Pancreaticoduodenectomy Research Articles

Long-Term Reoperation Rates Following Pancreatoduodenectomy for Pancreatic Adenocarcinoma.

Short-term outcomes after pancreatoduodenectomy (PD) are well-studied, but long-term reoperation rates and their indications remain poorly characterized. A single-center retrospective chart review was performed on patients who underwent PD for pancreatic adenocarcinoma between 1/2011 and 12/2021. Reoperations occurring >90days after PD were dichotomized to being related or unrelated to the index PD or pancreatic adenocarcinoma. The Kaplan-Meier analysis estimated the incidence of long-term reoperation at 1 and 5years postoperatively. Six-hundred twenty-eight patients were included. The 5-year incidence of any additional operation >90days after PD was 30.0% (95% CI 23.2-36.2%), and the 5-year incidence of any long-term related reoperation was 21.2% (95% CI 15.0-26.8%). The most common indications for reoperations by 5-year incidence were cancer recurrence (12.8%, 95% CI 7.6-17.7%), incisional hernia (6.2%, 95% CI 2.6-9.7%), small bowel obstruction (1.3%, 95% CI 0.2-2.4%), and leak, fistula, or infection (1.0%, 95% CI 0.1-2.0%). Of the examined risk factors, only 90-day reoperation was found to be predictive of long-term related reoperations (P = 0.02). Additionally, the 5-year incidence of endoscopic or interventional radiology procedures was 20.2% (95% CI 14.5-25.4%). However, 40.9% (95% CI 33.6-47.3%) of patients required additional surgery or procedures of any kind between 90 days and 5years after PD. Within 5years of PD, one in three patients required additional surgery, and one in five had operations for related indications. Related reoperative indications included recurrence, hernia, PD-specific complications, and small bowel obstruction. However, the rates of each of these reoperations were relatively low.

Pushing the Boundaries of Ampullectomy for Benign Ampullary Tumors: 25-Year Outcomes of Surgical Ampullary Resection Associated with Duodenectomy or Biliary Resection

Background: Surgical resection for ampullary lesions lacks clear guidelines. Pancreaticoduodenectomy (PD) is the standard treatment for malignant ampullary tumors but is often excessive for ampullary adenomas (AAs) due to its high morbidity and mortality. Transduodenal ampullectomy (TDA) is generally reserved for small benign lesions where endoscopic treatment fails, but its role in early ampullary cancers is debatable. This study presents our 25-year outcomes with TDA for benign ampullary tumors. Methods: We conducted a retrospective cohort study with prospectively collected data from patients with benign ampullary lesions who underwent TDA between January 1996 and November 2023. Primary outcomes were the 30-day overall and severe (Clavien–Dindo ≥ IIIa) morbidity rates and the 90-day mortality rate. Categoric variables were presented as absolute and relative frequencies, and quantitative variables were presented as means (standard deviation, SD) or medians (range or interquartile range, IQR). Results: Fifty-three patients (29 male; mean [SD] age 62.5 [14.6] years) underwent TDA. The 30-day morbidity rate was 32.1% (17/53 patients), with five (9.4%) cases being severe. The 90-day mortality rate was 1.9%. Definitive histopathology identified 38 (71.7%) AAs and five (9.4%) infiltrating ampullary adenocarcinomas, two (40.0%) of which required subsequent PD. Six (11.3%) patients experienced recurrence. Overall, nine (16.9%) patients died. Conclusions: TDA is a safe and effective technique with acceptable morbidity for non-infiltrating lesions, especially in patients with poor clinical status. Choosing between TDA and PD depends on tumor size, dysplasia grade, and institutional expertise. Lifelong endoscopic surveillance post-TDA is essential for timely recurrence detection.

The impact of COVID-19 on pancreaticoduodenectomy outcomes in a hepatopancreatobiliary centre of excellence.

At the beginning of the COVID-19 pandemic, access to "planned" surgical care was restricted as the health care system responded to the coronavirus. We hypothesized that the pandemic resulted in diagnostic and therapeutic delays, leading to stage migration among patients with malignancies treated with a Whipple procedure. This study is a retrospective review of adults who underwent surgical exploration for a planned pancreaticoduodenectomy for malignancy at St. Joseph's Health Centre between March 11, 2019, and March 11, 2021. We included 180 patients in the study. Baseline characteristics, pathologic diagnoses, and perioperative outcomes were similar between the 2 cohorts. The post-COVID group had longer median wait times from date of consent (p < 0.001), and from computed tomography (CT) scan (p < 0.001), to surgery. There were increased rates of R1 margin positivity in the post-COVID group (p = 0.01). We saw an association between higher wait times from consent and the last CT scan to the date of operation, and increased rates of R1 margin positivity in the first year of the pandemic. This study demonstrated the importance of prioritizing care during a pandemic and provided evidence for potential long-term consequences when there are delays in surgery for aggressive gastrointestinal malignancies.

Impact of Enhanced Recovery After Surgery Protocol Compliance on Outcome After Pancreatic Surgery: Results From a Certified ERAS Center

Objective: The aim was to evaluate the sustainability of the pancreatic Enhanced Recovery After Surgery (ERAS) program and the effect of ERAS items on patient morbidity and hospital stay. Background: The current ERAS guideline recommendations encompass 27 items to improve recovery after pancreatoduodenectomy (PD). Methods: Patients who underwent pancreatic resection at the University Hospital Hamburg-Eppendorf between February 2016 and June 2023 were included. The datasets were retrospectively collected from a central database. The effects of individual ERAS items and compliance on morbidity and hospital stay were assessed by uni- and multivariable analyses. Results: In total, 594 patients who underwent PD (44.8%), distal pancreatectomy (14.6%), total pancreatectomy (17.8%), or other pancreatic resections (22.7%) were included. Of these, 90 patients (15.2%) achieved a high overall ERAS compliance of ≥70%. High compliance was associated with significantly less complications (Clavien–Dindo ≥ 3a), reduced 30-day mortality, and a shorter hospital stay. Early mobilization on the first postoperative day (POD1), restrictive intravenous fluid administration, and timely removal of urinary catheters were significant multivariable predictors for lower morbidity. Early mobilization on POD1 also correlated with reduced morbidity in the subcohort of PD cases. Conclusions: The pancreatic ERAS protocol can be sustainably implemented and applied to both, PD and non-PD cases. A high level of compliance with the ERAS protocol after pancreatic resections correlated with improved outcomes but was achieved by less than one-fifth of patients. Early mobilization on POD1 and restrictive fluid management were key indicators for optimized short-term outcomes.

Pylorus-preserving pancreatoduodenectomy preserving blood supply for pancreatic cancer with a history of proximal gastrectomy and sigmoidectomy: a case report

BackgroundBlood supply to the remnant stomach should be preserved during pancreatectomy in patients with a history of gastrectomy. Moreover, ischemic complications should be considered when performing pancreatoduodenectomy in patients with celiac axis and superior mesenteric artery (SMA) stenosis. However, whether these surgical procedures can be safely performed remains unclear.Case presentationA 75-year-old man had a history of laparoscopic proximal gastrectomy (PG) with double-flap technique for gastric cancer and laparoscopic sigmoidectomy for sigmoid cancer treated 4 years ago. Follow-up computed tomography (CT) revealed an irregular nodular tumor measuring 13 mm in the pancreatic head. The patient was diagnosed with resectable pancreatic head cancer without lymph node metastasis (cT1cN0M0, cStageIA) according to the Union for International Cancer Control, 8th edition. As a standard pancreatic cancer treatment, two courses of preoperative chemotherapy with gemcitabine plus S-1 were administered. CT after preoperative chemotherapy identified no significant changes in tumor size but revealed SMA stenosis due to atherosclerosis. Blood flow to the left-sided colon was supplied from the middle colic artery via the SMA because of the past sigmoidectomy with inferior mesenteric artery detachment. Therefore, SMA stent placement was performed 1 day preoperatively. Subsequently, pylorus-preserving pancreatoduodenectomy (PPPD) was performed, preserving the remnant stomach with the right gastroepiploic (RGE) artery and vein. After resection, indocyanine green fluorescence imaging confirmed a good blood supply to the remnant stomach. The operation time was 467 min, and the blood lost was 442 mL. Histopathologically, the tumor was diagnosed as moderate adenocarcinoma and pT1cN0M0, Stage IA. The postoperative course was uneventful. The patient was discharged on postoperative day 23. S-1 as adjuvant chemotherapy was administered on postoperative day 63. The patient has been alive without recurrence for 7 months.ConclusionsWe performed PPPD preserving blood supply for pancreatic head cancer in a patient with benign SMA stenosis and a history of PG and sigmoidectomy. Blood supply was preserved through preoperative SMA stent placement and a surgical procedure preserving the RGE vessels. Furthermore, S-1 adjuvant chemotherapy was successfully initiated. These multimodal therapies contributed to a favorable clinical outcome.

The clinical significance of intraoperative lavage fluid culture during pancreaticoduodenectomy on organ/space surgical site infection

Organ/space surgical site infection (SSI) are common after pancreaticoduodenectomy (PD). There is limited research on the clinical impact of intraoperative lavage fluid contamination in patients undergoing PD. One hundred five patients who underwent PD between August 2022 and July 2023 were retrospectively enrolled. The intraoperative bile and peritoneal lavage were collected for bacterial culture. Postoperative drainage bacterial cultures were performed every 2–3 days thereafter until drains were all removed. The bacteria isolated from intraoperative lavage fluid, intraoperative bile, and postoperative drainage fluid were examined in detail. The risk factors associated with positive intraoperative lavage fluid culture were analyzed through both univariate and multivariate analyses. Organ/space SSI occurred in 59(56.2%) of the 105 patients. The positivity rates of cultures in intraoperative lavage fluid, intraoperative bile, and postoperative drainage fluid were found to be 41.0%, 67.6%, and 84.8%, respectively. Patients with positive intraoperative lavage fluid culture had a significantly higher occurrence of organ/space SSI compared to the negative group (69.0% vs. 29.4%, P < 0.001). Preoperative biliary drainage (PBD) was identified as the only independent risk factor for the contamination of intraoperative lavage fluid (OR = 7.687, 95% CI: 2.164–27.300, P = 0.002). K. pneumoniae was the most common isolates both in the intraoperative lavage fluid and postoperative drainage fluid. Intraoperative lavage fluid contamination closely correlated with organ/space SSI after PD. Meanwhile, PBD was the only risk factor for the contamination of intraoperative lavage fluid.

Comparison between pancreatojejunostomy and pancreaticogastrostomy in pancreaticoduodenectomy in a gastroenterology and hepatology teaching hospital

Background: Pancreatoduodenectomy (PD) is a surgical procedure used to treat diseases of the pancreatic Head, the distal common bile duct (CBD), and the duodenum, as well as trauma to the head of the pancreas. Once the pancreatic head and the duodenum are resected, the surgeon needs to reconnect the stomach, the biliary tract, and the pancreatic stump. The technique for reconstructing the biliary tract is fairly standard, represented by the anastomosis of the CBD to the jejunum, but the reconstruction of the pancreatic stump is a matter of debate. In general, two procedures can be used: pancreaticojejunostomy (PJ), which is an anastomosis between the pancreatic stump and the jejunum, and pancreaticogastrostomy (PG), which is an anastomosis between the pancreatic stump and the stomach. Aim: The objective of this study was to compare the impact of PJ and PG on the occurrence of postoperative pancreatic fistula (POPF), morbidity, and mortality following PD. Patients and Methods: This study took place between April 1, 2021 and April 1, 2023 at Gastroenterology and Hepatology Teaching Hospital in Baghdad Medical City. The cases in the study were designed prospectively. It is a comparison between PG and PJ after undergoing Whipple surgery. A total of 30 patients were selected and divided into two groups. The first group consisted of 16 patients who underwent PJ, while the second group consisted of 14 patients who underwent PG. The cases were prepared in the surgical consultation clinic. On the one hand, through PG, it was determined whether the texture of the pancreas was soft and the size of the main pancreatic duct (MPD) was less than 3 mm. On the other hand, through PJ, it was determined whether the texture of the pancreas was firm or hard and the size of the MPD was more than 3 mm. Results: The age group of males and females ranged from 11 to 68 (median 57) years. There were a total of 16 males and 14 females. The ampullary tumor was present in 11 patients of the PJ group and 7 patients of the PG group. Histopathology of tumors showed adenocarcinoma in 13 patients of the PJ group and in 6 patients of the PG group. POPF occurred in 3 patients of the PJ group, type A in 1 patient and type B in 2 patients, and no POPF was observed in the PG group. Hemorrhage occurred in 1 patient of the PG group and 2 patients of the PJ group. Delayed gastric emptying occurred in 5 patients: 3 patients of the PJ group (type A) and 2 patients of the PG group. SSI (surgical site infection) occurred in 7 patients: 5 patients of the PJ and 2 patients of the PG group. Finally, mortality occurred in 3 patients of the PJ group. Conclusion: Pancreatic intestinal anastomosis must be tailored to the surgeon's preferences and experience level, and any innovative technique that reduces the prevalence of POPF is welcome in pancreatic surgery. PG seems to be associated with less POPF, morbidity, and mortality than PJ after undergoing Whipple surgery, especially given the soft texture of the pancreas and the size of the MPD &lt; 3 mm. Recommendations: 1. Because our study included a limited number of samples, further prospective randomized studies with larger samples are required to confirm that PG had fewer complications. 2 Surgeons should be encouraged to use PG more frequently in the future.

Network Meta-Analysis and Trial Sequential Analysis of Randomised Controlled Trials Comparing Robotic, Laparoscopic, and Open Pancreatoduodenectomy

Background: The use of minimally invasive (laparoscopic and robotic) pancreatoduodenectomy (PD) is being increasingly adopted despite the lack of hard evidence to support its utilisation. With recent randomised controlled trials (RCTs) comparing open pancreatoduodenectomy (OPD) with robotic or laparoscopic pancreatoduodenectomy (RPD or LPD), we undertook a network meta-analysis (NMA) comparing all 3 approaches to evaluate comparative outcomes. Methods: A systematic search of MEDLINE, EMBASE, and Cochrane CENTRAL was conducted up to May 2024 and relevant RCTs were identified. A random-effects meta-analysis and trial sequential analysis (TSA) were conducted for primary outcomes, followed by a Bayesian NMA of length of stay (LOS), duration of surgery, intraoperative blood loss, and pancreas resection-related outcomes Results: Seven RCTs involving 1336 patients were included, 5 investigating LPD compared with OPD and 2 RPD to OPD. Pairwise meta-analysis indicated that LPD was associated with shorter hospital stay (mean difference [MD], −1.39; 95% confidence interval [CI], −2.33 to −0.45) and lower intraoperative blood loss compared with OPD (MD, −131; 95% CI, −146 to −117). However, LPD was associated with significantly longer operative duration (MD, 39.5; 95% CI, 34–45). TSA confirmed the robustness of the positive and negative findings on pairwise meta-analysis. In comparison, there were no significant differences between RPD and OPD in pairwise meta-analysis, which could not be confirmed by TSA. Network meta-analysis tended to favour LPD in most outcome parameters including LOS, duration of surgery, and pancreas resection-related outcomes. Conclusions: The current RCT evidence suggests potential better outcomes in LPD in comparison with RPD and OPD. However, few studies demonstrated robust statistical significance in outcome measures, suggesting an underpowered evidence base and possible selection bias. Hence, with current equivocal data, there is a need for ongoing RCTs to validate the role of minimally invasive approaches in PD.

Current trends in types of pancreatoduodenectomy: Focus on the advancement of robot-assisted pancreatoduodenectomy with 630 consecutive cases.

Pancreatoduodenectomy (PD) is a complex abdominal surgery, and the adoption of robotic PD has been on the rise because of its numerous benefits. This study aimed to investigate the current PD trends, focusing on advancements in robotic surgery. Between 2015 and 2023, 1231 patients underwent open PD, whereas 630 underwent robot-assisted PD (RAPD). Demographics and surgical outcomes were analyzed according to the time period. Moreover, a propensity score-matched (PSM) analysis was performed to evaluate the clinical outcomes. The proportion of RAPD cases gradually increased from 6.3% in 2015 to 50.9% in 2020, reaching a plateau of >50% thereafter. The proportion of patients receiving neoadjuvant chemotherapy increased during the late period (11.4% vs. 17.6%), with many of these patients undergoing open PD. Additionally, RAPD was performed in patients with a high probability of postoperative pancreatic fistula. However, the two groups demonstrated no significant difference in the occurrence of clinically relevant postoperative pancreatic fistula (10.6% vs. 9.5%, p = .532). Among periampullary cancer cases, RAPD demonstrated comparable survival outcomes to open PD after PSM (5-year survival rate: 61.8% vs. 49.8%, p = .189). RAPD has become a stable approach, accounting for over 50% of all PD cases in high-volume centers, and it can be safely performed. However, open PD remains important owing to the development of neoadjuvant therapy and the aging population. Therefore, establishing appropriate indications to maximize the benefits of both RAPD and open PD is necessary.

Is there a place for surgery in oligometastatic ductal carcinoma of the pancreatic head?

Background: New chemotherapy regimens (gemcitabine / nab-paclitaxel, FOLFIRINOX) have improved overall survival rates in ductal carcinoma, which has renewed the interest in surgical treatment for isolated liver metastases. Aim: To identify the role of surgery in ductal carcinoma of the pancreatic head with liver oligometastases. Methods: We retrospectively analyzed the data from 490 patients with morphologically verified ductal carcinoma of the pancreatic head in two specialized centers, who had undergone pancreatoduodenectomy (PD) from January 2011 to April 2024. In 21 patients, PD was performed simultaneously with liver resection (liver oligometastases were found during the surgery). Results: In the postoperative period after PD with liver resection, compared to that after PD without liver resection, intra-abdominal abscesses were more frequent (4/21 (19.0%) versus 10/469 (2.2%), p = 0.002) and relaparotomy was performed more often by 9.8% [95 confidence interval (CI, Miettinen-Nurminen score method) 0.21–30.3] (3/21 (14.3%) versus 21/469 (4.5%), p = 0.077). The postoperative death rates were comparable (1/21 (4.8%) versus 19/469 (4.1%), p = 0.8). The median overall survival of the patients after PD with liver resection was 11 (95% CI: 6–16) months, and overall 1-, 2-, and 3-year survival rates were 39.2, 16.8 and 7.2%, respectively. In the patients after PD with liver resection without any adjuvant chemotherapy (n = 5), the median overall survival was 6 (95% CI: 5–7) months, and in those with chemotherapy, 13 (95% CI: 6–16) months (p = 0.006). The overall three-year survival of the patients after PD with liver resection and adjuvant chemotherapy was 11.5%. In the patients after PD with liver resection R0, the median overall survival was 13 (95% CI: 6–32) months, with R1 resection 6 (95% CI: 6–7), and with R2 resection 6 (95% CI: 6–7) months (p = 0.021). The median overall survival of patients after PD with liver resection for G1 tumors was 17 (95% CI: 6–32) months. Conclusion: Surgery as a component of combination therapy for oligometastatic pancreatic head cancer can be considered in a certain category of patients with high tumor differentiation grade and mandatory preliminary assessment of the feasibility of R0 surgery and systemic chemotherapy.

The proinflammatory status, based on preoperative interleukin-6, predicts postpancreatectomy acute pancreatitis and associated postoperative pancreatic fistula after pancreaticoduodenectomy.

Early predictors of morbidity after pancreaticoduodenectomy (PD) can guide tailored postoperative management. Preoperative inflammatory data in patients who underwent PD remained poorly studied in investigating the clinical significance of predicting postpancreatectomy acute pancreatitis (PPAP) and PPAP-associated postoperative pancreatic fistula (POPF). The clinical data of 467 patients receiving PD between January 2020 and December 2022 were retrospectively reviewed. Preoperative inflammatory data were stratified according to PPAP, and independent risk factors were analyzed. Multivariate logistic regression and subgroup analyses were conducted to compare risk factors of PPAP-associated POPF and non-PPAP-associated POPF. PPAP occurred in 17.6% of patients. The incidence of other complications increased following PPAP. Among the preoperative inflammatory factors, only interleukin-6 (IL-6) increased (P<0.001), leading to a higher incidence of PPAP and POPF (P<0.001; P=0.002). The area under the curve of IL-6 in predicting PPAP was 0.71 (0.65-0.77; P<0.001). Abnormal preoperative IL-6 levels (odds ratio [OR]: 5.01; P<0.001), soft pancreatic texture (OR: 2.15; P=0.007), and pathology (OR: 2.03; P=0.012) were independent risk factors for PPAP. The subgroup analysis showed that increased IL-6 (OR: 1.01; P=0.006) and soft pancreatic texture (OR: 2.05; P=0.033) resulted in a higher risk of PPAP-associated POPF, while increased IL-8 (OR: 1.01; P=0.007), older age (OR: 1.05; P=0.008), and higher body mass index (OR: 1.12; P=0.021) correlated with non-PPAP-associated POPF. PPAP is common after PD; a high preoperative IL-6 level can predict its occurrence, in addition to associated POPF, which could be due to a preoperative proinflammatory status.

MS O06 - HPB The ORDEAL Study: A National Survey of Surgeon Operative Preferences for Resection of Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of data on outcomes, no UK guidelines for surgical management, and current national standards of practice are unknown. There is ongoing debate whether long-term survival, perioperative outcomes, resection margin, and lymph node yield differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD and limited resection (LR) in distal DA (D3/D4). The study aimed to discern current standards of practice and identify underlying reasons for operative preferences for proximal and distal DA. Method An anonymised survey was included as part of the registration form for a wider multicentre retrospective study looking at outcomes following resection for proximal and distal DA on Google Forms®. The survey was distributed via direct surgeon email correspondence, weekly newsletters and surgical society endorsement by PSGBI. Responses were collected between February-June 2024 and responses were analysed with quantitative and qualitative (inductive thematic analysis) methods. Results Responses were received from 61 surgeons across 27 centres. For proximal DA, surgeons are more likely to consider a classical Whipple’s (93.4%) compared to PPPD (29.5%). For distal DA, surgeons are equally likely to consider LR (73.8%) as PD (classical Whipple’s -37.7%, PPPD - 41%). These preferences have mostly remained consistent over time. Key themes identified from thematic analysis included oncological considerations, morbidity, surgeon preference, tumour characteristics, standards of practice, patient factors and anatomical considerations, with the former two themes being the most prominent. Conclusion For proximal DA, cPD is preferred over PPPD and for distal DA, LR and PD are equally considered, with oncological and morbidity considerations largely influencing decision making. This qualitative data will be compared to actual practice following completion of the wider ORDEAL study to identify discrepancies in practice and possible effect on patient outcomes.

MS O05 - HPB The ORDEAL Study: A Multi-Centre Retrospective Cohort Study Assessing the Optimal Resection for Proximal and Distal Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of cases and outcome data, no UK guidelines for surgical management, and a lack of contemporaneous UK patient data. There is debate as to whether oncological and perioperative outcomes differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD (cPD or PPPD) and limited resection (LR) in distal DA (D3/D4). This study aimed to determine the optimal type of resection for proximal and distal DA through investigating differences in long-term survival and perioperative outcomes. Method A national retrospective audit of consecutive patients from 2008-2023 undergoing curative resection for DA was conducted, with data collected anonymously via REDCap. Baseline demographics, radiological, operative, pathological and short and long-term outcomes were collated. Analysis was performed using SPSS with standard descriptive statistical methods. Chi-Square, Mann-Whitney and ANOVA were used as appropriate to compare variables and outcomes between two groups, with statistical significance set at p&amp;lt;0.05. Survival analysis (overall survival (OS) and disease-free survival (DFS)) was performed using the Kaplan–Meier method and the log-rank test to compare differences between survival curves. Time-to-event analysis was calculated with Cox regression. Results The study cohort (median age 68 years, 54.4% males) had a mean follow-up of 35.6 months. For proximal DA, 56 underwent PPPD and 87 underwent cPD; for distal DA, 26 underwent PD and 37 underwent LR. For proximal DA, survival and lymph node clearance were similar, with severe complications and no adjuvant chemotherapy independently decreasing survival. For distal DA, survival was similar despite greater lymph node clearance with PD, with age and no adjuvant chemotherapy independently decreasing survival. Complications including pancreatic fistula, delayed gastric emptying, and post-pancreatectomy haemorrhage, were comparable for proximal DA but greater with PD in distal DA. Conclusion Preliminary findings suggest adequate lymphadenectomy and comparable long-term survival for cPD and PPPD in proximal DA. For distal DA, LR is associated with similar long-term survival but lower morbidity despite greater lymph node clearance with PD. Additional records will validate these findings further.

HPB SO01 - Preoperative respiratory disease and outcomes of pancreatoduodenectomy performed for malignancy

Abstract Background Despite improvements to morbidity and mortality rates in recent decades, pancreatoduodenectomy (PD) remains a high-risk operation. Patients with pre-existing respiratory disease are likely to be at increased risk of developing postoperative complications but few prior studies have investigated this. This may be as few patients with significant respiratory pathology are considered appropriate surgical candidates. This study aimed to compare PD outcomes in patients with a prior respiratory condition to those without. The outcomes of interest were median length of stay (LOS), 30-day readmission, 90-day mortality, unplanned return to theatre rate and five-year survival. Method Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Pre-existing respiratory disease included a prior diagnosis of asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, pulmonary embolism, asbestosis, obstructive sleep apnoea, pleural effusion, tuberculosis, pulmonary sarcoidosis, pneumoconiosis or hypersensitivity pneumonitis. The Mann-Whitney U test and Fisher exact test were used to compare the two groups. Results Out of a total of 1484 cases, 142 patients (9.6%) had a pre-existing respiratory comorbidity. Asthma and COPD both affected 4.2% of patients. All other included pathologies affected less than one percent of patients. 30-day readmission (8.5% vs 9.1%, p=0.1), 90-day mortality (1.4% vs 3.7%, p=0.2), and unplanned return to theatre rate (3.5% vs 5.1%, p=0.5) were similar between the two groups, however, median LOS was significantly longer in those with a prior respiratory disease (14 vs 13 days, p&amp;lt;0.0001). Five-year survival was also higher in those without respiratory disease, but this was not quite significant (24.6% vs 32.5%, p=0.06). Conclusion In our multicentre study of patients with confirmed malignancy, PD patients with a preoperative respiratory disease had significantly longer length of stay. Five-year survival rates were slightly lower but this was not quite significant.

HPB SO10 - Evaluation of the impact of an Enhanced Recovery Pathway on clinical outcomes after Pancreaticoduodenectomy

Abstract Background Southampton General Hospital (SGH) is a high-volume HPB centre with a well-established Enhanced Recovery After Surgery pathway (ERAS). Despite the morbidity associated with pancreatic surgery, there is a large body of evidence supporting the use of a multi-modal approach to accelerate patient recovery. Within SGH, ERAS is utilised for all patients undergoing Pancreaticoduodenectomy (PD). Initial assessment of the pathway in SGH demonstrated a reduction in length of stay. Since its implementation, ERAS has been modified to optimise the pathway. The aim of this study was to assess whether the impact of ERAS had progressed over time. Method Single centre retrospective analysis of patients undergoing open PD from 2007-2023. Pancreatic reconstruction was with pancreaticojejunostomy. Pre and Post ERAS data were analysed. Post ERAS data was subdivided into Early, Middle and Late implementation time phases. Length of Stay, Complications (Clavien-Dindo Grade 3 and above), Readmissions and Mortality were all examined. Non-parametric data analysis was undertaken with Kruskal-Wallis, Spearman rank correlation and Wilcoxon rank-sum tests. Significance further assessed with Multi-variate regression (MVR). All Data were analysed using STATA. Results Overall, 861 patients underwent an open PD, the yearly volume increasing with time. Mean age was 66 years, which did not change with time. With ERAS implementation, Median Length of Stay (LOS) fell 13 to 9 days (p&amp;lt;0.01) and there was no statistically significant increase in Grade 3 complications or Readmissions (p=0.931, p=0.163). Grade 3 complications increased LOS (p&amp;lt;0.01). Increased age led to a small increase in LOS (p&amp;lt;0.01). Median LOS across Early, Middle and Late ERAS periods was 10, 9 and 9 respectively. LOS did not consistently demonstrate a statistically significant improvement across ERAS phases (MVR p=0.387, K-Wallis p&amp;lt;0.05). Conclusion The implementation of ERAS significantly reduced the median LOS for patients undergoing PD, without increasing their risk of complications or readmissions. This benefit has also been safely maintained across the period of its implementation.

HPB SO26 - Evaluation of Theatre Database Accuracy in a Tertiary HPB Center According to NCIP Standards in the UK

Abstract Background The goal of creating the NCIP (National Clinical Improvement Programme) theatre data set discovery information system is to allow NHS Improvement to evaluate how theatre data can improve the attribution of surgical activities, as documented in Hospital Episode Statistics (HES) Admitted Patient Care (APC) data, to individual consultants. The success of NCIP is at risk due to the inaccurate attribution of existing activity data to consultants. Method The NCIP theatre database for the Hepato-Pancreato-Biliary (HPB) surgery department was compiled over a 12-month period (from April 2022 to April 2023) and analyzed based on the operating consultant recorded in the operative notes, clinical letters, and the Carfelow system (admitting office records). Results In Nottingham University Hospitals (NUH), 143 major liver and pancreatic resections were performed, including 38 Whipple’s procedures (both classic and Pylorus-preserving Pancreatico-Duodenectomy), 19 Distal Pancreatectomies, and 86 Liver resections. Of these, only 58 patients (40.6%) had correct entries in the NCIP database regarding the operating surgeon. The NCIP data inaccuracies for the operating consultant were 65.8% (25/38) for Whipple’s procedures, 57.9% (11/19) for Distal Pancreatectomies, and 56.97% (49/86) for Liver resections. Conversely, the NCIP data was 100% accurate concerning the assigned consultant on Careflow, which matches the clinical letters from the outpatient clinic. Conclusion The gap between the NCIP database and the admitting office database leads to inaccurate attributions of surgical activity. This hinders learning and improvement efforts essential for achieving program benefits and prevents providers from complying with license conditions and delivering efficient healthcare services. To ensure accurate HES data, admitting officers should request proper communication and accurate consultant codes from consultant secretaries to ensure accurate data across the different hospital systems

HPB SO28 - Pre-operative Biliary Drainage in Pancreatic Adenocarcinoma and its Effect on Surgical Oncological Outcomes

Abstract Background Pre-operative biliary drainage (PBD) in patients undergoing pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been associated with a significantly increased risk of serious complications. This retrospective study investigated if PBD has a significant effect on lymphovascular (LVI) or perineural (PNI) invasion compared to direct surgery (DS). Method Data was collected retrospectively from patients undergoing PD for PDAC from 01/01/2014 to 30/12/2022. Patients were grouped according to whether they received any form of PBD or not. Patients’ T and N stage, as well as lymph node ratio (LNR), R status, Mortality, disease free (DFS) and overall survival (OS) were recorded. The primary outcome measure was lymph node ratio. Results A total of 87 patients were identified (48 PBD group vs 39 DS group), with a mean age of 68. The median LNR was 0.2 in PBD vs 0.21 in DS Group (p=0.87). There was no significant difference in median DFS (310 days PBD vs 285 DS p=0.94) or median OS (513 days PBD vs 515 DS p=0.39). PBD was not associated with a greater incidence of LVI (67% PBD vs 69% DS p=0.8), or PNI (94% PBD vs 97% p=0.41). PBD did not have a significant effect on resection margin status (p=0.75). Conclusion Despite evidence in the literature on its effects on the rate of complications, PBD has not been shown to have an effect on LVI or PNI, disease progression, nor overall survival in our patient group.

HPB SO03 - Preoperative biliary drainage prior to pancreaticoduodenectomy for pancreatic head malignancy: Guidelines versus the reality

Abstract Background British guidelines currently advise against routine preoperative biliary stenting (PBS) unless patients have cholangitis or organ failure secondary to biliary obstruction. If stenting is required, self-expanding metal stents are advocated. Using a large multicentre cohort, this study aimed to investigate the proportion of patients who underwent PBS prior to pancreatoduodenectomy (PD) and describe the approach used. Method Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for histologically confirmed pancreatic head malignancy (29 centres from 8 countries, n=1484). Patients who underwent PBS were identified and the details surrounding this were obtained. Results 1482 patients had data on use of PBS. 427 didn't undergo PBS, 1055 underwent attempted PBS. Of the latter, 989 had a stent placed successfully, 38 had PBS failed , and 28 had an external biliary drain . when PBS performed, Among 857 were primary endoscopically placed , 75 had percutaneously placed PBS having failed endoscopy , and 50 had a primary percutaneously placed PBS . 755 patients known stent material ( 66% were plastic, 34% metal). In 671 who had data regarding cytology from PBS known, 48% had cytology suggestive/diagnostic of malignancy, 25% had inadequate histology, and 28% did not send a cytology sample. Conclusion Despite guidelines advising against routine PBS, over two thirds of PD patients in our study underwent stenting. Despite guidelines advocating metal stents when PBS is necessary, two thirds of the stents deployed were plastic. Stent cytology has a low sensitivity for pancreatic head malignancy.

CT Surveillance for Local Recurrence After Pancreatic Cancer Resection: Evaluation of Imaging Findings From the SAR Disease-Focused Panel Consensus Statement.

BACKGROUND. A Society of Abdominal Radiology (SAR) Pancreatic Ductal Adeno-carcinoma (PDAC) Disease-Focused Panel (DFP) consensus statement described findings suspicious for local recurrence (LR) on surveillance imaging after PDAC resection. OBJECTIVE. The purpose of this study was to evaluate interreader agreement and predictive utility of potential imaging findings of LR on serial surveillance CT examinations after the Whipple procedure for PDAC, using the SAR PDAC DFP consensus statement. METHODS. This retrospective study included 126 patients (mean age, 68.5 ± 10.3 [SD] years; 72 men, 54 women) who underwent the Whipple procedure for PDAC between January 2009 and December 2014. Three radiologists independently reviewed baseline and subsequent postoperative contrast-enhanced abdominopelvic CT examinations performed within 2 years after surgery, evaluating features in the SAR PDAC DFP consensus statement relating to surgical bed stranding, surgical bed soft tissue, vessel encasement, main pancreatic duct dilatation, and ascites. Interreader agreement was calculated. The reference standard for LR development within 2 years after surgery incorporated all available information. The frequencies of imaging features were calculated for the recurrence examinations (i.e., the first surveillance examinations indicating LR). For baseline postoperative examinations, associations of the imaging features with eventual LR development were assessed by multivariable logistic regression analysis. RESULTS. LR developed within 2 years after surgery in 81 of the 126 patients. For both the baseline and subsequent examinations, agreement for stranding and agreement for soft-tissue morphology were poor, for vessel encasement was fair, for soft tissue and ascites were moderate, and for main pancreatic duct dilatation was substantial. On recurrence examinations, across readers, new or increased stranding was present in 27-77%; new or increased soft tissue, 80-88%; soft tissue with vessel encasement and luminal narrowing, 36-59%; new or increased main pancreatic duct dilatation, 25-26%; and new or increased ascites, 20-23%. On baseline postoperative examinations, independent predictors of eventual LR were soft tissue for all three readers (OR = 2.78-6.85) and stranding for reader 1 (OR = 3.59); main pancreatic duct dilatation and ascites were not independent predictors of LR for any reader. CONCLUSION. This study highlights the role of soft tissue, particularly when associated with vessel encasement and luminal narrowing, in raising suspicion for LR after PDAC resection. CLINICAL IMPACT. This study supports the SAR PDAC DFP consensus statement, while highlighting opportunities for continued optimization.

AHP SO05 - First year experience of running a specialist pre-op clinic for patients undergoing a Whipple procedure that focuses on patient education and improving theatre utilisation

Abstract Background The Whipple’s pre-operative clinic was organised to ensure patients were fully aware of the impact of this operation. Additionally, it was implemented to reduce the risk of preventable theatre cancellations and unfilled operating theatre slots arising given the challenges currently faced in the current NHS climate. The primary aim of the clinic is to improve education to ensure the patients are aware of what the procedure and aftercare entails. A secondary aim is to identify correctable issues in the pre-operative period which could prevent surgery from proceeding safely. Method The clinic ran over 12 months in the tertiary HPB centre at University Hospital Southampton. The clinic has two elements: a 30min video appointment with a specialist nurse for each individual patient to provide comprehensive information regarding the procedure This was followed by a checklist to ensure there was appropriate up-to-date imaging available, as well as a review of the latest blood tests and current medications. Results There were a total of 105 patients reviewed in the clinic. Due to this new service, 21 (20%) essential interventions were made. These included requesting or reviewing new imaging (n=14) correcting anticoagulation plans (n=2) and admitting patients for optimisation prior to surgery (n=2). A total nine all day theatre lists were saved as a direct result of this clinic. Costing of each theatre is estimated at £12,000. Five (5%) patients had their surgeries cancelled in advance and all theatre slots were subsequently re-allocated. Four (4%) patients had interventions which directly prevented an on the day cancellation. Conclusion These results show that there are significant benefits from running a specialised pre-operative Whipple’s clinic. Multiple interventions have led to improving patient safety, optimising theatre utilisation and improving patient experience.