% T. Hirano1, K. Maemura1, Y. Mataki1, H. Kurahara1, had functional tumors. The resection was pancreaticoduo- M. Sakoda1, S. Iino1, Y. Kawasaki1, M. Hashiguchi1, denectomy in 41.2%, distal pancreatectomy in 32.4%, H. Shinchi2 and S. Natsugoe1 enucleation in 17.6% and central pancreatectomy in 8.8%. 1Digestive, Breast and Thyroid Surgery, Kagoshima Uni- Mortality at postoperative day 90th was 0. Concerning versity, Graduate School of Medical and Dental Sciences, pathological analysis, 64.7% were Grade 1, median Ki 67 and 2Kagosima University, Faculty of Medicine School of was 2%, with 1 mitosis in 10 HPF, and 29.4% of patients Health Sciences, Japan had positives lymph nodes. The median follow up was 33.4 Purpose: To clarify the clinical features of recurrent cancer monts (IQR 19-54) and 32.4% had recurrence in a median in the remnant pancreas. fi time of 16.9 months with 62% in the rst 18 months. The Method: Seven patients who developed remnant pancre- RR for recurrence in G2 vs G1 was 4.88 (CI95% (1.58-15- atic cancer in our hospital between 2001 and 2017 were 06), p = 0.0016. retrospectively reviewed the clinical findings.

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S585

Result: Two cases were IPMC( intraductal papillary Conclusion: CT-guided percutaneous IRE is minimally mucinous carcinoma ) and six cases were PDAC( invasive and effective for patients with LAPC, especially pancreas ductal adenocarcinoma) and the median interval those who cannot tolerate standard chemotherapy. time between first operation and diagnosis of remnant pancreas cancer was 37( range: 11-84 ) months. The patients who had metachronous recurrence were 5 and EP02C-174 recurrence of resection stump were 2, respectively. CLINICAL APPLICATION OF ROBOT Radical resection were performed all of two IPMC pa- tients but only one PDAC patient. The resectability ASSISTED NANOKNIFE ABLATION FOR status of PDAC patients were R( resectable ) 1, BR( THE TREATMENT OF PANCREATIC borderline resectable ) 3, UR ( unresectable ) 1, HEAD CARCINOMA respectively. Multimordal therapy were performed four X. He, Y. Xiao, X. Zhang and Y. Wei unresected PDAC patients and the median survival time The General Hospital of People’s Liberation Army (301 was 18 months (range: 13-23). Hospital), China Conclusion: PDAC of remnant pancreas were diagnosed Introduction: To evaluate the feasibility and safety of advanced stage regardless of regular follow up and moni- robot (MAXIO) auxiliary CT guided by nanoknife ablation toring after initial pancreatectomy. To determine adequate for the treatment of pancreatic head carcinoma. surveillance and therapeutic strategies, further more Methods: There are 18 cases with pancreatic head carci- investigation is needed. noma wrapped around the portal vein, celiac axis and so on,which the puncture of nanoknife is difficult in case of EP02C-173 bleeding.There are two groups, 9 cases (group A) with traditional method, 9 cases (group B) with navigation CT-GUIDED PERCUTANEOUS (MAXIO).Two groups of puncture check number, piercing IRREVERSIBLE ELECTROPORATION operation time, puncture accuracy and nanoknife the probe FOR PATIENTS WITH LOCALLY parallel to the degree of satisfaction are compared. ADVANCED PANCREATIC CANCER Results: Group A the number of IRE puncture is 4－5,the WHO ARE UNABLE TO TOLERATE times of puncture verification is 4-8 times, the time of － PERIODIC STANDARD piercing operation is 25 35 minutes, the puncture devia- tion is 2－6 mm respectively. Group B the number of IRE CHEMOTHERAPY puncture is 4-6,the times of puncture verification is 3e4 Y. Wei times, the time of piercing operation is 18e28 minutes, the Chinese PLA General Hospital, China puncture deviation is 1－3 mm respectively.The traditional Introduction: To investigate the safety and efficacy of CT- pucture method is step-by-step for one probe by one probe. guided percutaneous irreversible electroporation (IRE) in However,all probes are punctured at the same time by the ablation of locally advanced pancreatic cancer (LAPC) MAXIO,and then take CT scan to verify for fine tuning. tumors，predominantly for patients have not underwent Conclusion: The MAXIO can achieve the goals:shorten standard chemotherapy before IRE or as adjuvant the puncture operation time, reduce the time of anes- treatment. thesia,decrease the times of puncture verification and Method: An institutional review board approved study improve the precision of puncture, which reduces risk of registered at clinicaltrials.gov (identification number the damage the surrounding normal pancreas and vascular NCT02567734) was held from October 2015 to risk and incidence of complications. It is a safe, rapid and January2017, and included a total of 17 patients with 17 effective method that MAXIO auxiliary CT guided nano- lesions in our hospital. All patients received CT-guided knife ablation for the treatment of pancreatic head percutaneous IRE. Both pre- and post-treatment bloodwork carcinoma. as well imaging examinations were performed，and compared regularly to evaluate the safety and efficacy of IRE as well as to examine the potential benefits of CT- EP02C-175 guided percutaneous IRE (notably for patients who cannot PANCREATIC NEUROENDOCRINE tolerate standard chemotherapy). TUMOR, AS THE ONLY VOMIT Result: The postoperative 90-day dynamic imaging showed that 6 of 15 (40%) patients accomplished complete SYMPTOM, PRESENTATION OF A CASE response (CR),7 of 15 (47%) reached partial response (PR) V. Carrillo-Maciel1,2, A. L. Acosta-Saludado3, and 2 of 15 (13%) had stable disease (SD). 1-year survival V. A. Carrillo-Acosta4, F. G. Estrada Alonso5, J. Garza6, rate after percutaneous IRE in this small cohort was 47.1%. Y. Jaramillo Rodriguez7 and F. J. Rosales Hernandez8 The median survival of patients without regular standard 1Cirugia, Universidad Autonoma de Coahuila, 2Cirugia, chemotherapy was 322 days (10.6 months), inferior to IRE Instituto de Ciencia, 3Medical Family, IMSS 80, 4Medical combined chemotherapy but longer than chemotherapy Sudent, Universidad Autonoma de Coahuila, 5Cirugia, alone（6.6 months for gemcitabine. Complications IMSS, Clinica 18, 6Cirugia, Hospital Angeles, 7IMSS, and included slight nausea and vomiting (n = 4), peripancreatic 8Oncology, IMSS, Mexico exudation (n = 3), retroperitoneal infection (n = 1), Introduction: Pancreatic neuroendocrine neoplasms are mesenteric (2 of 4）and portal（2of4）venous throm- second most common neoplasm. Incidence are fewer than 1 bosis, and duodenum stenosis (n = 1). 2 people died from per 100 000 individuals per year. 2017 World Health serious gastrointestinal bleeding 3.0 months after IRE Organisation (WHO) classification: As well-differentiated (unclear etiopathogenesis). pancreatic neuroendocrine tumours (PanNETs), poorly

HPB 2018, 20 (S2), S505eS684 S586 Electronic Posters (EP02A-EP02F) e Pancreas differentiated pancreatic neuroendocrine carcinomas was 84 (13e110) M, which was significantly better than (PanNECs) and mixed neuroendocrine-non-neuroendo- that of R pancreatic cancer 38 M (p = 0.01). crine neoplasms (MiNENs) of the pancreas. PanNETs are Conclusion: Even in unresectable pancreatic cancer with much more common than PanNECs and present typically in distant metastasis, it is important to perform multidisci- adults between the fifth and sixth decades and may be plinary treatment considering conversion surgery. asyntomatic or syntomatic due to inappropriate hormone secretion. Methods: We reported one patient with well-differentiated EP02C-177 pancreatic neuroendocrine tumour, female, 54 year old she LAPAROSCOPIC DISTAL had only vomiting, was examined physically and nothing was found, ultrasound and Computerized axial tomography PANCREATECTOMY USING was performed and a tumor was found in the pancreas, was INTRAOPERATIVE NAVIGATION obstructs the Wirsung duct and did not obstruct the bile SYSTEM duct, the laboratory tests were normal and tumor markers in M. Yasunaga, S. Kojima, K. Mikagi, R. Kawahara, normal range, two weeks after pancreatoduodenectomy H. Sakai, H. Ishikawa, T. Hisaka, Y. Akagi, K. Okuda and was performed. Hepato-Biliary-Pancreatic Surgery Group Results: Pancreatoduodenectomy was performed with Department of Surgery, Kurume University School of Mizumoto type reconstruction (Double omega of Braun) Medicine, Japan without transoperative or postoperative complications, Background and aim: Three dimensional (3D) visuali- evolves favorably and is discharged six days after surgery zation has a critical impact on surgical decision making and tolerating the oral route, currently one month old, operated 3D digital models of patient physical phantoms can be and is asymptomatic and with his normal life. made commercially. We have experienced not a few cases Conclusion: to be difficult to understand and identify vascular anatomy 1.- It is important to carry out complementary studies to by the lack of three dimensional perception in the 2D- patients even when they present insidious symptoms to image. Our institute introduced laparoscopic distal discover these pathologies. pancreatectomy (Lap DP) using 3D virtual reality(VR) 2.- The success in the postoperative evolution is that they image and 3D printer model for intraoperative navigation are treated by surgeons who are experts in liver, pancreas system. and biliary tract surgery. Methods: From November 2008 to December 2017, a total of 24 patients underwent Lap DP for benign/ low grade malignant pancreatic tumor. CT images containing EP02C-176 pancreatic lesions were segmented into pancreas tissue, EXAMINATION OF CONVERSION contrast-enhanced vessels, and pancreatic tumor using SURGERY FOR UNRESECTABLE Synapse Vincent (Fuji Film, Japan). PANCREATIC CANCER Results: 24 patients underwent LAP-DP. In the Lap-DP, 1 1 1 1 the median blood loss was 240cc, the median operating T. Tanaka , Y. Mataki , K. Maemura , H. Kurahara , times was 365 min. The postoperative hospital stay after Y. Kawasaki1, K. Tanoue1, M. Sakoda1, S. Iino1, 2 1 Lap-DP was 15.4days. In morbidity for Lap-DP, pancreatic H. Shinchi and S. Natsugoe fistula, rebleeding, were one case(ISGPF-Grade B), one 1Department of Digestive, Breast and Thyroid Surgery, 2 case(reoperation). and Department of Health Science, Kagoshima Univer- Conclusion: It became possible to create an inexpensive sity, Japan 3D model of the pancreas for surgical navigation system. There are some reports conversion surgery contributes to The 3D visualization is useful for optimizing the operation the prognosis of pancreatic cancer. 335 cases with advanced scheme preoperatively and navigation surgery accurately pancreatic cancer were enrolled in this study. According to intraoperatively in real time. resectability, R cancer was in 92, BR in 39, UR-L in 98, UR-M in 106, respectively. Conversion Surgery was performed in 20 cases among 202 UR(10%). Unresectable EP02D e Electronic Poster: 2D e Pancreas factor in the initial diagnosis was local advance in 9, hepatic Surgical Outcomes metastasis in 5, LN16 metastasis in 3, peritoneal metastasis in 3. Median period between initial therapy and conversion EP02D-001 surgery was 15.5M. Therapy included various chemo- PREOPERATIVE NEUTROPHIL-TO- therapy, and CRT was performed in 9 locally advanced and LYMPHOCYTE RATIO AS A in 5 even for metastatic cases. The operation time is 573 PROGNOSTICATOR IN EARLY STAGE e (352 919) minutes in median, the bleeding volume is 1273 PANCREATIC DUCTAL (90e3600) ml, the length of hospital stay is 18 (8e50) days. There was no mortality. Down stage was pathologically ADENOCARCINOMA obtained in all cases. Postoperative adjuvant therapy was T. Abe, H. Amano, T. Bekki, H. Takechi, T. Mochizuki, performed in 6 out of 20 patients. The median period of T. Yano, H. Okuda, N. Fujikuni, M. Nakahara and relapse free survival after surgery was 52 (3.7e97) M, T. Noriyuki Recurrence occurred in half of them, but recurrence type Surgery, Onomichi General Hospital, Japan was varied. Compared with relapse-free survival of UR-L Background: The neutrophil-to-lymphocyte ratio (NLR), and UR-M, no significant difference was observed (p = which reflects the cancer-induced systemic inflammation 0.31). The median survival time of conversion surgery cases response, has been proposed as a risk factor for poor long-

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S587 term prognosis in cancer. We investigated the prognostic (25% vs 50%; p=0.003) and less PPH (12% vs 30%; role of the NLR and the relationship between the NLR and p=0.012). Selective drainage policy was associated with TNM stage in pancreatic ductal adenocarcinoma (PDAC) shorter length of stay (19.6 Æ 11.6 vs 28.4 Æ 16.9 days; patients following curative resection. p < 0.001) and lower reintervention rate (23% vs 53%; Methods: One-hundred thirty-eight consecutive patients p < 0.001). Logistic regression analysis showed that with resected PDAC were enrolled between 2004 and 2013. pancreas texture was the only independent risk factor of Univariate and multivariate analyses identified variables postoperative pancreatic fistula (POPF) (OR=3.69; p=0.019). associated with overall survival (OS) and recurrence-free Conclusion: After PD, selective policy drainage in patients survival (RFS). Patients were stratified according to the at high risk of POPF (soft/medium pancreas and MPD size NLR, with an NLR cut-off value of 2.2 being estimated by 3 mm) appears to be a safe drainage policy. receiver operating characteristic curve. Results: Compared to patients with a low NLR ( 2.2), those with a high preoperative NLR (> 2.2) had worse OS EP02D-003 and RFS (P = 0.017, P = 0.029, respectively). For early- LEARNING CURVE FOR ROBOTIC stage tumors, tumor size  20 mm and a high NLR were independent risk factors for poor OS (hazard ratio (HR): PANCREATICODUODENECTOMY 3.255, 95% confidence interval (CI): 1.082-9.789, P = WITH MODIFIED BLUMGART 0.036; HR: 3.690, 95% CI: 1.026-13.272, P = 0.046, RECONSTRUCTION respectively) and RFS (HR: 3.575, 95% CI: 1.174-10.892, Y. -M. Shyr and S. -E. Wang P = 0.025; HR: 5.380, 95% CI: 1.587-18.234, P = 0.007, Taipei Veterans General Hospital, Taiwan, Republic of respectively). The NLR was not correlated with prognosis China in patients with advanced stages. Objective: Pancreaticoduodenectomy has been a techni- Conclusions: An elevated preoperative NLR was an cally demanding and challenging procedure carrying a high important prognosticator for early TNM stage PDAC. The morbidity.This study was to identify the learning curve of NLR, which is calculated using inexpensive and readily console time (CT) for robotic pancreatectomy (RPD). available biomarkers, could be a novel tool for predicting Perioperative outcomes were compared between early long-term survival in patients, especially those with early group before the learning curve and late group after the stage PDAC. learning curve. Methods: Data for RPD were prospectively collected for analysis. The learning curve was assessed by cumulative EP02D-002 sum (CUSUM). Based on CUSUM analyses, patients were PLACE OF A SELECTIVE INTRA- was divided into early group before learning curve and late ABDOMINAL DRAINAGE AFTER group after learning curve. PANCREATICODUODENECTOMY: Results: There were 70 RDP and 100 RPD cases. It took 37 RETROSPECTIVE STUDY FOR 134 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was also significantly PATIENTS shorter in the late group for both RDP (112 min. vs. J. Périnel1, G. Nappo1, C. Payet2, M. -C. Le Goff3, 225 min., P < 0.001) and RPD (360 min. vs. 520 min., Y. Bouffard3, V. Kepenekian1, M. El bechwaty1 and P < 0.001). The median blood loss was significantly less in M. Adham1 the late group for both RDP (30 c.c. vs. 100 c.c., P = 0.003) 1Digestive Surgery, Edouard Herriot Hospital, France, and RPD (100 c.c. vs. 200 c.c., P < 0.001). No surgical 2Pôle Information Médicale Evaluation Recherche des mortality in both groups. Clinical relevant pancreatic fistula Hospices Civils de Lyon, and 3Anesthesia, Edouard was 22.9% for RDP (32.4% in early group vs. 12.1% in late Herriot Hospital group, P = 0.043), and 11.5% for RPD (0 in early group vs. Background: The question of intra-abdominal drainage 17.1% in late group, P = 0.084). after pancreaticoduodenectomy (PD) remains challenging Conclusions: Robotic surgery is feasible both RDP and and unsolved. RPD. Moreover, earlier experience in RDP might shorten Objectives: The aim of the study was to evaluate the effect the learning curve for RPD. of a selective drainage policy, based on the pancreas texture and the main pancreatic duct size, on the postoperative morbidity after PD. EP02D-004 Methods: A no drain policy from January 2012 to PREOPERATIVE RATIO OF VISCERAL September 2014 was compared to a selective drainage ADIPOSE TISSUE AREA TO SKELETAL policy from October 2014 to May 2017 in patients under- MASS INDEX AS A RISK FACTOR FOR going PD. Drains were placed in case of soft/medium PANCREATIC FISTULA FOLLOWING pancreas and/or in case of MPD size 3 mm. The primary endpoint was the postoperative morbidity graded according PANCREATECTOMY to Clavien-Dindo classification. T. Abe, H. Amano, T. Bekki, H. Takechi, T. Mochizuki, Results: 134 patients were included: 74 in the no-drain group T. Yano, H. Okuda, N. Fujikuni, M. Nakahara and and 60 in the selective drain group. Postoperative morbidity T. Noriyuki was 82% in the no-drain group versus 75 % in the selective Surgery, Onomichi General Hospital, Japan drain group (p=0.293). After selective drainage, uneventful Background: Postoperative pancreatic fistula (POPF) is a postoperative course was more frequent (11% versus 25%; life-threatening postoperative complication. Our study p=0.03), patients developed less complications grade III-IV investigated whether preoperative visceral fat tissue and

HPB 2018, 20 (S2), S505eS684 S588 Electronic Posters (EP02A-EP02F) e Pancreas skeletal mass distribution would impact POPF develop- There was one death 30-d mortality. More than half ment after pancreatectomy. (51.5%) of the patients received adjuvant chemotherapy. Study design: A total of 225 consecutive patients who Overall survival for pancreatic head and periampullary underwent distal pancreatectomy and pancreaticoduode- tumor was 26 and 32.7 months, respectively. A total of nectomy (PD) were enrolled. Univariate and multivariate 32.3% of patients had recurrent disease. Estimated 3-year analyses were performed to investigate variables associated survival for Pancreatic head and periampullary tumor was with POPF (grade B and C) according to the criteria of the 40% and 85%, respectively. International Study Group on Pancreatic Fistula. To over- Conclusion: Pancreaticoduodenectomy is a safe procedure come bias due to different distributions of covariates, a one- with excellent postoperative outcome and survival, if car- to-one match was created using propensity score analysis. ried out in a specialized hepato-pancreato-biliary unit with The preoperative visceral adipose tissue area (VATA), multidisciplinary team management. PG reconstruction can skeletal mass index (SMI), and subcutaneous adipose tissue be a safer alternative to PJ especially in patients with soft area (SATA) were calculated using computed tomography pancreas and non-dilated duct. (CT). Results: The median age of subjects was 69 years. Overall 30-day mortality and morbidity rates were 0.4% and 25%, EP02D-006 respectively. The incidence of POPF grade B and C was PANCREATICOGASTROSTOMY e AN 18.7% and 2.4%, respectively. Univariate analysis identi- fied that male sex, smoking habit, alcohol habit, sarcopenia, ALTERNATE FOR DEALING WITH VATA/SATA ratio 0.9, VATA/SMI 1.8, bleeding PANCREATIC REMNANT AFTER volume 450 mL, proportion of PD, CRP on postoperative PANCREATICODUODENECTOMY e day (POD)1 8.0 mg/dL, and drain amylase (Amy) con- EXPERIENCE FROM A TERTIARY  fi centration on POD1 1500 U/L were signi cantly asso- CARE CENTER OF PAKISTAN ciated with POPF. Multivariate analysis indicated that 1 2 2   H. Bari , T. Chawla and S. Effendi VATA/SMI 1.8 and drain Amy 1500 U/L on POD1 1 2 were independent risk factors for POPF. After propensity Surgery, Shaukat Khanum Cancer Hospital, and Sur- matching analysis, POPF was significantly more prevalent gery, Aga Khan Univeristy Hospital, Pakistan in patients with VATA/SMI 1.8. Introduction: Whipple’s pancreaticoduodenectomy has Conclusion: Preoperative evaluation of body composi- been refined over the years to be a safe operation though the tional factors using CT was useful for predicting POPF morbidity rate still remains high (30e50%). Pancreatic development. Clinicians should pay particular attention to fistula is the most important cause of mortality following patients with a VATA/SMI 1.8. pancreaticoduodenectomy. To prevent it, surgeons have used two anastomotic techniques: pancreaticojejunostomy and pancreaticogastrostomy. Recent studies found that EP02D-005 pancreaticogastrostomy is associated with fewer overall complications than pancreaticojejunostomy. This is a MANAGING PANCREATIC CANCER; retrospective review of patients who underwent Whipple’s EXPERIENCE FROM AN HBP UNIT OF at Aga Khan University Hospital and had pancreaticogas- ONCOLOGY CENTER OF PAKISTAN trostomy as a preferred anastomosis for pancreatic stump. H. Bari and F. Hanif Methods: It is a case series collected at the Department of Surgery, Shaukat Khanum Cancer Hospital, Pakistan Surgery of Aga Khan University Hospital, Karachi from 2008 till 2016. This case series includes all adult patients Objective: To report the results in the surgical treatment of who were diagnosed to have peri-ampullary mass on pre- pancreatic head and periampullary neoplasms with operative imaging and underwent Pancreaticoduodenec- emphasis on surgical technique, short-term postoperative tomy (Whipple procedure) with pancreaticogastrostomy as outcome and the lessons learnt. preferred anastomoses, instead of pancreatico-jejunostomy, Methodology: Patients with resectable pancreatic head and to maintain pancreaticoenteric continuity. Beside baseline periampullary neoplasms were selected. This is a 3 year demographics postoperative 30-day mortality and study, carried out at Shaukat Khanum Memorial Cancer morbidity were also recorded. Hospital, Lahore, from 2014 to 2017. Patients’ character- Results: Forty four patients met the inclusion criteria, 27 istics, surgical technique, and 30-day morbidity and mor- were male. Our mean age was 55.5 Æ 11.5 years. Ampul- tality were recorded. ISGPF classification was used to lary Adenocarcinoma (36.4%) was the most common pa- define postoperative pancreatic fistula and Clavien-Dindo thology followed by Carcinoma head of Pancreas (25%). classification to grade complications. Survival curves were No patient developed post-operative pancreatic fistula, 13 estimated by K-M Analysis. (31%) patients had postoperative-morbidities including Results: A total number of 99 patients underwent delayed gastric emptying 4 (9.1%), wound infection 3 dissection, 58% were males and mean age was (6.8%), and haemorrhage 6 (13.6%). Mortality is reported 51.4 Æ 14.2 years. Most common tumor was periampul- to be five (11.4%). lary (50.5%) followed by pancreatic head (32.3%); mean Conclusion: Pancreaticogastrostomy seems to be a safe operating time was 470 Æ 358.28 minutes. Pancreatico- and easier anastomosis to perform with less postoperative gastrostomy (PG) was the preferred reconstruction tech- morbidity and leak rates. However more data is required to nique (88.8%). There were 14 Grade-A, 3 Grade-B and 2 validate these results. Our mortality rate is comparable to Grade-C pancreatic fistulas. Gastrointestinal-hemorrhage regional low-volume centers. was observed in five patients from pancreatic stump.

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S589

EP02D-007 Methods: This retrospective study involved nine high- volume Chinese institutions, in which, 5115 patients un- THE ROBOTIC-ASSISTED derwent PD between January 1, 2012 and December 31, PANCREATICODUODENECTOMY 2016. Of them, 53 (1.04%) underwent re-laparotomy for WITH VASCULAR RECONSTRUCTION: grade-C POPF. We retrospectively reviewed their clinical OUR PERSONAL EXPERIENCE data. We compared the re-laparotomy techniques used in terms of their outcomes and evaluated risk factors for un- M. V. Marino1, A. L. Komorowski2 and G. Shabat3 favorable outcomes by using multivariate regression 1Emergency and General Surgery, Azienda Ospedaliera analysis. Villa Sofia-Cervello, Italy, 2Department of Surgical Results: The following surgical strategies for re-laparotomy Oncology, Maria Skłodowska-Curie Memorial Institute of were used in this cohort: external wirsungostomy (20 pa- Oncology Cancer Centre, Poland, and 3Brigham and tients, 37.7%), re-pancreaticojejunostomy (15 patients, Woman’s Hospital (BWH) Harvard Medical School, 28.3%), simple peritoneal drainage (15 patients, 28.3%), United States completion pancreatectomy (2 patients, 3.77%), and Introduction: Firstly described in 2003, the widespread of pancreatogastrostomy (1 patient, 1.89%). Postoperative robotic pancreaticoduodenectomy (PD) is still slow. The hospital stay in the external wirsungostomy group was complexity of the procedure, the higher cost of this tech- significantly shorter than that in the simple peritoneal fi fi nology and the lack of a speci c training con ned this drainage group (20 days vs. 38 days, P = 0.03), and tended procedure to high-selected centres. We investigated the to be lower than that in the re-pancreaticojejunostomy group fi perioperative outcomes of our rst 50 robotic PD including (20 days vs. 34.5 days, P = 0.068). Mortality and morbidity our initial experience with resection and reconstruction of were comparable among the above three groups. Multivar- superior mesenteric/portal vein (PD-SMV/PV) in order to iate regression analysis showed that the presence of evaluate the safety and feasibility of this approach. biochemical leakage or grade-B POPF prior to the devel- Methods: We performed a retrospective analysis from opment of grade-C POPF (odds ratio: 0.20, 95% confidence January 2012 to April 2017 of our prospectively maintained interval: 0.05e0.82) was independently associated with database on robotic pancreatic surgery. unfavorable outcomes. Results: A total of 50 patients during the time period Conclusion: Pancreas-preserving approaches were evaluated underwent to robotic PD. We performed 45 ro- preferred for grade-C POPF. External wirsungostomy was botic PD and 5 robotic PD-SMV/PV. The overall operative associated with shorter postoperative hospital stay. Patients e time was 425 min (290 550), with a reduction over the with less severe POPF before progressing to grade-C POPF course of learning curve, while the median blood loss was may have better outcomes after re-laparotomy. 170 ml (30e700). We observed a low conversion rate 5/50 (10%) and an acceptable overall postoperative morbidity rate of 12/50 (24%). The pancreatic fistula rate was 8/50 (16 %), but only 3 (6%) clinically significant. We achieved a EP02D-009 R0 resection rate in 46/50 (92%) of patients with a mean PANCREAS-PRESERVING lymph nodes retrieved of 20.5 (17e25). The reoperation MANAGEMENT OF GRADE-C rate for all series was low 6/50 (12%) as well as the 90-day PANCREATIC FISTULAS AFTER mortality rate 3/50 (6%). PANCREATICODUODENECTOMY: A Conclusions: Despite our initial learning curve, the robotic ’ approach seems to be safe and effective giving some po- SINGLE CENTER S EXPERIENCE tential advantages in terms of estimated blood loss and T. Ma, X. Bai, W. Chen, G. Li, M. Lao and T. Liang conversion rate, preserving a good oncologic adequacy. The Second Affiliated Hospital, Zhejiang University School of Medicine, China Background: Optimal surgical strategy for grade-C EP02D-008 postoperative pancreatic fistula (POPF) after pancreati- fi WHAT IS THE OPTIMAL SURGICAL coduodenectomy (PD) is not justi ed. External wirsun- gostomy is feasible. However, the subsequent repeat STRATEGY FOR GRADE-C pancreaticojejunostomy (PJ) is challenging. This study PANCREATIC FISTULA AFTER aims to introduce our experience of external wirsun- PANCREATICODUODENECTOMY? A gostomy for grade-C POPF and a novel technique to do LARGE RETROSPECTIVE the repeat PJ (re-PJ). MULTICENTER STUDY Methods: From January 1, 2012 to December 31, 2016, all 1 1 1 2 3 4 consecutive patients who underwent pancreaticoduode- T. Ma , X. Bai , W. Chen , G. Jin ,D.Fu, R. Qin , nectomy (PD) with PJ were identified. The clinical data W. Lou3, K. Jiang5, C. Shao2 and T. Liang6 1 2 were retrospectively collected and analyzed. Zhejiang University, Second Military Medical Univer- Results: Out of 325 patients, 11 patients (3.38%) un- sity, 3Fudan University, 4Huazhong University of Science 5 6 derwent salvage re-laparotomy for grade-C POPF. and Technology, Nanjing Medical University, and The External wirsungostomy was performed in 10 patients fi Second Af liated Hospital, Zhejiang University School of (3.08%). Four patients died of severe complications Medicine, China within 90 days postoperatively or tumor progression Background: The optimal surgical strategy for grade-C before the scheduled re-PJ was performed. Three pa- POPF is controversial. We aim to identify the optimal tients got their external pancreatic drainage tube pulled surgical strategy for grade-C postoperative pancreatic fis- out accidentally without causing severe consequences. tula (POPF) following pancreaticoduodenectomy (PD). Three patients underwent planned re-PJ after external

HPB 2018, 20 (S2), S505eS684 S590 Electronic Posters (EP02A-EP02F) e Pancreas wirsungostomy, including one with duct-to-mucosa PJ EP02D-011 and two with the novel bridging technique. The opera- tive time of the two patients undergoing the novel PANCREATIC RESECTIONS FOR bridging technique is 120 min, 135 min, respectively, PRESUMED MALIGNANCY: and the length of post-operative hospital stay (LPHS) is AVOIDABLE PITFALLS? 7 d, 5 d, respectively. The operative time and the LPHS A. Giardino1, V. Allegrini2, R. Girelli1, I. Frigerio1, of whom underwent duct-to-mucosa PJ is 315 min, 24 d, P. Regi1, F. Scopelliti1, S. Gobbo3, P. Tinazzi Martini4 and respectively. There was no major post-operative G. Butturini1 complication. 1Hepato-Pancreato-Biliary Surgery Unit, Pederzoli Hos- Conclusions: External wirsungostomy is an easy and safe pital, 2University of Verona, 3Pathology, and 4Radiology, way to preserve the pancreas remnant in grade-C POPF Pederzoli Hospital, Italy patients. The novel bridging technique may be a simpler Context: Despite the progress of Imaging unexpected alternative to traditional PJ with a comparable prognosis. benign diseases occur in 5-10% of Pancreaticoduodenec- tomies (PD) for presumed malignancy, most of them in the periampullary area. Accessory spleen is detected in almost EP02D-010 2% of Distal Pancreatectomies (DP) for presumed NET. MAJOR PANCREAS RESECTION FOR We analyzed the rate of benign pathology in resections for ADENOCARCINOMA IN THE ELDERLY presumed malignancy or pNETs and discussed pitfalls in PATIENTS: DOES AGE IMPACT THE the diagnostic workup. Methods: All patients resected for presumed malignancy OUTCOME? from January 2009 to February 2017 are included. Clinical 1 2 3 2 A. Hamidian Jahromi , G. Zibari , Q. Chu , G. Wellman , presentation, imaging, pathology and outcome are reported. 4 2 R. Shi and H. Shokouh-Amiri Results: We enrolled 865 patients, 14 (1,6%) of them for 1 Surgery, LSU Health Shreveport; John C McDonald unforeseen benign disease: 8 PD, 5 DP, 1 middle pancre- 2 Transplant Center, Surgery, John C. McDonald Regional atectomy. Complications occurred in 13 pts (93%). POPF Transplant Center, Willis Knighton Health System, Shre- rate was 28% (n=4). Mortality rate was 14% (n = 2). 3 4 veport, LA, Surgery, and Medicine, LSU Health Shre- Symptoms were jaundice (n = 5), abdominal pain (n = 6), veport, United States weight loss (n = 2) and acute pancreatitis (n = 1). Long Safety/survival benefit of curative resection (CR) of lasting symptoms were reported in 4 pts. Five were borderline resectable pancreatic adenocarcinoma (PA) in asymptomatic. Ca 19.9 was abnormal in 4 pts (28%). the elderly patients (70 years) compared to a younger Preoperative biopsy was performed in 10 pts (71,4%): 1 group of patients were assessed. malignancy, 9 benign. Imaging showed biliary stricture in 7 This IRB approved retrospective cohort study included pts (87%), 5 of them with associated Wirsung dilatation. patients with pancreatic surgery (N = 274) between Gallium 68 PET/CT scan was positive in 2 of 4 pts with 1998e2012. Patient’s outcome/survival were compared suspected pNET of the tail. between 70 patients (age < 70) who underwent major Conclusions: Periampullary area is challenging to inves- pancreatic resection for PA (group-I) with their elderly tigate. Accurate imaging is mandatory especially in case of counterparts (age70) (group-II) (N = 27). De- long lasting symptoms or no evidence of masses. Pathology mographics, tumor markers, operative and follow-up could obfuscate the diagnosis but must be taken under were reviewed. consideration in case of uncommon clinic presentation. Operations: Standard Whipple (N = 53), pylorus- Short follow-up could represent an alternative to up-front sparing-Whipple (N=41), total pancreatectomy (N = 3). resections in all unclear findings. The 5-yr-(overall survival)OS for the entire group was 19%. The 5-year-OS for N0 and N(+) was 24.7% and 16.5% (p = 0.128), respectively, and for R0 and R1 the 5- EP02D-012 year-OS was 23.3% and 11.1% (p = 0.037). The median- TUMOR BIOLOGY AND SURGICAL OS for Groups 1, 2 were 17 months, and 12 months, respectively (p = 0.042). The risk of intra-operative and ASPECTS OF R1 RESECTION IN post-operative complications were not different between PANCREATIC CANCER SURGERY the groups. Tumor characteristics including the tumor size, W. Tummers1, J. Groen1, B. Sibinga Mulder1, margin, and LN, vascular and peri-pancreatic soft tissue A. Farina-Sarasqueta2, H. Morreau2, H. Putter3, (PST) involvement, tumor stage and grades, tumor marker A. Vahrmeijer1, B. Bonsing1, J. S. Mieog1 and levels were not different between the groups (P > 0.05). R. -J. Swijnenburg1 Cox regression analysis demonstrated that while grade 1Surgical Oncology, 2Pathology, and 3Medical Statistics, (HR = 2.7), PST involvement (HR = 2.3), margin status Leiden University Medical Center, The Netherlands (HR = 1.9) were independent predictor of mortality Background: The prognosis of patients with pancreatic < (P 0.05), age was not an independent predictor of ducal adenocarcinoma (PDAC) remains poor, and iden- > outcome (P 0.05). tifying patients who will benefit from surgery is chal- While pancreatic CR in the elderly patients seems to be lenging. Here, we examined the impact of margin- fi feasible and safe and is not associated with signi cant risk positive (R1) resection on local recurrence and overall of intra-operative/post-operative complications; survival of survival (OS), tumor biology and/or surgical technical the elderly patients undergoing CR for PA is poor. Age is factors that determine R1 resection in PDAC surgery, and not an independent predictor of outcome in the elderly which factors affect outcome. patient with PA.

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Methods: This retrospective study included 494 patients Conclusion: The size and topology of the first JVT are who underwent surgery for PDAC. The effect of tumor associated with the number of JVs involved. This is margin status, patient characteristics and tumor character- important for understanding the resectional area of the istics on local recurrence, distant recurrence, and OS were mesojejunum and the pathogenesis of jejunal congestion. assessed. Results: Among all patients who underwent resection, 38.2% underwent R1 resection. R1 resection was associated EP02D-014 < with decreased OS (p 0.001) and reduced time until local EXTERNAL VERSUS INTERNAL recurrence (p < 0.005). In contrast, long-term recurrence patterns were similar between R1 and R0 patients. Among all PANCREATIC DUCT STENTING IN margins, the vascular margin was most commonly affected DUCT-TO-MUCOSA and associated with an increased risk of local recurrence PANCREAICOJEJUNOSTOMY AFTER (p < 0.05). Approximately 29% of patients had recurrence PANCREATICODUODENECTOMY: A within 6 months, and main risk factors were tumor stage, PROSPECTIVE RANDOMIZED STUDY tumor-positive lymph nodes (N1), and perineural invasion. M. Sharshar1, E. S. El Kayal1, A. Shawky1, Among patients with tumor-negative lymph nodes (N0), R1 1 2 patients had significantly reduced OS compared to patients A. El Gendi and A. Aldouri 1HPB Surgery Unit, Faculty of Medicine - Alexandria who underwent radical resection (R0), although tumor 2 biology factors were similar between these two groups. University, Egypt, and HPB Surgery Unit, Saint James Conclusion: For pancreatic cancer surgery, R1 status is University Hospital, United Kingdom determined largely by the tumor’s biological factors. Background: A pancreatic duct stent is often placed across the Although R1 resection is a major contributor to reduced pancreaticojejunostomy after pancreaticoduodenectomy to survival and early recurrence, long-term recurrence patterns decrease the incidence rate of postoperative pancreatic fistula. are similar between R0 and R1 patients. Finally, in N0 However, there are few reports in the literatures compared patients, surgical factors affect R1 status. between external and internal pancreatic duct stents. Methods: We conducted a prospective randomized study with 30 patients who underwent pancreaticoduodenectomy and we EP02D-013 compared the effects of using external stent versus internal stent in pancreaticojejunostomy on postoperative course, VASCULAR ANATOMY OF THE particularly on incidence of postoperative pancreatic fistula. JEJUNAL MESENTERY AND Results: The incidence rate of pancreatic fistula according COMPLICATIONS ASSOCIATED WITH to the International Study Group on Pancreatic Fistula DIVISION OF THE FIRST JEJUNAL criteria was significantly higher in external stent group VENOUS TRUNK DURING (external, 26.7%; vs internal, 13.3%). In subgroup analysis PANCREATICODUODENECTOMY of patients with soft pancreas, we found similar rates of pancreatic fistula in the two studied groups. The incidence 1,2 1 1 1 Y. Kobayashi , Y. Sakamoto , J. Arita , N. Akamatsu , of overall morbidity was similar between both groups while 1 1 1,3 J. Kaneko , K. Hasegawa and N. Kokudo mortality was higher in external stent group. The mean 1 Hepato-Biliary-Pancreatic Surgery Division, Department postoperative hospital stay was not significantly different of Surgery, Graduate School of Medicine, University of between the two studied groups. 2 Tokyo, Department of Digestive Surgery, Toranomon Conclusions: Both external stent and internal pancreatic 3 Hospital, and Department of Surgery, Center Hospital of duct stents were safely used for pancreaticojejunostomy. the National Center for Global Health and Medicine, Japan Internal stent had less incidence of postoperative pancreatic Introduction: Little is known about the anatomy of the fistula and simplifies postoperative management and it jejunal veins (JVs) flowing into the superior mesenteric might be a better option than external stent in pancreati- vein (SMV), and whether they can be safely divided during cojejunostomy after pancreaticoduodenectomy. pancreaticoduodenectomy(PD). Methods: Computed tomography was used to review the jejunal branches off the superior mesenteric artery (SMA) EP02D-015 and into the SMV in 123 consecutive patients who under- OUTCOMES OF went PD between 2014 and 2016. The JVs were numbered PANCREATICODUODENECTOMY IN . as J1v, J2v, J3v based on the accompanying jejunal ar- PATIENTS AGED 80 OR OLDER teries (J1a, J2a, J3a.). The common trunk of the JVs (jejunal venous trunk, JVT) was classified as ventral or I. Justo, L. Alonso, P. Rioja, A. Marcacuzco, O. Caso, dorsal to the SMA. A. Nutu, A. Manrique, J. Calvo, F. Cambra and Results: The first JVT involved multiple JVs in 108 C. Jimenez-Romero (87.8%) cases. The first JVT diameter (7or<7 mm) was 12 de Octubre UH, Spain significantly associated with the number of JVs (4or<4; Introduction: We assume that age over 80 years increases P < 0.05). Surgical outcomes were not significantly this risk of morbidity/mortality after pancreatoduodenec- different between cases in which the first JVT was sacri- tomy . We analyse our outcomes for pancreatoduodenec- ficed (n = 32) or preserved (n = 91), except for operation tomy performed in patients 80 and older. time and portal venous resection frequency. One of the 32 Method: Between January 2012 and December 2016 101 cases (3.1%) with first JVT sacrifice showed severe patients underwent pancreaticoduodenectomy. We divided congestion of the jejunal limb requiring emergency jejunal the patients in 2 groups: group A <80 years (91 patients) resection. and group B 80 years (10 patients).

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Results: The median age was 65 (57e74) years for group A EP02D-016 PD patients with and without neoadjuvant therapy vs 83 (80e86) years for group B (p = 0.002). Alcohol consumption in group A was 11% vs 30% in group B (0.295). Diabetes mellitus in group A was 22% vs 40% in B (p = 0.197), and patients with an ASA risk score over III were 45.1% in group A and 60% in group B (p = 0.766). Operative time was longer in young patients, at 5.9 h (3.87e 7.87) vs 3.5 (3e4) (p = 0.036). Lymph node retrieval rate was higher in group A, 15.1 (11e19) than B, 11 (8e14) (p = 0.221). Positive lymph nodes were identified in 77.8% of older patients (vs 52.5% of younger patients; p = 0.336), and R0 surgery was achieved in 75.8% of younger patients vs 44.4% of older patients (0.057). Pancreatic fistula was observed in 35% of young patients vs 20% of older ones (p = 0.487) and postoperative mortality was 4% vs 0% (0.670). Dindo grade III/IV complications occurred in 15.5% of patients in group A vs 0% in B (p = 0,167). No differences have been found when comparing both groups in terms of complications or survival.

EP02D-016 BILIARY MICROBIOME IN PANCREATIC CANCER: ALTERATIONS WITH NEOADJUVANT THERAPY N. Goel1, H. Pitt2, A. Nadler3, L. Selesner4, W. Ward1, 1 1 S. Reddy and J. Hoffman EP02D-017 1Surgical Oncology, Fox Chase Cancer Center, 2Chief Quality Officer, Temple University, United States, 3Sur- RISK FACTORS FOR POST- gical Oncology, University of Toronto, Canada, and PANCREATICODUODENECTOMY 4Temple University, United States DELAYED GASTRIC EMPTYING IN THE Background: Neoadjuvant therapy for pancreatic cancer is ABSENCE OF PANCREATIC FISTULA being employed more commonly. Most of these patients OR DEEP SURGICAL SITE INFECTION undergo biliary stenting which results in bacterial coloni- R. J. Ellis1,2, D. B. Hewitt2, R. P. Merkow2, J. B. Liu1, zation and more surgical site infections (SSIs). However, K. Y. Bilimoria1,2, D. J. Bentrem2 and A. D. Yang2 the influence of neoadjuvant therapy on the biliary micro- 1American College of Surgeons, and 2Department of biome has not been studied. Surgery, Northwestern University, United States Methods: From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative Introduction: Delayed gastric emptying (DGE) is a bile cultures were studied. Patient demographics, stent common complication following pancreaticoduodenec- fi placement, bile cultures, bacterial sensitivities, SSIs and tomy. Pancreatic stula or deep surgical site infection (SSI) clinically-relevant postoperative pancreatic fistulas (CR- may contribute to development of DGE, but less is known POPF) were analyzed. Patients who underwent neoadjuvant about risk factors for DGE in the absence of these other therapy were compared to those who went directly to sur- complications. Our objective was to explore risk factors for fi gery. Standard statistical analyses were performed. postoperative DGE in patients without pancreatic stula or Results: Eighty-three patients received neoadjuvant ther- deep SSI. apy while 89 underwent surgery alone (Table). Neoadju- Methods: American College of Surgeons National Surgical vant patients were more likely to undergo biliary stenting Quality Improvement Program (ACS-NSQIP) pancreatec- (76 vs 56% p < 0.01). Patients who received neoadjuvant tomy variables were used to identify patients with DGE therapy were more likely to have enterococci (45 vs 22%, following pancreaticoduodenectomy. Multivariable models p < 0.01), and Klesbiella (37 vs 19%, p < 0.01) in their were developed to assess preoperative, intraoperative, and bile. Multidrug resistant bacteria were not increased in technical factors associated with DGE. patients receiving neoadjuvant treatments. Of patients with Results: A total of 10,614 pancreaticoduodenectomies fi bactobilia, resistance to cephalosporins was more common were identi ed with an overall DGE rate of 17.1%. DGE fi in those who received neoadjuvant therapy (76 vs 60%, was not associated with pancreatic stula or deep SSI in p < 0.05). Neoadjuvant therapy did not affect the incidence 56% of cases. The rate of DGE was 11.9% in patients fi or type of SSIs or CR-POPFs. without pancreatic stula or deep SSI. These patients were  Conclusions: The biliary microbiome is altered in patients more likely to develop DGE if age 75 (OR 1.29 [95%CI e undergoing PD after neoadjuvant therapy. Most patients 1.09-1.52]), male (OR 1.44 [95% CI 1.26 1.65]), black e undergoing PD with a biliary stent have microorganisms race (OR 1.25 [95% CI 1.01 1.55]), or underwent pylorus- resistant to cephalosporins. Antibiotic prophylaxis in these sparing pancreaticoduodenectomy (OR 1.31 [95% CI e patients should have a broad spectrum of coverage for 1.08 1.58]). Factors not associated with DGE included enterococci and gram-negative bacteria. diabetes, BMI, malignancy, open/laparoscopic approach, and antecolic/retrocolic gastric reconstruction.

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Conclusion: The incidence of DGE after pancreaticodu- preoperative bilirubin on outcomes following pancreatico- denectomy is notable even in patients without other duodenectomy (PD). abdominal complications. Identification of patients at In this retrospective study data were analyzed from 80 increased risk for DGE can be used to make more informed patients with periampullary tumors underwent PD between decisions regarding selective use of pylorus-sparing 2013 and 2017. Regarding the preoperative bilirubin levels, pancreaticoduodenectomy, enteral feeding access, naso- we opted 20 mg/dl for cut-off point to divide patients into gastric tubes, and adjustment of enhanced recovery two groups to be subjected for analysis. pathways. 80 patients underwent PD with mean age of 54.90 Æ 14.33 (22e82). Of them, 40 (50%) were male. 9 (11.3%) patients died within 30 days of operation and early EP02D-018 morbidity rate was 37.5%. The median preoperative bili- ENHANCED RECOVERY FOLLOWING rubin was 4.7 mg/dl and majority of cases (88.8%) had bilirubin <20 mg/dl. However there was a tendency for PANCREATICODUODENECTOMY postoperative mortality to be higher in patients with bili- V. Ganzha, O. Gulko, V. Serdyuk, I. Galochka, A. Skums, rubin 20 mg/dl (22% vs. 9% for bilirubin <20 mg/dl), the A. J. Skums, B. Tsubera, O. Simonov, S. Chaykovska and relationship was not statistically significant (P = 0.266). In A. Makedon contrast, in both univariate and multivariate analyses, pre- Department of Combined Pathology and Retroperitoneal operative bilirubin was observed to be the only independent Space, Shalimov National Institute of Surgery and variable affecting 30-day postoperative morbidity status; In Transplantology, Ukraine the way that bilirubin 20 mg/dl remarkably increased the Introduction: Mortality after pancreaticoduodenectomy morbidity (P = 0.012, Odds ratio = 3.04). 57.5% of our (PD) decreased from 25% to 1e3% in the last decade. cases underwent preoperative biliary drainage (PBD) which However, the number of early postoperative complications did not impact the mortality and morbidity (P > 0.05). varies from 29.5% to 70%. Therefore, there is a need in new In this study, however preoperative bilirubin affected methods of perioperative management of patients after PD overall morbidity status; it could not predict the mortality to improve the immediate results. accurately. Also, since PBD did not show benefits for pa- Materials and methods: For the comparative analysis, 70 tients with periampullary tumors, our study suggested that patients with pathology of the pancreatic head and peri- PBD should not be part of the routine medical approach to ampulary zone, who underwent PD, were divided into two surgical candidates unless for cases with high bilirubin groups: I group-31 patients, perioperative management was levels (20 mg/dl) or expected delayed surgery. carried out with the enhanced recovery program (ERAS), II group - 39 patients, who were treated with the traditional way. Results: There was no mortality in two groups. The number of complications in the group I was significantly less than in group II (12 (38, 7%) vs 20 (51, 2%) (p < 0,05). Removal of nasogastric tube and oral nutrition at 1 POD was observed in 21 (67.7%) patients of the group I. The frequency of gastrostasis was lower in group I comparing II - 5 (16, 1%) vs 9 (23, 1%) patients, but not significant (p > 0.05). The incidence of pancreatic fistula was the same in two groups 4(12, 9%) and 5(12,8%) (p > 0.05). The median length of hospital stay after PD was lower in I group comparing with II (14; 95% CI: [13,5; 17] vs 18; 95% CI: [16; 18]; Mann-Whitney U Test, p = 0,012), Conclusions: The results of the ERAS program after PD shows the reducing number of postoperative complications and length of hospital stay, demonstrating the feasibility in clinical practice. Figure Approach to periampullary tumors, based on study

EP02D-019 THE PREDICTIVE POWER OF EP02D-020 PREOPERATIVE BILIRUBIN FOR THE DISTAL PANCREATECTOMY IN THE OUTCOMES FOLLOWING ELDERLY: AN UNCONTROLLED CASE- PANCREATICODUODENECTOMY COMPARISON STUDY M. Aliakbarian1, S. Saeidi Shahri1 and L. Jarahi2 A. K. -Y. Fung, C. C. Chong, K. F. Lee, J. Wong, 1Surgical Oncology Research Center, and 2Department of Y. S. Cheung, A. K. W. Fong, H. T. Lok and P. B. S. Lai Community Medicine, Mashhad University of Medical Prince of Wales Hospital, Hong Kong Sciences, Islamic Republic of Iran Introduction: Pancreatectomy in the elderly can be asso- fi Obstructive jaundice may increase morbidity or mortality ciated with signi cant morbidity and mortality. This study after curative surgery. We aimed to assess the impact of examined the outcomes of elderly patients who underwent distal pancreatectomy.

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Methods: All patients who underwent distal pancreatec- mortality rates were 56.0% and 1.2%, respectively. No tomy with or without splenectomy from January 1997 to baseline differences were observed among groups. Patients April 2017 were recruited. Elderly patients were defined as in the short group (n = 106) experienced shorter operation >65 years (WHO definition). Two groups of patients were time than intermediate (n = 115) and long (n = 91; compared (Group A: age 65 and Group B: age >65). p < 0.001), higher rate of major morbidity (43.4% vs. Patients with distal pancreatectomy as part of radical gas- 20.0% vs. 24.2%, p < 0.001), biliary fistulae (13.2% vs. trectomy were excluded. 4.3% vs. 5.5%, p = 0.031) and length of in-hospital stay Results: The mean patient age was 55+/-14 years. There (21 Æ 16 days vs. 15 Æ 13 days vs. 16 Æ 15 days, were 50 (78%) patients in Group A and 14 (22%) patients p = 0.027). A multivariate adjusted model identified the in Group B. There were more females (71.4% vs 56%, short stent duration as an independent risk factor of severe p=0.30), greater numbers of major comorbidities (2: postoperative morbidity (OR 2.64, 95% CI 1.23-5.67; 35.7% vs 16%, p = 0.34) and higher ASA (ASA2: 92.9% p = 0.013). vs 83.7%, p = 0.11) in Group B. There were no statistical Conclusion: When jaundice treatment cannot be avoided, differences in the operative approach to distal pancreatec- delaying surgery up to 1 month after biliary stenting might tomy (laparoscopic/open/robotic), conversion (8% vs 7%, reduce major morbidity, procedure-related complications p=0.86) and splenic preservation rates (36% vs 21%, and length of in-hospital stay. p = 0.31) between Group A and B. Median operation times were 300min vs 265 min (p = 0.82). Total morbidity was higher in Group B (50% vs 24%, p = 0.06). Pancreatic EP02D-022 fi stula rate was 12.2% in Group A and 21.4% in Group B PANCREATICOJEJUNOSTOMY VERSUS (p = 0.37). There were 4 and 3 Grade B (ISGPF definition) pancreatic fistulas in Group A and B respectively. The total PANCREATICOGASTROSTOMY ON length of stay was 10 days longer in Group B (p = 0.08) RATES OF POST-OPERATIVE with no 30-day mortality. PANCREATIC FISTULA FORMATION Conclusion: Distal pancreatectomy can be safely AND OTHER COMPLICATIONS: A performed in selected elderly patients, with acceptable META-ANALYSIS post-operative morbidity but longer total length of hospital 1 2 2 2 stay. I. B. Dabu , M. S. De Leon , C. H. Cua , K. Sarong , J. K. Silvano2 and P. M. Tan2 1Surgery, and 2Chinese General Hospital & General Hospital, Philippines EP02D-021 Introduction: Pancreatic fistulas (PF) are the most PREOPERATIVE BILIARY STENTING common complication following pancreaticoduodenec- AND MAJOR MORBIDITY AFTER tomy. This study evaluated the impact of pancreaticogas- PANCREATODUODENECTOMY e DOES trostomy (PG) versus pancreaticojejunostomy (PJ) on PF ELAPSED TIME MATTER? THE occurrence and secondary outcomes such as post-operative FRAGERITA STUDY GROUP hemorrhage, intra-abdominal abscess, delayed gastric emptying, length of hospital stay and death. M. Sandini1, K. C. Honselmann2, D. Birnbaum3, 4 5 3 2 Methods: RCTs comparing pancreaticogastrostomy versus F. Gavazzi , M. Chirica , V. Moutardier , T. Keck , pancreaticojejunostomy were identified from literature da- A. Zerbi4 and L. Gianotti1 1 2 tabases. A systematic review and meta-analysis was con- Surgery, University of Milano-Bicocca, Italy, Surgery, ducted among the chosen RCTs comparing patients who University Medical Center Schleswig-Holstein, Germany, 3 underwent PG versus PJ following pancreaticoduodenec- Digestive Surgery, Hôpital Nord, Aix-Marseille Univer- tomy . The primary outcome was the occurrence of PF as sity, France, 4Surgery, Humanitas Research Hospital, 5 proposed by the International Study Group of Pancreatic Italy, and Digestive Surgery and Liver Transplantation, Fistula (ISGPF). Secondary outcomes were also noted. Hôpital Michalon, France Results: Three RCTs including 772 participants met the Introduction: The effect of preoperative stent duration on inclusion criteria. The incidence of PF (OR 0.88, 95% 0.49, postoperative outcomes after pancreatoduodenectomy 0.95, p 0.02) was found to be lower in the PG group. Grade (PD) has not been investigated. We aimed to analyze B/C fistula according to the ISGPF was found to be higher whether the time-frame from stent to surgery was associ- in the PJ group (OR 0.21, 95% 0.12, 0.37, p 0.00001). ated with the occurrence and severity of postoperative Other complications such as intra-abdominal abscess (OR complications. 0.65, 95% CI, 0.43, 0.98; p < 0.04) was found to be lower Methods: From 2013 to 2016, patients who underwent PD in the PG group. Hemorrhage was found to be higher in the after biliary stent placement at 5 European Academic PG group (OR 1.71, 95% CI, 1.13; p < 0.01). Delayed Centers were analyzed from prospectively maintained da- gastric emptying was prolonged in the PG group tabases. The primary end-point was the associations be- (p < 0.38). Mortality was higher among the PJ group tween the duration of preoperative biliary stenting and however was not statistically significant (OR 0.81, 95% CI, postoperative morbidity. Patients were stratified into three 0.49, 1.59; p < 0.54). groups by stent duration: short (<4 weeks), intermediate Conclusion: This meta-analysis showed that pancreatico- (4e8 weeks) and long (8 weeks). gastrostomy has lower occurrence rates of PF following Results: 312 patients were analyzed. The mean age was pancreaticoduodenectomy and is associated with fewer 68 Æ 10 years, the median time from stenting to surgery complications. was 37 days (2e559 days) and most operations were Keywords: pancreatoduodenectomy, pancreatogastrostomy, performed for pancreatic cancer (68%). Morbidity and pancreatojejunostomy, postoperative pancreatic fistula.

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Materials and methods: We reviewed the clinical data and CT scans of 45 consecutive patients who underwent ’ EP02D-026 Whipple s procedure from 2007 to 2016. The aberrant anatomy was classified according to Hiatt and group A SHORT TERM OUTCOME OF THE included patients with aberrant hepatic artery while group B HEPATO-PANCREATO-BILIARY with normal anatomy. The 2 groups were compared in SURGERY IN PATIENTS ON terms of morbidity, mortality and oncological outcomes. MAINTENANCE HEMODIALYSIS Results: Aberrant hepatic artery was present in 11 (24%) patients and type V was the most common variant (n = 5, K. Hiramatsu, T. Arai, T. Amemiya, H. Goto, T. Seki, 45%). Mean estimated blood loss in group A was 922 ml and D. Kuga and H. Fujieda group B was 705 ml (p = 0.186) with significantly more Department of Surgery, Anjo Kosei Hospital, Japan packed cell transfusions in group A (p < 0.025). Morbidity Introduction: Major surgery for hemodialysis (HD) pa- rate in group A was 82% and group B was 62% (p = 0.288), tients with nephropathy seems to be at high risk for post- while 30-day mortality rate was 18% and 9% respectively operative management. HPB surgery is also considered as (p = 0.0582). There was no difference in the oncological one of the most invasive treatments compared with other clearance in both the groups with RO resection in 73% pa- categorized surgery. In this report we analysed post- tients in group A and 88% patients in group B (p = 0.337). operative complications of HPB surgery in HD patients. Conclusion: Aberrant hepatic artery does not seem to in- Methods: From January 2004 to December 2017, 24 HD fluence the morbidity, mortality and tumor resection mar- patients had undergone HPB surgery in our hospital. We gins in patients undergoing Whipple’s procedure. retrospectively reviewed the medical records of these pa- tients to assess postoperative complications. Surgical Pro- cedures were : Laparoscopic cholecystectomy (LC): 9, (Open) Cholecystectomy(OC): 6, Extended cholecystec- EP02D-028 tomy (EC) for the gallbladder cancer:1, Chol- THE SURGICAL STRATEGY FOR edocholithotomy(CL): 3, Pancreaticoduodenectomy (PD): ADVANCED PANCREATIC CANCER IN 3, Total pancreatectomy (TP): 1, Necrosectomy for trau- COMBINATION WITH NEOADJUVANT matic injury of the pancreas: 1. Major hepatectomy had not CHEMOTHERAPY been performed in this studied period. Results: The mean hospital stay was 29.7 (3e182) days. N. Nakamura, T. Sanada, T. Sato, T. Ishii, Postoperative complications were observed in six patients H. Kuwabara and N. Goseki (25%): Clavien-Dindo (CD) classification GradeⅡ: 2 (8.3%), Shuuwa General Hospital, Japan Ⅲa: 3 (12.5%), Ⅴ: 1 (4.2%). Hospital death was seen in only We present the surgical strategy for advanced pancreatic one patient (PD: caused by sepsis in POD155). In the nine cancer in combination with neoadjuvant chemotherapy. cases of LC, there was only one complication (11%): acute The patient was a 72-year-old male, who was diagnosed cholangitis (CDⅢa: endoscopic intervention). In contrast, in with pancreatic body cancer with multiple liver metastases major pancreatic surgery group (PD, TP, Necrosectomy) with no clinical symptoms. major complications (CDⅢa) were observed in three of the The laboratory data on admission were within normal five cases (60%) including a death case. limits including tumor marker such as CEA. Conclusions: Our results indicated that a less invasive Abdominal CT revealed tumor of 3 cm in size located the operation such as LC can be performed safely in HD pa- pancreatic body. Several liver tumors, 1cm in size were tients. On the contrary, invasive HPB surgery such as PD suspected as multiple liver metastases. Taken together, we was challenging treatment. diagnosed unresectable metastatic pancreatic cancer and planned adjuvant chemotherapy with nab-paclitaxel plus gemcitabine. Chemotherapy was administered for 6 cycles, EP02D-027 and adverse events showed peripheral neuropathy (G1) and myelosuppression. In follow-up CT, the tumor of the SURGICAL AND ONCOLOGICAL pancreatic body shrinks and also hepatic metastasis almost IMPLICATIONS OF ABERRANT disappears. Finally we planned adjuvant surgery which was ARTERIAL ANATOMY IN PATIENTS distal pancreatectomy with splenectomy. In the intra- UNDERGOING operative findings, liver metastasis was not palpated, hep- PANCREATICODUDENECTOMY atectomy was not performed. Histological diagnosis was a tiny tumor mass of adenocarcinoma of the pancreas and no S. Begum1, M. R. Khan1, D. B. Khan2 and K. M. I. Pal1 1 2 pathological CR. After that, postoperative adjuvant General Surgery, and Radiology, Aga Khan University chemotherapy with TS-1 took place, resulting in long-term Hospital, Pakistan survival of about 30 months. Introduction: Whipple’s pancreaticoduodenectomy is a We experienced a case of unresectable metastatic complex surgical procedure and any aberrant arterial pancreatic cancer that could be effectively treated by the anatomy may have serious surgical implications. Aberrant combination chemotherapy and surgical resection. In order hepatic artery may predispose the patient to inadvertent to improve the prognosis of pancreatic cancer, it is hemorrhage, ischemia or compromised surgical resection. important to use not only surgery but also effective The objective of our study was to analyze the frequency of chemotherapy. aberrant hepatic artery and compare the outcomes in pa- tients with normal anatomy.

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EP02D-029 underwent Whipple procedure. Median follow up was 48 weeks. Six patients had bleeding complications which ONCOLOGIC IMPACT OF LOCAL required re-exploration. Over sixty percent of patients were RECURRENCE IN RESECTED completely pain free, about thirty percent required occa- PANCREATIC CANCER: ITS sional pain killers, while five patients needed an additional TOPOGRAPHIC PREFERENCE IN procedure. The status of diabetes or steatorrhea was un- LOCAL RECURRENCE PATTERNS changed in 22 patients, 12.5 percent people developed new onset diabetes while almost half the patients developed ACCORDING TO TUMOR LOCATION steatorrhea in the post-operative period. About fifty five 1 2 2 2 S. H. Choi , H. K. Hwang , C. M. Kang , D. S. Yoon and percent patients had a median weight gain of 3 kg while the 2 W. J. Lee rest lost about 4 kg. Four patients developed obstructive 1 Surgery, CHA University, Bundang CHA Medical Center, jaundice in the late post-operative period (due to biliary 2 and Surgery, Severance Hospital, Yonsei University, Re- stricture) which was manged with hepatico-jejunostomy in public of Korea three and Whipple procedure in one patient. Two patients Introduction: The role of extended surgery and adjuvant had internal herniation (more than four years later). therapy to control local recurrence is still controversial. Little Conclusions: Surgery for chronic calcific pancreatitis is known about the oncologic impact of local recurrence and is effective in reducing pain. However, the clinicians the pattern of recurrence according to tumor location. and patients should be aware that there is no change in Methods: From July 1992 to December 2016, patients who the progressive nature of the disease despite the underwent curative-intent surgery for pancreatic ductal operation. adenocarcinoma were retrospectively reviewed. Results: 76.5% (n = 289) of the 378 patients had recurrence during the follow-up period (median 29.0 month EP02D-031 w [1.3 139.2]). There was no recurrence in 92 (24.3%) pa- THE IMPACT OF A COMPREHENSIVE tients. The first recurrence pattern was local in 83 (22.0%) patients, systemic in 152 (40.2%) patients, and loco-sys- INTEGRATIVE ENHANCED RECOVERY temic in 51 (13.5%) patients. The 5-year survival rates PROGRAM ON according to recurrence pattern were 76.6% (no recur- PANCREATICODUODENECTOMY AT A rence), 10.3% (local), 16.9% (systemic), and 11.3% (loco- SINGLE INSTITUTION systemic). Neoadjuvant chemoradiation was helpful in K. Watkins and N. Seeley lowering local recurrence (24.7% vs. 16.0%, p = 0.038), but Surgery, CTCA - Southeastern Regional Medical Center, not systemic recurrence. Remnant pancreas, common he- United States patic artery, celiac trunk, and paraaortic area were the common sites of frequent local recurrence. However, the Introduction: Enhanced surgical recovery programs are superior mesenteric artery (38 vs. 7, p = 0.005) and portal becoming more common due to proven outcome im- vein (34 vs. 2, p < 0.001) were more frequent local provements in colorectal surgery. The impact of such recurrence sites for the head tumor, and the surgical bed programs for pancreaticoduodenectomy is not clear at this was the one for the body and tail tumor (1 vs. 7, p = 0.002). point. Our completely integrated enhanced recovery pro- Conclusion: Local recurrence of pancreatic cancer has an gram for major abdominal/pelvic surgery (ASURE) was oncologic impact similar to systemic recurrence. Because implemented in January 2016. We hypothesized that of anatomical relationship of the pancreas and the sur- implementation of the ASURE program impacted out- rounding organs, there are frequent sites of local recurrence comes from pancreatico-duodenectomy. depending on the location of the tumor. Further investiga- Methods: A retrospective review was performed of all tion is necessary to effectively control local recurrence. patients undergoing pancreaticoduodenectomy from August 2013 through August 2017. Outcomes were compared for 23 control (prior to January 1, 2016) and 24 EP02D-030 ASURE patients. fi OUTCOMES FOLLOWING SURGERY Results: There was no signi cant difference in age, blood loss, need for vein resection, preoperative chemotherapy, or FOR CHRONIC CALCIFIC BMI. There was a statistically significant difference in PANCREATITIS mean length of stay for the ASURE group (15.1 vs 5.1 S. Patwardhan, S. Ramachandran and A. Gupta days, p < 0.05) with trend to improvement in readmission Department of Surgical Gastroenterology, Meenakshi rate (17.4% vs 12.5%, P = NS). Overall morbidity and Mission Hospital and Research Centre, India mortality were not significantly different (56.5% vs 50.0% Introduction: Troublesome, recurrent pain is a standard and 8.7% vs 8.3%). However, the incidence of Clavien fi indication for surgery in chronic calcific pancreatitis. We Dindo complications of 3 or greater was signi cantly lower < investigated the role of surgery in alleviating the pain and in in the ASURE group (47.8% vs 20.8%, p 0.05). There altering the natural history of the disease. were trends towards improvements in delayed gastric Methods: Retrospective analysis was done on patients emptying (21.7% vs 12.5%), deep space infection (21.7% fi operated between January 2013 and June 2017, with at least vs 16.7%) and all grade pancreatic stula rate (17.4% vs fi a six month follow up. They were assessed for pain relief, 4.2%) but these did not reach statistical signi cance. status of diabetes mellitus and steatorrhea, weight gain and Conclusion: An integrated recovery program appears to any late complications. have a positive impact on the outcomes from pancreatico- Results: A total of 116 patients were included. Frey’s duodenectomy. Continued work is necessary to track this procedure was performed in 111 patients, 5 patients improved outcome in a larger patient population.

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Results Summary EP02D-033 Control ASURE COMPARISON OF RISK FACTORS FOR (n[23) (n[24) *p<0.05 POSTOPERATIVE PANCREATIC Mean Age 60 56 FISTULA AFTER Vein Resection 30% 29% PANCREATICODUODENECTOMY Preoperative Therapy 43.5% 58.3% BETWEEN 2005 AND 2016 ISGPS POPF Mean BMI 27.9 29.2 DEFINITION AND GRADING ON 278 Mean Length of Stay (days) 15.1 5.1 * PATIENTS Readmission rate 17.4% 12.5% X. Zhang, Y. Shen, C. Guo, X. Bai and T. Liang 3+ Complication Rate 47.8% 20.8% * Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Delayed Gastric Emptying 21.7% 12.5% Medicine, Zhejiang University, China All Grade Pancreatic Fistula 17.4% 4.2% Postoperative pancreatic fistula (POPF) is the most important complication after pancreaticoduodenectomy. In 2005, International Study Group for Pancreatic Surgery EP02D-032 (ISGPS) drew up a standardized POPF definition and PANCREATICOJEJUNOSTOMY USING classification. But ISGPS definition and grading of POPF TWO LAYERS END-TO-SIDE have been updated in 2016 in light of controversial prob- fi INVAGINATION METHOD WITHOUT lems of 2005 de nition and grading. The risk factors for POPF have been changed, due to significant differences of STENTING TUBE FOLLOWING between 2005 and 2016 ISGPS definition and grading. PANCREATICODUODENECTOMY We conducted an analysis of 278 patients after pancreati- I. Watanobe, R. Ichikawa, Y. Sekine, S. Miyano, coduodenectomy between January 2013 and October 2017 in M. Machida, T. Kitabatake, H. Sugo, Y. Lee and our hospital. Compared 2016 definition with 2005, the overall K. Kojima morbidity was from 46.0% to 20.9%. The incidence of General Surgery, Juntendo University Nerima Hospital, biochemical leak (BL) was 25.2% of patients. Grade B Japan increased from 10.4% to 16.5%, while grade C decreased fi Introduction: We examined the pancreaticojejunostomy from 10.4% to 4.3%. According to 2005 de nition, diabetes < using two layers end-to-side invagination anastomosis mellitus (P = 0.019), soft pancreatic texture (P 0.001), without stenting tube following pancreaticoduodenectomy narrowed pancreatic duct diameter (P = 0.001), pancreatic at our hospital. duct stent (P = 0.029) and venous invasion (P = 0.02) have fi Methods: This study included 80 patients, 52 men and 28 been con rmed as being associated with POPF. However, in fi women, average age 69 years, who underwent pancreati- 2016 de nition, diabetes mellitus was not risk factor for POPF coduodenectomy (68 PpPD, 11 PD, 1 SSpPD) at our hos- while pancreatic pathology (pancreatic cancer or others) pital. Primary diseases are 25 bile duct cancers, 24 (P = 0.046) was included. Based discussion of our study, pancreatic cancers, 12 papilla Vater cancers, 10 IPMNs, 3 underlying pathology is added into risk factors, due to the duodenal cancers, 3 PNETs, 2 GISTs and 1 metastatic clinical severity of POPF, whereas the diabetes maybe a false- fi pancreatic cancer. Endo-to-side pancreaticojejunostomy positive risk factor. 2005 and 2016 POPF de nition differed fi was performed for all patients without stenting. In the first signi cantly in terms of incidence of any complications place, the outer layer encompasses the posterior wall of the (P = 0.001) and postoperative hospital stay (P =0.007). remnant pancreas and the jejunal seromusucularis sepa- rately using 4-0 nonabsorbable sutures. The inner layer encompasses the capsular parenchyma of the pancreas and EP02D-034 the jejunum through all layers of the bowel continuously PREDICTORS AND PROGNOSIS OF using 4-0 absorbable sutures. POSTOPERATIVE HIGH FLUID Results: There was no mortality in any of the 80 patients. DISCHARGE AFTER Postoperative pancreatic fistula was evaluated using an PANCREATICODUODENECTOMY FOR fi international study group (ISGPF) de nition. Thirty nine PANCREATIC DUCTAL patients (48.7%) developed pancreatic fistula ; Grade A:32 (40.0%), Grade B:5(6.3%), Grade C: 2(2.5%). All of 5 ADENOCARCINOMA grade B patients healed with conservative therapy. None of K. Ito1, Y. Kawaguchi1, Y. Sakamoto1, J. Arita1, the patients developed postoperative intra-abdominal ab- N. Akamatsu1, J. Kaneko1, N. Kokudo2 and K. Hasegawa1 scess formation. Four patients developed delayed gastric 1Department of Surgery, University of Tokyo, and 2Na- emptying, 2 patients developed intra-abdominal bleeding tional Centre for Global Health and Medicine, Japan and one case developed portal vein thrombosis. The Background: Pancreaticoduodenectomy (PD) is widely average post-operative stay were 29.4 days. performed for peri-pancreatic head tumors. High non- Conclusion: The incidence of fistula has been consider- chylous fluid discharge is a frequent complication after PD ably decreased by the technique of invagination anasto- in addition to pancreatic fistula, delayed gastric emptying mosis (end-to-side anastomosis) without stenting. Because (DGE) and chylous ascites, and can extend hospital stay or this technique is easier than the duct-to-mucosa pancrea- increase fatal sequelae. ticojejunostomy, younger surgeons may execute Methods: From August 2008 to June 2015, consecutive 102 pancreaticojejunostomy. patients underwent PD for pancreatic ductal adenocarcinoma

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(PDA). High non-chylous fluid discharge was defined as Conclusion: PD for selected elderly patients is acceptable. postoperative daily discharge exceeding 10 mL/kg. Predictive With regards to survival, less invasive and safe manage- factors for high fluid discharge and prognosis were analyzed. ment is a first priority for elderly patients. PG can be one of Results: Fifty-one patients developed high fluid discharge (the feasible and important reconstruction options. high-fluid group). Median body mass index (BMI) and the levels of hemoglobin, total protein, and cholinesterase were EP02D-037 significantly lower in the high-fluid group than in the low-fluid PANCREATIC NECK THICKNESS e fi group, respectively. DGE rate was signi cantly higher in the POSSIBLE KEY TO SELECTION OF high-fluid group than in the low-fluid group: 35.3% vs. 11.8%, P=0.009. Multivariable analysis revealed that BMI < 22.0 kg/ STUMP CLOSURE TECHNIQUE AFTER m2 (odds ratio, 10.6, P < 0.001), hemoglobin <12.0 g/dl (odds DISTAL PANCREATECTOMY ratio, 4.9, P = 0.014), and intraoperative blood loss 800 mL A. Nikov, P. Záruba, F. Belina and M. Ryska (odds ratio, 3.8, P = 0.038) were independent predictive factors Department of Surgery, Central Military Hospital Prague, for high fluid discharge. The extent of lymph nodes (LN) Charles University, Czech Republic dissection, portal vein (PV) resection and reconstruction, su- Introduction: Statement that pancreatic stump closure perior mesenteric artery (SMA) plexus dissection were not technique after distal pancreatectomy does not influence significant predictors. There were no significant differences in risk of postoperative pancreatic fistula (POPF) is overall survivals between the groups. supported by RCTs. Though experience with stapler Conclusions: Preoperative poor conditions (low levels of crushing thick pancreatic neck is generally known, this BMI and hemoglobin) and intraoperative high blood loss was omitted in RCTs design. Therefore, studies suggest- were associated with higher incidence of high fluid ing that thick pancreas increases risk of POPF after sta- discharge rather than the extent of LN and SMA plexus pler closure have emerged. Evidence of POPF risk dissection or PV resection. reduction by stump closure technique selection according to pancreatic thickness is still lacking. That is a purpose EP02D-036 of our study. PANCREATICOGASTROSTOMY Methods: Retrospective analysis of 115 consecutive patients RECONSTRUCTION IS SUITABLE FOR who underwent distal pancreatectomy at single center between PATIENTS 79 YEARS AND OLDER IN 1/2011 and 12/2017 was performed. Thickness of pancreatic PANCREATICODUODENECTOMY: tissue at transection site (predominantly pancreatic neck) was ’ measured on preoperative CT. Patients were divided according SINGLE CENTER S EXPERIENCE to neck thickness and sub-divided according to stump T. Ochiai1, H. Inoue1,H.Fu1, K. Harada1, H. Ito1, closure technique. Incidence of POPF, morbidity, mortality K. Koshino1, A. Toma1, R. Morimura2, H. Ikoma2 and and baseline-characteristics were investigated. E. Otsuji2 Results: Overall incidence of POPF was 46, 1% and did not 1Surgery, North Medical Center, Kyoto Prefectural Uni- differ among stapler and hand-sewn closed stump groups versity of Medicine, and 2Surgery, Kyoto Prefectural (41,8% vs. 52, 1%; OR 0, 66; 95% confidence interval (CI) University of Medicine, Japan 0,29-1,48; p=0,3435) - regardless of pancreatic thickness. In Background and aim: The age of patients who received group with transection site 12 mm incidence of POPF was pancreaticoduodenectomy (PD) has been elevating. How- 11, 6% in stapler subgroup vs. 59, 1% in hand-sewn sub- ever, clinical features of elderly patients with cancer who group (OR 0,09; 95% CI 0,02e0,37; p = 0,0001). In pa- received PD are unclear. This study analyzed the outcomes tients with transection site >12 mm incidence of POPF was of PD in patients > or =79 year of age. 95,8% in stapler subgroup vs. 46,2% in hand-sewn sub- Patients and methods: We studied 33 patients who had group (OR 26,83; 95% CI 3,14-229,3; p = 0,0001). received PD in our center between 2005 and 2017.The Conclusion: Stapler closure of thin pancreas and hand- patients were divided into two groups based on recon- sewn closure of thick pancreas significantly reduce risk of struction type: Pancreaticogastrostomy (PG:n = 16) and POPF after distal pancreatectomy. pancreaticojejunostomy (PJ:n = 17) groups. We compared Supported by MO1012 these two groups clinically. Elderly candidates of PD fulfilled performance status 0 or 1. Results: In all patients, mortality was 0.6% (2 patients of PJ group) and morbidity (Clavien-Dindo 2 = or <) was 70%. Median survival was 23 months. There was no significant difference in the incidence of complications including postoperative pancreatic fistula and the duration of post- operative hospital stay between two groups. Operating time and amount of operative blood loss of PG were less than these of PJ group (p < 0.05). Risk factors of survival of all patients were PJ, presence of combined resection, blood loss and worsen of activities of daily living (ADL). Among them, worse of ADL was the independent risk factor. Moreover, risk factor of worse of ADL was presence of combined resection (p < 0.05). Cumulative postoperative survival of PG was significant better than that of PJ group Figure Transection site thickness vs. POPF occurrence (p < 0.05).

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EP02D-038 study aims to compare between DmPJ and InvPJ tech- niques after pancreaticoduodenectomy in terms of CR- THE STUDY OF EARLY RECURRENCE POPF rate in different risk groups. RISK FACTOR FOR PANCREATIC Method: We retrospectively collected the data of all pa- CANCER tients who underwent pancreaticoduodenectomy in our H. Izumi1, H. Yoshii2, M. Mukai2, E. Nomura2 and center. Patients were categorized into 2 groups: DmPJ and H. Makuuchi2 InvPJ group. Demographic data, intraoperative and post- 1Department of Gastrointestinal Surgery, and 2Tokai operative data were collected. FRS was assigned to stratify University Hachioji Hospital, Japan patients in both groups. Primary outcome is CR-POPF. Results: From January 2007 - August 2017, 274 patients Introduction: Pancreatic cancer is a poor prognostic dis- met the inclusion criteria. Demographic data was compa- order. Even it is a resectable pancreatic cancer, postexci- rable in both groups. Patients in both techniques(DmPJ vs sional recurrence could occur in many cases. Early InvPJ) were stratified into high(n = 20 vs 43), inter- recurrence would often occur within 6 months and it is mediate(n = 111 vs 48) and low(n = 24 vs 7) risk group necessary to comprehend early recurrence risk factors for according to FRS. We found no significant difference in improvement of treatment outcome and also effective term of CR-POPF, Length of stay, Reoperation rate, Mor- chemotherapy for recurrence prevention. tality rate and postop complications rate between both Purpose: The study aims to clarify early recurrence risk techniques. factors by comparing histopathological factors between the early recurrence group and the non-early recurrence group in the resected cases of pancreas cancer. CR-POPF after PD in different risk groups Subject and method: The study has retrospectively CR-POPF DmPJ InvPJ P-value examined 92 resected cases of pancreas cancer in our High risk 4 (20%) 11 (25.6%) 0.63 hospital. The study divided the subjects into 2 groups as the Intermediate risk 18 (16.2%) 9 (18.7%) 0.69 early recurrence group (ER group, n = 20) and the non- early recurrence group (NR group, n = 72), then compared Low risk 0 (0%) 1 (14.3%) 0.23 the histopathological factors. Early recurrence was defined as recurrence within 180 days after surgery. Conclusion: Duct to mucosa PJ and invagination PJ Result: Total recurrence rate for pancreatic cancer was anastomosis techniques after pancreaticoduodenectomy 69.3%. However, the early recurrence rate within 6 months have no significant difference in term of CR-POPF and was 21.7%. Hepatic metastasis was the largest initial other postoperative results in all risk groups of patients. recurrence region in ER group (50.0%) and significantly than NR group. When examining the histopathological factors, serosal side of the anterior pancreatic tissue inva- EP02D-040 sion (S), multiple organ infiltration (OO) and lymph node CT ATTENUATION RATIO OF fi metastasis (N) were signi cantly higher in ER group. In PANCREATIC PARENCHYMA PREDICT multivariate analysis, the study found early recurrence risk factors with an independence of multiple organ infiltration POSTOPERATIVE PANCREATIC (OO) (p = 0.034, odds ratio 0.081, 95% CI: 0.008e0.827). FISTULA AFTER Conclusion: The early recurrence risk factor for pancreas PANCREATICODUODENECTOMY fi cancer was multiple organ in ltration (OO). Hepatic H. Maehira, H. Iida, N. Kitamura, H. Mori, N. Nitta, metastasis actually occurred most commonly in ER group. T. Miyake, T. Shimizu and M. Tani Department of Surgery, Shiga University of Medical Sci- ence, Japan EP02D-039 Introduction: Postoperative pancreatic fistula (POPF) after DUCT-TO-MUCOSA VS INVAGINATION pancreaticoduodenectomy (PD) is the dangerous compli- PANCREATICOJEJUNOSTOMY cation. This study’s aim is to quantify the pancreatic stiff- RECONSTRUCTION AFTER ness by computed tomography (CT) attenuation and assess PANCREATICODUODENECTOMY: the relationship of CT attenuation and POPF. Methods: Between January 2011 and October 2017, the FISTULA RISK SCORE medical records of 115 patients who underwent PD and STRATIFICATION ANALYSIS performed dynamic CT preoperatively were reviewed A. Sattaratnamai and P. Navicharern retrospectively. POPF group defined as any cases with Surgery, King Chulalongkorn Memorial Hospital, POPF Grade B and C by ISGPS criteria. The CT attenua- Thailand tion value of non-enhanced (N), arterial (A), portal (P), and Introduction: The rate of clinically relevant postoperative late (L) phase in the remnant pancreas was determined by pancreatic fistula (CR-POPF) remains high. Regarding the dynamic CT, and A/N, A/P, and P/L ratio were calculated. techniques of pancreaticojejunostomy anasmosis to reduce The CT attenuation ratio were compared between POPF POPF, still no consensus exists. Duct to mucosa PJ(DmPJ) and non-POPF groups. and invagination PJ(InvPJ) are two classic techniques. Results: Thirty-two patients (27.8%) categorized POPF fi Many studies have compared both techniques, but the group. In univariate analysis, A/N ratio was not signi cant < outcomes are still inconclusive. Recently, the Fistula risk difference (P = 0.908), yet A/P ratio (P 0.001) and P/L fi score (FRS) for CR-POPF was proposed to stratify patients ratio (P=0.018) were signi cantly higher in POPF group. In fi into negligible, low, intermediate and high risk groups. Our the preoperative ndings, multivariate analysis showed that A/P ratio (p < 0.001, Odds ratio 13.1) and P/L ratio

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(p = 0.042, Odds ratio 3.33) were independent predictive EP02D-041 National outcomes factors for POPF. A/P ratio and P/L ratio cut-off value for a predictor of POPF was determined using ROC curve analysis; A/P ratio and P/L ratio cut-off value were 1.19 (AUC 0.811, sensitivity 81.2%, specificity 75.9%) and 1.17 (AUC 0.643, sensitivity 71.9%, specificity 54.2%) respectively. Conclusions: The enhancement pattern of pancreatic pa- renchyma related with the occurrence of clinically relevant POPF. Especially, A/P ratio had a high diagnostic value for POPF.

EP02D-041 CONTEMPORARY OUTCOMES AFTER PANCREATODUODENECTOMY IN A COMPLETE NATIONAL COHORT: SHORT-TERM MORBIDITY AND MORTALITY WITHIN A UNIVERSAL HEALTH CARE SYSTEM L. S. Nymo1,2, K. Søreide3,4,5, F. Olsen6, D. Kleive7,8 and K. Lassen1,8 1Institute of Clinical Medicine, The Arctic University of Norway, 2Department of Gastrointestinal Surgery, Uni- versity Hospital of North Norway, 3University of Bergen, 4Stavanger University Hospital, Norway, 5Royal Infirmary Conclusion: In contrast to other national series, the of Edinburgh, United Kingdom, 6Centre for Clinical contemporary practice of pancreatoduodenectomies in Documentation and Analysis (SKDE), Regional Health Norway demonstrates favourable short-term outcomes on a Authority North, 7University of Oslo, and 8Department of national level with negligible regional differences in Hepatobiliary and Pancreatic Surgery, Rikshospitalet, outcomes. Oslo University Hospital, Norway Introduction: Outcomes from selected patient series and trials excluding old and frail patients may underestimate the EP02D-042 real burden of complications after pancreatoduodenec- SURGICAL MANAGEMENT OF BILIARY tomies. The aim of this study was to describe the outcomes STRICTURES DUE TO CHRONIC after pancreatoduodenectomy in an unselected cohort with follow-up beyond in-hospital data. PANCREATITIS: A PROSPECTIVE NON- Methods: An observational, cohort study from the Na- RANDOMIZED STUDY tional Patient Registry (NPR) for the period of 2012e2016 S. Tratsyak1, S. Rashchynski2, N. Rashchynskaya3 and including all pancreatoduodenectomies in Norway. Y. Baravik4 Outcome measures were 90-d mortality, rate of reoperation 1Hospital of Emergency Medical Care, 2Belarusian State (relaparotomy) and readmissions, and all nights spent in Medical University, 3Hepatobiliary Surgery, Hospital of any hospital within 30 days from index surgery (aggregated Emergency Medical Care, and 4Hepatobiliary Surgery, Length-of-Stay, a-LoS). Belarusian State Medical University, Belarus Results: Some 930 patients underwent pancreatoduode- Introduction: Biliary stricture (BS) has been increasingly nectomy during the study period. The 90-day mortality recognized as complication of chronic pancreatitis (CP). rate was 3.7% (n = 34). Reoperation rate was 14.1% The aim of this single-center non-randomized prospective (n = 131) and 18.3% (n = 24) of reoperations were study was to analyze and compare results of different types performed outside index hospital. Readmission rate was of biliary reconstruction during carried out local resection e 12.4% (n = 115). Median a-LoS was 14 days (IQR 10 of the head of the pancreas. fi 21). In multivariate analysis, male patients had signi - Methods: Forty nine patients were included in this study. cantly higher 90-day mortality and reoperation rate The common bile duct was widely opened into resulting compared to women, and 90-day mortality rates increased cavity after pancreatic head resection and Roux-en-Y je- fi  signi cantly for both genders if aged 65 years. Vascular junal limb was included to drain BS in 21 cases (group“1”). reconstruction (national rate 14.9%) was not associated Choledochojejunostomy with Roux-en-Y anastomosis has with mortality or reoperation. Multi-visceral resection been performed at 28 patients (group“2”). Early post- (national rate 4.7%) was associated with reoperation but operative morbidity and mortality were evaluated in both not mortality. The national pancreatoduodenectomy groups. Quality of life was measured prospectively before resection rate was 3.4/100 000 inhabitants per year. Age- surgery and during follow-up (12 and 36 months) using the тМ and gender adjusted resection rates did not differ between MOS SF-36 v.2 . the geographical regions (p = 0.929), and the outcomes Results: The overall surgical morbidity was significantly were comparable. higher in the “1”-group (c2 = 6,504, df = 1, p = 0,011).

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Mortality - only one case in group“1” (c2 = 3,200, df = 1, utilized in this study, and was determined by body mass р = 0,783). There was an average communication between index, pancreatic duct diameter and pancreatic pathology. biliary reconstruction and frequency of relapse of symp- A cut-off cumulative risk score 6wasconsidereda toms and progressions CP after operation group’s “1”/“2” predictor for PF after PD. The risk score was applied to (Fisher exact р = 0,014). Total pain score decreased and our local hospital data to assess its utility as a clinical quality of life increased significantly after surgery in both tool. groups after 12 months and were not significant to increase Methods: Data for PD patients were retrieved from a during 36 months follow up. prospectively collected database. The risk score was Conclusion: Both surgical procedures led to significant calculated and clinically relevant pancreatic fistula (Grade improvement in the quality of life and pain relief after sur- B/C fistula according to the 2016 ISGPF definition) was gical BS reconstruction due to CP. Under equal conditions, recorded. Benign and malignant pancreatic diseases the preference should be given to choledochojejunostomy requiring PD were included in the study. Patients with with Roux-en-Y anastomosis because has better shot-term incomplete risk score data were excluded. results. Results: The study period was between June 2012 and July 2017. Eighty patients underwent PD (male, n = 46) with mean age 62.9 years (range 35e83). Biochemical EP02D-043 leak occurred in sixteen patients (20%) and grade B/C fi INITIAL EXPERIENCE OF stula occurred in eleven patients (13.8%). In the pa- tients with risk score <6, there were three grade B/C LAPAROSCOPIC ROBOT-ASSISTED fistulas. For patients with risk score 6, there were PANCREATICODUODENECTOMY eight grade B/C fistulas. The sensitivity, specificity, M. -S. Park positive predictive and negative predictive values for a Surgery, Kyung Hee University, Republic of Korea risk score 6 in the prediction of clinically relevant PF Background: Laparoscopic robot-assisted pancreatico- after PD in our patient cohort were 0.73, 0.64, 0.24 and duodenectomy is a novel minimally invasive surgery 0.94 respectively. fi technique. Robotic surgery has the significant advantage of Conclusion: The clinical utility of the pancreatic stula  3D magnified view, stable handling and precise suturing score 6 in predicting clinically relevant PF was limited by due to enhanced degree of freedom. We sought to deter- the low sensitivity and positive predictive value when mine the safety and feasibility of the first laparoscopic applied to our local PD patient cohort. robot-assisted pancreaticoduodenectomies performed at our institution. Methods: Six patients underwent laparoscopic robot- EP02D-045 assisted pancreaticoduodenectomy from January 2017 to DRAIN FLUID AMYLASE ON POST- December 2017. OPERATIVE DAY 5 AS PRONOSTIC Results: Eight patients were scheduled for laparoscopic FACTOR OF GRADE BeC PANCREATIC robot-assisted pancreaticoduodenectomy; 2 were conver- ted to a mini-laparotomy during the laparoscopic portion FISTULA AFTER DISTAL of the procedure. The patients were diagnosed as PANCREATECTOMY pancreatic adenocarcinoma(n = 2), cholangiocarcino- N. Ridaura Capellino, G. P. Protti Ruiz, ma(n = 1), ampullary adenocarcinoma(n = 1), and C. Dopazo Taboada, L. Blanco Cuso, E. Pando, M. Caralt, intraductal papillary mucinous neoplasm (n = 2). The J. Balsells and R. Charco mean operative time was 545Æ49 minutes. The mean Hospital Universitari Vall Hebron, Spain Æ blood loss was 193 126 ml. There was 1 (16.6%) Background: Post-operative pancreatic fistula (POPF) is Clavien III-IV complication which required readmission. one of the most feared complications after distal pancrea- Æ The mean postoperative hospital stay was 17.9 10.1 tectomy (DP) and associates an increased morbidity and days. mortality. Conclusion: Laparoscopic robot-assisted pancreaticoduo- Aim: To analyze the incidence and risk factors of POPFs in denectomy could be performed successfully in selected our series and stratify the risk factors for grade B/C POPFs patients. after DP. Methods: We performed a single-center retrospective study which analyzes patients who underwent DP between EP02D-044 2010 and 2017. We recollected demographic, surgical, UTILITY OF A RISK SCORE IN THE post-operative and histological data. Drain fluid amylase PREDICTION OF CLINICALLY was examined on postoperative day 3, 5 and 7, following fi RELEVANT POST- our protocol. POPFs were classi ed according to the In- ternational Study Group of Pancreatic Fistula definitions. PANCREATICODUODENECTOMY We performed a descriptive analysis and multivariate lo- PANCREATIC FISTULA gistic regression to determine the prognostic factors of A. K. Y. Fung, C. C. Chong, K. F. Lee, J. Wong, POPF Y. S. Cheung, A. K. W. Fong, H. T. Lok and P. B. S. Lai Results: A total of 92 patients underwent DP. Laparoscopic Prince of Wales Hospital, Hong Kong approach was performed in 39 (42%) patients, with a Introduction: Pancreatic fistula (PF) is a life-threatening conversion rate of 22%. In 85% of the cases we used complication after pancreaticoduodenectomy (PD). The endostapler and in 24% we performed manual suture of the pancreatic fistula risk score devised by Casadei was pancreatic stump. Sealant was placed on the resection

HPB 2018, 20 (S2), S505eS684 S602 Electronic Posters (EP02A-EP02F) e Pancreas surface in 60% of the cases. POPF was diagnosed in 26% of EP02D-048 the patients, of whom 19% were grade B-C. None of the variables analyzed were significantly associated with ESTIMATED PANCREATIC REMNANT POPF, but the drain fluid amylase >1000 U/L on post- VOLUME AS A PREDICTOR OF operative day 5, was associated with grade B-C POPFs [OR CLINICALLY SIGNIFICANT 20, p = 0.028 (CI 1.301e287)]. PANCREATIC FISTULA POST Conclusion: In our series, no overall POPF predictive PANCREATODUODENECTOMY factors were found after DP. However, an elevated drain 1 1 1 1 fl S. Kaushik , N. Nagesh , B. Vinay , H. Venugopal , uid amylase on post-operative day 5 can predict a 1 2 fl K. Ashok Kumar and K. Harisha worst outcome and should in uence our therapeutic 1 strategy. Surgical Gastroenterology and Liver Transplant, and 2Department of Radiodiagnostics, PMSSY, Bangalore Medical College and Research Institute, India fi EP02D-047 Introduction: Pancreatic stula is a major causative factor in post operative morbidity and mortality especially after a POSTOPERATIVE REACTIVE C pancreatoduodenectomy. Studies to ascertain “at risk” pa- PROTEIN ASSOCIATED WITH tients in the past have incorporated intra operative and post MORBIDITY (GASTROPARESIS AND operative parameters. We aimed to identify distal pancre- FISTULA) AFTER WHIPPLE atic remnant volume as a pre operative predictor of Clini- PROCEDURE cally significant post operative pancreatic fistula (CS- POPF). M. Rodriguez-Lopez, F. J. Tejero-Pintor, Methods: This prospective single blinded study was con- B. Perez-Saborido, A. Barrera-Rebollo, ducted at a tertiary referral centre from August 2016 to M. Bailon-Cuadrado, K. T. Plua-Muniz, September 2017. All patients (n = 24) who underwent a E. Choolani-Bhojwani, F. Acebes-Garcia and pancreatoduodenectomy were included and those who D. Pacheco-Sanchez succumbed to the procedure during the index hospital General and Digestive Surgery, Rio Hortega University admission were excluded (n = 1). All patients were Hospital, Spain subjected to a multi phasic computerised tomography pre Introduction: Early postoperative biomarkers (C reactive operatively and the estimated pancreatic remnant volume protein PCR, procalcitonin PCT, arterial lactate) analysis (EPRV) calculated (to the left of the superior mesenteric for prediction of morbidity after pancreatoduodenectomy artery) (Fig 1). (PD). Methods: Prospective case-control analysis of consecutive PD performed during 2015, 2016 and 2017 at the Rio- Hortega University Hospital, Valladolid, Spain. Main out- comes: overall morbidity (OM), Clavien III morbidity, surgical site infection (SSI). Secondary outcomes: gastro- paresis, pancreatic fistula (PF), hemorrhage (according to ISGPS: no appearance versus grades A, B and C). Mean values of RCP, PCT and arterial lactate (obtained from morning blood samples on first and second postoperative days [POD1, POD2]) were compared among cases (appearance of complication) and control patients (without complication). ROC curves and AUC were obtained. Sta- tistics: SPSS 24. Results: 41 patients (age 64.1 Æ 10.5 years, 61% males). Rates of OM, Clavien III morbidity, SSI, gastroparesis, PF, hemorrhage were respectively: 87.8%, 34.1%, 19.5%, 37.5%, 26.8%, 24.4%, respectively. For OM, PCT-POD1 and Lactate-POD1 lower among controls (0.33 versus 1.49 p = 0.02, 1.31 versus 1.81 p = 0.08). For gastroparesis, PCR-POD2 was lower among controls (177 versus 264 p = 0.005). For PF, PCR-POD2 and Lactate-POD2 were lower among controls (186 versus 278 p = 0.005, 1.2 versus 1.5 p = 0.003). No biomarker was associated with Clavien III complications or hemorrhage. AUC were highest for PCT-POD1 (0.816, Figure Estimated pancreatic remnant volume 95% CI = 0.655e0.976 p = 0.01) and PCR-POD2 (gastroparesis: 0.772, 95% CI = 0.628e0.916 p = 0.004; CS-POPF was defined as per the ISGPF group. PF: 0.753, 95% CI = 0.57e0.935 p = 0.014). Results: Receiver operating characteristic curve analysis Conclusion: Increased PCT-POD1 is associated to OM as showed that the estimated pancreatic remnant volume of well as increased PCR-POD2 to gastroparesis and PF. They >40.41 cc had a high sensitivity (1.0) and a low false positive should be determined during early postoperative period in rate (0.235) with an AUC of 0.908 for the development of patients undergoing PD. CS- POPF. Multivariate analysis including the well known

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S603 risk factors and the remnant volume also indicated volume of prompt a re do anastomosis or a low threshold for in- >40.41cc to be significant (longer duration of drain tube terventions in the post operative period. placement, more interventions and longer hospital stay). Conclusions: Estimation of EPRV using the pre operative CT is highly predictive of developing a CS- POPF and may EP02D-051 help in the management and developing a pre operative risk COMPARISONS OF OUTCOME IN score for patients undergoing a Pancreatoduodenectomy. ELDERLY AND YOUNG PATIENTS UNDERGOING EP02D-049 PANCREATICODUODENECTOMY INTRA OPERATIVE AMYLASE VALUES WITH ENHANCED RECOVERY AFTER AS A PREDICTOR FOR CLINICALLY SURGERY PROTOCOL RELEVANT PANCREATIC FISTULA L. Kaman, D. Dahiya, K. Chakarbarthi and A. Behera FORMATION General Surgery, Post Graduate Institute of Medical Ed- ucation and Research, India S. Kaushik, N. Nagesh, B. Vinay, H. Venugopal and Introduction: The numbers of patients undergoing K. Ashok Kumar pancreaticoduodenectomy is increasing and considerable Surgical Gastroenterology and Liver Transplant, Banga- percentage are elderly patients. Pancreaticoduodenectomy lore Medical College and Research Institute, India is a major and complicated surgery. The morbidity and fi Introduction: Pancreatic stula formation after pancrea- mortality following pancreaticoduodenectomy has signifi- toduodenectomy can jeopardise the recovery from this cantly reduced in recent times; it still remains unclear in historically morbid surgery and also is potentially life elderly patients. Applications of Enhanced Recovery after threatening. We aim to determine a risk factor for devel- Surgery protocol have contributed for this better outcome. oping CR-POPF intra operatively thereby potentially Methods: Retrospective study. Patients who underwent avoiding a tumultuous post operative course. pancreaticoduodenectomy with Enhanced Recovery after Methods: This prospective study at a tertiary referral centre Surgery protocol were included and divided into two was conducted between August 2016 and September 2017. groups (<60 years Vs 60 years). Outcomes were Patients who underwent a pancreatoduodenectomy were analyzed in terms of post-operative morbidity, mortality included (n = 24) and those who succumbed to the procedure and length of hospital stay. were excluded. After the duct to mucosa pancreatojejunos- Results: Total 103 patients underwent pancreaticoduode- tomy was done by a single surgeon in all cases, a thorough nectomy during the study period (Jan 2011- Dec 2017). The fl abdominal lavage was carried out and all the uid suctioned mean age was 56.6 Æ 10.32 years. Fifty six (54.37%) pa- fi off and the eld made dry. After rest of the gastrointestinal tients were aged <60 years (Young group) and 47 fl reconstructions were done, about 3 ml of uid collected in the (45.63%) patients were aged 60 years (Elderly group). peri pancreatic area was collected and analysed. Post oper- There was no difference between the groups in terms of fi fi ative pancreatic stula was de ned as per the ISGPF criteria. age, gender, co-morbidity, preoperative drainage and Results: Intra operative amylase levels were determined in diagnosis. There was no significant difference in the 24 patients. They were compared with post operative day 3 morbidity and mortality (p > 0.05). Delayed gastric fi amylase estimations and found to be statistically signi cant emptying was the most common complication 25.24% to predict the development of clinically relevant post (21% vs 23.41%). Pancreatic fistula rate was 13.59% (8.9% fi operative stula. At levels of 366 U/ml, the test had a high vs 12.76%) and hemorrhage was 4.85% (5.4% vs 4.3%). sensitivity (1.0) and a false positive rate of 0.52 and AUC Mortality was 4.85%. Post-operative hospital stay was of 0.64 (Fig 1). comparable (14.7 days vs 15.3 days) (p = 0.164). Conclusions: Pancreaticoduodenectomy is a safe surgical procedure in elderly patients in comparison to young pa- tients. Application of Enhanced Recovery after Surgery protocol can improve the outcome further.

EP02D-053 THE PREDICTORS AND PATTERNS OF THE EARLY RECURRENCE OF PANCREATIC CANCER AFTER SURGERY: THE INFLUENCE OF PREOPERATIVE CHEMORADIOTHERAPY Figure ROC- Intra operative amylase levels H. Suto, K. Okano, M. Oshima, Y. Ando and Y. Suzuki Gastroenterological Surgery, Kagawa University, Japan Conclusion: Intra operative amylase determination can Introduction: The perioperative factors predicting or accurately predict the development of clinically relevant influencing early pancreatic ductal adenocarcinoma pancreatic fistula in the post pancreatoduodenectomy sce- (PDAC) recurrence are unclear. This study attempted to nario. For patients with a positive test or high levels,it can identify the predictive factors for early PDAC recurrence

HPB 2018, 20 (S2), S505eS684 S604 Electronic Posters (EP02A-EP02F) e Pancreas post-pancreatectomy and the influence of preoperative 3.1 cm (range 1.2e12.5 cm) and all cases had benign chemoradiotherapy (CRT). tumors at the final pathologic diagnosis. Two patients (9%) Method: One hundred and fifteen patients undergoing developed pancreatic fistula. There were no differences of curative resection for PDAC between 2000 and 2016 at our clinical outcomes between open and laparoscopic enucle- institution were retrospectively analyzed. Patients were ation groups. During follow-up period (median, 80 divided into two groups: those who did and did not expe- months), all patients were alive with no recurrence or new rience PDAC recurrence within 6 months postoperatively. onset of diabetes. Results: Thirty-four (30%) patients experienced early Conclusion: Excellent result was achieved after pancreatic recurrence. Multivariate analyses demonstrated that post- enucleation, supporting the consideration as the treatment operative carbohydrate antigen 19-9 (CA19-9) de-normal- option for benign and borderline pancreatic neoplasms. ization, no postoperative adjuvant chemotherapy, and serosal invasion were independent risk factors for early recurrence (P < 0.001, P = 0.001, and P = 0.010, respec- EP02D-055 tively). A subgroup analysis showed that patients with PREOPERATIVE INFLAMMATORY AND (n=51) and without (n = 64) preoperative CRT had different predictors. CA19-9 denormalization and serosal invasion NUTRITIONAL STATUS SCORES AND were significant indicators in patients with preoperative BIOMARKERS ASSOCIATED WITH CRT, but postoperative adjuvant chemotherapy was not a MORBIDITY AFTER WHIPPLE significant indicator. However, CA19-9 de-normalization PROCEDURE and no postoperative adjuvant chemotherapy were signifi- M. Rodriguez-Lopez, F. J. Tejero-Pintor, cant indicators in patients without preoperative CRT. B. Perez-Saborido, A. Barrera-Rebollo, Recurrence pattern analyses indicated that preoperative M. Bailon-Cuadrado, E. Asensio-Diaz, CRT strongly prevented early local recurrence; post- L. M. Diez-Gonzalez, P. Pinto-Fuentes and operative adjuvant chemotherapy prevented early distant D. Pacheco-Sanchez recurrence. Only 6/39 (15%) patients who were treated with General and Digestive Surgery, Rio Hortega University both preoperative CRT and postoperative adjuvant Hospital, Spain chemotherapy had early recurrence. fl Conclusions: Although postoperative adjuvant chemo- Introduction: Preoperative in ammatory and nutritional therapy was an important preventive measure against early status scores and biomarkers (neutrophil/lymphocyte ratio recurrence, particularly for distant recurrence, preoperative NLR, platelet/lymphocyte ratio PLR, prognostic nutritional CRT might compensate for a lack of postoperative adjuvant index PNI, Glasgow prognostic score GPS, albumin and chemotherapy. Preoperative CRT could prevent the early prealbumin) analysis for prediction of morbidity after local recurrence of PDAC. These perioperative adjuvant pancreatoduodenectomy (PD). therapies could have a complementary relationship. Methods: Prospective case-control analysis of consecutive PD performed during 2015, 2016 and 2017 at Rio-Hortega University Hospital (Valladolid, Spain). Main outcomes: overall morbidity (OM), Clavien III morbidity, surgical EP02D-054 site infection (SSI). Secondary outcomes: gastroparesis, FEASIBILITY AND ONCOLOGIC pancreatic fistula (PF), hemorrhage (according to ISGPS: OUTCOMES OF PANCREATIC no appearance versus grades A, B and C). Mean values of ENUCLEATION: SINGLE-CENTER NLR, PLR, PNI, GPS, albumin and prealbumin (obtained EXPERIENCE WITH 22 CONSECUTIVE from blood samples immediately before operation) were PATIENTS compared among cases (complication appearance) and control patients. ROC curves and AUC were obtained. J. C. Chung, H. C. Kim and J. S. Lee Statistics: SPSS 24. Soonchunhyang University Bucheon Hospital, Republic of Results: 41 patients (age 64.1 Æ 10.5 years, 61% males). Korea Rates of OM, Clavien III morbidity, SSI, gastroparesis, Introduction: Although major standard pancreatic resec- PF, hemorrhage were respectively: 87.8%, 34.1%, 19.5%, tion can be performed with low morbidity and mortality 37.5%, 26.8%, 24.4%. Statistical association was found rate, resection of a large amount of normal pancreas can be between:- associated with an increased risk of endocrine or exocrine insufficiency. Compared with major pancreatic resections, NLR: higher values among cases suffering SSI (1.56 pancreatic enucleation leads to less morbidity and preserves versus 2.29, p = 0.015).- normal parenchyma as well as pancreatic function. There- PLR: higher values among cases suffering PF (102 fore, the purpose of this study was to present our experience versus 135, p = 0.025) and SSI (102 versus 148, p = 0.03).- and to evaluate the clinical outcomes after pancreatic Prealbumin: lower value among cases suffering Clavien enucleation. III morbidity (18.3 versus 24.4, p = 0.04). Method: Between May 2005 and June 2017, 22 patients who underwent pancreatic enucleation were analyzed Highest AUC was obtained for PLR and SSI (0.837, 95% through a retrospective review of medical records. CI = 0.690e0.985, p = 0.006) Results: The patients comprised 17 women and 5 men, Conclusion: Impaired inflammatory and nutritional con- with a median age of 49 years (range 19e67 years), all of dition is somehow associated with worse outcomes after whom were treated by pancreatic enucleation (eleven open/ PD. Particularly, PLR and prealbumin might predict PF and eleven laparoscopic). The median diameter of tumor was severe morbidity, respectively.

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EP02D-056 cases) in whom decreased slightly were compared and IS FISTULA RISK SCORE FOR examined. Results: The median rate of decrease in muscle mass at 3 POSTOPERATIVE PANCREATIC months after pancreatic cancer surgery was 10.9%. There FISTULA STILL APPLICABLE IN was no significant difference in background, perioperative MINIMALLY INVASIVE APPROACH OF factor, treatment outcome and cumulative survival rate PPPD? between the two groups (High MCR group 358 days vs. Low MCR group 456 days, p = 0.463). In a subgroup S. Y. Rho, J. W. Jung, H. K. Hwang, C. M. Kang and analysis of 21 patients of distal pancreatectomy (DP), the W. J. Lee survival was significantly poor in the low muscle group Department of Surgery, Yonsei University College of (High MCR group 456 days vs. Low MCR group 1014 Medicine, Republic of Korea days, p = 0.044). Background: Despite the technological advancement of a Conclusion: Pancreatic cancer patients had muscle mass minimally invasive approach to Pylorus -preserving decreasing more than 10.9% in 3 months after surgery. In pancreaticoduodenectomy (PPPD), the morbidity is still DP, postoperative muscle mass decreasing may contribute fi high. The aim of this study is validate the stula risk score to survival. in minimally invasive approach of PPPD and find the other meaningful parameter for prediction of POPF. Method and materials: We retrospectively reviewed 99 patients who underwent minimally invasive approach to EP02D-058 PPPD in Severance hospital, Seoul, Korea from January COMPARATIVE STUDY OF 2008 to August 2017. ENDOSCOPIC AND SURGICAL Results: Among the total patients (N = 99), POPF were AMPULLECTOMY FOR BENIGN 51 (51.5%). Biochemical leak were 39 (39.4%) and Grade AMPULLARY LESIONS B was 9 (9.1%), Grade C was 3 (3.0%). Fistula risk scroe A. Gracient1, R. Delcenserie2, D. Chatelain3, F. Brazier2, (FRS) 6 was 29 patients and FRS 3 (N = 19), FRS J. -P. Lemouel2 and J. -M. Regimbeau1,4 5(N = 14), FRS 1 (N = 12). In univariate analysis of 1Digestive and Metabolic Surgery, 2Gastroenterology POPF (biochemical leak, B and C), soft gland texture Department, 3Department of Pathology, Universitary (OR 19.056 , p value 0.000 ) , pancreatic duct size (OR Hospital of Amiens, and 4SSPC (Simplification des Soins 0.809, p-value 0.019) and FRS (OR 1.526, p-value 0.000) des Patients Complexes), Research Unit Universitary of were statistically significant. In multivariate analysis of Picardie Jules Verne, France Clinically relavant POPF (POPF B, C), body mass index(BMI) was statistically significant (adjusted OR Purpose: To evaluate and compare the results of endo- 1.367, 95% CI 1.035e1.806, p-value 0.028). Area under scopic and surgical ampullectomy for presumed benign  curve of BMI was 0.676 in Receiver operating charac- lesions (adenoma, us T1N0). teristic curve (p-value 0.049). Material and method: From 2007 to 2017, 65 patients Conclusions: Fistula risk score is significant prediction were eligible for ampullectomy. The criteria studied were: fi factor of POPF including biochemical leaks. In addition morbidity, mean length of stay (LOS), de nitive histology, to the previously known FRS variables, our data showed complete resection, follow-up, recurrence, distant compli- that BMI is an important predictor of POPF with clin- cations and the complete treatment rate (mean complete ical relavancy in a minimally invasive approach of resection and no recurrence). PPPD. Results: In the endoscopy group, 40 were eligible, 35 ampullectomy were performed, 5 were sent to surgeon: the EP02D-057 morbidity was 10%; the LOS was 3.3 days; 9 patients had fi SIGNIFICANCE OF MUSCLE MASS no adenomatous lesions on the de nitive histology; 30% resection was R1, 0% was R2; average follow-up was 17 DECREASING ON PROGNOSIS AFTER months; recurrence rate was 19%; biliary stenosis rate was PANCREATIC CANCER SURGERY 2%; complete treatment rate of 53%. In the surgical group, H. Mori, H. Iida, N. Kitamura, H. Maehira, T. Miyake, 30 were eligible (Initially 25 + 5 sent by endoscopists), 22 T. Shimizu and M. Tani ampullectomy were performed, 7 were convert to Surgery, Shiga University of Medical Science, Japan pancreatoduodenectomy, 1 abstention (discovery of Aim: The relationship between preoperative sarcopenia metastasis): morbidity was 35%; LOS was 10 days; 6 pa- and its prognosis has been drawing attention in cancer tients had invasive adenocarcinoma; 14% of the resection patients. We examined the influence of postoperative was R1, 5% was R2; average follow-up was 28 months; muscle mass change in patients with pancreatic cancer. recurrence rate of 4%; biliary stenosis rate was 8%; com- Methods: In 71 patients of pancreatic cancer surgery be- plete treatment rate of 93%. tween January 2011 and June 2016, 63 patients who un- Conclusion: The short-term and long-term results of pa- derwent CT imaging at 3 months after surgery were tients undergoing endoscopic or surgical ampullectomy are evaluated the rate of decrease of preoperative muscle mass different. The lesions are less severe, with simpler suites in to postoperative muscle mass using L3 level skeletal endoscopy group. The lesions are more severe, with more muscle area (cm2) on CT imaging. The survival of high morbid sequels, but with a better rate of complete treatment grade muscle change rate (High MCR group: 31 cases) in and better long-term results for surgical ampullectomy whom muscle mass decreased significantly after surgery, group. and low grade muscle change rate (Low MCR group: 32

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EP02D-059 2016, the subjects were 261 (74.4%) who underwent R0 resection. According to the 8th version of the TNM clas- THE CLINICAL IMPACT OF sification, T/N/stage classifications were conducted. NEOADJUVANT THERAPY FOLLOWED Results: With respect to the T classification, the 5-year sur- BY SURGERY AND CA19-9 LEVEL FOR vival rates in the T1, T2, and T3 patients were 57.4, 26.2, and LOCALLY ADVANCED PANCREATIC 5.8%, respectively, showing significant differences. With fi CANCER respect to the N classi cation, the rates in the N0, N1, and N2 patients were 43.0, 22.8, and 9.2%, respectively, showing S. Takano, H. Yoshitomi, S. Kagawa, K. Furukawa, significant differences. With respect to the stage, the 5-year T. Takayashiki, S. Kuboki, D. Suzuki, N. Sakai, survival rates in the stage IA, IB, IIB, and III patients were H. Nojima and M. Ohtsuka 66.4, 36.3, 22.8, and 10.9%, respectively. In the stage IIA and General Surgery, Chiba University Graduate School of IV patients, it was impossible to calculate the rates. The sur- Medicine, Japan vival rates in the stage IIA (p = 0.036) and III (p = 0.003) Introduction: Pancreatic cancer (PDAC) has a highly patients were significantly lower than in the stage IIB patients. invasive and metastatic potential. To overcome this, cura- Conclusion: The T and N classifications based on the 8th tive resection with multidisciplinary therapy is crucial for version of the TNM classification accurately reflected the the improvement of patients’ prognosis. Herein, we prognosis of pancreatic cancer patients who underwent R0 compared the clinico-pathological parameters and out- resection, suggesting their usefulness. Staging mostly re- comes between surgery first (SF) group and neoadjuvant flected the prognosis, but the survival rates were reversed therapy (NAT) group for treatment of patients with locally between the stage IIA and IIB patients. Of the subjects, the advanced pancreatic head cancer (BR, UR-LA PDAC). prognoses of the stage IIA, III, and IV patients were Methods: Consecutive all 137 patients with BR/UR-LA particularly unfavorable. head-PDAC were performed pancreaticoduodenectomy or total pancreatectomy in our department from April 2002 to Oct 2016. Among all these patients, 63 and 44 patients in EP02D-061 BR, and 12 and 18 patients in UR-LA were classified into SF and NAT groups, respectively. THE IMPACT OF TUMOR Results: Comparing between SF and NAT, no significant DIFFERENTIATION ON differences were observed in the major clinico-pathological PERIOPERATIVE OUTCOMES AND factors. Median overall survival times of patients were 22.3 PATTERNS OF RECURRENCE months for SF and 27.4 months for NAT in BR, and 9.5 FOLLOWING PREOPERATIVE months for SF and 18.7 months for NAT in UR-LA. THERAPY FOR RESECTABLE Furthermore, the Kaplan-Meier analyses showed significantly better prognosis in NAT than those in SF, specifically in BR- PANCREATIC ADENOCARCINOMA A (p = 0.0054) and UR-LA (p = 0.0025). Focusing on the J. Lindberg1, L. Prakash1, J. N. Vauthey1, T. Aloia1, clinical significance of CA19-9 level, we determined whether C. -W. Tzeng1, J. Fleming2, J. Lee1, M. Katz1 and CA19-9 level after NAT is useful as a surrogate marker for M. Kim1 longer survival of patients after surgery. The analyses sug- 1Surgical Oncology, University of Texas MD Anderson gested that CA19-9 < 100 after NAT is a good prediction Cancer Center, and 2Gastrointestinal Oncology, Moffitt marker for longer survival of patients after operation. Cancer Center, United States Conclusion: NAT is a crucial option in treatment for pa- Background: Tumor differentiation affects local invasion tients with BR/UR-LA PDAC. CA19-9 level after NAT and patient survival in many cancers. The impact of might be a useful marker for determining optimal patients pancreatic ductal adenocarcinoma (PDAC) differentiation undergone surgery. on patterns of recurrence and complications following preoperative therapy and pancreatectomy is poorly defined. Methods: A retrospective analysis of a prospectively EP02D-060 maintained database was conducted of all patients who RECLASSIFICATION OF PANCREATIC underwent pancreatectomy for PDAC from 2011e2015 CANCER PATIENTS WHO UNDERWENT following preoperative therapy (chemotherapy, radiation, or combination). Differences in clinicopathologic charac- R0 RESECTION USING THE TNM teristics, operative details, perioperative complications, CLASSIFICATION (8TH VERSION) AND overall (OS) and recurrence-free survival (RFS) were RESULTS OF TREATMENT compared between patients stratified by tumor differentia- N. Yazawa1, D. Furukawa1, H. Izumi2, M. Yamada1, tion (moderate or poor). Y. Masuoka1, T. Mashiko1 and T. Nakagori1 Results: Among 156 pancreatectomy patients, 112 (72%) 1Department of Surgery, Tokai University School of had moderately differentiated (MD) tumors and 44 (28%) Medicine, and 2Department of Surgery, Tokai University poorly differentiated (PD) tumors. The groups had similar Hachioji Hospital, Japan demographics, median CA19-9, co-morbidity index, and type of preoperative therapy. Tumor size, T and N stage, Purpose: The purpose of this study was to reclassify lymph node ratio, and incidence of lymphovascular inva- pancreatic cancer patients who underwent R0 resection sion were similar, while perineural invasion was more based on the 8th version of the TNM classification and common in PD than MD tumors(91% vs 76%, p = 0.03). clarify the results of treatment. There were no differences in the incidence of Clavien- Methods: Of 351 patients with pancreatic adenocarcinoma Dindo grade III/IV complications, rates of grade B or C who underwent resection between May 2003 and February

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S607 fi post-operative pancreatic stulae or delayed gastric EP02D-063 emptying. There were no differences in median OS (32 vs 48 months, p = 0.86), median RFS(16 vs 36 months, IS PANCREATICOGASTROSTOMY A p = 0.17), or patterns of recurrence (local, regional, or SAFER ALTERNATIVE TO RESTORE distant) between MD and PD tumors. PANCREATICO-DIGESTIVE Conclusions: Poorly differentiated PDAC is characterized CONTINUITY THAN by more frequent or persistent perineural invasion relative to PANCREATICOJEJUNOSTOMY moderately differentiated tumors following preoperative M. Nambada1,P.V.S.1 and M. K. Voonna2 therapy. However, tumor differentiation has no impact on 1 2 postoperative patterns of local or distant tumor recurrence or Surgical Gastroenterology, Apollo Hospital, and Surgi- the incidence or severity of post-operative complications. cal Oncology, Mahatma Gandhi Cancer Hospital & Research Institute, India

Complications Table Background: Pancreatic anastomotic leakage posesone of the biggest challenges to a pancreatic surgeon. Many techniques have been described for restoring pancreatico-digestive con- tinuity, none of which is proven to be the best till date. Objective: To assess the outcomes following pancreati- cojejunostomy (PJ) and pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD). Methods: It is a retrospective analysis of 41 Whipple pro- cedures done between June 2014 and September 2017. PJ was performed in duct to mucosa fashion in patients with dilated ducts (>3.3 mm, the size of 10Fr feeding tube). PG was EP02D-062 performed in a dunking manner through the posterior stomach THE OUTCOME OF THE wall in patients with small ducts (<3.3 mm). The primary fi LAPAROSCOPIC outcome measure was rate of pancreatic stula. Secondary outcomes measured were, overall morbidity, postoperative PANCREATODUODENECTOMY IN A length of hospital stay and rates of reintervention. CENTER Results: PJ was performed in 21 and PG in 20 patients. L. Tran Cong Duy, T. Nguyen Duc, D. Le Tien, Age, gender, preoperative bilirubin, incidence of preoper- V. Dang Quoc and P. Pham Hong ative biliary drainage, pancreatic texture, operating time, University Medical Center, Viet Nam blood loss and blood transfusions were identical in both the fi Introduction: Laparoscopic pancreatoduodenectomy (LP) study groups. The rate of pancreatic stula (p = 0.01) and fi remains one of the most advanced applications for mini- the overall morbidity (p = 0.017) were signi cantly higher mally invasive surgery. Thanks to new advances in tech- in the PJ group. Rates of delayed gastric emtying did not fi nology and instrument within the past decade, the attain statistical signi cance (p = 0.099). Rates of re- fi sophisticated laparoscopic procedures, such as pancreato- intervention and mortality did not attain statistical signi - duodenectomy, are gaining in popularity. cance. The length of postoperative hospital stay was fi Methods: Data were collected from 35 patients who un- signi cantly lower in the PG group (p = 0.041). derwent an LP from 2010 to 2017. The authors analyzed Conclusions: Pancreaticogastrostomy appears to be a safe mean age, operating time, blood loss, pathological findings, procedure for pancreatico-digestive continuity following complications, mortality and recurrent rate. pancreaticoduodenectomy in patients with small pancreatic Results: The mean age of 54.1 Æ 2.3 years. Intra- ducts. The choice may be extended to those with dilated operatively, the mean operative time was 7.6 Æ 1.3 hours, ducts too. and the mean blood loss of 131.4 Æ 40.4 ml. The compli- cations included 11.4% grade C pancreatic fistula (ISGPS 2016) reoperated and 11.4% abdominal fluid collection. EP02D-064 There was no death case in hospital stay, with the median INCREASED POSTOPERATIVE length of 12 days. 65.7% of LP was total and the other was COMPLICATIONS IN OCTOGENARIANS hybrid procedure. The pathological results included 77.1% adenocarcinoma, 14.3% mucinous cystadenoma, and 8.6% FOLLOWING chronic inflammation. Those malignant lesions were at the PANCREATICODUODENECTOMY ampulla of Vater (74.1%), terminal part of common bile LEADS TO HIGHER POSTOPERATIVE duct (18.5%) and head pancreas (7.4%). Lymph node MORTALITY AND COSTS involvement was not in 22 out of 27 malignant specimens. F. Yuan1, L. Latchupatula2, L. Ruo3, D. Dath3, 21 patients with cancerous tumors were followed-up. The M. Marcaccio3, V. Tandan3, C. -S. Gu4, A. Gafni5 and overall survival rates within 1- and 5-years of resection P. Serrano3 were 66.7% and 13.3%, respectively. The recurrent rate 1University of Virginia, United States, 2Medicine, 3Sur- was 20% with disease-free survival time within 1- and 5- gery, 4Oncology, and 5Health Research Methods, Evi- years of resection being 70% and 15%, respectively. dence, and Impact, McMaster University, Canada Conclusion: This research shows that the laparoscopic Introduction: We investigated the risks factors for post- pancreatoduodenectomy is not only a feasible but also safe operative complications, mortality and costs associated procedure for wide application with acceptable rates of with pancreaticoduodenectomy in octogenarians. complications and recurrence.

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Methods: Retrospective cohort of consecutive patients Introduction: Patient comorbidities and body mass index undergoing pancreaticoduodenectomy at one institution (BMI) analysis for prediction of morbidity after pancrea- from 2009e2017. Demographics, operative data, including toduodenectomy (PD). costs were obtained from databases. Risk for postoperative Methods: Prospective cohort analysis of consecutive PD complications were calculated by univariable and multi- performed during 2015, 2016 and 2017 at Rio-Hortega variable analyses. University Hospital (Valladolid, Spain). Results: 448 patients were included: 402 patients (<80 Outcomes: Overall morbidity (OM), Clavien III years-old, median = 65) and 46 octogenarians morbidity, surgical site infection (SSI). Secondary out- (median = 82). Median ASA class was higher in octoge- comes: gastroparesis, pancreatic fistula (PF), hemorrhage narians (4 vs. 3, P = 0.005). Length of hospital stay was (according to ISGPS: no appearance versus grades A, B and longer in this group also (11 vs. 8 days, P = 0.002). Overall C). Rate of these outcomes were compared between cohort postoperative complication (74% vs. 67%, P = 0.337), of patients presenting or not cardiovascular diseases major complications (28% vs. 23%, P = 0.438) and the (including hypertension), diabetes, hyperlipidemia, smok- comprehensive complication index (21 vs.12, P = 0.104) ing. Cohorts according to ASA score (I, II versus III, IV) were similar between groups. Mortality was higher among and BMI (<25 versus 25e30 versus >30) were also octogenarians (11% vs. 4%, P = 0.048); mainly due to compared. Highest relative risks (RR) will be notified. higher pneumonia (22% vs. 6%, P < 0.001) and myocardial Statistics: SPSS 24. infarction rate (17% vs. 5%, P = 0.002). Age remained the Results: 41 patients (age 64.1 Æ 10.5 years, 61% males). most important factor associated with postoperative mor- Rates of OM, Clavien III morbidity, SSI, gastroparesis, tality in the multivariable analysis. There was a trend for a PF, hemorrhage were respectively: 87.8%, 34.1%, 19.5%, higher mean overall cost among octogenarians, $40,767 37.5%, 26.8%, 24.4%. Statistical differences between co- (SD = 46,678) vs. $31,473 (SD = 31,222) mainly driven by horts are shown in Table 1.

EP02D-065 Table 1 OM Clavien ‡III SSI Gastroparesis PF Hemorrhage Diabetes (no/yes) 90% / 60% n.s. n.s. n.s. 35% / 0% p=0.039 n.s. p=0.047 Hyperlipidemia (no/ n.s. 22% / 50% ** n.s. 22% / 59% n.s. n.s. yes) p<0.10 p=0.024 Smoking (no/yes) n.s. n.s. n.s. n.s. n.s. 17%/46% ** p<0.10 ASA (I,II / III,IV) n.s. 25% / 54% ** n.s. 25% / 67% p=0.03 18% / 46% ** n.s. p<0.10 p<0.10 BMI (<25 / 25-30 / n.s. 17% / 31% / 75% 6% / 19% / 50% 18% / 44% / 71% 6% / 37% / 50% n.s. >30) p=0.019 p=0.042 p=0.034 p=0.02 Highest RR (for BMI: BMI (RR=14.0, 95% BMI (RR=16.0, 95% BMI (RR=11.7, BMI (RR=16.0, 95% <25 versus >30) CI=1.8-106.5) CI=1.4-185.4) 95%CI=1.5 CI=1.4-185.4) -91.5) a higher cost of primary surgery, $37,950 (SD = 45,306) vs. CV diseases did not obtain statistical significance for any $27,528 (SD = 21,342). outcome. Conclusions: Pancreaticoduodenectomy in octogenarians Conclusion: Some baseline patient’s comorbidities worsen is associated with a higher rate of major postoperative outcomes after PD. Obesity has an important impact, complications such as pneumonia and myocardial infarc- increasing postoperative complications rate. Inconsistent tion which leads to higher postoperative mortality. This results for diabetes as protective factor are probably due to higher rate of complications also leads to a longer hospital low heterogeneous sample size. stay and higher costs for the healthcare system, which if considered affordable, the decision to proceed with surgery should be left to the informed patient. EP02D-066 THE IMPACT OF AGE ON TREATMENT FOR PANCREATIC DUCTAL EP02D-065 ADENOCARCINOMA (PDAC) WITH PATIENT’S BMI AND SOME BASELINE CURATIVE INTENT: IS AGE A COMORBIDITIES ARE ASSOCIATED BARRIER? WITH COMPLICATIONS AFTER 1 2 1 WHIPPLE PROCEDURE A. K. Malik , A. Lamarca , A. K. Siriwardena , D. A. O’Reilly1, R. Deshpande1, A. Sheen1, S. Jamdar1, M. Rodriguez-Lopez, A. Barrera-Rebollo, M. G. McNamara2,3, J. W. Valle2,3 and B. Perez-Saborido, E. Asensio-Diaz, M. Bailon-Cuadrado, N. De Liguori-Carino1 K. T. Plua-Muniz, F. J. Tejero-Pintor, 1Department of HPB Surgery, Manchester Royal In- S. Mambrilla-Herrero and D. Pacheco-Sanchez firmary, 2Department of Medical Oncology, European General and Digestive Surgery, Rio Hortega University Neuroendocrine Tumour Society (ENETS) Centre of Hospital, Spain Excellence, The Christie NHS Foundation Trust, and

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3Division of Cancer Sciences, Manchester Academic Results: From 12/2002 to 12/2017, 26 patients with LAPC Health Science Centre, University of Manchester, United (16 males and 10 females, median age 61.5 yrs (range: 49e Kingdom 87 yrs)) underwent pancreatic resection with concomitant Introduction: Surgery followed by adjuvant chemotherapy resection and reconstruction of major visceral arteries in (aCT) is the standard of care for resectable pancreatic ductal our institution. The arterial involvement included CA adenocarcinoma (PDAC). The impact of age on the cura- (n = 13), SMA (n = 11) and both CA and SMA (n = 2). tive management and outcomes of patients with PDAC was Resections included Whipple resection) (n = 16), distal investigated. pancreatectomy (n = 5), and total pancreatectomy (n = 5). Methods: Patients who underwent curative resection for Management of the arterial involvement included: resection PDAC at two units (merged in 2014) were retrospectively without reconstruction (n = 4), reconstruction of one reviewed (between 2005e2017). Patients were stratified by (n = 13), two (n = 7), three (n = 1), and four (n = 1) visceral age (elderly defined 70-years). Logistic and Cox regres- arteries. All arterial reconstructions were performed using sion were employed to explore factors impacting on autologous veins. R0 resection was accomplished in 22, R1 administration of adjuvant chemotherapy and survival in 2, and R2 in 2 patient. Median hospital stay was 13 days. analysis, respectively. The Kaplan-Meier method was used Thirty-day peri-operative mortality was 4%. Six patient did to estimate overall survival (OS) (time from surgery to not receive chemotherapy. Twenty patients received death). Statistical significance was set at p < 0.05. neoadjuvant and/or adjuvant chemo- or chemo-radiation Results: From 2005e2014, 101 and 54 patients were therapy outside protocols. For those patients, PD-OS was identified from each unit and from 2014, 67 patients were 21 months, PO-OS - 19 months and DFS - 15 months identified from the merged unit (n = 222; <70-years (Fig.1). n = 128; 70-years n = 94). Elderly patients (EP) were less Conclusions: R0 resection combined with arterial resection likely to receive aCT compared to younger patients (YP) and reconstruction can be accomplished with improved (odds-ratio 0.57, p = 0.041). Tumour stage, resection survival of patients with LAPC. margin, gender and year of surgery (post-2011 vs. pre- 2011) were not predictors for aCT receipt (p > 0.05). Post- operatively, frailty was the commonest reason (36.8%) to decline aCT in EP; relapse was the predominant reason in YP (42.9%). In patients receiving aCT, completion rates (p = 0.32) and OS (24-months vs. 30-months, p = 0.50) were no different; disease-free survival was greater in EP (17-months vs. 14-months, p = 0.04). Conclusions: EP receiving aCT demonstrate similar out- comes to YP, yet are less likely to commence chemotherapy due to frailty. Holistic preoperative assessment, tools predicting post-operative outcomes and prehabilitation pro- grams may improve selection of EP for curative treatment.

Figure PD-OS, PO-OS and DFS of patients on chemotherapy EP02D-067 R0 RESECTION OF LOCALLY ADVANCED PANCREATIC CANCER EP02D-068 (LAPC) INVOLVING MAJOR VISCERAL ANALGESIC MANAGEMENT AND ARTERIES (T4 LESIONS) USING OUTCOMES IN PATIENTS ARTERIAL RESECTIONS AND UNDERGOING PANCREATECTOMY RECONSTRUCTIONS: SHORT- AND J. V. Groen1, J. Vuijk2, C. H. Martini2, D. Slotboom1, LONG-TERM OUTCOMES A. Dahan2, R. J. Swijnenburg1, A. L. Vahrmeijer1, Y. Genyk1, E. Alicuben1, A. Barzi2, A. Sahakian2, B. A. Bonsing1 and J. S. Mieog1 A. El-Khoueiry2, J. Buxbaum2, S. Iqbal2, J. Van Dam2, 1Surgery, and 2Anesthesiology, Leiden University Medical H. -J. Lenz2 and R. Selby1 Center, The Netherlands 1 2 Surgery, and Medicine, University of Southern Califor- Epidural analgesia (EA) is the golden standard for nia, United States analgesic management in abdominal surgery. However, the Introduction: Surgical management of LAPC invading golden standard in patients undergoing pancreatectomy has visceral arteries remain controversial. The objective of this yet to be determined, demonstrated by the variety of re- study was to analyze the outcomes of resection of LAPC ported use of EA (z10%e84%). The aim of this study was encasing visceral arteries using arterial resection and to evaluate the pratice of analgesic management and out- reconstruction. comes after pancreatectomy in our tertiary referral center. Method: The data were collected prospectively in surgical All patients undergoing open pancreatectomy from June patients with LAPC involving the celiac axis (CA) or su- 2013 through December 2016 were reviewed. Patients were perior mesenteric artery (SMA). The post-operative (PO- screened preoperative to determine eligibility for EA. The OS) and post-diagnosis (PD-OS) medium overall survival, type of analgesia during surgery determined the group in and disease-free survival (DFS) were calculated utilizing which patients were included: EA or non-EA (N-EA). Kaplan-Meier survival probability estimates. According to protocol EA is stopped on postoperative day

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(POD) 3. Primary outcome was mean painscore (11-point Results: Overall POPF occurred in 22 (16.4%). POPF rate scale) per POD. was 17.2% (n = 14) in the PG group and 15.1% (n = 8) in In total, 163 (74.8%) patients with EA and 55 (25.2%) pa- the PJ group (P = 0.466). In High risk group (n = 45) for tients with N-EA (of which 48 (87.3%) patients received POPF, there was 3 (18.8%) POPF in PG group and 9 intravenous Morphine) were included. The groups were (31.9%) in PJ group, respectively (p = 0.30). POPF rate largely comparable regarding patient characteristics. Initial were not different in moderate, low and negligible risks analgesia was stopped prematurely in 47 (28.8%) patients with between two reconstructive methods. There were also no EAandin1(2.1%)patientwithintravenous Morphine. Pa- significant differences of other morbidity such as post tients with EA had significantly lower painscores on POD0-1, pancreatic hemorrhage, intra abdominal abscess, delayed whereas they experienced higher painscores on POD3-4. gastric emptying and mortality between two groups. Conclusion: In PD, there was no superior method of recon- struction with regards of POPF, even in high risk glands.

EP02D-070 RISK FACTORS OF PANCREATIC LEAK AFTER DUODENOPANCREATECTOMY L. Alonso Murillo, P. Rioja Conde, M. García Conde, I. Justo Alonso, O. A. Nutu, P. Del Pozo Elso, S. Salamea Sarmiento, A. A. Marcacuzco Quinto, O. Caso Maestro and L. C. Jiménez Romero Hospital Universitario 12 de Octubre, Spain Introduction: Duodenopancreatectomy is the only cura- tive option in the management of malignant neoplasms involving the head of the pancreas. However, this is not a morbidity-free procedure (30-50%); pancreatic leaks are one of its major complications. Methods: From January 2012 to December 2017, 104 duodenopancreatectomies were performed in our center. We compared two groups: group 1 patients without clini- FigurePainscores per postoperative day cally relevant pancreatic leak (83 patients), and group 2 patients with grade B or C pancreatic leak (21 patients). Fluid balances were similar between the groups. The EA Results: There were no differences between both groups in group received more catecholamines perioperative. Post- terms of age, sex, alcohol intake, smoking, ASA Class, tumor operative complications did not differ between the groups. stage or whether a pylorus-preserving technique was used. The results of this study demonstrate EA is safe and Pancreatic leak development was associated with a Wirsung reliable in selected patients after open pancreatectomy. duct smaller than 3 mm in 55% of cases in group 2 vs 32.5% fi Patients with EA experience signi cantly lower painscores in group 1 (p = 0.037). A soft pancreas was described in fi in the rst PODs, therefore extending the period of EA after 38.6% in group 1 vs 57.1% in group2 (p = 0.209). Reopera- POD3 could be considered. tion rate was higher in group 2 38.1% vs 10% (p = 0.009), as were delayed gastric emptying grades B and C 47.6% vs 19.3% (p = 0.000), postoperative haemorrhage B and C EP02D-069 23.8% vs 9.6% (p = 0.079) and bile leak 23.8% vs 3.6% MATCHED ANALYSIS OF POPF USING (p = 0.008). Postoperative mortality (90 d) was 2.6% in group FISTULA RISK SCORE ACCORDING TO 1 vs 19% in group 2 (p = 0.064). Multivariate analysis shows a fi < PANCREATICOENTEROSTOMY signi cant association between Wirsung size 3mmand pancreatic leak; OR3.88 (1.27e11.88; p = 0.017). METHOD Conclusion: Pancreatic leak is one of the most dangerous K. Paik1 and J. S. Oh2 complications after pancreaticoduodenectomy, and is often 1Yeouido St.Mary’s Hospital, Catholic Univ. Korea, and associated with other complications. Wirsung size <3mm 2Yeouido St.Mary’s Hospital, Republic of Korea is the only risk factor for pancreatic fistulas B and C ac- Background: Postoperative pancreatic fistula (POPF) is cording to our data. the most important morbidity after pancreaticoduodenec- tomy (PD). However, the best reconstruction method to reduce occurrence of fistula is not conclusive, especially in EP02D-071 high risk gland for POPF. TOO OLD FOR WHIPPLE SURGERY? A Aim: To examine whether pancreaticogastrostomy (PG) or RETROSPECTIVE STUDY COMPARING pancreaticojejunostomy (PJ) is the better reconstructive method to reduce POPF, after PD according to Fistula Risks. MORBIDITY AND MORTALITY OF NON- Methods: Retrospective analysis of prospectively collected FRAIL PATIENTS STRATIFIED BY AGE data of 134 patients who underwent PG (81, 60.4%) and PJ P. Vuong, M. Zubair and P. Saldinger (53, 39.6%) reconstruction between January 2002 and New York Presbyterian Queens, Weill Cornell Medicine, December 2016 in single institution. United States

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Introduction: The incidence of pancreatic cancer in the Results:1. aging population is likely to increase but there is a lack of data regarding the mortality and morbidity of pancreatico- Among57patients,thePSVTwasfoundin25 duodenectomy in the elderly. We aim to delineate whether (48.9%) patients. There were 4 (16%) patients in type A, increasing age is an independent risk factor for worse 8 (32%) in type B, 3 (12%) in type C and 10 (40%) in outcomes when looking at non-frail elderly patients. type D. In patients with the PSVT, average age was 50.0 Method: A retrospective study was conducted of 18,256 years, male to female ratio was 15/10 and average BMI patients undergoing pancreaticoduodenectomy from the was 22.7 kg/m2. Ten patients (40%) underwent anti- 2010e2016 National Surgical Quality Improvement Pro- coagulation therapy. There was no mortality due to the gram. Patients with a modified frailty index of 0e0.2 were PSVT.2. considered non-frail or “robust”, and stratified into six co- In univariate analysis of predictive factors for the PSVT, horts by age: 45 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, RSV length (>30 mm) (P < 0.0001), SV mechanical 85 to 89. Multivariate logistic regression was used to dissection (P = 0.037), intra-abdominal abscess (P = 0.037), compare 30-day mortality and morbidity between each laparoscopic surgery (P = 0.029) and type A were extrac- cohort and those aged 45 to 64 years while adjusting for ted. In multivariate analysis, RSV length (P < 0.0001), differences in preoperative patient characteristics. intra-abdominal abscess (P = 0.01) and type A (P = 0.01) Results: Of the 18,256 patients, 54.2% were 65 years or were independent predictive factors. older with 8.7% aged 80 and up. Increasing age was Conclusion: RSV length, intra-abdominal abscess and type associated with a step-wise increase in risk of 30-day A after DP were predictive factors for the PSVT, therefore; mortality with those aged 80 and up 2.1 times more likely it is necessary to evaluate carefully the imaging study in to die and those aged 85 and up 3.5 times more likely to die cases with these factors. after surgery.

EP02D-073 Risk adjusted odds ratio of mortality ABDOMINAL SKIN CLOSURE USING Age, years Odds ratio (95% CI) SUBCUTICULAR SUTURES PREVENTS 65 to 69 1.72 1.21 – 2.43 INCISIONAL SURGICAL SITE 70 to 74 2.05 1.45 – 2.90 INFECTION IN HEPATO-PANCREATO- 75 to 79 2.27 1.56 – 3.39 BILIARY SURGERY 80 to 84 2.09 1.33 – 3.28 S. Okubo, N. Gotohda, D. Takahashi, M. Sugimoto, 85 to 89 3.53 1.90 – 6.57 S. Kobayashi, S. Takahashi and M. Konishi Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, Japan Conclusions: Although the risk of major complication was Background: Hepato-pancreato-biliary (HPB) surgery has similar across the different age groups, the risk-adjusted a high incidence of postoperative morbidity including mortality increased substantially in the elderly. This sug- incisional surgical site infection (SSI). Although several gests that even in the robust elderly patient undergoing studies showed that subcuticular sutures reduced incisional pancreaticoduodenectomy, chronological age may start to SSI in other fields of surgery, their impact on HPB surgery show its effect with each postoperative complication. remains unknown. The aim of this study was to assess whether subcuticular sutures could reduce incisional SSI in patients undergoing HPB surgery. EP02D-072 Methods: The data of 435 consecutive patients who un- PREDICTIVE FACTORS FOR PORTAL derwent laparotomy and surgical resection for HPB tumors AND SPLENIC VEIN THROMBOSIS at our department from May 2013 to December 2015 were analyzed. The incidence of incisional SSI was compared AFTER DISTAL PANCREATECTOMY between use of subcuticular sutures and of stapling using N. Tanaka, S. Yamada, H. Takami, M. Suenaga, propensity score analyses. M. Hayashi, Y. Niwa and Y. Kodera Results: In the baseline cohort (n = 435), abdominal skin Gastroenterological Surgery, Nagoya University Graduate closure was performed by subcuticular sutures in 249 School of Medicine, Japan patients (57.2%) and by stapling in 186 patients (42.8%). Introduction: The aim was to identify predictive factors The incidence of incisional SSI was 5/249 (2.0%) in the for Portal or Splenic Vein Thrombosis (PSVT) after Distal subcuticular suture group and 22/186 (11.8%) in the Pancreatectomy (DP). stapling group (chi-squared test, P < 0.01). In the pro- Methods: Two hundred thirty patients who underwent DP pensity score-matched cohort (n = 326), patient de- were enrolled, and the PSVT was evaluated by post- mographics were well balanced between the two groups, operative CT examination. Cases with Spleen-preserving and the incidence of incisional SSI was 4/163 (2.5%) in DP and no residual splenic vein (RSV) were excluded, and the subcuticular suture group and 15/163 (9.2%) in the 57 patients were evaluated. The correlation between the stapling group (chi-squared test, P < 0.01). Propensity PSVT and clinicopathological factors, and predictive fac- score analyses (matching and inverse-probability weight- tors were analyzed. Patterns of drainage vein into RSV ing model), as well as simple regression analyses, showed were classified into type A (IMV/LGV preserved), type B that subcuticular sutures could meaningfully and consis- (IMV preserved), type C (LGV preserved) and type D (no tently reduce incisional SSI (with odd ratios between 0.15 drainage vein). and 0.25).

HPB 2018, 20 (S2), S505eS684 S612 Electronic Posters (EP02A-EP02F) e Pancreas

Conclusions: Use of subcuticular sutures is preferred to Methods: This study is a retrospective review of a pro- stapling for preventing incisional SSI in HPB surgery. spectively maintained database collected from consecutive patients who underwent minimally invasive distal pancre- atectomy between January 2011 and January 2016. EP02D-074 Results: Thirty and 13 patients underwent robotic and EFFECTS OF NUTRITIONAL STATUS laparoscopic distal pancreatectomy (RDP and LDP). The mean operative time was 232.6 Æ 63.6 minutes in laparo- ON FUNCTION AND CLINICAL scopic group and 214.5 Æ 83.7 minutes in robotic group. OUTCOMES IN ELDERLY PATIENTS The mean blood loss in the two groups were 465.3 Æv642.3 WITH PERIAMPULLARY NEOPLASM and 375 Æ 419.5 mL. All of the 30 RDPs were successfully E. Kim, J. -Y. Jang, Y. Han, J. Kim, W. Kwon and completed, however, there was one case of open conversion S. -W. Kim in laparoscopic group. Spleen preservation in robotic group fi Department of Surgery and Cancer Research Institute, was achieved in 16 (53.3%) patients. Clinically signi cant fi Seoul National University College of Medicine, Republic postoperative pancreatic stula in robotic group was detec- fi of Korea ted in 4 (13.3%) patients. There were no signi cant differ- ences between the two groups regarding the postoperative Malnutrition affects morbidity, functions and quality of outcomes (P > 0.05). The rate of mortality was zero. life (QOL) in the elderly. Yet, it often remains unaddressed Conclusion: This study suggests that RDP is feasible for before and after surgery. The aim was to investigate func- patients with benign or borderline tumors at the body or tail tion, QOL, and clinical outcome after pancreatoduodenec- of the pancreas. It may be considered as an effective sur- tomy according to the nutritional status in elderly with gical procedure for benign or borderline tumors of the periampullary neoplasm. pancreas in the future; however, further studies to confirm Data were prospectively collected from 154 elderly this are warranted. (65) between 2008 and 2014. Nutritional status was evaluated with Mini Nutrition Assessment (MNA). Nutri- tional status was classified as well-nourished (MNA22), at-risk of malnutrition (MNA15.5-21.5), and malnourished EP02D-076 (MNA15). Five function scales (physical, cognitive, OUTCOME OF 112 FREY’S PROCEDURE emotional, social, role) and QOL were measured using the IN HEAD DOMINANT CHRONIC EORTC QLQ-C30 questionnaires. Data were collected PANCREATITIS, IN TERTIARY serially for 1 year. REFERRAL CENTERS OF DHAKA, The prevalence of preoperative malnutrition was 27.3%, and more than 50% were at-risk of malnutrition. One year BANGLADESH after the surgery, over 70% of patients were at-risk of H. Rabbi1,2, M. M. Rashid1, H. N. Hakim3, M. Ali1, malnutrition or malnourished.The advanced age (75) had M. M. Sarder4, A. T. Ahmaed1, A. Q. Chowdhury4, more complication and longer hospital stay (p = .047; M. A. Islam4 and A. N. Azam4 p = .043). Preoperatively, malnourished group demonstrated 1Hepato-Biliary-Pancreatic Surgery, BIRDEM General worse performance compared to other groups in physical Hospital, 2BRB Hospitals Ltd., 3Dhaka Medical College (p < .001), emotional (p = .031), social (p = .002), role Hospital, and 4Surgery, Dhaka Medical College Hospital, function (p < .001) and QOL (p < .001). Cognitive function Bangladesh did not differ (p = .127). The physical, role function scores Background: Frey’s Procedure is an organ preserving and QOL of the malnourished group were significantly technique with lateral pancreatico-jejunostomy using lower over all periods compared to other groups. coring of pancreatic head. Resection of “pacemaker of Malnourished elderly undergoing pancreatoduodenec- pain” (Pancreatic head) gives remarkable outcome. tomy are more likely to suffer from long-term physical, role Methods: This prospective observational study, intended to function impairment and low QOL. Vigorous efforts are further validate Frey’s procedure in head dominant chronic needed to improve nutritional status before and after sur- pancreatitis, carried out on 112 Bangladeshi patients from gery, which ultimately may improve functional outcomes January 2000 to December 2017. They were mostly from and QOL. poor socioeconomic group, followed up for 2e72 months. Result: The study revealed 54 patients (48.21%) in 3rd decade of life with 48 male and 64 female. We found, 81 EP02D-075 patients were diabetic, Steatorrhoea in 82 patients and MINIMALLY INVASIVE DISTAL Malnutrition in 85 patients. 101 patients presented with PANCREATECTOMY: COMPARISION recurrent abdominal pain with moderate pain in 72 patients (64.28 %) and severe or intolerable pain in 24 patients BETWEEN ROBOTIC AND (21.42%). Following Frey’s procedure moderate pain LAPAROSCOPIC PROCEDURES control in 37 patients (33.03%), good pain relief in 66 cases J. H. Kim, W. Jung and W. H. Kim (58.98%). Only 09 (8.03%) patients had poor pain relief. Surgery, School of Medicine, Ajou University, Republic of Postoperative morbidity was noted in 21 patients (18.75%). Korea Conclusion: Management of Pain and pancreatic insuffi- Introduction: Surgical procedures using robot-assisted ciency are major challenges that hampers quality of life in ’ surgery, including pancreatic surgery, have recently Chronic Pancreatitis. Frey s procedure with adequate become popular. This study aimed to report our initial ex- ductal clearance and wide pancreato-jejunal anastomosis is periences with distal pancreatectomy procedures using the key to better pain control, improves quality of life and robot-assisted surgery system. prevents recurrence.

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EP02D-077 EP02D-078 SURGICAL RESECTION FOR FACTORS INFLUENCING OPERATIVE ADENOSQUAMOUS CARCINOMA OF MORTALITY IN PANCREATICO THE PANCREAS DUODENECTOMY IN INDONESIA T. Ito, T. Sugiura, Y. Okamura, Y. Yamamoto, T. Lalisang1,2, W. Jeo1,2 and Y. Mazni1,2 R. Ashida and K. Uesaka 1Digestive Surgery Division, Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Universitas Indonesia, and 2Cipto Mangunkusumo Hos- Cancer Center, Japan pital, Indonesia Introduction: Adenosquamous carcinoma of the pancreas Introduction: Operative mortality in Pancreatico is a rare malignancy less than 4% of pancreatic tumors. Duodenal (PD) resection has already decreased to less than Previous series have demonstrated a poor prognosis for this 5% in excellent and high volume Pancreatic center. How- disease, with a median survival in the range of 5 to 6 ever, the factors influencing operative mortality in PD may months. differ between countries due to difference in characteristics. Method: Between 2002 and 2016, a total of 568 patients This report demonstrates the demographic data and char- underwent surgical resection for invasive ductal carcinoma acteristics in Operative Mortality Group (OpMG) and of the pancreas at our institute. Of them, 17 patients (2.9%) Operative Survivor Group (OpSG) in PD resection cases. were identified as having adenosquamous carcinoma of the Methods: Retrospective analytic study was done on PD pancreas. Operative, pathologic and survival evaluations resection due to Periampulary tumor cases at Cipto were conducted. Mangunkusumo Hospital 1998e2016. Results: Operative procedures included pancreaticoduo- Result:

EP02D-078 Factors Influencing PD Operative Mortality Group OpSG OpMG p value Number of Patients 168 (81.3%) 34 (18.7%) Demographic Data Female/ Male; Mean age 80 (47.6)/88 (52.4); 50.35 ± 9.68 13 (38.2)/21 (61.8); 53.41 ± 9.56 0.317; 0.095 (year) Blood Count Result Hemoglobin (g/dL); 11.4 ± 1.56; 33.75 ± 4.13; 9850 11.62 ± 1.49; 34.01 ± 4.98; 9635 0.519; 0.817; Hematocrit (%); WBC (ml) (3700-27600) (4410 - 37100) 0.518 Bilirubin (mg/dL); Albumin (mg/L) 5.93 (0 - 30); 3.41 ± 0.61 7.76 (0 - 18); 3.41 ± 0.56 0.586; 0.426 Ureum (mg/dL); Creatinin (U/L); Bile Duct 23.50 (6-134); 0.70 (0 - 4); 93 27.50 (13 - 107); 0.80 (0 - 3); 14 0.250; 0.124; decompression (55.4) (41.2) 0.131 Operative Procedure Whipple P3D 53 (32.7); 109(64.3) 14 (43.8); 18 (54.2) 0.230 Operative time (minute) Blood lost (mL) 420 (245 - 700); 500 (100 - 3000) 450 (300 - 600); 600 (200 - 2000) 0.568; 0.784 Outcome Re-laparotomy ; SSI; Pneumonia 15 (9.8); 51 (40.8); 3 (1.8) 15 (46.9); 6 (35.3); 3 (8.8) <0.001; 0.664; 0.061 DGE; Pancreatic Leaks; Bleeding 11 (6.5); 5 (3); 4 (2.4) 0(0); 3 (8.8); 9 (26.5) 0.217; 0.134; <0.001

denectomy in six and distal pancreatectomy in eleven. There was no statistically significant difference in de- Combined resection due to macroscopic cancer invasion mographic factors, perioperative laboratory data, and bile included stomach in six, colon in five, kidney in one, portal duct decompression procedure between the two groups. vein in seven and celiac axis in three, respectively. R0 Two out of four operative variables and six operative out- resection could be achieved in 16 (94%) patients. Eleven comes had statistically significant difference. patients received postoperative adjuvant chemotherapy. Conclusion: Re-laparotomy and post-operative bleeding The median size of tumor was 50 mm (19e96 mm). Lymph were the factors influencing operative mortality. node metastasis was detected in eleven patients. Micro- scopic cancer invasion to the other organs were detected in four patients. Five year disease-free survival rates and EP02D-079 median disease-free survival time were 27% and 9.0 MORPHOLOGICAL AND FUNCTIONAL months, respectively. Five year overall survival rate and median survival time were 39% and 30.0 months, respec- CHANGES IN REMNANT PANCREAS tively. At the time of analysis, four patients survived for LONG-TERM AFTER more than 5 years without recurrence. PANCREATICODUODENECTOMY Conclusions: Compared to the previous reports, the T. Adachi, S. Ono, H. Matsushima, T. Adachi, present study of our single-center experience has M. Yamashita, A. Soyama, M. Hidaka, M. Takatsuki and demonstrated a longer survival. Although this is a small S. Eguchi series, we recommend aggressive surgical resection for Department of Surgery, Nagasaki University, Japan these patients. Background and aim: Pancreaticoduodenectomy (PD) may lead to long-term pancreatic exocrine and endocrine

HPB 2018, 20 (S2), S505eS684 S614 Electronic Posters (EP02A-EP02F) e Pancreas insufficiency. Our previous study revealed that the time- (HR = 9.419; 95% Cl = 2.015e44.036; P = 0.004), as well as signal intensity curve (TIC) of the pancreas obtained from neural infiltration (HR = 0.197; 95.0% CI: 0.044e0.876; dynamic contrast enhanced MRI reflects the fibrosis of the P = 0.033) were independent prognostic factors for overall remnant pancreas (Tajima et al. J Surg Res, 2010). Here we survival. In conclusion, changes in the KRAS mutation status retrospectively investigated the long-term functional and between pre- and postoperative cfDNA may be a useful morphological changes of the remnant pancreas after PD. prediction biomarker of survival and treatment responses Patients and method: Twenty-five patients who survived after surgery for PDAC patients. more than 5 years after PD underwent yearly monitoring of the main pancreatic duct (MPD) size by CT and determi- nation of the TIC of the remnant pancreas. Clinical profiles EP02D-081 fi and postoperative pancreatic stula (PF) were also assessed. IS THERE ANY DIFFERENT RISK Results: There was a statistically significant relationship between the presence of postoperative PF (36% (9/25)) and FACTOR FOR CLINICAL RELEVANT development of postoperative MPD dilatation (16% (4/25)) PANCREATIC FISTULA ACCORDING (p=0.03). The patterns of preoperative pancreatic TIC of the TO THE STUMP CLOSURE METHOD patients were normal in 19 patients and fibrotic in six pa- FOLLOWING LEFT SIDE tients. Of these 6 patients, 4 changed to normal TIC and PANCREATECTOMY? showed no postoperative MPD dilatation after 5 years. Of 1 2 the 19 preoperative normal TIC patients, 5 changed to a K. Paik and J. S. Oh 1 ’ fibrotic TIC postoperatively and all five of these patients Yeouido St.Mary s Hospital, Catholic Univ. Korea, and 2 ’ showed sustained postoperative MPD dilatation. There Yeouido St.Mary s Hospital, Republic of Korea were no patients who newly developed diabetes mellitus Background: No consistent risk factor for PF after LP after 5 years even in the patients with fibrotic pancreas. according to the stump closure methods had not been Conclusion: MPD dilation after PD was related to PF revealed yet. This study investigated risk factor for PF development. Although preoperative pancreatic fibrosis according to the closure methods during LP. was reversible after PD, it would cause postoperative pro- Methods: The risk factors of pancreatic fistulas were gressive MPD dilatation. However, glucose tolerance is investigated in 49 underwent LPs according stump closure: maintained relatively well even after pancreatic fibrosis. hand-sewn suture (n = 19), and stapler closure (n = 30). The risk factors for PF after LP with a stapler and hand sewn were identified based on univariate and multivariate analyses. fi EP02D-080 Results: There was no signi cant difference in the inci- dence of POPF between the two types of stump closure KRAS MUTATIONS IN CELL-FREE DNA (hand-sewn suture 42.1% vs stapler closure 50.0%), CR- FROM PRE- AND POSTOPERATIVE POPF was not different in 5.3% HS than ST 6.7% also. In SERA AS A PANCREATIC CANCER ST, the pancreas was significantly thicker at the transection MARKER line in patients with CR-POPF (27 mm) in comparison to patients without CR-POPF (17 mm) and tumor were larger M. Kitago, Y. Nakano, M. Shinoda, H. Yagi, Y. Abe, (58 mm vs 27 mm). In HS, longer operation time was K. Takano, G. Oshima, S. Matsuda, Y. Nakamura and observed in CR-POPF group (515 min vs 292 min). Wider Y. Kitagawa pancreatic duct (27 mm vs 16 mm) were associated with Dept. of Surgery,, School of Medicine, Keio University, Japan postoperative POPF in a univariate analysis in HS. There Pancreatic ductal adenocarcinoma (PDAC) has the worst was no difference of risk factor for POPF in ST. prognosis among gastrointestinal malignancies despite of Conclusions: Although near the half of patients experi- existing multimodal therapies. Circulating cell-free DNA enced POFP after LP, almost POPF were clinically insig- (cfDNA) can be used for cancer diagnosis and prediction of nificant in this study. Thicker pancreas and larger tumor treatment response. The aim of this study was to investigate significantly associated with the incidence of CR-POPF whether KRAS mutations at codon 12/13 in cfDNA of pre- after LP using stapler closure and longer operation time operative and postoperative sera from PDAC patients can associated with CR-POPF in hand sewn closure. serve as a predictive biomarker of treatment response and outcomes after surgery. Pre- and postoperative serum sam- ples obtained from PDAC patients who underwent curative pancreatectomy at our institution between January 2013 and EP02D-082 July 2016 were retrospectively analyzed. Peptide nucleic MAJOR POSTOPERATIVE acid (PNA)-directed PCR clamping was used to identify COMPLICATIONS AFTER KRAS mutations in cfDNA and a Cox proportional hazards PANCREATICODUODENECTOMY AND model was employed to determine prognostic factors for ITS ASSOCIATED FACTORS e A PDAC after surgery. Among 45 enrolled patients, 11 (24.4%) and 20 (44.4%) had KRAS mutations in cfDNA RETROSPECTIVE ANALYSIS 1 2 2 1 from preoperative and postoperative sera, respectively. Z. Zuhdi , M. I. Mohd Tamrin , S. Mokhtar and R. Jarmin 1 Multivariate analysis revealed that KRAS mutations in Hepatobiliary, Surgery, UKM Medical Centre, and 2 postoperative serum (hazard ratio [HR] = 2.919; 95% con- Hepatobiliary, Hospital Selayang, Malaysia fidence interval [CI] = 1.109e5.621; P = 0.027) was an Introduction: There are two major complications independent prognostic factor for disease-free survival. following Pancreaticoduodenectomy (PD); postoperative Furthermore, the shift from the wild type KRAS in preop- pancreatic fistula (POPF) and delayed gastric emptying erative to mutant KRAS in postoperative cfDNA (DGE). The aim of this study is to identify the risk factors

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S615 associated with both complications, as well as perioperative One patient suffered from post-pancreatectomy hemor- fluids administration. rhage (ISGPS gr. C). In total, ten patients had a major Methodology: We conducted a retrospective observational complication ( gr. III Clavien-Dindo). There were no study in 243 patients who underwent elective PD between grade IV postoperative complications and there was no the period of January 2011 until June 2016 and analysed mortality. Median length of hospital stay was 16 days (IQR: using univariate and multivariate models. There were 60 9e24). Five patients had to be readmitted within 90 days patients with POPF and 2 patients with DGE. for surgery-related complications. Result: After univariate analysis, weight, BMI, WBC at day Conclusion: Robotic pancreatoduodenectomy is safe and 3, post op INR derangement, CRP, surgical site infections feasible in selected patients. (SSI), intraabdominal collections, total fluid volume given postoperatively and fluid balance in 24 hours duration were significantly associated with higher incidence of POPF EP02D-084 < (p 0.05). Univariate analysis for the DGE showed only PERIOPERATIVE ANTIBIOTHERAPY signs of infection (p = 0.021) and intra-abdominal collec- tions (p = 0.033) were significantly associated with higher REDUCED NUMBER AND GRAVITY OF incidence of DGE. In multivariate analysis, postoperative SEPTIC COMPLICATION AFTER INR derangement OR 2.376 (p = 0.048), intra-abdominal PANCREATODUODENECTOMY < collection OR 9.842 (p 0.001), SSI OR 3.736 (p = 0.003) E. Buscail, O. Degrandi, A. Dewitte, J. -P. Adam, fl and postoperative uid balance (24 hours) OR 1.001 C. Laurent and L. Chiche < fi fi (p 0.001), were identi ed as independent signi cant risk CHU Bordeaux, France factors for POPF; and SSI OR 2.415 (p = 0.009) was the only Introduction: Pancreatoduodenectomy (PDC) is still independent significant risk factor for DGE. associated with a high morbidity rate, ranging from 30 to 50 Conclusion: Sepsis have higher association in developing %, even in high volume centers. Several retrospective both POPF and DGE. Where as BMI and postoperative studies have reported that preoperative biliary drainage fluid balance is associated with increased risk of developing (PBD) is associated with a higher rate of infectious com- POPF. plications after PDC because of bile contamination. Switching antibioprophylaxy (AP) for adapted anti- biotherapy (ATB) has been already proposed. The aim of EP02D-083 this study is to compare AP and perioperative ATB. ROBOTIC Methods: This study included 282 consecutive patients who PANCREATODUODENECTOMY: underwent PDC at the Department of Surgery, Bordeaux RESULTS OF THE FIRST TWENTY Hospital between July 2008 and July 2016, 108 patients PROCEDURES have a PBD. Patients were separated in to 2 groups: Group classic AP (n = 61), who have a single injection peroperative 1 1 1 Ò C. Nota , I. Borel Rinkes , L. de Guerre , (Cefotaxine ) and Group Perioperative ATB (n = 47) who 2 2 3 3 Ò H. van Santvoort , W. te Riele , H. Zeh , M. Hogg , have 5 days of Tazocilline started during the intervention. 1 1 J. Hagendoorn and Q. Molenaar Morbidity and abdominal infectious complication rates were 1 2 Surgery, University Medical Center Utrecht, St. Anto- evaluated. 3 nius Ziekenhuis, and University of Pittsburgh Medical Results: There were 84, 3% biliary infection with bacte- Center, United States rium resistance against the AP. There were no preoperative Introduction: Minimally invasive surgery is gaining mo- significantly differences between the 2 groups. Abdominal mentum in pancreatoduodenectomy. Presumed benefits abscess (17% vs 36, 1%, p = 0,0285), septicemia (3% vs include fewer major complications, less blood loss and a 27%, p < 0,0001), pancreatic fistula (21,3% vs 39,3%, shorter hospital stay. However, conventional laparoscopy is p = 0,0045), was higher in group AP. hindered by the straight, non-articulating instrumentation. Conclusions: PBD is associated with higher biliary in- The robot was designed to overcome these technical re- fections and septic complications after PDC. Perioperative strictions. The aim of this study was to demonstrate safety ATB decreased the rate and the gravity of infectious and feasibility of robotic pancreatoduodenectomy. morbidity. This study pushes us to change our practice in Methods: Patients underwent robotic pancreatoduodenec- patients who underwent PBD. tomy in two centers in the Netherlands, performed by the same surgical team, between March 2016 and September 2017. Patients were selected in a multidisciplinary meeting. EP02D-085 Tumors with vascular involvement were excluded. Data OUTCOME OF WHIPPLE’S were prospectively collected. Postoperative outcomes were scored up to 90 days after resection. PROCEDURE IN 448 PATIENTS: 17 Results: In total, twenty robotic pancreatoduodenectomies YEAR EXPERIENCE IN TERTIARY were performed. Two procedures were converted to an CARE HOSPITALS OF BANGLADESH open procedure: one due to failure to progress and one due M. Ali1,2, M. M. Rashid1, H. Rabbi1, H. N. Hakim3, to a portal bleeding that could not be controlled robotically. A. N. Azam3, M. M. Sarder3, A. T. Ahmed1 and A. Islam3 e Median operative time was 415 min. (IQR: 355 457). 1Hepato-Biliary-Pancreatic Surgery, BIRDEM General e Median blood loss was 325 mL (IQR: 178 675). Four Hospital, 2National Liver Foundation of Bangladesh, and fi patients had postoperative pancreatic stula (ISGPS gr. B/ 3Surgery, Dhaka Medical College Hospital, Bangladesh C). Eight patients suffered from delayed gastric emptying Introduction: Whipple’s Procedure (Partial Pancreatico- (ISGPS gr. B/C). One patient had a bile leak (ISGLS gr. C). duodenectomy) is the definitive treatment for common

HPB 2018, 20 (S2), S505eS684 S616 Electronic Posters (EP02A-EP02F) e Pancreas malignant & nonmalignant conditions of the pancreas, bile tumor resection (PR), and synchronous metastasectomy duct & duodenum. Tertiary care facilities offer better (SM) were performed in 34, 54 and 36 patients, respec- outcome as the volume started growing. tively. In the SM group, there were 25 patients for liver Method: This retrospective study includes 448 patients of resection, 5 for peritoneum, 1 for liver and peritoneum, 1 Classic Whipple’s procedure during last seventeen years for liver and lung, and 2 for non-regional lymph node. The (January 2000 to December 2017) at three tertiary care median time between initial treatment and surgery of EX, hospitals at Dhaka. Training of young surgeons on Hepato- PR and SM was 5.2, 5.1 and 5.5 months (P = 0.333). Biliary-Pancreatic surgery in one specialized center leads to Median survival time (MST) was 16.1, 33.4 and 21.9 the development of other two centers. Surgeries were months. MST of PR and SM was higher than that of EX performed by the surgical teams following the same sur- (P = 0.001 and 0.048). gical technique. The outcome of these patients was retro- Conclusion: Synchronous metastasectomy after FOLFIR- spectively reviewed and centrally monitored data based. INOX with a considerable response to chemotherapy is an Result: Patients include males 295 (65.85%) and females option in multimodality treatment of PDAC. The optimal 153 (34.15%), mean age 59.5 yrs. Periampullary carcinoma duration of chemotherapy and the indications for resection in 302 (67.41%). Difficulty encountered in 44 (9.82%) due need to be further refined. to vascular encasement, anomaly of hepatic artery & portal vein. Soft pancreatic texture & small duct in 287 (64.06%) needed special attention. Median operative time, blood EP02D-087 transfusion & hospital stay decreased as the volume in- RADIOGRAPHIC AND PATHOLOGICAL creases. Complications were delayed gastric emptying 95 (21.20%), wound infection 67 (14.95%), Internal hemor- FINDINGS OF RESECTED PANCREATIC rhage 26 (5.80%), abdominal collections 36 (8.03%), CANCER AFTER GEM + NAB-PTX Pancreato-jejunal anastomotic leakage 43 (9.59%) & THERAPY fi Pancreatic stula 14 (3.12%). Thirty-day mortality 6 S. Kawakatsu1, Y. Inoue1, Y. Mise1, T. Ishizawa1, H. Ito1, (1.33%) & Post-operative deaths 18 (4.01%). Five-year Y. Takahashi1, M. Hiratsuka2, Y. Matsuda3 and A. Saiura1 survival in periampullary carcinoma 134 (29.91%). 1Department of Gastroenterological Surgery, 2Department Conclusions: Careful selection of patients addressing of Diagnostic Imaging, Cancer Institute Hospital of Jap- comorbidities and meticulous surgical technique are the anese Foundation of Cancer Research, and 3Department key issues. Vascular anomalies need vigilant evaluation. of Pathology, Tokyo Metropolitan Geriatric Hospital and Margin-negative & node-negative cases have better sur- Institute of Gerontology, Japan vival. Outcome improves with increasing experience of Objective: The criteria as for the effect of chemotherapy Whipple’s procedure and growth of high volume center. for pancreatic ductal adenocarcinoma (PDAC) has never been established and the indication of resection and the depth of dissection are sometimes difficult to determine. EP02D-086 From 2015, GEM + nab-PTX (GnP) was administered SYNCHRONOUS METASTASECTOMY before resection for BR and UR PDAC in our institute. In FOR PANCREATIC CANCER e DOES this analysis, we assessed the radiographic and pathological SURGERY CONFER A BENEFIT AFTER changes after GnP. FOLFIRINOX? Methods: Fifty patients who underwent GnP before resection for BR and UR PDAC between June 2015 and M. Tanaka, C. W. Michalski, U. Heger, O. Strobel, November 2017 are subject of analysis. Changes of tumor M. W. Büchler and T. Hackert markers and radiographic findings on dynamic CT were Department of Surgery, Heidelberg University Hospital, analyzed and compared with pathological findings. Germany Resectability status was classified according to the NCCN Introduction: Effective chemotherapy such as FOLFIR- guideline. A resection margin wider than 1mm was INOX are currently changing the treatment of metastasized considered R0. Continuous data were shown as median pancreatic ductal adenocarcinoma (PDAC). More patients with range. with synchronous metastases from PDAC present with Results: The courses of GnP was 4 (3-9). Operative pro- considerable response to polychemotherapy and may thus cedure included 38 PD, 11 DP, and 1 TP. Resectability be surgical candidates. Aim of this study is to evaluate status before GnP was BR-A (n = 40), BR-PV (n = 4), UR- synchronous metastasectomy for those PDAC patients who LA (n = 4) and UR-M (n = 2). The size of tumor shrunk in received FOLFIRINOX before resection. 42 patients (84.0%) and abnormal shadow of periarterial Methods: From a prospective database, patients undergo- and periportal tissue shrunk in 14 (28.0%). Twenty-two ing surgery for PDAC after FOLFIRINOX between 2011 patients (44%) had EVANS score >II. Tumor necrotic rate and 2016 were identified. All patients with locally was 5 (5-70) % and was not correlated to tumor shrinkage advanced PDAC and metastatic PDAC underwent on preoperative radiographic findings. CA19-9 decreased chemotherapy as the first treatment. Synchronous meta- in 91.8% (45/49). The R0 resection was achieved in 64.0% stasectomy was planned after at least three months of (32/50). chemotherapy if the primary and metastatic tumors shrunk Conclusions: Radiographic findings could not difinitely and were resectable. represent the efficacy of GnP. BR and UR PDAC patients Results: 124 patients were scheduled for resection by re- without progression after GnP should be offered the chance staging after FOLFIRINOX. Exploration (EX), primary of resection.

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EP02D-088 Preoperative therapy was performed in 4 cases. Concomitant PV resection and reconstruction was performed in 4 cases. THE VALUE OF POST-OPERATIVE Postoperative hospital stay was 19 days (11e55). Grade B MEASUREMENT OF DAY ONE DRAIN pancreatic fistula occurred in five patients. Mortality was zero. FLUID AMYLASE, SERUM AMYLASE There were no significant differences in the postoperative AND SERUM CRP AS PREDICTOR OF complications and mortality between the two groups. More- PANCREATIC FISTULA IN over, the prognosis of octogenarians was similar with that of younger patients. Median survival time was 24 months in PANCREATIC SURGERY elderly group (22 months in control group). Ten patients have H. Singh, M. K. Singh, V. Gupta, R. Kocchar, died in this series. The causes of death were recurrence of B. Medhi and T. D. Yadav PDAC in eight patients and unknown causes in two patients. PGIMER Chandigarh, India Conclusion: This study demonstrates that the post- Introduction: To determine the utility of the measurement operative prognosis in octogenarian patients was compa- of serum amylase (SA), drain fluid amylase (DFA) and rable with that in younger patients. serum CRP on post-operative day (POD) 1, 3, 5 and 7 as a predictor for development of pancreatic fistula (PF) after EP02D-090 pancreatic resection. GRADE B AND GRADE C PANCREATIC Methods: A prospective clinical study enrolled Seventy- LEAKAGE CAN BE PREDICTED BY THE four patients who underwent pancreatic resection, out of which 65 had Pancreaticoduodenectomy. All patients had VOLUME OF PERIPANCREATIC estimation of DFA, SA and 55 patients had estimation of INTRAABDOMINAL DRAINAGE ON CRP levels on POD 1, 3, 5 and 7. Post-operative PF was POSTOPERATIVE DAY 1 classified according to International Study Group of Y. -Q. Yu1,Y.Ye2,Y.Jin1,X.-G.Qi1,Y.-Y.Feng1, Pancreatic Surgery into three grades (A, B, C). D. -E. Zhou1,D.-R.Liu1,L.Wang1, J. -T. Li1 and S. -Y. Peng1 Results: Twenty two (29.72%) patients developed PF, 1Department of Surgery, Zhejiang University/Second 13(17.6%) had PF grade A(PF-A), 8(10.8%) had PF grade Affiliated Hospital, China, and 2Department of Surgery, B(PF-B), 1(1.4%) patient had PF grade C(PF-C). Out of Hangzhou Red Cross Hospital, China fi them clinically relevant stula (CR-POPF) were 9(12.2%). Introduction: Based on the current ISGPS grade of DFA levels on POD 1 were not different in patients after pancreatic leakage, is there any possibility for predicting Pancreaticoduodenectomy or all pancreatic surgery for CR- the Grade B and Grade C using the volume of peri- POPF vs. no PF/PF-A (p = 0.649, 0.679). CRP was signif- pancreatic intraabdominal drainage would be discussed. icantly elevated in both Pancreaticoduodenectomy and all Method: The volume of intraabdominal drainage of 86 pancreatic surgery group on POD 3 in CR-POPF vs. no PF/ cases from Janaury 2013 to September 2016 who under- PF-A (234 vs 146 mg/l, p = 0.016). SA on POD 1 was also went pancreatectomy by single group was respectively fi signi cantly higher in patients who developed PF in both collected, the correlation between the volume of peri- Pancreaticoduodenectomy and all pancreatic surgery group pancreatic intradominal drainage on postoperative day 1 for CR-POPF vs no PF/PF-A (p = 0.008, 0.006). and pancreatic leakage was analyzed. fl Conclusion: Measurement of drain uid amylase on POD Results: The overall pancreatic leakage was 26% (22/83), 1 is not helpful in prediction of PF. CRP level on POD 3 including biochemical leakage 16 cases, grade B and grade C and serum amylase on POD 1 however can predict he 6 cases. The grade B and grade C of median volume of development of POPF. drainage was more than 150 ml and had significant compared difference with no leakage and biochemical group (P < 0.05). EP02D-089 Conclusions: Grade B and grade C pancreatic leakage can be PROGNOSIS AFTER SURGERY FOR predicted by the volume of peripancreatic intraabdominal PANCREATIC CANCER IN PATIENTS drainge on postoperative day 1. Early intervention should be AGED 80 YEARS OR OLDER considered if the median volume of peripancreatic intra- abdominal drainage was more than 150ml. The more cases Y. Kyoden and evidence need to be accumulated to verify this possibility. Surgery, Shizuoka General Hospital, Japan Background: Surgery for pancreatic ductal adenocarci- noma(PDAC) is prevalent worldwide with acceptable mortality and morbidity. Recently, in this rapidly graying EP02D-091 society, invasive surgery has been performed even for the A COMPARATION OF TWO NOVEL elderlies due to advancement of perioperative management PROGNOSTIC INDEX IN PANCREATIC and medical technology. However, the benefits of them SURGERY. EXTERNAL VALIDATION IN were not clearly proven and remained still controversial. WHIPPLE PROCEDURE The aim of this study was to clarify the role of pancreatic resection in patients 80 years of age or older. F. J. Tejero-Pintor, M. Rodriguez-Lopez, Method: From June 2007 to January 2017, 166 pancrea- B. Perez-Saborido, A. Barrera-Rebollo, tectomies for PDAC was performed in our hospital. The M. Bailon-Cuadrado, K. Plua-Muñiz, patients aged 80 years (n = 27) were compared with a E. Choolani-Bhojwani, E. Asensio-Díaz, control group <80 years of age (n = 138). P. Pinto-Fuentes and D. Pacheco-Sanchez Result: All the data was written in median (range). Age was General and Digestive Surgery, Rio Hortega University 81 years (80-85), 11 male and 16 female patients. Hospital, Spain

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PREPARE and Wiltberger score were recently defined to Methods: Between January 2012 and December 2016, 293 stratify patient’s risk of postoperative complications ac- consecutive patients underwent LC at our hospital. The cording to Dindo-Clavien classification. Our aim is to clinical date and treatment outcome of 81 elderly patients compare these scores and perform an external validation. (elderly group), defined as those aged 75 years or older, and Prospective analysis of 30 patients undergoing Whipple 211 patients (younger group), defined as those younger procedure at Rio-Hortega University Hospital (Spain) from than 75 years, were compared retrospectively. January 2015 to February 2016. Results: More patients in the elderly group than in the PREPARE and Wiltberger score were calculated and younger group had acute cholecystitis (p < 0.001), previ- postoperative complications (Clavien’s classification) were ous abdominal surgery (p = 0.03), use of anticoagulants registered up to discharge. Severe complications in PRE- (p < 0.001), and hypertension (p < 0.001). Operation time, PARE score was defined as Clavien  IIIa and in Wilt- amount of bleeding, and conversion rate of open surgery berger score Clavien IIIb. did not differ significantly between the two groups. The Sex: 63% males. Age 63.2 Æ 11.1. elderly group had longer hospital stay and higher post- PREPARE analysis: Albumin: 3.5Æ0.4 gr/dl. Cardiac operative complication rate (Clavien-Dindo class S2) than rate: 72Æ13 bpm. Systolic blood pressure: 129Æ21 mmHg. the younger group. The independent risk factor for post- Hemoglobin: 13.3Æ1.5 gr/dl. Pancreatic origin: 40%. operative complication was bleeding volume S90 ml (95% Procedure: 100% Whipple. ASA grade: 10% I, 60% II, confidence interval: 1.36e12.3, odds ratio: 4.01). 30% III. Overall Clavien IIIa morbidity: 36.7%. PRE- Conclusion: LC for elderly patients with gallbladder benign PARE value: 7.7Æ3.2 points. PREPARE categories and disease can be safely performed. Although LC is a feasible distribution of severe complications: 10 low risk patients, treatment, accurate selection of patients and careful surgery 10 moderate risk, 10 high risk (1/10 patients 10%, 4/10 are required to decrease postoperative complications. 40%, 6/10 60% respectively, p = 0.05). ROC curve ob- tained AUC = 0.739 (95% CI = 0.557e0.922, p=0.031) RR =13.5 (95% CI = 1,2e152.21.) Table 1. EP02D-093 Æ 2 Wiltberger analysis: BMI 25.9 4.2 Kg/m . Cardio- CLINICAL IMPLICATIONS OF vascular disease 57%. Respiratory disease 6.7%. Overall Clavien IIIb morbidity: 23.3%. Wiltberger value: INTRAOPERATIVE FLUID THERAPY IN 5.3 Æ 3.9 points. Wiltberger categories and distribution of PANCREATIC SURGERY: IT IS NOT severe complications: 11 low risk patients, 17 moderate “JUST WATER” risk, 2 high risk (3/11 patients 27.3%, 4/17 23.5%, 1/2 50% S. Andrianello1, G. Marchegiani1, E. Bannone1, respectively, p = 0.74). ROC curve obtained AUC=0.520 G. Masini1, G. Malleo1, G. Montemezzi2, E. Polati2, e (95% CI = 0.273 0.766, p = 0.87) RR = 2.67 (95% C. Bassi1 and R. Salvia1 CI = 0.12e57.6.) Table 1

EP02D-091 Table 1 Statistics Data AUC in ROC curve Proportion in low and high risk categories Own data Prepare Score 0.739 (CI 95%=0.557-0.922) p=0.031 66.6% of patients Uzunoglu et al. Prepare Score 0.709 (CI 95%=0.657-0.760) p<0.001 75.5% of patients (*different kind of pancreatic resections) Own data Wiltberger Score 0.520 (CI 95% = 0.273-0.766) p=0.87 43.2% of patients Wiltberger et al. Wiltberger Score 0.83 (CI 95%= 0.75-0.89) 82% of patients

In our study, Wiltberger score has shown a lower ca- 1General a Pancreas Surgery - The Pancreas Institute, pacity than PREPARE score to predict severe complica- and 2Intensive Care Unit, University of Verona, Italy tions in Whipple procedure. Background: Recent studies have suggested that intra- operative fluid overload is associated with a worse outcome after major abdominal surgery. However, evidence in the EP02D-092 field of pancreatic surgery is still not consistent. The aim of VALIDATION OF LAPAROSCOPIC this study was to evaluate whether intraoperative fluid CHOLECYSTECTOMY FOR ELDERLY management could affect the outcome of a major pancreatic resection. PATIENTS WITH GALLBLADDER Methods: Prospective analysis of 350 major pancreatic DISEASE resections performed in 2016 at The Pancreas Institute, Y. Mushiake University of Verona Hospital Trust. Patients were Iwakuni Clinical Center, Japan dichotomized according to intraoperative fluid volume fl Introduction: In recent years, the average life expectancy administration into near-zero uid balance (NZF - infusion fl has been increasing in many countries. Although the rate 3 mL/kg/h) and liberal uid balance groups (LF - > fl number of benign gallbladder diseases with surgical indi- 3 mL/kg/h). Intraoperative uid administration was then cation has been increasing, the usefulness and safety of correlated to the postoperative outcome. surgery are unclear. The aim of study was to investigate the Results: Overall, a LF balance was associated with an validation of laparoscopic cholecystectomy (LC) for increased rate of Clavien-Dindo IIIB (50.5% vs. 34.5%; elderly patients. p = 0.02) and delayed gastric emptying (DGE) (8.8% vs.

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1.8%; p = 0.05). A NZF balance was associated with a subpopulation, further systemic therapy and/or meta- reduced incidence of biliary fistula (0% vs. 7.9%; p = 0.05) stasectomy was associated with improved survival after and DGE (5% vs. 11.6%; p = 0,04) but an increased rate of recurrence. post-operative acute pancreatitis (75% vs. 49.2%; p = 0.02) after pancreaticoduodenectomy. Considering patients with Univariable and multivariable Cox regression a soft pancreatic remnant, a NZF balance was associated with an increased rate of pancreatic fistula (60% vs. 45.2%, p = 0.02). Conclusion: Considering all pancreatic resections, a LF balance is associated with an increased rate of postoperative morbidity. However, in the case of PD with a soft pancreas, a NZF balance could lead to pancreatic stump ischemia and anastomotic failure. Intraoperative fluid management should be managed according to patient’s pancreas-specific risk factors.

EP02D-095 ISOLATED PULMONARY RECURRENCE FOLLOWING PANCREATECTOMY FOR PANCREATIC CANCER: THE EFFECT OF PATIENT FACTORS AND TREATMENT MODALITIES ON SURVIVAL V. P. Groot1,2, A. B. Blair1, G. Gemenetzis1, EP02D-098 R. A. Burkhart1, I. Q. Molenaar2, J. L. Cameron1, EARLY OUTCOMES FOLLOWING M. J. Weiss1, S. C. Yang3, C. L. Wolfgang1 and J. He1 IMPLEMENTATION OF ERAS FOR 1Dept. of Surgery, Johns Hopkins University School of 2 PANCREAS SURGERY Medicine, United States, Dept. of Surgery, UMC Utrecht, 1 1 1 1 2 3 W. Lane , S. Zani , J. Thacker , K. Landa , K. Rhodin , The Netherlands, and Dept. of Thoracic Surgery, Johns 1 1 Hopkins University School of Medicine, United States D. Blazer and K. Shah 1Department of Surgery, and 2Duke University, United Introduction: Isolated pulmonary recurrence occurs in States approximately 15% of patients who recur after resection of pancreatic ductal adenocarcinoma (PDAC). Although the Introduction: Enhanced Recovery After Surgery (ERAS) literature suggests favorable survival in these patients, it is a multimodal perioperative program to reduce post- remains unclear what factors are associated with improved operative morbidity. A number of European institutions outcomes. reported improvements in short-term outcomes following Methods: Patients who developed isolated pulmonary ERAS implementation for pancreas surgery; however there recurrence were selected from a prospective database of are no similar data from the US. In this study, we examined patients who underwent upfront pancreatectomy for PDAC early outcomes following ERAS implementation at a major between 2000 and 2013. Overall survival (OS) and recur- US academic institution among patients undergoing rence-free survival (RFS) were estimated from date of sur- pancreaticoduodenectomy (PD) or distal pancreatectomy. gery. Factors associated with post-recurrence survival (PRS) Methods: Using institutional NSQIP outcomes from 2013- fi were analyzed using a multivariable Cox regression model. 2017 we identi ed patients who underwent PD or distal Results: Ninety-six patients were included. Median RFS, pancreatectomy before and after implementation of ERAS PRS and OS were 16.3, 18.8 and 39.6 months, respectively. (May 2016). Categorical variables were compared using Following recurrence, treatment details were unknown for Fischer exact test. LOS was compared using Mann-Whitney fi fi < 11 patients (12%). Patients undergoing further systemic U test. Statistical signi cance was de ned as p value 0.05. treatment and/or metastasectomy (n=64, 67%) had signifi- Results: 247 patients underwent PD (164 before and 83 cantly improved PRS and OS when compared to those who following ERAS) and 149 patients underwent distal did not (n=21, 22%) (26.3 vs 5.3 and 48.1 vs 18.4, pancreatectomy (111 before and 38 following ERAS). Of respectively; both P < 0.001). Patients who were able to those undergoing PD, there was a trend towards reduced undergo metastasectomy (n = 19) achieved a PRS and OS median LOS following ERAS implementation from 10 e e of 35.0 and 68.9 months, respectively. On multivariable days (range 5 79 d; IQR 7) to 8 days (range 4 52 d; IQR analysis, recurrence-associated symptoms (HR 2.76, 8)(p = 0.17). Additionally, there was a reduction in 30-day P = 0.009) and CA 19-9 100 U/mL at time of recurrence readmission rates (18.9% to 13.3%, p = 0.29). For patients (HR 2.65, P = 0.001) were predictive of decreased PRS. A undergoing distal pancreatectomy, there was no difference prolonged RFS of >12 months (HR 0.37, P = 0.002) and in median LOS (6 vs. 5d; p = 0.55). any treatment for recurrence (HR 0.22, P < 0.001) were Conclusions: The early results following ERAS imple- independently associated with improved PRS. mentation for pancreas surgery demonstrate a reduced LOS Conclusions: Patients with pulmonary PDAC recurrence for PD patients without increased readmission rates. show favorable survival outcomes. Within this unique Similar LOS improvements did not apply to distal pancreatectomy. Given that PD is a complex surgical

HPB 2018, 20 (S2), S505eS684 S620 Electronic Posters (EP02A-EP02F) e Pancreas procedure with persistently high morbidity, ERAS may Introduction: Pancreatic surgery in the pediatric, adoles- have a more profound impact on short-term outcomes cent and young adult (PAYA) population is rare. Conse- among these patients. quently, data on well-defined post-operative outcomes for this group is scarce. The aim of this study was to determine the epidemiology and surgical outcomes of PAYA patients EP02D-099 who underwent pancreatic surgery in a large, nationwide VASCULAR RECONSTRUCTION (SM/ cohort. Methods: A nationwide retrospective multicenter cohort PV) IN PERIAMPULLARY TUMORS IS study was performed in PAYA patients who underwent THERE A DIFFERENCE? pancreatic surgery between January 1st 2007 and T. Yassein December 31st 2016 in one of the 17 Dutch Pancreatic Surgery, Menoufia University, Egypt Cancer Group (DPCG) centers. Only DPCG centers with  fi Surgical resection remains the treatment of choice and 5 PAYA patients were included. PAYA was de ned as < fi only hope for long-term survival for patients with pancre- patients aged 40 years. All pancreatic surgery-speci c atic cancer.Numerous studies have supported the safety and complications were assessed according to International fi feasibility of combining PD with vascular resection in an Study Group of Pancreatic Surgery de nitions and graded attempt to obtain negative margins. according to Clavien-Dindo. Aim: To evaluate the impact of vascular reconstruction on Results: A total of 211 patients were included with a the early postoperative outcome after resection of peri- median (IQR) age of 31 (23-36) years. Most patients were ampullary tumors. female (61%). Pancreatic surgery was performed for neuro- Methods: From January 2010 to October 2015,114 pa- endocrine tumors (27%), periampullary carcinoma (22%), tients underwent PD for periampullary tumors in National solid pseudopapillary neoplasm (10%), and mucinous  Liver Institute, Monufia University. Patients who under- cystic neoplasm (8.3%). Clavien-Dindo (grade 3) com- went PD with vascular resection (N = 18) were compared to plications occurred in 20% of the PAYA patients and 90- fi patients who underwent standard PD (N = 96) as regard:- day mortality was 0.4%. Clinically signi cant post- fi Vascular reconstructions were performed due to: vascular operative pancreatic stula (grade B/C) developed in 14%, invasion in 14 patients and vascular injury in another 4 delayed gastric emptying (grade B/C) occurred in 19%, and patients. Vascular reconstructions were performed with severe post-pancreatic hemorrhage (grade B/C) occurred in resection of the involved vascular segment with: primary 7% of all PAYA patients, respectively. Median hospital e repair (N = 12), vein patch (N = 4), & interposition grafting stay was 9 (6 14) days. in 2 patients. Conclusion: Pancreatic surgery in the PAYA population is Results: Male 11(61.1%) and female7 (38.9%) age range largely performed for non-pancreatic cancer indications. < (39 -72) with the mean 56.pancreatic duct stent in three Although uncommon, pancreatic surgery in patients 40 patients(16.75), operative time range(4 -8 h) with mean Æ years is safe with low mortality. SD6.1Æ1.6 ,blood loss range (350 e1300)with mean Æ SD 581.25 Æ 308.1, and blood transfusion occurred in four patients(22.2%)LN involvement in 10(55.6%), vascular EP02D-102 invasion in 7(38.8%) and surgical margin free in MACHINE LEARNING AND 15(83.4%). There is no statistically significant difference PREDICTIVE ANALYTICS AID IN ’ between the postoperative 6 month s survival in patients INDIVIDUALIZING RISK PROFILES with vascular reconstruction and those without vascular reconstruction (P value = 0.098). FOR PATIENTS UNDERGOING Conclusion: Perioperative mortality, readmission rates, MINIMALLY INVASIVE LEFT length of stay, and overall complication rates does not PANCREATECTOMY fi signi cantly differ between standard PD and PD with R. Kirks, M. Passeri, W. Lyman, K. Murphy, D. Iannitti, VR. J. Martinie, E. Baker and D. Vrochides HPB Surgery, Carolinas Medical Center, United States Introduction: An increasing proportion of left pancrea- EP02D-101 tectomies (LP) are being performed in a minimally invasive OUTCOME AFTER PANCREATIC fashion; however, patients undergoing minimally invasive SURGERY IN THE PEDIATRIC, LP remain at risk for significant postoperative morbidity. ADOLESCENT AND YOUNG ADULT Machine learning and predictive analytics may be able to fi POPULATION (PAPAYA): A provide surgeons with more accurate risk pro les on indi- vidual patients. NATIONWIDE RETROSPECTIVE Methods: 273 patients who underwent minimally invasive ANALYSIS LP from January 2008 through June of 2017 at our insti- B. Pranger1, C. H. van Eijck2, B. Groot. Koerkamp2, tution were included in the study. We used that population B. A. Bonsing3, J. S. Mieog3, M. G. Besselink4, to construct our predictive model. Bivariate analysis was O. R. Busch4, M. Stommel5, M. F. Gerhards6, used to exclude those independent variables not attaining a G. P. van der Schelling7, K. de Jong1, V. de Meijer1 and significance of p < 0.25, followed by multivariate analysis, Dutch Pancreatic Cancer Group which excluded those not significant at p < 0.05. Receiver 1Surgery, University Medical Center Groningen, 2Erasmus operating characteristic (ROC) value and Brier scores were MC, 3Leiden University Medical Center, 4AMC, 5Radboud used to assess the predictive ability of the model. Internal UMC, 6OLVG, and 7Amphia Hospital, The Netherlands validation was assessed with bootstrap logistic regression.

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The outcomes chosen for analysis were 90 day mortality, EP02D-104 length of stay, pancreatic leak rate, and postoperative Ⓡ hyperglycemia. COMPLIANCE WITH ERAS Results: ROC values for predicting 90 day mortality, type PROTOCOLS IMPROVES OVERALL B/C pancreatic leak rate, and postoperative hyperglycemia AND DISEASE FREE SURVIVAL were 0.93 (p = 0.0001), 0.74 (p = 0.0002), and 0.85 AFTER (p = 0.001), respectively. The model also demonstrated a PANCREATICODUODENECTOMY strong correlation between our independent variables and length of stay (r2 = 0.53). M. Fruscione, M. Passeri, W. Lyman, R. Kirks, Conclusion: The data show that this novel predictive K. Murphy, D. Iannitti, J. Martinie, E. Baker and model can be used to anticipate important postoperative D. Vrochides outcomes with a high degree of accuracy. This may aide HPB Surgery, Carolinas Medical Center, United States Ⓡ in both perioperative decision making, discussing ex- Introduction: Compliance with ERAS protocols has pected outcomes with patients, and in allocation of yielded improved oncologic outcomes in the colorectal resources. literature. There is little data to illustrate the effect of Ⓡ ERAS compliance on oncologic outcomes after pancreaticoduodenectomy (PD) for adenocarcinoma. This Ⓡ EP02D-103 study seeks to evaluate whether ERAS compliance at our institution has had a positive impact on overall and disease- THE CLINICAL IMPACT OF LEFT free survival after PD. Ⓡ GASTRIC ARTERY RECONSTRUCTION/ Methods: We used the ERAS Interactive Audit PRESERVATION DURING DISTAL System (EIAS) to compiled a list of all patients who underwent PD at our institution since September of PANCREATECTOMY WITH CELIAC Ⓡ AXIS RESECTION FOR PANCREATIC 2015, at which point an ERAS pathway was imple- mented. We then case-matched those patients to others BODY CANCER Ⓡ who underwent PD prior to ERAS introduction. We A. Oba, Y. Inoue, T. Sato, Y. Ono, S. Irie, Y. Mise, H. Ito, analyzed differences between these two cohorts in T. Ishizawa, Y. Takahashi and A. Saiura postoperative and oncologic outcomes, with a focus on 1 Cancer Institute Hospital, Japanese Foundation for overall and disease-free survival. We then subcatego- Ⓡ Cancer Research, Japan rized the ERAS patients into two tiers of protocol item Background: For locally advanced pancreatic body compliance (>85% and 65%e85%), and subjected them cancer with contact to or close to the celiac axis, distal to similar analysis. Ⓡ pancreatectomy with celiac axis resection (DP-CAR) is Results: The median follow-up for the ERAS cohort was necessary to achieve R0 resection, and also postoperative 19 months. Overall survival at 19 months was significantly Ⓡ adjuvant chemotherapy is important. To avoid ischemic higher for ERAS patients when compared to pre-ERAS complication and delayed administration of adjuvant patients (65% versus 39.8%; p 0.003). Disease-free sur- chemotherapy, we have introduced the left gastric artery vival was also significantly higher at 19 months (50% Ⓡ (LGA) reconstructing/preserving DP-CAR. versus 21.4%; p 0.017). Among ERAS patients, the high- Methods: This study reviewed 42 consecutive patients compliance group had an overall survival of 80% (versus with pancreatic body cancer who underwent LGA recon- 60% in the low-compliance group) and disease free sur- structing/preserving DP-CAR at our institution. If the dis- vival of 70% (versus 43%). Ⓡ tance between the tumor and the LGA was less than 1 cm, Conclusion: Adherence to ERAS protocols has resulted the LGA was cut and reconstructed. in a significant improvement in oncologic outcomes after Results: Among 42 patients (24 men and 18 women with a PD. These benefits seem to correspond to the degree of Ⓡ median age of 68 years), the LGA was reconstructed in 20 ERAS compliance. patients and preserved in 22 patients, median blood loss was 590 ml and median surgical time was 446 min. 16 patients (38%) had neoadjuvant chemotherapy, R0 resec- tion rate was 85%, and the perioperative blood transfusion rate was 0%. Ischemic gastropathy occurred in two patients (4.8%), no ischemic liver dysfunction or mortality occurred. Postoperative adjuvant chemotherapy was given 87% patients with median starting time of 67 postoperative days and the treatment continuation rate for half a year was 88%. For all 42 patients, the 1-, 3-, and 5-year overall survival rates were respectively 89.4, 44.5, and 22.9 %, and the median survival time was 28.3 months. Conclusion: LGA reconstructing/preserving DP-CAR is good approach for locally advanced pancreatic body cancer with high surgical radicality and preservation of organ function leading to smooth introduction of adjuvant Figure therapy.

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EP02D-106 EP02D-107 LYMPH NODE YIELD DURING VARIATION IN AND PREDICTORS OF PANCREATIC CANCER SURGERY: A INPATIENT OPIOID UTILIZATION POPULATION-BASED ANALYSIS USING AFTER PANCREATECTOMY NOVEL ADVANCED STATISTICAL T. Newhook1, W. Dewhurst1, H. -C. Chen2, X. Wang2, MODELING METHODS M. Kim1, T. Aloia1, J. N. Vauthey1, J. Lee1, M. Katz1 and 1 1 2 1 1 C. -W. Tzeng C. Tsai , R. Warschkow , J. Maubach , S. Erdem , 1 2 B. Schmied2, D. Nussbaum3, D. Blazer3, B. Gloor1 and Surgical Oncology, and Biostatistics, M.D. Anderson M. Worni1 Cancer Center, United States 1Department of Visceral and Transplantation Surgery, Introduction: Optimal strategies to limit inpatient expo- 2Cantonal Hospital St. Gallen, and 3Department of Surgery sure to opioids for postoperative pain are unclear. We Introduction: While the relevance of lymphadenectomy aimed to characterize variations in post-pancreatectomy during pancreatic cancer resection is well-established, the opioid administration in order to identify predictors of importance of lymph node (LN) yield is ill-defined. We usage. assessed the impact of LN yield on overall survival (OS) as Methods: Clinical characteristics and total inpatient oral a continuous measure using novel advanced statistical morphine equivalent (OME) utilization were downloaded modeling methods. from electronic records for patients who underwent Methods: The population-based National Cancer Database pancreatectomy at a single institution between 3/2016-8/ from the USA was queried for patients with resected pancreatic 2017. Regression analyses were performed to identify adenocarcinoma (stage IA-IIB) from 2004-2014. LN yield predictors of total usage and highest vs. lowest quartiles of was assessed as a continuous measure, and dichotomized to 1- OME. 14 LN and 15 LN yield. Survival was analyzed using Results: 158 patients underwent pancreatectomy (73% multivariable-adjusted Cox regression, Joinpoint regression pancreaticoduodenectomy, 27% distal). Transversus and covariance-balanced propensity score analyses, and near- abdominus plane (TAP) block was performed in 80% far-matching to account for unmeasured biases. (n = 127), almost always with intravenous patient- Results: In 25,609 patients, mean age was 65.2 (SD: 10.7) controlled analgesia (IV-PCA), while 15% received years, 49.1% were female. Mean LN yield was 16.0 (SD: epidural alone. All patients received additional non- 9.3). Analyzing LN yield on a continuous scale, OS narcotic analgesics (median 2 medications). Median total e improved with increasing LN retrieval, even when stratified OME administered was 423.2 mg (range = 0 4,362 mg). by tumor stage. Joinpoint regression revealed that LN With IV-PCA users, the median OME attributable to IV- < positivity increased by 4.2% per collected LN up to 8 LNs, PCA alone was 373mg. Length-of-stay (LOS, p 0.001) then 0.7% per LN >8. 5-year OS was 16.0% for 1-14 and and no epidural (p = 0.01) were independently associated 18.0% for 15 LNs (adjusted HR 0.92, CI: 0.89e0.94, with higher total OME on linear regression. Notably, prior p < 0.001) (Figure). Near-far-matching showed significant abdominal surgery (57.6% patients) was not associated OS improvement (HR 0.91, CI 0.88e0.94, p < 0.001) and with increased OME. Patients within the lowest/best  a trend towards improved relative survival (HR 0.97, CI: quartile utilized 180mg OME, while highest/worst quar-  0.93e1.00, P = 0.055) in 15 compared to 1-14 LNs. tile patients utilized 892.5 mg. Adjusting for age, LOS, Conclusion: LN positivity increases with increasing LN and inpatient team, only epidural (OR-3.3, p = 0.01) yield, which when analyzed as a continuous measure independently predicted lowest quartile OME on logistic translates into survival benefit across all tumor stages. regression. Longer operative time (OR 3.4, p = 0.04) and Thus, adequate lymphadenectomy should be assessed by LOS (OR 1.1, p = 0.02) independently predicted highest continuous parameters rather than definite LN cut-offs. quartile OME. Conclusions: Epidural use was associated with reduced total inpatient OME, while with TAP-block with paired IV- PCA settings represented the vast variation in total OME. These use patterns can serve as the basis for further im- provements in reducing inpatient narcotic exposure.

EP02D-108 PANCREATICODUODENECTOMY IN A LOW VOLUME CENTER IN NIGERIA: IMPACT OF NORTH TO SOUTH COLLABORATION O. I. Alatise1,2, O. Olasehinde1,2, A. Arowolo1,2, O. Lawal1,2, T. P. Kingham3 and M. Brennan3 1Surgery, Obafemi Awolowo University Teaching Hospi- tals Complex, 2Surgery, Obafemi Awolowo University, Nigeria, and 3Surgery, Memorial Sloan Kettering Cancer Center, United States Introduction: Pancreaticodudenectomy (PD) is a highly demanding surgical operation associated with substantial Figure

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S623 perioperative morbidity and mortality even in a developed data and complication data were compared between study center. Two surgeons had training at Memorial Sloan groups. Kettering Cancer Center, New York, USA and subse- Results: In group A, 40 out of 211 patients (19%) had quently started the procedure in Nigeria. This review is PALN metastases. Of these, 33 patients underwent DBP, intended to evaluate the initial experience and perioperative whereas 7 patients underwent PD. In group B, PALN me- outcomes of PD done in a single gastrointestinal surgery tastases were found in 27 out of 135 patients (20%) who unit of a university teaching hospital. underwent PD. Median overall survival for patients with Methods: Consecutive patients who underwent PD from PALN metastases in group A was 7 (95%CI 5.4-8.6) February 2010 and December 2017 were recruited to the months, versus 10 (95%CI 6.2e13.8) months in group B study. The patient demographics, type of surgery, histo- (P = 0.225). Patients with PALN metastases who under- pathology, operatives findings and perioperative morbidity went PD had significantly increased comprehensive and mortality were evaluated. The factors associated with complication index scores, when compared to patients who mortality and morbidity were analysed. underwent DBP (P < 0.001). Results: Twenty-one patients underwent PD of the 170 cases Conclusion: In patients with PALN metastases PD did not of obstructive jaundice managed during the study period. result in survival benefit but was associated with increased There were three peri-operative deaths. The overall morbidity risk of morbidity. was 23%, with a pancreatic fistula rate of 14%. Factors associated with peri-operative death include intra-operative blood loss, associated liver fibrosis, experience of surgeon EP02D-110 and age of the patient. For those that survive the procedure, CASE MATCHED COMPARISON OF overall survival ranges from 13 to 84 months. Histology of those leaving above 5 years include papillary cancer, peri- PERI-OPERATIVE AND ampullary cancer and adenocarcinoma of pancreatic head. PATHOLOGICAL OUTCOMES Number of cases performed is increasing every year. BETWEEN LAPAROSCOPIC AND Conclusions: With adequate mentoring, difficult surgeries ROBOTIC like PD can be performed in low volume center in devel- PANCREATICODUODENECTOMY oping countries with comparable result. We recommend that such model be adopted by high volume centers to improve S. Srivatsan Gurumurthy, P. Senthilnathan, S. Sabnis, the availability of this skill set in developing countries. E. Senthil Anand, V. P. Nalankilli, A. V. Natesan and C. Palanivelu HPB & Minimal Access Surgery, Gem Hospital & Research Centre, India EP02D-109 Introduction: Minimally invasive pancreaticoduodenec- PANCREATODUODENECTOMY tomy (MIPD) is being performed with increasing frequency SHOULD BE AVOIDED WHEN PARA- for pancreatic cancer, but the most preferred and oncolog- AORTIC LYMPH NODE METASTASES ically radical surgical platform, whether robotic or laparo- ARE FOUND DURING SURGICAL scopic, is yet to be determined. This study aims to assess EXPLORATION FOR SUSPECTED the surgical outcomes of robotic pancreaticoduodenectomy PANCREATIC DUCTAL relative to its laparoscopic counterpart. Currently, there are no studies in India comparing the peri-operative outcomes ADENOCARCINOMA and pathological radicality between robotic (RPD) and B. Pranger1, D. Tseng2, S. Ubels1,2,3, G. Patijn3, laparoscopic (LPD) pancreaticoduodenectomy. I. H. Borel Rinkes1,2,3, J. H. Offerhaus2, V. Nieuwenhuis3, Methods: This was a retrospective study done between K. P. de Jong1,2,3, J. M. Klaase1, I. Q. Molenaar2, 2017 Jan to 2018 Jan, where patients who underwent ro- J. Erdmann1 and V. de Meijer1 botic pancreaticoduodenectomy (RPD) were compared 1University Medical Center Groningen, 2UMC Utrecht, with case matched controls from the LPD arm. Periopera- and 3Isala, The Netherlands tive data including operative time, estimated blood loss, Introduction: Routine intraoperative para-aortic lymph complications, morbidity, mortality, postoperative length node (PALN) sampling during surgical exploration in pa- of stay, margin status and lymph node yield were analyzed. tients with suspected pancreatic head cancer remains Results: 15 cases of RPD were case matched with LPD on controversial. The aim of this study was to assess the value 1:1 basis; based on tumour location, tumour size and ASA of routine PALN sampling and the consequences of grade. Though operative time was slightly longer in the different treatment strategies on overall patient survival. RPD arm, compared to the LPD, it was not statistically Methods: A retrospective multicenter cohort study was significant (p value-0.7). No statistical difference was performed in patients who underwent surgical exploration observed between the two groups in terms of complication for suspected pancreatic head cancer. In group A, PALN rate, mortality rate, R0 resection rate, number of harvested were routinely sampled and immediately examined by the lymph nodes, median length of stay, 90-day mortality and pathologist during surgery. In case of PALN metastasis, 30-day readmission rate. treatment strategy was to avoid resection with curative intent, Conclusion: In this case matched series, LPD and RPD i.e. pancreatoduodenectomy (PD), and to perform double were associated with equivalent perioperative outcomes bypass procedure (DBP) by indication. In group B, routinely and comparable pathological radicality. RPD is a feasible harvested PALN were not examined intraoperatively and PD alternative to the laparoscopic procedure, however further was performed regardless. PALN were examined with the studies are needed to evaluate the cost effectiveness of the final resection specimen. Clinicopathological data, survival robotic approach for PD.

HPB 2018, 20 (S2), S505eS684 S624 Electronic Posters (EP02A-EP02F) e Pancreas

EP02D-111 more aggressive tumor biology with advanced T stages 3 and 4, nodal involvements, poor differentiation, perineural PERIOPERATIVE IMMUNONUTRITION invasion, lymphovascular invasion and pancreatobiliary or IN PANCREATIC CANCER SURGERY: mixed subtype. The 5-year overall survival rate was 70.2% WESTERN HEALTH EXPERIENCE in IAPN group and 51.4% in FD group (p = 0.001). The 5- O. Onasanya1, J. Choi1, V. Usatoff1, I. Deftereos2, year disease-free survival rate was 70.8% in IAPN group < M. Smith1, S. Chan1 and N. Houli1 and 49.6% in FD group (p 0.001). The rate of recurrence 1Surgery (UGI/HPB Unit), and 2Allied Health (Nutrition), was also higher in FD group (49.1% versus 30.9%; Western Health, Footscray, Australia p = 0.005). On multivariate analysis, the precursor lesion was an independent prognostic factor for recurrence Introduction: The impact of perioperative immunonu- (HR = 1.844, 95% CI 1.162e2.927, p= 0.009). trition in pancreatic cancer surgery remains controversial 1, Conclusion: Patients in the FD group showed significantly 2, & 3. While some studies showed a positive impact on worse prognosis with a greater tendency toward advanced outcome in well-nourished patients, others showed no disease, and a precursor lesion was an independent prog- difference in outcomes 1, 4. In a study examining pancre- nostic factor for recurrence on multivariate analysis. More atic and gastric cancer surgery, benefits were only identified studies are needed to clarify the impact of precursor lesions in malnourished patients 4. Our aim is to assess the effect of and to develop adjuvant therapies for the patients with more perioperative immunonutrition on the surgical outcomes of aggressive precursor lesion. patients undergoing pancreatic cancer resection in our Centre. Methods: A retrospective review of a prospectively collected database of 88 consecutive patients undergoing EP02D-115 pancreatic resection for cancer in our institution over an PORTOMESENTERIC VENOUS 11year period (2005e2016) was conducted. The de- COMPLICATIONS FOLLOWING mographics, nutritional status and relevant data relating to PANCREATODUODENECTOMY: surgical outcomes such as length of stay, complications INCIDENCE AND RISK FACTORS were extracted. Results: 36 patients received immunonutrition while 43 L. Yohanathan, S. M. Thompson, J. C. Andrews, patients did not; the remaining 9 patients had incomplete M. J. Truty, R. L. Smoot, D. M. Nagorney, T. E. Grotz and data with regards to receiving immunonutrition. The M. L. Kendrick median lengths of stay in both groups were similar, so was Mayo Clinic Rochester, United States the severity of complications in both groups. Introduction: Risk factors for and optimal management of Conclusion: The efficacy of immunonutrition in improving portomesenteric venous complications after pancreatoduo- the outcomes of pancreatic cancer resections remains to be denectomy (PD) are not well-defined. proven. Given our study is retrospective with its attendants Methods: Single-center, retrospective review of patients limitations, further RCTs are required to answer this with PD (2016e2017). Clinical data, operative details and pertinent question. postoperative portomesenteric venous complications were recorded based on data abstraction and independent radiologic re-review. EP02D-112 Results: Of 105 patients, the mean age was 64 years. PROGNOSTIC IMPACT OF PRECURSOR Neoadjuvant therapy was received in 51 (48.6%) patients and included chemoradiation in 42. PD with portomesen- LESIONS OF AMPULLARY teric vein resection occurred in 24 (23%) and arterial ADENOCARCINOMA: INTRA- resection in 5 (5%). Postoperative fluid collections were AMPULLARY PAPILLARY TUBULAR identified in 46 (49%) patients with 12.5% confirmed as NEOPLASM VERSUS FLAT DYSPLASIA pancreatic fistula. On postoperative surveillance, portal vein (PV) or superior mesenteric vein (SMV) narrowing S. Han, D. W. Choi, S. H. Choi, J. S. Heo, I. W. Han, was present in 18 (19%) and 38 (40%) of patients respec- Y. H. You, D. Park and Y. Ryu tively. Resolution occurred without intervention in 23 Department of Surgery, Samsung Medical Center, Re- (41%) patients whereas venous stenting was performed in 8 public of Korea (14%). PV narrowing and thrombosis were associated with Introduction: The aim of this study is to clarify the presence of a postoperative fluid collection (p < 0.01, prognostic impacts of two precursor lesions of ampullary p < 0.03). SMV narrowing was associated with post- adenocarcinoma, intra-ampullary papillary-tubular operative fluid collection (p < 0.001), neoadjuvant radia- fl neoplasm (IAPN) and at dysplasia (FD), on survival and tion (p < 0.02) and vein resection (p < 0.0001). Stenting of to determine the actual survival duration after curative the PV and SMV were associated with vein resection surgery. (p < 0.01 and p < 0.05). Methods: From December 1994 to December 2012, a total Conclusion: These preliminary data suggest that neoad- of 366 patients underwent curative surgery for ampullary juvant radiation, vein resection and postoperative fluid adenocarcinoma in Samsung Medical Center. collection may be risk factors for portomesenteric venous Results: The 5-year overall and disease-free survival rates complications following PD. Validation of independent of all patients were 59% and 57.9%, respectively. The risk factors may allow development of a clinical risk precursor lesion of 136 (37.2%) patients was IAPN, while score to assess optimal surveillance and treatment that of the other 226 (61.7%) was FD. The FD group had strategies.

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S625 fi EP02D-116 and 2016. CR-POPF was de ned as grades B and C of the International Study Group (ISGPS) classification. Preop- SERUM LIPASE LEVEL AT erative, intraoperative and early postoperative (up to third POSTOPERATIVE DAY 1 IS A MORE postoperative day) risk factors for CR-POPF were evalu- USEFUL BIOMARKER IN OBJECTIVE ated by multivariable analysis. EVALUATION OF PANCREATIC Results: 63/309 patients (20%) developed CR-POPF, EXOCRINE FUNCTION: A which was associated with a higher frequency of severe (Clavien-Dindo 3) postoperative complications (40% vs. PRELIMINARY STUDY 19%, p< 0.001), higher mean Comprehensive Complica- K. Okura, M. Narita, S. Jikihara, A. Maeda, M. Saji, tion Index, CCI (30 ÆStandard deviation:16 vs. 8 Æ 13, R. Matsusue, H. Hata, T. Yamaguchi, T. Otani and I. Ikai p < 0.001), reoperation rate (8% vs. 2%, p = 0.008) and Kyoto Medical Center, Japan longer median hospital stay (20 [interquartile range: 12e Background: The aim of this preliminary study was to 32] vs. 8[7e11] days, p < 0.001). The optimal cut-off for evaluate if serum lipase level at postoperative day (POD) 1 first postoperative day drain fluid amylase (DFA1) of (Lipase1) would be a useful biomarker in objective evalu- 300 UI was determined by receiver operating characteristic ation of pancreatic texture. curve (ROC) analysis (sensitivity 0.89, specificity 0.80). Patients and methods: Between January 2016 and On multivariable analysis, pancreatic duct width < 3mm on December 2017, 36 patients who underwent pancreatico- preoperative computed tomography (CT) (OR=3.9, 95% duodenectomy (PD) were analyzed. Normal value of serum CI:2e9, p = 0.001) and DFA1 > 300 UI (OR=19.0; 95% lipase level was defined as ranging from 8-49 U/L. CI:8e46, p< 0.001) were independent predictors of CR- Pancreatic texture was defined by the operating surgeon as POPF. soft or hard based on the palpation during surgery. Clini- Conclusion: Pancreatic duct width and first postoperative cally relevant pancreatic fistula (PF) was defined as Grade day drain fluid amylase are independent predictors of B/C PF according to the International Study Group of clinically relevant pancreatic fistula after pancreaticoduo- Pancreatic Surgery 2016. denectomy. High risk patients may benefit from earlier Results: Median Lipase1 was 111U/L (0-727U/L) in this postoperative imaging and/or intervention. population. Of 36 patients, Lipase1 was elevated beyond normal range in 23 patients (Group 1), in whom median Lipase1 was 255 U/L (50e727 U/L). Meanwhile, Lipase1 EP02D-118 was below normal range in 13 patients (Group 2), in whom DOES LOW LEVEL OF DRAIN median Lipase1 was 2 U/L (0e23 U/L). In this study pop- ulation, 19 patients had soft pancreatic texture, and all of AMYLASE WARRANT THE ABSENCE them were included in Group 1. Of 17 patients having hard OF POSTOPERATIVE PANCREATIC pancreatic texture, 13 patients were included in Group 2, FISTULA AFTER LAPAROSCOPIC while Lipase1 was elevated in 4 patients with median value DISTAL PANCREATECTOMY? of 76 U/L (50-199 U/L). Clinically relevant PF occurred in 9 I. G. Hyun, Y. -S. Yoon, H. -S. Han, J. Y. Cho, Y. Choi, patients, consisting of 8 patients in Group 1 and one patient S. Kim and K. H. Kim in Group 2. Among 9 patients, 8 patients had soft pancreatic Department of Surgery, Seoul National University texture and all of them were included in Group 1. Bundang Hospital, Republic of Korea Conclusions: Lipase1 may be a more useful biomarker to fi objectively evaluate of pancreatic exocrine function. Introduction: The de nition of postoperative pancreatic fistula (POPF) by the international study group in pancre- atic surgery (ISGPS) is based on the drainage amylase level. However, this definition is valid as long as abdominal EP02D-117 drains are well positioned around the pancreatic anasto- EARLY PREDICTORS OF CLINICALLY mosis or stump. The aim of this study is to evaluate post- RELEVANT POST-OPERATIVE operative outcomes and the location of drains in PANCREATIC FISTULA AFTER postoperative computed tomography (CT) scan in patients PANCREATICODUODENECTOMY with low level of the drainage amylase after laparoscopic distal pancreatectomy. A. Pinter Carvalheiro da Silva Boteon, Methods: Among 250 patients who underwent LDP from Y. Longatto Boteon, B. Dasari, J. Isaac, January 2004 to December 2016, 181 patients in whom R. Marudanayagam, D. Mirza, P. Muiesan, drain amylase and postoperative CT scan were checked J. K. Roberts and R. Sutcliffe were selected for this study. Liver Unit, Queen Elizabeth Hospital Birmingham, United Results: Eighty-three (43.7%) patients had a low level of Kingdom drainage amylase (<300 U/L), of whom 38 had malposi- Introduction: Early prediction of clinically relevant post- tioned drains. Among those, 13 (15.7%) patients experi- operative pancreatic fistula (CR-POPF) after pancreatico- enced complicated intra-abdominal fluid collection duodenectomy (PD) may facilitate earlier intervention, (defined when associated with fever or leukocytosis, and potentially improving patient outcomes. Several scoring required antibiotics or percutaneous/endoscopic interven- systems are available which predict POPF, but none were tion). CT revealed that the drain was migrated away from specifically developed to predict CR-POPF. The aim of this the pancreatic stump in 9 patients and well positioned in 4 study was to identify early predictors of CR-POPF after PD. patients. Percutaneous drainage was required for compli- Methods: Retrospective review of a prospective database cated fluid collection in 12 patients, of whom 9 patients of 309 consecutive patients undergoing PD between 2011 were newly diagnosed to have grade B POPF due to high

HPB 2018, 20 (S2), S505eS684 S626 Electronic Posters (EP02A-EP02F) e Pancreas amylase level in percutaneous drainage. Finally, the inci- EP02D-120 dence of grade B POPF was 18.8% (n=34). Conclusions: The results suggest that ISGPS definition of POST PANCREATICO- POPF based on the criteria of the drainage amylase level DUODENECTOMY PANCREATITIS has some limitation in application to distal pancreatectomy (PPDP) e A TEN YEARS AUDIT FROM A due to frequent malposition or malfunction of the abdom- TERTIARY CARE HOSPITAL IN NORTH inal drain. INDIA EP02D-119 A. Kumar, R. Saxena, P. Varshney, C. H. B. D. T. Saxena and S. G. E. Saxena PERIOPERATIVE OUTCOMES OF FAST Surgical Gastroenterology, Sanjay Gandhi Post Graduate TRACK Institute of Medical Sciences, India PANCREATICODUODENECTOMY FOR Introduction: A poor outcome of patients developing PERIAMPULLARY MALIGNANCY PPDP prompted this audit to define factors influencing F. Marcon, P. Prasad, M. Kalisvaart, B. Dasari, PPDP. R. Marudanayagam, P. Muiesan, D. Mirza, J. Isaac, Methods: Audit of our prospectively maintained database R. Sutcliffe and K. Roberts of patients undergoing PD from 2005 to Feb 2015, Liver Unit, Queen Elizabeth Hospital Birmingham, United comparing patients developing PPDP (group 1) with those Kingdom without, PPDP being defined as serum amylase of more Introduction: Fast Track pancreaticoduodenectomy (FT- than 3 times of upper normal of laboratory value between PD) aims to avoid preoperative biliary drainage (PBD) in post-operative day 0-2. The demographic, intraoperative jaundice patients, in order to reduce the time to surgery and and post-operative variables and outcomes were compared. reduce complications due to PBD. However, the effect of Results: 523 patients undergoing PD were analyzed. PPDP FT-PD upon post operative outcomes are unclear. This occurred in 47(9%). On univariate analysis all preoperative study sought to address this by comparing outcomes among factors were comparable between the two groups. The patients undergoing PD after PBD. mortality in PPDP group was 13/47 (27.6%) compared to Methods: Consecutive patients with jaundice and peri- 28/476(5.9%) in the other. Among intraoperative factors  ampullary cancer were identified between August 2015 and soft pancreas (p=.001), pancreatic duct diameter 3mm December 2017. Demographic characteristics and periop- (p = .000113), use of internal pancreatic stent (p = .011), erative outcomes were extracted from a prospectively and continuous duct to mucosa pancreaticojejunostomy v/s maintained database. FT-PDs were then compared to interrupted (p=.005) duct to mucosa v/s dunking (p = .062) fi standard group of patients receiving PBD. were signi cantly affecting PPDP. In the post-operative fi Results: 156 PD were eligible for the study (PBD n = 74, period, almost all complications except DGE were signi - 47%; FT-PD n = 82, 53%). All patients had histologically cantly higher in group 1 patients. On multivariate regres- confirmed adenocarcinoma. There was no significant dif- sion analysis, soft pancreas (p = .018), pancreatic duct  ference in overall complications between the cohorts. diameter 3 mm (p = .047), internal pancreatic fi However, there was a lower rate of post operative pancre- stent(p = .020) emerged signi cant. PPDP development led atic fistula (POPF) 10% vs. 28%, p = 0.037, FT-PD vs to an increase in the incidence of POPF (p=.035), post- PBD-PD respectively. Also, FT-PD shows a lower inci- operative new onset diabetes (p = .028), wound dehiscence dence of Grade I complications (27% vs. 13%, p = 0.04). (p = .046) and mortality (p = .002). No differences were found in length of hospital stay, Conclusion: Avoiding continuous suture duct to mucosa mortality, pathology and comprehensive complication anastomosis and use of internal pancreatic stent appear to index (CCI). To further evaluate the rate of POPF, risk be the only controllable factors to reduce the incidence of adjustment was performed using the Birmingham Fistula PPDP which is a common complication after PD with Risk Score. After risk adjustment a significant difference in serious consequences. POPF rates remains (fig 1). Conclusions: These preliminary results on fast track sur- gery for PD demonstrate a lower rate of POPF when sur- EP02D-121 gery is performed without PBD. Reasons for this are SERUM AMYLASE ELEVATION unclear but after risk adjustment the difference remains FOLLOWING suggesting this is a true observation. PANCREATODUODENECTOMY WITH PANCREATOGASTROANATOMOSIS IS STRONGLY ASSOCIATED WITH POSTOPERATIVE COMPLICATIONS G. Zimmitti1, S. Langella2, V. Sega1, A. Manzoni1, N. Russolillo2, R. Lo Tesoriere2, A. Ferrero2 and E. Rosso1 1Fondazione Poliambulanza - Istituto Ospedaliero, and 2Ospedale Mauriziano Umberto I, Italy Introduction: Recent reports suggest that, following Figure Risk adjusted CUSUM assessment of POPF after PD pancreatic resection, serum amylase elevation may be a surrogate indicator of Postoperative Acute Pancreatitis

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(PAP) and predict clinically relevant-(cr-) postoperative Perioperative data were prospectively collected and statis- pancreatic fistula (POPF). However, increasing evidence tically analysed. suggests cr-POPF may not account for majority of Results: 20 (35.7%) patients were in group A and 36 complication when pancreatoenteric continuity is restored (64.3%) in group B. Group B showed a significantly higher by pancreatogastrostomy. We aimed at evaluating, among incidence of MDR bile colonization if compared to group A patients undergoing pancreaticoduodenectomy with (n = 23 (63.9%) vs 1 (5%); P < 0.0001). However, broad pancreatogastrostomy, types and rates of postoperative spectrum antibiotic prophylaxis revealed to be fully complications and radiological changes and their associa- appropriate in 83.3% of group A patients, based on MDR’s tion with PAP occurrence. antibiograms. No statistically differences were found be- Methods: Perioperative data from 102 patients who un- tween the two groups comparing median length of stay (12 derwent pancreaticoduodenectomy with pancreatogas- vs 13 days; P = 0.843), mortality rate (0% vs 2,8%; trostomy at two Italian Hospitals (January 2015eJanuary P = 1.000), post-operative complications (80% vs 66.7%; 2017) were retrospectively analyzed. PAP was defined as P=0.453) and pancreatic fistula rate (35% vs 25%; serum amylase elevation more than three times normal P=0.628). concentration at postoperative day one. Postoperative Conclusion: Our series seems to show that preoperative abdominal CT-scan was routinely performed and retro- broad spectrum prophylaxis based on Tazobactam/Piper- spectively re-assessed for findings consistent with PAP. acillin plus Fluconazole may prevent a negative impact on Results: Among 102 study patients, overall and major overall surgical outcome by MDR infection secondary to complications and mortality occurred in 68%, 24%, and 3% preoperative biliary stenting. However, further prospective of cases, respectively. POPF and postoperative pancreatic trials are needed to achieve firm evidences. haemorrhage (PPH) occurred in 27% and 28% of patients, and were clinically relevant in 8% and 22%, respectively. Interestingly, in 15% of patients cr-PPH occurred in the EP02D-123 absence of cr-POPF. PAP occurred in 38 patients who, RISK FACTORS AFFECTING compared to 62 non-PAP patients, more frequently showed CT-scan findings consistent with pancreatic stump INCIDENCE OF MORBIDITY AFTER inflammation (p=.002). PAP was independently associated PANCREATICODUODENECTOMY with the occurrence of major complications, cr-POPF, and J. Park1, S. -S. Han1, S. -J. Park1 and S. W. Park2 cr-PPH (Hazard Ratio (HR):3.27, p=.032, HR:3.94, National Cancer Center, Republic of Korea, and National p=.012, HR:12.26, p=.002, respectively). Cancer Center, Republic of Korea Discussion: PAP occurrence is strongly associated with a Complication of pancreaticoduodenectomy has been higher rate of postoperative complication. Strategies to regarded as a remarkable concern. Incidence rate of minimize PAP occurrence may help in improving outcomes morbidity is relatively high as ever. The aim of this study is of pancreaticoduodenectomy with pancreatogastrostomy. to investigate risk factor of complication following pancreaticoduodenectomy. Medical records of 220 patients who underwent EP02D-122 pancreatic resection between 2013 and 2017 were reviewed ROLE OF STANDARDIZED BROAD retrospectively and clinical data were collected. We divided SPECTRUM PROPHYLAXIS IN the patients into two groups: 158 patients with no compli- PATIENTS WITH BILIARY DRAINAGE cation or complication of Clavien-Dindo scale I to II and 62 patients with complication of scale III to V. Risk factors UNDERGOING PANCREATIC affecting incidence of major complication were analyzed SURGERY. A SINGLE CENTER statistically. EXPERIENCE One hundred eleven patients (50.5 %) had at least one P. Regi1, M. Ramera2, R. Girelli1, I. Frigerio1, complication after pancreaticoduodenectomy and mortality A. Giardino1, F. Scopelliti1 and G. Butturini1 rate was 0.9 % (2/220). Age, male sex, long hospital period, 1Hepato-Biliary-Pancreatic Surgery, Pederzoli Hospital, blood loss amount, blood transfusion, pancreatic stent fi and 2Surgery, Pancreas Institute, University and Hospital insertion, and soft pancreatic texture were signi cantly Trust of Verona, Italy associated with incidence of major complication. Several risk factors related to morbidity after pancreati- Introduction: Biliary tree colonization by multidrug- coduodenectomy can be elucidated to predict incidence of resistant germs (MDR) frequently follows biliary stent major complications. placement and may negatively impact on overall outcome after pancreatic surgery. The role of a standardized broad spectrum antibiotic prophylaxis in this subgroup of patients is still unknown. EP02D-124 Methods: Between July 2016 and August 2017 intra- PREHABILITATION IN PATIENTS operative bile culture was routinely performed on 56 UNDERGOING consecutive patients undergoing either pancreaticoduode- PANCREATICODUODENECTOMY: A nectomy or total pancreatectomy for pancreatic malig- RANDOMIZED CONTROLLED TRIAL nancies. We administered a standard antibiotic prophylaxis 1 1 1 2 (Amoxicillin/Clavulanic acid) for unstented patients (group F. Ausania , R. Melendez , P. Senra , R. Palmeiro , 3 1 A) and a broad spectrum association (Tazobactam/Piper- R. Oubiña and I. Otero 1 2 3 acillin plus Fluconazole ) for those patients who had pre- Surgery, Endocrinology, and Physiotherapy, Hospital operatively undergone biliary drainage (group B). Alvaro Cunqueiro de Vigo, Spain

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Introduction: Prehabilitation has been postulated as an perioperative outcomes and we also compare the patient’s affective tool to prevent postoperative complications in quality of life of Lap TP and Open TP. patients undergoing major abdominal surgery. However, no Results: The patients’ age was older (66.9 Æ 10.1 vs. studies have shown its effectiveness in pancreatic surgery 52.0 Æ 13.9 years, p = 0.019) in laparoscopic group. patients. The aim of this study was to assess the impact of However, estimated intraoperative blood loss (EBL) prehabilitation on postoperative complications in patients (488.9 Æ 191.1 vs. 1318.8 Æ 1140.5, p = 0.002) was small undergoing pancreaticoduodenectomy. and length of hospital stay (15.1 Æ 4.5, vs. 23.5 Æ 12.5 Methods: This was a randomized controlled trial. Eligible days, p = 0.029) was shown to be short in laparoscopic candidates accepting to participate were randomized (1:1 group. When comparing patients with more than 6 months ratio) to control (standard care) or intervention (standard follow up period (median, 38 months (range: 6-83) after care + prehabilitation) groups. All patients with peri- surgery, % change of body weight, albumin, and choles- ampullary tumours were included. Those patients receiving terol were compared. There was no significant differences neoadjuvant treatment were excluded. between two groups (p>0.05, Table). And no statistical Prehabilitation covered 3 actions: difference was also noted in follow up period (38.6 Æ 31.3 i) nutritional support vs. 43.1 Æ 23.3 months, p = 0.876). ii) control of diabetes and exocrine pancreatic Conclusion: Lap TP is feasible and safe in selected pa- insufficiency tients. However, the comparison analysis of the quality of iii) physical and respiratory training. life was no difference between the Lap TP and Open TP. The main study outcome was the proportion of patients And we must carefully determine the surgery. suffering postoperative complications. Secondary out- comes included the occurence of specific complications (pancreatic leak, delayeg gastric emptying, etc) and hos- EP02D-126 pital stay. MORPHOLIGICAL AND FUNCTIONAL Results: 38 patients were included in the intention-to-treat analysis. We randomized 20 patients to the control arm and CHANGES OF REMNANT PANCREAS 18 to intervention. No statistically significant difference AFTER PANCREATODUODENECTOMY was observed in terms of complications between prehabi- S. G. Kim1, H. J. Kwon1, Y. S. Han1,H.Ha1, A. Seo2, litation group and standard care group. Pancreatic leak was M. K. Kang3, J. M. Chun1, G. -S. Yoon2 and Y. J. Hwang1 less frequent in prehabilitation group, however this differ- 1Surgery, 2Pathology, and 3Radiation Oncology, Kyung- ence was not statistically significant. DGE and hospital stay pook National University Chilgok Hospital, Kyungpook were significantly lower in the prehabilitation group National University School of Medicine, Republic of (P=<0.05). Korea Conclusion: Prehabilitation did not reduce postoperative Introduction: Atrophy of the pancreatic parenchyma, complications in pancreaticoduodenectomy patients. which occurs frequently after pancreatoduodenectomy However, a reduction of DGE and hospital stay was (PD), is often associated with functional changes. The aim observed. of this study was to evaluate about morphological and functional changes of the remained pancreas and to deter- mine risk factors for these changes after PD. EP02D-125 Methods: 48 patients who underwent pancreatoduode- LAPAROSCOPIC TOTAL nectomy were enrolled into this study. Clinicopathological PANCREATECTOMY IN BENIGN AND findings were collected retrospectively. BORDERLINE MALIGNANT TUMOR OF Results: The remnant pancreatic volume decreased by average 49.3% and the decline of volume reduction was THE PANCREAS: PERIOPERATIVE the largest within 3 months after PD. Eleven patients OUTCOMES AND QUALITY OF LIFE (34.4%) developed ductal dilatation after surgery. Dia- J. H. Lee1 and C. M. Kang2 betes mellitus was newly present in 13 of 48 (27.1%) 1Surgery, National Health Insurance Service Ilsan Hos- patients. The volume reduction of the remnant pancreas pital, and 2Surgery, Yonsei University College of Medi- in malignant disease was larger although there was no cine, Republic of Korea statistical difference (p = 0.058). Postoperative pancre- Background: Laparoscopic pancreas surgery has been atic atrophy was associated with origin of disease practiced with development of the surgical technique and (p = 0.003). Atrophic change was prominent in fi the laparoscopic instrument. Also total pancreaticoduode- ampullary and bile duct tumor. A signi cant atrophy nectomy has been applied for benign and borderline was frequently observed in patients who were occurred pancreatic disease. We have analyzed the patient’s quality pancreatitis (P = 0.042). The amount of pancreatic at- of life and perioperative outcomes of laparoscopic versus rophy was larger in the patients who were occurred fi fi open total pancreatectomy. pancreatic stula than that of others but no signi cant Methods: From 2005 to 2015, 13 consecutive patients difference was found (p = 0.308). underwent laparoscopic total pancreatectomy (Lap TP) and Conclusion: The loss of pancreatic parenchyma did not 35 patients underwent open total pancreaticoduodenectomy correlated with postoperative diabetes. The morphological (Open TP) in Yonsei University severance Hospital. change was mainly happened in short term postoperative Among them we were select the patient who diagnosed period. Early operative complications such as pancreatitis fi benign and borderline pancreatic tumor and renal cell and pancreatic stula seem to be associated with atrophic carcinoma metastases to pancreas. We compared the change of the pancreatic remnant. Therefore, perioperative consideration for reducing pancreatic inflammation should

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S629 include strategies to minimize atrophic change of the Methods: Consecutive all 143 patients with R PDAC were pancreatic tissue. performed pancreaticoduodenectomy and total pancrea- tectomy in our department from 2002 to 2016. Among all, 130 and 13 patients were classified into surgery first (SF) EP02D-127 group and NAT group, respectively. PATTERN OF LOCOREGIONAL Results: Among NAT group, the combination of gemci- tabine (Gem) and S-1 for 9 patients, the combination of RECURRENCE AFTER CURATIVE Gem and nab-paclitaxel for 1 patient and carbon-ion RESECTION IN PANCREATIC DUCTAL radiotherapy (CIRT) for 4 patients, and CIRT with Gem for ADENOCARCINOMA ACCORDING TO 1 patient were administrated as neoadjuvant therapies. THE LOCATION OF THE TUMOR Comparing between SF and NAT group, no significant differences were observed in the major clinico-pathological J. R. Kim, W. Kwon, J. -Y. Jang and S. -W. Kim factors. In terms of clinical outcomes of patients, overall Surgery, Seoul National University College of Medicine, survival, disease free survival and recurrence site also did Republic of Korea not show significant differences between these two groups. Purpose: There are little studies on the recurrence pattern Initial CA19-9 >500 (P = 0.042), lymph nodes metastasis of pancreatic ductal adenocarcinoma (PDAC). The aim was (P = 0.0025) and blood volume loss (P=0.0030) were to analyze the recurrence pattern after curative resection in considered as independent prognostic factors for overall PDAC patients according to the tumor location. survival in multivariate analysis. Method: This study included 361 patients with PDAC who Conclusion: We demonstrated that initial CA19-9 level is underwent curative-intent surgery between 2007 and 2014. an independent prognostic factor in R PDAC. The initial Results: Among 361 patients, 75.1% (n = 271) had recur- CA19-9 level will become a good indicator for determining rence during the follow up period (median 31.9month the R PDAC patients who should be undergone NAT. [1.9w124.7]) and the 5-year overall survival rate was 29.4%. The first recurrence patterns were divided as local (n = 48, 13.3%), systemic (n=168, 46.5%) and combined (n = 55, 15.2%) type. According to the preoperative tumor location, EP02D-129 patients with head and uncinate process mass had more local MANAGEMENT OF POST- recurrence than those with body and tail mass (47.8% vs. PANCREATICODUODENECTOMY 18.2%, p< 0.001). Regarding the head and uncinate mass, HEMORRHAGE: A META-ANALYSIS uncinate process mass showed higher recurrence rate around E. Zwart1, B. Zonderhuis1, I. Jansma2, T. Hellingman1, the superior mesenteric artery/vein (SMA/SMV) compared F. Daams1 and G. Kazemier1 to head mass (76.7% vs. 35.6%, p = 0.001). On the other 1Department of Surgery, and 2Medical Library, VU Uni- hand, head mass showed more frequent recurrence around versity Amsterdam, The Netherlands the hepatoduodenal ligament (42.2% vs. 18.6%, p = 0.021). Conclusion: Most of the patients with pancreatic ductal Introduction: Post-pancreaticoduodenectomy hemorrhage adenocarcinoma succumb to the recurrence after curative (PPH) has an incidence of 2-17%. Despite patients under- resection. While systemic recurrence is beyond the hands of going multiple interventions, mortality rates are up to 50%. surgery, local recur may be prevented by meticulous sur- Treatment guidelines are not available. The aim of the gery. With this in mind, different patterns of locoregional study is to compare different treatment strategies for PPH. recurrence according to the tumor location should be of an Method: A search was conducted in Embase, Medline, the important consideration. Therefore, customization of the Cochrane library and reference lists of articles. Titles and extent of surgery according to the location of tumor is abstracts were screened and full-texts were assessed by two necessary for better local control. authors. Data concerning characteristics of the bleeding, diagnostic accuracy, treatment of PPH and mortality were extracted using a data-extraction form. The Newcastle- Ottowa Quality Assessment scale was used as quality EP02D-128 assessment and analysis was performed using the Mantel- THE INVESTIGATION OF PROGNOSTIC Haenszel Random Effects model. FACTORS AND SIGNIFICANCE OF Results: Thirty studies were included from 5921 screened NEOADJUVANT THERAPY FOR articles, reporting on 565 patients with PPH. Sixty-nine Æ RESECTABLE PANCREATIC CANCER percent was male and the mean age was 61,5 years ( 5.2 SD). Fifty-one were classified as early and 514 as late PPH. R. Shimazaki, S. Takano, H. Yoshitomi, S. Kagawa, Arterial origin was the most common source (67%). K. Furukawa, T. Takayashiki, S. Kuboki, D. Suzuki, Angiography had the highest detection rate of 80% (182/ N. Sakai and M. Ohtsuka 227) to diagnose PPH. As primary intervention for late Department of General Surgery, Chiba University, Japan PPH, 28% (146/514) underwent a re-laparotomy, 43% Introduction: Pancreatic cancer (PDAC) has a highly (221/514) endovascular treatment, 8% (41/514) endoscopic malignant potential. In recent years, it was reported that treatment and 21% (106/514) non-invasive treatment. neoadjuvant therapy (NAT) for borderline resectable Endovascular therapy has better odds on rebleed and PDAC would contribute to improvement of patients’ mortality compared to re-laparotomy as primary and sec- prognosis, however, there is no evidence for NAT in ondary intervention for late PPH, respectively 0.46 and resectable (R) PDAC. In this study, we aim to investigate 0.19. The mean mortality for PPH was 23,2%. the clinical significance of NAT and analyze prognostic Conclusions: As a diagnostic tool, angiography has the parameters for head R PDAC patients. highest detection rate for localizing the bleeding.

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Endovascular treatment is more successful than re-lapa- last 25 yrs. POPF grade C is a risk factor for mortality rotomy for patients with late PPH as primary and secondary following pancreaticoduodenectomy with a mortality rate intervention. of approximately 25%e50%. There is limited literature for factors predicting mortality in POPF C. Objective: To determine the risk factors associated with EP02D-130 mortality in Grade C POPF LAPAROSCOPIC Methods: We retrospectively analysed patients who un- derwent pancreaticoduodenectomy from January 2013 to PANCREATICODUODENECTOMY FOR October 2017. The pancreatico-jejunostomy was performed ADENOCARCINOMA OF THE DISTAL with duct to mucosa technique in four layers in all patients. BILE DUCT AND AMPULLA: A CASE- Patient demographics, clinical data, surgery details, post- MATCHED COMPARISON surgical recovery and complications were recorded. Results: Five hundred and ninety-two patients underwent T. Adachi1, T. Adachi1, S. Ono1, H. Matsushima1, pancreaticoduodenectomy during the study period. Clinically M. Yamashita1, A. Soyama1, M. Hidaka1, M. Takatsuki1, relevant POPF (CR-POPF) was seen 108 patients (18.2%). T. Kuroki2 and S. Eguch1 Grade C POPF occurred in 31 patients (5.2%). The overall 1Department of Surgery, Nagasaki University Graduate mortality rate was 2.8% and the mortality rate associated with School of Biomedical Sciences, Nagasaki, and 2Depart- POPF grade C was 38.7% (12/31).Factors associated with ment of Surgery, National Hospital Organization Naga- increased risk of mortality in patients with POPF grade C are saki Medical Center, Japan listed in table no 1. On multivariate analysis, none of the Introduction: Laparoscopic pancreaticoduodenectomy factors were found to be statistically significant due to high (LPD) have increased in number. Although there are some inter-variable co-relations. The strength of co-relation was reports showing the usefulness of LPD for benign or low- found highest with bile leak, post pancreatectomy haemor- fi grade malignant tumor, the oncological bene ts for cancer rhage (PPH) and chest complications. such as distal bile duct carcinoma (BDCa) or papilla vator Conclusions: Post pancreatectomy haemorrhage, bile leak carcinoma (PVCa) were unclear. The aim of this study was and chest complications are associated with higher risk of to compare the surgical and oncological outcomes of LPD mortality in patients with Grade C POPF. Analysis in larger and open PD (OPD) for BDCa or PVCa. cohort of patients is required to support our results. Patients: The consecutive patients who underwent LPD (n = 21) for BDCa or PVCa and patients who underwent Table 1. Factors associated with mortality OPD (n = 21) were enrolled in this study. The indications of LPD was T2N0M0 or less.These OPD patients were S.no Factors Association selected by statistical matching with LPD patients based on with mortality following parameters: age, gender, ASA score, BMI, Univariate HbA1c, diagnosis, and TNM stage. analysis fi Results: There was a signi cant difference in intra- 1. Post pancreatectomy Haemorrhage p = 0.005 operative bleeding between two groups (mean: 496 vs (PPH) (n = 16) < fi 1443 mL, P 0.001). No signi cant differences were seen 2. Bile leak (n = 11) p = 0.000 in operative time (640.5 Æ 184.4 vs 570.5 Æ 146.5 min), 3. Associated chest complications p = 0.000 occurrence of postoperative complications (19.0% vs (n = 11) 28.6%), the number of retrieved lymph nodes (21.0 Æ 9.1 4. Positive blood culture ( n = 7) p = 0.000 vs 18.1 Æ 9.4 ) and surgical margin-positive rate (4.8% vs 9.5%) between two groups. The 1-, 3-, and 5-year overall 5. Number of interventions p = 0.0001 survival rates were 95.2%, 76.2% and 66.7% in LPD group 6. Number of explorations p = 0.008 and 85.7%, 71.4%, and 57.1% in OPD group, with no 7. Pre-intervention Sr.Albumin levels p = 0.016 fi signi cant differences between two groups. 8. Post-operative day of suspicion for p = 0.750 Conclusions: LPD is a safe and feasible as minimally inva- POPF sive surgery for BDCa or PVCa, and it can achieve long-term 9. Post-operative day/ Time of first re- p = 0.093 prognostic result which is not inferior to those of OPD. exploration

EP02D-132 FACTORS PREDICTING MORTALITY IN EP02D-133 PATIENTS WITH GRADE C OUTCOMES AFTER POSTOPERATIVE PANCREATIC PANCREATICODUODENECTOMY FISTULA AFTER WITH 12 STITCHES DUCT-TO-MUCOSA PANCREATICODUODENECTOMY PANCREATICOJEJUNOSTOMY K. Khobragade1, M. Bhandare1, V. Chaudhari1, Y. Iizawa, A. Hayasaki, Y. Murata, Y. Azumi, R. Dusane2 and S. Shrikhande1 N. Kuriyama, M. Kishiwada, S. Mizuno, M. Usui, 1Department of Surgical Oncology, and 2Department-Clinical H. Sakurai and S. Isaji Research Secretariat(CRS), Tata Memorial Hospital, India Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Japan Introduction: The mortality rate for postoperative fi pancreatic fistula (POPF) has remained stable at 2%-4% for Background: To prevent the postoperative pancreatic s- tula (POPF) after pancreaticoduodenectomy (PD), we have

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S631 used a standardized duct-to-mucosa pancreaticojejunos- lower bleeding rate (5% vs. 15%) and lower mortality (1 vs. tomy (PJ), named “pair-watch suturing technique (PWST)” 6), none of these findings were statistically significant. since 2007, in which 12 stitches (6-0) are put on duct-to- Conclusion: The use of piperacillin/tazobactam suggests an mucosa PJ regardless of the diameter of pancreatic duct. improvement of postoperative outcome. Nevertheless, this The aim of this study was to evaluate the complications antimicrobial regimen is more expensive and the selection after PD with PWST. of resistant bacteria poses a serious threat. Further investi- Patients and methods: The subjects were the consecutive gation and bigger studies are required to conclusively assess 341 patients who underwent PD with PWST from April a possible change in standard antibiotic treatment. 2007 to March 2017. We evaluated complications accord- ing to Clavien-Dindo classification. Especially POPF was also evaluated according to ISGPF classification. EP02D-135 Results: Median age of subjects was 69 years old. The 206 PORTAL VEIN STENTING FOR patients were male and 135 were female. Pancreatic cancer was shown in the 171 patients (50.1%), soft pancreas in 150 SYMPTOMATIC PORTAL VEIN (44.0%), dilated pancreatic duct (more than 3mm) in 178 OCCLUSION AFTER (52.2%) and pancreatic stent placement 179 (52.5%). The PANCREATICODUODENECTOMY fi incidence of clinically relevant postoperative pancreatic s- D. J. Park and J. S. Heo tula (CR-POPF: ISGPF grades B and C) was 11.4% (n = 39). Samsung Medical Center, Sungkyunkwan University fi Clavien-Dindo classi cation of these 39 patients with CR- School of Medicine, Republic of Korea POPF was grade II in 9, grade IIIa in 24, grade IVa in 2, grade Introduction: Portal vein occlusion is the worrisome late IVb in 2 and grade V in 2. Severe complications (grade IIIa or complication following pancreaticoduodenectomy that more) were found in 103 patients (30.2%): CR-POPF (8.2%, caused variceal bleeding, which must be diagnosed n = 28), intra-abdominal abscess (6.7%, n = 23), bleeding correctly and treated promplty. This study aimed to (n = 14, 4.1%), pneumonia (n = 8, 2.3%) and others (n = 23). describe characteristics and evaluate patency of portal vein Conclusion: Our standardized duct-to-mucosa PJ using stent for post pancreaticoduodenectomy. PWST is a safe and reliable procedure regardless of Methods: Eleven consecutive patients (age range 45 to 78; pancreatic duct size and pancreatic texture. nine men and two women) who underwent portal vein stenting between January 2000 and December 2016, all of them suffer portal vein occlusion after pancreaticoduode- EP02D-134 nectomy, were retrospectively reviewed. Primary stent COMPARING TWO ANTIMICROBIAL patency was plotted using the Kaplan-Meier method. PROPHYLACTIC STRATEGIES IN Results: All patients underwent pancreaticoduodenectomy. PANCREATIC RESECTIONS: A SINGLE Portal vein occlusion was caused by benign postoperative CENTER OUTCOME ANALYSIS change (n = 8) and local tumor recurrence (n = 3). Symp- toms were gastrointestinal bleeding (n = 10) and uncon- 1 2 1 G. Edler , S. Weixelbraun and F. Längle trolled ascites (n = 1). Symptoms occurred at 38 moths (2 to 1 Department of General Surgery, LK Wiener Neustadt, 121 months), on average, postoperatively. Technical suc- 2 and Medical University of Vienna, Austria cess, treatment efficacy and clinical success rates were 90.9, Introduction: Pancreatic resection appears to be the central 100 and 90.9%, respectively. The primary patency rate of element in treating patients with pancreatic cancer. Wound portal stent was 91.9% during the mean follow-up period of infection after pancreaticoduodenectomy is a severe and 12months. There was no procedure related complication or complex problem, which causes a prolongation of the mortality occurred. hospital stay and an increase of costs. There is a strong Conclusions: Portal vein stenting is a feasible and safe recommendation for the use of a 2nd generation cepha- treatment for symptomatic portal vein occlusion after losporine combined with metronidazole as a preoperative pancreaticoduodenectomy. antibiotic prophylaxis. This combination doesn’t affect Enterococcus, which is very common in abdominal surgery. The aim of this study was to compare the standard antibiotic EP02D-136 prophylaxis with an Enterococcus-affecting combination DIAGNOSTIC ACCURACY OF (piperacillin/tazobactam) with regard to infection rate (CDC-NHSN definition), postoperative complications and COMPUTED TOMOGRAPHIC (CT) mortality. ANGIOGRAPHY FOR DETECTION OF Methods: We retrospectively analysed data of 116 patients POST-PANCREATECTOMY who underwent pancreatic resections. We statistically HAEMORRHAGE compared patients who recieved cefuroxime/metronidazole M. Pease, S. Jamdar, M. Baltatzis, V. Nadarajah, with patients who recieved piperacillin/tazobactam preop- A. Sheen and A. Siriwardena eratively. The primary endpoint of the study was the post- Manchester University Hospitals NHS Foundation Trust, operative infection rate and the resulting complications. United Kingdom Results: The overall infection rate in our patients was 22%. Although in the piperacillin/tazobactam group we found a Introduction: Post pancreatectomy haemorrhage (PPH) is lower infection rate (14% vs. 26%), a lower Clavien-Dindo a rare but important complication of pancreas resection. Score, a lower percentage of postoperative pancreatic fistula, Therapy for PPH has evolved from surgical management to

HPB 2018, 20 (S2), S505eS684 S632 Electronic Posters (EP02A-EP02F) e Pancreas endovascular diagnosis and treatment. CT angiography is Results: There were 96 consecutive patients who un- widely utilised as a first diagnostic test. This study exam- derwent PD in our department between January 2013 ines the diagnostic accuracy of CT angiography for PPH. and December 2017. Multivariate analyses were Methods: Patients undergoing pancreatic resection in a performed to investigate the effectiveness of the Pruca- regional Hepato-pancreato-biliary surgery unit during the lopride in the treatment of DGE. The overall incidence studyperiodOctober2014toFebruary2017were of DGE was 26,04 % (patients underwent PD: 96, pa- identified from a prospective database. Clinical and tient with DGE post PD: 25) Of these, 7 patients (6 F, 1 electronic records were interrogated to collate data on M) were treated with Prucalopride after the failure of patient demographics, operative details, evidence of medical therapy with common prokinetic (metoclopra- bleeding, management and clinical outcomes including mide, domperidone). Each of these had a resolution of complications and mortality. Grade of bleeding was the DGE with improvement of the outcome and with recorded according to ISGPF guidelines. Sensitivity, early discharge. specificity and receiver-operating characteristic curve Conclusion: Prucalopride may serve as a post-operative were calculated. The study was registered as a prospec- tool for DGE after PD, further studies are needed to validate tive audit. this proof of concept. Results: 173 patients underwent pancreatic resection. 22 demonstrated evidence of PPH (15 Grade B, 7 Grade C). 24 CT angiograms were performed. 2 patients required EP02D-138 mesenteric angiography and embolization, 1 patient IMPACT OF AGE ON SHORT- AND required endoscopic therapy and 2 patients required lapa- rotomy. 1 (5%) patient died as a result of PPH. CT angi- LONG-TERM OUTCOME AFTER ography had a sensitivity of 26 % and specificity of 98%. PANCREATODUODENECTOMY Area under the curve was 0.621 with p = 0.093. Y. C. Spolverato, M. Gruppo, F. Tolin, B. Martella, Conclusions: Although CT angiography will likely remain I. Angriman, F. Zingales and R. Bardini the first diagnostic test, this study demonstrates that it has a Department of Surgery, Oncology and Gastroenterology, poor sensitivity for detection of PPH. University Hospital of Padua, Italy Introduction: Although mortality and morbidity of pancreatoduodenectomy (PD) have improved signifi- EP02D-137 cantly over the past years, the impact of age for patients PRUCALOPRIDE FOR THE undergoing PD is still debated. This study aimes to TREATMENT OF DELAYED GASTRIC analyze short- and long-term outcomes of PD in elderly EMPTYING AFTER patients. Methods: 124 consecutive patients, undergone PD for PANCREATICODUODENECTOMY: A pancreas neoplasm in our center between 2012 and 2017, PILOT STUDY were analyzed. Patients were divided into two groups: D. Pagano, S. Calamia, C. Ricotta, S. Li Petri, group I (<70 years), group II (70 years). Demographic F. di Francesco, B. Pasquale, A. Tropea, G. Checchini, features, intraoperative and clinic-pathological data were D. Cintorino and S. Gruttadauria collected. Primary endpoints were perioperative Department of Abdominal Surgery and Organ Trans- morbidity and mortality; complications were classified plantation Unit, Department for the Treatment and Study according to Clavien-Dindo score. Secondary endpoints of Abdominal Diseases and Abdominal Transplantation, included feasibility of adjuvant treatment and overall Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) survival rates. - Istituto Mediterraneo per i Trapianti e Terapie ad Alta Results: 106 patients were included in this study. There Specializzazione (ISMETT)/University of Pittsburgh Med- were 64 (60.4%) patients in group I and 42 (39.6%) in ical Centre Italy (UPMCI), Italy group II. Perioperative deceases were 4 (3.6%), post- fi Introduction: Delayed gastric emptying (DGE) is one of operative pancreatic stulas were 34 (32,1%). Post- the most common complications after pancreaticoduode- operative outcome data are summarized in table 1. fi nectomy (PD) reported in 19e57% of patients. Pruca- Signi cant difference was demonstrated for ASA score < lopride, a 5-hydroxytryptamine, 5HT-4 receptor agonist (p 0.01), pancreas consistency (p = 0.03), Karnofsky < has been shown to be an excellent drug to treat post-oper- index (p 0.01), preoperative jaundice (p = 0.03). ative ileus. In this pilot study we wanted to test Pruca- 68,7% of patients in group I underwent adjuvant treat- lopride in the treatment of DEG after PD. ment vs 40,6% of older ones (p = 0,012). Mean overall Methods: We conducted a monocentric study on a survival was 26 months in group I vs 21,1 months in consecutive series of PD performed in patients affected by group II (p = 0,8). pancreatic adenocarcinomas from January 2013 to Conclusions: PD can be performed safely in elderly pa- December 2017 at IRCCS-ISMETT-UPMC. Patient’s de- tients. Advanced age should not be a contraindication for mographics, oncologic staging, operative times, intra- PD. The outcome of elderly patients who have undergone operative vitals, and all early surgey-related complications PD is similar to that of younger patients, even though fi using Clavien grading system were collected and analyzed. adjuvant treatment administration is signi cantly lower, Post-operative DGE was determined by the inability to demonstrating that surgery remains the main therapeutic return to a standard diet by the end of the first post-opera- option. tive week and includes prolonged nasogastric intubation on the patient.

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Postoperative outcome in 106 patients EP02D-140 Parameter Group I (64 Group I (42 p LONG TERM ONCOLOGICAL pts < 70yrs) pts ‡ 70yrs) OUTCOMES OF RESECTION FOR Operative time, min 309±96 303±82 0.75 DUODENAL ADENOCARCINOMA Hospital Stay, days 22±10 21±12 0.57  E. Kontis, M. Pizanias, O. Barbouti, E. Prassas, Reoperation, n (%) 4 (6,2) 2 (4,8) 0.87 P. Srinivasan and A. Prachalias Postoperative 1 (1,6) 3 (7,1) 0.14 Institute of Liver Studies, Kings Health Partners of King’s Deceases, n(%) College Hospital, NHS Foundation Trust, King’s College Pulmonary 0 (0) 2 (4,7) 0.08 Hospital NHS Trust, United Kingdom Complications, n(%) Introduction: Duodenal adenocarcinoma is a rare malig- Cardiovascular 3 (4,7) 5 (11,9) 0.26 nancy with surgery remaining the only curative option. The complications, n(%) aim of this study is to analyse the outcomes of surgery and Other complications, 21 (32,8) 10 (23,8) 0.32 identify potential prognostic factors. n(%) Methods: Retrospective observational study of patients Clavien-Dindo Score  6 (9,3) 4 (9,5) 0.98 undergoing resection of duodenal adenocarcinoma with 3B, n(%) curative intent between 2010 and 2014. fi Pancreatic fistula 22 (34,4) 12 (28,6) 0.53 Results: Twenty- ve patients (8 male and 17 female) with a (Grade B-C), n(%) mean age of 63.2 Æ 12.73 years underwent surgery. The majority of the patients (80%) presented with advanced tumors (Stage 2B or 3). 17 patients underwent pancreato- EP02D-139 duodenectomy (Whipple’s or PPPD), 5 underwent multi- LOWER IS HIGH ENOUGH: NEW visceral resection along with vascular resection (e.g. right SUGGESTED THRESHOLD FOR colon kidney or IVC), while 3 had partial duodenectomy. R0 POSTOPERATIVE DAY 1 DRAIN-FLUID- resection was achieved in 92% of the cases. The mean overall survival was 51.4 months (95% CI: 37.22e65.59 months). AMYLASE POST Seven patients experienced recurrence with an average in- PANCREATODUODENECTOMY terval to recurrence of 8.71 months (95% CI: 0.358e17.71). E. M. Aleassa1,2, G. Sharma1, S. Malik1 and Adjuvant chemotherapy offered a clear survival benefitto G. Morris-Stiff1 patients (log-rank Mantel-Cox p=0.007, 62.67 months versus 1Department of Surgery, Cleveland Clinic Foundation, 20.8 months). Although tumour differentiation did not appear United States, and 2Department of Surgery, United Arab to affect recurrence rates (Chi-square p = 0.952), poorly Emirates University, United Arab Emirates differentiated tumours tend recur earlier than moderate or well Introduction: The use of day one drain-fluid-amylase differentiated tumors. ((log-rank Mantel-Cox p = 0.039) (DFA-1) to predict post-operative pancreatic fistula (POPF) Conclusion: Surgery with curative intent, albeit extensive, fi following pancreatoduodenectomy (PD) remains contro- offers a survival bene t to patients with duodenal adeno- versial. We aim to assess the significance of a DFA-1 level carcinoma; this could be further complemented by adjuvant of 5000 U/L. chemotherapy. The rarity of this tumor, necessitates larger Methods: The American College of Surgeons-National studies to identify potential prognostic factors. Surgical Quality Improvement Program (NSQIP) pancrea- tectomy targeted files were queried from 2014e2016 to identify patients who underwent PD. Only patients with a EP02D-142 recorded DFA-1 level were included for analysis. DFA-1 DELAY IN was recorded as a dichotomous variable using the cut off of PANCREATICODUODENECTOMY TILL less or greater than 5000 U/L. A Receiver Operator Char- acteristic (ROC) curve was plotted to determine the optimal NORMALIZATION OF C-REACTIVE DFA-1 to predict fistula formation. PROTEIN AND PROCALCITONIN DOES Results: We identified a total of 9432 cases of PD, of which NOT AFFECT OPERATIVE OUTCOMES: only 2545 (27%) had a postoperative DFA-1 level recor- EARLY RESULTS OF AN ONGOING ded. A fistula was recorded in 410 (16.2%) consisting of PROSPECTIVE STUDY 277 (67.5%) A and 133 (32.5%) B/C grade fistulae. A postoperative DFA-1 level of 5000 U/L significantly cor- G. Desai, P. Pande, V. Mansukhani, R. Shah and relates with development of a grade B/C pancreatic fistula P. Jagannath with a specificity of 84.4% and sensitivity of 32.3% (pos- Department of Surgical Oncology, Lilavati Hospital and itive predictive value of 10.3% and negative predictive Research Centre, India value of 95.7%). The area under the curve for B/C was Introduction: Our earlier study highlighted that preoper- 0.792 (p < 0.001) setting a specificity of 80%, the ROC ative C-reactive protein{CRP} and procalcitonin{PCT} curve demonstrated that a cut-off value of 800 U/L, pro- levels 48 hours before surgery are predictors of post- vided a sensitivity of 68.6%. operative infective complications. Surgery is delayed till Conclusion: The DFA-1 value of 5000 U/L is statistically normalization of CRP and PCT to avoid infective compli- significant of fistula development post PD, however its cations. This study evaluates the duration and impact of this sensitivity is poor. The ROC determined value of 800 U/L delay on operability. would appear to be a more appropriate level for detection of Methods: The present prospective study includes 178 B/C fistulae. consecutive patients who underwent PD from January 2011

HPB 2018, 20 (S2), S505eS684 S634 Electronic Posters (EP02A-EP02F) e Pancreas to December 2017 at our centre. Delay in non-stented pa- Method: The American College of Surgeons-National tients was time till normalization of CRP and PCT whereas Surgical Quality Improvement Program (NSQIP) pancre- in stented patients, delay was recorded from bilirubin atectomy targeted files were queried from 2014-2016 to <12 mg/dl to normalization of marker levels. identify patients who underwent PD. Only patients with a Results: 97 patients with normal PCT and CRP were recorded DFA-1 level were included for analysis. operated without delay(Group A) of which 31 patients were Results: Of 2543 patients with DFA-1 levels, 422 patients stented. 6 were unresectable, 9 needed vascular recon- (17 %) had DFA-1 levels 5000 U/l. Among the patients struction, 1 arterial reconstruction, mean operative time was with available DFA-1 levels, most common early 30-day 247 minutes and blood loss 148 ml. 28 had R1 resection. 81 complications included: POPF (n = 430, 17%), delayed patients with elevated PCT and/or CRP were operated after gastric emptying (DGE) (n = 398, 16%), organ space SSI normalisation (Group B). 42 were stented, 30 had mean (n=286, 11%) and intraoperative or early postoperative delay of 13.5 days. 39 non-stented patients had mean delay transfusion with 72 hours (n = 416, 16%). On multivariate of 12.9 days. 4 were unresectable (p = 0.99), 10 needed analysis in patients with POPF, DFA-1 levels 5000 U/l vascular reconstruction(p = 0.72), mean operative time was were associated with organ space SSI (OR: 2.0, p < 0.001) 253 minutes(p = 0.86) and mean blood loss was and DGE (OR: 1.5, p = 0.002). However, after eliminating 162 ml(p = 1). 22 had R1 resection(p = 0.97). On patients with POPF from the analysis, DFA-1 levels  comparing groups (see Table), no parameters differed 5000 U/l were still associated with development of organ significantly. The limitation is small sample size. In most space SSI (OR: 2.4, p < 0.001). patients, levels returned to normal in two weeks. This, as in Conclusions: Early postoperative drain fluid amylase level this study, does not show any adverse impact on outcome. is a useful tool to predict organ space infection. In this Conclusion: Delay in pancreaticoduodenectomy till cohort a selective imaging policy may allow early inter- normalization of C-reactive protein and procalcitonin does vention and prevent readmission. not affect operative outcomes.

EP02D-142 Table Comparative analysis between Group A and B Parameter Group A {Normal Group B {Elevated CRP Test of significance[p value] CRP and PCT} and/or PCT} Number of patients 97 81 - Preoperative stenting 31 42 - Vascular reconstruction 9 venous 1 arterial 10 venous Chi square test [p = 0.89] Unresectable on exploration 6 4 Chi square test [p = 0.99] Operative time {Mean} 247 minutes 253 minutes Unpaired t test [p = 0.86] Blood loss {Mean} 148 ml 162 ml` Unpaired t test [p = 1] R1 resection 28 22 Chi square test [p = 0.97] Delay None 30 of Stented {mean – 13.5 days} - 39 of non-stented {mean – 12.9 days}

EP02D-144 EP02D-143 CURATION OF LATE SEVERE POSTOPERATIVE DAY 1 AMYLASE POSTOPERATIVE HEMORRHAGE IN A LEVELS ARE USEFUL IN PREDICTING PATIENT WITH A PANCREATIC NON-FISTULA 30-DAY FISTULA OF CLASS C COMPLICATIONS AFTER O. Kvasivka PANCREATODUODENECTOMY HPB, National Cancer Institute Ukraine, Ukraine 1 2 2 2 S. Malik , G. Sharma , E. Aleassa ,C.Tu and In our study, we analyzed patient with POPF grade 2 G. Morris-Stiff C, where postoperative hemorrhage occurs. Between 1 Internal Medicine, Cleveland Clinic Akron General 2015 and 2017 late severe hemorrhage occurred in 17 2 Medical Center, and General Surgery, Cleveland Clinic, patients with complicated postoperative period. Spe- United States cific attention was paid to the tactics during the first Introduction: Postoperative day one drain fluid amylase relaparotomy. (DFA-1) levels in patients undergoing pancreatoduode- All patients were operated. Five patients survived, 12 nectomy (PD) have been used to predict the subsequent patients died. Postoperative mortality in this group of development of a postoperative pancreatic fistula (POPF). patients was 70,6%. Among these patients 3 died in the However, literature with respect to the association of first 24 hours after relaparotomy, due to hemorrhagic DFA levels with additional complications is limited. Our shock. aim was to interrogate a national database to assess if In 4 patients completion pancreatectomy was done early DFA-1 levels 5000 IU/l could be utilized to during the first relaparotomy (in all patients that included predict 30-day complications in addition to POPF after resection of the left pancreas remnant). In 2 patients 1 PD. recurrent bleeding occurred, causing 1 postoperative death.

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Postoperative mortality was 25,0% in this subgroup of EP02D-146 patients. In 10 patients completion pancreatectomy was not IS LAPAROSCOPIC PANCREATIC performed during first relaparotomy, including 1 pa- ENUCLEATION APPROPRIATE FOR tient after gastrectomy and 4 patients after left ALL PANCREATIC DISEASES? pancreas resection. 8 patients (80%) of this group died. F. S. Ftériche, B. Aussilhou, O. Soubrane, A. Sauvanet and Of 2 survived patients from this group in 1 patients S. Dokmak there was no recurrent bleeding, and in another patient HPB and Liver Transplantation, Beaujon Hospital, completion pancreatectomy was done after recurrent Assistance Publique Hôpitaux de Paris, University Paris bleeding. In all other 8 patients from 1 to 5 recurrent VII, France bleedings occurred (mean 2,1 Æ 1,4), fatal in 4 pa- Introduction: With the widespread of laparoscopic tients. Other 4 patients died of septic complications. pancreatic surgery, enucleation is considered as an excel- Mortality in patients without completion pancreatec- lent indication to the laparoscopic approach. Our aim was tomy was 88,9%. to analyze our indications and results. Completion pancreatectomy should be done whenever Methods: From January 2008 to September 2017, among possible in patients with late severe hemorrhage and POPF the 422 patients who underwent laparoscopic pancreatic grade C. resection, 41(10%) underwent laparoscopic enucleations and were studied retrospectively. Results: The mean age was 50 (17-74), mean BMI 25 (19- EP02D-145 36) and 29 were females (71%). Main indications were THE OUTCOME OF LAPAROSCOPIC neuroendocrine tumor (26; 63%); Mucinous cystadenoma PANCREATICODUODENECTOMY IS (7; 17%), other benign cysts (7; 17%) and only one intra- BETTER WITH THE LEARNING CURVE. ductal papillary mucinous neoplasia (IPMN) (3%). Lesions were located in the head (n=14; 34%).The mean size was ANALYSIS IN 100 PATIENTS 24 mm (9-80). The mean operative time was 110 mn (30- 1 1 1 2 S. Dokmak , B. Aussilhou , F. S. Ftériche , P. Lévy , 330), the mean blood loss was 64 ml (0-800) ml and no 1 1 O. Soubrane and A. Sauvanet transfusion and one conversion. No 90 days mortality. 1 2 HPB and Liver Transplantation, and Departement of Overall morbidity in 14 patients (34%), represented by Pancreatic Diseases, Beaujon Hospital, Assistance Publi- pancreatic fistula of grades B and C (5;12%), bleeding que Hôpitaux de Paris, University Paris VII, France (2;5%), one drained collection and no -intervention. Lymph Introduction: In our first experience Laparoscopic nodes was harvested in 14 patients (34%) with a mean pancreaticoduodenectmoy (LPD) was associated with number 0.7(0-5) and negative in all. The mean hospital stay higher morbidity and we restricted our indications to pa- was 11 days (4e42). tients at lower risk of pancreatic fistula (PF). Our aim was to Conclusion: The excellent outcome of laparoscopic analyse the learning curve effect on the outcome. enucleation is explained by the low rate of enucleation for Method: Between April 2011 e September 2017, 100 LPD IPMN, which are theoretically at higher risk of complica- were performed by pure laparoscopic approach and one tions. IPMN of good indications to the laparoscopic layer pancreaticojejunal anastomosis. The demographics, approach (peripheral branch ducts) do not necessary need surgical and the outcome data of the last 50 LPD were surgery, and those who need surgery (small revealed by compared to the first 50 LPD. pancreatitis) are not good indications for the laparoscopic Results: No difference regarding age (57 vs 60, p = approach related to inflammation and difficult location 0.20), female (42% vs 42%) and BMI (24 vs 23, p = (deep and small). 0.39). Less resections for pancreatic adenocarcinoma (22% vs 32%, p [ 0.047) and for ampulloma (14 vs 26, p = 0.26). No difference on the operative time (335 vs EP02D-147 342, p = 0.62) and conversion (8% vs 8%) but Less ANALYSIS OF A SINGLE CENTER blood loss (250 vs 368 vs, p [ 0.024) and transfusion (4% vs 12%, p = 0.50). Similar 90 days mortality (4% vs EXPERIENCE OF 422 LAPAROSCOPIC 4%). Less overall morbidity (68% vs 76%, p = 0.37), less PANCREATIC RESECTIONS grades B and C PF (33% vs 42%, p = 0.33), less S. Dokmak1, B. Aussilhou2, F. S. Ftériche2, P. Lévy3, bleeding (18% vs 26%, p = 0.47), less re-interventions J. Cros4, M. P. Vullierme5, O. Soubrane2 and A. Sauvanet2 for severe complications (6 % vs 14%, p [ 0.039), less 1HBP and Liver Transplantation, Beaujon Hospital, 2HPB readmission (4% vs 8%, p = 0.40), less delayed gastric and Liver Transplantation, 3Departement of Pancreatic emptying (10% vs 16%, p = 0.37), similar drained col- Diseases, 4Departement of Pathology, and 5Departement lections (4% vs 4%) but more biliary fistula (18% vs 8%, of Radiology, Beaujon Hospital, Assistance Publique p = 0.137). Hospital stay was shorter (22 vs 28, p [ Hôpitaux de Paris, University Paris VII, France 0.033). Introduction: Although laparoscopic pancreatic resection Conclusions: Although in the second period less resec- (LPR) has become a routine, large single center series are tion were done for pancreatic adenocarcinoma, at lower still lacking. We analyze our large European single center risk of PF, the outcome of LPD was better related to series of LPR. patient selection, improved surgical technique and Method: Between January 2008 and September 2017, 422 management. LPR were performed and studied prospectively including

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215 (51%) distal pancreatectomies, 100 (24%) pancreato- p < 0.001). In unadjusted analysis, there were no differ- duodenectomies (PD), 41 (9%) enucleations, 64 (15%) ences between the two groups with respect to 30-day all- central pancreatectomies and 2 (1%) total pancreatec- cause morbidity (15.2% vs 16.8%; p = 0.40), or serious tomies. The main contraindication was vascular invasion morbidity (0.8% vs 1.1%; p = 0.8). The 30-day readmission needing reconstruction. rate was lower in the ED group but not statistically so Results: Mean age was 55 years (17-87), mean BMI was (10.5% vs 13%; p = 0.16). 25 (16e39), and most were women (247; 58%). Main in- Conclusions: Early discharge, and by extrapolation ERAS, dications were adenocarcinoma (112; 27%), NET (96; in patients undergoing pancreatoduodenectomy is safe 23%), IPMN (89; 21%), Mucinous cyst (38; 9%), solid and without additional risk of short-term morbidity, or cystic pseudo-papillary tumor (24; 6%) and others (63; increased risk of readmission. 15%). The mean operative duration was 208 min (30-540), mean blood loss was 226 ml (0-1500), transfusion (18; 4%) and conversion (19; 4.5%). Mortality (4; < 1%) and only EP02D-149 after PD (4%). Overall morbidity (248; 59%) represented FEASIBILITY OF ENHANCED by pancreatic fistula (163; 39%) of grade A (63;15%), B (66; 16%) and C (29; 7%), bleeding (44; 10%), re-inter- RECOVERY PROCTOCOL FOR vention (n=37; 9%), drained collections (17; 4%), delayed DUODENOPANCREATECTOMY: A gastric emptying (18; 4%), readmission (27; 6%) and MULTICENTRIC COHORT STUDY hospital stay 18 (2-104) . For pancreatic adenocarcinoma D. Roulin1, E. Melloul1, D. Vrochides2, M. Bockhorn3, (69), the mean size was 2.8 cm (0.5-9), the mean number of J. Izbicki3, D. Ianniti2, M. Adham4 and N. Demartines1 harvested lymph nodes was 19 (0-59), invaded 1.8 (0-27) 1Department of Visceral Surgery, University Hospital and R1 resection (20, 29%). Lausanne, Switzerland, 2Department of General Surgery, Conclusions: The laparoscopic approach is safe with high Carolinas Medical Center, United States, 3Department of feasibility rate for distal and central pancreatectomy. It can Surgery, University Medical Center Hamburg-Eppendorf, be proposed for the majority of candidates to pancreatic Germany, and 4Department of Digestive Surgery, Edouard resections. Herriot Hospital, France Introduction: Specific enhanced recovery after surgery (ERAS) guidelines for duodenopancreatectomy (Whipple) EP02D-148 were published, mostly by extrapolating data from colo- COMPARATIVE OUTCOMES OF EARLY rectal surgery. This study aimed to assess the feasibility of AND STANDARD DISCHARGE IN an ERAS protocol for duodenopancreatectomy by deter- PATIENTS UNDERGOING mining the compliance to the guidelines. PANCREATODUODENECTOMY Methods: Retrospective analysis based on a prospective database, including all consecutive patients undergoing 1 2 1 1 G. Sharma , S. Malik , E. Aleassa ,C.Tu and duodenopancreatectomy within an ERAS program in four 1 G. Morris-Stiff centers (Switzerland, United States, France, and Germany). 1 2 General Surgery, Cleveland Clinic, and Internal Medi- Postoperative outcome (length of stay, complication ac- cine, Cleveland Clinic Akron General Medical Center, cording to Clavien classification) and compliance to the United States ERAS protocol (defined as the number of fulfilled element Introduction: Literature with respect to enhanced recovery divided by the total number of recommended ERAS items) after surgery (ERAS) protocols in patients undergoing were analyzed. pancreatoduodenectomy (PD) is limited to small retro- Results: Between October 2012 and June 2017, 404 spective series. Using early discharge (ED) as a surrogate consecutive patients with a mean age of 65 years (standard for ERAS, we utilized a national database to compare deviation +/À 12) underwent duodenopancreatectomy. perioperative outcomes in patients undergoing early and Median length of stay was 14 days (interquartile range 9e standard discharge (SD) after PD. 22). There were 46 readmissions (11.8%). The 30 days Method: Patients who underwent elective PD were overall complication rate was 83.3% (n = 325) with 46.2 % extracted from the ACS-NSQIP 2014 and 2015 datasets. (n = 180) minor (Clavien grade I-II) and 37.2 % major After excluding all patients who developed complications (Clavien grade III-IV) complications. The 30 days mor- prior to discharge, patients were divided into either ED (0e tality was 3.1% (n = 12). The pancreatic fistula rate was 5 days) from the index operation, or SD (Days 6e10). The 30.5% (n = 119) and the delayed gastric emptying rate was primary outcomes were all-cause morbidity within 30 days 33.3% (n = 130). Mean overall compliance was 63.6% and readmission rates, whilst the incidence of specific (Standard deviation (SD) +/À 9.5), with pre-, intra- and complications were considered secondary outcomes. post-operative compliance of 92.9% (SD +/À 10.1), 80.8% Results: In total, 2759 patients met inclusion criteria, of (SD +/À 18.9), and 40.7% (SD +/À 15.3) respectively. whom 495 patients (18 %) constituted the ED group. The Conclusion: Enhanced recovery after surgery protocol ED group included patients with a younger median age (64 according to published ERAS guidelines can safely be vs 65 years; p = 0.003), and fewer patients with hyper- performed with favorable outcome. A high compliance to tension (41.8% vs 51.4%; p < 0.001), but were similar in the protocol was observed in the preoperative and intra- all other preoperative characteristics investigated. The ED operative period. group had a lower median operative time (324 vs 347 min;

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EP02D-150 Methods: We retrospectively analyzed the cases of 161 consecutive patients who underwent PD between January CAN C-REACTIVE PROTEIN PREDICT 2000 and December 2015 and performed comparisons OCCURRENCE OF POSTOPERATIVE between the patients aged 80 years and those aged < 79 PANCREATIC FISTULA (POPF) AFTER years. Correlations between 6 systemic inflammation-based PANCREATECTOMY? prognostic score such as Glasgow prognostic score (GPS), modified-GPS (mGPS), High sensitive-mGPS, neutrophil- O. Benoit, N. Tabchouri, H. Hermand, S. Dokmak, lymphocyte ratio, platelet-lymphocyte ratio (PLR), prog- B. Aussilhou, F. Cauchy, S. Gaujoux, O. Soubrane and nostic nutritional index (PNI) and major postoperative A. Sauvanet complications (grade III or higher according to the Clavien- Hopital Beaujon, France Dindo classification) were evaluated in octogenarian group. fi Introduction: Postoperative pancreatic stula (POPF) Results: There were no cases of operative morality. The fl diagnosis is based on amylase level on drainage uid. There preoperative hemoglobin level and the controlling nutri- are no blood markers allowing early diagnosis of POPF. C- tional status score were significantly worse in the 22 (14%) Reactive protein (CRP) is useful for diagnosis of anasto- octogenarians than in the younger patients. The complica- fi motic stula after colic resection. The aim of this study was tions rates of the two groups were comparable. The disease- to assess the value of CRP for the diagnosis of clinically specific survival did not differ significantly between the relevant POPF (CR-POPF). two groups. 10 patients (45%) experienced major compli- Methods: Post-operative outcomes were collected retro- cations in octogenarian group. Among 6 systemic inflam- spectively, including POPF occurrence and CRP values mation-based prognostic score, only PLR was revealed as until POD 6. POPF was graded according ISGPF-2005 and predictor of major complications (p=0.012) and optimal CR-POPF included grade B and C. Overall, 345 pancrea- cutoff value was determined to be 145.3 (sensitivity = 33%, ticoduodenectomies (PD) and 216 distal pancreatectomies specificity = 100%). (DP) were included. Conclusion: Under perioperative strict management of Results: After PD, 95 (27.5%) patients had a CR-POPF. nutritional condition, PD can be performed safely in pa- CRP value at POD 1-2 was higher when CF-POPF tients 80 years and older. In octogenarians the preoperative Æ Æ occurred (194 75 versus 150 65mg/L, p = 0,002). Even PLR is a simple and useful predictor of major complica- when patients developed CR-POPF after POD 7, CRP tions after PD. value at POD 1-2 was higher (181 Æ 71 versus 143 Æ 64mg/L, p = 0,04). The difference remained significant at POD3-4 and thereafter. Fourty (18.5%) patients developed CR-POPF after DP. POD1-2 CRP value was higher in EP02D-152 patients that had CR-POPF compared with patients that had PANCREATIC FISTULA RATE AFTER no CR-POPF (156 Æ 90 versus 103 Æ 70mg/L; p = 0,002). PANCREATO-DUODENECTOMY NOT There was no significant difference in CRP value after POD ASSOCIATED WITH PREOPERATIVE 2. At POD 1-2, PPV was 81% after PD and 90% for the BILIARY STENTING IN diagnosis of CR-POPF for a CRP value >200mg/L. CRP value <100mg/L at POD 1-2 excluded CR-POPF with RETROSPECTIVE ANALYSIS 1 1 NPV of 89% after PD and 71% after DP. K. Saribeyoglu , A. Katsougiannopoulos , 1,2,3 1,2,4 Conclusion: CRP measurement at POD 1-2 may be useful R. Kube and B. L. D. M. Brücher 1 2 for predicting CR-POPF particularly after PD. Some pro- Department of Surgery, Pancreatic Cancer Center, 3 spective studies should be conducted to confirm these pri- Visceral Cancer Center, Carl-Thiem-Klinikum, Germany, 4 mary results. and Theodor-Billroth-Academy, United States Purpose: We retrospectively investigated the postoperative pancreatic fistula (PF) rate in patients (pts) undergone EP02D-151 pancreatico-duodenectomy (PD) measured by positive fi PREOPERATIVE PLATELET- amylase in accordance to International Study Group de - nition and grading compared to the occurrence of preop- LYMPHOCYTE RATIO (PLR) PREDICT erative biliary stenting. POSTOPERATIVE MAJOR Methods: Patients between June 2014 and October 2017 COMPLICATIONS AFTER PD IN were evolved. Group 1 patients did not while Group 2 OCTOGENARIAN underwent preoperative biliary stenting. Data were evalu- ated according to age groups (above/less 60 years of age). S. Sawada1, I. Yoshioka2, S. Sekine2, K. Shibuya2, Results: 81 consecutive patients (44 men, 37 female) un- T. Okumura2 and T. Fujii2 derwent PD, mean age 65.6 Æ 9.978 (range 35e82). The 1Department of Surgery, Itoigawa General Hospital, overall PF rate was 28.4% (23 out of 81 pts), predominantly Niigata Federation of Agricultural Cooperative Associa- consisting of Grade A (91.3%, 21 out of 23 pts). Group 1 tionsI, and 2Department of Surgery and Science Graduate (without preoperative stent) consisted out of 46.9% (38 out School of Medicine and Pharmaceutical Sciences, Uni- of 81 pts), while Group 2 revealed 53.1% (43 out of 81pts) versity of Toyama, Japan (p = 0.26). The PF-rate did not differ between the groups: fi Background: In this study we reveal the risk and bene tof 26.3% (10 out of 38 pts) [95% CI 0.134-0.431] in Group 1 PD in elderly patients aged over 80 years. In addition, to (without stent) versus 30.2% (13 out of 42 pts) [95% CI identify simple and sensitive marker for postoperative 0.172-0.461] in Group 2 (with stent) (p=0.7). The PF-rate complications after PD in octogenarian, the predictive values in accordance to age did not differ: 32.1% (18 out of 56 pts) were compared among candidate preoperative factors. [95%CI 0.203-0.46] in pts 60y versus 20% (5 out of 25

HPB 2018, 20 (S2), S505eS684 S638 Electronic Posters (EP02A-EP02F) e Pancreas pts) [95% CI 0.068-0.407] in patients <60y (p = 0.26). No Surgical site infections (SSIs) are the most common difference in regard to sex (p = 0.22) or sex plus preoper- cause of morbidity following pancreatic surgery. We aim to ative stenting could be observed (p = 0.7). assess the adequacy of first generation cephalosporin pro- Conclusion: Limited to its retrospective approach, no dif- phylaxis in the prevention of SSIs following pancreatic ference in pts undergone PD and the PF-rate in regard to resection. preoperative biliary stenting could be observed. The American College of Surgeons - National Surgical Quality Improvement Program Participant-Use Data-File 2016 was queried to identify patients who underwent distal EP02D-153 pancreatectomy (DP) or pancreatoduodenectomy (PD).The EFFECT OF ANTIBIOTIC CHOICE ON Antibiotic given was grouped into: 1st generation cepha- losporin (Abx1) vs 2nd/3rd generation cephalosporin or THE DEVELOPMENT OF broad spectrum antibiotics (Abx2). POSTOPERATIVE PANCREATIC A total of 1762 (32.5%) and 3659 (67.5%) patients un- FISTULA: A NSQIP STUDY derwent DP and PD, respectively. The rate of SSIs for the E. M. Aleassa1,2, G. Sharma1, K. M. El-Hayek1 and whole cohort in groups Abx1 and Abx2 were: 126 (6.1%) fi G. Morris-Stiff1 and 192 (5.7%) for super cial SSIs (P = 0.55), 8 (0.4%) and 1Department of Surgery, Cleveland Clinic Foundation, 30 (0.9%) for deep SSIs (P = 0.03) and 305 (14.8%) and United States, and 2Department of Surgery, United Arab 468 (13.9%) organ-space SSIs (P = 0.39), respectively. The fi Emirates University, United Arab Emirates choice of antibiotic did not signi cantly change the rate of SSIs in patients who underwent DP (P > 0.05). However, a Choice of antibiotic surgical site infection for pancreatic significant change in the rate of organ-space SSI by choice surgery is variable, with no consensus on their optimal of antibiotic was noted in PD patients; 225 (18%) and 359 choice of prophylactic antibiotics. We aim to assess the (14.9%), P = 0.017, for Abx1 and Abx2, respectively. influence of antibiotic choice on the development of post- The choice of antibiotic prophylaxis influences the rate of operative pancreatic fistula (POPF). SSIs post-pancreatic surgery with lower rates of deep SSIs in The American College of Surgeons - National Surgical both DP and PD, and a lower rate of organ space infections Quality Improvement Program Pancreatectomy Targeted after PD. Limiting coverage to first generation cephalospo- Participant Use Data File 2016 was queried to identify rins would appear inadequate. Broader coverage of gram patients who underwent distal pancreatectomy (DP) or negative infections and anaerobes should be considered and pancreatoduodenectomy (PD). The incidence of POPF was is currently been evaluated in the ACS-AHPBA trial. compared by genre of antibiotic given: 1st generation cephalosporin (Abx1) vs 2nd or 3rd generation cephalo- sporin or broad spectrum antibiotics (Abx2). A total of 1762 (32.5%) and 3659 (67.5%) patients un- EP02D-155 derwent DP and PD, respectively. Abx1 was given intra- SURGICAL OUTCOMES OF DISTAL operatively as prophylaxis to 2060 (38%) patients. The rate PANCREATECTOMY WITH OR of fistula formation was 18.4% (n=995). The rate of fistula WITHOUT SPLENECTOMY formation was significantly different by the extent of anti- biotic coverage; 19.9% (n=409) and 17.4% (n=586) for the R. Dama, P. Rebala and G. Rao Abx1 and Abx2 groups (P=0.026), respectively. The choice Surgical Gastroenterology, Asian Institute of Gastroen- of antibiotic did not significantly change the rate of fistula terology, India formation in patients who underwent DP (P>0.05). How- Introduction: Distal pancreatectomy(DP) can be done ever, a significant change was noted in PD patients; 20.2% with splenectomy (DPS) or without. We analyse our sur- (n=253) and 17.2% (n=414), P=0.023, for Abx1 and Abx2, gical results and the complications. respectively. The choice of antibiotic coverage did not Methods: 126 patients had DP/DPS for various pathol- change the severity of fistulae (P=0.77) for either DP or PD. ogies, between 2005 to 2017. After resection the pancreatic Prophylactic antibiotic choice affects the rate of fistula stump was always suture closed along with a separate formation following PD but not DP. Further prospective suture for the pancreatic duct (PD), if identified. Stapled studies assessing the specific bacteria and its role in fistula transection was also oversewn, done in 20 patients. Drain formation is warranted, and indeed underway in the ACS- was always kept. AHPBA trial. Results: 70/120 males and 56 females. Average age was 49 years (12e72). Mean operating time was 139 minutes and blood loss (220 ml). 93/127 patients underwent DPS. 33 EP02D-154 patients had DP (spleen preserving). 25 patients had lapa- roscopic approach. Multivisceral resections in 22 patients EFFECT OF ANTIBIOTIC CHOICE ON included stomach, colon, gallbladder, adrenal and kidney. THE DEVELOPMENT OF SURGICAL Associated procedures were lateral pancreaticojejunostomy SITE INFECTIONS FOLLOWING -12, duvals procedure- 5, excision of fistulous tract-3. PANCREATIC RESECTION: NSQIP Average stay was 9 days. 22/127 (17.3%) patients had post STUDY op new onset Diabetes mellitus. Two patients had mortality 1,2 1 1 (1.57%)- due to septic collection and bleed. 30 patients E. M. Aleassa , G. Sharma , K. M. El-Hayek and fi 1 (23.6%) had postoperative pancreatic stula, 22 pts required G. Morris-Stiff ercp and pd stenting. 11 pts (8.6%) required postoperative 1Department of Surgery, Cleveland Clinic Foundation, 2 percutaneous drainage (PCD). Saio- 8 pts, wound infection - United States, and Department of Surgery, United Arab 13. Postoperative bleed in 5 patients. Emirates University, United Arab Emirates

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Conclusion: Distal pancreatectomy with or without sple- wound protectors on the rate of surgical site infections nectomy with varied indications, has very low mortality (SSI) post-pancreatic surgery. and acceptable morbidity. Pancreatic fistula may require The American College of Surgeons - National Surgical pcd, or ercp and pd stenting. Quality Improvement Program Database 2016 was queried for distal pancreatectomy (DP) or pancreatoduodenectomy (PD) patients. The incidence of surgical site infections EP02D-156 (SSI): superficial, deep and organ-space; were compared by VASCULAR RESECTION FOR LOCALLY use or not of wound protectors. A total of 4797 patients were included in the study. ADVANCED PANCREATIC Among them, 22.6% (n = 1085) and 77.4% (n = 3712) MALIGNANCIES: TIME-TREND AND patients underwent DP and PD, respectively. The SSIs rates OUTCOME ANALYSIS FROM 100 were 6.7% (n = 323), 0.8% (n = 39) and 15.3% (n = 734) CONSECUTIVE RESECTIONS AT A respectively superficial, deep and organ-space SSIs. The HIGH-HPB VOLUME CENTER SSIs rates for cases in which a wound protector was used and not used were: 5.1% (n = 55) and 7.2% (n = 268) for E. Vicente López, Y. Quijano, R. Caruso, B. Ielpo, superficial SSIs (P = 0.018), 0.7% (n = 8) and 0.8% (n = 31) H. Duran, D. Eduardo, I. Fabra, V. Ferri, E. Barzola and for deep SSIs (P = 0.79); and 13.6% (n = 145) and 15.8% (n R. Iserna = 589) organ-space SSIs (P = 0.07), respectively. The use Sanchinarro University Hospital, Spain of wound protector did not significantly change the rate of Introduction: Involvement of major vascular structures SSIs in patients who underwent DP. However, a significant has been considered a limiting factor for resectable change in the rate of superficial SSI by noted in PD pa- advanced tumors. The aim of this study is to investigate the tients; 5.6% (n = 50) and 8.1% (n = 229), P = 0.015. clinical outcomes of patients with advanced APA with The use of a wound protector was associated with a vascular resection and to identify significant survival decrease in the rate of superficial SSIs following pancrea- predicting variables. toduodenectomy patients but not distal pancreatectomy. As Material and methods: We retrospectively reviewed our such, the use of a wound protector should be considered a experience of consecutive pancreatic surgeries with VR, part of a package to reduce SSIs in patients undergoing achieved at Sanchinarro University Hospital (Madrid, pancreatic surgery, and in particular PD. Spain) from 2007 to December 2017. Results: A total of 100 patients underwent VR for locally advanced pancreatic cancer. The average age of all patients EP02D-158 was 60 years and the mean operating time (560 min, range 400e900). We performed 38 pancreaticoduodenectomies PANCREATIC NECROSECTOMY (PD), 20 distal-pancreatectomies (DP), 42 total pancrea- MORBID BUT LIFE SAVING tectomy (TP). Furthermore, the patients were classified R. Dama, P. Rebala and G. Rao according to the type of VR: venous vascular resection (72 Surgical Gastroenterology, Asian Institute of Gastroen- patients); arterial vascular resection (16 patients); arterial terology, India and venous vascular resection (12 patients)). The mean Introduction: Pancreatic necrosectomy has high morbidity hospital stay was 16 days in PD group, 12 days in DP group and hence is the last resort in necrotizing pancreatitis. and 15 days in TP group. Major vascular reconstruction Ò Retrospective analysis was done to study its morbidity and was accomplished through Goretex patch (n = 17), pri- sequalae mary end-to-end anastomosis (n = 61), tangential resection Method: Between 2005 to 2017, 110 patients underwent (n = 22). In 30 % histopathologic examination revealed closed pancreatic necrosectomy. After adequate debride- cancer invasion of the vessel, whereas the remainder had ment and washes, multiple tube drains were kept for post- fl peritumoral in ammation extending to the vessel wall. operative irrigation. Need for diversion stoma and feeding Two-year survival rate were 22%. jejunostomy was decided on clinical, radiological and Conclusion: Major arterial vascular resection to achieve intraoperative findings. macroscopic tumor clearance can be performed safely with Results: 93 males & 17 females. Mean age was 36 years acceptable operative morbidity and mortality. Nevertheless (21e77). Pancreatic necrosis was due to alcohol-56, biliary fi it is justi ed only in carefully selected cases. -44 , whereas trauma and idiopathic 3 each ,post ercp and autoimmune pancreatitis -2 each. 53/110 ( 48%) pts had diversion stoma . 68/110 (62 %) patients had feeding EP02D-157 jejunostomy. Preoperative percutaneous drainage was done EFFECT OF WOUND-PROTECTOR USE in 35 patients. Average time of intervention was 54th day ON SURGICAL SITE INFECTIONS POST- since onset of pancreatitis. Average amount of necrotic material was 62 gms. Necrotic fluid grew e.coli in 48, PANCREATIC SURGERY: NSQIP STUDY klebsiella in 26, pseudomonas in 9. Average post op stay 23 1,2 1 1 E. M. Aleassa , G. Sharma , K. M. El-Hayek and days.(8-70). Post op prolonged ventilation(>48 hrs) 1 G. Morris-Stiff required in 28 patients. 11 patients required tracheostomy. 1 Department of Surgery, Cleveland Clinic Foundation, 12/ 110(11%) patients had mortality. 49/110 (45%) patients 2 United States, and Department of Surgery, United Arab had pancreatic fistula, out of which 30 required post- Emirates University, United Arab Emirates operative ERCP and pancreatic duct stenting, for the fistula There is currently no published data on their role in to heal. New onset DM and incisional hernia was seen in 10 pancreatic surgery. We aim to assess the effect of using and 5 patients respectively.

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Conclusion: Surgical pancreatic necrosectomy done after malignant tumors of the pancreatic head between 2007e 6-7 weeks is less morbid. Diversion stoma and feeding 2015. Postoperative outcomes were retrieved from patients’ jejunostomy are often required. ERCP and PD stenting are records to identify factors associated with development of required for prolonged pancreatic fistulae to heal. POBF. Postoperative complications were classified ac- cording to Clavien-Dindo and postoperative pancreatic fistula (POPF) according to ISGPF-classification. EP02D-159 Results: Of the 290 patients analyzed, 12.4% had carci- PANCREAS CANCER, NUTRITIONAL noma of the distal bile duct, 9.0% had ampullary cancer and 78.9% had pancreatic adenocarcinoma. Total incidence of STATUS, QOL AND SURVIVAL POBF was 3.1%. The underlying tumor entity did not in- D. B. Hopanci1, R. Uslu1, S. C. Guney1 and A. Coker2 fluence the rate of POBF (p = 0.970). Patients without 1Medical Oncology, and 2Surgery, Ege University, Turkey preoperative biliary drainage (PBD) (5.9% vs. 1.2%; p = Aim: In this prospective study we tried to define a corre- 0,034) and negative lymphnodes (7.6% vs. 1.4%; p = lation between nutritional status survival and Quality of 0.014) had increased rates of POBF. In patients with POBF Life in patients with pancreas cancer re-laparotomies were more frequent (23.1% vs. 2.2%; p = Material and methods: Ninety six pancreas cancer pa- 0.005), while inhospital-mortality was not affected (14.8% tients stpe into Oncology Clinic (59,6% female, 61,4% vs. 2.8%; p = 0.200). The presence of POPF (p = 0.236), male, mean age:60,7 (min:28,max:80) has been followed hemorrhage (p = 0.642), woundhealing disorder (p = 0.118) up min 6 mos and max 2 years. PG-SGA has been applied or postoperative cholangitis (p = 0.101) was not associated to all patients following informed consent and antropo- with POBF. metric measurements have been performed. ECOG scale Conclusion: The present study revealed patients without has been used for detecting performance status. Survival PBD and negative lymphnodes being at risk for the time have been recorded in every patient and Kaplan-Meier development of POBF. This may reflect conditions without method has been used for statistical test. cholestasis and consecutive dilatation of the common bile Results: 56.3% percent of all patients werein postoperative duct, making biliodigestive anastomosis more challenging. period during an application. 94,8% of all patients have been received a Chemotherapy. Eighty-two patients (85,5%) had severe malnutrition according to PG-SGA. EP02D-161 Only 11,1% Patients had normal ECOG status and 54,2% NODAL STATUS IN PANCREATIC of them revealed low ECOG Score. Only 9 pats¸ents had not DUCTAL ADENOCARCIMOA: A reported any weight loss (9,4’%) But 87 pateints were suffering (90,6%) severe weight loss (min 2%-max 37% SURVIVAL ANALYSIS of ideal body weight) There was a positive correlation S. -A. Safi1, L. Dizdar1, L. Haeberle2, A. Rehders1, between ECOG Score and malnutrition score. (p < W. T. Knoefel1 and A. Krieg1 0,01). Low antropometric values had shorter survival 1University Hospital of Duesseldorf, Department for but it was not statistically significant. SGA values A-B General-, Visceral- and Pediatric Surgery, and 2University and C patients had 19,5 Æ 3,9 mos, 37,7 Æ 6,7 mos, and Hospital of Duesseldorf, Institute for Pathology, Germany 12,0 Æ 1,3 mos respectively (p < 0,005) OS after surgery for pancreatic ductal adenocarcinoma Conclusion: Malnutrition has a negative effect on survival (PDAC) is poor. While some studies suggest that N1 is an and performance status in pancreas cancer patients. Every important prognostic factor after R0 resection, other data patients with pancreas cancer should be evaluated in terms imply that nodal disease per se is not associated with sur- of nutrition score. vival outcome. The aim of this study was to identify prognostic variables in PDAC and to investigate the value of lymph node (LN) involvement, LN ratio (LNR) and log EP02D-160 odds of positive LN (LODDS). Clinicopathological data POSTOPERATIVE BILE FISTULA from 284 patients who received resection for PDAC were AFTER analysed. LNR (ratio of positive LN to examined LN) and LODDS (log(positive LN+0.5)/(total LN+0.5)) were PANCREATICODUODENECTOMY (PD) calculated. Of the 284 patients, 252 underwent surgery for FOR MALIGNANT TUMORS OF THE pancreatic head carcinoma. 223 patients showed N1, while PANCREATIC HEAD 36 presented with M1. 102 patients displayed a LNR >0.2.  < F. Scheufele, C. Jäger, E. Demir, S. Schorn, E. Tieftrunk, 120 patients showed -0.5 LODDS 0. In our cohort, N1 M. Sargut, H. Friess and G. O. Ceyhan status was not associated with poor prognosis (p=0.158). > Department of Surgery, School of Medicine, Klinikum LNR 0.2 and LODDS subgroup were correlated with rechts der Isar, Technical University Munich, Germany poor survival in univariate analysis (p=0.001 and p=0.012). In multivariate analysis, only LNR >0.2 and M1 status Introduction: Besides postoperative pancreatic fistulas correlated with poor survival. Furthermore a subgroup (POPF), postoperative bile fistula (POBF) displays a major analysis was performed for 163 patients who received R0 complication following PD for malignant tumors of the resection for N1 PDAC without M1. In both MV and UV pancreatic head. While risk factors for the development of analysis, LNR >0.2 and LODDS subgroup were correlated POPF are well studied, risk factors for the development of with poor survival. While N1 per se is of no prognostic POBF remain elusive. Thus, the aim of the study was to value in PDAC, interestingly, LNR and LODDS are an identify risk factors associated with the development of POBF. independent prognostic factor in PDAC. Therefore, should Methods: Therefore, we performed a unicenter retro- be included in pathologic reporting after PDAC resection spective database-analysis of patients receiving PD for

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S641 and taken into consideration for prognosis assessment of Method: Single database was obtained. An operation, PDAC patients. pathologic condition, complications, and disease-free survival. Results: Of 72 patients with PETs, 46 (17%) had preop- EP02D-162 erative computed tomography evidence of major vascular ANALYSIS OF THE OUTCOME AFTER involvement. 12 patients with PETs diagnosis was performed. The mean size of the primary PETs was 3.0 cm. PANCREATICODUODENECTOMY (PD) Stage T3N1 was more frequent . The involved major vessel FOR PANCREATIC HEAD CANCER VS. was as follows: portal vein (n = 3), superior mesenteric vein CARCINOMA OF THE DISTAL BILE (n = 4), mesenteric-porto axis (n=4)and hepatic artery (n = DUCT OR THE AMPULLA OF VATER 1). We had performed 4 Whipple procedures, total pancreaticoduodenectomy(n=4) and spleen-pancreatecto- F. Scheufele, C. Jäger, S. Schorn, E. Demir, H. Friess and mies(n = 4). In vessels infiltrated than more 2 cm We have G. O. Ceyhan used a prosthesis (Figure 1), surgical median time was 640 Department of Surgery, School of Medicine, Klinikum minutes. There were 2 deaths postoperative complications rechts der Isar, Technical University Munich, Germany and 3 recurred with follow-up, leaving 60% disease-free Introduction: Malignant tumors of the pancreatic head after one year of surgery. Infiltrated adenopathies were arise from different entities. Independent of the type of associated with a better overall survival (P < .001), and cancer, radical PD is the only curative treatment option. liver metastases decreased overall survival (P < .001). Because of different anatomical and biological behavior, Conclusion: These findings suggest that surgical resection the aim of this study was to investigate outcomes after PD of PETs with vascular abutment/invasion and nodal or for pancreatic head cancer (PDAC) vs. carcinoma of the distant metastases is indicated when is possible to obtain distal bile duct (dCCC) or the ampulla of vater (AmpC). good surgical margin tumor. Methods: We performed a unicenter retrospective data- base-analysis of patients receiving PD for PDAC, dCCC or AmpC between 2007e2015. Postoperative complications were classified according to Clavien-Dindo and post- operative pancreatic fistula (POPF) according to ISGPF- classification. Long-term survival was assessed. Results: Of 290 patients analyzed, most presented with PDAC (n = 228; 78.6%), while 36 (12.4%) had dCCC and 26 (8.9%) presented with AmpC (p = 0.023). Patients with PDAC had more advanced tumor stages, when compared to dCCC and AmpC in respect of T-Stage >2(p< 0.001), N1- stage (p = 0.004) and Pn1-Stage (p < 0.001). Postoperative complications (p = 0.019) and severity (C.D.>2; p = 0.003) were most frequent among patients with AmpC followed by dCCC and PDAC. Patients with dCCC and AmpC had more POPF (p < 0.001) as wells as clinically-relevant POPF (p < 0.001) when compared to PDAC. Consequently, dCCC and AmpC needed more interventional drainages (p < 0.001) and postoperative antibiotics (p = 0.007), while inhospital- mortality (p = 0.559) was not affected. Survival was best in AmpC, followed by dCCC and PDAC (p = 0.008). Conclusion: Patients with dCCC and AmpC have more postoperative complications and POPF than patients with PDAC, while this had no effect on inhospital-mortality. Long-term survival was best in AmpC, followed by dCCC and PDAC.

Figure Interposition grafts for reconstruction EP02D-163 VASCULAR RESECTION FOR PANCREATIC ENDOCRINE TUMORS EP02D-166 E. Vicente López, Y. Quijano, R. Caruso, E. Barzola, RANDOMIZED CONTROLLED TRIAL B. Ielpo, H. Duran, E. Diaz, V. Ferri, L. Malave and OF INTRAOPERATIVE CHEMICAL R. Isarnia SPLANCHNICECTOMY FOR PATIENTS HM Sanchinarro, Spain WITH RESECTED Introduction: Surgery for pancreatic endocrine tumors (PETs) with blood vessel involvement is controversial. PANCREATOBILIARY MALIGNANCIES Studies have shown vascular invasion in advanced PETs is R. Carr, A. Roch, X. Zhong, M. Motamed, E. Ceppa, associated with decreased survival. But other studies have N. Zyromski, C. Schmidt, A. Nakeeb and M. House shown after resection RO of PETs with major blood vessel Surgery, Indiana University School of Medicine, United involvement can be beneficial. States

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Introduction: This prospective double-blind placebo National Surgical Quality Improvement Program (NSQIP) controlled trial studied the benefits of intraoperative celiac database. neurolysis for durable postoperative pain control, long-term Methods: All patients undergoing elective, non-hybrid quality of life and survival for patients with resected MIPD (laparoscopic and robotic) and OPD in the 2014 and pancreatobiliary cancer. 2015 NSQIP pancreatectomy-specific database were Method: Chemotherapy naïve patients undergoing resec- included and their outcomes compared using univariate and tion for pancreatic adenocarcinoma or distal chol- multivariate analyses. angiocarcinoma were randomized to receive either 50% Results: 7544 patient underwent PD e 7162 (94.9%) OPD ethanol (E) or saline (S) injection of the celiac plexus and 382(5.1%) MIPD. There was no statistically significant during pancreatoduodenectomy (PD). The primary study difference in the overall rate of complications, length of endpoint was postoperative pain severity over two years stay (LOS), or 30-day mortality after MIPD compared to from randomization. Secondary endpoints included pain OPD. Patients undergoing MIPD had a significantly interference with daily life and overall survival. increased 30-day readmission rate (21.5% vs 16.5%, p = Results: Patient and disease characteristics between the 0.012), and MIPD was independently associated with two treatment groups are summarized in the table. Adverse increased 30-day readmission (OR = 1.32, p = 0.033). events related to treatment did not differ between the two However, MIPD patients who did not experience post- groups within 90 days of operation. Postoperative delayed operative complications (n = 3624, 48%) had significantly gastric emptying was observed in 4 (14%) pts in the E shorter LOS (7.2 days vs 8.3 days, p = 0.003) and a reduced group compared to 9% in the S group, p = 0.24. The mean risk of being discharged to a facility other than home pain severity at 12 mos for the E and S groups was 2.12 vs postoperatively (2.3% vs 8.6%, p = 0.003) compared with 2.42, p = 0.65, with no significant increases over respective OPD patients without complications, and there was no baseline preoperative pain severity. Mean pain interference difference in the rate of 30-day readmission or 30-day with daily life did not differ between the two treatments at mortality. After risk adjustment, MIPD was independently any 3 month interval over two years. Actual survival for the associated with decreased LOS (mean difference = À1.2 entire study population at 2 yrs was 35%. Ethanol injection days, p = 0.002) and decreased odds of being discharged to of the celiac plexus did not influence the timing or pattern a facility other than home postoperatively (OR = 0.26, p = of tumor recurrence, H.R.1.21, p = 0.57. 0.001) in patients who did not experience postoperative Conclusions: Intraoperative chemical splanchnicectomy complications. during PD for resectable pancreatobiliary cancer is safe but Conclusion: Among the roughly one-half of patients who does not benefit patients with regards to long-term pain do not experience postoperative complications after PD, the control, pain interference with daily life, or disease-free minimally invasive approach is associated with a decreased survival. length of hospital stay and improved likelihood of being discharged home postoperatively.

Table E Group S Group P-value (N [ 23) (N [ 28) EP02D-168 Mean age +/– SEM 63.4y ± 10 65.3y ± 9.7 0.63 DRAIN AMYLASE LEVELS Preop pain – Low 20 (87%) 22 (79%) 0.49 FOLLOWING Preop pain – Mod/High 3 (13%) 6 (21%) 0.49 PANCREATICODUODENECTOMY FOR Tumor site – Pancreas 21 (91%) 25 (89%) 0.67 CANCER; CORRELATION WITH T stage – pT3 20 (87%) 24 (86%) 0.61 OUTCOMES AND PROPOSAL FOR A N stage – pN1 19 (83%) 19 (68%) 0.33 UNIFORM GRADING SYSTEM 1 2 3 R0 margin status 18 (78%) 24 (85%) 0.71 H. Ramesh , M. Subramaniaiyer and J. Mathew 1Dr., 2Department, and 3Department of Surgical Gastro- Perineural invasion 18 (78%) 25 (89%) 0.24 enterology, VPS Lakeshore Hospital, India Histologic grade – G3 19 (83%) 19 (68%) 0.29 Aim: Analyse drain fluid amylase levels after surgery and correlate with clinical outcomes. Methods: The drain fluid amylase levels of 300 consecu- EP02D-167 tive patients who underwent pancreaticoduodenectomy THE BENEFIT OF MINIMALLY were correlated with clinical parameters such as fever, INVASIVE leucocytosis, intra-abdominal collection, systemic sepsis, PANCREATICODUODENECTOMY ON delayed restoration of intestinal function, postoperative bleed, and hospital stay. ENHANCED RECOVERY IS Results: Three were 3 groups: RESTRICTED TO PATIENTS WHO a) Low amylase: group A; n = 141 AVOID POSTOPERATIVE b) High drain amylase levels returning to normal byby COMPLICATIONS Day 5; group B; n = 114 c) Peristently high drain amylase levels at or beyond day D. Sanford, R. Panni, M. Doyle, W. Chapman, 5; Group C. n = 45 S. Strasberg, R. Fields, C. Hammill and W. Hawkins There was a significantly increased number of patients Washington University School of Medicine, United States with turbid drain fluid, fever, leukocytosis, intraabdominal Background: We sought to determine how postoperative collection, systemic sepsis, intolerance to enteral feeds, late fi complications impact the bene t of MIPD using the bleeding in group C as compared to group A and B.

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Hospital stay was also prolonged in group C (17 versus abdominal collections and higher incidence of infected 12.5 days). intra-abdominal collections compared with CRP <15 group (47.6% vs 17.6%, p = 0.044 and 66.7% vs 35.3%, p = 0.027 respectively). No difference was found in hospital Table stay or mortality between groups. Parameter Group A Group 2 Group 3 > (141) (114) (45) Conclusions: CRP 15 mg/dl on PO day 3 relates to occurrence of PF-BC, and clinically relevant intra-abdom- Turbid drain fluid 9 9 39 inal collections. Routinely CT scan based on this simple Leucocytosis 42 51 33 tool could guide an early diagnostic and treatment of PD Fever 21 27 30 complications. Intraabdominal 18 12 24 collection Systemic sepsis 0 0 6 EP02D-170 POSTOPERATIVE EXTREMELY A classification is proposed: LOWER VALUE OF SERUM AMYLASE Type 1: Drainage of clear fluid with amylase levels over IS RELATED WITH LESS INCIDENCE 1000 Units/ml OF POST OPERATIVE PANCREATIC Type 2: Type 1 plus turbid/’coca cola’ fluid drainage or two of the following: FISTULA AFTER fever, leukocytosis, intra-abdominal collection, delayed PANCREATICODUODENECTOMY intestinal function N. Ortega, N. Puertolas, E. Pando, C. Dopazo, C. Gomez, Type 3: Type 1 + 2 plus systemic sepsis as evidenced by L. Blanco, M. Caralt, I. Bilbao, J. Balsells and R. Charco a) hypotension below 90mm of hg, serum lactate  4 Hepato-pancreato-Biliary and Transplant Surgery, Hos- mmol/l pital Universitario Vall d’Hebron, Universidad Autónoma Type 4: Bleeding de Barcelona, Spain a) intraperitoneal b) luminal, and c) combined Background: Extremely lower values of serum amylase fl Conclusion: Persistent drain uid amylase following after pancreaticoduodenectomy (PD) and its relation with pancreaticoduodenectomy is associated with a higher risk less incidence of post operative pancreatic fistula (POPF) is of serious complications and prolongation of hospital stay. not well define. Methods: Clinical data of 127 consecutive retrospectively enrolled patients who underwent PD were analyzed. Post- EP02D-169 operative day 3 serum amylase (SA) was registered. Two POSTOPERATIVE C-REACTIVE groups were compared; SA 10 UI/l vs SA >10 UI/l. PROTEIN ‡ 15 MG/DL AND ITS Outcomes measured were POPF grade B and C (POPF- BC), mortality, hospital stay and infected intra-abdominal RELATION WITH CLINICAL collections. RELEVANT INTRA-ABDOMINAL Results: Incidence of PF grade B/C was 24.4%. POPF-BC ABSCESS AND POSTOPERATIVE occurrence was lower in the SA 10 UI/l group compared PANCREATIC FISTULA GRADE B-C with SA >10 UI/l group (2% vs. 39.5%, p = 0,000). For AFTER local complications, SA 10 UI/l group was related with PANCREATICODUODENECTOMY lower incidence of intra-abdominal collections and lower incidence of infected intra-abdominal collections compared N. Ortega, N. Puertolas, E. Pando, C. Dopazo, L. Blanco, with SA >10 UI/l group (28.9% vs 11.8%, p=0.022 and C. Gomez, M. Caralt, I. Bilbao, J. Balsells and R. Charco 43.4% vs 11.8%, p = 0.000 respectively) and lower hospital Hepato-pancreato-biliary and Transplant Surgery, Hos- stay >20 days (52.2% vs 23.4%, p = 0.002). No difference pital Universitario Vall d’Hebron, Universidad Autónoma was found in delayed gastric empty, bile leak and mortality de Barcelona, Spain between groups. Background: An early recognition of clinically relevant Conclusions: SA 10 UI/l on PO day 3 relates to less pancreatic fistula (PF) and clinically relevant intra- incidence of PF-BC, and others complications. abdominal abscess (CRIA) after pancreaticoduodenectomy (PD) is essential. C-reactive protein (CRP) is widely used as a predictor for gastrointestinal leak in colorectal and EP02D-171 esophageal surgery. PANCREATICODUODENECTOMY Methods: Clinical data of 120 consecutive retrospectively enrolled patients who underwent PD were analyzed. Post- WITH IRREVERSIBLE operative day 3 CRP was registered. Two groups were ELECTROPORATION (IRE) MARGIN compared; CRP 15 mg/dl vs CRP <15 mg/dl. Outcomes ENHANCEMENT FOR BORDERLINE measured were PF grade B and C (PF-BC), mortality, RESECTABLE PANCREATIC hospital stay and infected intra-abdominal collections. CARCINOMA Results: Mean age was 64.5+/-11.6. Incidence of PF grade B/C was 25.6%. PF-BC occurrence was higher in the CRP A. Sastry, M. Passeri, K. Murphy, E. Baker, J. Martinie, 15 mg/ml group compared with CRP <15 mg/dl (group D. Vrochides and D. Iannitti 38.8% vs. 10.3%, p = 0,001). For local complications, CRP HPB Surgery, Carolinas HealthCare System, United >15 mg group was related with higher incidence of intra- States

HPB 2018, 20 (S2), S505eS684 S644 Electronic Posters (EP02A-EP02F) e Pancreas

Background: Borderline resectable pancreatic carcinoma Conclusion: POPF is more frequent and more severe in (BRPC) as defined by NCCN guidelines, remains a chal- proximal pancreatectomies (PD) than in distal ones lenging surgical problem, particularly in obtaining negative (DPCT): (p < 0.01). margins. In this study, surgical resection with irreversible electroporation for margin enhancement was evaluated to EP02D-173 determine the long-term outcomes in BRPC. INCISIONAL HERNIA RATE IN Methods: Patients with BRPC were included; those who MIDLINE VS TRANSVERSE INCISION underwent surgical resection with IRE (SIRE) were compared to those undergoing surgical resection alone FOR MAJOR PANCREATIC SURGERY 1 1 1,2 1,2 (SR). The SR cohort was case-matched to demographic, G. Lane , P. Aujla , R. Adair , A. Aldouri , 1,2 1,2 1,2 operative, and oncologic parameters. Patients with C. Macutkiewicz , A. M. Smith and Y. S. Khaled 1 2 concomitant vascular resection were excluded. Primary University of Leeds, and Leeds Teaching Hospitals NHS outcome measures included overall survival and disease Trust, United Kingdom recurrence. Introduction: Incisional hernia is a complication of Results: Twenty patients were evaluated, ten in each group. midline or transverse abdominal approach. We present a Median overall survival was numerically higher in the SIRE comparative case-matched study that compares the out- group (13 months vs. 8 months, p = 0.72). At 2 years, SIRE comes of midline to transverse incision for major pancreatic patients had improved survival versus SR alone (70% vs. surgery in terms of incisional hernia rates, wound compli- 20%, p = 0.0145). 1-year recurrence was numerically less in cations and length of hospital stay. the SIRE group (20% vs. 30%, p = 0.9770). Methods: From February 2007 to December 2014, 321 Conclusion: Surgical resection with IRE margin consecutive patients were identified from a prospectively enhancement for BRPC may improve long term survival. maintained database according to predefined inclusion and exclusion criteria. 180 were matched on a 1:1 basis (90 midline, 90 transverse) according to age, gender, tumour EP02D-172 size, pancreatic duct diameter and histopathological diag- POST-OPERATIVE PANCREATIC nosis. Comparison between groups was performed on intention-to-treat basis. FISTULA AFTER 340 PROXIMAL OR Results: The midline and transverse groups were compa- DISTAL PANCREATECTOMY, rable for age (65 vs. 64.3 years, p = 0.89), gender distri- ACCORDING TO 2016 UPDATE OF IHE bution (p = 0.92) and tumour size (2.0 vs. 2.2 cm, p = 079). ISGPS. A COMPARATIVE STUDY There was no significant difference between midline and transverse groups in incisional hernias at one year (14 vs. M. A. Secchi1, L. Rossi2, M. Cantaberta3 and E. Mateljam2 15, p = 0.89), 30-day mortality (2 vs. 2, p = 0.92), mortality 1Surgery, Instituto Universitario Italiano de Rosario, after one year (21 vs. 19, p = 0.43) and median length of 2Surgery, Modelo Clinic of Rufino. IUNIR, and 3Surgery, hospital stay (10 vs. 12 days, p = 0.15). However, the Italian Hospital and IUNIR. Rosario wound infection rate was higher in the transverse group (18 fi Introduction: The rate of post-operative pancreatic stula vs 10, p = 0.04). (POPF) in pancreatic surgery (PS) is between 4% and 35%. Conclusion: There is no statistical difference in the rate of The 2016 update of the ISGPF were considered in this incisional hernia for midline vs. transverse approach. The rewiew of our experience. (Surgery. 2017 Mar;161(3): rate of wound infection appears to be higher in the trans- e 584 591.) verse group but the decision about the incision should be fi Methods: An apropiate classi cation and multidisciplinary dictated by the patient’s disease and anatomy and the sur- approach to POPF was used based on optimal patient geon’s discretion. management reduced morbi-mortality and costs to fistula ’ treatment with a shorter hospital stay. X2 and Student t test EP02D-174 were used to compare POPF between proximal pancreaticoduodenectomy (PD) (G1) and distal PCT EVALUATION OF EFFICACY OF (DPCT): body and tail (G2)./ PHYSIOLOGIC ABILITY AND Results: Our personal experience (between 1994-2017) SURGICAL STRESS SCORE TO from 340 PCT (tumors, cysts and chronic pancreatitis), 235 PREDICT POSTOPERATIVE PDs (G1) and 105 DPCTs (G2) includes 75 patients (22.05 COMPLICATIONS AND OF LONG-TERM %) with POPF: 58 PDs (G1) and 17 DPCTs (G2) In 46 OUTCOME IN ELDERLY PATIENTS patients with Grade A POPF, “Biochemical leak”:no clinical importance. The drains were always maintained in WITH place. No mortality. 16 patients with Grade B POPF “Re- PANCREATICODUODENECTOMY quires a change in the postoperative management” Were M. Yamashita, T. Adachi, S. Ono, H. Matsushima, supported with partial or total parenteral or enteral nutri- T. Adachi, A. Soyama, M. Hidaka, M. Takatsuki and tion. The drains were always maintained in place, IV an- S. Eguchi tibiotics (ATB) were administered, and the use of . No Dept of Surgery, Nagasaki University, Japan mortality. There were 13 patients with Grade C POPF: Introduction: Pancreaticoduodenectomy (PD) is a high “ ” Clinical multiple organ failure or require reoperations . invasive surgery, and indication of PD for elderly patients All required aggressive clinical intervention and nutrition. is problematic. In addition, it is unclear whether PD Reoperation were used in 8 of 13 cases; the use of Octeo- contribute to better prognosis in elderly patients. The esti- tride and IV ATB was always instituted (n = 11) in an ICU mation of physiologic ability and surgery stress (E-PASS) < setting.(G1:11 vs. G2:2 p 0.01). system would be able to predict the development of

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S645 complication after PD by using the preoperative risk score Conclusion: Our initial experience demonstrates that MIS (PRS), surgical stress score (SSS), and comprehensive risk can be safely adopted for the treatment of periampullary score (CRS) . In this study, we evaluated the efficacy of E- tumors. The learning curve for RobS seemed to be shorter PASS in predicting operative outcome and overall survival than LapS as we could transition quickly from hybrid PDs in elderly patients with PD. to totally MIS. Methods: We retrospectively analyzed 282 patients who underwent PD. We classified them into an elderly group EP02D-176 (over 80 years old) and a non-elderly group (under 79 years PREDICTIVE EFFECT OF old). The correlation between the complications and E-PASS POSTOPERATIVE 1ST DAY DRAIN score and survival outcome in two groups were compared. Results: There were no statistical background differences AMYLASE VALUE ON THE between two groups. Occurrence rate of PF (non-elderly 18 DEVELOPMENT OF PANCREATIC vs elderly 9%, p = 0.16), hospital stay (26 vs 24 days), FISTULA THAT OCCURS AFTER mortality rate (1 vs 0%) were equivalent in two groups. In PANCREATICODUODENECTOMY: A addition, overall survival rate (p = 0.49) and disease free PROSPECTIVE CLINICALAL STUDY survival rate (p = 0.54) were also equivalent in two groups. In risk evaluation, PRS in elderly group was higher than M. Kerem, K. Dikmen, H. Bostanci, I. Ermis and non-elderly group (0.267 vs 0.360, p< 0.01).In elderly A. C. Buyukkasap General Surgery, Gazi University, Turkey group, there were 17 patients (39%) who developed some complications, CRS in complication (+) patients was higher Introduction: The diagnosis of postoperative pancreatic than (À) patients (0.505 vs 0.669, p = 0.02). fistula (POPF) is established according to the value of drain Conclusion: PD for elderly patient could be contribute to amylase. However, the time of the removal of drain is prolong the prognosis as same as non-elderly patients. controversial. The aim of this study was to determine the predictive effect of the postoperative 1st day drain amylase EP02D-175 values on the development of POPF. LAPAROSCOPIC AND ROBOTIC Methods: This study was conducted on 135 patients un- dergone PD between August 2015 and August 2017. Drain SURGERY FOR THE TREATMENT OF amylase on the postoperative 1st, 3rd, and 5t days were PERIAMPULLARY TUMORS AT recorded. Clinic-related pancreatic fistula was determined SINGAPORE GENERAL HOSPITAL: according to the criteria of the International Study Group of EARLY EXPERIENCE WITH THE FIRST Pancreatic Fistula revised in 2017 (Grade B/C). The cut-off 30 CONSECUTIVE CASES values of postoperative 1st day drain amylase were detected according to the ROC analysis for using in the prediction of B. K. Goh, T. Y. Low, J. H. Kam, S. Y. Lee and the development of clinic-related POPF. C. Y. Chan Results: In 18 of 135 patients (13%), grade B and C POPF Hepatopancreatobiliary and Transplantation Surgery, developed. The median postoperative 1st day value of drain Singapore General Hospital, Singapore amylase was 7153 (440-138300 U/L) in patients devel- Introduction: Concerns have been raised about the safety oping fistula. The AUC value was found to be 0,91 (p = of minimally-invasive surgery (MIS) for pancreatoduode- 0,0001; 95% CI: 0,865e0,973) for the prediction of POPF nectomy (PD) during the early learning phase. In this study, determined by using postoperative 1st day drain amylase. we present our initial experience with MIS for periampul- In the prediction of POPF development, 1st day drain lary tumors. amylase cut-off value was 1363 U/L. The duration of Methods: Review of the first 30 patients who underwent hospitalization was longer in patients having the cut-off laparoscopic (LapS)/robotic surgery (RobS) for peri- value of >1363 U/L (p < 0,001). ampullary tumors between 2014e2018. Conclusions: Drain amylase on the postoperative 1st day Results: Twenty-seven underwent PD including 3 total can be useful for early detection of POPF. The postoperative pancreatectomies (TP) and 3 underwent palliative bypasses. 1st day drain amylase >1363 U/L is a risk factor for the Twenty-five were hybrid (open reconstruction) procedures. development of POPF. However, further prospective studies Twenty patients underwent LapS of which 18 were hybrid on larger populations are needed for reliable cut-off value. LapPDs including 2 TPs and 2 were bypasses. Ten underwent RobS of which 9 were RobPDs including 1 TP and 1 bypass. Five of 10 RobS were totally MIS procedures. There were 4 EP02D-177 PDs with venous resection of which 3 were by RobS. There were 4 (13.3%) open conversions. The median operation time IT IS POSSIBLE TO PREDICTE was 595 (range, 235e930) min. There were 5 (16.7%) major PANCREATIC FISTULA WITH (>grade 2) morbidities and there were 3 pancreatic fistulas (2 PREOPERATIVE IMAGING OR OTHER grade B, 1 grade C). There was no 30-day and 1(3.3%) 90- PERIOPERATIVE PARAMETERS AFTER day mortality. Comparison between 10 RobS and 20 LapS PANCRETIC SURGERY? demonstrated that RobS was associated with a longer oper- 1 1 1 2 e R. Schirren , M. Smierzynska , M. Sargut , F. Lohöfer , ation time [670 (range, 500 930) vs 577 (range, 235-715) 2 1 1 2 minutes, P = 0.056], lower open conversion rate [0 vs 4 G. Kaissis , E. Tieftrunk , S. Schorn , R. Braren , H. Friess1 and G. Ceyhan1 (20%), P = 0.129)], higher likelihood of being completed via 1 2 totally MIS [5(50%) vs 0, P = 0.002) and shorter stay [8 Department of Surgery, and Department of Radiology, (range, 6e36) vs 14.5(range, 6e62) days, P = 0.058]. Technical University Munich, Germany

HPB 2018, 20 (S2), S505eS684 S646 Electronic Posters (EP02A-EP02F) e Pancreas

Indroduction: Postoperative pancreatic fistula (POPF) them were in other group. There was no significant dif- poses an unsolved problem in pancreatic surgery. Predic- ference between the two groups in terms of parameters such tion of the risk of POPF can optimize individual treatment as age, gender, BMI, operation time, blood loss, period of decisions for patients undergoing pancreas surgery. The starting solid food, biliary leakage, intraabdominal/gastro- aim of this study is to investigate perioperative variables to intestinal bleeding, intraabdominal abscess/collection, predict risk factors of developing a clinically relevant POPF wound site infection and reoperation(p < 0,05). NG tube after pancreatic surgery. staying period, duration of hospitalization, DGE, pancreatic Methods: We reviewed 324 consecutive patients under- fistula and total morbidity rate were found significantly going pancreatic surgery between July 2007 and March lower in Braun group compared to the non-Braun group (p 2016 in our hospital. We investigated perioperative pa- < 0,05). rameters. Particularly the pancreatic anastomosis region Conclusions: It was observed that performing Braun was segmented manually using OsiriX in axial CT slices. anastomosis after PD decreased the rate of morbidity inci- Pixel values from the segmentation regions were exported dence and duration of hospitalization. as a single 3D VOI region. Histograms of the 3D VOIs This abstract was presented in 13th Congress of the were obtained and histogram statistics calculated using Turkish Association of Hepato-Pancreato-Biliary Surgery Prism. The histogram skewness values were used for on December 2017 in Antalya, Turkey. calculations. Results: Postoperative pancreatic fistula occurred in 52/ 324 patients (31,7%). Parameters like age, gender, body EP02D-179 mass index, the American Society of Anesthesiologists COMPLETE RESPONSE TO (ASA) score, medical comorbidities, preoperative biliary drainage, type of anastomosis, and pancreatic duct size NEOADJUVANT CHEMOTHERAPY IN were analyzed.In our study main pancreatic duct (MPD) LOCALLY ADVANCED PANCREATIC diameter on computed tomography (CT) scan <1,95 mm, ADENOCARCINOMA: 2 CASE REPORTS high BMI, duration of the operation, proof of Enterococcus H. Bostanci, M. Kerem, K. Dikmen, fl fi faecium in drain uid were statistically signi cant pre- A. C. Buyukkasap and S. Altiner dictors for clinically relevant POPF. Analyzing the skew- General Surgery, Gazi University, Turkey ness values of contrast-enhanced CT scan we found no Introduction: Surgical resectability rates are given after significance for developing pancreatic fistula. chemotherapy for locally advanced PDA patients are very Conclusions: Perioperative risk factors like main pancre- low. In here, receiving a complete radiologic reply after the atic duct (MPD) diameter, BMI, duration of the operation, neoadjuvant chemotherapy because of the superior proof of Enterococcus faecium in drain fluid predicts POPF mesenteric artery (SMA) invasion, two cases will be after pancreatic surgery. presented. Case 1: A 40cm lesion surrounding SMA 360 in uncinate process was detected in 61-year-old male patient in the EP02D-178 radiological examination. Twelve cures of neoadjuvant BRAUN ANASTOMOSIS REDUCES THE FOLFIRINOX were administered to the patient. Pathologic PROBLEM OF DELAYED GASTRIC involvement was not seen on PET-CT imaging. With these EMPTYING THAT OCCURS AFTER findings, pancreaticoduodenectomy was performed. His- PANCREATICODUODENECTOMY: A topathologically, no residual tumor was detected and 20 reactive lymph nodes were dissected. After adjuvant RANDOMIZED CONTROLLED STUDY chemotherapy treatment, 18 months later, the patient died K. Dikmen, H. Bostanci, M. Kerem, Y. Kelesoglu, by peritoneal carcinomatosis. A. C. Buyukkasap, H. Gobut and C. Emral Case 2: A 6cm mass surrounding the SMA 360 was found General Surgery, Gazi University, Turkey in the pancreas head localization in a 45-year-old female Introduction: Delayed gastric emptying (DGE) is an patient in the radiological examination that performed due important complication seen after pancreaticoduodenec- to jaundice. Neoadjuvant FOLFIRINOX regimen (14 tomy (PD) at the rate of 15e30%. The purpose of study is cures) was given. Pancreaticoduodenectomy was to evaluate the effectiveness of Braun anastomosis on performed to patient who had a complete radiological delayed gastric emptying after PD. response. Although tumor was not observed macroscopi- Methods: Ninety-four patients who were performed PD cally, 3 mm free tumor deposit was seen in the peri- between November 2015 and June 2017 were included. pancreatic fat tissue. No metastases were seen in the The patients were randomized into two groups in the wat removed 18 lymph nodes. After adjuvant chemotherapy that sealed envelope method as the group who was (oxaliplatin-gemcitabine), the patient is followed up for 30 performed Braun anastomosis (n = 47) and the group who months without disease. was not performed (n = 47). Postoperative pancreatic fistula Conclusion: Locally advanced PDA patients giving and DGE description were made according to the recom- radiologically complete response after neoadjuvant mendations of Pancreas Surgery Study Group. Nasogastric chemotherapy should be given a chance of surgery. In these tubes were inserted in all patients and they were removed in patients, survival is close to these resectable tumors. case the postoperative drainage was <200mL. This abstract was presented in 13th Congress of the Results: Delayed gastric emptying was seen in 21.2%. Six Turkish Association of Hepato-Pancreato-Biliary Surgery of the patients with DGE were in Braun group and 14 of on December 2017 in Antalya, Turkey.

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EP02E e Electronic Poster: 2E e Pancreas Methods: All the data for patients undergoing robotic distal pancreatectomy (RDP) were prospectively collected. The Technical Surgery incidence and clinical significance of spleen infarction and EP02E-001 gastric varices after spleen preservation by robotic HOW WE SECURE SAFETY OF Warshaw technique were also evaluated. LAPAROSCOPIC Results: A total of 66 patients were included, with 33 in PANCREATODUODENECTOMY: each group. The console time was significantly shorter in COMPARISON WITH OPEN RDP-SP group than that in RDP-S group (165 vs. 220 min.). The wound length was also shorter in RDP-SP group PANCREATODUODENECTOMY FOR (2.3 vs. 4.0 cm). The median blood loss was 50 c.c. in RDP- SIMILAR DISEASE SP group and 100 c.c. in RDP-S group. The surgical Y. Kaneoka and A. Maeda morbidity was significantly lower in RDP-SP group (18% Surgery, Ogaki Municipal Hospital, Japan vs. 58%). Grade B pancreatic leakage (no grade C) rate was fi Introduction: Laparoscopic pancreatoduodenectomy 20% for overall patients, and signi cantly lower in RDP-SP (LPD) is still a challenging operation and its safety and group (12 % vs. 27%). No intraabdominal abscess occurred feasibility are controversial. We demonstrate our institu- in RDP-SP group, vs. 15% in RDP-S group, P = 0.020. tional procedure to obtain satisfactory results comparing to Spleen infarction (15%), gastric (6%) varices and peri- open pancreatoduodenectomy (OPD) for similar disease gastric (45%) varices after RDP-SP were not associated (benign and low-grade malignant tumor). with any subsequent complication. Postoperative platelet fi Methods: From 2016, 14 consecutive patients underwent count and white blood cell (WBC) count were signi cantly LPD for 6 PNET, 3 IPMN and 5 Duodenal tumors. Our higher in RDP-S group. techniques are following; 2 surgeons who have experienced Conclusions: RPD-SP is not only feasible but also time- over 200 laparoscopic digestive surgeries and 200 OPD saving. Although gastric/perigastric varices and spleen perform Operator or Scopist alternatively; Scopist provides infarction are not uncommon after RPD-SP, they appear to a good field of vision as first assistant; usage of 3-dimen- be clinically irrelevant. tional visualization; via mini-laparotomy (7cm) a pancreatico-jejunostomy and duodeno-jejunostomy are performed; a choledoco-jejunostomy is performed lapa- EP02E-003 roscopically. All patients revealed soft pancreatic texture ANASTOMOSIS BETWEEN MAIN and the Fistula Risk Score (FRS) demonstrated 5 high and 9 HEPATIC ARTERIES: MYTH OR moderate-risk patients in LPD and 4 high and 6 moderate in OPD. REALITY? 1 1 2 3 Results: Mean operation time was not different between V. Egorov , R. Petrov , N. Starostina and N. Chernaya 1 2 the groups (LPD, 284 min; OPD, 289 min). Mean blood Surgical Oncology, Radiology, Bakhrushin Brothers 3 loss was significantly greater in OPD (LPD, 181 ml; OPD, Moscow City Hospital, and Radiology, Sklifosovsky 461 ml; p = 0.024). Median postoperative hospital stay was Emergency Institute, Russian Federation not different between the groups, but shorter in LPD (LPD, Background: The knowlege about anastomoses between 15d; OPD, 21d). There were no differences in postoperative major hepatic arteries do not used by surgeons. It is sup- complications (LPD, 43%; OPD, 40%) and clinical posed that this knowledge is theoretical. pancreatic fistula (LPD, 36%; OPD, 30%). There were no Aim: To show the importance of this knowledge to prac- reoperation and mortality in both groups. tical purposes. Conclusion: LPD offers the equivalent surgical outcome Method: Analysis of 10 cases of liver survival due to with OPD, while achieve less intraoperative blood loss and communicating interlobar artery after major pancreatic and shorter hospital stay. The candidates of this surgery corre- gastric resections and hepatic artery embolization, accom- spond to high FRS, thus we have to continue the meticulous panied by dearterialization of one of the liver lobes. surgery using partially open method to minimize morbidities. Monitoring of liver arterial supply intraoperatively was carried out by US Doppler of liver parenchima, and after surgery e by CT angiography(CTA) and angiography. EP02E-002 Results: Distal pancreatectomy with celiac (CA) and ROBOTIC DISTAL gastroduodenal artery resection (Michels IV), total duode- nopancreatectomy with CA resection (Michels III), PANCREATECTOMY: COMPARISON OF pancreaticoduodenectomy with common hepatic artery SPLEEN-PRESERVATION BY resection (Michels IX), total gastrectomy with resection of WARSHAW TECHNIQUE AND right hepatic artery originated from the CA (Michels I), SPLENECTOMY total duodenopancreatectomy with resection of the left hepatic and embolization of the right hepatic artery and S. -E. Wang and Y. -M. Shyr embolysatioembolization of the right hepatic arteries for Taipei Veterans General Hospital, Taiwan, Republic of multiple gunshot injuries (Michels I) and for huge hepa- China tocellular carcinoma (Michels I) were performed without Purpose: Warshaw technique has gained the favor of some vascular reconstructions and ischemic sequelae within surgeons due to its simplicity. Outcomes and surgical risks short- and long- term postoperative period. Postsurgical after robotic distal pancreatectomy with spleen preservation CTAs have shown that arterial supply to the liver lobes (RDP-SP) by Warshaw technique and with splenectomy lacking their main arteries is provided through the anasto- (RDP-S) were compared. moses between major hepatic arteries.

HPB 2018, 20 (S2), S505eS684 S648 Electronic Posters (EP02A-EP02F) e Pancreas

Conclusion: The knowledge about the capability of anas- both superior and inferior edges of the gland, performing a tomoses between major hepatic arteries allows to resect or tunnel under the neck and above the anterior aspect of su- embolise the main feeding lobar hepatic artery without perior mesenteric vein, section and sealed of the pancreatic reconstruction. In so doing intraoperative monitoring of parenchyma with staplers, and placing two drainages blood supply must be used, which depending on circum- beneath the pancreatic closure. stances can be ultrasound Doppler or angiography. Results: No postoperative mortality was observed and perioperative complications occurred in 5 out of 17 patients (29.4%) including 3 cases of Type A pancreatic fistula EP02E-004 (17.6%). Histopathological examination revealed 5 HOW TO SEPARATE PANCREAS FROM mucinous cysts, 5 serous cysts, 1 simple cyst, 4 adeno- carcinoma and 2 neuroendocrine tumors. In all cancer THE DUODENUM MAKING PANCREAS- specimens the surgical margins were tumor free (R0). PRESERVING DUODENAL RESECTION Length of stay was 5.7 days in average (range: 4-10). FOR DUODENAL DYSTROPHY Conclusions: According to other several publications in (GROOVE PANCREATITIS). HOW I DID the literature LDP is a recognized worldwide as a feasible, fi IT IN 15 CONSECUTIVE CASES safety and bene cial procedure. V. Egorov and R. Petrov Surgical Oncology, Bakhrushin Brothers Moscow City Hospital, Russian Federation EP02E-007 Background: Standard treatment for duodenal dystrophy RESECTION OF A DISTAL (DD) (groove pancreatitis, GP) is pancreaticoduodenec- CHOLANGIOCARCINOMA AFTER tomy. But for isolated form of DD (pure form of GP) TOTAL GASTRECTOMY: A CASE pancreas-preserving duodenectomy with replantation of REPORT pancreatic and bile duct into the neoduodenum can be a F. Berrospi, R. Paz-Manrique, R. Fernández, good organ-sparing option. One of the key points of this A. Guevara-Jabiles and E. Ruiz procedure is safe separation of the pancreas from the Abdominal Surgery, National Cancer Institute Peru, Peru duodenum. Method: The technique of separation of the pancreas from Introduction: Long-term gastric cancer survivors may the duodenum in case of chronic inflammation is demon- develop a second cancer. When this arises in the peri- strated by photo and video. ampullary region, concerns about diagnosis, resection and Results: Use of the abovementioned method has made a reconstruction techniques may appear. A case of a sparing of the whole pancreas possible in 15 cases of pancreaticoduodenectomy for distal cholangiocarcinoma in isolated forms of DD (pure forms of GP) with zero lethality a long-term gastric cancer survivor is presented. and 33% morbidity. Method: A 78-year-old male patient was admitted for Conclusion: Despite the prominent fibro-inflammatory evaluation in June 2017. He had undergone total D2 gas- changes in cases of isolated form of DD (pure form of GP) trectomy with Roux-en-Y anastomosis for an early gastric the safe separation of the duodenum from the pancreas adenocarcinoma in 2002. In 2017, a Magnetic Resonance along the groove area is possible. It helps to save all the cholangiopancreatography showed gallbladder and pancreas unchanged. common bile duct stones. The patient had an open chole- cystectomy and bile duct exploration in another hospital. . Bile stones and a sample of tumor were extracted from the bile duct. Choledochojejunostomy was performed and the EP02E-006 patient was referred to our institution with a diagnosis of LAPAROSCOPIC DISTAL biliary adenocarcinoma. Upper GI endoscopy identified the PANCREATECTONY jejuno-jejunostomy 120 cm distal to the esoph- R. Bracco, Federico García, Damián Huerta, agojejunostomy, the pancreatobiliary limb was inspected Ignacio G. Merlo, Diego Fernández, 50 cm and a kinking was found and the duodenum could Pedro J. Angiolini and Jorge P. Grondona not be reached. HPB Surgical Unit, Clinica Pueyrredon de Mar del Plata, Results: Pancreaticoduodenectomy was scheduled. Gas- Argentina trectomy anastomoses were preserved since the remaining pancreatobiliary limb was long enough for reconstruction. Aim: Laparoscopic distal pancreatectomy (LDP) is pro- An end-to-side duct-to-mucosa pancreaticojejunostomy gressively expanding. The aim of this study is to report our and an end-to-side hepaticojejunostomy were performed initial experience regarding the benefit of the laparoscopic (Fig. 1). Operative time was 315 min. No blood transfusion approach of pancreatic lesions located in the body and/or was needed. Postoperative outcome was uneventful. Pa- the tail of the pancreas. thology reported a pT2N2 mucinous adenocarcinoma of the Patients and methods: Between July 2013 and July 2017, distal bile duct with R0 resection and 7 of 13 lymph nodes a total of 17 patients, 15 females (88.2%) and 2 males resected were involved. The patient is recurrence free after (11.8%) were operated on by the laparoscopic approach in 6 months. our Surgical Oncological Centre (UNACIR HPB). Tumoral Conclusion: Distal cholangiocarcinoma after total gas- locations at the pancreas were: 8 in tail (47%), 8 in body (47 trectomy can be treated safely with pancreatico- %) and 1 (6%) in both tail and body. Size average of lesions duodenectomy. was 48.7 mm (range: 17-150). LDP was carried out with the standard technique that in summarize included isolation of

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EP02E-009 DOES PYLORIC-RING RESECTION IN PANCREATICODUODENECTOMY PREVENT DELAYED GASTRIC EMPTYING? T. Pitakteerabundit, T. Thongkun and N. -A. Wiboonkhawn Department of Surgery, Prince of Songkla University, Thailand Introduction: Pylorus-preserving pancreaticoduodenec- Figure tomy (PPPD) has been widely used in periampullary and pancreatic head cancer treatment; however, delayed gastric emptying is not infrequent. Delayed gastric emptying after pancreaticoduodenectomy increases treatment cost and length of hospital stay. We report the rate of delayed gastric EP02E-008 emptying between two surgical methodsdpyloric-ring EXTERNAL WIRSUNG-DRAINAGE PLUS resection pancreaticoduodenectomy (PRPD) and pylorus- REDO PANCREATICO-JEJUNOSTOMY preserving pancreaticoduodenectomy (PPPD). AS TREATMENT FOR PANCREATICO- Methods: We retrospectively reviewed all patients who JEJUNOSTOMY STENOSIS AFTER underwent pancreaticooduodenectomy in a single institu- PANCREATICODUODENECTOMY tion between June 1, 2014 and July 31, 2017, and placed them into either the pyloric-ring resection or the pylorus- 1 2 2 2 I. Justo , O. Caso , A. Marcacuzco , L. Alonso , preserving pancreaticoduodenectomy group. Descriptive 2 2 2 A. Manrique , A. Nutu , M. Garcia-Conde , analyses were conducted on the demographic, preoperative, 2 2 2 A. Garcia-Sesma , F. Cambra , C. Jimenez-Romero and intraoperative and postoperative details. The rate of delayed Study Group 12 de octubre gastric emptying according to the definition proposed by 1 2 Surgery, H. U., and 12 de Octubre UH, Spain the international study group of pancreatic surgery (ISGPS) Introduction: Stenosis of pancreaticodigestive anasto- was the primary endpoint. The secondary endpoints were mosis (pancreaticogastrostomy and pancreaticojejunos- postoperative hospital stay, intraoperative blood loss and tomy) is a very rare complication that usually develops blood transfusion, operative time and postoperative several years after pancreaticoduodenectomy (PD). Only a complications. few cases have been previously reported. We review the Results: Seventy-four patients were enrolled; 25 patients in literature and present 2 more cases of pancreaticojejunos- the PPPD group and 49 in the PRPD group. The overall tomy stenosis incidence of DGE was 29.7% (22 of 74 patients). The Results: We report two patients, 66 and 45 years old incidence of DGE in the PPPD group was statistically respectively, presenting with a clinical picture of recur- higher than that of the PRPD group (48.0% vs. 20.4%, P = rent acute pancreatitis at 6 years and 1 year after PD. 0.029). Postoperative hospital stay was 8 days in both Diagnosis of anastomotic stricture was established based groups. There was no significant difference in operative on symptoms of pancreatitis (12e15 episodes between 5 times, blood loss, incidence of perioperative blood trans- and 20 months after PD), and CT scan and MRI findings. fusion and postoperative complications. ERCP was attempted in both patients prior to surgery, Conclusion: Patients undergoing pyloric-ring resection being unsuccessful in both cases. Resection of the pancreaticoduodenectomy fared better in terms of delayed pancreaticojejunostomy stenosis was performed, gastric emptying compared to their counterparts who un- including a slice of 1cm of the pancreatic parenchyma in derwent pylorus-preserving pancreaticoduodenectomy. contact with the jejunum, followed by a new well- Complication rates between two groups were not statisti- vascularized two-layer end-to-side PJ with external cally significantly different. drainage of the Wirsung duct. Catheter drainage was exteriorized through a jejunal limb using the Witzel technique. Postsurgical course was uneventful in both EP02E-010 cases, and after a follow-up period of 3 and 2.5 years LAPAROSCOPIC respectively, the patients remain asymptomatic but have developed endocrine and exocrine insufficiency. We PANCREATICODUODENECTOMY FOR believe Witzel technique is useful in patients with RESECTION OF PERIAMPULLARY pancreatico-jejunostomy stenosis, as it contributes to TUMORS SHOULD BE ROUTINE? fi fi reduce stula rate and maintains suf cient Wirsung duct A. El Nakeeb and W. Askar patency in order to avoid postoperative pain. Mansoura University, Gastrointestinal Surgery Center, Conclusion: Resection of the PJ and construction of a new Egypt PJ with external stent drainage of the Wirsung duct is our Background: PD is acomplex abdominal procedure. The preferred surgical option in cases of PJ stenosis after a hospital mortality rate has decreased to <5% however the Whipple procedure.

HPB 2018, 20 (S2), S505eS684 S650 Electronic Posters (EP02A-EP02F) e Pancreas Ò rate of postoperative morbidities remains high 40%. Tobii X-60 eye-tracker as subjects were presented with Laparoscopic pancreaticoduodenectomy (LPD) has not yet three videos of critical steps of LPD. Main outcome mea- been well established approach for periampullary tumour. sures included number of fixations, fixation time and length We present our experience with LPD. of saccades. Methods: Patients undergoing LPD between 2014 and Eighteen participants were included. There was a high 2018 Included in the study. Patients who underwent a Pearson correlation coefficient (>0.6; p < 0.05) between hybrid LPD (HLPD) mobilization approach and resection the three videos regarding each physician, which indicates followed by open reconstruction and totally LPD (TLPD) consistent performance. The mean fixation time was longer approach were included in this study. Operative charac- for laparoscopic experts (475 ms, n = 8) compared to open teristics, perioperative outcomes, and pathological were experts (142 ms, n = 3) and residents (285 ms, n = 7; p = collected. 0.01), whereas the number of fixations were lower (631 vs. Results: Thirty Eight patients underwent LPD including 10 796 vs. 735 respectively, p = 0.042), indicating that lapa- HLPD (26.3%) and 28 TLPD (73.7%) patients. HLPD roscopic experts were quicker in finding regions of interest. patients were mostly converted to open for planned Surgical residents had the longest length of saccades (336 reconstruction or anesthetic problem. Median operating pixels), although not statistically significant compared to time was 370 min (420 min for TLPD). Median length of laparoscopic and open experts (327 and 134 pixels hospital stay was 6 days. Histology showed 35 invasive respectively; P = 0.42). malignancies, two neuroendocrine tumours, and one benign This pilot study shows that eye-tracking can demonstrate lesions. Median nodal harvest was 14. Margin negative differences in fixation between surgeons and residents with resection was achieved in 97.4 % of patients. Twenty-two different grades of experience in performing LPD. Eye- percent of patients developed a Grade 3∕4 complication, tracking could be a tool to monitor surgical expertise and including 12% clinically significant pancreatic fistula. discover which elements of LPD are critical to lay emphasis There was one perioperative mortality (2.6%) due to on during training. pancreatic fistula. These results are comparable with a well marched cases underwent open PD in the same period of study. EP02E-012 Conclusions: LPD is a technically challenging operation USE OF NEOVEIL OR TACHOSIL TO with a steep learning curve. The early surgical outcomes are satisfactory. LPD offers benefits to patients as it is minimal PREVENT PANCREATIC LEAK invasive procedure so it should be a routine procedure in a FOLLOWING well equipped center with good selection of the patients. PANCREATICODUODENECTOMY: RETROSPECTIVE STUDY S. P. Yun1, H. I. Seo1 and M. H. Yoon2 EP02E-011 1Department of Surgery, and 2Pusan National University EYE-TRACKING TO DIFFERENTIATE Hospital, Republic of Korea VIEWING BEHAVIOR OF SURGEONS Introduction: The aim of this study is to evaluate the AND TRAINEES DURING effectiveness of Neoveil or Tachosil sponge on pancreati- LAPAROSCOPIC cojejunostomy anastomosis site in reducing the rate and fi PANCREATODUODENECTOMY severity of postoperative pancreatic stula (POPF). Methods: This is a retrospective study of prospectively 1,2 3 4 D. Brinkman , W. van der Vliet , M. Besselink , collected data after pancreatioduodenectomy. Patients were 4 3 5 1 O. Busch , R. van Dam , S. Festen , I. de Hingh , divided in three groups: without application of any patch, 6 7 1 D. Lips , Y. Song , M. Luyer and on behalf of the Dutch Neoveil and Tachosil patch. Demographic and surgical data Pancreatic Cancer Group and LEOPARD-2 Investigators were analyzed. 1 2 Department of Surgery, Catharina Hospital, Tytgat Results: One hundred sixty-five patients with pancreatio- 3 Instituut, Academic Medical Center, Department of Sur- duodenectomy were enrolled in this study. They were 4 gery, Maastricht University Medical Center+, Depart- divided into three groups. In group 1 (n=43), patch was not 5 ment of Surgery, Academic Medical Center, Department applied while in group 2, 3 (n=84, n=38), the pancreati- 6 of Surgery, Onze Lieve Vrouwe Gasthuis, Department of cojejunostomy anastomosis site was covered with Neoveil 7 Surgery, Jeroen Bosch Hospital, and Faculty of Industrial and Tachosil. Postoperative fistulas above grade B were Design Engineering, Technical University Delft registered in 37.2% (16/43), 14.3% (12/84) and 18.8% (6/ Training is important to reduce learning curve associated 38) in groups 1, 2 and 3, respectively. In occurrence of morbidity and mortality after laparoscopic pancreatoduo- postoperative fistulas above grade B, there were significant dectomy (LPD). However, it remains unclear how surgical difference between no apply of patch group and patch apply performance differs between experts and trainees. Eye- group (p=0.004). In the multivariate logistic analysis of tracking is a novel tool that can be used to objectively predictive factor for postoperative pancreatic fistula, male, measure surgical performance through viewing patterns patch apply and hospital day were significant independent and could help identify crucial steps of the procedure. factor of POPF above grade B. Participants consisted of experts on laparoscopic Conclusion: This study showed that the Neoveil and pancreatic surgery, experts on open pancreatic surgery and TachoSil patch reduce the incidence of POPF after surgical residents. Eye movement was captured using a pancreatioduodenectomy.

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EP02E-013 not only pancreas parenchyma but also MPD, especially in case of small size of MPD. We have modified the pancreas IS ROUTINE SPLENECTOMY STILL dividing method using LCS to overcome this disadvantage. JUSTIFIED FOR LEFT-SIDED Methods: Pancreas dividing method we have adopted PANCREATIC CANCER? consist followings steps. HISTOLOGICAL REAPPRAISAL OF 1) Make total of four stich at the both side of upper and SPLENIC HILAR LYMPHADENECTOMY lower border of pancreas parenchyma to make appropriate 1 1 2 3 retraction during transection. T. Marchese , M. Collard , N. Guedj , M. Ronot , 2) Vibrate the active blade of LCS left and right in an F. Cauchy1, S. Dokmak1, P. Levy4, S. Gaujoux5 and 1 active state to transect the pancreas parenchyma. This A. Sauvanet motion is very similar to transection of liver parenchyma 1HBP Surgery, 2Pathology, 3Radiology, 4Gastroenter- 5 using CUSA. ology, Beaujon Hospital, France, and HPB Surgery, 3) Once the MPD is detected, isolate it. Remaining Cochin Hospital, France pancreas parenchyma is divided with LCS. Finally, Introduction: Splenectomy is recommended during pancreas head and body are connected only with MPD. resection for left-sided pancreatic ductal adenocarcinoma Results: Total cases we have adopted this method was only (PDAC) to perform lymphadenectomy of station 10 8 to date. The number of soft pancreas was 5, whereas hard (splenic hilum), but there is no level I evidence available to pancreas was 3. The number of below 2 mm size MPD was justify this procedure. Our aim was to evaluate both lymph 4, whereas over 2 mm was 4. We could detect and isolate node (LN) involvement and contiguous involvement of MPD successfully in all cases. Median time required for splenic hilum in resectable distal PDAC. this method was 341sec. Amount of blood loss during this Methods: We retrospectively reviewed all patients who method was below 1ml. underwent splenopancreatectomy for PDAC during the last Conclusion: Although our experience using this maneuver 10 years. Station 10 LN were routinely dissected and is still small, we could detect and isolate it successfully in isolated, and all corresponding microscopic slides were all cases. We believe, not only experienced surgeon but reinterpreted by a pathologist. CT-scans of patients with also beginner surgeon could introduce this method easily. tumoral involvement of the spleen or of the splenic hilum by contiguity (TISOSH) and those with less than 10mm between tumor and spleen at pathologic examination were EP02E-015 reviewed blindly by a radiologist to evaluate CT-scan for diagnosis of TISOSH. DOUBLE PURSE-STRING TELESCOPED Results: We included 110 consecutive patients, including PANCREATICOGASTROSTOMY USING 104 with analyzable station 10. Tumor was N+ in 58 pa- AN ATRAUMATIC SELF-RETAINING tients (53%). The median number of nodes identified at RING RETRACTOR FOLLOWING station 10 was 2.0Æ3.0 (range: 0e12). No node was PANCREATICODUODENECTOMY e detected at station 10 in 42 patients (40%). No patients had tumor-positive lymph nodes at station 10 (0/104). A DETAILS OF SURGICAL PROCEDURE TISOSH was found in 9 patients (8%). TISOSH was AND EARLY POSTOPERATIVE significantly associated with tail location (p=0.001), tumor OUTCOME size on the CT-scan (p=0.005), multivisceral resection M. Narita, H. Hata, R. Matsusue, T. Yamaguchi, (p=0.001) and multivisceral involvement (p=0.015). T. Otani and I. Ikai Sensitivity, specificity, positive and negative predictive Kyoto Medical Center, Japan values of CT-scan for diagnosis of TISOSH were respec- Background: Since May 2012, pancreatico-gastrostomy tively 89%, 95%, 89% and 95%. (PG) using an atraumatic self-retaining ring retractor Ò Conclusions: Splenic preservation during resection of left- (Alexis Wound Retractor ) has been used in patients who sided PDAC seems possible in selected patients without underwent pancreaticoduodenectomy (PD) in our suspected TISOSH at preoperative CT. department. Aim: The present study shows our surgical technique with video and evaluates early postoperative outcome of our EP02E-014 procedures. SIMPLE AND EASY METHOD TO Patients and methods: BetweenMay2012and ISOLATE MAIN PANCREATIC DUCT December 2017, 71 patients with peri-ampullary tumors DURING underwent PG. PG was performed as following; the anterior wall of upper stomach was incised and opened by Ò PANCREATODUODENECTOMY Alexis Wound Retractor . The remnant pancreas was Y. Kawasaki, K. Maemura, H. Kurahara, Y. Mataki, inserted into the gastric cavity through the posterior wall K. Tanoue, M. Hashiguchi, S. Iino, M. Sakoda, of stomach and sutured circumferentially with running H. Shinchi and S. Natsugoe stitches to fix on the gastric muco-muscular layer. After Department of Digestive Surgery, Breast and Thyroid closure of the anterior wall of stomach, purse-string su- Surgery, Graduate School of Medical Sciences, Kagoshi- tures were tightened. Closed suction drains were placed at ma University, Japan the site of Winslow’s foramen, and both cranial and Introduction: Using laparosonic coagulating shears (LCS) caudal sides of the PG. Pancreatic fistula (PF) was defined has been regarded as useful for division of pancreas in the according to the International Study Group of Pancreatic time of pancreatoduodenectomy. However, it might seal Surgery.

HPB 2018, 20 (S2), S505eS684 S652 Electronic Posters (EP02A-EP02F) e Pancreas

Results: Pancreatic cancer, extrahepatic bile duct cancer, Surgery Division, Department of Surgery, University of cancer of ampulla of Vater, and other diseases were in 27, Tokyo, Japan 23, 14, and 7 patients, respectively. Fifty-five patients had Objective: To focus on overall RHA variations and also soft pancreatic texture. Grade BL and B/C PF were discussed aberrant RHA arising from the GDA, which was observed in 14 and 11 patients, and all patients who had not noted in the classifications reported by Michels and Grade B/C PF had soft pancreatic texture. Serious com- Hiatt. plications associated with PF including intraabdominal Summary background data: Among patients with right hemorrhage and infectious portal vein thrombosis occurred hepatic artery (RHA) variations, the identification of an in 4 and 2 patients. Postoperative mortality was nil. aberrant RHA arising from the gastroduodenal artery Conclusions: Early postoperative outcome of PG was (GDA) is vital to avoid damaging the RHA, since GDA acceptable. PG would be safe and easy applicable procedure. ligation is necessary during a pancreaticoduodenectomy (PD). However, this variation is not frequently reported. EP02E-016 Methods: A total of 574 patients undergoing a PD between IMPACT OF PROPHYLACTIC January 2001 and December 2015 at a tertiary care hospital OCTREOTIDE TO PANCREATIC in Switzerland (n = 366) and between January 2009 and EXOCRINE SECRETION AND May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and PANCREATIC FISTULA AFTER MRI angiography findings were available for 532 patients. PANCREATODUODENECTOMY: RCT We retrospectively analyzed the hepatic artery variations, D. You, K. Paik and I. Park patient demographics, and surgical outcomes. College of Medicine, The Catholic University of Korea, Results: Among 532 patients who received a PD, an RHA Republic of Korea originating from the GDA was observed in 19 cases (3.5%). Background: Prophylactic octreotide is known to decrease Between the patients with an aberrant RHA (Hiatt type 3, 4 the rate of postoperative complication after pancreatic and 5) and those with an aberrant RHA arising from the fi resection by diminishing exocrine function of the pancreas. GDA, signi cant differences in surgical duration and blood The aim of this study was to evaluate the effect of octreo- loss were observed. tide in decreasing exocrine excretion of pancreas. Conclusions: We observed rarely reported but important Methods: We performed single-blind, controlled, ran- aberrant RHA variations arising from the GDA in 19 domized trial. Of 42 randomized patients undergoing (3.5%) out of 532 patients. When performing a PD, sur- pancreatoduodenectomy and pancreaticojejunal anasto- geons should pay attention to the possible presence of this mosis for either malignant or benign tumor, 20 were arterial anomaly to avoid any risk of liver failure, bilo- allotted to receive octreotide; 22 served as controls. All PJ enteric anastomotic leakage, and/or stenosis. anastomosis was performed with external stent of nega- tively-pressured drainage and the amount of drained pancreatic juice through the external stent was measured EP02E-019 until postoperative 7th day. THE MODIFIED DUCT-TO-MUCOSA Results: Of 60 patients, 6 patients were excluded because PANCREATICOJEJUNOSTOMY FOR of changing the operative procedures, 36 patients were analyzed. There were no difference between octreotide SMALL PANCREATIC DUCT DURING group (n=27) and control group (n=29), such as age, sex, PANCREATICODUODENECTOMY body mass index, disease entity, biliary drainage, diameter T. Y. Kim, J. D. Kim and D. L. Choi of pancreatic duct, pancreatic texture, OP time, estimated Surgery, Catholic University of Dagu, Republic of Korea blood loss, transfusion, complication and hospital stay. The Purpose: Postoperative pancreatic fistulas(POPFs) due to fi fl days of rst atus, sips of water and soft diet were com- anastomotic leak are closely related to significant morbidity parable in both groups. The amounts of pancreatic juice and mortality following pancreaticoduodenecto- through the negatively drained system were shown to have my(PD).The aim of this study is to introduce modification no differences in both groups. of the conventional duct-to-mucosa (DM) pancreaticoje- Conclusions: Our results suggest that prophylactic nunostomy(PJ) and the improved outcomes of this modi- octreotide is not effective to inhibit the exocrine secretion fied PJ technique for small main pancreatic duct. fi of the pancreas. Furthermore, it did not show a signi cant Methods: The modified DM anastomosis is characterized decrease in the rate of postoperative complications. that matching internal stent was inserted into the pancreatic duct remnant and secured with suture at the opening of the EP02E-018 pancreatic duct to enhance sealing, prior to the anasto- ABERRANT RIGHT HEPATIC ARTERY mosis. From January 2012 to October 2017, 102 patients ARISING FROM THE underwent PD for small main pancreatic duct ( 3mm). In GASTRODUODENAL ARTERY: A total, 33 cases received conventional DM pancreaticojeju- fi PITFALL FOR nal anastomosis and 69 cases received modi ed DM pancreaticojejunal anastomosis. PANCREATICODUODENECTOMY Results: The postoperative stay time, diet resumption time T. Yamaguchi1, K. Hasegawa2, M. -O. Sauvain1, and timing of drain removal in the modified DM group Y. Kazami2, T. Kokudo2, A. Cristaudi1, E. Melloul1, were lower than those in conventional DM group. The E. Uldry1, N. Demartines1 and N. Halkic1 overall incidence of POPFs was not significantly different 1Department of Visceral Surgery, Lausanne University between two groups. But, the clinical POPFs (grade B/C) in Hospital, Switzerland, and 2Hepato-Biliary-Pancreatic the modified DM group occurred less frequently than those

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S653 in the conventional DM group. (4.3 % vs. 24.2 %, Introduction: Although interventional approach is thought p=0.002). Moreover, neither grade C POPF nor in-hospital to be the first choice for the treatment of postoperative mortality occurred in the modified DM group. hemorrhage from pseudoaneurysm after pancreatic surgery, In addition, multivariate analysis showed a significant interventional approach can be difficult in some cases. In difference between both groups on significant POPFs (OR such cases, we usually perform surgery but it often becomes 0.211, 95% CI 0.09 to 0.51, P=0.001). difficult due to severe inflammation and adhesion. However, Conclusion: The modified DM anastomosis technique in hybrid approach may represent an attractive solution. We our study is a safer anastomotic method than the traditional report a case of pseudoaneurysm after pancreaticoduode- DM pancreaticojejunostomy technique. This new tech- nectomy treated with a hybrid approach in our institution. nique could effectively reduce the incidence of POPF. Method: A case report. Result: A 66-year-old man was given a diagnosis of ampullary carcinoma as a result of further examination for EP02E-020 jaundice. Stenosis of celiac axis (CA), superior mesenteric LESSONS LEARNED FROM THE artery (SMA) were detected preoperatively. He underwent pancreaticoduodenectomy by preserving pancreaticoduode- INTRODUCTION OF LAPAROSCOPIC nal arcade originating from gastroduodenal artery (GDA) to PANCRETICODUODENECTOMY maintain the blood flow of SMA. On post-operative day 31, V. B. Nieuwenhuijs, P. van Duijvendijk and G. A. Patijn he vomited blood and computed tomography (CT) revealed Surgery, Isala, Netherlands pseudoaneurysm of GDA. Selective angiography of CA and Introduction: Laparoscopic pancreaticoduodenectomy SMA was impossible because of severe occlusion at the (LPD) is rapidly gaining popularity. Open PD has been proximal portion. Therefore, he underwent hybrid surgery fi described a technically demanding operation. In the (surgery with an interventional approach). We rst cannu- Netherlands, pancreatic resections are restricted to centres lated right gastroepiploic artery, then embolized pseudoa- with volume 20 PDs/year. In 2016 we started with the LPD. neurysm of GDA. Postoperative course was uneventful and In this study we aimed to identify the pitfalls of the intro- he was discharged from our hospital on postoperative day 20. duction of minimal-invasive PD. Conclusion: To our knowledge, there is no report on Methods: All operations were done by two senior surgeons. hybrid surgery for the treatment of postoperative hemor- All surgeons had extensive laparoscopic experience with each rhage from pseudoaneurysm after pancreatic surgery. more than 500 advanced laparoscopic procedures (colorectal, Hybrid surgery can be a less invasive option in the case fi liver, spleen, upper GI, nephrectomy). The first 5 laparo- which interventional approach is dif cult. scopic PDs were supervised by a proctor. We retrospectively reviewed the first 20 laparoscopic PD cases. All data were obtained from our prospectively maintained database. The EP02E-022 primary outcome was all anastomosis-related morbidity. NEW PANCREATICOJEJUNOSTOMY Results: After 2 complicated cases and discussion with an PREVENTING FROM PANCREATIC international expert, we decided to change from a full LEAKAGE BY PUNCTURED STENT laparoscopic approach to a hybrid approach in which the anastomoses were done through a small midline laparot- SLIDE GUIDING METHOD TO THE omy. In 11 patients a full laparoscopic approach was MECHANISMS OF PANCREATIC attempted, 4 patients were converted. In 7 fully laparo- LEAKAGE scopic procedures, 6 patients experienced anastomosis- Y. Sato1,2 and J. Tanaka1 related complications. There was one in-hospital mortality 1Digestive and General Surgery, Showa University Fuji- in this group. In the 9 patients a hybrid technique was used. gaoka Hospital, and 2Digestive Disease Center, Showa There was no anastomosis-related morbidity in the hybrid University Yokohama Northern Hospital, Japan group (p = 0.01, Fischer’s exact test). There were no con- The most cause of pancreatic leakage might be a tech- versions en there was no mortality in the hybrid group. nical failure because of the anastomosis technique, the Conclusions: Anastomosis- related complications were difference of anastomosis between pancreatic duct and frequently seen after the introduction of the full laparo- caliber of jejunum, and the threads. In this study, we scopic pancreaticoduodenectomy. The hybrid approach devised the new anastomotic method of pancreato-jeju- may be safer in the earliest phase of the learning curve of nostomy, so called ‘ Punctured Stent Sliding Guide` minimal-invasive pancreaticoduodenectomy. method using a pancreatic duct stent. We demonstrated its method and results. The pancreatic duct stent, which is fit for a diameter of EP02E-021 pancreatic duct, is used for the direct puncture without any A CASE OF HYBRID SURGERY FOR A incineration. The aims of direct puncture are both the PSEUDOANEURYSM AFTER avoidance of the enlargement of anastomotic opening and PANCREATICODUODENECTOMY IN A disturbance of blood flow. The contralateral of anastomotic PATIENT WITH CELIAC AXIS AND opening is also punctured and the stent is pulled out of the jejunum. The 6-0 PDS with the needles at both ends is used SUPERIOR MESENTERIC ARTERY for anastomotic thread. Firstly, the eversion anastomosis of STENOSIS posterior wall is done by sliding the needle on the stent. Y. Seki, S. Hata, C. Shirata, H. Yamaguchi, M. Teruya and And then the anastomosis of anterior wall is done by the M. Kaminishi same way. Afterthat, modified Kakita method is done. The Department of Surgery, Showa General Hospital, Japan stent of contralateral side is cut and the hole is closed. The

HPB 2018, 20 (S2), S505eS684 S654 Electronic Posters (EP02A-EP02F) e Pancreas

14 cased of pancreato-jejunostomy by PSSG method were Background: In patients with pancreatic ductal adenocar- done. The disease of patients were pancreatic cancer (n=5), cinoma (PDAC), metastasis to para-aortic lymph nodes bile duct cancer (n=5), and Papilla vater cancer (n=1). The (PALN) implies systemic metastasis. Although non inva- pancreatic leakage by the ISGPF were Grade 0:13, A:1, sive imaging is commonly used to identify metastatic dis- B:0, C:0 respectively. The total incidences of PL among the ease, a significant number of patients with PALN first period (2004e2013), the second period (2014w), the involvement undergo exploration by invasive laparotomy. third period (PSSG mehod only) were 38%, 16.6%, 7.1%. From an oncological point of view, minimally-invasive The our new device of PSSG method for pancreato-jeju- laparoscopy represents a better approach for PALN sam- nostomy might be very effective. pling. To address this issue, we describe the surgical technique and demonstrate the technical feasibility of EP02E-023 laparoscopic PALN sampling performed during staging TOTALLY LAPAROSCOPIC laparoscopy for localized PDAC. PANCREATICODUODENECTOMY Methods: Laparoscopic PALN sampling during staging laparoscopy was attempted in 31 patients with resectable or USING 3D FLEXIBLE LAPAROSCOPIC borderline PDAC between November 2015 and February SYSTEM 2017. Patients’ demographic data and intraoperative, Y. S. Han, H. T. Ha, J. R. Han, J. M. Chun, H. J. Kwon, postoperative and pathological characteristics were exam- S. -G. Kim and Y. J. Hwang ined. Surgical technique is presented in detail. Hepato-Biliary-Pancreas Surgery and Liver Trans- Results: The median operative time was 35 (range 18e65) plantation, Kyungpook National University School of minutes. The median number of PALN analyzed per patient Medicine/Kyungpook National University Hospital, Re- was 2 (range 1e5). Four (13%) of 31 patients had positive public of Korea PALN in frozen section analysis. Three (9%) patients Robotic PD has not yet been expanded due to the needs presented chyle leak and the median hospital stay for pa- of the dedicated teams and the excessive costs. 3D flexible tients with positive PALN was 2 (range 1e7) days. laparoscopic system (3D) with depth perception and spatial Conclusion: Staging laparoscopy is largely admitted in orientation allows the precise dissection of the dangerous onco-surgical practices, to avoid futile laparotomy. We site and facilitate the comfortable reconstruction. We pre- report the safety and feasibility of laparoscopic PALN sent experiences regarding the efficacy of L-PD using 3D. sampling and suggest that it should be performed system- Methods: Totally L-PD was attempted in 15 patients from atically during staging laparoscopy in patients with local- June 2016 to June 2017. However, conversion to open PD ized PDAC. was required in one patient with tumor invasion to the su- perior mesenteric vein. Pancreaticojejunostomy was completed with the dunking procedure in 1 patient and with EP02E-025 duct-to-mucosa technique in 13 patients. NON-INFERIORITY OF OPEN PASSIVE Results: Mean operation time was 500 min. The replaced DRAINS VS. CLOSED SUCTION IN right hepatic artery originated from superior mesenteric artery of hepatic artery was identified in one patient and PANCREATIC SURGERY OUTCOMES. A preserved well because of the precise dissection under the PROSPECTIVE OBSERVATIONAL excellent visual field. The mean size of pancreatic duct and STUDY hepatic duct were 3 mm and 10 mm. There was no major G. Perri intra-operative complications and post-operative mortality. Verona University, Italy Postoperative complications were detected in 7 patients, Introduction: Open passive drains (OPD) and closed- including pancreatic fistula (n = 5), and delayed gastric suction drains (CSD) are both currently used in clinical emptying (n = 2). All pancreatic fistula was grade A and practice worldwide, without reliable data regarding poten- were recovered with conservative treatment. tial differences in the postoperative outcomes. Aim of the Conclusion: In selected patients, L-PD is a safe and study is to compare OPD and CSD in determining post- effective procedure with comparable surgical outcomes to operative drainage fluid contamination and overall open surgery. Especially, we believe that 3D will play an morbidity and mortality. important role in the expansion of complicated PD surgery Methods: Prospective observational analysis of 320 and will provide a bridge role for future robot systems. consecutive standard partial resections at a single Institu- tion. Either OPD or CSD were used according to the op- EP02E-024 erator’s choice. Postoperative outcomes were registered LAPAROSCOPIC PARA-AORTIC including samples of drainage fluid collected on POD V LYMPH NODE SAMPLING FOR and sent for microbiological analysis. PANCREATIC DUCT Results: The OPD and CSD cohorts did not differ in terms ADENOCARCICOMA e AN of clinical features and FRS. Overall rate of POD V drain fl ONCOLOGICAL PRACTICE uid contamination was similar (27.5% vs. 20.6% p = 0.1), as well as the POPF rate (20.6% vs. 17.5% p = 0.4). Same 1 1 2 3 P. Tortajada , J. J. Tuech , G. Pittau , F. Di Fiore , result was confirmed also for the specific procedure (PD 3 1 2 2 D. Sefrioui , V. Bridoux , A. Laurenzi , A. Sa Cuhna and and DP). The main postoperative outcomes and overall 30 1 L. Schwarz days morbidity and mortality did not differ between the two 1 2 Digestive Surgery, Rouen University Hospital, Paul groups. At qualitative microbiological analysis, the 61.5% 3 Brousse Hospital e Université Paris Sud, and Rouen of bacteria contaminating the drainage fluid of a PD were University Hospital, France attributable to human gut flora, while in DP the 84.8% of

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S655 bacteria belonged to human skin and mucous flora (p < Background: Recently, stapler closure is performed after 0.01). However, the spectrum of bacterial contamination distal pancreatectomy (DP). However, the selection of an did not significantly differ between OPD and CSD groups. optimal cartridge of stapler is unclear. Conclusion: The use of OPD and CSD for major pancre- Material and methods: Between 2011 and 2017, it was atic resection does not significantly impact on postoperative reviewed the 44 patients who underwent DP transected by outcome. The spectrum of drain contamination depends on linear stapler (pre-compression of 5 min, stapling of 5 min, the specific surgical procedures rather than on the type of and dissection of 5 min). Postoperative pancreatic fistula drain used. (POPF) was defined as a clinical relevant POPF (Grade B/ C) by ISGPS criteria. EP02E-026 Result: POPF was occurred in 8 patients (18.2%). The used EARLY REMOVAL OF cartridges were Endo GIA Tri-Staple purple 11 Endo GIA INTRAPERITONEAL DRAINAGE AFTER Tri-Staple black 11, Endo GIA green 8, Echelon blue 2, Echelon gold 4, and Echelon black 2. The pancreatic PANCREATODUODENECTOMY IN thickness, compression ratio, and the height after staple SELECTED PATIENTS: A RANDOMIZED formation were not significant differences between 2 CLINICAL TRIAL groups. We examined the subgroup analysis; (PC) or non- J. Dembinski1, C. Mariette2, J. -J. Tuech3, F. Mauvais4, PC, In pancreatic cancer PC, the pancreatic thickness, G. Piessen2, D. Fuks1, L. Schwarz3, S. Truant2, compression ratio, and the height after staple formation F. -R. Pruvot2 and J. -M. Regimbeau1 were not significant difference. In non-PC, the pancreatic 1University Hospital of Amiens, 2University Hospital of thickness and compression ratio were not significant dif- Lille, 3University Hospital of Rouen, and 4Hospital of ference between two groups, however, the height after Beauvais, France staple formation tended to be lower in the POPF group than non-POPF group (p = 0.066), and the 33.3% patients of the Objectives: To determine whether the timing of removal of height after staple formation <1.5 mm were occurred abdominal drainage (AD) after pancreatoduodenectomy POPF, however, POPF did not occur in the height after (PD) influences the 30-day surgical site infection (30-day staple formation 1.5 mm. SSI) rate. Conclusions: In the non-PC patients, we may reduce POPF Methods: A multicenter randomized, intention-to-treat trial by usage of 1.5 mm cartridges regardless of the pancre- with two parallel arms (superiority of early vs. standard AD atic thickness. However, in the PC patients, we should try removal on SSI) was performed between 2011 and 2015 in other efforts for POPF. patients with no pancreatic fistula (PF) on POD3 after PD (NCT01368094). The primary endpoint was the 30-day SSI rate. The secondary endpoints were specific post-PD complications (grade BC PF), postoperative morbidity, EP02E-028 reoperation rate, 30-day mortality, postoperative infectious COMPLETE GASTRIC WRAPPING complications and length of stay. METHOD FOR Results: 141 patients were randomized: 71 in the early arm, PANCREATICOGASTROSTOMY USING 70 in the standard arm (70.2% of pancreatic adenocarci- nomas; 91.5% of pancreatojejunostomies; 66.0% of bilat- TWIN HORIZONTAL MATTRESS eral drainages; feasibility: 39.9%). Early removal of drains SUTURES was not associated with a significant decrease of 30-day SSI K. Maemura1, Y. Mataki1, H. Kurahara1, Y. Kawasaki1, (14.1% vs. 24.3%, p = 0.12). A lower rate of deep SSI was M. Hashiguchi1, S. Iino1, M. Sakoda1, S. Ueno2, observed in the early arm (2.8% vs. 17.1%, p = 0.03), H. Shinchi3 and S. Natsugoe1 leading to a shorter length of stay (17.8 Æ 6.8 vs. 21.0 Æ 1Department of Digestive Surgery, 2Clinical Oncology, 6.1, p = 0.01). Grade BC PF rate (5.6%), severe morbidity and 3Graduate School of Health Sciences, Kagoshima (17.7%), reoperation rate (7.8%), 30-day mortality (1.4%) University, Japan and wound-SSI rate (7.8%) were similar between arms. Background: Recent studies indicate that pancreatico- After multivariate analysis, the timing of AD removal was gastrostomy (PG) has advantages over pancreaticojeju- not associated with an increase of 30-day SSI (OR = 0.74 nostomy in reducing the incidence of post-operative (95%CI 0.35 - 1.13, p = 0.38)). pancreatic fistulas (POPF). Here we report the use of the Conclusion: In selected patients with no PF on POD3, modified anastomosis for PG, comparing perioperative early removal of abdominal drainage does not seem to in- outcomes between the new method and the conventional ’ crease or decrease surgical site infection s occurrence. method. Patients and methods: 181 of patients undergoing PG EP02E-027 after pancreaticoduodenectomy since 2008 were included THE RELATIONSHIP WITH THE in the study. We investigated following subjects; 1) the STAPLER CLOSURE OF PANCREATIC relationship between perioperative factor and post-oper- STUMP AND POSTOPERATIVE ative CT evaluation of fluid pooling around PG (CT-fluid) PANCREATIC FISTULA AFTER DISTAL and contact degrees of pancreatic stump and stomach, 2) the verification of modified PG (twin square wrapping PANCREATECTOMY (TSW)) method which employed horizontal mattress M. Tani, H. Maehira, H. Iida, N. Kitamura, H. Mori, anastomotic technique for achieving complete wrapping N. Nitta, T. Miyake and T. Shimizu of pancreatic stump by gastric wall, 3) clinical assessment Department of Surgery, Shiga University of Medical Sci- of TSW method comparing with our conventional PG ence, Japan method.

HPB 2018, 20 (S2), S505eS684 S656 Electronic Posters (EP02A-EP02F) e Pancreas

Results: Introduction: Dissection of the superior mesenteric artery 1) The significant factors concerning POPF were iden- (SMA) is one of the most important procedure in tified as follows; lymphatic dissection, drainage amylase pancreaticoduodenectomy (PD) for pancreatic cancer. In level on post-operative day (POD) 3 and CT-fluid score. cases of pancreatic head cancer, surgery often results in The significant factors concerning overall post-operative noncurative resection, which is frequently related to inad- complications (Clavien-Dindo classification grade IIIa) equate clearance of the mesopancreas. Since 2015, we have were identified as follows; CRP level on POD 7, CT-fluid used the left posterior approach (LPA) for superior score, body mass index and pancreatic texture. mesenteric vascular dissection with total mesopancreas 2) The TSW group (n=82) had a significantly lower CRP excision, in which the SMA and superior mesenteric vein level and CT-fluid score, a reduced incidence of POPF and are dissected first in a clockwise fashion. post-operative complications, and a shorter duration of Methods: A consecutive 45 patients who underwent PD for drain placement and post-operative hospital stay compared pancreatic head cancer at our institution between 2012 and to the conventional group (n=99). 2017 were retrospectively enrolled. 22 patients underwent a Conclusions: The new PG technique based on our con- LPA between 2015 and 2017 and were compared to 23 ventional PG concept should be considered for reducing patients treated with a conventional approach (CA) between pancreatic fistulas by diminishing the post-operative in- 2012 and 2014. Intraoperative outcomes, postoperative flammatory response and improving patient outcomes. outcomes and pathological findings were evaluated. Results: The mean operative time did not differ between EP02E-029 two groups. The mean blood loss in the LPA group was THE IMPACT OF HAVING MORE THAN significantly less than that in CA group (p < 0.05). The ONE HPB SURGEON IN AN OPEN incidence rate of severe postoperative complications fi WHIPPLE OPERATION (Grade 3/4 according to Clavien-Dindo classi cation) did not differ between the groups. No surgery-related deaths J. R. C. Kit1 and T. C. W. Huey2 1 2 occurred in either group. As for pathological residual National University of Singapore, and Department of cancer status, number of positive dissected peripancreatic General Surgery, Tan Tock Seng Hospital, Singapore tissue margin cases was 4/23 in CA group and 1/22 in LPA Introduction: The Whipple operation involves technicalities group. which may at times benefit from the assistance of additional Conclusion: Pancreaticoduodenectomy with left posterior HPB surgeons e.g. portal vein involvement. It is therefore approach may contribute to decreasing total blood loss and important to understand the implications on patients when improvement of curative resection rate without increasing involving more than one surgeon. We aim to compare patient postoperative complications. outcomes between having one HPB surgeon versus more than one HPB surgeon conduct an open Whipple operation. Methods: Patients who underwent an open Whipple EP02E-031 operation at our centre from 2014 to 2017 were identified from our database. Demographic, surgical and post-surgical AUTOLOGOUS GRAFT OF FALCIFORM data were extracted. Patients were divided into two groups: LIGAMENT FOR VASCULAR Group I underwent an open Whipple operation involving RECONSTRUCTION IN PANCREATIC one HPB surgeon; Group II had more than one HPB sur- SURGERY geon performing the surgery. E. Herrero1, M. Galofré1, J. Camps1, Results: The study comprised 50 patients (Group I: n=13; M. I. García Domingo1, L. Martinez de la Maza1, J. Tur1, Group II: n=37). Comparing the average values of group I A. Rodríguez2 and E. Cugat1 versus II: Charlson Comorbidity Index was 5.615 vs 6.189 1Hospital Universitari Mutua Terrassa, and 2Anaesthesia, (p=0.22), operative time was 448 vs 500 minutes (p=0.09 ), Hospital Universitari Mutua Terrassa, Universitat de lengthofstay18vs21days(p=0.33), high dependency length Barcelona, Spain of stay 4.4 vs 5.2 days (p=0.26) and blood loss 315 vs 543mls fi (p=0.05). Despite cases in group II being more complicated Introduction: Vascular invasion is a common nding e.g. requiring portal vein reconstruction, the operative time, during pancreatic body and head tumors resection. In these length of stay and blood loss were not significantly different, cases, vascular resection should be performed to obtain free suggesting that additional HPB expertise can help mitigate resection margins. Sometimes, vascular reconstruction can problems from more complex cases. not be performed by primary anastomosis, so venous grafts Conclusion: More complicated patients tended to be are required. operated on by more than one surgeon and these cases can Methods: A 50-year-old patient was diagnosed with a fl give comparable outcomes to more straightforward cases pancreatic body tumor with splenoportal con uent operated by a single HPB surgeon. involvement. Intraoperatively, vascular involvement of the lateral aspect of the portal vein was confirmed. The patient EP02E-030 underwent an en bloc resection of the body and tail of the pancreas and partial resection of the portal vein. LEFT POSTERIOR APPROACH TO THE Results: Vascular reconstruction was performed with SUPERIOR MESENTERIC ARTERY IN autologous falciform ligament graft using continuous PANCREATICODUODENECTOMY FOR prolene sutures.The pathological findings confirmed a PANCREATIC HEAD CARCINOMA ductal adenocarcinoma of the pancreas with portal vein fi S. Hata, C. Shirata, H. Yamaguchi, M. Teruya and in ltration. Resection margins were free. Conclusion: Autologous peritoneal grafts are non-throm- M. Kaminishi Department of Surgery, Showa General Hospital, Japan bogenic and have some advantages, such as the ease of

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S657 obtaining and its low cost.A recently described alternative preoperative diagnosis of serous (6) and mucinous (6) is the use of the falciform ligament, which adds an cystadenomas, branch-duct intraductal papillary mucinous advantage to the peritoneal graft as it is a double membrane tumors (7), neuroendocrine adenoma (4) and metastatic structure that gives a greater strength and allows being used renal cell carcinoma (1). Careful attention paid to superior by both sides. posterior pancreatico-duodenal artery preservation. Alimentary tract reconstruction was performed by pancreatojejunostomy (21) and pancreatogastrostomy (3). EP02E-032 Laparoscopic approach was chosen in 7 cases. Double DUCT PENETRATING METHOD FOR pancreatojejunostomy (1) was performed after laparoscopic proximal pancreatectomy combined with medial pancrea- PANCREATOJEJUNOSTOMY WITH tectomy.Total pancreatic head resection combined with LOST STENT PLACEMENT BY PUSH & segmental duodenectomy (PHRSD) was performed in 25 PULL TECHNIQUE patients in chronic pancreatitis complicated by duodenal M. Uraoka, T. Ueno, T. Okada, S. Mineta, Y. Okamoto, dystrophy (22), large serous cystadenoma (2), neuroendo- Y. Watanabe, H. Kubota, M. Higashida, A. Tsuruta and crine adenoma (1). Duodenoduodenostomy was performed Y. Fujiwara in all patients and combined with pancreaticojejunostomy Digestive Surgery, Kawasaki Medical School, Japan and choledochojejunostomy (8); pancreatogastrostomy and choledochoduodenostomy (15), pancreaticoduodenostomy Introduction: We developed a novel anastomotic tech- duct-to-mucosa and choledochoduodenostomy (2). Chol- nique (duct penetrating method: DPM) using a suture-as- edochoduodenostomy was carried out below the duode- sistant device for the reliable performance of duct-to- noduodenostomy level always. mucosa pancreaticoenterostomy. Although whether the Results: No differences were noted in the mean operation placement of lost stent is superior to no stent or external time and estimated blood loss between the two procedures. stent remains controversial, we performed duct-to-mucosa Ischemia of duodenum was not observed. Major post- pancreaticojejunostomy with lost stent placement using operative complication constituted the following: bile duct “push and pull technique”. stricture (3) and postoperative bleeding (3), delayed gastric Method: An atraumatic needle is purposely driven to emptying (2). Newly developed diabetes mellitus occurred penetrate both walls of the duct, while sparing the stump of in 2 patients. Exocrine pancreatic insufficiency after the pancreas and incorporating an amount of pancreatic PHRSD was observed in 2 patients with chronic pancrea- parenchyma with adequate depth and width around the titis. There was no hospital or long-term mortality. duct. Suture placement is established by simple rotation of Conclusions: We found benign periampullary le- the needle driver along the curvature of the needle. A 5- sions could be conservatively treated with DPPHR and 0PDSII string is tied around a part of a pancreatic duct stent PHRSD, which could substitute for classic pancreatico- (4Fr).One side of the string is cut short, and the other side is duodenectomy. cut long. The proximal and distal side of the stent should be cut 1.5cm apart from the knot. The lost stent is entirely EP02E-034 pushed into the main pancreatic duct, then the proximal side of the stent is gradually induced into the jejunum side MINIMALLY INVASIVE by holding the 5-0PDSII string until the string appears from PANCREATICO-DUODENENCTOMY: the main pancreatic duct. WHICH IS THE GOOD “WAY”? Result: We performed DPM on 44 patients, and there was SYSTEMATIC REVIEW AND NETWORK fi no cases of Grade C stula. Over 100 patients were META-ANALYSIS OF NON performed push and pull technique, the failure rate of this procedure is approximately 2%. RANDOMIZED COMPARATIVE Conclusion: A safe and reliable pancreaticojejunostomy is STUDIES guaranteed by duct penetrating method. With push and pull C. Ricci1, C. A. Pacilio2, G. Taffurelli2, F. Minni1 and technique, an appropriate insertion of an internal short stent R. Casadei1 would be guaranteed. 1University of Bologna, and 2S. Orsola Malpighi Hospital, Italy EP02E-033 Background: Many mini-invasive pancreaticoduodenec- DUODENUM-PRESERVING TOTAL tomy (MIPD) techniques are reported, but their advantages PANCREATIC HEAD RESECTION AND respect to the open one (OPD) and between each other are TOTAL PANCREATIC HEAD unclear. RESECTION WITH SEGMENTAL Method: A systematic literature search of studies comparing different types of MIPD: laparoscopic-assisted DUODENECTOMY IN TUMORS AND (LAPD), totally-robotic (TRPD), totally-laparoscopic CHRONIC PANCREATITIS (TLPD) or totally-laparoscopic-robotic-assisted (TLPD- I. Kozlov, M. Baydarova, V. Vishnevsky and A. Chzhao RA) to OPD. Primary endpoint was postoperative mortal- A.V. Vishnevsky Institute of Surgery, Russian Federation ity. Secondary endpoints were intraoperative, postopera- Objectives: To estimate possibility of performance and tive and oncological outcomes. A network meta-analysis results of the duodenum-preserving pancreatic head re- (NMA) was built to generate direct, indirect and mixed sections in benign and borderline periampullary lesions. estimates effects, between different approaches, for each Method: Duodenum-preserving total pancreatic head variable. Effects were reported as pairwise comparisons resection (DPPHR) was performed in 24 patients with a and hierarchical ranking that each approach could be the

HPB 2018, 20 (S2), S505eS684 S658 Electronic Posters (EP02A-EP02F) e Pancreas best or the worst for each outcome, expressed by the surface EP02E-036 under the cumulative ranking curve (SUCRA). Results: Nineteen studies were identified, involving 2640 LAPAROSCOPIC DISTAL patients: 1777 OPDs; 81 LAPDs; 420 TRPDs; 226 TLPDs; PANCREATECTOMY: WHICH 136 TLPD-RAs. No differences regarding postoperative FACTORS ARE RELATED TO OPEN mortality were found in pairwise comparison. LAPD had CONVERSION? LESSONS LEARNED high probabilities of being the worst approach, while TRPD FROM 68 CONSECUTIVE PROCEDURES had high probabilities of being one of the best. Regarding secondary endpoints, OPD resulted the best for operative IN A HIGH VOLUME PANCREATIC time and postoperative bleeding, but the worst for blood CENTER loss and wound infection. TRPD or TLPD-RA seemed the C. Ricci1, C. A. Pacilio2, G. Taffurelli2, F. Minni1 and best for delayed gastric emptying, length of hospital stay, R. Casadei1 harvested lymph nodes and postoperative morbidity. TLPD 1University of Bologna, and 2S. Orsola Malpighi Hospital, resulted the worst approach, especially for overall and Italy major complications, postoperative bleeding and biliary Background: Laparoscopic distal pancreatectomy repre- leak. sents a difficult surgical procedure with an high conversion Conclusion: The safest MIPDs are those involving a ro- rate to open procedure. The factors related to its difficulty botic system, which seems to have a promising role in order and to conversion to open distal pancreatectomy were to ameliorate the outcomes of OPD, especially if compared rarely reported. The aim of the present study was to identify to a pure laparoscopic approach. which factors are related to conversion from laparoscopic to open distal pancreatectomy. Methods: A retrospective study of a prospective database EP02E-035 of 68 patients who underwent laparoscopic distal pancre- IS PANCREATICOGASTROSTOMY atectomy was conducted at a high-volume center by SAFER THAN pancreatic surgeons experienced with laparoscopic surgery. Pre-intra and postoperative data were collected. Patients PANCREATICOJEJUNOSTOMY AFTER who completed a laparoscopic distal pancreatectomy were PANCREATICODUODENECTOMY? A compared with those who needed a conversion to the open META-REGRESSION ANALYSIS OF approach as regards demographic, clinical, radiological and RANDOMIZED CLINICAL TRIALS surgical data. Univariate and multivariate analyses were carried out. C. A. Pacilio, C. Ricci, G. Taffurelli, F. Minni and Results: Univariate analysis suggested that the site of the R. Casadei lesion, the extension of pancreatic resection and the University of Bologna, Italy requirement for an extended procedure to adjacent organs Background: The superiority of pancreatogastrostomy were significantly associated with the risk of conversion to (PG) with respect to pancreaticojejunostomy (PJ) after the open approach. Multivariate analysis showed that only pancreaticoduodenenctomy is still under debate. the extension of the pancreatic resection (subtotal pancre- Method: A systematic literature search of all randomized atectomy) was significantly related to the odds of conver- clinical trials (RCTs) comparing PG to PJ with an Inter- sion (odds ratio (OR) 19.5; 95% confidence interval (CI) fi national Study Group of Pancreatic Fistula (ISGPF) de - 1.1-32.3; P=0.038). Preoperative suspicion of malignancy fi nition of postoperative pancreatic stula (POPF) was differed between the two groups; however, this difference carried out. Primary endpoint was clinically relevant POPF did not reach statistical significance (P=0.078). rates, analyzed using risk difference (RD) and number Conclusions: Despite the limitations of the study, only the needed to treat or harm (NNT and NNH). Secondary extension of pancreatic resection seemed to be the main endpoint was to evaluate the impact of confounding factor related to conversion during laparoscopic distal covariates on the meta-analytic results, reported as linear pancreatectomy. regression between Risk Ratio (RR) of the covariate and the RD of the primary endpoint expressed as a b coefficient Æ standard error (SE), using meta-regression analysis. Results: Seven RCTs were identified involving 1184 pa- EP02E-037 tients: 603 PG and 581 PJ. The RD in the fixed model of THE SINGLE CENTER EARLY clinically relevant POPFs suggested that PG was superior EXPERIENCE IN ROBOT-ASSISTED to PJ (RD À0.07; 95% CI: À0.11 to À0.03) with an NNT of PANCREATODUODENECTOMY 14. In a random model, PG was no more superior to PJ (RD M. Efanov, R. Alikhanov, V. Tsvirkun, I. Kazakov, À0.06; 95% CI: À0.13 to 0.01) with a possibility of harm in A. Vankovich, P. Kim and N. Elizarova some cases (NNH = 100). Meta-regression suggested that The Loginov Moscow Clinical Scientific Center, Russian the increase in the proportion of a “soft pancreas” in the PG Federation arm corresponded to a more positive value of RD (b = 0.47 Æ 0.19; P value: 0.045 Æ 0.003). Aim: The aim was to analyze the short-term results of robot- Conclusion: A PG is not superior to PJ in the prevention assisted pancreatoduodenectomy in patients with benign and of clinically relevant POPF. A soft pancreatic remnant malignant tumors of the pancreas and distal part of CBD. represents the main factor limiting the efficacy of PG and PJ Materials and methods: In period from April to November anastomoses. 2017 in the department of surgery of the liver and pancreas

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S659 were performed 11 robotic-assisted pancreatoduodenec- Results: Six distal pancreatectomies were performed, by a tomy in 8 women and 3 men for cancer of the pancreas head single surgeon, during the study period. Indications (9), cancer of the distal part of CBD (1) and cystadenoma of included neuroendocrine tumor, adenocarcinoma, IPMN the pancreatic head (1). The mean age was 65Æ6,6 years. and lymphoepithelial cyst. A laparoscopic approach was All malignant tumors were estimated as "T3". utilized in 50%. All but one patient underwent splenec- Results: The mean operative time was 714Æ115 and tomy. Mean drain amylase one day after initiating a diet decreased 1.5 times as experience had being accumulated. was 47 (19 e 91), with no patients exhibiting evidence of The mean BVL e 222Æ68 ml, blood transfusions were not leak. At thirty day follow up, all 6 patients remained required. Major morbidity took place in 4 patients (3 e IIIa without signs or symptoms of leak or fistula. and 1 e IIIb according to Clavien-Dindo classification). Three Conclusion: A novel technique using electrothermal and of 11 patients had a "soft” pancreas. In all of them pancreatic saline-coupled bipolar devices resulted in no pancreatic fistula occurred: B (2) and A (1) according to ISGPS. Bile leaks or fistulae in our small series of distal pancreatec- leakage (1) was treated percutaneously. Delay gastric empty tomies. Larger series and comparative studies are required (1) resolved in 3 weeks. There were no 90-day mortality. The to determine the optimal method of pancreatic transection mean postoperative hospital stay was 17Æ9days.Theaverage for preventing pancreatic leaks. number of harvested lymph nodes were 14Æ5,3. Resection was performed as R1 in 1, R0 in 10 patients. Conclusion: short-term results of the robot-assisted EP02E-040 pancreatoduodenectomy are comparable to those for laparo- TRANSPAPILLARY ENDOPANCREATIC scopic and open operations, and justify this approach as one of the standard techniques. Due to complexity of procedure SURGERY: DECOMPRESSION OF DUCT further results need to be estimated in learning curve analysis. SYSTEM AND COMPARISON OF GREENLIGHT LASER WITH MONOPOLAR ELECTROCAUTERY EP02E-039 P. Müller1, D. Steinemann1, F. Nickel1,K.Z’graggen2 and A NOVEL TECHNIQUE FOR B. Müller-Stich1 PREVENTING POSTOPERATIVE 1University of Heidelberg, Germany, and 2Beau-Site Bern, PANCREATIC FISTULAS AFTER Switzerland DISTAL PANCREATECTOMY Background: Endopancreatic surgery (EPS) is an experi- mental minimally invasive technique for resection of A. Wilson and A. Mavanur pancreatic tissue from inside the pancreatic duct, accessed Department of Surgery, Sinai Hospital of Baltimore, via the duodenum and papilla. It is proposed as an alter- United States native to duodenum-preserving pancreatic head resection in Introduction: Many techniques have been described for benign diseases such as chronic pancreatitis (CP). This the transection and closure of the pancreatic remnant during study evaluated the use of EPS for resection of pancreatic distal pancreatectomy, yet the pancreatic fistula rate after duct stenoses. Moreover, greenlight laser (GLL) and distal pancreatectomy remains 15e40%. Herein, we monopolar electrocautery (MC) were compared as resec- describe a novel technique which has decreased the tion tools for EPS. pancreatic fistula rate at our institution. Methods: The suitability of EPS for resection of stenoses Methods: A case series was performed evaluating the was evaluated in ex-vivo bovine pancreas (n=8). Artifi- pancreatic leak rate in patients undergoing distal pancrea- cially created stenoses in the pancreatic head were accessed tectomy. A novel non-closure technique was applied, uti- via the duodenal papilla and resected from inside the organ lizing an electrothermal bipolar tissue sealer in an “open with MC through a rigid endoscope. Furthermore, stan- jaw” technique to transect the pancreas, followed by saline- dardized pancreatic resections were performed in an in-vivo couple bipolar tissue sealer to coagulate the stump of the porcine model using either GLL (n=18) or MC (n=18) to pancreatic remnant. Drain amylase was measured one day compare blood loss, operating time, and complications. after initiating patients’ diets to detect pancreatic leak. Thermal damage to the surrounding tissue was assessed Thirty day follow up was also performed for detection of using a standardized histological classification. late pancreatic leaks or formation of fistulae. Results: StenosisresectionbyEPSwasfeasiblein8/8 bovine pancreases, with a procedure time of 17 (12e24) min. No perforation of the organ occurred. Resection by GLL was associated with reduced blood loss [median 1.7(IQR 0.6e2.6) ml vs. 5.1(3.8e13.2) ml; p < 0.01] and shorter operating time [109 (81e127) s vs. 390 (337e 555) s; p < 0.01] compared with MC. The zone of ther- mal tissue damage was more extensive when using GLL than with MC [4.12 (3.48e4.89) mm vs. 1.33 (1.09e 1.48) mm; p < 0.01]. Conclusion: Transduodenal-transpapillary-EPS can be used to resect stenoses and decompress the pancreatic duct system. Both GLL and MC are feasible resection methods for EPS. However, GLL showed better hemostatic char- acteristics than MC in an in-vivo model. Figure Pancreatic remnant stump

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EP02E-041 after DP, and 5 after TE. Four patients had postoperative transfusion in PD group and one in DP group. Conversion ROBOTIC VERSUS STANDARD OPEN to open laparotomy occurred in four patients (8%). No PANCREATECTOMY: A CASE serious intraoperative complications were observed. MATCHED ANALYSIS COMPARISON Conclusions: From our early experience, robotic pancre- R. Caruso, E. Vicente, Y. Quijano, B. Ielpo, H. Duran, atic surgery is a safe and feasible procedure. Further fi I. Fabra, V. Ferri, E. Barzola, R. Isernia and C. Plaza experience and follow-up are required to con rm the role of Sanchinarro University Hospital, Spain robotic approach in pancreatic surgery. Background: Interest in robotic pancreatectomy has been greatly increasing over the last decade. However, evidence EP02E-043 supporting the benefits of robotic over open pancreatec- A NEW TECHNIQUE FOR tomy is still outstanding. This study aims to assess the LAPAROSCOPIC PANCREATIC safety and efficacy of robotic pancreatectomy compared RECONSTRUCTION: WRAPPING with the conventional open surgical approach. DOUBLE MATTRESS Methods: Propensity score matched (1:1) was used to RECONSTRUCTION balance age, sex, BMI, ASA, tumour size and malignancy of 17 robotic pancreaticoduodenectomies (PD), 12 pancreatic G. Kiguchi, I. Uyama, M. Kojima, T. Kagawa, A. Yasuda, enucleations (PE) and 28 distal pancreatectomies (DP) and S. Nakajima, Y. Tanahashi, Y. Kato and A. Sugioka were compared with the open standard approach. Department of Surgery, Fujita Health University, Japan Results: Robotic PD was associated with longer operative Introduction: The difficulty in laparoscopic reconstruction of time (594 vs 413 min; p = 0.03) and decreased blood loss the pancreatic anastomosis is one of the main risk factor of the (190 vs 394 ml; p = 0.001). Robotic PE showed a lower mean pancreatic leakage in the Laparoscopic pancreaticoduode- length of hospital stay (8.4 vs 12.8 days, p = 0.04) and, in nectomy (LPD). To resolve this problem, we have developed addition robotic DP showed less blood loss (175 vs 375 ml; p a new technique: Wrapping double mattress reconstruction = 0.01), less severe morbidities (7.14 vs 17.9%; p = 0.02), and (Kiguchi-method) for laparoscopic pancreaticojejunostomy. a reduced mean length of hospital stay (8.9 vs 15.1; p = Methods: Kiguchi-method consists of three transpancreatic 0.001). Overall conversion rate was 4 (7%). The histopa- outer-layer sutures and four inner-layer sutures using hor- thology of specimen showed disease-free margins in all cases. izontal mattress sutures. 3-cm-long seromuscular incision is Conclusion: Robotic pancreatectomy is as safe and effec- made in the antimesenteric wall of the jejunal loop extra- tive as the standard open surgical approach with reduced corporeally. Intracorporeally three transpancreatic outer- blood loss in PD and DP, length of hospital stay in PE and layer sutures are preset without tying for horizontal DP, and severe morbidity in DP. mattress sutures on the jejunum with the double needle polypropylene 3-0. For inner-layer sutures of the duct to EP02E-042 submucosa anastomosis, two stiches are placed into the ROBOTIC-ASSISTED PANCREATIC pancreatic duct on the both ventral and dorsal walls in the SURGERY: TIME-TREND FROM 65 horizontal mattress fashion with the double needle poly- propylene 5-0, and two interrupted stiches are placed on the CONSECUTIVE RESECTIONS AT A cranial and caudal side of pancreatic duct. After pancreatic HIGH-HBP SINGLE CENTER intraductal tube is placed into the pancreatic duct and fixed, R. Caruso, E. Vicente, Y. Quijano, B. Ielpo, H. Duran, all inner-layer stiches are tied. And then outer anterior E. Diaz, V. Ferri, E. Barzola, C. Plaza and R. Isernia horizontal mattress sutures on the jejunum are completed Sanchinarro University Hospital, Spain and tied. Background: Minimally invasive surgery has achieved Results: Since September 2016, we have performed 12 worldwide acceptance in various fields, however, pancre- LPD with pancreatic reconstruction by Kiguchi-method. fi atic surgery remains one of the most challenging abdominal All cases had soft and non brotic pancreatic tissue, average procedures. In fact, the indication for robotic surgery in diameter of the pancreatic duct was 2.5mm. Average pancreatic disease has been controversial. The present duration of the Kiguchi-method was 123 min. POPF grade fi study aimed to assess the safety and feasibility of robotic Ade ned ISGPF was only one case, there was no cases pancreatic resection. developed POPF grade B-C. Average hospital stay was Methods: We retrospectively reviewed our experience of 16.3 days. robotic pancreatic resection done in Sanchinarro University Conclusion: Laparoscopic pancreatic reconstruction by Hospital. Clinicopathologic characteristics, and perioperative Kiguchi-method seems to be safe and suitable technique for and postoperative outcomes were recorded and analyzed. LPD. Results: From October 2010 to December 2017, 65 pa- tients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed EP02E-044 using the da Vinci robotic system. Of the 65 patients, 36 TRANSECTION USING A REINFORCED were male and 29 female. The average age of all patients STAPLER REDUCES THE INCIDENCE was 65 years. Operative time was 350 minutes. Among the procedures performed were 22 pancreaticoduodenectomies OF PANCREATIC FISTULA AFTER (PD), 29 distal pancreatectomies (DP), 14 tumor enucle- DISTAL PANCREATECTOMY ations (TE). The mean hospital stay was 16 days in PD K. Suzumura, E. Hatano, T. Okada, Y. Asano, N. Uyama, group, 9 days in DP group and 8 days in TE group. I. Nakamura, S. Hai, M. Tada, H. Sueoka and J. Fujimoto Pancreatic fistula occurred in 13 cases (20%), 5 after PD, 3 Surgery, Hyogo College of Medicine, Japan

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Purpose: The appropriate procedure for closure of the EP02E-046 remnant pancreatic stump in distal pancreatectomy (DP) remains unresolved. The purpose of this study was to 3D PLANNING OF IRREVERSIBLE compare the incidence of pancreatic fistula (PF) among the ELECTROPORATION TREATMENT IN 3 methods, and to determine the risk factors for PF after DP. PANCREATIC CARCINOMA: A USE Methods: Between July 2009 and December 2016, 66 CASE patients underwent pancreatic stump closure with 1 of 3 B. Eigl1, S. Weber1, M. Peterhans2, D. Candinas3, methods: the clamp-crushing method (n = 26), ultrasonic B. Gloor3 and M. Worni3 scissors (n = 18), and a reinforced stapler (n = 22). 1ARTORG Center for Biomedical Engineering Research, Results: There were significant differences in the incidence University of Bern, 2CAScination AG, and 3Department of of PF (clamp-crushing method [38%] vs ultrasonic scissors Visceral Surgery and Medicine, University of Bern, [61%] vs reinforced stapler [9%], p< 0.001), and in the Inselspital, Switzerland incidence of postoperative intra-abdominal hemorrhage (clamp-crushing method [0%] vs ultrasonic scissors [17%] Introduction: Irreversible-electroporation (IRE) is an vs reinforced stapler [0%] p = 0.047). A multivariate ablation technique that spares vessels and is therefore analysis revealed that intraoperative blood loss (605 mL), suitable for treatment of locally advanced pancreatic pancreatic thickness (11 mm), and the stump closure cancer. Our surgery planning software supports pre-oper- fi method were independent risk factors for PF after DP (p = ative simulation of possible needle con gurations in 3D to 0.03, p = 0.001, p=0.018 respectively). prepare for the ablation treatment. We present herein the fi Conclusion: The use of a reinforced stapler for the tran- application of the proposed software tool to one out of ve section of the pancreas can reduce PF after DP. Intra- cases which we already planned within a proof of concept operative blood loss ( 605 mL), pancreatic thickness ( study. 11 mm), and the stump closure method remained as inde- Method: For planning of an open IRE treatment of a car- pendent risk factors for PF after DP. cinoma located in the body of the pancreas, pre-operative CT image data was analyzed with a commercial surgery planning tool. The resulting 3D anatomy models as well as the original CT data were loaded into our tablet-based EP02E-045 software. We then performed simulation of two different LAPAROSCOPIC IRE needle configurations (Figure 1) and evaluated them HEPATICOJEJUNOSTOMY with respect to vicinity to critical structures versus A. Maeda, Y. Kaneoka, Y. Takayama, Y. Fukami, achieving the recommended needle spacing and parallelism T. Takahashi and M. Uji for IRE. Department of Surgery, Ogaki Municipal Hospital, Japan Results: During the surgery the decision was to target ac- cording to plan # 1 as the superior mesenteric vein was not Introduction: In laparoscopic pancreaticoduodenectomy mobilizable enough to obtain a window for the inferior (LPD) and resection of choledocal cysts (LRCC), hepati- right needle in #2. The number and placement of the cojejunostomy (LHJ) is required for less invasive surgery. needles relative to each other did not significantly depart The authors present our procedure and feasibility. from the pre-operatively defined plan. Methods: Between June 2014 and December 2017, 25 Conclusions: Our software gives to surgeon the possibility patients underwent LHJ (19 LPD and 6 LRCC). Synopsis to pre-operatively verify the feasibility of needle placement of surgical procedure: Operators were limited to 2 surgeons strategies and enables a better orientation of the upcoming with experiences more than 250 advanced laparoscopic situs. Our next step is to enable intraoperative computer- surgeries. Cauterized jejunal orifice was placed in the assisted navigation to target according to the pre-operative ventral side. A polydioxanone surture (PDS II, 5-0) was plan. placed in the 9 o’clock position for suturing the anterior wall. Another PDS II was placed in the 8 o’clock and ligated for continuous suture of the posterior wall toward 3 o’clock positon. Former thread was ligated and sutured continuously from the right side to the left side and tied together accomplishing LHJ. To avoid excessive tension to the anastomosis, jejunum was fixed to the cystic plate. Results: Median age was 62 year-old in LPD and 43.5 in LRCC, and male to female ratio was 12:13 and BMI 23 kg/m2. Although LHJ duration of the first 5 cases were 35 to 50 minutes, median time of the latest 5 cases was 19 (range 17e21) minutes. Anastomosis insufficiency was observed in one (4%) patient of LPD followed by biliary stricture after 11 months. No other biliary complications were observed with median follow-up time of 18 (1e41) months. Conclusion: Laparoscopic bilioenteric reconstruction is feasible within 30 minutes with acceptable morbidity. Figure 3D reconstructions and trajectories Further follow-up is required for long time outcomes.

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EP02E-047 Methods: Prior to surgery, all patients underwent a computered tomography scan. Those patients who had an LAPAROSCOPIC DISTAL inflammatory mass of the head of pancreas underwent a PANCREATECTOMY FOR INVASIVE Frey’s Procedure. Otherwise, the rest underwent a lateral DUCTAL CARCINOMA OF THE pancreticojejunostomy. The key difference in technique is PANCREATIC BODY AND TAIL the extension of the longitudinal incision into the head of pancreas, removing the sentinel stone if it exists, and M. Doi, G. Honda, Y. Homma, Y. Ome, H. Ishida and using the entire length for the pancreaticojejunostomy Y. Oguri anatomosis. Department of HBP-Surgery, Tokyo Metropolitan Cancer Results: Decompressive procedures in chronic pancrea- and Infectious diseases Center Komagome Hospital, titis in the management of chronic pain poses significant Japan challenges. Although the Peustow’s lateral pancreatico- Background: We standardized laparoscopic distal jejunostomy has been classically described, inadequate pancreatectomy (LDP) for patients with invasive pancreatic drainage of the Duct of Wirsung or a sentinel stone within ductal carcinoma (PDAC) of the pancreatic body and tail. the head of pancreas is a possible cause of persistent We present our standardized procedure with our results. chronic pain. Procedure: The patient was placed in a lithotomy position Conclusion: The technique described above allows for with only the upper body twisted to the right. After opening more adequate decompression of the duct within the head the bursa omentalis, the gastrosplenic ligament was of pancreas. dissected and the anterior and right aspects of the crus were exposed as the cranial margin. The splenic artery was ligated at the root after removing the lymph nodes around the common hepatic artery. The meso-transverse colon was EP02E-049 incised around the jejunum origin and the left renal vein ONE VERSUS TWO SURGEONS and left adrenal vein were exposed as the dorsal margin. APPROACH FOR LAPAROSCOPIC The left and ventral sides of the superior mesenteric artery PANCREATICODUODENECTOMY: A with enveloped nerve fibers were exposed and this led to PILOT STUDY the exposure of the celiac ganglion. The pancreatic neck was then divided using a stapler. The retropancreatic tissue S. Sabnis, P. Senthilnathan, N. Anand Vijai, including the left adrenal gland was resected. Lastly, the S. Srivatsan Gurumurthy, V. P. Nalankilli and spleen was detached. C. Palanivelu Result: Between January 2012 and December 2017, 25 Surgical Gastroenterology & HPB Surgery, Gem Hospital patients with PDAC underwent LDP. The mean operative and Research Center, India time was 357 min, and the mean blood loss was 100 ml. Introduction: Laparoscopic major organ resections POPF (grade B/C) rate was 8% (2/25). There were no have become common in today’s era. Ultra-major mortalities. oncological resections via minimally invasive approach Conclusion: LDP for PDAC could be performed safely and has significant impact on operative time which tends to feasibly in selected patients. be longer than its open counterpart. This study was aimed to analyse the effect of surgical fatigue on out- comes of surgery. EP02E-048 Methods: This is a prospective, case matched analysis of 24 patients of periampullary and carcinoma head of A COMPLETE LATERAL pancreas, who underwent laparoscopic pancreaticoduode- PANCREATICOJEJUNOSTOMY FOR nectomy by two surgeons (separate surgeons for resection CHRONIC PANCREATITIS e HOW I DO and reconstruction part) considered here as group A, which IT are compared with similar number of patients who were stage matched controls (group B), who underwent the M. Y. Tan and K. K. Madhavan procedure by either of the two surgeons. Hepatobiliary & Pancreatic Surgery, National University Results: Most of demographic and pre-operative vari- Hospital, Singapore ables didn’t show any significant difference. Operative Introduction: Chronic pancreatitis can affect both the time was significantly lower in group A (p = 0.03). Other endocrine and exocrine function of the pancreas, and often operative parameters were comparable. The incidence of presents as intractable chronic pain. This pain is often the rate of pancreatic fistula was lower in group A (9% vs most common indication for surgical intervention. Peustow 13%), but couldn’t achieve significance level (p = 0.07). initially described a lateral pancreaticojejunostomy where Pancreas specific and other complications were similar. the pancreatic duct is opened longitudinally and anasto- There was no difference in hospital stay, pathological mosed to a jejunal loop. Up to 65-80% of patients experi- outcome or mortality. ence initial pain relief after this procedure, but only about 1 Conclusion: This small pilot study aimed to highlights out of 3 experience long term pain relief. Failure of this importance of impact of prolong surgical procedures, technique is often attributed to inadequate drainage of the longer operating times, surgeon’s fatigue, and its influence duct of Wirsung. Frey subsequently described a procedure on final surgical outcomes. Two surgeon approach defiantly combining the lateral pancreaticojejunostomy with the reduce the operating time. The effect on pancreatic fistula ” "coring out of the head of pancreas, which creates its own exists, but without statistical significance. set of complications.

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4 EP02E-050 University of the Sacred Heart, Rome, and San Camillo Hospital, Italy BENEFITS OF THE SUPERIOR Introduction: Though both pancreatogastrostomy (PG) MESENTERIC ARTERY FIRST and isolated jejunal loop pancreatojejunostomy (IJLPJ) APPROACH DURING OPEN AND have been associated with reduced rate and gravity of LAPAROSCOPIC POPF, the safest technique of reconstruction following PANCREATODUODENECTOMY pancreatoduodenectomy (PD) is still a matter of debate. We compared postoperative results of IJLPJ with those of PG in G. Zimmitti1, A. Manzoni2, V. Sega2, M. Garatti2, patients at high risk for POPF. C. Codignola2, E. Treppiedi1, F. Guerini2 and E. Rosso2 Methods: Two groups of 48 patients each were obtained 1Istituto Ospedaliero Fondazione Poliambulanza, and from 3 specialized HPB Units, two performing PG and one 2Fondazione Poliambulanza e Istituto Ospedaliero, Italy IJLPJ as their preferred technique following PD. Only pa- Introduction: Initially proposed to assess resectability and tients with soft pancreas and a Callery risk-score >6 were improve surgical resection margin status of patients un- included in this study. Primary outcomes were rates of dergoing pancreatoduodenectomy for pancreatic head postoperative major complications and mortality and of fi tumors, the superior mesenteric artery (SMA)- rst clinically relevant (grades B-C according to ISGPS) POPF, approach may also improve surgical safety allowing better postoperative pancreatic hemorrhage (PPH), and delayed fi identi cation of pancreatoduodenal arteries originating gastric emptying (DGE). from the SMA and easier preservation of aberrant/replaced Results: Major (Dindo>2) complication and mortality right/common hepatic arteries (RHA/CHA) originating rates were 26% and 1%, respectively, and did not differ fi from the SMA. We describe our experience with SMA- rst between two groups of patients. Overall, clinically relevant approach during Open and Laparoscopic pancreatoduode- POPF, PPH, and DGE occurred in 22%, 11%, and 24% of nectomy (OPD and LPD). patients, and did not differ significantly between two fi Methods: We used the SMA- rst approach in 63 consec- groups. A trend toward faster abdominal drain removal in e utive patients (June 2015 June 2017), 44 undergoing OPD the IJLPJ was observed, matching a significantly shorter and 19 LPD. Demographic, clinical-pathological, and hospitalization (median duration: 18 days versus 24 days in perioperative data were prospectively collected and retro- PG group, p=.012) spectively analyzed. Conclusion: IJLPJ and PG, when performed by surgeons fi Results: The SMA- rst approach was feasible in all study specialized with the concerned technique, have similar re- patients and was useful in the management of RHA/CHA sults in terms of postoperative complications both overall anomalies in 14% of patients. Overall, median intra- and specific for PD. operative blood loss was 150 ml, with 16% of patients undergoing intraoperative blood transfusion. OPD patients had higher intraoperative median blood loss (200 ml) and more frequently needed intraoperative blood transfusion EP02E-052 (23%), compared to LPD (100 ml and 0%,respectively, p< DUCT-PENETRATING METHOD FOR .05). OPD patients underwent more complex procedures PANCREATICOJEJUNOSTOMY USING with higher rates of vascular resection/reconstruction A SUTURE-ASSISTANCE DEVICE (55%) and total pancreatoduodenectomy (43%), compared AROUND A NON-DILATED MAIN < to LPD (0% and 5%; p .005 for both comparisons). PANCREATIC DUCT Among 34 patients affected by pancreatic ductal adeno- carcinoma, the rate of R0 resection was 85% overall and T. Ueno, T. Okada, M. Uraoka, Y. Okamoto, S. Mineta, similar between LPD and OPD. Y. Watanabe, H. Kubota, M. Higashida, A. Tsuruta and Conclusion: SMA-first approach is feasible, safe and onco- Y. Fujiwara logically sound, allowing for low intraoperative blood loss and Department of Digestive Surgery, Kawasaki Medical high rate of R0 resection, and may be of help when a vascular School, Japan resection/reconstruction is needed or a LPD is attempted. Introduction and aims: We conceived a novel anasto- motic technique (duct-penetrating method: DPM) using a specially prepared suture-assistance device (InnerSure Ò EP02E-051 Ace ). This suture placement allows appropriate suture OUTCOMES OF PANCREATO- bites around the duct without damaging the duct by lifting, pulling and pushing forces on the edge of the GASTROSTOMY AND OF ISOLATED duct. JEJUNAL LOOP PANCREATO- Methods: We performed a duct-to-mucosa pancreaticoje- Ò JEJUNOSTOMY FOLLOWING junostomy in 44 patients using InnerSure Ace . InnerSure Ò PANCREATODUODENECTOMY IN Ace is a forceps having two flexible members connected PATIENTS WITH SOFT PANCREAS: A to each other at the tip, which makes a front loop. During the DPM, an atraumatic needle stabbed the cut surface of Ò CENTER EXPERIENCE-BASED the pancreas in which the tip of the InnerSure Ace was ANALYSIS placed deeply into the MPD. The needle traveled along its G. Zimmitti1, A. Coppola2, F. Ardito3, R. Meniconi4, arc and pierced both duct walls while incorporating G. M. Ettorre4, E. Rosso1, M. Colasanti4, G. Clemente3, pancreatic parenchyma with adequate depth and width M. Murazio3 and F. Giuliante3 around the MPD. When the needle passed through the front Ò 1Fondazione Poliambulanza e Istituto Ospedaliero, loop of the InnerSure Ace , a paired thread was trapped 2Campus Biomedico, 3Gemelli Hospital, Catholic while the instrument was withdrawn. Two suture threads

HPB 2018, 20 (S2), S505eS684 S664 Electronic Posters (EP02A-EP02F) e Pancreas were prepared by dividing the thread at the midpoint for of hospital stay was 12.4 Æ 2.7 days and no postoperative approximation to the jejunum. mortality occurred. Results: The average inner diameter of the duct was 1.9 Æ Conclusion: LPD can be safely performed in selected pa- 0.1 mm during surgery. More than 8 suture threads were tients with periampullary disease. placed in all patients. We encountered no grade C pancre- atic fistulas and 8 patients (18.1%) with grade B fistulas. Conclusion: We achieved a safe and reliable pancreatico- EP02E-054 jejunostomy for a small-sized duct in a soft and fragile Ò SINGLE INSTITUTE 5 CONSECUTIVE pancreas using the DPM with the InnerSure Ace . Our anastomotic technique might become a unique clin- ROBOTIC SINGLE SITE PLUS ONE ical approach to pancreaticoenterostomy and/or duct- PORT PANCREATIC SURGERY: SHORT enterostomy. TERM PERIOPERATIVE OUTCOMES J. H. Lee1, C. M. Kang2 and K. H. Kwon3 1Surgery, National Health Insurance Service Ilsan Hos- EP02E-053 pital, 2Surgery, Yonsei University College of Medicine, LAPAROSCOPY-ASSISTED PYLORUS and 3Surgery, National Health Insurance Service Ilsan PRESERVING Hospital, Republic of Korea PANCREATODUODENECTOMY FOR Background: In benign and borderline malignant tumor of PERIAMPULLARY DISEASE: EARLY the pancreas, function-preserving minimally invasive pancreatectomy is ideal approach. Nowadays, we have EXPERIENCE OF SECOND MOVER been able to perform more advanced laparoscopic single- H. J. Kwon1, S. G. Kim2, Y. S. Han3,H.Ha3, A. Seo4, site surgery due to the development of robotic single-site M. K. Kang5, J. M. Chun3, G. -S. Yoon4 and Y. J. Hwang2 devices. 1Surgery, Kyungpook National University Chilgok Hos- Methods: Five consecutive patients underwent robotic pital, 2Surgery, Kyungpook National University Chilgok single-site plus one port (RSSP1) pancreatic surgery from Hospital, Kyungpook National University School of Med- January 2017 to December 2017. We investigate of short icine, 3Surgery, Kyungpook National University Hospital, term perioperative outcomes for feasibility and safety of Kyungpook National University School of Medicine, 4Pa- RSSP1 for beginner. We were using robotic single site Ò thology, Kyungpook National University Chilgok Hospital, surgical system (the da Vinci Xi Surgical System (Intui- Ò Kyungpook National University School of Medicine, and tive Surgical , Sunnyvale, CA)) with one additional ro- 5Radiation Oncology, Kyungpook National University botic 12mm port. Single-site Port was placed at the Chilgok Hospital, Kyungpook National University School umbilicus and one additional port was placed left side of of Medicine, Republic of Korea umbilicus at the axillary line. We used the 3rd robot arm, Tri-staple technology 600 mm medium/thick Endo-GIA Introduction: Laparoscopic approaches are routinely used Ò for a variety of procedures in abdominal surgery. However, Universal stapler and EndoWrist Vessel SealerÔ through application of laparoscopic pancreatoduodenectomy (LPD) the additional port. was a challenging abdominal operation requiring complex Results: Five female patients underwent RSSP1 pancreatic dissection and difficult reconstruction, and as a results has surgery. Among them four patients underwent spleen pre- been adopted slowly until recently. In the present report, we serving distal pancreatectomy and the other one patient describe our experience with LPPPD, including early underwent central pancreatectomy with duct to mucosa postoperative results. pnacreaticojejunostomy. The mean operative time was 431 Methods: Between May 2016 and January 2018, twenty min. And estimated blood loss was 390 ml but there was no eight patients with periampullary disease underwent LPD. intraoperative transfusion. The mean length of hospital day After surgery, data for demographics, operation time, RBC was 8.4 days without any problem except for the small transfusion, histology, postoperative complication, and amount of fluid collection on the pancreas resection length of hospital stay after surgery were collected. surface. Results: Twenty two patients received laparoscopic pylo- Conclusion: Robotic single-site plus one port pancreatec- rus preserving pancreatoduodenectomy (LPPPD) and six tomy was technically feasible and safe even in beginner. patient was converted to open. In ten cases, an extracor- poreal bilioenteric anastomosis was performed as conven- tional open PPPD. In other eleven cases, an intracorporeal EP02E-055 laparoscopic bilioenteric anastomosis was performed. The PANCREATICOGASTROSTOMY THE pancreaticojejunostomy was carried out using our inverted SAVE TECHNIQUE mattress method, end-to-side invagination method. Duodenojejunostomy was extracorporeally using the S. Almuhmmadi retrieval incision site. The mean age was 64.3 Æ 19.6 years. General Surgery, Military Hospital in Jeddah, Saudi Mean ASA score and BMI were 1.8 and 22.7 respectively. Arabia The mean operation time was 527.9 Æ 66.7 min and Pancreaticoduodenectomy (PD) is the treatment option average blood loss 107.8 Æ 194. Grade B postoperative for most resectable periampullary tumors. Different tech- pancreatic fistula (POPF) occurred in only 1 case. Also, niques have been described in an attempt to decrease the delayed gastric emptying (DGE) occurred in 3 patients and anastomotic leak rate and related complications. The aim of it was Grade B defined by ISGPF and postpancreatectomy this study is to share our experience with the pancreatico- hemorrhage (PPH) occurred in 1 patient. The mean length gastrostomy technique.

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Design: Retrospective review for all pancreaticoduode- Web-of-Science. Articles meeting predefined criteria were nectomy reconstructed using pancreaticogastromstomy extracted and meta-analysis was performed. technique between 2008 to December 2017 in Kingdom Results: 19 studies comparing BE-Child or Isolated-Roux- of Saudi Arabia by single surgeon at four different En-Y vs. s-Child could be identified. Whereas BE-Child institutions. (p=0.44) nor Iso-Roux-En-Y (p=0.54) displayed an impact Methods: A total of 48 patients were reviewd. Variables on postoperative mortality, BE-Child showed a decreased studied included indications for surgery, intraoperative/ morbidity (p=0.0002) compared to s-Child. BE-Child postoperative factors and postoperative complications. (p=0.27) and Iso-Roux-En-Y (p=0.29) did not affect post- Results: 48 patients underwent pancreaticogastrostomy, 31 operative pancreatic fistula/POPF in general. Strikingly, males and 17 females; the mean age was 57.15 years (SD BE-Child was associated with a decrease of clinically 15.257). The mean for the BMI was 32.555 with SD of relevant POPF (p<0.00001), delayed gastric emptying/ 34.920 (10 are missing). Variable histopathology diagnosis DGE (p=0.02), bile leaks (p<0.01) and hospital stay was identified, the mean tumor size was 3.21 cm in diam- (p=0.05) compared with s-Child. Moreover, BE-Child eter (range, 0e11 cm) with (0e18) lymph node involve- depicted also a slight decrease of DGE (p=0.06), an ment, vascular invasion in 27.08% of the cases. increased operation time (p=0.0002) with no impact on Complications encountered: wound infection 22.9%, atel- haemorrhage, surgical site infections and pulmonary ectasis 16.7%, postoperative bleeding 10.4%, abscesses, complications. collections and delayed gastric emptying 6.3%. Others Conclusion: BE-Child favourably affects the outcome of including intraoperative operative hemorrhage, wound patients after PD, whereas Iso-Roux-En-Y does not seem to dehiscence and pulmonary embolism (PE) counted for affect the clinical course after PD. Therefore, BE seems to 4.2% of the complications. Lymphatic duct injury, acute be a valuable surgical method to improve patients’ outcome pancreatitis, deep venous thrombosis (DVT), Pancreatic after PD. and biliary fistulas occurred in 2.1% of the patients. 87.5% of the patients are still alive, 10.4% died and 2.0% lost their EP02E-057 follow up. Conclusion: Pancreaticogastrostomy techniques is a save, PANCREAS TRANSECTION WITH easy techniques and associated with a lower risk of LINEAR STAPLER AND BIPOLAR pancreatic anastomosis failure compared to other used CAUTERY FORCEPS IN DISTAL techniques for pancreatic remenant reconstruction. PANCREATECTOMY T. Okada, T. Ueno and M. Uraoka Digestive Surgery, Kawasaki Medical School, Japan EP02E-056 Introduction: Pancreatic fistula (PF) is a major compli- THE EFFECT OF DIFFERENT cation after distal pancreatectomy (DP). A stapler in com- SURGICAL RECONSTRUCTION bination with reinforcement (PGA felt) is usually used at TECHNIQUES ON THE the reinforcement. At the dissection of pancreas, bipolar POSTOPERATIVE COURSE OF cautery forceps is applied rather than surgical scalpel, as we fi PATIENTS AFTER PANCREAS HEAD can easily detect the main pancreatic duct and con rm to e ligate. Furthermore, tiny branches of the stump would be RESECTION A SYSTEMTAIC REVIEW sealed by the bipolar cautery forceps. Finally, the pancre- WITH META-ANALYSIS atic remnant is cared using an additional absorbable rein- S. Schorn, E. I. Demir, T. Vogel, R. Schirren, D. Reim, forcement material and fibrin glue. In this study, we report D. Wilhelm, G. O. Ceyhan and H. Friess our technique and the outcome. Patients and surgical Department of Surgery, Klinikum rechts der Isar, Tech- manipulations: 23 patients undergoing DP were enrolled nical University of Munich, Germany in this series. The procedure was as follows; Background: To reduce postoperative mortality and 1. Reinforcement of staple line using 2-plys of com- mercial available polyglycolic acid (PGA) sheet. morbidty, several reconstruction techniques have been Ò introduced after pancreaticoduodenectomy/PD. These 2. Guide of a Linear Stapler (Ethicon PROXIMATE ) techniques include with a Penrose tube. 1) The Child reconstruction defined as pancreatojeju- 3. Compression of the pancreas parenchyma by the the nostomy/PJ followed by hepaticojejunostomy/HJ and the jaws of the stapler gently. gastrojejunostomy/GJ (“the standard/s-Child”), 4. Ligation of the distal pancreas and wait for 5 minutes. Firing the stapler. 2) The s-Child reconstruction with an additional Braun Ò enteroenterostomy (“BE-Child), or 5. Transection of the pancreas using SuperGliss non- 3) Isolated-Roux-En-Y-pancreaticojejunostomy (“Iso- stick bipolar cautery forceps. Roux-En-Y”), in which the pancreas anastomosis is 6. Detection and Ligation of the main pancreatic duct. reconstructed in a separate loop after the GJ. Strikingly, 7. Sealing of the pancreatic remnant incorporating the fi the impact of these reconstruction methods patients’ staples with PGA sheet and brin glue. outcome has not been sufficiently compared in a system- Results: The numbers of grade A and grade B PF were 8 atic manner. (34.8%) and 1 (4.3%) in each others; none of the patients Methods: We designed a systematic review and meta- PF (C) in this series. fi analysis according the Preferred-Reporting-Items-for-Sys- Conclusion: Our procedure combined with this modi ca- tematic-review-and-Meta-Analysis/PRISMA-guidelines by tion may become accepted as a unique approach at the screening Pubmed/Medline, Scopus, Cochrane Library and transection of the pancreas in DP.

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7 8 EP02E-058 Ospedale Careggi, and Humanitas University, Human- itas Clinical and Research Center, Italy INITIAL EXPERIENCE WITH DOUBLE Background: The value of minimally invasive pancreatic PURSE-STRING TELESCOPED surgery (MIPS) is still debated. Our aim is to assess the PANCREATICO-GASTROSTOMY diffusion of MIPS in Italy and identify the barriers AFTER PANCREATICO- preventing wider implementation. DUODENECTOMY Methods: A questionnaire was developed under the aus- pices of three Scientific Societies (AISP, It-IHPBA, SICE) A. David, P. M. V. Lugtu, I. M. Liboro, R. J. Romero, and was sent to the largest possible number of Italian sur- R. Ong Abrantes, R. Sarmiento, R. Fernandez, E. Tan and geons using also the mailing list of the two main Italian R. Barroso Surgical Societies (SIC and ACOI). The questionnaire Department of Surgery, Section of Hepatopancreatobiliary consisted of 25 questions investigating: center character- Surgery, Rizal Medical Center, Philippines istics; center facilities and technologies; type of MIPS fi Introduction: Pancreatic stula is one of the most feared performed; surgical techniques employed; opinions on and serious complication encountered after a pancreatico- present and future value of MIPS. Only one reply per unit duodenectomy (PD). Currently, there are various techniques was considered. available in the management of the pancreatic remnant after Results: Fifty-five units answered the questionnaire. PD. This study aims to describe our experience and out- While 54 units (98.2%) declared to perform MIPS, the comes using the double purse-string telescoped pancreati- majority of responders were not dedicated to pancreatic cogastrostomy and its safety and effectivity as a surgery Twenty-five units (45.5%) performed < 20 reconstruction technique after pancreaticoduodenectomy. pancreatic resection/year and 39 (70.9%) < 10 MIPS per Methods and procedures: From January 1, 2015 to year. Forty-nine units (89.1%) had performed at least one December 31, 2017, 31 patients who consecutively under- MI distal pancreatectomy (DP), and 10 (18.2%) at least went pancreaticoduodenectomy were included. Double one MI pancreatoduodenectomy (PD). Robotic assis- purse-string telescoped pancreaticogastrostomy as described tance was used in 18 units (31.7%) (14 DP, 7 PD). The by Bachellier and colleagues in 2012, was performed for all major constraints limiting the diffusion of MIPS were cases during the reconstruction phase. Outcome measures the intrinsic difficulty of the technique and the lack of noted were patient characteristics, preoperative risk factors, specific training. The overall value of MIPS was perioperative variables and postoperative outcomes, highly rated. including morbidity and mortality rates. Conclusions: Our survey illustrates the current diffusion of Results: A total of 31 patients underwent double purse- MIPS in Italy and underlines the great interest for this string telescoped pancreatico-gastrostomy reconstruction approach. Further diffusion of MIPS requires the imple- after pancreato-duodenectomy. The most common initial mentation of standardized protocols of training. Imple- symptoms were jaundice (64.5%) and abdominal pain mentation of a prospective National Registry should also be (25.8%). The 4 most common histopathologic diagnosis considered. were pancreatic adenocarcinoma (38.7%), ampullary car- cinoma (25.8%), chronic pancreatitis (12.9%) and duodenal carcinoma (9.7%). Median operation time was 545Æ165 minutes. Median blood loss was 580Æ690 mL. The median EP02E-060 intraoperative blood transfusion was 300Æ770 mL. The PANCREATODUODENECTOMY median postoperative length of stay was 13Æ7 days. The PRESERVING COLLATERAL ARTERY most common complications were delayed gastric FOR CASES WITH CELIAC AXIS emptying (9.7%) and pancreatic stump bleeding (9.7%), STENOSIS with no pancreaticogastrostomy leak observed. Overall morbidity rate was 29.0% and 30-day mortality was 9.7%. C. Shirata, S. Hata, M. Teruya and M. Kaminishi Conclusion: There were no pancreaticogastrostomy leak Digestive Surgery, Showa General Hospital, Japan observed in this series. The double purse-string telescoped Introduction: Celiac axis stenosis (CAS) is a risk of pancreaticogastrostomy is a safe, feasible and easily impaired hepatic arterial flow after pancreatoduodenectomy reproducible reconstruction. (PD) because collateral pathways from superior mesenteric artery (SMA) disappear. EP02E-059 Method: We describe two cases with CAS undergoing PD APPLICATION OF MINIMALLY preserving collateral pathways from SMA to hepatic artery. Result: INVASIVE PANCREATIC SURGERY: AN Case 1; 70-years-old man diagnosed with pancreatic ITALIAN SURVEY head intrapapillary mucinous carcinoma, CAS. Preoper- G. Capretti1, U. Boggi2, R. Salvia3, G. Belli4, R. Coppola5, ative Angiography revealed collateral pathway from M. Falconi6, A. Valeri7 and A. Zerbi8 inferior pancreatododenal artery to splenic artery (No. 1 in 1Humanitas Research Hospital, 2Università di Pisa, Figure) and pancreatic head collateral pathway (No. 2 in 3Università di Verona, 4Ospedale Loreto Mare, 5Campus Figure). Biomedico, 6Università Vita Salute San Raffaele,

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mesenteric artery (10%). Postoperative pancreatic fistula occurred in 9% patients (4% Group A, 5% Group B). Delayed Gastric Emptying was seen in 20.8% patients of Group A, 20% patients of Group B. Postoperative com- plications were seen in 54% patients of group A and 60% in Group B. The median operative time was 450 minutes (495 min Group A, 445 min Group B). Median blood loss was 355 ml (Group A 380 ml, Group B 300 ml). Median hos- pital stay was 10 days (Group A 11 days, Group B 9 days). There was no significant difference between the operative or postoperative outcomes among the two groups. Conclusion: Aberrant hepatic arterial anomalies should preferably be identified on pre operative imaging. Meticu- lous surgical dissection with artery first technique is useful in minimizing inadvertent damage to aberrant vessels. However presence of aberrant arterial anatomy has no impact on post operative course and recovery.

Figure EP02E-063 No. 2 collateral pathway was embolized. After emboli- IMPACT OF THE GASTROJEJUNAL zation, common hepatic artery (CHA) was enlarged. Three ANATOMICAL POSITION AS THE weeks after embolization, PD was performed. Right hepatic MECHANISM OF DELAYED GASTRIC artery flow was preserved postoperatively. Case 2; 66-years-old man diagnosed with ampullary EMPTYING FOLLOWING carcinoma, CAS, SMA axis stenosis. Preoperative angi- PANCREATODUODENECTOMY ography revealed collateral pathways from retroperitoneum M. Nojiri, Y. Yokoyama, T. Maeda, T. Ebata, T. Igami, to CHA/SMA. Angiopraphy also revealed pancreatic head G. Sugawara, J. Yamaguchi and M. Nagino arcade pathways which had antegrade flow, indicating Division of Surgical Oncology, Department of Surgery, supply from CHA to SMA. PD preserving pancreatic head Nagoya University Graduate School of Medicine, Japan arcade pathways and right gastroepiploic artery was Objective: This study investigated the impact of gastro- performed. jejunal anatomical position on the incidence of delayed Conclusions: PD preserving corrateral pathways can be an gastric emptying (DGE) following pancreatoduodenectomy. option for patients with CAS if it is radical operations. Methods: A total of 160 patients were included in the retrospective analysis. The relative anatomical position of the gastrojejunostomy was evaluated using the coronal and EP02E-062 sagittal plane images of computed tomography on post- IMPACT OF HEPATIC ARTERIAL operative day 7; the coronal cardia anastomotic angle ANOMALIES ON SURGICAL (CCAA) and the sagittal fundus anastomotic angle (SFAA) were measured. In the validation study, 64 consecutive DISSECTION, POST OPERATIVE patients were enrolled, and gastric emptying was evaluated RECOVERY AND COMPLICATIONS using water-soluble contrast medium. The extent of gastric FOLLOWING emptying was graded as grade I (no gastric dilatation and PANCREATICODUODENECTOMIES no stasis), grade II (gastric dilatation but no stasis), and M. Baig1, F. Hanif2 and H. Bari2 grade III (gastric dilatation and stasis). 1Surgical Oncology, Shaukat Khanum Cancer Hospital Results: Patients with grades B (n=8) and C (n=22) DGE “ ” Lahore, and 2Surgery, Shaukat Khanum Cancer Hospital, were included in the DGE group (n=30), and the others “ ” Pakistan were included in the non-DGE group (n=130). The CCAA was not significantly different between the two Objective: Variations in hepatic arterial anatomy are groups, whereas the SFAA was significantly greater in the frequently encountered in patients undergoing Pancreati- DGE group compared to the non-DGE group (median 50.3 coduodenectomies (PD). Unidentified aberrant arterial vs. 64.5 degree, p<0.001). Multivariate analysis, including anatomy can cause inadvertent injury and complications. various risk factors of DGE, indicated that an SFAA >60 Methods: Patients undergoing PD between December degrees was the only independent risk factor of DGE (odds 2014 till 2017 were included and divided into two groups; ratio, 16.59). In the validation study, the median degree of according to presence (group A) or absence (group B) of SFAA increased as the gastric emptying grade increased vascular anomalies. Preoperative imaging, operative find- (grade I, 44.3 degrees; grade II, 55.3 degrees; grade III, ings, postoperative complications, recovery and hospital 60.7 degrees; p=0.014 by ANOVA). stay of these patients were reviewed and compared. Conclusions: The gastrojejunal anatomical position Results: Among a total of 106 cases, vascular anomalies following pancreatoduodenectomy has a significant impact were seen in 31 (30%) cases. Most common anomaly seen on the incidence of DGE. was the replaced Right Hepatic artery arising from Superior

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EP02E-064 tumour using the CLASP technique. Four of those operations were done laparoscopically. Only one patient developed CENTRAL PANCREATECTOMY DONE grade A PF. No other postoperative complications were FOR BODY AND NECK LESIONS OF noticed. The mean length of stay was 5.4 days. CLASP THE PANCREAS, PRESERVES BOTH technique was applicable in both laparoscopic and open distal ENDOCRINE AND EXOCRINE pancreatectomy. It is a useful alternative technique to the FUNCTIONS OF THE PANCREAS current traditional methods, especially in the cases of bulky pancreas and very proximal tumours located at the neck of R. Dama, P. Rabela and G. Rao pancreas. In the short video we demonstrate the steps of the Surgical Gastroenterology, Asian Institute of Gastroen- laparoscopic DP including mobilisation of the pancreatic terology, India body from the retroperitoneum, division of the parenchyma Introduction: Pancreatic pathologies in the neck and body with energy device isolating the pancreatic duct (PD), when treated by pancreaticoduodenectomy or distal application of a double ligaclip on the proximal duct, division pancreatectomy result in a significant loss of normal of the PD and finally suturing of the pancreatic stump. pancreatic parenchyma and impairment of exocrine and Conclusions: CLASP technique is an effective, reproduc- endocrine function. We assess the safety and effectiveness ible, cheap and safe alternative technique, particularly for of central pancreatectomy regards preservation of the bulky pancreas, that could be compared to the traditional pancreatic function. methods of pancreatic stump closure. Methods: 30 patients underwent central pancreatectomy between 2004 to 2017 for various pathologies. After fi con rming the resectability and the separation of the lesion EP02E-066 from the splenic vessels, the proximal end was transected with a linear stapler and edges oversewn, and the distal PANCREATICO-DUODENECTOMY stump was anastomosed to roux-en- y- jejunal loop (24) or WITH MODIFIED DOUBLE LAYER T-L pancreaticogastrostomy (6). All patients were followed up PANCREATO-JEJUNOSTOMY fi for exocrine and endocrine insuf ciency with fecal elastase N. Vladov, I. Takorov, M. Iakova, I. Vasilevski, and fasting blood sugar levels. V. Mihaylov, T. Lukanova, C. Trichkov, Results: 20/30patients had uneventful recovery. Nine pa- R. Kostadinov and E. Odisseeva fi tients (30%) had postoperative grade A pancreatic stula HPB and Transplant Surgery, Military Medical Academy, fi and 1 patient had grade B stula. Preoperative diabetes Bulgaria mellitus in 9 patients did not worsen during follow up. One Introduction: The surgical morbidity after pancreatico- patient had postoperative new onset diabetes. No patient duodenectomy is still high, despite of the significant im- had denovo exocrine insufficiency on mean follow up of 80 provements in the surgical techniques and postoperative months (10 e 154 months). Mean operative time, blood care and the lowered mortality rate. One of the most sig- loss, length of segment excised were, 123 minutes, 100 ml, nificant complications is postoperative pancreatic fistula & 4 cms respectively. (POPF). The choice of method for pancreatic anastomosis Conclusion: Central pancreatectomy is a safe and function is still difficult and may be based on the preference of the conserving surgery in patients with benign tumors/trauma/ surgeon, as this anastomosis involves the highest rate of lesions of low malignant potential in the neck / body of the surgical complications. pancreas. Methods: In the Department of HPB and Transplant Sur- gery in Military Medical Academy, Sofia, has been adopted EP02E-065 and modified a certain method for the pancreato-jejunos- A NOVEL TECHNIQUE FOR tomy e double layer with external continuous 5/0 mono- PANCREATIC STUMP CLOSURE filament suture and inner duct-to-seromuscularis interrupted FOLLOWING DISTAL monofilament suture 6/0 with protective “perdue” drainage PANCREATECTOMY e THE CLASP 4-8 Fr. For the period, October 2014 e December 2017 this TECHNIQUE anastomosis has been used in 147 pancretico-duodenec- tomies. A prospective study of these 147 patients has been M. Papoulas, E. Kontis, A. Dolcet, N. Heaton and done, including types of postoperative complications, K. Menon morbidity and mortality rate. ’ Institute of Liver Studies, King s College Hospital NHS Results: An analysis has shown a morbidity of 49.65% Foundation Trust, United Kingdom (n=73). The complications associated with the pancreatico- Introduction: Pancreatic fistula (PF) remains the primary jejunostomy were POPF in 8.84% (n=13) and haemorrhage source of morbidity following distal pancreatectomy (DP). of the anastomotic side in 6.80% (n=10). POPF were There is currently no optimal stump closure technique to classified as biochemical leak in 23.07%, B in 46.15% and reduce pancreatic fistula rates. C in 30.77%. Conservative treatment was undertaken in Methods: Presentation of a novel technique for pancreatic 46.15% (n=6) of the cases of POPF, mini-invasive in stump closure using Clip Ligation of the duct and Asso- 30.77% (n=4) and operative in 23.07% (n=3), due to related ciated Suturing of Pancreas (CLASP). Retrospective study complications as haemorrhage and infected intraabdominal of the clinicopathological data and outcome of five patients collection. that underwent distal pancreatectomy and splenectomy Conclusion: According to the obtained results this surgical (DPS) using the CLASP technique. technique for pancreatic anastomosis shows excellent Results: Five patients with a median age of 65 underwent short-term outcome with satisfactory postoperative distal pancreatectomy splenectomy for pancreatic body or tail morbidity and mortality rates.

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EP02E-067 A complete dissection of the mesopancreas is important to achieve R0 resection. However, the area of meso- MODIFIED APPLEBY PROCEDURE IN pancreas has not been clarified. The structure of the nerve LOCALLY ADVANCED CARCINOMA OF and fibrous tissue(NFT) surrounding the SMA is regulated THE BODY OF PANCREAS WITH and can be identified by appropriate retraction of NFT INADEQUATE CIRCULATION during surgery. We attempted to determine the classifica- THROUGH THE tion according to the anatomy of NFT, and the resection was performed based on the classification. Method; We PANCREATICODUODENAL ARCADE examined structure of NFT around the SMA using autopsy, 1 2 1 1 1 S. Pal , R. Kilambi , A. N. Singh , S. Roy and A. Bhoje pathological and surgical findings. Five areas was classi- 1 2 All India Institute of Medical Sciences, and Institute of fied. Area A; NFT between the celiac ganglion and Liver and Biliary Sciences, India pancreatic head, Area B; NFT between the SMA and the Background: Modified Appleby procedure or distal uncinate process, Area C; NFT between the SMA and the pancreatico-splenectomy with excision of celiac axis (CA) mesentery, Area D; NFT between the uncinate process and enables an R0 resection in carcinoma of the body of pancreas behind the mesentery, Area S; superior mesenteric nerve encasing the CA, thereby leading to better long-term sur- plexus. The complete dissection of the mesopancreas was vivals. The hepatic arterial flow is maintained by retrograde performed by resecting NFT of each area. Result; Total 156 flow through the gastroduodenal artery (GDA) from the patients underwent pancreaticoduodenectomy using this superior mesenteric artery via an intact pancreaticoduodenal classification. Magnifying glass was used during operation arcade. Herein, we report how a worrisome situation of to recognize the NFT. In 66 patients with PDAC, area A, B, inadequate hepatic flow after a modified Appleby procedure C, D, S dissection was performed in 37 patients, and area A, was tackled intraoperatively by supercharging the proper B, C, D dissection is performed in 27 patients. Area A, B, C hepatic artery (PHA) with an interposition graft from aorta. dissection was performed in 27 patients with bile duct Case: A 49-years-old male presented with abdominal pain cancer. Surgical margin was evaluated by inking. In 98.5% and anorexia of 4 months duration and was diagnosed with of patients with PDAC, SMA margin was negative. adenocarcinoma of the pancreatic body encasing CA. He Conclusion; Regions for appropriate dissection of the underwent 4-cycles of FOLFIRINOX chemotherapy, and mesopancreas can be easily identified by using this classi- angioembolization of common hepatic artery (CHA) else- fication. The surgical approach using this retraction method where. He presented to us and was planned for surgery. He improves the R0 ratio. underwent staging laparoscopy followed by a modified Appleby procedure and duodenal sleeve resection. Blood flow within GDA and PHA was assessed with intra- EP02E-069 operative Doppler and found to be inadequate. Hence, de- LAPAROSCOPIC "ANTEGRADE cision was taken to supercharge the PHA with a saphenous vein interposition graft from the supra-celiac aorta. Repeat STANDARD Doppler confirmed adequate flow. Postoperatively, patient PANCREATOSPLENECTOMY” e A NEW recovered well with normal liver functions, though he had APPROACH FOLLOWING an intra-abdominal collection which was managed with ONCOLOGICAL PRINCIPLES drainage. Histopathology showed moderately-differenti- M. Papoulas, E. Kontis, N. Heaton and K. Menon ated adenocarcinoma with negative margins. He is Institute of Liver Studies, King’s College Hospital NHS currently receiving adjuvant chemo-radiotherapy and is Foundation Trust, United Kingdom doing well at 6-months follow-up. Conclusion: Modified Appleby procedure with hepatic Introduction: Although laparoscopic distal pancreatec- arterial supercharging allows for safe, margin-negative tomy (LDP) is gradually recognized as a safe and effective resection of locally advanced tumors of the pancreatic body alternative to open distal pancreatectomy (ODP), it is not with minimal morbidity. yet widely accepted. To describe our experience in LDP and identify any possible contraindications for laparoscopic approach. Methods: The "clockwise technique” is an established EP02E-068 technique for LDP. We present a standardization of a A NOVEL CLASSIFICATION OF laparoscopic “antegrade standard pancreatosplenectomy” MESOPANCREAS BASED ON THE that is routinely performed in our institution. Technical ANATOMICAL STRUCTURE OF NERVE steps include early tunneling of the pancreatic neck AND FIBROUS TISSUE AS NEW followed by control of the splenic artery and vein. Paren- chymal transection is then performed and an antegrade LANDMARK IN mobilization of the pancreatic body and tail en bloc with the PANCREATICODUODENECTOMY FOR spleen is performed. Depending on the nature and extend of PANCREATIC AND PERIAMPULLARY the lesion, radicality of the posterior plane is defined. CANCER Retrospective study of all the patients who underwent LDP Y. Nagakawa, Y. Sahara, C. Takishita, T. Shirota, between September 2015 and August 2017 in our Y. Hijikata, H. Osakabe, N. Kobayashi, T. Nakajima, institution. fi Y. Hosokawa and A. Tsuchida Results: Twenty- ve patients underwent LDP. Mean Æ Department of Gastrointestinal and Pediatric Surgery, operative time was 225 75min. There were three Tokyo Medical University, Japan conversions to open surgery. Pathology included

HPB 2018, 20 (S2), S505eS684 S670 Electronic Posters (EP02A-EP02F) e Pancreas neuroendocrine tumour (n=10), IPMN (n=7), ductal are equally regarded as complex and time consuming. The adenocarcinoma (n=3), mucinous cystic neoplasm (n=3) most concerning event during reconstruction is the and solid pseudo papillary tumour (n=2). Mean lesion pancreatojejunostomy (PJ), responsible for most of the diameter was 4.7cm (range, 1e12). The average lymph morbidity related to the operation. nodes harvested were 8.7 and the resection margins were Methods: From September 2016 to December 2017, negative in 96% of the cases. Length of stay was 8.2 Æ consecutive patients undergoing PD were included. The 4.58. There were no major postoperative complications and initial study period was set at the time our institution settled no mortality. Overall, five patients developed pancreatic a dedicated HPB program. Patients were operated with a fistula (grade A). patterned technique, duct-to-mucosa PJ was performed Conclusions: The antegrade approach for LDP is a safe and associating concepts of a Shrikhande-Buchler anastomosis stepwise technique respecting all the oncological and Blumgart stitches. Biliary and pancreatic secretion principles. were diverted in a double-limb reconstruction. All patients had drains placed. Results: Twenty-three consecutive patients were operated. EP02E-070 Male: female rate was 9:14. Median age was 68 years. 8 SURGICAL IRREVERSIBLE patients (35%) were operated for pancreatic head carci- nomas, being other diagnosis less frequent. Median oper- ELECTROPORATION FOR LOCALLY ative time was 315 minutes, two patients received operative ADVANCED PANCREATIC CANCER blood transfusion and median time to discharge was 9 days. AFTER CHEMORADIOTHERPAY Median peak of drainage was 720 ml. There were 10 pa- K. -W. Huang tients with biochemical leaks (BL) and no patient has fi Department of Surgery and Hepatitis Research Center, clinically relevant stulas grades B and C. CT scans fi National Taiwan University Hospital, Taiwan, Republic of performed in patients with high-output BL con rmed China integrity of the PJ. 90-day mortality was 4% (1 patient) due to a pulmonary thromboembolism after discharge. Introduction: Irreversible electroporation (IRE) is a non- Conclusion: Reconstruction after PD can be performed thermal focal therapy that utilizes high voltage electric through innumerous techniques, but our series indicate that pulses to permanently rupture the cellular membrane and the association of techniques employed might result in a induce cell death resembling apoptosis. In the multicentric low rate of anastomotic complications. study from Asia, we evaluated the safety and efficacy of a protocol based on intra-operative ultrasound-guided IRE in patients with locally advanced pancreatic cancer (LAPC). Methods: From 2013-2016, we performed surgical IRE EP02E-073 under US guidance in a total of 42 patients presenting with LAPAROSCOPIC NO-TOUCH stage III LAPC smaller than 3 cm in diameter. Adjuvant PANCREATICODUODENECTOMY chemoradiotherapy had been applicated for at least 3 O. Kvasivka months before IRE treatment, and tumor response was National Cancer Institute, Ukraine observed. Results: No IRE-related deaths occurred. A median follow- One of the techniques in open pancreatic surgery is no- up of 31 months showed that 11.9% of patients sustained touch PD. Laparoscopic access could bring some advan- complications with a median Grade of II (range IeIII). tages to pancreatic resections. The aim of the present study Three patients (7.1%) experienced local recurrence and 6 was to determine possibility and safety of laparoscopic no- (14.3%) experienced distant progression. Overall mean touch Pancreaticoduodenectomy in patients with peri- survival from the time of treatment was 28.4 months. ampullary tumors. In the period 2013-2017 we performed Conclusions: Our study suggests that IRE after effective 12 laparoscopic pancreaticoduodenectomy in the National chemoradiotherapy is safe and effective in the control of cancer institute of Ukraine. Of these patients 4 were locally advanced pancreatic cancer. We surmise that the selected for laparoscopic no-touch pancreaticoduodenec- fi addition of IRE to a chemoradiotherpay for small localized tomy. We represent our rst experience in laparoscopic no- pancreatic cancer may provide a survival advantage. touch pancreaticoduodenal resection. No strong evidence is available for advantages of both no-touch and laparoscopic techniques of PD. Potential benefit of the no-touch PD in selected patients was shown in some single center trials. In EP02E-072 our experience no-touch technique could be done at least as COMBINING TECHNIQUES FOR A SAFE good, as standard procedure. The main advantage of the PANCREATOJEJUNOSTOMY: INITIAL procedure is the increase of the postoperative survival. In RESULTS FROM A RECENTLY comparison with decrease of rates of intraoperative tumo ESTABLISHED HPB CENTER dessemination that may occur during Kocher maneuver. Our preliminary results show, that no-touch technique J. Kruger, S. Freire, S. Rezende, R. Macedo, J. Ferrari, could be done from laparoscopic access in a selected group R. Takahashi, H. Carneiro, A. Oliveira and of patients. Potential advantage is fast rehabilitation of M. G. Adriano Junior patients with early start of adjuvant chemotherapy. That Surgical Oncology - Sancta Maggiore Hospitals, Brazil could be achieved in patients with uncomplicated post- Introduction: Pancreatoduodenectomy (PD) is a complex operative period. and unique operation in which resection and reconstruction

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EP02E-074 multivisceral resections. Here we share our experience with such an unusual procedure, in which both multi- LAPAROSCOPIC LATERAL visceral resection and combined vascular resections PANCREATICOJEJUNOSTOMY (LPJ) were performed. FOR THE TREATMENT OF CHRONIC Method: This was a 79 year-old lady diagnosed with CALCIFIC PANCREATITIS cancer of the body of the pancreas. She had received six cycles of FOLFIRINOX neoadjuvant chemotherapy for A. Javed1, P. Aravinda2, S. Tyagi2, P. Sheetal2, downsizing of the tumor, which had partly invaded SMA at M. Saravanan2 and A. Agarwal2 the beginning of treatment. CT scan obtained before sur- 1G.I Surgery and Liver Transplant, and 2GB Pant Institute gery showed complete tumoral involvement of the SMV- of Post Graduate Medical Education and Research, India splenic vein confluence, celiac axis, common hepatic Introduction: Surgical options for patients of chronic artery, left gastric artery and splenic artery as well as 70 pancreatitis with refractory pain include drainage and or degree contact with SMA. resectional procedures. Lateral pancreatojejunostomy Results: Following exploration to rule out peritoneal dis- (LPJ), the commonly performed drainage operation has ease, hepatic artery, GDA, portal vein and common bile traditionally been done as open procedure. duct were exposed. Dissection was continued to expose Methods: Retrospective analysis of chronic pancreatitis SMV and distal SMA. Since right gastroepiploic, left e patients managed surgically between January 2010 gastric, splenic and middle colic arteries and corresponding December 2017. All patients were evaluated with a contrast veins were invaded by the tumor, duodenum, stomach, left enhanced CT abdomen and an magnetic resonance chol- colon and spleen were skeletonized for enbloc resection angiopancreatography (MRCP). An Endoscopic USG was with pancreas. Following harvesting of the left saphenous done selectively. Surgery was offered to patients with re- vein, specimen was removed after portal vein and celiac fractory pain despite adequate medical management. A axis resection. Portal venovenous anastomosis and saphe- laparoscopic LPJ was done in patients with dilated nous vein interposition for hepatic arterial flow was done. pancreatic duct with/without intraductal calculi. Post- The procedure was finalized with re-establishment of operatively, patients were managed in surgical intensive gastrointestinal continuity. The patient was discharged care and after discharge followed up at 2 weeks, 1, 3 and 6 home on POD#22. months thereafter. Conclusions: Complex multivisceral and vascular re- Results: During the study period 39 patients underwent a sections can offer cure for patients with locally advanced laparoscopic LPJ and constituted the study group. There pancreatic cancer who otherwise deemed unresectable. were 23 females and mean age was 37 (12e58) years. Pain was main indication of surgery. Nine patients had diabetes e and 6 steatorrhea. Mean MPD diameter was 14.3(8 25) e e mm. The mean duration of surgery was 180 (140e340) min EP02F Electronic Poster: 2F Pancreas and blood loss was 110 mL. There was no mortality. Miscellaneous Postoperative hospital stay was 5 (3e9) days and satis- EP02F-003 factory pain relief was seen in 91% on at least 3 months LYMPH NODE RATIO PREDICTS follow-up. RECURRENCE FOLLOWING Conclusion: Laparoscopic LPJ is feasible and safe and RESECTIONS OF NON-FUNCTIONAL offers good pain control with added benefits of laparo- scopic approach. PANCREATIC NEURO-ENDOCRINE TUMOURS (NF-PNET): A RATIONAL APPROACH TO POSTOPERATIVE EP02E-075 SURVEILLANCE TOTAL M. Feretis1, T. Wang2, E. Ghorani3, C. Brandt4, PANCREATICODUODENECTOMY+ A. Balakrishnan1, S. Harper1, A. Jah1, E. Huguet1, 1 1 TOTAL GASTRECTOMY+ R. Praseedom and S. -S. Liau 1Hepatobiliary Surgery, Addenbrookes Hospital SPLENECTOMY+ LEFT Cambridge, 2Department of Statistics, University of HEMICOLECTOMY+ PORTAL VEIN Cambridge, 3University College London, United Kingdom, RESECTION+ CELIAC AXIS and 4University of Freiburg, Germany RESECTION WITH HEPATIC Introduction: Non-functional pancreatic neuroendocrine ARTERIAL SAPHENOUS GRAFT tumours (NF-PNETs) are rare and have highly variable INTERPOSITION FOR CURATIVE outcomes. Current guidelines recommend surveillance for < PANCREATIC CANCER TREATMENT NF-PNETs 2cm in diameter. Patients who ultimately have surgical resection are at risk of disease recurrence, and 1 1 1 2 M. F. Can , R. Senocak , E. Lapsekili , K. Karabacak , rational postoperative surveillance protocol is lacking. The 2 2 G. Erol and C. Bolcal aims of this study were to i) identify post-operative pre- 1 2 Surgery, and Cardiovascular Surgery, University of dictors of recurrence and ii) risk stratify patients at risk of Health Sciences Gulhane School of Medicine, Turkey recurrence on follow-up. Introduction: Recent years have witnessed efforts Methods: Consecutive patients who underwent curative to push boundaries of resectional procedures in an surgery for NF-PNETs between 2002e2015 were iden- attempt to achieve cure in pancreatic cancer. These tified and their electronic medical records were reviewed include combined venous and arterial resections and retrospectively. Data were collected on demographics,

HPB 2018, 20 (S2), S505eS684 S672 Electronic Posters (EP02A-EP02F) e Pancreas pre-operative laboratory results and histopathological parts of the gastrointestinal tract, not only a Mercke’s tumour characteristics. Statistical analyses were based diverticulum, can indeed be the primary site of a malig- on penalised Cox-regression modelling and decision-tree nant melanoma. approach. Results: We identified 73 patients (38 males) with a median age of 61.5 years (range: 31e79). The median EP02F-006 e period of follow-up was 49 (5 131) months. During follow USEFULNESS OF THE MILK TEST TO up, 10 deaths (13.9%) were recorded and disease recur- rence occurred in 12 patients (16.4%). The Kaplan-Meier PREVENT CHYLOUS ASCITES AFTER predicted 1-, 3- and 5-year recurrence-free survival rates for PANCREATECTOMY the study’s cohort were 98.6% (95% CI =[95.9, 100%]), H. Aoki1, M. Utsumi1, K. Hioki2, H. Sadamori2, 85.4% (76.9-94.8%) and 72% (58.7-88.2%) respectively. K. Monden2, N. Takakura2, D. Sato3, S. Siozaki3 and Cox multivariate analysis identified poor tumour differen- H. Matsukawa3 tiation (G3 stage-WHO 2010 classification) and lymph 1Surgery, Iwakuni Clinical Center, 2Surgery, Fukuyama node ratio (LNR) as independent predictors for recurrence City Hospital, and 3Surgery, Hiroshima City Hiroshima (p < 0.05). A pilot decision analysis for post-operative Citizens Hospital follow-up of patients was constructed. Decision tree Introduction: The usefulness of the milk test to prevent > modelling of all measured covariates yielded LNR 0.1 as chylous ascites after pancreatectomy was investigated fi the most signi cant criterion to guide postoperative using a randomized controlled trial. surveillance. Method: The milk test involves injecting 100 mL milk Conclusion: Our results highlight LNR as a potential cri- through a nasogastric tube during pancreatectomy. If a fi terion for risk strati cation to guide postoperative surveil- chyle leak is present, the patient tests positive. Drain tri- lance. Prospective validation is now warranted. glyceride (DTG) was measured on the first and third postoperative day (POD). Results: From November 2013 to June 2017, 253 patients EP02F-005 were enrolled; 211 patients underwent pancreatic head ONE YEAR FOLLOW UP OF A resection, 39 underwent distal pancreatectomy, and 3 un- MALIGNANT MELANOMA OF THE derwent middle pancreatectomy. The milk test was used in DUODENUM TREATED WITH 125 patients (group A) and not used in 128 patients (group B). In group A, the milk test was positive in 29 patients PANCREATICODUODENECTOMY (23.2%). The superior mesenteric artery (11 patients) and WITH NO TUMOR RECURRENCE: middle colic artery (10 patients) were common leakage AFTER ALL, WAS IT THE PRIMARY sites. The incidence of postoperative chylous leaks defined TUMOR? by the ISGPS was on Table 1. R. Cañada Surjan1, E. Santana dos Santos2, M. Autran Cesar Machado1, F. Ferrari Makdissi3 and T. de Castro Basseres1 Table 1Surgery, University of Sao Paulo Medical School, Chyle leak Group A milk Group A milk Group B Total 2Oncology Department, University of São Paulo, and test positive test negative 3Gastrointestinal Surgery Department, University of Sao None 21 93 116 230 Paulo Medical School, Brazil Grade A 7 3 10 20 The most frequent site of a malignant melanoma Grade B 1 0 2 3 compromising the gastrointestinal tract is the small intes- Grade C 0 0 0 0 tine. In the great majority of the cases, due to metastatic spread from a cutaneous tumor. The origin of a malignant Total 29 96 128 253 melanoma as a primary lesion in the gastrointestinal tract is until present days questioned in the literature. It is assumed that Merck-s diverticulum can be the primary site of a Chylous ascites occurred in 3 patients (1.2%), all melanoma, as it has been proved before that melanocites during pancreatic head resection. In group B, grade B can be found on Merck’s diverticula. chyle leaks were observed twice as often as in group A, fi We had a 40 year old female patient that presented with but the difference was not signi cant. DTG levels on upper abdominal pain, weight loss and anemia. Investiga- POD 1/POD 3 were 123.9/83.5 in milk test-positive tion disclosed an obstructive 10 cm mass in the duodenum. patients and 63.2/47.1 in milk test-negative patients in The patient was treated with pancreaticoduodenectomy and group A, 52.8/52.3 in group B patients, 58.1/42.4 in the pathology disclosed an malignant melanoma. After the no chyle leak patients, 144.3/186.9 in grade A and 73.3/ procedure, we did an extensive search for a primary 62.3 in grade B patients. melanocit tumor in the skin, the anus, the retina and no Conclusion: DTG level was not a predictor of post- other lesion was found. operative chylous ascites. Without the milk test, Grade B One year after the pancreaticoduodenectomy, there is chyle leaks occurred twice as often, but this was not sta- fi no sign of recorrence. This raises the question if other tistically signi cant.

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EP02F-007 margins free from tumor. There was less than 50% of ne- crosis and 9 mitosis per 10 high-power fields. Cells stained LAPAROSCOPIC TREATMENT OF positive for smooth muscle actin and desmin; and negative RETROPERITONEAL for S100 stain. LYMPHANGIOMA: A CASE REPORT IN Conclusion: Renal vein leiomyosarcomas are very difficult AN ADULT to diagnose preoperatively because USE, CT and MRI studies are nonspecific and do not allow an adequate differ- D. Huerta, Ignacio G. Merlo, Pedro J. Angiolini and ential diagnosis with other retroperitoneal tumors. The best Jorge P. Grondona treatment consists of complete surgical removal of the mass, Sanatorio San Lucas de San Isidro, Argentina including nephrectomy. The prognosis is bad and chemo- Introduction: Lymphangiomas are rare benign mesodermal therapy may be offered to cases with metastatic disease. tumors of the lymphatic system. The intra-abdominal and the retroperitoneal location of these lesions is one of the most EP02F-009 infrequent sites of appearance. Usually comes out in infancy more than in adulthood. Most patients experience chronic CLINICAL SIGNIFICANCE OF symptoms and magnetic resonance imaging is the best PSEUDOCYST FORMATION radiologic study for their diagnosis. Excision is the treatment FOLLOWING DISTAL of choice and laparoscopic resection is a very good option PANCREATECTOMY WITH STAPLE but there are very few publications reported in literature. The CLOSURE aim of this presentation is to confirm the benefits of the N. Watanabe, T. Niguma, T. Kojima, K. Suemori, laparoscopic approach for this tumour localization. T. Sakata and T. Mimura Case presentation: A 49-year-old woman with no relevant Okayama Saiseikai General Hospital, Japan history was admitted to our institution with left lumbar pain of six months of recurrent history. A 60 mm in diameter retro- Background: Pseudocyst formations around the pancreatic peritoneal cystic tumour was diagnosed by abdominal stump may occur at late-onset after distal pancreatectomy fi computed tomography and magnetic resonance imaging. No with staple closure. Although this nding may be associated fi fi percutaneous guided-biopsy was performed. The tumour was with pancreatic stula, its clinical signi cance is not clear. successfully resected by laparoscopic approach. No post- Object: Between January 2006 and June 2017, distal operative complications occurred and was discharged at the pancreatectomy was performed on 154 patients. Among second day. The patient’s pain disappeared. Histopathological them, 82 patients who underwent pancreatectomy with examination revealed a benign retroperitoneal lymphangioma. staple closure were retrospectively studied. Conclusions: The laparoscopic approach is a safe and Result: Eighty patients (97.6%) were followed with CT effective alternative for treatment of retroperitoneal and MRI postoperatively and subjected to be analyzed. 20 lymphangioma. As in other laparoscopic procedures, the cases (25%) showed pseudocyst formation at the pancreatic patient have all the advantages of the mini-invasive surgery. stump. On the other hand, 7 (9.7%) of 72 cases in which the pancreas was closed with hand sewing during the same EP02F-008 period showed pseudocyst formation. There was a signifi- A CHALLENGING DIAGNOSIS: RENAL cantly higher rate of pseudocyst formation in the group with staple closure (P=0.013). The postoperative drain VEIN LEIOMYOSARCOMA, amylase values (POD 1, 3, 4) were significantly higher INIATIALLY RESEMBLING A (8154 vs 2714, 1380 vs 542, 848 vs 358, respectively) in RETROPERITONEAL TUMOR the pseudocyst formation group than the non-formation S. Alonso Batanero1, J. Quiñones Sampedro2, group. Univariate analysis for the prediction of pseudocyst fi E. Sanchez Lara2, M. Caraballo Angeli1, formation revealed that there were no signi cant differ- M. D. C. Esteban Velasco1, L. M. Gonzalez Fernandez1, ences in pancreatic thickness or hardness, the diameter of M. J. Iglesias Iglesias1 and L. Muñoz Bellvis1 the main pancreatic duct, ISGPF grade, or the number of 1Surgery, Salamanca, and 2Complejo Asistencial Univer- days for drain removal. sitario de Salamanca, Spain Conclusion: Distal pancreatectomy with staple closure may induce the formation of pseudocysts at the pancreatic A 74-year-old male patient was referred to our hospital stump. Although there was no significant association with due to an incidental finding. pancreatic fistula, the value of amylase in drains was CT scan and MRI revealed a retroperitoneal mass (4, 5 x associated with pseudocyst formation. 4,6 cm) in the hilum of right kidney. Which was in close contact with the second part of the duodenum, the uncinate process of pancreas, the right hepatic lobe and the infun- dibulum of gallbladder. CT scan also showed right hydro- EP02F-010 nephrosis and no evidence of metastatic disease. FACTORS ASSOCIATED WITH BETTER An endoscopic-ultrasound-guided fine-needle-aspiration SURVIVAL IN PATIENTS UNDERGOING of the paraduodenal mass was performed, which was re- PANCREATICODUODENECTOMY FOR ported as a likely mesenchymal tumor. PANCREATIC ADENOCARCINOMA We carried out an open abdominal approach: there was a 1 1 1 1 tumor arising from the right renal vein without involving J. Martinez , A. Troncoso , E. Briceño , J. F. Guerra , 1 2 1 adjacent structures. A right radical nephrectomy with en- S. Guzman , J. Cerda and N. Jarufe 1 2 bloc resection of the tumor was performed. Digestive Surgery Department, and Public Health Pathological exam revealed a well-differentiated leio- Deparment, School of Medicine, Pontificia Universidad myosarcoma originated from the right renal vein with Católica de Chile, Chile

HPB 2018, 20 (S2), S505eS684 S674 Electronic Posters (EP02A-EP02F) e Pancreas

Introduction: The prognosis of pancreatic adenocarci- 300 units/l (three times the serum value for our lab) yielded noma (PAC) remains poor even after better surgical and a specificity of 90% and a sensitivity of 75%. perioperative care. Conclusion: Lipase concentration in the abdominal drain Objective: To identify factors associated with better sur- correlated with pancreatic fistula. A threshold of 500 units/l vival in patients with PAC treated with pancreaticoduode- yielded a high sensitivity and specificity for the diagnosis nectomy (PDD) at our institution. of clinical fistula. Analysis with higher powered study will Methods: Case-control study of PAC patients treated with be able to differentiate if drain lipase can predict the PDD at our Hospital between January 2002 and December severity of clinical fistula. 2015. For statistical analysis, we compared the patients surviving more than 36 months after the operation, to the ones who did not reach this period. Biodemographic, EP02F-012 clinical, histopathological and morbimortality data were SMA MARGIN AS A POSSIBLE compared between cases and controls using logistic regression. MEASURE TO EVALUATE THE Results: Seventy patients were analyzed; mean age of 62, EFFECTIVENESS OF NEOADJUVANT Æ 11 years; 40 (57%) women. Mean and overall survival THERAPY fi was 34 months and 22% at ve years for the entire series. H. Ann, R. Nishitai, T. Ota, Y. Nishikawa, R. Kudou, Æ Mean resected lymph nodes was 18 9. Twenty-one cases K. Kawaguchi, S. Konishi, S. Hamasu and D. Manaka (30%) reached a survival greater than 36 months. At uni- Kyoto Katsura Hospital, Japan variate analysis, R0 resection, the absence of positive Introduction: 1 mm surgical margin for pancreatic cancer lymph nodes, the absence of perineural infiltration and has been known to correlate with favorable postoperative early stages (IA, IB and IIA) were associated with survival survival ,but it is sometimes impossible to achieve 1 mm greater than 36 months (p < 0,05). After multivariable margin in cases of locally advanced tumors adjacent to the analysis, the absence of diabetes mellitus at the time of SMA. In order to acquire sufficient SMA margin, neoad- diagnosis (OR:12, 95% CI 1.7e84.3); the absence of juvant chemo-radiotherapy (NACRT) was introduced to perineural infiltration (OR: 7, 95% CI 1.3e36.3) and early borderline resectable pancreatic cancer patients in our stages (OR: 10, 05% CI 2.1e49.1) were demonstrated to be institute in July 2013. The protocol was changed from independent factors associated with survival greater than stereotactic radiation therapy (NAC-SRT) to intensity three years. modulated radiation therapy (NAC-IMRT) in October Conclusion: Early stages of the disease, the absence of 2016. The aim of this study is to evaluate the therapeutic diabetes mellitus and no perineural infiltration at specimen effect of NACRT by measuring accurate SMA margin. were associated with survival greater than three years. Methods: The consecutive 14 borderline resectable pancreatic cancer patients who underwent pancreatico- duodenectomy after NACRT between July 2013 and EP02F-011 December 2017 were studied. Patients with R2 resection COMPARISON OF DRAIN FLUID LIPASE (n=1) and extensive tumor growth towards celiac axis (n=2) WITH DRAIN FLUID AMYLASE IN THE were excluded. The SMA margin was measured in the CONTEXT OF POST-OPERATIVE axially sliced pathological specimen. (n=11). e PANCREATIC FISTULA Results: Median age was 61(range: 42 86). 5 patients were male and 6 patients were female. Median interval M. Roy, E. Ban, S. Mohandas, O. Mownah, A. Banerjee, from NACRT to surgery was 32 days (range: 28e48). R. Valente, A. Abraham, H. Kocher, S. Bhattacharya and Median SMA margin was 1.5mm (0.5 mme5 mm). Five R. Hutchins patients underwent surgery following NAC-SRT and 6 HPB Surgery, Barts & the London NHS Trust, United patients following NAC-IMRT. Median SMA margin in Kingdom NAC-IMRT group was larger than NAC-SRT group (2.3 Introduction: Some studies have evaluated the use of drain mm vs 1.1 mm, p=0.16) amylase in pancreatic fistula but the data is limited. The aim Conclusion: SMA margin measurement can be useful to of this study was to evaluate association of drain and serum evaluate the power of local control of neoadjuvant therapy. amylase level and lipase level with pancreatic fistula with respect to the new international study group for pancreatic fistula definition. EP02F-013 Methods: Amylase and lipase levels in the abdominal drain LAPAROSCOPIC REMOVAL OF were measured 3 days after pancreatic resection. The RESIDUAL PANCREATIC TISSUE fi fi pancreatic stula group included patients with clinical s- AFTER DISTAL PANCREATECTOMY tula (grade B & C) and positive amylase level (biochemical fistula) according to the new ISGPF definition. H. I. Jung and S. H. Bae Results: Fifty patients were included in the study. The Soonchunhyang University Cheonan Hospital, Republic of median level of abdominal drain lipase was higher in pa- Korea tients with positive amylase than in those with negative Solid pseudopapillary neoplasm (SPT) of pancreas amylase: 5434 vs 91 (P < 0.0001). Lipase vs amylase level occurs predominantly in young woman with abdominal in patients with a clinical fistula lipase level was 2838 vs mass and discomfort. Hear in, we described remnant 1323 units/l (P < 0.001). A lipase level higher than 500 pancreatic tissue masquerading of postoperative abscess units/l yielded a sensitivity of 86% and a specificity of 95% after the distal pancreatectomy for SPT. Initially, A 21 year for clinical fistula whereas an amylase level greater than old female patient, with no prior medical history, was

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S675 underwent distal pancreatectomy for huge SPT. She was Methods: Retrospective analysis of 16 patients treated for discharged uneventfully POD#7. One month after the pancreatic trauma, between 2015 to 2017 with analysis of initial operation, she was readmitted for PCD drainage demographics, mode of injury, associated injuries, AAST because of subphrenic abscess. After 3th readmission, we grade and management. decided a reoperation. The patient was placed in right Results: Patients were ageing from 10-36 years. 14 were lateral decubitus position and laparoscopic removal of re- males and all had blunt trauma. 15 had grade 3 injury while sidual tissue with abscess in subphrenic area. The histo- the 1 had grade 2 injury. Patient with grade 2 injury was logical analysis of specimen suggested remnant pancreas hemodynamically unstable and required laparotomy, distal with splenic tissue. She was discharged on the 6th post- pancreatectomy with splenectomy. 1 patient (grade 3 operative day with uneventfully. injury) with delayed presentation succumbed to sepsis within few hours of admission. Of the remaining 14 pa- tients with grade 3 injury 5 were managed conservatively EP02F-014 with ERCP and sphincterotomy with percutaneous catheter INVESTIGATION OF MARGINAL drainage (PCD) in 2 patients, PD stenting with PCD in 1 patient and just PCD in another. The associated injuries ULCER AFTER involved liver(1), transverse colon (1), duodenum (1), PANCREATICODUODENECTOMY jejunum (1), spleen (2), kidney (2). 9 patients required K. Suemori, T. Kojima, T. Niguma, N. Watanabe, operative management, distal pancreaticosplenectomy (6), T. Sakata and T. Mimura spleen preserving distal pancreatectomy (1), lateral Okayama Saiseikai Gerenal Hospital, Japan pancreaticojejunostomy with serosal patch closure of Introduction: Marginal ulcers after pancreaticoduodenec- proximal stump (2). The mean hospital stay in the conser- tomy (PD) are a relatively common complication. When vative treatment group was relatively short, while it was 20 massive bleeding or ulcer perforation occurs simulta- days in the operative treatment group albeit with multiple fi neously with marginal ulcers, it may become fatal. In this admissions in the former. Postoperative pancreatic stula study, we investigated the risk of marginal ulcers and was encountered in 5 patients, 3 managed conservatively, epidemiological features. two required PCD. Methods: Four-hundred-thirty-eight patients who under- Conclusion: Management of pancreatic trauma is chal- went PD from 2003 to 2017 in our institution were retro- lenging and delayed presentation following trauma pre- spectively reviewed and analyzed. disposes to sepsis and hence portends a poor outcome with Results: Standard PD was performed on 46 patients, sub- high risk of mortality. total-stomach- preserving pancreaticoduodenectomy (SSPPD) in 253 patients, and pylorus-preserving pancrea- ticoduodenectomy (PPPD) in 139 patients. For PD and EP02F-017 SSPPD, the gastrointestinal tract was reconstructed with DEVELOPMENT AND EVALUATION OF Brown anastomosis. After a median follow-up of 32 A DUAL ELECTRODE-SINGLE NEEDLE months, 29 patients (6.6%) developed marginal ulcers. In PROBE WITH NEXT GENERATION the PPPD group, marginal ulcers developed significantly more than the SSPPD group (P=0.02). On the other hand, HIGH-FREQUENCY IRREVERSIBLE there was no significant difference in incidence observed ELECTROPORATION (HFIRE) FOR between the PD and SSPPD groups, and the PD and PPPD PANCREATIC TISSUE ABLATION IN groups. Marginal ulcers occurred significantly lower in VIVO patients who used proton pump inhibitors (PPI) or H2- M. Passeri1, W. Lyman1, M. Lorenzo2,T.O’Brien2, blockers (P=0.001). Univariate analysis revealed that fac- J. Swet1, D. Vrochides1, E. Baker1, R. Davalos2, tors such as age, sex, primary disease, operation time, D. Iannitti1 and I. Mckillop1 bleeding amount, postoperative pancreatic fistula, and 1Surgery, Carolinas Medical Center, and 2Biomedical characteristics of the pancreas showed no significant dif- Engineering and Mechanics, Virginia Polytechnic Institute ference in the incidence of marginal ulcers. and State University, United States Conclusion: After pancreaticoduodenectomy, marginal ulcers may develop even after a long time has passed. Pa- Introduction: Irreversible electroporation (IRE) employs tients who have undergone PPPD without the use of pro- multiple electrodes to induce tumor cell apoptosis within phylaxis such as PPIs or H2-blockers should be concerned the ablation zone while sparing underlying tissue archi- as being at risk for marginal ulcers. tecture. High-frequency IRE (HFIRE; ultrashort bipolar pulses) is an experimental alternative to existing IRE that EP02F-015 obviates the need for paralytics or cardiac synchronization. We developed a novel, dual electrode-single needle MANAGEMENT OF PANCREATIC fi e (DESN) probe for HFIRE delivery, and evaluated ef cacy TRAUMA A SINGLE CENTER in performing pancreatic ablations in vivo. EXPERIENCE Methods: Using a swine model the DESN-HFIRE probe K. Muthalampet was placed in the pancreatic head or tail and, in the absence Surgical Gastroenterology, Rajiv Gandhi Government of paralytics or cardiac synchronization, HFIRE ablations General Hospital and Madras Medical College, India (2,250 V) were performed using 1-5-1, 2-5-2, or 5-5-5us fi Introduction: Pancreatic trauma is rare and challenging to (on-off-on) pulse con gurations. Animals were maintained manage. The challenges are pre- operative diagnosis of duct under anesthesia (6Hrs) prior to euthanasia and tissue re- disruption and delayed presentation beyond 48 hours. covery/evaluation.

HPB 2018, 20 (S2), S505eS684 S676 Electronic Posters (EP02A-EP02F) e Pancreas

Results: All animals survived the experimental period and Discusion: IPAS is an uncommon diagnosis and can mimic no EKG abnormalities or muscle spasm were observed PNET on MRI. AS only needs surgical treatment if it is during treatment. HFIRE delivery time was 5.4 Æ 0.7mins associated with a blood disease. Surgeons should include and reproducible pancreatic ablations were created (903 Æ IPAS in the differential diagnosis of lesions of the 70 vs. 935 Æ 148 vs. 2498 Æ 3433 [1-5-1/2-5-2/5-5-5]), n = pancreatic tail to avoid unnecessary surgery. 4/setting). Histological analysis revealed clear demarcation between ablated-normal tissue, and preservation of under- lying architecture within the ablation zone. Histochemistry EP02F-019 and immunohistochemistry (caspase-3 activity) revealed A COMPARATIVE SINGLE-CENTER electrically-induced necrosis (without thermal necrosis) adjacent to the probe, and extensive caspase-3 activity/ STUDY COMPARING LAPAROSCOPIC apoptosis at the ablation-healthy tissue margin. AND ROBOTIC PANCREAS RESECTION: Conclusions: H-FIRE delivery using a DESN probe CLINICAL OUTCOMES AND COSTS rapidly and reproducibly ablated pancreatic tissue without ANALYSIS significant thermal necrosis or the need for cardiac syn- V. Ferri, E. Vicente, Y. Quijano, B. Ielpo, R. Caruso, chronization or intraoperative paralytics. Development, H. Duran, I. Fabra, E. Barzola, R. Isernia and C. Plaza optimization, and testing of pulse parameter variations for Sanchinarro University Hospital, Spain SNDE-HFIRE may overcome the limitations and reserva- tions associated with established IRE technology and in- Background: The robotic surgery cost presents a critical crease the potential for use with minimally invasive issue which has not been well addressed yet. This study approaches. aims to compare the clinical outcomes and cost differences of robotic distal pancreatectomy (RDP) versus laparoscopic distal pancreatectomy (LDP). Methods: A database of laparoscopic and robotic pancre- EP02F-018 atic surgeries has been developed, and data have been INTRAPANCREATIC ACCESSORY prospectively recorded from October 2011 up to May 2017. SPLEEN WITH AMYLODOSIS An independent company performed the financial analysis. MIMICKING PANCREATIC The study was approved by the institutional review board. NEUROENDOCRINE TUMOR All consecutive cases were conducted by the same group of 1 2 surgeons who all possess a high degree of experience in R. Latorre Fragua , A. Manuel Vazquez , both the laparoscopic and robotic approaches. C. Ramiro Perez2, A. Lopez Marcano2, 1 1 1 Results: A total of 28 RDP and 26 LDP were included. The B. Gonzalez Sierra , D. Diaz Candelas , L. Diego Garcia , fi 1 1 mean operative time was signi cantly lower in the LDP V. Arteaga Peralta , R. De La Plaza Llamas and (294 vs 241 min; p = 0.02). The main intra and post- J. M. Ramia Angel1 1 2 operative data were similar, except for the conversion rate Hospital Universitario de Guadalajara, and General (RDP: 3.6% vs LDP: 19.2%; p = 0.04) and hospital stay Surgery, Hospital Universitario de Guadalajara, Spain (RDP: 8.9 vs LDP 13.1 days; p = 0.04). The mean total Introduction: The most frequent location of the accessory costs were similar in both groups (RDP: 9198.64 V vs spleens (AS) is splenic hilium and pancreas (10.4e17%). LDP: 9399.74 V;p> 0.5). The overall rate of pancreatic AS parenchyma may suffer the same diseases as spleen leak was 10.7% in the RDP group and 15.4% in the LDP such as amyloidosis. Amyloidosis comprise diseases group (p > 0.5). characterized by an abnormality in the folding of the pro- Conclusions: RDP showed lower conversion rate and tein that leads to the deposition in the organs. Primary shorter hospital stay than LDP at the price of longer oper- amyloidosis (AL), most common subtype, mainly affects ative time. RDP is financially comparable to LDP. the kidney, the heart and the liver. Spleen amyloidosis occurs only in 15%. We report the first case of amyloidosis in an intrapancreatic-AS (IPAS) that was initially EP02F-020 misdiagnosed as a neuroendocrine tumour (NET) Clinical case: A 57-years-old-male, with hypertension and DISLOCATION OF INTRA-ABDOMINAL sleep apnea syndrome, was sent to Outpatient Clinic after DRAINS AFTER PANCREATIC incidentally discovered of a 21mm enhancing lesion in the SURGERY: RESULTS OF A tail of the pancreas with subcentimetric peripancreatic, PROSPECTIVE OBSERVATIONAL celiac trunk and hepatic hilum lymphadenopathies, on STUDY abdominal CT and MRI. 1 1 1 2 Laboratory findings: Chromogranin A: 131.1 ng/ml, no G. Marchegiani , M. Ramera , E. Viviani , F. Lombardo , A. Cybulski2, M. Chincarini2, G. Malleo1, C. Bassi1, hypersecretion of hormones. EUS: peripancreatic lymph- 2 1 adenopathies. FNA-EUS: inconclusive. Suspecting a G. A. Zamboni and R. Salvia 1General and Pancreatic Surgery Department, and nonfunctioning pancreatic NET, we decided surgical 2 intervention. We observed pancreatic tail tumor and some Radiology Department, Pancreas Institute, University liver nodules and performed distal splenopancreatectomy and Hospital Trust of Verona, Italy and liver biopsy were performed (CCI: 33.7). Introduction: The use of intra-abdominal drains after Pathology: IPAS with AL-amyloidosis, with hepatic and pancreatic surgery represents a well-established but splenic involvement. The patient continue treatment by He- controversial practice. No data are available regarding both matology with Bortezomib-Cyclophosphamide-Dexametha- the occurrence and the potential impact of their post- sone, with good response (decreasing BNP and troponin I). operative accidental dislocation. The aim of the study is to

HPB 2018, 20 (S2), S505eS684 Electronic Posters (EP02A-EP02F) e Pancreas S677 assess the actual rate of dislocation of intra-abdominal Malignancy includes distal gastric cancer and hepato- drains and to evaluate its clinical impact. biliary-pancreatic (HBP) neoplasms. In metastatic/unre- Method: This is a prospective observational study. Ninety- sectable HPB tumors, GOO decrease quality of life and one consecutive patients undergoing pancreatoduodenec- treatment should be necessary. Options are duodenal stent tomy (PD) or distal pancreatectomy (DP) underwent low- or gastrojejunostomy (GJ), but there is no consensus. dose, non-enhanced computed tomography on post- In benign diseases, 1-5% of patients with chronic operative days (POD) 1 and 3 in a blinded fashion to assess pancreatitis (PC) would develop GOO. the position of drains. We compared the outcomes of pa- We retrospectively review all consecutive patients who tients with dislocated and non-dislocated drains. underwent laparoscopic GJ for GOO due to CP or advanced Results: Overall, drains were dislocated in 30 patients HBP cancer at University Hospital of Guadalajara, Spain. (33%), without differences between PD and DP. Most of We studied 10 patients with laparoscopic GJ. dislocations were already present on POD 1 (77%). Post- HBP neoplasms: Age: 78,01Æ6,8 years. Albumin: 28,36 operative complications occurred in 57% of patients, and Æ2,7. No patient received prior chemo. the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%. P=0.020), and rate of POPF (3% vs. 39%. P < EP02F-021 Table 0.001). After PD patients with dislocated drains had a Age/ GOOSS Clinical Time to LOS Duration of shorter hospital stay (12 vs. 20 days. P = 0.015). No sig- Sex success initiate (days) food intake nificant differences in terms of need for percutaneous intake drainage procedures, abdominal collections, or grade C 77/F 0 Yes 4 12 402 (until death) POPFs were found between the groups. 76/M 3 Yes 3 12 228(until death) 91/F 0 Yes 1 5 278 (until death) 78/F 0 Yes 3 10 78 68/M 0 Yes ND 12 82 76/M 0 Yes ND 13 220 (until death) 76/F 0 Yes ND 5 ND

CP: 3 males. Age: 56,2Æ3,4. Median albumin: 37,7Æ6,6. Clinical success: 100%. Median LOS: 6,33Æ0,6. Previous literature on GOO treatment mixes different causes with different prognosis, so level of evidence is low. In benign diseases, such as CP, data are limited and patients typically requires surgical GJ. In malignancy, literature on GJ showed better long-term relief and lower reintervention rates. In other hand, stents EP02F-020 Figure Correctly placed (A-C) and dislocated (B- are associated with lower hospital stay, faster initial relief D) drains and shorter time to intake, with more recurrent symptoms. Survival is essential for the choice of treatment. In HBP Conclusions: Dislocation of intra-abdominal drains is an neoplasms, chemotherapy has increased survival. Stent is early and frequent event after major surgical procedure. Its usually preferred in patients with poor general condition or occurrence might protect against the negative effects of life expectancy of less than 90 days but more studies are maintaining drainage, eventually leading to better post- needed to standardize treatment. Laparoscopic GJ is a operative outcomes. This data reinforces the knowledge feasible, safe and efficient technical option. that surgical drains might be detrimental in selected cases.

EP02F-021 EP02F-022 LAPAROSCOPIC HYPERSPECTRAL IMAGING BASED ON GASTROJEJUNOSTOMY FOR GASTRIC COMPRESSIVE SENSING TO OUTLET OBSTRUCTION: PERSONAL DETERMINE CANCER MARGINS IN SERIE HUMAN PANCREATIC TISSUE EX VIVO 1 2 R. Latorre Fragua , A. Manuel Vazquez , M. Passeri1, J. Peller2, K. Thompson1, C. Jacobs3, 2 2 C. Ramiro Perez , A. Medina Velasco , J. Martinie1,4, E. Baker1,4, D. Vrochides1,4, 2 2 B. Gonzalez Sierra , D. Diaz Candelas , S. Trammell2 and D. Iannitti1,4 2 2 V. Arteaga Peralta , L. Diego García , 1Surgery, Carolinas Medical Center, 2Physics and Optical 2 2 R. De La Plaza Llamas and J. M. Ramia Angel Sciences, UNC at Charlotte, 3Pathology, Carolinas Med- 1 2 Hospital Universitario de Guadalajara, and General ical Center, and 4Surgery, Levine Cancer Institute, United Surgery, Hospital Universitario de Guadalajara, Spain States Traditionally, benign diseases were responsible for most Introduction: Pancreatic adenocarcinoma (PA) is the of the causes of gastric outlet obstruction (GOO), but in fourth-leading cause of cancer-related mortality in the recent years, 50-80% could be attributable to malignancy. United States, with a 5-year survival rate of less than 10%.

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Surgical resection is the most widely utilized treatment for preoperative gastric outlet obstruction (p=0.038) developed PA. Resection of locally advanced lesions, which postoperative grade B or C DGE. Additional risk factors frequently invade vasculature and surrounding tissue, did not reach statistical significance (Table 1). would benefit from novel intraoperative imaging modalities Conclusions: Although clinical judgement of the operative to assess tissue margins in real-time. We sought to develop surgeon will remain an integral part of decision making for and enhance a single pixel, hyperspectral imaging (HSI) intraoperative FT placement, we propose prophylactic system based on compressive sensing for detecting tumor- intraoperative FTs during PD for patients who present with normal tissue margins in resected human PA samples. gastric outlet obstruction. Methods: Freshly-resected pancreatic tissue from 20 pa- tients with a diagnosis of presumptive PA were analyzed. A [Table 1] spectral imaging system, comprising of a nitrogen laser (autofluoresence) and halogen lamp (polarized white light reflectance) were used to generate spectra from tumor, non- tumor and tumor/non-tumor margins. A Spectral Angle Mapping (SAM) algorithm was then used to reconstruct images and determine the changes in autofluoresence and reflectance spectra. Reconstructed images were used to delineate tissue from tumor and non-tumor pancreas, and compared to H&E stained sections following blinded scoring by a board-certified pathologist. Results: Our data demonstrated significant changes in both reflectance (and autofluorescent spectra based on a two- sigma change in SAM (sensitivity of 74.80 Æ 9.18%, and specificity of 68.59 Æ 10.43%) in non-tumor and tumor tissue from PA resections. Conclusion: HSI using the SAM algorithm represents a novel technology to map tumor and non-tumor margins EP02F-024 fi with high con dence. Additionally, polarization of white PANCREATIC HEAD RESECTION FOR light for reflectance spectroscopy may be useful in enhancing system performance/detection limits. SPHINCTER OF ODDI DYSFUNCTION E. J. Ban1, S. Ramoutar1, M. Roy2, C. Ainley2,3, EP02F-023 R. Hutchins1 and S. Bhattacharya1,2 1HPB Surgery, Royal London Hospital, 2The London DECISION MAKING FOR 3 INTRAOPERATIVE FEEDING TUBE Clinic, and Gastroenterology, Royal London Hospital PLACEMENT DURING Introduction: Sphincter of Oddi dysfunction (SOD) is a rare cause of recurrent/chronic pain. It can involve biliary PANCREATICODUODENECTOMY or pancreatic sphincter dysfunction. Treatment is largely R. Kirks1, W. Lyman2, A. Cochran1, J. Martinie1, medical/endoscopic, with surgical sphincteroplasty a last D. Vrochides1, E. Baker1 and D. Iannitti1 resort. We describe a group of patients with SOD 1Division of HPB Surgery, and 2Department of General (including some with pancreas divisum and accessory Surgery, Carolinas Medical Center, United States sphincter dysfunction), treated with pancreatic head Introduction: Placement of intraoperative feeding tubes resection. (FT) during pancreaticoduodenectomy (PD) remains a Methods: We audited patients undergoing pancreatic head topic of debate with no predictive model to date adequately resection for SOD in two centres (2009-2017). Data identifying which patients will require enteral access for included demographics, preoperative treatments, intra- postoperative nutrition. In this study we attempted to operative findings, complications, histology and duration of identify patients who would benefit from intraoperative FT follow-up. A validated quality of life (QoL) score (RAND placement with the help of a scoring system. SF-36) was completed for each patient. Patients were asked Methods: Through a combination of literature review, to subjectively compare pain and QoL before and after survey, and expert consensus within our surgical division, surgery, and if they would recommend surgery to others. we created a 12-point scoring system to predict the need for Results: Fourteen patients were included, all female, enteral supplementation postoperatively. We analyzed pa- Caucasian, mean age 41.8 years. Manometry was recorded tients from September 2015-present who underwent PD at in 71.4%, abnormal in 46.2%. Sphincterotomy and our institution on ERAS protocol (n=127). Of those pa- pancreatic stenting had been attempted in all (mean stent tients, 27 (21.2%) developed either grade B or C delayed attempts 3.1); 50% suffered post-ERCP pancreatitis. The gastric emptying (DGE) according to ISGPS guidelines. operation involved pancreatic head resection, with the du- We matched 27 patients who did not develop grade B or C odenum preserved in one, and the pylorus preserved in 13. DGE by age and sex for analysis. Our 12-point scale was Post-operative morbidity was 57.1%, including one Clav- then applied to the two groups and compared with Pear- ien-Dindo IIIa complication. There were no deaths. Mean son’s chi-squared test. follow-up was 17.7months. QoL scores were worse than Results: Our proposed scoring system did not correlate the average population across all domains, but improved with risk for development of postoperative DGE and need QoL and reduced pain was reported in 61.5%. 84.6% of for feeding tube placement. However, through subgroup patients would recommend surgery to others with a similar analysis of our risk factors, all patients who presented with problem.

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Conclusion: Pancreatic head resection is an alternative Introduction: Traditional initial settings on the intrave- where endoscopic interventions have failed, but only after nous patient-controlled analgesia (IV-PCA) pump can careful selection. QoL improved in 61.5% of our patients represent a significant source of postoperative opioid and most would recommend surgery. exposure. The primary aim of this study was to evaluate the impact of first-day IV-PCA use on total inpatient opioid use after pancreatectomy. EP02F-025 Methods: Clinical characteristics and total inpatient oral PROSPECTIVE STUDY OF morphine equivalent (OME, e.g. 5 mg hydrocodone=5mg morphine=0.5mg IV hydromorphone) utilization were PREOPERATIVE NUTRITIONAL downloaded from electronic records for pancreatectomy SUPPORT IN MALNUTRITIONAL patients treated with IV-PCA at a single institution from 3/ PANCREATO-BILIARY CANCER 2016-8/2017. Regression analyses were performed to PATIENTS identify predictors of total usage, highest vs. lowest quar- tiles of OME, as well as ideal first-day PCA limit. H. M. Park1, S. -J. Park1, S. -S. Han1, Y. H. Kang1, Results: Of 158 consecutive patients in the study period, K. -H. Son2, M. K. Yoo2, J. -Y. Kim3, Y. -A. Cho3, 132 were provided IV-PCA, which was almost universally D. E. Lee4 and J. N. Joo4 (89.4%) paired with concomitant transverse abdominus 1Center for Liver Cancer, 2Department of Clinical Nutri- plane (TAP) block. Median total OME in IV-PCA patients tion, Nutrition Support Team, 3Department of Clinical was 525mg (range 28e4,362 mg), with 373mg represent- Nutrition, and 4Biometric Research Branch, Research ing the median proportion ascribed to the IV-PCA. LOS Institute and Hospital, National Cancer Center, Republic and IV-PCA (both p < 0.001) were independently associ- of Korea ated with total OME on linear regression. The optimal first- Background and purpose: The purpose of this study is to day IV-PCA OME cutoff using Youden index was 56mg. evaluate the clinical impact of preoperative nutritional Using logistic regression, only first-day IV-PCA OME <56 support for malnourished cancer patients. mg independently predicted being in the lowest/ideal Methods: A total of 90 patients, 45 patients with nutrition quartile of total OME (OR-72.5, p < 0.001). Blood loss support group and 45 patients with well-nourish group, in (log transformation, OR-1.99, p = 0.01) and first-day IV- anticipating major surgery of pancreato-biliary cancer were PCA 56 mg (OR-7.91, p< 0.001) were independent enrolled in this study. We evaluated nutrition status by predictors of being in the highest/worst quartile. > weight loss ( 10% within 6 months), Patient-Generated Conclusions: Initial IV-PCA utilization is a major predic- Subjective Global Assessment (PG-SGA) grade B or C, tor of total post-pancreatectomy inpatient OME. Even < serum albumin level ( 3.0 g/dl) and assigned malnour- when using a TAP block, limiting the initial IV-PCA ished patients to the nutrition support group. dosing and optimizing the non-narcotic bundle may result Results: The postoperative complication rate in the nutrition in reduced inpatient exposure to opioids. support group was 51.1% and 42.2% in well-nourish group. The postoperative complications and day of hospital stay after operation were not different between each group. Although the patients whose nutritional status improved after EP02F-027 nutritional support showed lower complication rate than THE UTILITY OF CELIAC PLEXUS other patients whose nutritional status were not improved, BLOCK AS AN ADJUNCT FOR the complications rate in these patients were inferior to well- CONTROL OF POSTOOPERATIVE PAIN nourished patients. postoperative length of stay of subgroup AFTER MAJOR OPEN HEPATO- (PG-SGA grade B/C à B/C) was marginally longer than that PANCREATICO-BILIARY SURGERY of well-nourished group (21.0 vs. 15.0 days, p = 0.050). 1 2 3 4 Initial body mass index (OR, 1.49; 95% CI, 1.07e2.07; p = Z. H. T. Teo , C. W. Foo ,J.E.J.Tan and J. K. Low 1 2 3 0.020) and the amount of protein supplied (OR, 1.84; 95% General Surgery, Anaesthesia, Anaesthesiology, Inten- 4 CI 1.21e2.80; p= 0.004) were independently inhibit the sive Care and Pain Medicine, and General Surgery, nutritional improvement in malnutrition group. Hepato-Pancreaticobiliary Surgery Conclusion: It is suggested that preoperative nutritional Introduction: Celiac plexus block (CPB) has been support in malnutritional pancreato-biliary cancer patients commonly described as a procedure for control of pain in may be helpful to improve the clinical outcomes, but the patients with chronic pancreatic pain. We are exploring the postoperative results were still inferior to well-nourished use of CPB together with continuous wound infiltration via patients in clinical implications. pre-peritoneal catheters to reduce post-operative pain after major open hepato-pancreatico-biliary surgery. EP02F-026 Method: Five patients underwent open hepato-pancreati- IMPACT OF FIRST-DAY INTRAVENOUS co-biliary surgery; 2 open liver resections via reverse L- PATIENT CONTROLLED ANALGESIA incisions and 3 open pylorus-preserving-pancreaticoduo- denectomy via rooftop incisions. For the CPB, the celiac USE ON TOTAL INPATIENT OPIOID axis was identified and 10-20mls of 0.25% Marcaine was USE AFTER PANCREATECTOMY infiltrated around the celiac axis at the end of surgery. As W. Dewhurst1, T. Newhook1, H. -C. Chen2, X. Wang2, per standard regime, pre-peritoneal catheters were inserted M. Bruno1, M. Kim1, J. N. Vauthey1, J. Lee1, and 20ml Ropivacaine 0.2% bolus was injected into each M. Katz1 and C. -W. Tzeng1 catheter to initiate the pre-peritoneal analgesia. Post-oper- 1Surgical Oncology, and 2Biostatistics, M.D. Anderson atively, Patient-Controlled-Anlagesia (PCA) opioid was Cancer Center, United States commenced. The pre-perioneal infusion were continued till

HPB 2018, 20 (S2), S505eS684 S680 Electronic Posters (EP02A-EP02F) e Pancreas post-operative day (POD) 5. The opioid consumption is tabulated in Table 1 below.

EP02F-027 Table Patient Opioid Usage POD 1 POD 2 POD 3 POD 4 1 Oxycodone 20 mg 5 mg 0 0 2 PCA Fentanyl 60 mcg 340 mcg 0 0 3 PCA Morphine 16 mg 41 mg PO Oxycodone 30mg PO Oxycodone 5 mg 4 PCA Morphine 2 mg 7 mg 0 0 5 PCA Fentanyl 400 mcg 120 mcg 0 0

Results: The Visual Analog Score (VAS) for pain was EP02F-029 assessed up to fourth POD. All patients had pain scores of 3 or less at rest. For VAS on movement, 2 patients had VAS RECONSTRUCTION OF PORTAL VEIN of 4 to 5 on first POD. By second POD, dynamic VAS BY DIFFERENT TYPES OF scores were 3 or less and all patients were ambulating ALLOGENOUS VENOUS GRAFTS IN Conclusion: Our case series demonstrate that CPB, EXPERIMENTAL MODEL OF together with pre-peritoneal infusion, helped to minimise PANCREATICODUODENECTOMY the post-operative opioid consumption and pain of patients. V. Liska1,2, R. Palek1,2, J. Rosendorf1,2, V. Treska1, Patients are able to mobilise early and this is an important 2,3 4 measure of good pain control. Z. Tonar and J. Vimmr 1Department of Surgery, 2Biomedical Center, 3Institute of Histology and Embryology, Charles University, Medical Faculty Pilsen, Czech Republic, and 4Institute of Me- EP02F-028 chanics, West Bohemian University, Faculty of Applied PRIMARY HYDATID CYST OF THE Sciences, Czech Republic PANCREAS Introduction: Resectable Infiltration of portal vein is today R. Rhaiem, H. Maghrebi, F. S. Fteriche, A. Haddad, no more limitation of radical surgery. Many types of A. Makni, A. Daghfous, R. Ksantini and Z. Ben Safta autologous venous grafts can be used for reconstruction. Department of Digestive Surgery A, La Rabta University Unfortunately the use of these grafts is limited by several Hospital, Tunisia disadvantages. Experimental comparison of allogenous Introduction: Hydatid disease is a parasitic infection cadaveric grafts of inferior caval vein (ICV) and PV were caused by larval stage of Echinococcus granulosus in never performed in large animal experiments despite of human. Liver is the most common site of the disease. different features of PV and ICV. Pancreatic involvement is rare accounting for less than 1% Aim: The aim of our study is to verify whether there are fi of hydatid cases. any signi cant differences in PV and ICV wall which could fl Methods: This retrospective descriptive study evaluated in uence the behaviour of the portal system after interpo- clinical presentation of hydatid cyst of the pancreas and sition of the grafts. discussed the diagnostic and therapeutic pitfalls. Methods: We gained 8 allogenous grafts of PV and VCI Results: We report eight cases of primary hydatid cysts of from cadaveric donors with negative cross-match. We the pancreas. The most common clinical presentation was performed pancreaticoduodenectomy in 16 piglets with abdominal pain. Preoperative diagnosis of hydatid cyst of resection and reconstruction of portal vein (8 grafts of PV, 8 the pancreas was established in 6 patients (75%). In 2 ICV). Postoperative follow-up took 4 weeks and we patients, the preoperative diagnosis was cystic tumor of monitored the behaviour of portal system by ultrasound. the pancreas. Mean size was 100 mm (20-150 mm). The grafts were histologically examined before operation Immunology (ELISA) was positive in 7 cases. All patients and after termination of experiments. The data gained from underwent laparotomy. Surgical treatment included ultrasound were used for construction of mathematical resection of the prominent lump in 3 patients (37.5%) and model of portal system. radical surgery in 5 cases (62.5%). The postoperative Results: According to the ultrasound examination the course was uneventful for 7 patients. One patient experi- behaviour of the portal system was not involved by the type enced grade B pancreatic fistula after left pancreatectomy. of interposed graft. The histological features of venous After a median follow-up of 28 months, no recurrence grafts were different before transplantation but during occurred. healing of grafts the differences were lost by restructuring Conclusion: Primary hydatid cyst of the pancreas is a of both venous walls. differential diagnosis of cystic tumor of the pancreas. Pre- Conclusion: The both grafts are evaluated as comparable. operative imaging is of a paramount importance to establish The venous grafts metamorphosis during healing is the diagnosis preoperatively. Surgery, conservative or surprising. radical, is the gold standard treatment for all locations of the The project is supported by Center of experimental and disease. clinical liver surgery UNCE/MED/006.

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EP02F-031 Conclusion: Surgical intervention is the standard of care in high grade Blunt pancreatic injuries. There appears to be an MANAGEMENT OF GRADE IV BLUNT evolving role for conservative management in highly select PANCREATIC INJURY WITH BILIARY group of isolated high grade pancreatic injury patients, INJURY WITH STAGED APPROACH: however further studies with multi institutional collaboration CASE REPORT is required to form guidelines in identifying these patients. S. R. V. Gunturi1, J. R. Bathalapalli1, N. Kunduru1, V. Thumma1, G. Gondu1, B. Nagari1 and M. Nambada2 1Surgical Gastroenterology, Nizams Institute of Medical EP02F-033 Sciences, and 2Apollo hospitals, India PANCREATIC INSULINOMA. RESULTS Introduction: High grade pancreatic injuries after Blunt OF CASE SERIES fi Abdominal Trauma (BAT) were associated with signi cant R. Abularach1, F. Castillo1, J. Reyes1, F. Hernandez1 and morbidity and mortality even in experienced hands. Two R. Cerda2 fi stage approach may be bene cial in sick patients. 1Digestive Surgery, and 2Surgery, University of Chile/ Method and results: We present a case report of 28 year Barros Luco Hospital, Chile gentle man with grade IV (AAST) pancreatic injury with Background: The purpose of this study is to report the bile duct injury. He presented to us four days after BAT clinical features and surgical outcomes in a series of pa- with haemodynamic instability.After resuscitation initial tients undergoing to surgical procedure for Pancreatic Damage control surgery was done in the form of debride- Insulinoma (PI) ment ,repair of bile duct ,closure of proximal pancreatic Method: Retrospective case series of patient admitted and duct and exteriorization of distal pancreatic duct along with resolved surgically with diagnosis by PI in surgery cholecystostomy. A second stage surgery (Pancretico department of Barros Luco Hospital, between 2007 and jejunostomy to distal pancreas) was done three months after 2017. The variables was development: age, sex, clinics, primary surgery with good outcome. diagnosis exams, surgery procedure, surgical time, distri- Conclusions: Staged surgery can be considered in high bution of injuries and postoperative result were recorded. grde pancreatic injuries. Pancreas Preserving surgeries (by Descriptive statistics were used. avoiding Distal Pancreatectomy) in Grade IV injuries will Results: 11 consecutive patients were studied (54% result in better functional outcomes. women) with median age of 45 years (21 e 81 years). All cases had symptoms derived from the autonomic nervous EP02F-032 system and glycemia in fasting altered in the range of hy- poglycemia (<60 mg/dl). The most sensitive test was IS THERE A ROLE OF CONSERVATIVE pancreatic magnetic resonance (85%). The surgery was MANAGEMENT IN HIGH GRADE laparoscopic in 3 cases (enucleation). 54% presented PANCREATIC INJURIES IN BLUNT morbidity, 1 of them with Clavien Dindo >III. There was ABDOMINAL TRAUMA (BAT)? no mortality in this serie. S. R. V. Gunturi, V. Thumma, J. R. Bathalapalli, Conclusion: PI is a differencial diagnoses for hypoglyce- N. Kunduru, G. R. Gondu, A. Chincholi, D. Sarma, mia, with low incidence. The outcomes of our study are C. V. Vishnu, H. K. Dubey and B. Nagari consistent with those reported in the literature. Surgical Gastroenterology, Nizams Institute of Medical Sciences, India Introduction: Management of Pancreatic Trauma is a EP02F-034 challenge to the clinicians in terms of diagnosis and treat- ONODERA’S PROGNOSTIC ment.With increase in Road Traffic Accidents (RTA) Blunt NUTRITIONAL INDEX IN PATIENTS Pancreatic Trauma is not uncommon today.The traditional WITH PANCREATIC, HEPATIC AND approach is to operate high grade ductal injuries (AAST BILIARY TUMORS Grade III and above). 1 2 Methods: The clinical outcomes of patients with blunt M. G. Serna Thomé , G. D. Leal González , 1 1 pancreatic trauma in the last 7 years in our institute were H. M. Álvarez del Castillo , G. Miranda Dévora , 1 1 analysed. Our traditional approach is to operate the patients A. A. Meneses García and A. E. Padilla Rosciano 1 2 with Main pancreatic ductal injury(AAST Grade III and National Cancer Institute Mexico, and UANL, Mexico above ) if they present to our hospital immediately after Background: The nutritional prognostic index of Onodera is injury. The surgery can either a single stage or a two stage determined by the use of serum albumin and total lymphocyte surgery depending upon the severity of grade of injury, count. Biochemical indicators, such as the total lymphocyte associated injuries and stability of the patient. In Patients count (CTL) and serum albumin, are used as nutritional with delayed presentation or delayed referral surgical treat- indices and have been shown to be valid and reliable. The ment carried out in unstable patients and in patients with objective of this study is to evaluate the nutritional risk abdominal signs. A higly selective conservative treatment through the nutritional prognostic index of Onodera in pa- was attempted with close monitoringin in stable patients tients with pancreatic, hepatic and bile duct tumors. without much abdominal signs in isolated pancreatic injuries. Material and methods: We evaluated a 177 patients who Results: Conservative treatment was successful in 20% of entered the oncology surgery area at the National Cancer patients in delayed referral group. Those patients who Institute of Mexico City were evaluated. The nutritional required surgery in delayed presentation or referral had prognostic index of Onodera was used to determine the risk increased morbidity and mortality. of malnutrition. The variables to be considered were:

HPB 2018, 20 (S2), S505eS684 S682 Electronic Posters (EP02A-EP02F) e Pancreas albumine, CTL. Severe malnutrition (albumin <2.5 g/dl, cachectic state, which increases the degradation of skeletal CTL <800 cells/mm3), moderate malnutrition (albumin <3 muscle protein and reduces protein synthesis without g/dl, CTL <1200 cells/mm3), mild malnutrition (albumin affecting food intake. <3.5) were taken as CTL cut-off points. g/dl, CTL <1600 Objective: To measure the prevalence of malnutrition in cells/mm3), normal (albumin <3.5 g/dL, CTL <5000 cells/ relation to CRP in patients with liver, pancreatic and gall- mm3) and lymphocytosis (> 4999 cells/mm3). bladder cancer. Results: The results of the onodera prognostic index report Material and methods: Seventy six (76) patients were that 49.7% of the evaluated patients present high nutritional evaluated with cancer of liver tumors, lavatory and gall- risk using serum albumin and total lymphocyte count as bladder. We used variables such as age and gender, predictors. anthropometric measures such as current weight, usual Conclusions: A large number of the evaluated patients weight and BMI, biochemical variables such as C-reactive present a high nutritional risk referred by the onodera protein (CRP) taking as a high value serum concentrations prognostic index, the type of tumor that refers more cases of >1 mg/Dl, to make a relationship with nutritional status high nutritional risk is pancreatic cancer. were taken the results of the Subjective Global Assessment Generated by the Patient (VGS-GP) EP02F-035 Results: The results obtained from the VSG-GP, 57% (43) BODY WEIGHT LOSS IN PATIENTS with moderate malnutrition and 25% (19) with severe WITH LIVER, PANCREAS AND BILIARY malnutrition. In relation to the VSG-GP with the CRP values, it was demonstrated in those patients with values TUMORS <1 mg / dl 11% (6) were with good nutrition, 64% (34) 1 2 G. D. Leal González , M. G. Serna Thomé , Conclusions. 1 2 H. M. Álvarez del Castillo and A. E. Padilla Rosicano Conclusions: Patients with adequate nutritional status have 1 2 UANL, and National Cancer Institute Mexico, Mexico a lower concentration of CRP. Background: Malnutrition and weight loss is a frequent problem in cancer patients, affecting prognosis, prolonging EP02F-037 hospital stays, increasing costs and affecting quality of life PRE ERAS PERIOPERATIVE CARE FOR and survival. The objective of this study is to evaluate the PANCREATICODUODENECTOMIES, A percentage of weight loss with respect to the usual weight SINGLE INSTITUTION EXPERIENCE in patients with tumors of the liver, pancreas and bile ducts. Material and method: We evallated 192 patients with a J. R. Maddumba and C. Alfonso diagnosis of liver, pancreatic and biliary tract cancer were Hepato-Pancreato-Biliary Section, Department of Sur- included. As for the percentage of weight loss, it is consid- gery, The Medical City, Philippines ered severe when the loss is greater than 10% in 6 months. Introduction: With the accreditation of The Medical City Results: The incidence of tumors was: Pancreatic cancer hospital as currently the sole center of ERAS excellence in with 41% (79), followed by liver cancer 36% (69) and bile the Philippines, the study aims to assess the institution’s duct cancer 23% (44). 97% of the patients presented weight status in perioperative care for patients who underwent loss with respect to the usual weight, of which 59.4% (114) pancreaticuduodenectomy in relation to ERAS principles. presented severe loss. The type of cancer where there was Properly assessing perioperative practices will aid in better more weight loss was pancreatic cancer where 53 patients implementation of a formal ERAS program. lost >10% vs 27 with loss of <10%. Followed by liver Methods: This study will describe the pre-operative, intra- cancer where 42 patients lost >10% and 26 <10%. The operative and post-operative experience and care practice bile duct cancer with 26 patients with loss >10% and 26 of patients who underwent pancreaticoduodenectomy in < 10%. The bile duct cancer with 26 patients with loss The Medical City from 2004-2016 in comparison with the >10% and 18 < 10%. ERAS guidelines. Outcomes such as complications and Conclusions: Weight loss is a common problem in patients length of hospital stay will also be evaluated. Compliance with tumors of the digestive tract, in this study more than with the recommendations will be calculated using the half of the patients assessed with a serious weight loss were ERAS interactive software. classified, the type of cancer where there was more weight Results: Thirty-six pancreaticoduodenectomies were loss was pancreatic cancer. performed. Operating time, blood loss, and blood trans- fusion rates had decreased in trend throughout the years. EP02F-036 Enhanced recovery practices were well tolerated by pa- PREVALENCE OF MALNUTRITION IN tients. Overall morbidity rate was 53%. Median length of RELATION TO CRP IN PATIENTS WITH hospital stay was 8 days. Total compliance rate was 28.7%. Pre-operative, intra-operative and post-operative compli- HEPATIC, PANCREATIC AND BILIARY ance was 49%, 27%, and 14.8% respectively. Rate of CANCER compliance increased through the years of practice. There H. M. Álvarez del Castillo1, M. G. Serna-Thomé2, is a trend of higher ERAS compliance in patients without G. D. Leal González1 and A. E. Padilla Rosciano2 complications versus patients with complications. 1UANL, and 2National Cancer Institute Mexico, Mexico Conclusions: The direction of perioperative care in The Background: The acute phase response is a reflection of Medical City is towards principles of enhanced recovery; both acute inflammation and chronic inflammation which hence the implementation of a formal ERAS program is increase in the presence of infection, chronic inflammation highly achievable. Compliance to ERAS principles can also and metabolic risk generating a hypercatabolic state which be increased with proper documentation and monitoring of releases proteolysis inducing factors thus leading to the perioperative care.

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EP02F-038 gastrojejunostomy. Post operative course was uneventful and remained symptomfree for 2 years on follow up. MANAGEMENT OF BLUNT Conclusion: Here we adopted a less radical procedure for a PANCREATIC TRAUMA-TRENDS AND benign disease in form of lateral pancreatic jejunostomy OUTCOMES FROM 2 HPB TERTIARY with minimal morbidity. Due to different surgical options CENTRES IN MALAYSIA available for adult annular pancreas, we advocate a tailored individualised approach. S. Samsudin1, V. M. Leow2 and M. K. Subramaniam3 1Selayang Hospital, 2USM, Bertam, Oncology Unit, Advanced Medical and Dental Institute(AMDI), and EP02F-040 3Hospital Sultanah Bahiyah, Kedah, HPB Unit, Division of General Surgery, Malaysia WHEN TO CONSIDER TOTAL PANCREATECTOMY? Introduction: To review management trends and out- 1 2 2 comes of blunt pancreatic injury at 2HPB centres. A. Manuel , A. Carabias , L. Casalduero , 1 2 2 Methods: A retrospective review of patient registry at 2 R. Latorre Fragua , A. Serantes , P. Sanz , 2 2 public hospitals.(2001e2016).2 study groups were identi- M. A. Delgado and J. M. Jover 1 fied. Group 1 -patients who underwent operative manage- General and Digestive Surgery, University Hospital of 2 ment (pancreatic resection/repair) Group 2-patients who Guadalajara, and University Hospital of Getafe, Spain underwent non operative management (i-either had no Introduction: The choice of total pancreatectomy (TP) for abdominal surgery; had abdominal surgery but not pancre- the treatment of pancreatic lesions is conditioned by the atic surgery; had endoscopic or radiology guided in- postoperative morbidity, postoperative mortality and com- terventions only). Patients characteristics, clinical outcome, plications associated with this technique, such as diabetes length of stay, complications and mortality for each group mellitus, exocrine insufficiency and impaired quality of life were reviewed. Comparative analysis was performed. (QOL) The current improvement of postoperative man- Result: 85 patients with all grades of injury were identified. agement is conditioning an increase in the indication of this (AAST classification). As time of referral following trauma surgery. was variable, there was no specific management strategy Method: We present four patients with TP and discuss the that was adhered to. (mean referral time 8.7days-Gr 1 vs indications. 29.3 days-Gr 2) 46% Gr 1 and 26% of Gr 2 had ‘damage Results: A 79-years-old man with intraductal papillary control surgery’ prior to transfer. 40patients (49.3%) Gr 1 mucinous neoplasia (IPMN) with main duct >1 cm and vs 41patients (50.6%) Gr 2 sustained pancreatic injury pancreatic atrophy. He was chosen for obstruction of main grade I, II, III. All patients with grade IV,V were in Gr pancreatic duct. A 53-years-old woman with IPMN and 1.Overall specific pancreatic complications- fistula, pseu- recurrent pancreatitis. TP was performed due to multifocal docyst/collection, abscess, pancreatitis and haemorrhage IPMN. A 71-years-old woman with IPMN. She was chosen was lower in Gr 1 (67% vs 78%). Mean hospital stay was for the obstruction of Wirsung. A 73-years-old woman with longer in Gr 1(41 days vs 15 days, p value 0.000) 2 mor- pancreatic adenocarcinoma and portal infiltration. TP was talities were recorded in each group. On multivariate performed due to risk of anastomotic leakage. analysis, pseudocyst and isolated pancreatic injury favour Discussion: The mortality related to TP has decrease in the non operative management. last time and the survival and quality of life associated with Conclusion: Non operative management was associated this technique is similar to cephalic duodenopancreatec- with shorter hospital stay, no significant difference in tomy. Indications of TP include both benign and malignant complication rates and mortality, therefore may be pancreatic diseases. This technique may be indicated pre- attempted in stable group of blunt pancreatic injury (grade operatively due to multifocal tumors or pancreatic obstruc- I, II, III) without peritonitis. tion, or intraoperatively due to soft pancreatic remainder or risk of anastomotic leakage. Conclusion: TP is a treatment option in selected patients EP02F-039 with low morbi-mortality and good results in QOL. The EMPHASIS ON INDIVIDUALIZED decision to perform a TP is a challenge for the patient and the surgeon and must be carried out with caution. APPROACH IN SYMPTOMATIC ANNULAR PANCREAS J. M. r. Bathalapalli1, S. R. C. v. Gunturi2, EP02F-041 1 1 1 V. M. Thumma , N. K. Kunduru and B. Nagari BRUNNER`S GLAND HYPERPLASIA 1Nizams Institute of Medical Sciences, and 2NIMS, India MIMIC PANCREATIC NEOPLASIA Introduction: Annular pancreas is a rare congenital A. Manuel1, A. Carabias2, R. Latorre Fragua1, anamoly,diagnosed frequently in present era due to 1 2 2 improved imaging.Various surgical procedures have been C. Ramiro Perez , L. Casalduero , M. Gorosabel , M. A. Delgado2, J. M. Jover2 and J. M. Ramia Angel1 described due to variable presentations in adults.Hence we 1 2 report another such rare presentation and treatment to un- University Hospital of Guadalajara, and University derline the importance of tailored approach. Hospital of Getafe, Spain Methods and results: Wereportacaseof30yroldmale Introduction: The submucosal glands of the duodenum patient who presented with complaints of recurrent pain were initially described by Brunner in 1688. Brunner’s abdomen since 10 years. He was evaluated and diag- gland hyperplasia (BGH) is part of a spectrum of Brunner’s nosed to have annular pancreas with chronic pancrea- gland proliferation ranging from diffuse hyperplasia to titis. We performed lateral pancreatic jejunostomy and polypoid lesions.

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Method: We present a patient with suspected pancreato- Discussion: BGH is a rare disease reported for the first time duodenal neoplasia and a definitive histological diagnosis in 1835, with polypoid configuration. It is usually asymp- of BGH. tomatic, but pain, bleeding or pancreatitis may be associ- Results: A 57-years-old man had general weakness and ated. The challenge of BGH is the differential diagnosis of weight loss, without jaundice. Abdominal CT/MRI: hypo- malignancy, as our case. BGH is part of a spectrum of dense pancreatic mass with cystic degeneration in second proliferation ranging from diffuse nodular hyperplasia, as portion of the duodenum and head of the pancreas, and in our pat1`ient, to circumscribed nodular BGH or to inflammation that affects the pancreatic-duodenal area. hamartoma. Classification of these entities in the literature Endoscopy: obstructive polyp in the second portion of is variable with few established schemas. Current literature duodenum, suspected of malignancy. Suspecting a includes hamartoma of the Brunner’s glands within the pancreatic neoplasm with presence of duodenal obstruc- spectrum of groove pancreatitis. tion, a duodeno-pancreatectomy was performed. During Conclusion: Diseases that affect the pancreatoduodenal surgery, we identified a mass in pancreatic head and a area represent a challenge for the diagnosis of neoplasms. If sessile duodenal polyp. Histology: diffuse nodular BGH the diagnosis is unclear, the surgery is mandatory. with gastric metaplasia.

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