Pancreatic Head Tumor Research Articles

Etiology, Clinical Presentations, and Short-Term Treatment Outcomes of Extrahepatic Obstructive Jaundice in South-Western Uganda.

BackgroundThe diagnosis of extrahepatic obstructive jaundice (EHOJ) remains a challenge and is often made late in low-resource settings. Systematic data are limited on the etiology and prognosis of patients with obstructive jaundice in Uganda. The objective of this study was to determine the etiology, clinical presentations, and short-term treatment outcomes of patients managed for EHOJ at Mbarara Regional Referral Hospital (MRRH) in south-western Uganda.MethodsBetween September 2019 and May 2020, we prospectively enrolled a cohort of patients who presented with EHOJ at MRRH. A pretested, semi-structured data collection tool was used to abstract data from both the study participants and their files.ResultsA total of 72 patients, 42 (58.3%) of whom were male with a median age of 56 (range of 2 months to 95 years) were studied. Forty-two (58.3%) participants had malignancies: Pancreatic head tumors 20 (27.8%), cholangiocarcinoma 13 (18.1%), duodenal cancers 5 (6.94%), and gall bladder cancer 4 (5.6%). The remaining 30 (41.7%) participants had benign etiologies: choledocholithiasis 10 (13.9%), biliary atresia 7 (9.7%), pancreatic pseudo cyst 6 (8.3%), Mirizzi syndrome 5 (6.9%) and 1 (1.4%) each of chronic pancreatitis and choledochal cyst. Sixty-seven (93.1%) patients presented with right upper quadrant tenderness, 65 (90.3%) abdominal pain and 55 (76.3%) clay-colored stool. Cholecystectomy 11 (25.6%) and cholecystojejunostomy + jejunojejunostomy 8 (18.6%) were the commonest procedures performed. Twelve (17.0%) of cases received chemotherapy (epirubicin/cisplatin/capecitabine) for pancreatic head tumors and (gemcitabine/oxaliplatine) for cholangiocarcinoma. Mortality rate was 29.2% in the study, of which malignancy carried the highest mortality 20 (95.24%).ConclusionMalignancy was the main cause of EHOJ observed in more than half of the patients. Interventions aimed at early recognition and appropriate referral are key in this population to improve outcomes.

Prognostic Value of the Regional Lymph Node Station in Pancreatic Neuroendocrine Tumor.

Little is known regarding the impact of lymph node dissection on survival benefit after curative resection for pancreatic neuroendocrine tumor (PNET). This study aimed to evaluate the efficacy of lymph node dissection based on tumor location of PNET. A retrospective study, including 50 patients with surgical resection for PNET between 2004 and 2020, was performed. The efficacy index (EI) was calculated by multiplication of the incidence of lymph node metastasis (LNM) at the station and the 5-year survival rate of patients with LNM at the station. In the pancreatic head tumors, the peri-pancreatic head and superior mesenteric artery lymph node stations had high EI of 13.3 and 25, respectively. In contrast, other stations, including stations 8 and 12, had zero EI. In the pancreatic body and tail tumors, only the splenic artery lymph node station had a survival benefit from lymph node dissection with an EI of 6.7. The extent of lymph node dissection for PNET should be decided based on the efficacy of lymph node dissection in accordance with tumor location. Our findings may be helpful in determining the extent of lymph node dissection required.

Multiple vascular reconstructions during pancreatectomy: Surgical techniques and strategies.

Pancreatic body and tail tumors account for one-third of all pancreatic tumors and can be diagnosed later than pancreatic head tumors because they present symptoms much later. When analyzed, most of them are generally unresectable because they are invaded into adjacent organs and vascular structures. We aimed to present our cases of vascular resection and anastomosis, where isolated tumor resection cannot be performed due to invasion of adjacent vascular structures. Between January 2019 and January 2021, the files of eight patients who had one or more vascular invasions due to the pancreatic body and tail tumor and therefore underwent vascular resection in addition to pancreatectomy were accessed. Portal vein and hepatic artery repair were performed in all eight patients. Superior mesenteric artery anastomosis was performed in four patients, inferior vena cava repair was performed in two patients, and renal vein anastomosis was performed in two patients. Primary end-to-end repair, Dacron graft, ring-enforced polytetrafluoroethylene graft, and saphenous vein graft techniques were used during vascular interventions. We wanted to share our experience with the resection of vascular structures and anastomosis techniques. We believe that the indications of tumor surgery can be improved and redesigned by performing more routinely vascular resections and reconstructions in the future.

Assessing the Role of Operative Intervention in Elderly Patients With Nonfunctional Pancreatic Neuroendocrine Neoplasms.

Resection of locoregional pancreatic neuroendocrine neoplasms (PanNENs) is typically recommended, but there is a paucity of data on the management of elderly patients. The National Cancer Database (2004-2016) was queried for patients 80 years or older with localized PanNENs. Patients were grouped as nonoperative or operative management. Postoperative outcomes and survival were compared. In total, 591 patients were included: 202 underwent resection, and 389 did not. Increasing age and pancreatic head tumors were associated with lower likelihood of resection. The overall 90-day mortality rate was 6.4%, which was higher for pancreatoduodenectomy than distal pancreatectomy (13.6% vs 5.1%, respectively). Operatively managed patients had longer median survival (80.8 vs 45.0 months, P < 0.001), and this association was independent of tumor location. On multivariable Cox regression, resection remained associated with longer survival (hazard ratio, 0.69; 95% confidence interval, 0.50-0.95). Among operatively managed patients, age and tumor location were not associated with survival; however, greater comorbidity and high-risk tumor-specific features were associated with worse survival. Resection of nonfunctional PanNENs in elderly patients is associated with improved survival compared with nonoperative management. Resection could be considered in appropriate operative candidates, regardless of tumor location, but the perioperative mortality rate must be considered.

The effect of preoperative biliary stent on postoperative complications after the resection of pancreatic head tumour

Introduction. A preoperative biliary stent is often inserted because of obstructive jaundice due to pancreatic head tumour. However, it can also be the source of complications too. Aim and method. We retrospectively analyzed our operations which were performed between 01.10.2017 and 31.12.2019 for pancreatic tumour in association with stent related mortality and morbidity. The multiresistant bacteria and the spectrum of microorganism of intraoperative bile samples were investigated. Results. 82 patients were operated on with pancreatic tumour. There were 63 pancreatic head resections, and 19 palliative operations. 63 pancreatic head resections were analyzed. There were 36 open and 27 laparoscopic operations. Extended operation was needed in 12 cases (5 portal vein resections, 2 splenectomies, 1 right hepatolobectomy, 1 right hemicolectomy, 2 liver metastasectomies and 1 hepatic artery resection). The average age of 36 stented patients of which 24 were men and 12 women were 65 and 64 years respectively. The average age of 27 non-stented patients of which 14 were men and 13 were women, were 67.9 and 58 years respectively. The bile culture proved to be positive 30/36(83%) in the stented group and 13/27(48%) in the non-stented group (P= 0.005). The 3 most common bacteria were E coli, Enterococcus fecalis andKlebsiella pneumoniaein both groups followed by the yeast of Candida. 8 multiresistant bacteria were noticed in the stented group. 6 were ESBL producing (P= 0.033) and 2 vancomycine resistant (P= 0.5) bacteria. 3 patients of the stented group and 2 patients of the non-stented group were lost during the first 30 days. There were 4/0 wound infections, 6/2 haemorrhages, 2/2 pancreatic fistulas, and 2/3 abdominal abscesses in the stented vs. non stented groups. The average length of stay was 19.47 days in the stented and 14.62 days in the non-stented groups (P= 0.14). Conclusion. With regard to the fact that biliary stent changes the bacterial flora it is important to choose the proper antibiotic prophylaxis to reduce morbidity. On the basis of our own results and the literature an effective antibiotic therapy is suggested against enterococcus and ESBL producing bacteria. The prophylaxis against yeast in particularly in immunocompromised cases should also be considered. Regular antibiotic resistance check-up is essential.

Actinomycosis mimicking a pancreatic head neoplasm: A case report

IntroductionActinomycosis is a chronic suppurative disease caused by a filamentous, Gram-positive, facultative anaerobic bacterium Actinomyces. Abdominal actinomycosis accounts for 10 to 20% of reported Actinomyces infections and pancreatic involvement is extremely rare.Presentation of caseWe report the case of a 64-year-old man who presented with a 3-week history of abdominal pain, nausea, weight loss, and icterus. Abdominal CT scan revealed a 3.5 cm heterogeneously enhanced mass of the pancreatic head, associated with mild dilation of the main bile duct and the Wirsung duct. The diagnosis of pancreatic head malignancy was highly suspected and surgical management was decided. Intraoperatively, a 3 cm indurated mass of the pancreatic head was found. Whipple's procedure was performed. Histopathological examination revealed pancreatic actinomycosis.DiscussionPancreatic actinomycosis is extremely rare. To our knowledge, only 18 cases have been reported in the English literature to date. It commonly presents as a slow-growing mass with bile and pancreatic ducts obstruction, which can mimic malignancy. Therefore, it has often been misdiagnosed and over-treated with futile surgery, when medical treatment based on antibiotherapy is the only required treatment.ConclusionWe reported a rare observation of surgical management of actinomycosis mimicking a pancreatic head neoplasm. As clinical and radiological findings are nonspecific, the accurate diagnosis can only be made by histology. Through our case, we aim to highlight the importance of preoperative suspicion of pancreatic actinomycosis, given the still relevant morbidity of pancreatic resections.

Tumor-to-tumor metastasis: an extremely rare combination with renal cell carcinoma as the donor and a pancreatic neuroendocrine tumor as the recipient

BackgroundTumor-to-tumor metastasis is a rare phenomenon in which primary tumor cells metastasize hematogenously into another tumor. Herein, we report an extremely rare case of a renal cell carcinoma metastasis into a pancreatic neuroendocrine tumor exhibiting a tumor-to-tumor metastasis. Ours is the third reported case worldwide.Case presentationThe patient, a 72-year-old male, was referred to our hospital for further examination and treatment due to high levels of prostate-specific antigen. A left renal tumor and pancreatic head tumor were revealed incidentally on screening computed tomography. There were suspected to be a renal cell carcinoma and primary pancreatic neuroendocrine tumor or pancreatic metastasis from the renal cell carcinoma according to preoperative examination. The left nephrectomy and subtotal stomach-preserving pancreaticoduodenectomy were performed because of the pancreatic tumor indicated for operation in either case of diagnosis. Postoperative pathological examination showed a diagnosis of clear cell renal cell carcinoma for the left renal tumor. The pancreatic tumor was diagnosed with clear cell renal cell carcinoma metastasis into the pancreatic neuroendocrine tumor, that is to say tumor-to-tumor metastasis.ConclusionIn some cases, conservative approach is selected for pancreatic neuroendocrine tumor patients who meet some requirements. However, if such patients exhibit tumor-to-tumor metastasis which combines with renal cell carcinoma and pancreatic neuroendocrine tumor as this case, conservative approach leads to progression of renal cell carcinoma. Therefore, conceiving the possibility of tumor-to-tumor metastasis, it is necessary to carefully choose a treatment plan for pancreatic neuroendocrine tumor patients associated with renal cell carcinoma, not easily choosing conservative approach.

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

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

The Need for Pancreatic Enzyme Replacement Therapy (PERT) after Pancreatic Surgery is Determined by Tumor Location: A Prospective Cohort Study

Introduction: Patients undergoing oncologic pancreatic surgery are at risk for pancreatic exocrine insufficiency (PEI) and for needing PERT. There are few well-designed studies on the magnitude of this risk. Methods: In 198 patient undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for oncologic indications, we performed an 13C-labeled mixed-triglyceride breath test, immediately preoperative and approximately 6 weeks postoperative. This test gives an idea of the pancreatic remnant lipase-activity analyzing the 13CO2 in breath after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative 13CO2 recovery after 6 hours is expressed as ‘MTG%’ and a level <23% confirms PEI and the need for PERT. Results: In 159 patients undergoing PD for a pancreatic head tumor, MTG% decreased significantly from 33.69% to 15.61% postoperative (p=0.002) (table 1). The percentage patients diagnosed with PEI and need for PERT increased from 23.0% to 68.3% postoperative (p<0.001). This decrease in exocrine function was significant in all pathology subgroups (figure 1), but most important in pancreatic adenocarcinoma. The postoperative percentage PEI in this subgroup increased to 78.1%. The decrease in function was less pronounced, but still significant, in pancreatic neuroendocrine tumor and ampullary tumor patients (p=0.002). In contrast, 39 patients undergoing a DP for a body-tail tumor did not experience any significant change in exocrine function. Conclusion: Patients with a pancreatic head tumor treated with PD experience a significant drop in exocrine function, are at high risk for developing PEI and consequently need for PERT. Therefore, systematic screening for PEI is mandatory after PD. Patients undergoing DP rarely need PERT.Tabled 1EP02D-185 Table 1: Evolution MTG% in pancreaticoduodenectomy and distal pancreatectomy patients measured by 13C-labeled mixed-triglyceride breath testPD n=159MTG% median preopMTG% median postopp=Median Δ MTG%MTG% range preopMTG% range postop% PEI preop% PEI postopp=pancreatic adenoca30.6111.48<0.001-16.25.44-53.340.02-34.7326.678.1<0.001ampullary tumor35.5525.73<0.001-13.016.87 -67.22.1 -34.3710.045.00.034PNET38.8927.080.022-7.0618.67 - 127.3117.4 -36.6710.030.0nsIPMN32.615.610.009-5.343.5-52.324.23 -44.1226.760.0nsdist cholangioca34.0222.50.021-7.482.96-43.916.37 - 34.889.154.50.046total group PD33.4915.61<0.0001-14.972.96-127.310.02-64.7323,068.3<0.001DP n=39MTG% median preopMTG% median postopp=Median Δ MTG%MTG% range preopMTG% range postop% PEI preop% PEI postopp=total group DP38.2838.09ns-1.9119.31-56.665.76-48.7310.257.7ns Open table in a new tab

An Age-BMI Compound Variable Predicts Morbidity and Mortality Following Pancreaticoduodenectomy: An NSQIP Analysis

Introduction: Pancreaticoduodenectomy (PD) is the recommended surgical therapy for periampullary lesions including pancreatic head tumors or select iatrogenic and inflammatory conditions. We sought to explore the impact of age and BMI in determining outcomes of PD. Methods: The ACS-NSQIP pancreatectomy targeted file was used to identify PDs from 2014-2019. Patients were stratified into eight different categories according to a compound age-BMI variable and risk-adjusted. Age of 65 years was set for young vs elderly. Obesity was classified as class I (BMI 30-35), class II (BMI 35-40), and class III (BMI >40). Young-normal/overweight-(BMI<30) was considered as the reference group. Results: Young-obese class I (OR 1.23, p = 0.003), young-obese class III (OR 1.54, p = 0.03), and elderly-obese class II (OR 1.51, p-value = 0.003) had statistically significant higher odds of morbidity/mortality. Young-obese class I (OR 1.95, p <0.001), young-obese class II (OR 1.59, p = 0.018), young-obese class III (OR 3.24, p <0.001), elderly-obese class I (OR 1.38, p = 0.008), elderly-obese class II (OR 1.76, p = 0.001), and elderly-obese class III (OR 1.65, p = 0.005) had statistically significant higher odds of postoperative pancreatic fistula formation. Young-obese class I (OR 1.66, p = 0.002), elderly-obese class II (OR 1.96, p = 0.001), and elderly-obese class III (OR 2.19, p = 0.007) had statistically significant higher odds of drain remaining at POD30. Conclusions: The combination of age <65 years and BMI >40 kg/m2 composite variable constitutes a significantly increased risk of postoperative morbidity/mortality and POPF formation post PD.

Multivisceral Resection for Pancreatic Ductal Adenocarcinoma of the Body and Tail: Is it Worth? A Multicentre Retrospective Analysis from Western European Countries

Background: Ductal left-sided pancreatic adenocarcinoma is often associated with poor prognosis due to the delayed diagnosis, with a lower resectability rate compared to pancreatic head tumours. Multivisceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally advanced disease. Methods: We retrospectively analyzed a multicentric cohort of patients operated for ductal left-sided locally-advanced pancreatic adenocarcinoma over 11 years (from 2009 to 2020). Thirteen European high-volume HPB Units participated to this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP. Results: Among 258 patients treated curatively for locally advanced pancreatic adenocarcinoma of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in MVR group (295 min +/- 74 vs. 250min +/- 96, p= 0,248). Post-operative complication rate was comparable between the two groups (46,4 % in MVR group vs. 62,2% in control group, p= 0,108). The incidence of positive margin (R1) was similar between the two groups (8/28, 28,6% vs. 61/230, 26,6%; p=0,827). After a median of follow-up of 25 (9-111) months, overall survival was comparable between the two groups (14/28, 50% vs. 116/230, 50%; p= 0,519). Conclusions: Multivisceral resection in locally-advanced left-sided pancreatic adenocarcinoma is safe and feasible and should be considered in selected cases as it seems provide acceptable surgical and oncological outcomes.

Palliative Surgery in Pancreatic Head Cancer at the University Hospital of Bouaké

<i>Introduction</i>: Cancer of the head of the pancreas is increasing in incidence. It represents 3% of all cancers and 20% of digestive cancers. Diagnosis is most often late. Indeed, 80% of these cancers are discovered at an advanced stage. In this case, the treatment is essentially palliative. The reference treatment is chemotherapy associated with endoscopic treatment if there is obstruction of the bile duct. Palliative surgery is only indicated in the case of intraoperative discovery of a contraindication to a curative surgical procedure. However, this palliative surgery is still in the forefront in low-income countries with limited technical facilities. The aim of this work was to determine the frequency and modalities of palliative surgery in unresectable pancreatic head cancer and to evaluate the results. <i>Methods</i>: Retrospective and descriptive study of the files of patients who underwent palliative surgery for a malignant tumour of the head of the pancreas; operated at the University Hospital of Bouake from January 2011 to December 2020. <i>Results</i>: Palliative surgery was performed in 71 patients, or 80.6% of patients with locally advanced pancreatic head tumour. We performed a double biliary and digestive bypass systematically. The digestive bypass was a gastrojejunal anastomosis in all cases. For the biliary-digestive diversion, different modalities were performed, notably a choledocho-jejunal anastomosis in 53.6% (n=38), a cholecysto-jejunal anastomosis in 38.0% (n=27) and a choledochodenal anastomosis in 8.4% (n=6). The overall morbidity was 22.5% (n=16). Morbidity related to the surgical procedure was 18.3% (n=13). These were biliary leakage (n=6; 8.4%) and parietal bleeding (n=4; 5.6%). Three patients died immediately postoperatively, giving an operative mortality of 4.2%. The mean survival of the patients was 5.8±2.2 months. <i>Conclusion</i>: Palliative surgery occupies a privileged place in our practice, allowing an improvement in the quality of life of the patients without apparent influence on the long-term prognosis which remains appalling. The hope of improving the prognosis lies in early diagnosis and strengthening the technical platform.

Clinical effect of minimally invasive duodenum preserving pancreatic head resection for benign and pre-malignant lesions of pancreatic head

Objective: To examine the clinical effect of minimally invasive duodenum preserving pancreatic head resection(DPPHR) for benign and pre-malignant lesions of pancreatic head. Methods: The clinical data of patients with diagnosis of benign or pre-malignant pancreatic head tumor were retrospectively collected and analyzed,all of them underwent laparoscopic or robotic DPPHR between October 2015 and September 2021 at Division of Gastrointestinal and Pancreatic surgery,Zhejiang Provincial People's Hospital. Thirty-three patients were enrolled with 10 males and 23 females. The age(M(IQR)) was 54(32) years old(range: 11 to 77 years old) and the body mass index was 21.9(2.9)kg/m2(range: 18.1 to 30.1 kg/m2). The presenting symptoms included abdominal pain(n=12), Whipple triad(n=2), and asymptomatic(n=19). There were 7 patients with hypertension and 1 patient with diabetes mellitus. There were 19 patients who were diagnosed as American Society of Anesthesiologists class Ⅰ and 14 patients who were diagnosed as class Ⅱ. The student t test,U test, χ2 test or Fisher exact test was used to compare continuous data or categorized data,respectively. All the perioperative data and metabolic morbidity were analyzed and experiences on minimally invasive DPPHR were concluded. Results: Fourteen patients underwent laparoscopic DPPHR,while the rest of 19 patients received robotic DPPHR. Indocyanine green fluorescence imaging was used in 19 patients to guide operation. Five patients were performed pancreatico-gastrostomy and the rest 28 patients underwent pancreaticojejunostomy. Pathological outcomes confirmed 9 solid pseudo-papillary neoplasms, 9 intraductal papillary mucinous neoplasms, 7 serous cystic neoplasms, 6 pancreatic neuroendocrine tumors, 1 mucous cystic neoplasm, 1 chronic pancreatitis. The operative time was (309.4±50.3) minutes(range:180 to 420 minutes),and the blood loss was (97.9±48.3)ml(range:20 to 200 ml). Eighteen patients suffered from postoperative complications,including 3 patients experienced severe complications(Clavien-Dindo Grade ≥Ⅲ). Pancreatic fistula occurred in 16 patients,including 8 patients with biochemical leak,7 patients with grade B pancreatic fistula and 1 patient with grade C pancreatic fistula. No one suffered from the duodenal necrosis and none perioperative death was occurred. The length of hospital stay was 14(7) days (range:6 to 87 days). The follow-up was 22.6(24.5)months(range:2 to 74 months). None suffered from recurrence or metastasis. During the follow-up,all the patients were free of refractory cholangitis. Moreover,in the term of endocrine dysfunction,no postoperative new onset of diabetes mellitus were observed in the long-term follow-up. However,in the view of exocrine insufficiency,pancreatic exocrine insufficiency and non-alcoholic fatty liver disease (NAFLD) was complicated in 2 and 1 patient,respectively,with the supplement of pancreatic enzyme,steatorrhea and weight loss relieved,but NAFLD was awaited to be seen. Conclusions: Minimally invasive DPPHR is feasible and safe for benign or pre-malignant lesions of pancreatic head. Moreover,it is oncological equivalent to pancreaticoduodenectomy with preservation of metabolic function without refractory cholangitis.

Simultaneous transoral parathyroidectomy and laparoscopic pancreatic resection in type 1 Multiple Endocrine Neoplasia syndrome

The article presents a clinical observation of a patient with type 1 Multiple Endocrine Neoplasia syndrome (MEN 1). During the diagnostic search, a combination of primary hyperparathyroidism, parathyroid adenoma and hormonally inactive pancreatic head tumor was found. Simultaneous transoral parathyroidectomy and laparoscopic resection of the pancreatic head was performed. We haven`t found the literature data describing such kind of operations for MEN 1 syndrome. An original solution was applied to perform intraoperative ultrasonography monitoring. The results of 1-year postoperative follow-up are presented. This observation demonstrates the possibilities of endoscopic technologies in the treatment of MEN 1 syndrome.

Management of post-operative pancreatic fistulas following Longmire\u2013Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy

BackgroundPylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT.MethodsWe included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed.ResultsPGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT.ConclusionsEVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.

Emergent endoscopic ultrasound-guided cholecystoduodenostomy does not prevent R0 resection in a pancreaticoduodenectomy for pancreatic cancer.

Endoscopic ultrasound-guided biliary drainage, mainly choledochoduodenostomy, is commonly used as rescue therapy after Endoscopic Retrograde Cholangiopancreatography (ERCP) in malignant distal biliary obstruction due to un-resectable pancreatic cancer. An alternative when the cystic duct is patent and choledochoduodenostomy is not feasible is performing an Endoscopic Ultrasound-gallbladder drainage. The advent of the Lumen Apposing Metal Stents (LAMS) has shortened and simplified this procedure. However, many concerns exist about the performance of these procedures with metal stents preoperatively in resectable tumors. The evidence about Endoscopic Ultrasound-gallbladder drainage before surgery of pancreatic cancer is scarce. An emergent Endoscopic Ultrasound (EUS)-gallbladder drainage (cholecysto-duodenostomy) was performed due to acute cholangitis in the setting of a resectable pancreatic tumor. Surgery after neoadjuvant therapy was done three months later. A complete resection of tumor was feasible. EUS-guided gallbladder drainage using LAMS does not preclude performing a complete resection of a pancreatic head tumor.

Proposed Model of Dose Escalation in Localized Pancreatic Cancer Patients Eligible for Surgical Exploration: Neoadjuvant Intensity Modulated Radiation Therapy (IMRT) vs. Stereotactic Body Radiation Therapy (SBRT) and Intra-Operative Radiotherapy (IORT)

Multi-agent chemotherapy and radiation therapy (RT) has increased the proportion of locally advanced pancreatic cancer (LAPC) patients (pts) able to undergo resection and improve overall survival compared to those who are not resected. However, prior data from our institution (2016-2019) indicate that despite an R0 rate of 88%, LF developed in > 30% of LAPC pts resected after neoadjuvant therapy (NAT). This high LF rate is a rationale to explore dose escalation (DE) in the NAT setting, as data highlighting the value of DE have been limited to unresectable disease. Importantly, the optimal method for DE remains unclear. While conformal external beam RT can ablate part of the target, under-coverage in close proximity to the stomach and bowel remains problematic. For pancreatic head tumors, Whipple resection presents an opportunity for subsequent DE with IORT, as the duodenum is resected and direct access to microscopic peri-vascular residual disease is allowed. It also allows for precise DE based on the surgeons' recommendations. Herein, we model DE approaches, comparing pre-operative DE-IMRT with an approach in which a high-dose rate (HDR)-IORT boost is given after SBRT, with a goal biological effective dose (BED10) of 100 Gy.Ten consecutive LAPC pts were modeled with both DE-IMRT to 75 Gy in 25 fractions and SBRT to 40 Gy in 5 fractions followed by HDR-IORT to 15 Gy, using an 192Ir source. Notably, to minimize LF after surgery, our clinical tumor volume (CTV) has been the "Heidelberg Triangle" of tissue between the celiac, superior mesenteric, and common hepatic arteries and portal vein, which contains perineural and lymphatic tissue at risk of harboring subclinical disease. A 5mm planning tumor volume (PTV) expansion was used. A 3mm expansion on stomach and bowel was constrained to 60 Gy and 40 Gy for DE-IMRT and SBRT, respectively. For IORT modeling, the Freiburg Flap was superimposed on the planning CT, and dose was prescribed to the target volume surface. Given rapid dose fall-off with HDR-IORT, SBRT was optimized to compensate for IORT under-coverage, with higher dose allowed posteriorly but with an overall hotspot less than 50 Gy. Descriptive statistics were generated for coverage to target structures.With DE-IMRT, mean V75Gy for the CTV and PTV was only 79% +/- 14.4% and 52% +/- 13%, respectively. In comparison, posteriorly optimizing the SBRT plan in anticipation of anterior IORT supplementation improved coverage with ablative BED. For the anterior half of the target volume, HDR-IORT created a dose gradient of 10-15 Gy, whereas for the posterior half of the target volume, HDR-IORT created a dose gradient of 5-10 Gy. Optimizing the SBRT plan to complement this with 40 Gy to the anterior half of the volume and 45 Gy to the posterior half of the volume was feasible with > 90% coverage with BED10 of 100Gy in composite.Dose escalation with SBRT/IORT may allow for better target coverage with ablative RT dose as compared to DE-IMRT and should be explored clinically.

Modelling of Dosimetric Impact of Visceral Organ Variability During MRI-Guided Hypofractionated Stereotactic Ablative Radiotherapy (SABR) to the Pancreas

Evaluation of visceral organ motion and dosimetric impact during pancreas SABR in non-patient subjects during the time frame of an MR-guided online adaptive radiotherapy (MRgART).Breath-hold MR images were acquired from six subjects on 0.35T MR-Linac at 30-minute intervals up to 90 minutes (intra-fraction images: F1a-d). A fifth image was acquired on a separate day (inter-fraction images: F2). SABR plans were generated to a prescription of 50 Gy in 5 fractions to mock pancreatic head tumors (median GTV 9 cc (range 8-10)) based on F1a images. Dose to visceral organs were recalculated on F1b-d and F2 images. For each visceral organ, the dose constraints used were V36 < 0.1 cc (volume of organ receiving 36 Gy < 0.1 cc), V33 < 0.5 cc and V25 < 10 cc. Volume of stomach, duodenum, small bowel and large bowel within 3 cm and 0.5 cm of PTV were recorded from each image and compared. Dosimetric impact of visceral organ motion was evaluated by comparing dose delivered to visceral organs at baseline (F1a) and the other time points (F1b-d, F2).For each subject, there was low degree of correlation between timepoint and volume of visceral organ within 3cm and .5cm of PTV (R = 0.01 and .23). Dose constraint violations were observed intra-fractionally. The highest number of dose constraint violations occurred for the duodenum, followed by stomach and large bowel (see table). No dose constraint violation was observed for the small bowel. The median magnitude of dose violations, defined as volume of organ receiving dose above constraints over mandatory volume limit, were statistically significantly lower in intra-fraction compared to inter-fraction images for the duodenum (median = .6 vs 1.9, P = 0.01).There is irregular visceral organ motion within the time frame of pancreas MRgART. This would not have been accounted for with respiratory gating. Although the magnitude of intra-fraction dose violation appears to be lower compared to inter-fraction, violations may have significant impact on toxicity. These violations are likely to be present in patients currently undergoing MRgART. However, given the reported low toxicity of dose-escalated MRgART, estimation of normal tissue toxicity based on current constraints may be limited. Further work is required to validate these findings in patients. Management of peristalsis may need to be considered. Table: Total number of dose constraint violations at each time point for 6 subjects. Each visceral organ has to meet 3 constraints V36, V33 and V25.

Role of biliary stent and neoadjuvant chemotherapy in the pancreatic tumor microbiome

BackgroundIntra-tumor microbiota have been implicated in pancreatic ductal adenocarcinoma (PDAC) development, treatment response and post-treatment survivorship. Moreover, therapeutic interventions targeting microbiota may improve the response to chemotherapy and immunotherapy, further emphasizing the critical need to understand the origins of and growth of bacteria within the pancreatic tumor microenvironment. Here, we studied the role of several clinical factors on the bacterial colonization of PDAC.ResultsWe obtained matched tumor and normal pancreatic tissue specimens from 27 patients who had undergone surgical resection for PDAC between 2011 and 2015 from the University of Minnesota Biological Materials Procurement Network (BioNet). We found that 26 (48%) out of 54 pancreatic tissue samples harbored detectable bacterial communities using real-time PCR targeting the 16S rRNA gene. Bacterial colonization was detected significantly more frequently in samples from patients who had pancreatic head tumors, underwent Whipple procedure, or had preoperative biliary stent placement. There was also a significantly greater relative abundance of microbiota from the family Enterobacteriaceae among samples from patients who underwent biliary stent placement or neoadjuvant treatment with a combination of Gemcitabine and Paclitaxel.ConclusionsThese findings suggest that biliary stent placement and neoadjuvant chemotherapy are associated with specific alterations that promote the infiltration and growth of intra-tumor bacteria in the setting of PDAC. Further studies exploring whether specific bacterial communities could contribute to increased chemoresistance will be essential for optimizing medical therapies in the future.

S1597 A Rare Presentation of Lemmel’s Syndrome as Acute Cholangitis With Acute Pancreatitis

Introduction: Duodenal diverticula are most commonly found in the second part of the duodenum adjacent to the ampulla of Vater. Periampullary diverticula (PAD) are extraluminal pseudo-diverticula lacking a mucosal layer. Although typically asymptomatic, they can rarely cause pancreaticobiliary obstruction. Obstructive jaundice can develop secondary to PAD without choledocholithiasis, a rare phenomenon called Lemmel’s Syndrome. We report a rare case of Lemmel’s syndrome presenting not only with acute cholangitis but also with concurrent pancreatitis, successfully treated with ERCP. Case Description/Methods: An 83-year-old female presented with upper abdominal pain, nausea, diarrhea, and rigors. She is s/p cholecystectomy and labs revealed AST 688 U/L, ALT 305 U/L, Alkaline Phosphatase 201 U/L, total bilirubin 3.4 mg/dL, lipase 968 U/L, and lactate 2.9 mmol/L. An abdominal CT scan showed severe dilation of the common bile duct of 2.1 cm with edematous appearance of the pancreatic head, findings of acute pancreatitis, and a large duodenal diverticulum adjacent to the pancreatic head (Fig 1). Her hospital course was complicated by gram negative bacteremia, concerning for acute cholangitis. MRCP confirmed marked dilation of the common bile duct extending to the Ampulla of Vater with a large periampullary diverticulum, without choledocholithiasis or mass lesions (Fig 2). The patient underwent ERCP which revealed a large duodenal diverticulum compressing the distal bile duct, treated with biliary sphincterotomy and stent placement (Fig 3-4). She showed gradual clinical improvement with this endoscopic approach and was discharged home with subsequent follow up for stent removal performed 6 weeks later. Discussion: Although common among duodenal diverticula, PAD are rarely symptomatic. The underlying pathogenesis remains unclear but is believed to be related to mechanical obstruction, inflammation, and fibrosis. Lemmel’s syndrome can be mistaken for pseudocysts, necrotic collections, periampullary tumors, and pancreatic head neoplasms. Physicians should have a high index of suspicion for Lemmel’s syndrome in patients with large symptomatic PAD, which although commonly presents as biliary obstruction causing acute cholangitis, can rarely also cause pancreatic obstruction leading to pancreatitis, as seen in our patient. Timely diagnosis and endoscopic treatment of Lemmel’s syndrome can be effective in the treatment of acute cholangitis and pancreatitis.Figure 1.: CT scan showing CBD dilation with large periampullary diverticulum.Figure 2.: MRI showing dilated CBD and PD with distal large periampullary diverticulum.Figure 3.: Endoscopic view of large periampullary diverticula with intradiverticular papilla seen on ERCP.Figure 4.: Fluoroscopic view of dilated CBD as a result of Lemmel’s syndrome.