Classic Pancreaticoduodenectomy Research Articles

Impact of antecolic vs transmesocolic reconstruction on delayed gastric emptying following pancreaticoduodenectomy

BackgroundDelayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy. There remains an active debate over the effect of gastrointestinal (GI) reconstruction techniques, such as antecolic (AC) or transmesocolic (TMC) reconstruction, on DGE rates. This study compared the rates of DGE between AC reconstruction and TMC reconstruction after pylorus-preserving pancreaticoduodenectomy (PPPD) and classic pancreaticoduodenectomy (PD). MethodsThis was a retrospective analysis of a prospectively maintained pancreatic surgery database in a single, high-volume center. Demographic, perioperative, and surgical outcome data were recorded from patients who underwent a PD or PPPD between 2013 and 2021. DGE grades were classified using the International Study Group of Pancreatic Surgeons (ISGPS) criteria. Postoperatively, all patients were managed using an accelerated Whipple recovery protocol. ResultsA total of 824 patients were assessed, with 303 patients undergoing AC reconstruction and 521 patients undergoing TMC reconstruction. The risk of DGE was significantly greater in patients who received an AC reconstruction than in patients who received a TMC reconstruction (odds ratio [OR], 1.51; 95% CI, 1.07–2.15; P < .05). In addition, AC reconstruction was shown to have a greater incidence of severe DGE (ISGPS grades B or C) than TMC reconstruction, with approximately a 2-fold increase in severe DGE (OR, 1.94; 95% CI, 1.10–3.45; P < .05). Logistic regression and propensity score matching have found increased DGE incidence with AC reconstruction (OR: 1.69 and 1.73, respectively; P < .05). ConclusionsAlthough the correlation between GI reconstruction methods and DGE remains a subject of ongoing debate, our study indicated that TMC reconstruction may be superior to AC reconstruction in minimizing the development and severity of DGE for patients after PD.

Surgeon's Experience May Circumvent Operative Volume in Improving Early Outcomes After Pancreaticoduodenectomy.

Introduction Pancreaticoduodenectomy (PD) is a complex procedure with a significant proportion of postoperative complications and improving but notable mortality. PD was the prototype procedure that initiated the lingering debate about the relationship of better operative outcomes when performed at higher-volume centers. This has not translated into practice. Impediments include the absence of a universally accepted definition of a high-volume center among others. Contrary evidence suggests equivalent outcomes for PD at low-volume centers when performed by experienced hepatobiliary surgeons. We reviewed our perioperative outcomes for PD from an earlier period as a low-volume center with an experienced team. Methods A longitudinalstudy of all PDs completed in our department between 2012 and 2017 was performed. Results A total of 28 PD were performed during this period. Pylorus-preserving PD was performed in 23 patients and classical PD in the remaining. A separate Roux-en-Y loop was used for high-risk pancreatic anastomosis in six cases. The mean patient age was 49.3±12.4 years. The male-to-female ratio was 1.3:1. Preoperative drainage procedures were carried out in 19 patients. The mean serum total bilirubin level was 3.98(±4.5) mg/dL. There was no 90-day mortality. Postoperative complications included wound infection in 10 (36.7%)and respiratory complications in 10 (36.7%) patients. Postoperative bleeding requiring intervention occurred in one patient, and two patients had an anastomotic leak (one pancreatojejunostomy (PJ) and one gastrojejunostomy (GJ)). Delayed gastric emptying (DGE) was noted in three (10.7%) patients. The mean length of hospital stay was 14±7 days. The median overall survival (OS) was 84 months. Conclusion Comparable early outcomes can be achieved at low-volume centers for patients undergoing PDwith an experienced team, optimal patient selection, and the ability to rescue for complications.

Impact of route of reconstruction of gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A prospective randomized study.

Pancreaticoduodenectomy (PD) is commonly performed pancreatic procedure for tumors of periampullary region. Delayed gastric emptying (DGE) and pancreatic fistula are the most common specific complications following PD. DGE can lead to significant morbidity, resulting in prolonged hospital stay and increased cost. Various factors might influence the occurrence of DGE. We hypothesized that kinking of jejunal limb could be a cause of DGE post PD. Antecolic (AC) and retrocolic (RC) side-to-side gastrojejunostomy (GJ) groups in classical PD were compared for the occurrence of DGE in a prospective study. All patients who underwent PD between April 2019 and September 2020 in a tertiary care center in south India were included in this study. After classic PD, RC GJ was found to be superior to AC in terms of DGE rate (26.7% vs. 71.9%) and hospital stay (9 days vs. 11 days). Route of reconstruction of GJ can influence the occurrence of DGE as RC anastomosis in classical PD provides the most straight route for gastric emptying.

Salvage endoscopic ultrasound-guided gastrojejunostomy as a bridge to definitive surgical therapy for duodenal adenocarcinoma presenting with duodenal stent obstruction

The utilization of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) in the setting of an obstructed (ingrown) duodenal stent as a bridge to pancreaticoduodenectomy (PD) remains undescribed. Herein, we report a case study of a 51-year-old patient who underwent EUS-GJ using lumen apposing metal stent (LAMS) for an obstructed duodenal stent during neoadjuvant treatment for duodenal adenocarcinoma. The patient ultimately underwent surgical resection by a classic PD 14 weeks after LAMS placement. EUS-GJ using LAMS represents a potential option as a salvage bridge to surgery for duodenal obstruction in the setting of an obstructed duodenal stent.

Retrocolic gastrojejunostomy in pancreaticoduodenectomy reduces rates of delayed gastric emptying

Background: Delayed gastric emptying (DGE) is one of the most common postoperative complications in patients following pancreaticoduodenectomy (PD). This complication has been shown to effect 14-30% of patients postoperatively. Many randomized studies have shown no statistical difference between pylorus-sparing PD vs. classic PD. Additionally, the position of the anastomosis in classic PD, antecolic versus retrocolic, has also undergone randomized trials which have shown no difference in rates of DGE. The aim of this study was to report our incidence of DGE after a departmental change to a stapled retrocolic loop gastrojejunostomy as a result of high DGE with antecolic approach. The secondary aim was to identify risk factors for developing DGE on multivariate analysis.

Pylorus-Preservation Pancreatoduodenectomy Is Associated with Higher Rate of Delayed Gastric Emptying in Patients with Intermediate/High Risk for Pancreatic Fistula

INTRODUCTION: The association between delayed gastric emptying (DGE) and pylorus-preserving pancreatoduodenectomy (PPPD) vs classic pancreatoduodenectomy (PD) remains controversial. This study aims to identify preoperative and intraoperative factors associated with DGE based on the well-established pancreatic fistula risk score (FRS). We hypothesized that a stratified approach to surgical technique selection may be beneficial given the association of DGE with postoperative pancreatic fistula (POPF). METHODS: The 2014 to 2019 NSQIP pancreatectomy Participant User Data File (PUF) was queried for patients who underwent PPPD or PD. Multivariable logistic regression assessed perioperative characteristics associated with DGE. Sensitivity analyses stratified patients into negligible/low (FRS ≤2) or intermediate/high (FRS ≥3) cohorts based on their risk for clinically relevant POPF (CR-POPF). RESULTS: DGE was present in 15.5% of the overall cohort (N = 2,197/14,181), in 16.3% (N = 948/5,799) of the PPPD group, and in 14.9% (N = 1,249/8,382) of the classic PD group; 6.4% of patients (N = 903/14,181) were in the negligible/low-risk and 93.6% (N = 13,278) were in the intermediate/high-risk CR-POPF subgroups. In adjusted analysis of the overall cohort, patients who underwent PPPD were more likely to develop DGE (odds ratio [OR] 1.1, p = 0.02). In the negligible/low-risk CR-POPF subgroup, there was no association between DGE and PPPD (OR 1.05, p = 0.82). In the intermediate/high-risk CR-POPF subgroup, PPPD was significantly associated with DGE (OR 1.1, p = 0.04; Table). Table. - Predicting Delayed Gastric Emptying after Pylorus-Preserving vs Classic Pancreaticoduodenectomy, Stratified by Fistula Risk Score Surgical approach, pylorus preserving vs classic pancreatoduodenectomy Risk of clinically relevant- postoperative pancreatic fistula Adjusted odds ratio* 95% CI p Value Overall 1.11 1.01–1.22 0.02 Negligible/low risk 1.05 0.69–1.60 0.82 Intermediate/high risk 1.11 1.01–1.22 0.04 *Adjusted for age, sex, race, ASA class, history of comorbidities (eg smoking, hypertension, diabetes, blood disorder, weight loss, jaundice), preoperative stent placement, preoperative chemotherapy/radiation therapy, drain placement, pancreas gland texture, and duct size. CONCLUSION: Pylorus preservation in PD may have greater odds for developing DGE, driven by an increased association in patients who are at intermediate/high risk for CR-POPF. Use of the FRS for intraoperative decision-making regarding management of the pylorus may help minimize postoperative morbidity.

S58 Endoscopic Retrograde Cholangiopancreatography After Pancreaticoduodenectomy and the Utility of Rigidizing Overtube in Improving Procedural Success – A Tertiary Cancer Center Experience

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge in patients with a pancreaticoduodenectomy (PD). Advances in endoscopic technology may improve success of the ERCP after PD. Herein we report outcomes of ERCP after PD at a tertiary cancer center. We also summarize our experience with the use of a novel rigidizing overtube (RO) for ERCP post- PD. Methods: We performed retrospective review of patients with prior classic or pylorus-preserving PD who underwent ERCP with Pathfinder use at MD Anderson Cancer Center from 2006 to 2021. Outcomes included technical success (TS) rate, which was defined as successful cannulation of biliary tree and treatment of stricture with dilation or stent placement when applicable, and clinical success (CS) rate, defined as improvement in patient symptomatology with or without normalization of bilirubin level. Results: A total of 48 patients underwent 102 ERCPs; RO was used in 11 procedures (Table). ERCP was most commonly done for cholangitis in index and repeat cases. In cases where RO was used, 63.6% had biliary obstruction without cholangitis. TS was achieved in 81% of cases without RO and 91% cases with RO. Stent placement was done in 60% and 64% of cases without and with RO, respectively. The CS rate was 67%% and 100% of cases without and with RO, respectively. The overall adverse event rate was 5%. All adverse events occurred in cases where no RO was used, with an adverse event rate of 6% in cases without RO used; no complications were noted in the RO cases. Conclusion: ERCP after PD, despite being technically challenging, carries a favorable success rate. TS of ERCP after PD may be improved with use of RO based on our limited experience. There is a need of randomized controlled trials to further ascertain the utility of RO in improving TS and CS of ERCP in surgically altered anatomy. (Figure)Figure 1.: ERCP After Pancreaticoduodenectomy: Patient Characteristics and Indication for ERCP Table 1. - ERCP Results ERCP without Rigidizing Overtube ERCP with Rigidizing Overtube Technical Success, n (%) 74/91 (81.0%) 10/11 (90.9%) Clinical Success, n (%) 57/85 (76.2%) 10/10** (100.0%) Adverse Events, n (%) 5/91 (6.0%) 0/11 (0.0%) Post-procedure Fever, n (%) 4/5 (80.0%) - Cholangitis, n (%) 1/5 (20.0%) - **No follow-up data available for 1 case.

S1833 Single Operator Cholangioscopy in a Patient With Pancreaticoduodenectomy

Introduction: Cholangioscopy in patients with surgically altered anatomy can be technically challenging. In most patients with pancreaticoduodenectomy undergoing single operator cholangioscopy, the most common approach is through a percutaneous biliary drain placed by interventional radiology. We present a case in which a modified therapeutic upper endoscope (1T scope) was used for single operator cholangioscopy in a patient with pancreaticoduodenectomy. Case Description/Methods: A 64-year-old female with Gardner syndrome requiring colectomy and classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presented for surveillance endoscopy. She previously underwent endoscopic mucosal resection and intraductal radiofrequency ablation (RFA) of adenomatous tissue at the hepaticojejunal (HJ) anastomosis. She subsequently developed a stricture at the HJ anastomosis needing sequential dilations. A 1T scope was used and advanced to the HJ anastomosis. After balloon dilation of the HJ anastomotic stricture, cholangioscopy was performed and revealed abnormal biliary mucosa (Figure) approximately 2 cm below the hilum raising concern for intraductal extension of adenomatous tissue. Cholangioscopy directed biopsies were obtained and pathology revealed tubular adenoma without high-grade dysplasia. Intraductal RFA is planned in the future. Discussion: ERCP in patients with pancreaticoduodenectomy can be challenging. Different endoscopes have been used to overcome some challenges of ERCP in altered anatomy, each offering certain advantages and limitations. Commonly used endoscopes for ERCP in patients with pancreaticoduodenectomy include the adult and pediatric colonoscopes and single balloon enteroscope. These endoscopes do not allow for performing single operator cholangioscopy due to the length of the scope or the width of the accessory channel. Our report highlights that the 1T endoscope allows for performing single operator cholangioscopy in patients with prior pancreaticoduodenectomy when the HJ anastomosis can be reached.Figure 1.: Intraductal extension of adenomatous tissue seen on cholangioscopy.

Single-operator cholangioscopy in a patient with prior pancreaticoduodenectomy.

A 64-year-old woman with a history of Gardner syndrome requiring classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presents for follow-up of adenomatous tissue at the hepaticojejunal anastomosis ([Fig. 1]) with an intraductal extension of adenomatous tissue ([Fig. 2]). She previously underwent endoscopic mucosal resection (EMR) of the adenomatous tissue and intraductal radiofrequency ablation (RFA) ([Fig. 3]). After EMR and RFA, the patient developed a stricture at the hepaticojejunal anastomosis. Subsequently, stricture dilations at the anastomosis were performed. The decision was made to perform cholangioscopy to evaluate for intraductal extension of adenomatous tissue ([Video 1]). A modified therapeutic upper endoscope (1T; GIF-1TH190 Olympus, Center Valley, Pennsylvania, United States) was used and advanced to the anastomosis. Cholangioscopy showed intraductal extension of adenomatous tissue. Cholangioscopy-directed biopsies were obtained. Pathology revealed tubular adenoma without high grade dysplasia. Repeat intraductal RFA is planned.

Pancreaticoduodenectomy with Total Mesopancreas Excision for Pancreatic Head Cancer. Impact on Postoperative Complications

Introduction: Pancreatic ductal head adenocarcinoma (PDHAC) is a lethal disease with poor prognosis and surgical resection with complete microscopic resection (R0) in association with multimodal treatment currently represents the only curative strategy. Classical pancreaticoduodenectomy (PD) has a postoperative mortality of 5% and postoperative complications can be as high as 25-70%.

Curative resection of bladder cancer with pancreas head metastasis

Bladder cancer is the 9th most frequent cancer worldwide. Its incidence is increasing. The pancreas is an infrequent site of metastasis in relation to any type of malignancy. In this study, we report our experience with a patient who has undergone a pancreaticoduodenectomy for metastatic bladder cancer. A 61-year-old male was admitted with jaundice and pancreas head mass. He underwent robot assisted-cystectomy and ileal conduit for bladder cancer 7 months ago. Initial diagnosis under the imaging study was a resectable pancreas head cancer. However, we did not rule-out a metastatic bladder cancer. He underwent a classic pancreaticoduodenectomy. Based on histologic findings and immunohistochemistry results, a pancreas tumor with 4.9-cm sized metastatic urothelial carcinoma was diagnosed. He experienced no complication. He was discharged 11 days after the surgery. Four cycles of gemcitabine and cisplatin were administered. He remained recurrence-free of tumors for 16 months. Although the benefit of pancreatectomy for patient survival has been reported for metastases from renal cell carcinoma, it is unknown for bladder cancer because of no report. We believe that curative resection for metastasis to pancreas of urothelial carcinoma might be helpful for its management.

Contemporary Surgical, Oncological, and Survival Outcomes of Pancreaticoduodenectomy for Periampullary Tumours: a 5-Year Experience from Tertiary Cancer Center.

With advances in surgical management of pancreaticoduodenectomy (PD), mortality rate for PD has been reported to be less than 5%. Postoperative pancreatic fistula (POPF) remains a major complication and morbidity after PD with incidence of up to 40%. This is a retrospective analysis of patients who underwent PD in a tertiary cancer referral center in southern India. Data was collected for the patients operated during the period from Jan 2014 to Dec 2018. Surgicopathological, oncological, and survival outcomes were described. Of 76 patients presumed as operable, 16 were excluded and data analyzed for 60 patients. Forty-four percent underwent classical Whipple's PD and 56% pylorus-preserving PD. The most common postoperative complications were wound infection (25%); pneumonia (20%); clinically relevant POPF (13%); and delayed gastric emptying (19%). Thirty-day in-hospital mortality was 5%, 90-day mortality was 8.3%, and fistula-related mortality was 1.6%. Ampullary cancer was the most common histology. Three-year survival rate was 23.3% with a mean overall survival of 33.2months with significantly better survival in the node negative than positive group (41.3 vs 20.5months, P = 0.003) and significantly lower survival in pancreatic head cancer than other tumor histologies (16.6 vs 37.3months, P = 0.002). Multivariate analysis has shown pancreatic head histology (HR = 2.38, 95% CI (1.08-5.26), P = 0.033) and nodal positivity (HR = 2.38, 95% CI (1.27-4.44), P = 0.007) as poor prognostic factors. Pancreaticoduodenectomy is a safe operation in experienced hands. Adhering to a meticulous adaptable reproducible anastomotic technique with standard perioperative management strategies significantly decreases the operative morbidity and mortality.

Multiple Endocrine Neoplasia Type 1 with Concomitant Existence of Malignant Insulinoma: A Rare Finding

Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome of autosomal dominant inheritance defined by co-occurrence of two or more tumors originating from the parathyroid gland, pancreatic islet cells, and/or anterior pituitary. Insulinoma which has an incidence of 0.4% is a rare pancreatic neuroendocrine tumor. Malignant insulinoma is extremely rare, while primary hyperparathyroidism is a common occurrence in MEN1. We present a case of MEN1 syndrome with 2.6 cm insulinoma in the pancreatic head and parathyroid adenoma in a 56-year-old female who presented with symptoms suggestive of hypoglycemia like multiple episodes of loss of consciousness for four years. Classical pancreaticoduodenectomy was carried out, and the postoperative period was uneventful. Later, subtotal parathyroidectomy was performed, which showed parathyroid adenoma. Patients presenting with features of hypoglycemia should be vigilantly assessed for the presence of a sinister pathology.

Curative resection of bladder cancer pancreas head metastasis

Bladder cancer is the 9th most frequent cancer worldwide and the incidence is increasing. The pancreas is an infrequent site of metastasis in relation to any type of malignancy. In this study, we report our experience with patient who underwent pancreaticoduodenectomy for metastatic bladder cancer. In this study, we report our experience with patient who underwent pancreaticoduodenectomy for metastatic bladder cancer. A 61-year-old man was admitted with jaundice and pancreas head mass. He been received Robot assisted-cystectomy and ileal conduit for bladder cancer 7 months previously. Initial diagnosis under the imaging study was resectable pancreas head cancer but we didn't rule-out the metastatic bladder cancer. He was underwent a classic pancreaticoduodenectomy. Based on the histologic findings and immunohistochemistry result, the pancreas tumor was diagnosed as 4.9 cm sized metastatic urothelial carcinoma. He experienced no complication and was discharged 11 days after surgery. Four cycles of Gemcitabine and cisplatin were administered and he remained recurrence-free of tumors for 16 months. The benefit of pancreatectomy in terms of patients of survival has been reported for metastases from renal cell carcinoma, but this is not known in bladder cancer because of no report. We believe that curative resection for metastasis to pancreas of urothelial carcinoma might be helpful to manage.

Pancreaticogastrostomy as a choice of reconstruction after pancreaticoduodenectomy: a hospital based observational study

Background: The aim of this study was to compare the rate of occurrence of post-operative pancreatic fistulae (POPF) and other complications with pancreaticogastrostomy (PG) or pancreatojejunostomy (PJ) as a choice of reconstruction in classic Whipple’s Procedure.Methods: A hospital based prospective observational study collected data of 60 patients who underwent Whipple’s procedure from June 2018 to august 2019, in two different surgical units, where one-unit preferred PG as routine while the other unit preferred PJ.Results: Two out of 30 patients who underwent PG (Group A) developed POPF while Nine out of 30 patients who underwent PJ (Group B) developed POPF (p-value = 0.04) indicating a significant difference in outcome. The duration of hospital stay (DOHS) in our study in Group A was 12.82±1.74 days when compared to Group B was 13.88±2.01 days (p-value = 0.042).Conclusions: Our results indicate that the preferred reconstruction after classic Pancreaticoduodenectomy should be Pancreaticogastrostomy, but further validation with randomized control trials or multicenter studies with larger sample size are required.

S3081 The Common Clinical Manifestations and Interventions for Post-Pancreaticoduodenectomy-Related Adverse Events

INTRODUCTION: Despite improvements in surgical technique in pancreaticoduodenectomy (PD), postoperative morbidity is still present 30-40% of the time. Thus, as the indications for pancreatic resection have broadened, endoscopic retrograde cholangiopancreatography (ERCP) has become essential in the management of post-PD-related adverse events (AE). In this study, we characterized the common clinical manifestations and interventions performed for post-PD-related AEs. METHODS: We retrospectively evaluated patients with prior classic or pylorus-preserving PD who received ERCP from 01/13/06 - 01/16/19. The pertinent demographic information, oncologic history, and follow-up information were extracted. Outcomes included technical success rate - the ability to treat stricture with dilation or stent placement, and clinical success rate - a documented decrease in bilirubin to normal or 50% of peak value within 2 weeks. Statistical analysis was done using Stata/SE version 16.0. RESULTS: A total of 28 patients (75% male; median age 66 years, range 22-86 years) with prior PD received 66 ERCPs for choledochojejunostomy (25 patients received 63 ERCPs) and pancreaticojejunostomy (3 patients received 3 ERCPs) evaluation. All 3 ERCPs for pancreatic assessment were unsuccessful. PD was most commonly performed for pancreatic adenocarcinoma (n = 15) and pancreatic neuroendocrine tumor (n = 5) [Table 1]. A total of 11 patients received neoadjuvant therapy: 8 had chemoradiation, 3 had chemotherapy only. Most cases were performed with an advanced fellow and had a median duration of 56.5 min (range 12.0-161.0). The most common indications for initial ERCP were cholangitis (n = 15) and biliary obstruction without cholangitis (n = 7). An additional 38 ERCPs were necessary in 9 patients (median 4 ERCPs/patient; range 2-13/patient) most commonly for cholangitis (n = 17) and biliary stricture (n = 10) [Table 2]. All strictures were treated with balloon dilation and a total of 38 stents were placed. The technical success rate was 81.0% (51/63 ERCPs) and the clinical success rate was 76.2% (48/63 ERCPs). Procedure-related-AEs occurred in 5/66 ERCPs (7.6%): 4 cases of self-resolving fever, 1 case of mild cholangitis. CONCLUSION: Patients with prior PD commonly require routine ERCP for the management of postoperative AEs. ERCP is an effective and safe treatment modality for post-PD-related hepatobiliary sequela, but improvements are necessary for pancreatic intervention.Table 1Table 2

Survival outcomes of pancreaticoduodenectomy versus extended pancreaticoduodenectomy procedure for pancreatic head carcinoma: a propensity score matching study.

BackgroundIt is unclear if the modified extended pancreaticoduodenectomy (PD) has better outcome superior the conventional PD for patients with pancreatic head carcinoma (PHC). The objective of this study is to compare the survival outcomes of the classic PD procedure and the modified extended PD procedure for PHC.MethodsA total of 7,084 resected PHC patients with PD and extended PD procedure from the SEER database from 2004 to 2014 were stratified. With the utilization of propensity score matching (PSM), patient baseline characteristics were balanced to decrease the bias. Overall survival (OS) and cancer-specific survival (CSS) were analyzed in both groups.ResultsOf the 7,084 patients, 6,541 (92.3%) and 543 (7.7%) patients received PD and extended PD surgical procedures, respectively. After 2:1 ratio of PSM, 543 patients with extended PD procedure and 1,084 patients with PD procedure were completely matched. The median CSS and OS for PD and extended PD group were 20.0 and 19.0 months, and 19.0 and 18.0 months, respectively. The 5-year CSS and OS rates for PD and extended PD group were 17.5% and 16.1%, and 13.9% and 13.1%, respectively.ConclusionsThere is no distinct difference in survival outcomes between PD and extended PD procedure in patients with PHC.

2625 Intussusception After Classic Pancreaticoduodenectomy With a Roux-en-Y Pancreatico-hepaticojejunostomy

INTRODUCTION: Intussusception in adults is uncommon, accounting for 1%–5% of all intussusception cases. It usually occurs because of a lead point, frequently malignancy or adhesions from previous surgery. Here we report an exceedingly rare case of jejunal intussusception into the gastric lumen in a patient after classic pancreaticoduodenectomy with a Roux-en-Y pancreatico-hepaticojejunostomy. CASE DESCRIPTION/METHODS: A 49 year-old male with Down syndrome, celiac disease and surgical history significant for classic pancreaticoduodenectomy (Whipple procedure) with a Roux-en-Y pancreatico-hepaticojejunostomy for pancreatic mass with distal bile duct stricture and duodenal stricture presented with one-day history of abdominal pain. He was minimally verbal due to Down's syndrome however pointed to his upper and lower abdomen. Associated symptoms included mild nausea but no emesis, melena or hematochezia. Abdominal examination was negative for any mass or peritoneal signs. Initial labs were remarkable for only mild anemia; while blood cell count and lactic acid were normal. A CT scan demonstrated an approximately 7-cm length of jejunum protruding into the lumen of the stomach at the gastrojejunostomy site concerning for intussusception, but no high-grade mechanical obstruction observed. EGD showed intussusception of the blind jejunal limb with healthy appearing mucosa and jejunum biopsies were obtained to rule out ischemia; examination of gastrojejunal anastomotic site and the jejunum (efferent limb) was otherwise normal. Endoscopic reduction of intussusception was attempted but was unsuccessful. Remaining hospital course was uneventful. He was tolerating diet, having proper bowel movements and his abdominal pain resolved. No surgical intervention for repair was planned as he continued to improve clinically and he was safely discharged home. He was seen in surgery clinic a few months later and remained asymptomatic. DISCUSSION: Intussusception is a rare entity in adults and only a few cases have been reported after Whipple procedure. Diagnosis of intussusception in adults, regardless of previous surgeries, is primarily through imaging because presenting symptoms are often vague and nonspecific. Surgical management is often required. However, in our patient, due to the absence of bowel obstruction or ischemia, surgical intervention was not needed. This case highlights that intussusception should be considered as a potential diagnosis in patients with history of Whipple presenting with vague abdominal symptoms.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

Multicystic adenomatoid hamartoma of the pancreas

Abstract Multicystic adenomatoid hamartoma is an extremely rare tumor of the pancreas, with only 4 other cases reported in the literature. We report a case of a 4-year old boy who presented with an 8 month history of abdominal pain, steatorrhea, and failure to thrive. Work-up showed severe pancreatic insufficiency and a large, multiseptated, cystic mass originating from the head of the pancreas and compressing the duodenum. The child underwent a classic pancreaticoduodenectomy with portal vein reconstruction. He tolerated the procedure well and has been seen in follow-up.