Deep J. Malde

The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013

INTRODUCTION Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989-2013. METHODS The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. RESULTS Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14-35) for blunt trauma and 14 (IQR: 9-18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. CONCLUSIONS Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.

Laparoscopic versus open cystgastrostomy for pancreatic pseudocysts: a case-matched comparative study

Cystgastrostomy is the commonest method of internal drainage of pancreatic pseudocysts (PPs). While large and persistent retrogastric pancreatic pseudocysts are amenable to laparoscopic cystgastrostomy, the potential benefits of this minimally invasive laparoscopic approach over open surgery remain to be demonstrated. The aim of this study was to compare the outcomes of the laparoscopic and open approaches for cystgastrostomy.

OC-062 A comparative study of laparoscopic vs open cystgastrostomy for pancreatic pseudocysts

Introduction While large and persistent pancreatic pseudocysts are amenable to internal drainage by laparoscopic techniques, the benefits of this minimally invasive approach remain to be demonstrated. The aim of this study was to compare the open and laparoscopic approaches for internal drainage of large and persistent pancreatic pseudocysts. Methods Patients who underwent cystgastrostomy were selected, and the demographic features, clinical characteristics and outcomes of those who had the surgery performed laparoscopically were compared to those who had open surgery. The two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results Between 1997 and 2010, 42 patients (15 female and 27 male) underwent 45 surgical internal drainage procedures for pancreatic pseudocysts (36 laparoscopic with two conversions to open surgery, and nine open). The laparoscopic and open groups were comparable for age (56 vs 53 years, p=0.448), sex distribution, and size of pseudocyst (12 vs 13 cm, p=0.305). The two approaches had comparable operating times (90 vs 75 min, p=0.630) but laparoscopic surgery carried a significantly lower risk of postoperative morbidity (5.8% vs 54.5%, p=0.001) and shorter postoperative hospital stay (2 vs 10.5 days, p<0.001). Laparoscopic surgery was also associated with a more rapid resumption of dietary intake (median 4 vs 6 days, p=0.065). There was one death in the open group (11.1%) but none in the laparoscopic group. Conclusion The laparoscopic approach to cystgastrostomy for large and persistent retrogastric pancreatic pseudocysts is associated with a smoother and more rapid recovery and a shorter hospital stay compared with open surgery. Competing interests None declared.

PMO-099 A comparative study of laparoscopic vs open distal pancreatectomy

Introduction The laparoscopic approach to distal pancreatectomy for benign and malignant diseases appears to offer advantages and is replacing open surgery in some centres. However, well-designed studies comparing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP) are limited. We present a single-institution study comparing the outcomes of LDP to ODP. Methods The demographic details, clinical characteristics and outcomes of patients who underwent laparoscopic distal pancreatectomy were compared to those who had the surgery performed by open technique. The two approaches were compared on an intention-to-treat basis. Data shown represent medians. Results Between 2002 and 2009, 32 patients (20 female) underwent 16 LDP and 16 ODP respectively. The laparoscopic and open groups were comparable for age (57 vs 63 years, p=0.584), sex distribution and tumour size (3.9 vs 4 cm, p=0.939). Both groups had a comparable number of malignant cases (56% vs 50%, p=1.0). Although LDP took longer to complete (287.5 vs 240 min, p=0.061), it was associated with significantly lower blood loss (300 vs 500 ml, p=0.031) but comparable perioperative transfusion rate (p=0.471). The laparoscopic approach was associated with a significantly higher spleen-preservation rate (overall: 50% vs 12.5%, p=0.05; benign pathology: 85.7% vs 25%, p=1.0). LDP patients had a significantly lower HDU stay (1 vs 4.5 days, p<0.001) and a significantly lower postoperative hospital stay (6.5 vs 13.5 days, p=0.001). There was no significant difference in the postoperative morbidity and the R0 resection margin status. Conclusion The laparoscopic approach to distal pancreatectomy results in significantly lower blood loss, and shorter HDU and hospital stay compared with open surgery. The postoperative morbidity and R0 resection margin rates were comparably similar. Competing interests None declared.

PWE-154 Primary duct closure after laparoscopic bile duct exploration for choledocholithiasis is a safe and effective approach

Introduction The common bile duct is traditionally managed with T-tube drainage after choledochotomy and removal of common bile duct (CBD) stones, but this approach carries an associated tube-related morbidity rate, including bile leak, of 10.5–20%. This study examines the safety and effectiveness of laparoscopic CBD exploration (LCBDE) followed by primary duct closure. Methods This is a retrospective analysis of 94 consecutive patients (27 male) who underwent LCBDE between October 2002 and December 2011. The duct was primarily closed in all patients. The results shown represent the median (range). Results All procedures were completed laparoscopically. The maximum diameter of the CBD was 9.7 (3–30) mm, and it was dilated in 93% of patients. The number of CBD stones was 2 (0–20). The exploration was transcystic in 14 patients and trans-CBD in 80 patients. The biliary tree was clear at the end of exploration with no subsequent evidence of retained stones in 92 patients (97.8%). The operating time was 117 (22–395) min. Postoperative bile leak occurred in four patients (4.5%) who were managed successfully with re-laparoscopy and suturing of the choledochotomy (n=2), laparoscopic insertion of biliary stent (n=1) and conservatively (n=1). The overall morbidity rate was 8% and included pulmonary complications (n=3), cholangitis (n=2), myocardial infarction (n=1) and wound infection (n=1). There were no operative deaths, and the postoperative hospital stay was 1 (0–51) day. At a follow-up of 48.2 (24–82) months, 92.5% of patients (n=87) had no biliary symptoms, one patient required endoscopic extraction of a retained stone, one developed bile duct stricture that was managed successfully by endoscopic balloon dilatation, and four patients (4.5%) failed to attend the follow-up. Conclusion Primary duct closure following LCBDE is safe, and can be employed as an alternative to T-tube insertion with short hospital stay and lower morbidityrate. Competing interests None declared.

PMO-103 Prognostic value of post operative ca19-9 in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma

Introduction Pancreatic Adenocarcinoma accounts for over 90% of Pancreatic malignancy with overall survival being <5% at 5 years. CA 19-9 is a commonly used tumour marker with levels in excess of 200 U/ml being 90% sensitive for pancreatic malignancy. Pre-operative CA 19-9 has been used as a prognostic marker with higher levels being associated with poorer outcomes. The purpose of this study was to see if post operative Ca19-9 was an independent prognostic factor. Methods A retrospective analysis of a prospectively collected database from January 2005 to December 2010. Inclusion criteria was a normal preoperative bilirubin and pre and postoperative Ca 19-9 measurements (n=76). The primary endpoint was death or recurrence of disease. Data were also analysed for TNM staging, resection margin status and overall survival. Results 70 patients with pancreatic ductal adenocarcinoma were in the study. An elevated post operative CA19-9 (n=33) had a significantly poor mean survival of 26.8 months compared to patients with normal levels (n=37) who had a mean survival of 45.5 months (p=0.004). For patients with a postoperative value ≥200 U/ml (n=13) mean survival was 19.8 months compared with levels <200 U/ml (n=57) being 43.9 months (p=0.001). A <75% fall in post operative ca19-9 levels in comparison to preoperative levels (45 vs 25 patients) resulted in poor mean survival of 34.9 vs 45.9 months but did not reach statistical significance (p=0.218). Conclusion In patients who have undergone pancreaticoduodenectomy for ductal adenocarcinoma having a normal postoperative Ca 19-9 is a marker for improved outcome where as a level in excess of 200 U/ml is a negative predictive factor. A <75% fall in post operative readings of CA19-9 results in poor survival (11 months) but was not statistically significant. Competing interests None declared.

PWE-155 The safety and efficiency of laparoscopic liver resection for benign and malignant liver diseases

Introduction Advances in technology and techniques facilitated the development of laparoscopic liver resection (LLR). The study is aimed at the evaluation of the feasibility and effectiveness of LLR for benign and malignant pathology. Methods This is a retrospective study of 61 patients (27 female) aged 63 (25–83) years who underwent LLR for benign (n=9) and malignant (n=52) between 2003 and 2011 in a single UK tertiary centre. The results shown represent median (range). Results Surgery was completed laparoscopically in 60 patients (98.3%) and converted to open due to extensive abdominal adhesions in one patient. The procedures performed included the resection of one segment (n=16), two segments (n=36) and three segments (n=9). The overall operative morbidity was 8.5% and there was no mortality. The operating time was 162 (50–300) min. The estimated blood loss was 110 (25–1100) ml and two patients received blood transfusion. The postoperative hospital stay was 3.6 (1–14) days. The resected malignancy in 52 patients included metastases in 47 patients (44 colorectal adenocarcinoma, three others) and hepatocellular carcinoma (n=5), and the R0 resection rate was 86.6% (n=45). At 42 (6–108) months follow-up, 77% were disease-free, 19% showed recurrent metastasis (1 hepatic, 4 hepatic and elsewhere, 5 extra-hepatic) and 4% failed to attend the follow-up. Conclusion Our results support the expanding evidence that LLR is safe and efficient for the treatment of benign and malignant liver lesions in carefully selected patients. Competing interests None declared.