Implementation of an Enhanced Recovery Program for ... - HPB

E-HPBA: Poster Abstracts

PANCREAS CANCER 0171 PANCREATICOJEJUNOSTOMY AFTER PANCREATICODUODENECTOMY: SUTURE MATERIAL AND INCIDENCE OF POST-OPERATIVE PANCREATIC FISTULA S. Andrianello, A. Pea, A. Pulvirenti, V. Allegrini, G. Marchegiani, G. Malleo, G. Butturini, R. Salvia and C. Bassi Universita degli Studi di Verona, Italy Aims: Pancreatic fistula represents the most important complication in terms of clinical management and costs after pancreaticoduodenectomy. A lot of studies have investigated several techniques in order to reduce pancreatic fistula, but data on the effect of sutures material on pancreatic fistula are not available. The analysis investigated the role of suture material in influencing pancreatic fistula rate and severity. Methods: Results from 130 consecutive pancreaticoduodenectomy with pancreaticojejunostomy performed between March 2013 and September 2014 were prospectively collected and analyzed. In 65 cases pancreaticojejunostomy was performed with absorbable sutures (polydioxanone), in the other 65 cases using non-absorbable sutures (polyester, silk and polybutester). Results: Pancreaticojejunostomy with non-absorbable sutures had the same incidence of pancreatic fistula, but less severe and with less episodes of post-operative bleeding if compared with absorbable sutures. A sub-analysis was carried out comparing polydioxanone with polyester: the latter was associated with a lower pancreatic fistula rate (11,9% vs. 31,7%; p = 0,01) and less severe pancreatic anastomosis dehiscence (grade C - 0% vs. 30%; p = 0,05). Univariate and multivariate analysis confirmed that hard pancreatic texture, pancreatic ductal adenocarcinoma at final histology and the use of polyester for pancreaticojejunostomy were associated with a lower pancreatic fistula rate (p < 0,05). Conclusions: Further studies are needed to investigate the effects of pancreatic juice and bile on different sutures and pancreatic tissue response to different materials. However pancreaticojejunostomy performed with polyester sutures is safe and feasible and is associated to a lower incidence of pancreatic fistula with less severe clinical impact.

PANCREAS CANCER 0172 SUPERIOR MESENTERIC ARTERY RESECTION DURING PANCREATECTOMY FOR TUMOUR: POOLED OUTCOME AND SURVIVAL ANALYSIS S. Jegatheeswaran and A. K. Siriwardena Manchester Royal Infirmary, UK Aims: Pancreaticoduodenectomy (PD) is the treatment of choice for non-metastatic, localised tumours of the head of the pancreas in patients without major co-morbidity. Technically, resection can be prevented when disease progression involves the portal/superior mesenteric vein or the superior mesenteric artery (SMA). Although venous resection is increasingly accepted, SMA resection remains

HPB 2016, 18 (S2), e747ee781

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unestablished. Given the rarity of SMA resection in any given series, it is difficult to obtain an overview of any potential benefit. In this setting, analysis of pooled data may provide insight. Methods: This study undertakes an analysis of pooled data on arterial resection at PD in order to assess outcome. Medline and embase were searched for the period 2000 2013 selecting only articles in English which provided complication profile, outcome and survival data allocatable to patients undergoing arterial resection at PD. Case reports and reports which did not provide patient-specific data were excluded. Results: During this period 4 manuscripts provided information on 25 patients undergoing PD with SMA resection. Reconstruction (available for 17) was by flap rotation of the splenic artery in 9 (53%), graft in 6 (35%) and primary endend anastomosis in 2 (12%). Median (range) operating time was 820 (441e1190) minutes, blood loss 6650 (2400e 15,900) ml and 30-day mortality was 3 (12%). Median survival was 11 (0e29) months. Conclusions: When individual patient data are pooled the addition of SMA resection to PD produces a lengthy operative procedure with high reported blood loss and high mortality. As the median survival is similar to that for non-operated pancreatic cancer, SMA resection at PD should only be undertaken in the context of national clinical trials with mandatory reporting of quality of life measures.

PANCREAS CANCER 0179 IMPLEMENTATION OF AN ENHANCED RECOVERY PROGRAM FOR PANCREAS HEAD RESECTION IS HIGHLY COSTEFFECTIVE e RESULTS OF A COSTBENEFIT ANALYSIS OF 161 PATIENTS G. R. Joliat, I. Labgaa, D. Petermann, M. Hübner, A. C. Griesser, N. Demartines and M. Schäfer University Hospital CHUV, Switzerland Aims: Enhanced recovery (ERAS) programs have shown a decrease of complications and length of hospital stay after different types of surgery. Cost-effectiveness of ERAS programs was demonstrated mainly for colorectal surgery, but no data are yet available for pancreas surgery. The study aimed to assess the economic aspects of an ERAS program for pancreatoduodenectomy (PD). Methods: ERAS for pancreas surgery was implemented in our division in October 2012. From October 2012 to October 2014 all consecutive PD patients were recorded as ERAS group. They were compared in terms of costs to all PD performed between January 2010 and October 2012 (pre-ERAS group). Preoperative, intraoperative, and postoperative costs were collected for every patient via the hospital administration. They were compared between the two groups using a bootstrap independent T-test. Specific ERAS-related costs (i.e., ERAS database, full-time ERAS-dedicated nurse, ERAS meetings, carbohydrates drinks, ERAS logbooks) were calculated. Results: Seventy-four ERAS patients matched well in terms of demographic and surgical details with 87 patients in the pre-ERAS group. Overall complication rate was 68% (50/74) and 82% (71/87) in the ERAS and pre-

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E-AHPBA: Poster Abstracts

ERAS groups, respectively (p = 0.046). Median hospital stay was shorter for the ERAS group (15.5 vs. 19 days, p = 0.029). Specific ERAS-related costs were 922 euros per patient. Mean total costs per patient were 54,120 euros for the ERAS group and 62,112 euros for the pre-ERAS group (p = 0.262). The mean intensive care unit (ICU) and intermediate care costs per patient were 9,139 euros and 13,793 euros for the ERAS and the pre-ERAS groups, respectively (mean difference: -4,654 euros, p = 0.151). Conclusions: ERAS implementation for PD was costeffective in our cohort. Savings can be explained by a reduction of postoperative complications and hospital stay. Furthermore, fewer patients in the ERAS group required an ICU stay, and the duration of the ICU stay was shorter.

PANCREAS CANCER 0192 CALCULATING RISK OF PANCREATIC FISTULA FOLLOWING PANCREATICODUODENECTOMY: A SYSTEMATIC REVIEW A. E. Vallance1, A. L. Young1, C. Macutkiewicz1, K. Roberts2 and A. M. Smith1 1 Leeds Teaching Hospitals NHS Trust; 2University Hospitals Birmingham NHS Foundation Trust, UK Aims: Post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreaticoduodenectomy (PD). Early identification of patient risk may alter peri-operative decision making and scores to individually predict a patient’s risk of POPF have been proposed. This systematic review aims to identify all scoring systems to predict POPF following PD, assess their quality and consider their clinical applicability. Methods: An electronic search was performed of Medline (1946e2014) and EMBASE (1996e2014) databases. Results were screened according to PRISMA guidelines. Data was extracted and collated. The methodological quality was graded by two independent reviewers. Results: Six eligible scoring systems were identified. The median number of patients included in each study was 279 (range 146e445) with the median POPF rate in the modelling databases 31% (range 22e53%). Four studies used the International Study Group on Pancreatic Fistula (ISGPF) definition. Table 1 details the included variables in each proposed score. Scores featured between 2 and 5 variables and of the 16 total included variables, the majority (twelve) featured in only one score. One variable (age) was proposed twice and three variables (body mass index (BMI), pancreatic duct width and pathological diagnosis) three times. Three scores may be fully completed preoperatively, one score includes intra-operative and two studies post-operative variables. Four scores were internally validated with two scores being subject to subsequent multicentre review. The overall methodological quality varied from fairly poor to good. Conclusions: These six scores demonstrate variation in approach to predicting POPF. While further validation in larger cohorts is needed, POPF predictive scores can individualise a patient’s risk of POPF to guide peri-operative decision making.

PANCREAS CANCER 0214 PREOPERATIVE COMPUTED TOMOGRAPHY TO PREDICT AND STRATIFY THE RISK OF SEVERE PANCREATIC FISTULA AFTER PANCREATODUODENECTOMY M. Sandini1, D. P. Bernasconi1, D. Ippolito2, L. C. Nespoli1, M. Baini1, S. Barbaro1, D. Fior1 and L. V. Gianotti1 1 Milano Bicocca University; 2San Gerardo Hospital, Italy Aims: To assess whether measures of abdominal fat distribution, visceral density and antropometric parameters obtained from the preoperative computed tomography (CT) abdominal scan may predict postoperative pancreatic fistula (POPF) occurrence after pancreatoduodenectomy (PD). Methods: We retrospectively analyzed data from 117 patients who underwent classic Whipple or pylorus-preserving, followed by either Child or Roux-en-Y reconstructions, from January 2007 to March 2014 and performed a CT scan as staging at our center. CT images were processed to obtain measures of total fat volume (TFV), visceral fat volume (VFV), and density of spleen, liver and pancreas in Hounsfield units. The occurrence and severity of pancreatic fistula were assessed according to International Study Group for Pancreatic Fistula classification. The predictive ability of each parameter was investigated by receiver operating characteristic (ROC) curves methodology and assessing optimal cut-off thresholds. A stepwise selection method was used to determine the best predictive model. Results: Clinically relevant (grade B and C) POPF occurred in 24 patients (20.5%). Areas under ROC-curves showed that none of the parameters was per se significantly predictive. The multivariate analysis revealed that VFV > 2334 cm3, TFV > 4408 cm3, pancreas/spleen density ratio < 0.707 and pancreatic duct diameter < 5 mm were predictive of POPF. The risk of POPF progressively increased with the number of factors involved and age. Conclusions: It is possible to deduce objective information on the risk of POPF from a simple and routine preoperative radiologic workup.

PANCREAS CANCER 0221 THE DIFFICULTIES ENCOUNTERED IN CONVERSION FROM CLASSIC PANCREATICODUODENECTOMY TO TOTAL LAPAROSCOPIC PANCREATICODUODENECTOMY M. Battal1, A. Yilmaz2, G. Ozturk2 and O. Karatepe2 1 SisliEtfal Research Hospital; 2Medipol University, Turkey Aims: Recently, Total laparoscopic pancreatectomy has started to be done in many centers as an alternative to open surgery. In this study we aimed to present the difficulties that we have encountered in conversion from classic open pancreaticoduodenectomy to total laparoscopic pancreatectomy. Methods: Between December 2012 and January 2014 we had 100 open pancreaticoduodenectomies. Subsequently

HPB 2016, 18 (S2), e747ee781