P1
Annular pancreas: a high incidence of recurrent acute pancreatitis in
adults and review of literature.
H Mishra, R PhaniKrishna, R Pradeep, GV Rao, Asian Institute of Gastroenterology,
Hyderabad.
Introduction: Annular pancreas is a rare congenital anomaly. Most cases are
diagnosed early in life when patients present with duodenal obstruction. However,
some patients remain asymptomatic until well into adulthood, when the disorder
manifests as abdominal pain, pancreatitis, duodenal ulcer. We report a case series of
nine patients with 1infant, 2 child and 6 adults. Material and methods: A
comprehensive retrospective analysis of all patients with annular pancreas treated
between January 2005 and May 2009 was conducted. The factors evaluated included
sex, age at diagnosis, mode of presentation, presence and type of pancreatitis; type
of imaging used to confirm the diagnosis, comorbid factors, and associated
anomalies. Additionally, the type of operative intervention, length of hospitalization,
immediate and short-term outcomes were identified. Results: Recurrent abdominal
pain due to pancreatitis was the most common presentation (7/9 patients,77%)
followed by gastric outlet obstruction (6/9 patients,66.6%). Four of the six patients
with recurrent attacks of acute pancreatitis progressed to chronic pancreatitis
(66.6%). One patient presented with chronic pancreatitis. The annular pancreas was
detected by Barium meal follow through [BMFT] in 2/2 patients, by ultrasonography
in 1/9 patients, by Computerised tomography scan (CECT) in 2/5 patients, by
magnetic resonance cholangiopancreatography (MRCP) in 6/6 patients, by
Endoscopic retrograde cholangiopancreaticography (ERCP) in 2/6 patients, by
Endoscopic Ultrasonography (EUS) in 5/5 patients and at the time of laparotomy in
two patients. Duodenal bypass was done in six patients (6/9, 66.6%) and pancreatic
drainage procedure was done in five patients (5/9, 55.5%). Conclusion: Our case
series suggests that with development of newer imaging modalities (MRCP and EUS)
majority of patients with annular presenting late in life are diagnosed preoperatively.
Adult patients with annular pancreas have a high incidence of recurrent acute
pancreatitis which progress to chronic pancreatitis with time.
P2
Prognostic factors and feasibility of En-bloc vascular resection in stage II
adenocarcinoma of pancreas
KD Chakravarty K, JT Hsu, KH Liu, CN Yeh, TS Yeh, TL Hwang, YY Jan, MF Chen,
BGS Global Hospital, Bangalore, India.
Aim: Few studies investigate the prognostic factors and feasibility of vascular
resection in stage II adenocarcinoma of pancreas following
pancreaticoduodenectomy. The aim of this study is to find out the prognostic factors
and feasibility of en-bloc vascular resection in stage II adenocarcinoma pancreas,
localized to head and uncinate process. Methods: We retrospectively analyzed 87
patients of stage II pancreatic adenocarcinoma subjected to
pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy
between 1996 and 2006 in Chang Gung Memorial Hospital, Taiwan. 12 and 75
patients underwent pancreaticoduodenectomy / pylorus-preserving
pancreaticoduodenectomy with and without resection of portal vein-superior
mesenteric vein, respectively. Results: The overall 1-yr and 3-yrs survival rates of
patients undergoing pancreaticoduodenectomy / pylorus-preserving
pancreaticoduodenectomy with and without vascular resection were 50.0%, 16.7%
and 44.4%, 12.2%, respectively. Morbidity and mortality rates in PV-SMV resection
vs. non-resection groups were 50.0%, 0.0% and 40.0%, 2.7%, respectively. In
multivariate analysis serum bilirubin, histological differentiation and adjuvant
chemotherapy were independent prognostic factors influencing the survival.
Conclusion: In stage II adenocarcinoma of pancreatic head and uncinate process
serum bilirubin, histological differentiation and adjuvant chemotherapy were the
independent prognostic factors and en-bloc vascular resection is a feasible option in
carefully selected patients.
P3
Acute Pancreatitis -Management & complications in Rural Set up study of
27 cases.
S Dasgupta, P Nichkaode, A Chaudhary, V Kaushik, N Tulaskar, NKP Salve Institute
of Medical Sciences & Lata Mangeshkar Hospital, Nagpur
Introduction: Acute pancreatitis is a difficult problem to manage in a rural setup.
Aims & Objectives: To study the clinical and imaging methods and to define
patients requiring critical care and surgical intervention. Materials & Methods: 27
patients were studied. Clinical and imaging data were recorded prospectively.
Patients were managed conservatively unless there was clinical deterioration. Age
range was 17-57 years. Males outnumbered females. Aetiology included alcohol
abuse, gall stone disease, hypertriglyceridemia, and idiopathic. Six out of 27 patients
had previous h/o acute pancreatitis. Clinically -Tenderness, guarding, rigidity,
Palpable lump, Illius, bilateral pleural effusion, ascitis were findings noted during
examination. Leucocytosis, decreased sr. Albumen, deranged renal function with one
patient in renal failure. Sr. Amylase was significant in 87% pats, we could do sr.
lipase in only 16 patients with significant rise in 100%. In our study most patients
treated conservatively, a few patients needed surgical intervention in the form of
Necrosectomy-3, Pseudocyst in 2 patients, one patient explored for abscess, one
patient who had infected necrosis died during treatment after Necrosectomy. We
followed Ranson’s criteria, CT findings were ever possible for prediction of severity,
score < 3 in 21 patients – mild form-stay 10-12 days, mortality -0%, Score > 3- 6
pats. Stay was more than-36 days. Mortality -1 pat. Conclusion:- Acute
pancreatitis is not infrequent presentation in our set up. Alcoholism – followed by
Gall stone are common causes. For diagnosis-Clinical exam, Serological ( limited
pats. ) + Biochemical investigations . Ranson’s criteria + CT scans-used for
predicting severity. CT scan also used for surgical intervention, prognosis & follow
up plan. All our patients were not able to even bear the cost for Investigations &
management. Majority of pats though manageable conservatively some intervened
surgically for complications. But considering all this results are comparable to some
series in Literature.
P4
Ampulectomy: a retrospective audit. AK Pujahari, Command Hospital,
Bangalore.
Background: Duodenal ampulla of Vater is a complex anatomical and histological
site and a tumor may arise from more then one epithelium. Surgical obstructive
jaundice due to block at the ampulla is not uncommon. At times small impacted
stone and fibrosis cause diagnostic dilemma. Preoperative biopsies have a poor
diagnostic accuracy. Pancreaticoduodenectomy is an extensive procedure. In
selected cases local resection of ampulla of Vater is another option. Methods: Cases
of surgical jaundice with ampulla of Vater block were evaluated. Haematological and
biochemical test done. USG/CT/MRI and side viewing endoscopic evaluation and
biopsy were done besides other systemic disease evaluation. When the biopsy was
negative or in presence of severe systemic disease, contraindicating a Whipple’s
procedure, these cases underwent exploration. At exploration para duodenal and
peri bile ductal lymph nodes located were for frozen section biopsy was done. In
cases of negative frozen sections trans duodenal ampulectomy was done .All
received usual post operative care and followed up. Results: There were 6 cases
from between 2001-2009. There were 5 males and one female. The age range was
from 49-78 years. Only 1/6 had biopsy proven malignancy before surgery. The
operation time was 1hr: 45 mins to 3 hours (including the frozen section). One case
had post operative bleed and required re-exploration. Two required blood
transfusion. One case had severe post operative cardiac arrhythmia. Post operative
period in other cases were uneventful. One was benign and five were
adenocarcinoma. One patient, who had cardiac illness died at 14 months. One
patient lost to follow up after 20 months. Three are surviving after 8 yrs, 3 years and
4 months follow up: Conclusion: Ampullectomy is safe in localized Vaterian lesion
and in high risk patient.
P5
Rare indications for Pancreatoduodenectomy (PD)- report of 2 cases. BP
Bhole, PP Varty, PK Wagle, Lilavati Hospital & Research Center.
We present our recent experience of 2 rare cases requiring PD. Case 1) 54 yr non
addict male had recurrent attacks of acute pancreatitis for 9 years with vomiting and
16 kg weight loss. CT, MRI scan & Endosonography showed a cyst in the pancreatic
head with thickening of duodenum. Endoscopy revealed tight narrowing at D2. A
provisional diagnosis of “Groove Pancreatitis” was considered. At Whipple’s PD, there
was a hard mass near the groove & severe thickening of D2. The inferior pancreatic
head, uncinate process and remaining pancreas were normal. Gross examination
showed fibrosis in the wall of D2 & pancreatic groove as well as a adjacent hard
mass. The cyst was communicating with the minor papilla. Microscopy showed
extensive Brunner’s gland hyperplasia in the duodenum. The cyst showed calcified,
eosinophilic material and heterotopic pancreatic tissue. The pancreatic ducts around
the cyst wall showed lymphoplasmacytic infiltrate and there was no evidence of
malignancy. This confirmed Groove / Paraduodenal pancreatitis. Case 2) 58 yr lady
had pain in abdomen with a intra-luminal lesion in D2 as revealed on USG, CT and
PET scan. CT guided FNA of the lesion confirmed adenocarcinoma. Previously she
had undergone several surgeries: Laparoscopic cholecystectomy, Pancreatic
necrosectomy after acute pancreatitis and then Lateral head pancreatico &
pseudocyst-jejunostomy with hepatico-jejunostomy for chronic pancreatitis.
Subsequently, she had Total gastrectomy for gastric carcinoma followed by Bilateral
salpingo-oophorectomy for Ovarian Ca. At Whipple’s PD, there was a fleshy mass in
the D2 with no spread and the previous lateral jejunal anastomotic segment was
resected en bloc with remnant head of the pancreas and entire duodenum.
Pancreatic and biliary enteric anastomoses were not required. Histology confirmed a
well differentiated villous adenocarcinoma arising from pancreatic ampulla with
submucous spread only. There was multiple intraductal pancreatic villous
adenomatosis with foci of invasive carcinoma.
P6
A study of C-Reactive protein in early prediction of pancreatic necrosis and
its prognostic value. AK Sharma, A Saha, JK Banerjee, CS Naidu, Army Hospital (R
& R), Delhi Cantonment.
Objectives of the study:(a) To determine the relation between C-reactive protein
and pancreatic necrosis and, (b) To estimate the prognostic value of C- reactive
protein in early diagnosis of pancreatic necrosis. Material and methods: The sample
consisted of 50 (fifty) patients of acute pancreatitis who were a uniform admixture
of both etiologies of alcohol and gallstones. There were 29 males and 21 females. All
patients with previous episodes of acute pancreatitis were excluded from the study.
Cases of acute pancreatitis who presented with clinical data, laboratory values of
elevated serum amylase and lipase more than five times the baseline value i.e the
upper limit of normal and CECT findings of acute pancreatitis were part of the
study. Data collection included age, gender, aetiology, history of previous acute
pancreatitis, primary or referral admission, BMI, need for inotropic or ventilatory
support , renal failure, previous abdominal surgery and length of hospital stay. Creactive protein concentration in the serum was measured on day 1,2,3,5 and 7
after onset of disease by the nephelometric method. According to the severity of the
disease, patients were divided into two groups: Group – I: Pancreatic necrosis
Group – II: Edematous pancreatitis. Methods: C - reactive protein values were
compared between both groups by ‘T’ test for paired data. The sensitivity, specificity
and negative predicted values for different CRP concentrations (100- 150mg/dl)
were calculated. The difference was assumed to be statistically significant when
p<0.05. Results: There was no difference in the demographic data between the
two groups and the average age was similar. None of the patients had attacks of
acute pancreatitis previously. There were 11 (22%) patients with NP and 39 (78 %)
patients with PE .The average age of patients in both groups was similar. Men
predominated in both groups, but the difference was negligible in the NP group
(54% vs. 45%). Etiologic factor for pancreatic necrosis in 54% of patients was
gallstones. Gallstones and alcohol were shown to have induced mild pancreatitis in
28.2% and 25.6% of cases respectively. In more than one third of patients in both
groups causative factor was other than gallstones or alcohol. The contrast-enhanced
CT scan was performed in all cases, so all patients with pancreatic necrosis were
examined, some of them repeatedly. Low volume necrosis (<30%) was present in
5(45.4%), 30-50% necrosis in 3 (27.2%), and subtotal necrosis (>50%) in 3
(27.2%) cases. Six patients with pancreatic necrosis underwent surgery; two of
them in the first week of hospitalization because of the signs of peritonitis ,
uncertain diagnosis, suggestion of hollow viscus perforation, and four in the later
course of the disease after FNAB demonstrated pancreatic and/or peripancreatic
necrosis. The average concentrations of CRP in both groups were calculated using
the nephelometric method on day 1,2,3,5,7 of admission. Mean values of CRP
differed in the groups significantly from the day of hospitalization except for day 7.
Sensitivity, specificity, positive and negative predictive values for various CRP cut-off
concentrations were determined. The highest C-Reactive protein values were
detected on day 3 in group I patients. The difference of average C – reactive protein
concentration was significant between groups on all days except day 7. The highest
sensitivity and negative predicted value (94.1% and 95.7% respectively) was
obtained for C – reactive protein cut off at 110mg%. With a CRP cut-off value of 100
and 110 mg/l all the parameters were equal. Increasing CRP cut-off values resulted
in significant decrease of sensitivity and negative predictive value, whereas only
slight increase of specificity and positive predictive value was demonstrated.
Conclusions: This study shows that C-reactive protein is an important prognostic
marker of pancreatic necrosis with the highest sensitivity and negative prognostic
value in this respect. The study results show that CRP values increase significantly in
early stages of pancreatic necrosis. It is an important prognostic marker of
pancreatic necrosis with the highest sensitivity, specificity and negative prognostic
value given the cut of 110mg%. Patients with CRP values below 110mg% are at low
risk to develop pancreatic necrosis.
7
Disconnected Duct Syndrome: Diagnosis and management. B Abraham, MMS
Bedi, G Singh, A Venugopal, B Venugopal, V Lekha, M Jacob, H Ramesh, Lakeshore
Hospital & Research Center, Cochin.
Background: There is scanty data in the Indian literature about pancreatic duct
disconnection. Aim: Retrospective analysis of case records to identify the clinical
characteristics and outcomes of management of disconnected duct syndrome (DDS)
and evolve management approaches. Materials and Methods: 23 patients with
DDS were identified over a 10 year period (1999-2009). There were two groups: a)
acute pancreatitis related (n=16) and b) pancreatic trauma-related (n=7). There
were 18 males and 5 females, and 5 children (age range 7 to 56; median 27).
Diagnosis was achieved by ERCP in 10 cases, and by CT scan in 9 patients and
fistulograms in 4. Results:
Treatment modality
Post pancreatitis
Post trauma
Expectant treatment
3
0*
Distal pancreatectomy
2
1
End-to-end anastomosis
0
4
ERCP stent placement
3
0
Endoscopic
cystogastrostomy
2*
1*
Pancreaticojejunostomy
2
1
Fistulojejunostomy
5
0
Follow up ranged between 2 and 112 months. 20 out of 23 are well, 9 have new
diabetes mellitus and 13 are on pancreatic exocrine replacement therapy. 2 patients
treated by endoscopic cystogastrostomy have residual cystic collection posterior to
the stomach but have mild symptoms and are on follow up. One patient who
underwent fistulojejunostomy has recurrent pain and imaging showed a fluid
collection near the tail of pancreas, but is being managed conservatively.
Conclusions: DDS may be managed by endoscopic stenting; if it fails, then surgical
resection/drainage of the tail, or fistulojejunostomy is an option. Endoscopic
cystogastrostomy is not suitable for collections due to DDS.
P8
Selective drainage in patients undergoing pancreaticoduodenectomy. T
Singh, AS Arora, A Chaudhary, Sir Ganga Ram Hospital, New Delhi.
Introduction: Routine use of prophylactic abdominal drainage after elective
abdominal surgery has been a matter of debate. Recent reports suggest that most
upper abdominal surgeries including pancreatic resections can be performed safely
without drainage. We aimed to study the safety of a policy of selective drainage in
patients undergoing pancreaticoduodenectomy based on operating surgeon’s
assessment. Methods: Between January 2007 and June 2009, 103 consecutive
patients undergoing pancreaticoduodenectomy were included. Drains were placed
based on the discretion of the operating surgeon, in patients having one or more of
these factors: (a) soft pancreas, (b) undilated pancreatic duct making the
performance of a duct to mucosa anastomosis impossible, (c) unhealthy bile duct,
(d) high intraoperative blood loss (e) presence of pancreatitis or (f) multivisceral
resection. Retrospective analysis of prospectively collected data of these 103
patients was performed. Results: Only 36 patients (34.9%) were selected for
inserting abdominal drain while no drain was required in 67 patients (65.1 %) as
assessed by the operating surgeon. The mean hospital stay was 6.8 days (3-19
days) in the no drainage group while it was 7.3 days (4-27 days) in the drainage
group. Among patients without drainage, 4(5.97 %) required readmission: 2 for
delayed gastric emptying, 1 for wound infection and 1 for intra abdominal collection
for which an imaging guided drain was inserted. Readmission was required in
3(8.33) patients in the drainage group. There was one death in the drainage group.
Conclusion: A policy of selective drainage in patients undergoing
pancreaticoduodenectomy based on surgeon’s intraoperative assessment is probably
safe.
P9
Our Experience Of Outcome Of Lateral Pancreatico-Jejunostomy In
Chronic Pancreatitis. –a study of 15 cases. D Sarkar, S Chaudhuri, V Chandel,
Calcutta Medical & Research Institute, Kolkata.
Background: Patients with intractable pain due to chronic pancreatitis have been
managed successfully with LPJ. Major selection criteria was ductal diameter >1 cm,
poor pain relief on drugs [including opioids]& fair nutrition.Aim: To ascertain that LPJ
is a safe, cost effective procedure to treat chronic pancreatitis provided strict
selection criteria, judicious drugs & safe operative principles are followed. Methods:
Outcome of 15 patients with chronic pancreatitis treated with LPJ was assessed. Preop health status, alcohol intake, history of prior attacks, co-morbidities, and severity
of pain [VAS score] were noted .Post operatively patients were managed in general
ward except one, who required ICU stay for chest related complications. We
advocated early enteral feeds and ambulation and noted much fast recovery.
Regular follow-up has been done since last 4 years with a minimum period of 6
months and data recorded. Results: Mortality recorded till date has been nil. All our
patients have shown marked improvement in health as well as good pain relief and
currently receive no analgesics. Incidence of re-operation or re-hospitalisation has
been nil so far. Conclusion: LPJ is a safe operation in selected cases of chronic
pancreatitis and results are satisfactory on follow up.
P 10
Pancreaticogastrostomy versus pancreaticojejunostomy in reconstruction
after pancreaticoduodenectomy.MMS Bedi, B Kundil, G Singh, B Venugopal, A
Venugopal, V Lekha, M Jacob, H Ramesh, Lakeshore Hospital & Research Center,
Cochin.
Background: Despite many previous studies, a large randomized trial comparing
the two main anastomotic techniques after Whipple resection is lacking. Many
observational studies have shown superiority of PG while randomized trials have
shown no difference in outcome. Aim: prospective randomized controlled trial of PJ
vs PG after Whipple resection. Period of study 2004 to 2009. Patients: 234 patients
were screened, and 201 patients were randomized. Two patients were removed
from the study owing to surgeon preference. 99 patients underwent PJ and 101
underwent PG. Patient characteristics were similar in both groups. In both cases, a
Duct-to-mucosa technique was used. Methods: The following parameters were
analyzed: mortality, major complications, pancreatic fistula as defined by high drain
amylase at Days 1, 3, 5 and 10, intra abdominal collections, postoperative bleeding,
hospital stay, time to resumption of oral intake, and need for postoperative
intervention (endoscopy, interventional radiology or surgery). Data was analyzed
using SPSS v 11.0. Results: 3 patients died (2 PJ, 1 PG). Postoperative pancreatic
fistula rates were higher following PJ than PG. See Table. Patients had fewer
episodes of postoperative bleeding after PG, shorter hospital stay, and less
postoperative interventions. Oral intake was resumed earlier following PJ.
Parameter
PJ (n=99)
PG (n=101)
P Value
High amylase in
38
24
0.06
drain on Day 3
High amylase in
25
14
0.03
drain on Day 5
High amylase in
12
2
0.008
drain on Day 10
Postop fluid
18
13
NS
collections
Delayed gastric
23
24
NS
emptying
Bleeding
5
1
0.09
Need for
14
7
NS
intervention
Hospital stay
14.5 days
13 days
0.03
(median)
Mortality
2
1
NS
Conclusion: Postoperative pancreatic fistulas occur more commonly following
pancreaticojejunostomy. Intra abdominal collections, hemorrhagic complications,
and hospital stay were more in the PJ group, although mortality rates are similar.
There is thus a trend towards superiority of PG over PJ in terms of pancreatic fistula
rates and hospital stay.
P 11
Problems in laparoscopic management of pancreatic pseudocyst. SJ Baig, V
Chandel, CMRI, Kolkata.
Aim: To retrospectively analyze the problems (on non-edited video recordings)
encountered in 19 cases of laparoscopically managed pancreatic pseudocysts.
Material & Methods: This retrospective data comprised of 19 patients who
presented with pancreatic pseudocysts between 2007- 2009.
All patients fit for general anesthesia were selected for laparoscopic management.
18 patients underwent lap cystogastrostomy (LCG), 1 lap cystojejunostomy (LCJ).
Follow- up was done in all cases for a period of 6 month- 2years. Intra-operative
video recording & postoperative follow-up was analysed retrospectively. Results::
There were 3/19 conversions and 1 recurrence (at 3 months). Among successfully
completed lap managed cases, lack of working space due to large pancreatic
phlegmon with dilated bowel was seen in 2/ 16 cases. Retrospective analysis of
videos suggested that the struggle could have been reduced by appropriately citing
trocar position. The 3 conversions were due to as follows: 1. Uncontrolled
hemorrhage from cyst wall in a thick walled (>10 mm) infected pseudocyst. This
suggests that this pseudocyst was not ideal for lap management. 2. Cyst wall fell
away from posterior gastric wall after posterior gastrotomy. Lack of working space
led to mis-identification of colon as stomach leading to colonic injury. Problem 2 & 3
could have been avoided by use of laparoscopic USG & early open conversion if in
doubt regarding anatomy. Recurrence occurred in 1 case where site selection of
stoma was nondependent due to mis-interpretation of anatomy. Conclusion:
Management of pancreatic pseudocyst laparoscopically is possible in most cases.
Problems can be avoided in most cases & in some, early open conversion is probably
better to avoid complications.
P 12
Severe Colonic Complications requiring Sub-Total Colectomy in Acute
Necrotizing Pancreatitis - A Retrospective Study of 8 Patients. AP Nagpal,
HN Soni, S Haribhakti, Haribhakti Surgical Hospital, Ahmedabad.
Introduction: Colonic involvement in acute pancreatitis is associated with high
mortality. Diagnosis of colonic pathology complicating acute pancreatitis is difficult.
The treatment of choice is resection of the affected segment. The aim of this study
is to evaluate the feasibility of aggressive surgical approach when colonic
complication is suspected. Method: Retrospectively, 8 patients with acute
necrotizing pancreatitis and colonic complications (2006–2009) were reviewed.
Results: Eight patients with acute necrotizing pancreatitis requiring colonic
resection were evaluated. Presentation was varied, including rectal bleeding (2),
clinical deterioration during severe pancreatitis (4), colonic contrast leak on CT scan
(1) and large bowel obstruction (1). Typically, patients with severe acute pancreatitis
had colonic pathology obscured and unrecognized initially because of the ongoing,
fulminant inflammatory process. All eight patients underwent Sub-total colectomy &
ileostomy for suspected imminent or overt ischemia/perforation, based on the outer
aspect of the colon. There was one mortality due to severe sepsis and multiorgan
dysfunction syndrome. All other patients recovered well and later underwent closure
of the stoma. Conclusion:Recognition of large bowel involvement may be difficult
because of nonspecific symptoms or be masked by the systemic features of a critical
illness. Clinicians should be aware that acute pancreatitis may erode or inflame the
large bowel, resulting in life-threatening colonic necrosis, bleeding or perforation. In
our series of eight patients, we observed that mortality can be reduced by this
aggressive surgical approach. We recommend a low threshold for colonic resection
due to unreliable detection of ischemia or imminent perforation by outside inspection
during surgery for acute necrotizing pancreatitis.
P 13
Diaphragm perforation : an unusual complication of acute necrotizing
pancreatitis. AP Nagpal, HN Soni, S Haribhakti, Haribhakti Surgical Hospital,
Ahmedabad.
Acute Necrotizing Pancreatitis (ANP), also known as the Severe Acute Pancreatitis
(SAP) is associated with multi organ system failure and/or additionally may include
local complications. The severity of the local response can lead to development of
the systemic inflammatory response syndrome (SIRS) and multiorgan failure, with
considerable morbidity and mortality. The pancreatic and peri-pancreatic necrosis
occurs early in SAP and is fully established by 4 days. Sometimes the disease
presents with unusual delayed manifestations as a result of loco-regional or systemic
complications. A case of unusual presentation of necrotizing pancreatitis leading to
diaphragm perforation - a rare complication is presented here.
P 14
Short and Long term outcomes after Frey Procedure for chronic
pancreatitis: a 15 year, 400 case experience. MMS Bedi, B Venugopal, A
Venugopal, MD Gandhi, B Kundil, G Singh, M Jacob, V Lekha, S Mahesh, B Abraham,
H Ramesh, Lakeshore Hospital, Cochin.
Background: Data regarding long term outcomes after surgery for chronic
pancreatitis are lacking. Aim: Determine long term outcomes after
Pancreaticojejunostomy with head coring (Frey Procedure) for chronic pancreatitis
over the period 1993-2008. Patients: 400 patients (257 male, 143 female, age
range 8-71 years, median 42.5 years) underwent Frey procedure for intractable pain
(n=157), complications (n=219), or asymptomatic pancreatic calculi (n=24).
Methods: Early outcomes studied were mortality and morbidity rates, and long term
outcomes studied were pain relief, changes in exocrine/endocrine status (both
subjective and objective), and quality of life. Factors affecting outcome were
analysed by univariate and multivariate analysis. Minimum follow up was 1 year and
maximum was 15 years (median 98 months). Results: 5 patients died, all in the
period 1993-2000, (pancreatic leak with secondary hemorrhage = 2, intra-abdominal
sepsis secondary to leak (n=1), Adult respiratory distress syndrome n=1) and
unexplained (n=1). Postoperative complication rates occurred in 21% (intra
abdominal collection, postoperative chest infection, fever, pancreatic leak, bleed, and
wound related complications). 11 patients died due to intercurrent and related
illnesses during the follow up. Pain relief occurred in 336 patients (84%) when
calculated at the end of 1 year follow up. At 5 years, the pain relief figure was 94%.
43 patients underwent reoperation/reinterventions. Endocrine status improved in
18%, worsened in 16% and remained constant in 66% of survivors. On univariate
analysis, acute presentation, alcohol dependence, residual head calculi, pancreatic
head mass affected outcome. On Multivariate analysis, residual head calculi was the
only significant factor (OR 3.14, 95% CI 1.09-6.87). On QOL assessments, 92% had
excellent or good quality of life. Conclusion: a) Surgery relieves pain and provides
quality of life in over 90% of patients in the long term (against the myth that long
term results are poor). b) pancreatic function is maintained following Frey
procedure, c) a significant number of patients required postoperative interventions,
or died due to both related and intercurrent illness.
P 15
Clinical profile of tropical chronic pancreatitis in Orissa. S Jayasingh, P
Mallick, SP Singh, MK Mohapatra, SCB Medical College, Cuttack.
Background: Tropical chronic pancreatitis (TCP) is the commonest variety of
chronic pancreatitis in Orissa. This is characterized by moderate to severe abdominal
pain with/without diabetes. The present study was a retrospective study to find out
the clinical profile of TCP in Orissa. Methods: During the period 2000 – 2009, 243
cases of TCP were admitted to our department. The hospital records of all these
patients were reviewed and analyzed with respect to their history, clinical findings,
and investigations including blood sugar, lipid profile, pancreatic function test, UGIE,
CA-19-9, X-ray abdomen, ultrasound, CT scan, and other sophisticated tests.
Results: Among the 243 patients, 178 were male and 65 female (3:1 ratio); over
half of the patients belonged to age group of 20 to 40 years. About 86% of patients
hailed from low socio-economic background from costal belt of Orissa. Alcohol
consumption was observed in only 8% of cases. The following signs/symptoms were
present: moderate/severe abdominal pain in 237 (98%), diabetes in 28 (11%),
steatorrhoea/diarrhea in 5 (2%), jaundice in 9 (4%), pseudocyst in 11 (5%), ascites
in 2 (1%), malignancy in 8 (3%), and upper GI bleed in 2 (1%). Parenchymal
calcification and intraductal calculi were seen in almost all cases. Two thirds of the
patients were managed conservatively and the remaining third were subjected to
appropriate surgical intervention. Conclusion: Tropical Chronic Pancreatitis is
common in coastal Orissa predominantly affecting young males of lower economic
status. Moderate to severe abdominal pain is the commonest symptom. Only 11%
have diabetes, and steatorrhoea is very rare. Pancreatic calcification and ductal
calculi are seen in almost every case. One third of these patients require surgical
intervention.
P 16
Anterior transgastric Pancreatico-gastrostomy – Novel technique of
reconstruction following Whipple’s procedure. P Kumar, M Joshi, S Kalia, N
Mohan, R Ardhanari, Meenakshi Mission Hospital, Madurai.
Introduction: Management of the pancreatic stump following
Pancreaticoduodenectomy (PD) has always been a main source of concern among
pancreatic surgeons. The present pilot study describes the reconstructive technique
of a modified anterior transgastric pancreatico-gastrostomy (PG) after classical PD.
Materials & Methods: Outcome in 32 patients, who underwent classical Whipple’s
procedure during (March 2008 – June 2009)who also underwent this technique for
pancreatic reconstruction, is reported. The average duration of the procedure was
210 minutes (range: 180–290); only two patients needed intraoperative transfusion
with 2 units of blood. The postoperative period involved complications in 6 cases
(18.8%). In particular, two patients developed pancreatic fistulas (6.2%), which
were grade B in nature. Four patients (12.5%) had features of delayed gastric
emptying, of which two patient’s required surgical exploration. Two patients
developed (6.25%) post operative bleeding. There was one death (4.5%) due to
post operative myocardial infarction. The mean hospitalization time was 11.1 days
(range, 8–25 days). Conclusion: The results obtained in this pilot study appear
encouraging and merit further analysis in a randomized comparative trial.
P 17
Role of pancreatic drainage procedure on hyperglycaemia in chronic
pancreatitis. S DeBakshi, S Sen, CMRI, Kolkata.
Background : Chronic pancreatitis often leads to diabetes, and there is scanty data
on the impact of surgical drainage on the diabetic status. Aims & objectives: To
study the the role of drainage operations in chronic pancreatitis on control of disease
induced hyperglycaemia ( diabetes ) and its durability.We wanted to assess whether
there is improvement in glycaemic status as reflected by either decrease in In sulin
requirement s or patients becoming 1 step lower in treatment requirement i.e.those
who on insulin were on to OHA and OHA onto only diet and so on. Patients &
methods : Our study was done in CMRI hospital , Kolkata over a period extending
from Jan. 2006 to Jan 2009 (3yrs). We included all diagnosed cases of chronic
pancreatitis during this 3 yr period , total being 56 of which 41 who underwent
either Lateral pancreatojejunostomy or Frey’s procedure for chronic pancreatitis
were screened out. Of these 41 patients , 32 had concurrent hyperglycaemia
controlled on diet/ exercise/ Oral Hypoglycaemics /Insulin. These 32 patients were
finally included in the study. Results: Age/Sex : Total 24 males and 8 females (
M:F= 3:1 ) Etiology : ALCOHOLIC -- 10 ( M ), NON-ALCOHOLIC – 22 ( 14 M , 8 F )
Distribution of disease : Diffuse disease with dilated ducts with head mass: FREYS
(10 – 8Alc. +2Nonalc.), Diffuse disease with dilated ducts without head mass: LPJ
(22) Preoperative sugar range and control methods: 85 – 200: Diet and exercise ( 2
patients ), 150 – 300: OHA (10), 200 – 350+: Insulin (20) (all 10 cases of Freys ).
Postoperative control of glycaemia : (90 day) Insulin dependant (n= 20) down to 5,
rest 15 were on OHA, OHA dependant (n=10) down to 0 , all were dependant only
on diet and exercise. Postoperative control of glycaemia : (1 yr), Recurrence of
insulin dependence in 5 (all cases of Freys) (33.3%), Recurrence of OHA
dependence in 2 (20 %), Follow-up: All patients were followed up at 2 weeks , 4
weeks , 3 monthly for two years and then 6 monthly. Follow up varying from
3months to 3 yr 6 months , mean being 21 months Follow up was done with history
specifically regarding any changes in sugar control method , clinical examination ,
FBS , PPBS , CECT 2 yearly for all cases . No further recurrences were noticed so far.
Conclusion: Drainage operations appear to delay this progressive decline in
pancreatic function.
P 18
Multivisceral Resection in Pancreaticoduodenectomy. PS Rao, A Singh, A
Chaudhary, Sir Ganga Ram Hospital, New Delhi.
Introduction: With the improving outcomes of pancreaticoduodenectomy (PD) and
availability of newer adjuvant therapies, the overall prognosis in periampullary and
pancreatic cancer is improving. Keeping these in view, there have been attempts at
additional organ resection with PD but there is very data available regarding the
outcome of such procedures. This study shares our experience of the impact of
additional organ resection in patients undergoing PD. Patients and Methods:
Between September 2003 and June 2009, 204 patients underwent PD in our unit.
Analysis of prospectively collected data was performed to determine outcome in
patients undergoing additional organ resection. Results: There were a total of 152
(74.7%) males and 52 (25.3%) females with ages ranging from 18 to 80 years
(median 54.6 years). A total of 15 patients underwent resection of additional organs
with PD. Of these 7 (46.67%) patients underwent PD with liver resection, 6 (40%)
required simultaneous colonic resection and 1 (6.67%) patient each underwent
additional nephrectomy and segmental small bowel resection respectively. Liver
resections consisted of metastatectomy in 5 and left lateral segmentectomies in 2
patients. In the 6 patients with colonic resections, 4 had right hemicolectomy and 2
underwent transverse colectomy. The requirements for blood product transfusion
and postoperative hospital stay were similar to patients undergoing only PD,
however the operating time was longer in patients undergoing additional organ
resection. Complications in terms of delayed gastric emptying and pancreatic fistula
were also similar in both the groups. There was no perioperative mortality in the
patients undergoing additional organ resection. 4/7 patients undergoing liver
resection and 4/6 undergoing colectomy developed recurrence. Conclusion:
Resection of additional organs can be performed with pancreaticoduodenectomy
without additional mortality or morbidity. However its benefit on long term survival
needs further validation.
P 19
Should surgical intervention in acute pancreatic necrosis- be based on
clinical findings or be dictated by radiological findings-an evidence based
study. N Jain, RY Prabhu, CV Kantharia, RD Bapat, AN Supe, Seth GS Medical
College, and KEM hospital, Mumbai.
Background: Pancreatic necrosis shows varied spectrum of presentations from
sterile to infected and asymptomatic to symptomatic. While it is generally accepted
that infected pancreatic necrosis should be managed surgically, the management of
pancreatic necrosis, showing radiological signs of infection but clinically quiescent
abdomen patients remains controversial. Recent clinical experience has provided
evidence that conservative management in this subset of patients seems promising.
Objective: Evaluation of non-surgical management of pancreatic necrosis with
radiological evidence of infection at a tertiary referral center was reviewed to effect
better patient outcome. Methods: In the present study non-surgical management
for necrotizing pancreatitis with radiological evidence of infection (August 2003 July2007) were reviewed. Diagnosis was made on clinical and radiological
investigations. Patients were monitored with serum amylase and lipase, serial USG
and CT (on 7th day and then after 17th, 27th days). APACHE score was observed for
clinical response. FNAC was not done. Patients were treated with Imipenum+
Cilanem for an average period of 14 days in surgical ICU. The decision of surgery
taken based on deterioration of clinical features, multi-organ (respiratory, liver and
kidney) failure (MOF) with during conservative treatment. Results: Between April
2003 and July2007, 14 patients with necrotizing pancreatitis with radiological e/o
infection but clinically stable were reviewed. Early antibiotic administration with
(imipenem with cilastatin) was done. Organ failure occurred in 8 cases (57%) in
which 3 patients (21.4%) had MOF (two organs, liver and kidney),
pigtailing for collection in or around pancreas was required for 2 patients. Failure of
conservative treatment in 2 patients required surgical treatment (14.3%). Surgery
was done after 2 weeks of trial with conservative treatment in both the cases. 2
patients required elective cholecystectomy after 6 weeks as the cause was biliary.
2/8 (25%) patients with organ failure and 2/3 with more than one organ failure
needed surgery. All 3/3 of MOF needed some sort of intervention. The mean length
of hospital stay was 29 days (16-42days). The death rate was 0% (0/14).
Conclusions: These results support that the clinical judgment is superior to the
radiological criteria and patients with multi organ failure needed surgical intervention
in acute pancreatic necrosis.
P 20
Addition of obesity score (APACHE O) does not improve the apache-ii
score in predicting the severity of acute pancreatitis. VC Bada, K Venugopal,
K Ravindranath, Global Hospital, Hyderabad.
Introduction: Approximately 20% of the patients with acute pancreatitis develop
severe pancreatitis, which are associated with prolonged hospitalization, significant
morbidity, and mortality ranging between 30% and 50%. The fate of a patient with
acute pancreatitis depends greatly on early recognition of the severity of the
disease. There are several approaches that have been used in this regard. Few
studies have reported the utility of Obesity and thus APACHE-O score and its
superiority over APACHE-II score in predicting severe acute pancreatitis. However,
there is a lack of clinical data regarding this aspect on Indian patients. This study
was performed in a tertiary referral care hospital in South India and was aimed at
comparing the efficacy of obesity in predicting the severity of acute pancreatitis in
comparison to APACHE-II. Methods: A total of 53 patients were studied
prospectively from Feb. 2008 to May 2009. The diagnostic criteria used for Acute
Pancreatitis in this study were • CLINICAL: History of pain abdomen with/without
radiation to the back with tenderness/guarding in upper abdomen • BIOCHEMICAL:
S. Amylase and/or S. Lipase more than/equal to three times the upper limit. •
RADIOLOGY: Ultrasound or CT scan findings suggestive of acute pancreatitis
Patients who presented more than 72 hours after the onset of symptoms were
excluded from the study. BMI was calculated for all patients. APACHE-II score was
deduced at daily intervals for 72 hours after the onset of symptoms and the most
abnormal value was taken for analysis. APACHE-O score was calculated. Final
outcome of the patient in terms of Severity of Pancreatitis viz. Mild Pancreatitis or
Severe Pancreatitis was the end point of the study. The Atlanta Consensus
Symposium definitions of Mild and Severe Pancreatitis were used. Bivariate analysis
was used to explore potential associations with severity of pancreatitis. The Receiver
Operator Characteristic (ROC) curve and the area under the ROC (AUROC) were
used to explore the ability of the variable to predict severity. Results: There were
32(60%) mild and 21(40%) severe pancreatitis patients. Almost 23% of the patients
were obese with BMI&#8805;30. The APACHE-II score ranged from 4 to 20 with a
mean of 8.28 and a median of 8. The APACHE-O score ranged from 4 to 22 with a
mean of 8.79 and a median of 8. The area under ROC for APACHE-II for a cut off of
&#8805;8 in predicting severity of acute pancreatitis was 0.72 (95%CI 0.60-0.84)
and the same for APACHE-O was 0.74 (95%CI 0.63-0.87). The sensitivity and overall
accuracy for APACHE-II was 81 and 70% respectively, whereas it was 62 and 77%
respectively for APACHE-O. There was no significant difference between the two
scoring systems. Conclusion: APACHE-II scoring system is a reliable parameter and
the addition of obesity score and thus APACHE-O score does not significantly
improve the APACHE-II score in predicting the severity of acute pancreatitis.
P 21
Laparoscopic transperitoneal drainage and second look laparoscopy in
infected pancreatic necrosis. S Wani, V Wakade, I Shaikh, Arulvannan, R
Patankar, M Goel, SK Mathur, Wockhardt Hospital, Mumbai.
Background: Minimally invasive necrosectomy is fast emerging as a technique of
choice for pancreatic necrosectomy. It is associated with faster recovery, less
postoperative pain and earlier return to work. Methods: This video demonstrates
the surgical technique of Laparoscopic transperitoneal technique of pancreatic
necrosectomy. A 45 year female presented with acute pancreatitis which was
conservatively managed. She then developed organized pancreatic necrosis with
collection in the lesser sac which was drained laparoscopically at 6 weeks. One
umbilical camera port and three working ports were used. Confirmation of pancreatic
necrosis was done by aspirating the collection in the gastrohepatic omentum (lesser
sac) and then it was opened widely with harmonic shear. All the collection was
aspirated and solid necrotic material was debrided bluntly with laparoscopic blunt
forceps and drains were placed, one in the right flank and one through the umbilical
port draining the cavity. After 4 days, second look laparoscopy was done by guiding
the trocar through the umbilical port by seldinger technique under local anaesthesia
and residual necrosis was removed. Conclusions: It is a safe technique of
pancreatic necrosectomy in well localized pancreatic necrosis . Second look
laparoscopy offers advantage to look for residual necrosis under local anaesthesia
and completion necrosectomy can be achieved.
P 22
Minimally invasive approach in management of infected pancreatic
necrosis. S Wani, I Shaikh, V Wakade, R Patankar, M Goel, SK Mathur, Wockhardt
hospital, Mumbai.
Background: Management of acute necrotizing pancreatitis has changed
significantly over the past years. In the 1980’s, management was purely surgical.
With better understanding of pathophysiology of disease, currently early
management is non-surgical and solely supportive.Today, more patients survive the
early phase of severe pancreatitis due to improvements of intensive-care
medicine.Pancreatic infection is the major risk factor with regard to morbidity and
mortality in the late phase of severe acute pancreatitis. Whereas early surgery and
surgery for sterile necrosis can only be recommended in selected cases, pancreatic
infection is a well accepted indication for surgical treatment. Open surgical
debridement is the “gold standard” for treatment of infected pancreatic and
peripancreatic necrosis. However conventional surgery for infected pancreatic
necrosis has been reported to be associated with significant surgical morbidity i.e.
wound complications, fascial dehiscence and intestinal fistulae. Advances in
radiologic imaging, new developments of interventional radiology and other minimal
access interventions have revolutionized the management of many surgical
conditions over the past decades. Thus in recent years there has been an attempt to
reduce the surgical morbidity of open necrosectomy by adopting a number of
minimally invasive approaches. Methods: We have analysed results of 21 patients
of infected pancreatic necrosis treated by minimally invasive techniques i.e.
percutaneous drainage,endoscopic(transgastric), retroperitoneal and laparoscopic
transperitoneal approach via these routes - transmesocolic, transgastrocolic and
gastrohepatic omentum and compared the short term outcomes with 8 patients
drained by open necrosectomy. Conclusions: Minimal access approach can be
applied in selected cases with earlier postoperative recovery, less mortality and
earlier return to work and possibility of relook laparoscopy. A combination of
minimally invasive techniques is useful in some patients to achieve complete
necrosectomy.
P 23
Is Bactibilia a predictor of Poor outcome following
Pancreaticoduodenectomy? J Satheesh, SM Sivaraj, V Vimalraj, S Rajendran, S
Jeswanth, R Vennila, R Surendran, Govt Stanley Medical College, Chennai.
Background: Although Bile infection has been proposed to increase infectious
complications following pancreaticoduodenectomy its association with infective
complications & non infective complications like pancreatic fistula is still
controversial. Methods & materials: Between July 2007 to December 2008, 76
patients who underwent Pancreaticoduodenectomy were included in a prospective
database & analyzed. In all patients intraoperative bile culture from the bile duct was
done. Preoperative, intra operative & post operative variables were recorded &
analyzed. Results: Bile culture showed growth in 35 patients (46.1%).In the
positive bile culture group , 20 patients had undergone ERCP & stenting (57.1%).
All the patients who underwent ERCP & biliary stenting had positive bile cultures.
Patients in the positive bile culture group had higher incidence of infective
complications – Intra abdominal abscess (p=0.0002), wound infection (p=0.0148),
Bacteremia (0.0043) & renal failure (0.03746). There was no increase in the rate of
non infective complications of Pancreaticoduodenectomy - pancreatic fistula
(p=0.69681), delayed gastric emptying (p=0.16742), post operative hemorrhage
(p=1). The hospital stay was significantly prolonged in the positive bile culture group
(p=0.0002). Conclusion: Pre operative biliary drainage was significantly associated
with bile infection, other preoperative factors were not associated with Bile infection,
Bile infection increased the overall complications, infective complications & renal
insufficiency.
P 24
Autoimmune pancreatitis masquerading as malignancy of lower CBD and
head of pancreas. V Wakade, S Wani, I Shaikh, M Goel, SK Mathur, Wockhardt
Hospital, Mumbai.
Introduction: Autoimmune pancreatitis is a rare systemic fibrotic inflammatory
disorder involving the pancreas. Patients present with clinical picture of obstructive
jaundice and pain thus mimicking pancreatic malignancy. Two varies have been
described, i. e. Diffuse and Focal variety.Morphological characteristics include
diffusely enlarged ( Suusage Shaped) pancreas and an irregularly narrowed and
beaded main pancreatic duct. According to the revised Japan Pancreas Society
criteria, the diagnosis of autoimmune pancreatitis requires that one or more
secondary serologic or histologic criteria are also met: the presence of
autoantibodies, elevated levels of gamma-globulins, IgG(4), a lymphoplasmacytic
infiltrate, or pancreatic fibrosis. Aims and objectives: Autoimmune pancreatitis is
reported in about 5 to 10% of cases of chronic pancreatitis. The diagnosis requires a
high degree of clinical suspicion and interpretation of imaging findings. The most
crucial issue when caring for patients with suspected autoimmune pancreatitis is to
differentiate autoimmune pancreatitis from pancreatic carcinoma, because
pancreatic carcinoma requires surgery, whereas autoimmune pancreatitis responds
well to steroid treatment. We thus present two cases of autoimmune pancreatitis
one was operated as a carcinoma of the head of pancreas and on Histopathological
examination was negative for malignancy and one patient suspected of having
autoimmune pancreatitis based on the CT scan findings, confirmed with MRCP, EUS,
ERCP and serology and managed with steroids. Conclusion: Autoimmune
pancreatitis is an often unsuspected entity in patients with chronic pancreatitis or
lower CBD strictures. However newer diagnostic tools and further studies of
underlying pathophysiology and prognosis of autoimmune pancreatitis are needed
for adequate and effective treatment strategies to be developed.
P 25
Extrapancreatic infective complications in severe acute pancreatitis. PK
Sinha, TD Yadav, GSB Kishore, JD Wig, R Kochhar, P Ray, PGIMER, Chandigarh.
Background and aim: Infective complications account for significant morbidity and
mortality in severe acute pancreatitis (SAP). This study analyzes the incidence,
bacterial ecology, impact of extrapancreatic infective complications (EPIC) on
outcome in patients who underwent necrosectomy for SAP. Patients and
methods: Twenty patients of SAP who underwent necrosectomy over 1 year were
followed up prospectively until discharge or death. Pneumonia, urinary tract infection
(UTI) and central venous catheter infections (CVCI) were evaluated and documented
according to standard protocol, definitions. Patients with and without EPICs were
compared as regards to duration of hospital stay, mortality. Results: Seven out of
20 (35%) patients developed EPICs. Pneumonia occurred in 3, UTI, CVCI in 2
patients each. Acinetobacter baumanii, E.coli, Staph.aureus and Enterococcus fecalis
were the isolates. They were sensitive to third generation cephalosporins,
vancomycin. The mean duration of hospital stay was prolonged in patients with
pneumonia (53 vs. 40 days for no infection), CVCI (72 vs. 44 days) but not for UTI
(43 vs. 47 days). Overall mortality in this study group was 40% (8 out of 20). 50%
of patients (4 out of 8) who died had their course complicated by an extrapancreatic
infection. All 3 patients with pneumonia, 1 out of 2 with CVCI died while no patient
with UTI died. Conclusions: EPICs occur in a significant proportion of patients
undergoing surgery for SAP and contribute to morbidity and mortality. While CVCI
prolongs hospital stay, pneumonia kills. UTI is manageable and makes no difference
to the outcome.
P 26
Short term outcome of Frey’s procedure in chronic pancreatitis in an
Eastern Indian population. S Ghatak, S Ray, K Das, B Mukherjee, MR Kamal, K
Das, GK Dhal, IPGMER and SSKM Hospital, Kolkata.
Surgery is indicated in chronic pancreatitis when medical therapy fails or the patient
develops a complication which can not be managed non operatively. Frey’s
procedure has been described for this disease with excellent short term and long
term outcome. It involves opening of entire pancreatic duct along with coring of
tissues in the head till the posterior capsule becomes pliable. As the pace maker of
pain in chronic pancreatitis is situated in the head region, coring of head gives an
impressive pain relief. We reviewed our results of Frey’s procedure from the
beginning of our center. We analyzed the data of all chronic pancreatitis patients
who underwent Frey’s procedure from 22.08.2007 to 31.03.2009 and had a
minimum follow up of 3 months. All operations were done by SR and SG. This data
were entered prospectively in an electronic data base and included preoperative pain
status, biliary complications, diabetes status, operative details, immediate pain relief,
follow-up pain relief and diabetes status. Twenty seven patients underwent Frey’s
procedure during this period of 19 months (17 men, 10 women). The age range
was 6 years to 65 years (Mean 33.15, median 31). In all but one patient there were
calcifications in the pancreas and the duct was dilated, 7 patients had history of
chronic alcohol intake, 1 patient who did not have calcifications had endoscopic
cholangiography proved pancreas divisum. Seven patients also had bile duct
stricture at the lower end, 2 of them were stented before coming to us, 1 patient
had features of portal hypertension alongwith bile duct stricture, 2 patients had
previous lateral pancreatojejunostomies which failed to relieve pain. Intractable pain
was the indication of surgery in 26 patients, in one patient bile duct stricture led us
to surgery. 25/ 26 patients were pain free in the immediate postoperative period.
Operative specimen revealed adeno carcinoma in 1 patient and 1 patient developed
metastatic umbilical nodule after 18 months of surgery. After a mean follow up of 9
months (3 - 18 months) 23/25 patients (excluding 2 cancer patients) were
completely pain free- 92%, 1 patient had persistent pain after surgery and
underwent coeliac plexus block which also failed to relieve his pain, 1 patient had 1
episode of pain with rise in serum amylase after a follow-up of 11 months. Six
patients had diabetes before surgery, 3 of which became euglycaemic after surgery,
1 patient developed diabetes who was normoglycaemic preoperatively. Four patients
underwent choledochojejunostomy in the same Roux loop, 1 patient
choledochoduodenostomy and in 2 patients after head coring intrapancreatic bile
duct was freed of fibrotic tissue and patency of the bile duct lumen restored. All 7
patients are having normal bile flow to the intestine in the follow-up. Frey’s
procedure provided excellent short term pain relief (92%) in our eastern Indian
patient population. One interesting phenomenon noted was improvement in diabetes
status (3/6 patients) post procedure which requires further follow up.
P 27
Type of surgery in Head Mass of Chronic Pancreatitis: How easy is it
decide? D Varma, K Prakash, M Philip, GN Ramesh, P Zacharias, P Mahadevan,
Sreelatha KN, PVS Memorial Hospital, Cochin.
Head mass (HM) in chronic pancreatitis (CP), an indication for surgery is a clinical
dilemma. The aim was to evaluate the accuracy of available preoperative diagnostic
modalities in the diagnosis of malignancy in HM of CP. Methods: Out of the 78
patients who underwent surgery for CP between January 2006 and April 2009, 20
were operated for the presence of HM. All the patients underwent Ultrasonography,
Contrast Enhanced Computerised Tomography (CECT), Endosonographic Fine
Needle Aspiration Cytology (EUS FNAC) and intraoperative imprint cytology of
transduodenal tru-cut/ incision biopsy. Patients were categorized into either low
suspicion or high suspicion of malignancy by clinical, radiological, endosonographic
and operative findings. The accuracy of these parameters, by comparing with the
histopathology, was ascertained and the modality which had the maximum influence
on decision making of the surgical procedure was identified. Results: Eleven (55%)
patients underwent Pancreaticoduodenectomy, 5 (25%) Frey’s procedure and 4
(20%) bilio-digestive bypasses. The clinical suspicion of malignancy was high in 12
patients of which 7 had malignancy (sensitivity=87.5, specificity=58.3). The
sensitivity and specificity of CECT and EUS FNAC were 75, 37.5 and 87.5, 33.3
respectively. Imprint cytology had sensitivity and specificity of100 and 91.7 and
operative assessment 100 and 41.7 respectively. Five of the 11 patients who
underwent resection had malignancy and the decision to resect was based on
positive intra operative imprint cytology or EUSFNA. However, the decision in 6
patients who underwent resection who did not harbour malignancy was based on
clinical and operative findings in 4 and cytology in 2 patients. Conclusion:
Diagnosis of malignancy in HM of CCP remains difficult even with multiple pre
operative investigations. The decision making is heavily dependent on clinical
presentation and operative findings. The use of imprint cytology is a rapid and
accurate method to diagnose malignancy intra operatively.
P 28
To evaluate the efficacy of tumor markers CA 19-9 and CEA to predict
operability and survival in pancreatic malignancies. N Jain, RY Prabhu, CV
Kantharia, A Supe, KEM Hospital, Mumbai.
Aim: Pancreatic malignancies are one of the most dreaded cancers which are
diagnosed at a late stage and are accompanied with a poor survival. Hence, we
decided to evaluate the efficacy of CA 19-9 and CEA (elevated >2times of normal)
as predictors in determining operability and survival in pancreatic tumors. Methods:
Levels of CA 19-9 and CEA were measured (Pre and Post operatively) in 49 patients
of pancreatic malignancy. Contrast Enhanced CT scan was performed for diagnosis
and staging. A senior surgeon determined the operability. The levels of tumor
markers were correlated with the operability and the survival based on CECT and
intra-operative findings. Results: 16/24 (67%) patients with CA 19-9 levels
(<2times) and 19/24 (79%) patients with CEA levels (<2times) were found to be
operable. 22/25 (88%) patients having elevated CA 19-9 levels (pvalue-0.0002significant) and 17/25(70%) patients having elevated CEA levels (pvalue-0.0031significant) were found to be inoperable. Of the 27 patients, found operable on CTScan, 5 were inoperable intra-operatively. All of these had elevated levels of CA 19-9
and 4/5 (80%) had elevated levels of CEA. Only 5/21 (23%) inoperable patients,
with elevated levels of CA 19-9 reported at 1 year follow up. None of the inoperable
patients with CA 19-9 levels >1000U/ml reported at 6 month follow-up. None of the
operable patients pre-operatively showed evidence of recurrence. All achieved
normal values post surgery. Conclusion: Elevated levels of CA 19-9 and CEA (>2
times) predict increased chances of inoperability and poor survival in pancreatic
tumors. Levels >3times had increased inoperability even in patients deemed
operable on CT-Scan. Diagnostic laparoscopy would be beneficial in these patients.
Levels of CA 19-9 (>1000U/ml) indicate a dismal survival in inoperable group of
patients.
P 29
Giant insulinoma a rare presentation of pancreatic neuroendocrine
tumour. SP Matkari, D Jahagirdar, P Bhingare, Government Medical College,
Nagpur.
This case details the report of a 32 yr old male patient, K/c/o CML on Hydroxyurea &
Allopurinol since 5 yrs and on T. Imitanib since last 1 year. Patient presented with
recurrent episodes of giddiness which were relieved after taking sugar. Abdominal
examination revealed a large lump in epigastric region. Serum Insulin levels and Cpeptide were raised. MRI done was s/o a large soft tissue mass of size 10X10X6 cm
in uncinate process of the pancreas(?endocine neoplastic tumor of pancreas). USG –
guided FNAC from the mass s/o epithelial malignancy (adenocarcinoma) .In view of
biochemical analysis & clinical symptoms provisional diagnosis of malignant
Insulinoma was made. Exploratory laparotomy was done . The mass was present in
relation to the uncinate process of the pancreas, the tumor was dissected free from
IVC posteriorly and the pancreas, duodenum, portal vein & CBD anteriorly.
Enucleation of the tumor done. Post operatively patient was euglycemic.
Histopathology s/o Functional well-differentiated Pancreatic endocrine tumorInsulinoma of uncertain behavior (WHO criteria). Immunohistochemistry was
positive for Cytokeratin, Synaptophysin and Chromogranin A.
Review of Literature: Insulinoma is the most common pancreatic endocrine tumor.
Less than 5% are larger than 3 cm. More than 90% are benign. Larger tumors are
more likely to be malignant. Clinical diagnosis is by whipple’s triad and elevated
levels of Serum insulin, proinsulin, and C-peptide levels. Review of the world
literature identifies only three reported cases of insulinomas more than 9 cm in size,
all of which were benign by traditional criteria & located in tail of pancreas.
Conclusions: This report identifies the case of a giant Insulinoma arising from
uncinate process of pancreas ; which was enucleated. The matter of debate is
whether a radical surgery such as Whipple’s procedure should have been done
instead of a simple enucleation in this case, in a young patient.
We conclude that simple enucleation is justifiable if possible, as it carries much less
morbidity and has better survival advantage.
P 30
Is change really as difficult? Experience from pylorus preserving
pancreatoduodenectomy for periampullary malignancy. A Ramamurthy, A
Khakhar, A Shrivastava, Apollo Hospital, Chennai.
Background: The multitude of publications on pancreatoduodenectomy for
malignancy demonstrates that there is no single “best” technique. The practise in
high volume centres is adopted as the standard of care due to their excellent results.
The other biggest hindrance to change is lack of sufficient evidence. Pylorus
preserving pancreatoduodenectomy (PPPD) is one such issue. Though it saves
operating time, transfusions and gives better functional results, it has not reached
statistical significance. We analyzed our results with PPPD to ascertain the feasibility,
additional morbidity and mortality attributable to this change. Material and
Methods: Between March 2008 and March 2009, 12 consecutive PPPD’s were
performed at our unit. The author has previously worked in a high volume centre
where PPPD was not performed. A single Roux limb was used for reconstruction in
all cases. No stenting or tube jejunostomy was performed. Postoperatively, oral
liquids were commenced on the second day and progressed to a normal diet as
tolerated. Results: There were 8 male and 4 female patients with a median age of
45 years (28 to 64). PPPD could be performed in all patients with resectable
tumours. Two patients required sleeve resection of portal vein. Three patients
received transfusions in the perioperative period. There was no mortality. Two
patients had grade 2 complications requiring prolongation of hospital stay by a day.
None of the patients had delayed gastric emptying. All patients were discharged on a
normal diet. Median hospital stay was 6 days (5 to 8 days). Conclusion: Change
(PPPD) is possible in the majority of cases with periampullary malignancy with
similar morbidity and mortality as reported at other high volume centres. Though it
is our belief that functional results are better, it is not possible to conclude so on the
basis of the present study.
P 31
Use of combination of minimally invasive techniques for pancreatic
necrosectomy . S Wani, R Patankar, V Wakade, I Shaikh, N Arulvanan, M Goel, SK
Mathur, Wockhardt Hospital, Mumbai.
Background: Minimally invasive necrosectomy is fast emerging as a technique of
choice for pancreatic necrosectomy. The techniques include percutaneous drainage,
endoscopic transgastric drainage, retroperitoneal drainage, laparoscopic
transperitoneal drainage. It is associated with faster recovery, less postoperative
pain and earlier return to work. Sometimes a combination of techniques is required
to achieve complete necrosectomy. Methods: We describe two cases (videos) of
infected pancreatic necrosis managed by combination of minimally invasive
techniques. A 32 yr female of acute biliary pancreatitis, managed conservatively,
later presented with walled off pancreatic necrosis in the retrogastric
region.Endoscopic transgastric drainage was done at 8 weeks followed by
laparoscopic transperitoneal drainage of residual necrosis. Second video
demonstrates initial percutaneous pigtail drainage of pancreatic necrosis, followed by
retroperitoneal drainage of residual necrosis by dilatation of the tract, Amplatz
sheath insertion, passage of nephroscope and necrosectomy under vision.
Conclusions: Fusion of the different minimally invasive approaches is useful in
achieving complete necrosectomy.
P 32
Tumor Induced Acute Pancreatitis: Surgical Implications. M Joshi, P Kumar,
S Kurhade, Peethambaran, S Kalia, N Mohan, R Ardhanari, Meenakshi Mission
Hospital and research Centre, Madurai.
Introduction: Pancreatic neoplasms are an uncommon etiology of acute
pancreatitis. Methods: Of 18 patients of periampullary cancer operated at our
Hospital in 2008, we report two patients having first attack of acute pancreatitis and
the implications for surgical management. Results: Both patients had classical
Whipples operation. One with APACHE II score 8 had delayed surgery after 6 weeks
and other patient with APACHE II score 3 was operated in the same admission.
Contrary to expectations, surgery was not difficult. Both patients had uneventful
recovery. Conclusions: In acute pancreatitis of unknown etiology, a tumour should
be ruled out, especially in the elderly. we recommend management in a specialist
centre.
P 33
Neuroendocrine tumors of the pancreas: a single institutional experience.
U Datta Ram, P Dhar, N Ramachandran, OV Sudheer, S Sudhindran. Amrita Institute
of Medical Sciences and Research Centre, Cochin.
Introduction: Data regarding clinicopathological spectrum and survival of
Neuroendocrine (NET) tumors of the pancreas from India is sparse. Aims and
objectives: Study the clinical spectrum of NET’s from a tertiary referral centre in
south India and analyze the management and survival outcome. Materials and
methods: Over a period ranging from 1998 to 2009, 25 patients were diagnosed
with NET of the pancreas by the histology of the resected specimen/ biopsy. Their
demographic data, tumor characteristics, diagnostic work up, treatment methods
and survival outcomes were analyzed form prospectively maintained electronic
medical records. Results: The median age at presentation was 41years (30-74)
with female to male ratio of 1.3:1. Abdominal pain was the most common symptom
of the non functional tumors. Patients with insulinoma were diagnosed on workup
for hypoglycemic attacks. Contrast CT scan was the most common imaging modality
employed. Presence of hypervascular/ enhancing lesions on CECT was suggestive of
NET. Non-functional tumors (60%) were the commonest tumors. Insulinoma was
the most common functional tumor (24%), followed by gastrinoma (8%). Two
patients had MEN (Multiple endocrine neoplasia) type I. 52% of the NET’s were
located in the body and tail region while 48% of the tumors were in the head and
uncinate region. 24 patients underwent surgery of which 23 were resectable.
Whipple’s operation was done in 8 patients (32%), tumor enucleation in 6 patients
(20%), distal pancreatectomy and splenectomy in 6(24%)(One patient had Rt
hepatectomy combined with distal pancreatectomy for liver metastases from an
insulinoma). One patient underwent wedge resection of the liver for a solitary
metastasis in the liver. This patient had a distal pancreatectomy and splenectomy in
another centre for a proven gastrinoma of the tail of the pancreas. One patient had
multivisceral resection for a locally advanced NET who is on regular follow up. There
was one histological surprise of a NET in a patient who underwent Frey’s procedure
for chronic calcific pancreatitis. There was one post operative mortality after
whipple’s pancreaticoduodenectomy. Five patients died during the follow up. The
median follow up was 16 months. Cumulative overall survival over a 127 month
follow up was 57%. Conclusions: Contrast CT is a valuable tool in the diagnosis
and localization of NET’s. Surgical resection can offer excellent survival.
P 34
Stool elastase1- in assessment of pancreatic exocrine function. S Daga V
Varma, N Bheerappa, RA Sastry, Nizams institute of medical sciences, Hyderabad.
Background: Pancreatic insufficiency is usually seen in patients with chronic
pancreatitis and following resectional procedures of pancreas. Clinical presentation
of pancreatic insufficiency includes steatorrhea or weightloss. Pancreatic
insufficiency usually manifest clinically only when more than 90% of pancreatic
parenchyma is damaged. We aim to assess pancreatic insufficiency using stool
elastase1 in this group of patient and correlate with clinical insufficiency. Materials
and methods: This is prospective study done during July 2007 to June 2009. Total
number of patients included in this study where 77. Of these 77 patients 64 are of
chronic pancreatitis and 13 are of post pancreatic resection. Pancreatic insufficiency
was evaluated by clinical features and stool elastase1. Stool elastase1 was measured
using a commercially available ELISA kit, which employs two monoclonal antibodies
to bind to two distinct epitopes of human pancreatic elastase-1 and graded
accordingly. After assessment of pancreatic insufficiency all patient with pancreatic
insufficiency were started on pancreatic supplement. The follow up was done by
assessing weight gain, pain score and presence or absence of clinical steatorrhea.
Results: Clinical pancreatic insufficiency in form of steatorrrhea and weight loss was
present in 30 (39%) and 41(53.2 %) respectively. Pancreatic insufficiency diagnosed
using stool elastase1 was present in 96.1% of patients. 62 (80.5%) & 12 (15.6 %)
of patients had severe and moderate pancreatic insufficiency respectively. Clinical
parameters were correlated before and after treatment with enzymes supplements .
Patients supplemented with pancreatic enzyme showed better outcome in the form
of weight gain , low pain score and no further increased incidence of steatorrhea.
Conclusion: Pancreatic insufficiency is clinically under diagnosed. Stool elastase1 is
good screening tool for assessment of exocrine function of pancreas and initiation of
pancreatic supplement , particularly in after pancreatic resection.
P 35
The role of fat and fibrosis in pancreatic texture and in the incidence of
postoperative pancreatic fistula. TV Madhav, V Varma, Shantveer, G Uppin, N
Bheerappa, RA Sastry, Nizams Institute of Medical Sciences, Hyderabad.
Background: Although soft pancreas is traditionally associated with increased risk
of pancreatic fistula, the histological features of soft and hard pancreas have not
been clearly defined. Aim: To analyze the role of fat and fibrosis in a.Pancreatic
texture with particular reference to soft pancreas b.In the incidence of postoperative
pancreatic fistula. Materials and methods: Between Jan 2007 and May 2009, 59
patients underwent Whipples procedure of whom 13 (22%) developed pancreatic
fistula (Grade A: 6, Grade B: 4 and Grade C: 3 ). The pancreatic texture was
subjectively graded by the operating surgeon as soft (20) or hard (39). Histological
sections from the pancreatic neck were graded (0-4) for intralobular fat, interlobular
fat, total fat and fibrosis by standard methods. The amount of pancreatic fat and
fibrosis was correlated with the softness of pancreas identified at surgery. The
influence of fat and fibrosis on postoperative pancreatic fistula was analyzed. The
influence of other factors like age, sex, diabetes, hypertension, alcoholism, smoking,
BMI, preoperative stenting and chronic pancreatitis on the amount of fat and fibrosis
were also studied. Results: Soft pancreas was identified as a significant risk factor
(OR 10.8; CI 2.55 - 45.8; p=0.001) for pancreatic fistula.Soft pancreas had more fat
(p=0.08) and less fibrosis (p=0.09) when compared with hard pancreas. Negative
correlation existed between fat and fibrosis (R = -0.148; p=0.19). Intralobular fat
(p=0.001), interlobular fat (p=0.13), total fat (p=0.03) and fibrosis (p=0.017) were
found to be significant in development of pancreatic fistula. Incidence of pancreatic
fistula in patients with total fat score > 1 was 40% whereas in patients with score
&#8804; 1 it was 12.8% (p=0.02).No patient developed pancreatic fistula with
fibrosis score >1. Fatty pancreas was more common with advanced age. Fibrosis
was more common in smokers (p=0.09) and chronic pancreatitis (p=0.01).
Undilated pancreatic duct (PD <3mm) was more common in fatty pancreas
(p=0.04). Conclusions: Soft pancreas was associated with increased amount of fat
and less amount of fibrosis. Pancreatic fat and fibrosis play a significant role in
development of pancreatic fistula.
36
P 36
Incidence of Delayed Gastric Emptying (DGE) in Pylorus Preserving
Pancreaticoduodenectomy (ppPD) Based on New International Study
Group on Pancreatic Surgery (ISGPS) Definition - A Prosepective Study. V
A Iyoob, Shabeerali, R Rajan, B Natesh, AP Kuruvilla, Medical College,
Thiruvanathapuram.
Objective: Standardization of calculating incidence of DGE by adopting a unified
definition according to ISGPS guidelines and comparing with old definitions.
Materials and Methods: This prospective study conducted at a single specialized
Surgical Gastroenterology unit on all patients who underwent ppPD from January
2008 to June 2009. All patients underwent similar kind of reconstruction and uniform
postoperative protocol. Patient data, pathology, operative details, postoperative
events, morbidity and mortality recorded in detail. Incidence of DGE calculated as
per the ISPGS definition and few popular old definitions. Results: Of the total 48
patients posted, 45 underwent ppPD. 4 patients died during postoperative period.
Incidence of DGE by new definition was grade A 9.75% and grade B 7.32%. But
according to old definition it was 7.32%. Conclusion: Adoption of a unified graded
definition for DGE may help to standardize further comparative studies and critically
analyze ppPD techniques.
P 37
A non functioning endocrine tumor of pancreas presenting as
hemetemesis. MG Prakash, NS Nagesh, Divakar murthy, RS Bhat, KV Ashok
Kumar, Bangalore Medical College and Research Institute, Bangalore.
Non functional endocrine tumors of pancreas may be most common pancreatic
endocrine tumor with incidence of 10-25% of all islet cell tumors. Mostly present late
as large masses with metastatic disease. Patients generally present with weight
loss, abdominal pain or jaundice mimicking adenocarcinoma. Presenting solely with
upper gastrointestinal bleed is rare. Bleeding may be due to moulting from varices
from portal hypertension secondary to tumor invasion of splenic, superior mesenteric
or portal veins. We here by present such a rare presentation in young 35 year old
lady. In the absence of symptomatology, it is not surprising that most of the non
functioning tumors are diagnosed incidentally by cytologic or histologic examiniation.
When possible surgical resection should be attempted. Aggressive resections are
indicated to these tumors even when portal or superior veins are involved. For
tumors involving body or tail of the pancreas distal pancreatectomy is indicated.
Encapsulated tumors of head can be enucleated, but whipple operation is usually
required for large invasive tumors of head. In contrast to exocrine pancreatic tumors
prolonged survival is possible even with incurable disease (60% at 3 yrs and 44% at
5 yrs). Patients with liver metastasis should be treated with long acting
somatostatin.
P 38
Ectopic pancreas ampulla of vater presenting as periampullary tumor-Case
report. VK Chorasiya, N Goyal, S Goja, P Dargan, M Wadhawan, S Gupta,
Indraprastha Apollo Hospital, New Delhi.
Background: Ectopic pancreas is an uncommon condition and is usually found in
the gastrointestinal tract, such as stomach, duodenum and jejunum. However,
ectopic pancreas in the ampulla of Vater is rare and its clinical presentations may
mimic periampullary cancer, making a pre-operative diagnosis difficult. We present
such a case where the diagnosis was proven postoperatively. Case summary: A 54
year old female presented with epigastric pain and weight loss. Imaging study,
including abdominal sonography, abdominal computerized tomography with contrast
and EUS showed a mass in the periampullary region with dilated CBD and pancreatic
duct. EUS biopsy was inconclusive. The patient was taken for surgery. Intraoperative
peripancreatic nodes were found to be enlarged, the frozen of which revealed
reactive pathology. However in view of the palpable growth, a standard Whipple’s
procedure was done. The histological examination of the specimen revealed an
ectopic pancreas at the ampulla of Vater. Discussion: Ectopic pancreas is a
common congenital disorder which is referred to as pancreatic rest. The incidence in
autopsy series varies from 1-2% (range0.55-13%).Most common site of ectopic
pancreatic tissue is the stomach, although it can be found anywhere in the foregut
and the proximal midgut. Ectopic pancreatic tissue in the ampulla of vater is a very
rare condition. Searching in the literature, using the terms “ectopic pancreas and
ampulla of Vater” we found only 11 case reports. The patient presented with
symptoms of periampullary tumor but the imaging study did not reveal an obvious
lesion for us to consider the possibility of ectopic pancreas. Surgical excision is
indicated for symptomatic cases.
P 39
Cystic lesions of pancreas – management options. R Dama, R Pradeep, GV
Rao, DN Reddy, Asian Institute of Gastroenterology, Hyderabad.
36 Cases of Cystic lesions of pancreas presented to our department between June
2008 to June 2009. 31 were males and 5 were females. 20 cases of Pseudocyst of
Pancreas, all of them following ethanol induced pancreatitis were managed
conservatively. 9 cases of Pseudocysts were managed with Cystogastrostomy
including a patient who developed Pseudocyst following resection of Cystic tumour
of pancreas(done elsewhere) and a patient who developed pseudocyst following
Carinoma head of pancreas with Chronic calcific pancreatitis. Two patients
underwent External drainage of Pseudocyst. Of them, One patient developed
persistent pancreatic fistula, drainage output decreased gradually and managed
conservatively. One patient underwent distal pancreatectomy and Splenectomy for
severely symptomatic pseudocyst of Tail of Pancreas. 4 cases of Cystic Neoplasm of
pancreas underwent resection. 2 patients had Solid Pseudopapillary neoplasm of
Pancreas arising from Body region of Pancreas underwent Distal Pancreatectomy
and splenectomy. 2 cases of Serous cystadenoma of Body of Pancreas underwent
Distal Pancreatectomy and splenectomy. One patient had minimal pancreatic fistula,
managed conservatively, All the other patients had uneventful postoperative period.
P 40
Outcome of Whipple’s Pancreaticoduodenectomy using Microsurgical
Techniques and SMA first approach in a Surgical Gastroenterology & Liver
Transplantation Unit. S Sasturkar, N Goyal, P Dargan. S Goja, M Wadhavan, V Vij,
S Gupta, Indraprastha Apollo Hospital, New Delhi.
Background: Pancreaticojejunostomy leak is the principle cause of morbidity
following Whipple Pancreaticoduodenectomy (PD). Decision analysis for resectability
in large head tumors (> 4 cm) with doubtful vascular involvement on preoperative
imaging takes a long time using conventional surgical approach. In our unit , with
the experience gained from liver transplantation, superior mesenteric artery first
approach helps in faster assessment of resectibility . Similarly with increased
experience from microvascular anastomotic techniques, outcome of the duct to
mucosa, pancreaticojejunostomy has improved. We share our experience with the
same. Materials and Methods: Thirteen patients with large tumors (>4cm) with
doubtful vascular involvement on preoperative imaging were included between
October 2008 to June 2009 in the study. Three out of thirteen patients were female.
The median age was 59 yrs (range 33- 78yrs).In 3 patients the SMA first approach
was followed. Four patients underwent bypass in view of non resectibility. In nine
patients Whipple Pancreaticoduodenectomy was performed. All
pancreaticojejunostomy anastomoses were performed as end to side, duct to
mucosa, interrupted, 6’o Prolene, using 3.5 x surgical loops. Results: The average
time required for the procedure was 5 hr 30 min. One patient expired on 16th post
operative day due to subarachnoid hemorrhage.One out of nine patients had
peripancreatic collection & required CT guided drainage. Two patients had delayed
gastric emptying. Surgical site infection was observed in two patients. All patients
had R0 resection. Conclusion: Microsurgical techniques for duct to mucosa PJ
anastomosis give good results.SMA first approach is useful for faster assessment of
resectibility in patients with doubtful vascular involvement on pre operative imaging.
P 41
Inflammatory pseudotumour of pancreas managed with central
pancreatectomy and pancreaticogastrostomy - a case report and review of
literature. R Dama, R Pradeep, GV Rao, DN Reddy, Asian Institute of
Gastroenterology, Hyderabad.
Introduction: A 38 year old female presented with 1 month history of left upper
quadrant pain and intermittent fever. USG and CECT scan of the abdomen done
showed a solid mass arising from the mid body of the pancreas of 13x7x6cms. No
vascular invasion was seen. A pancreatic neoplasm was suspected. Patient
underwent central pancreatectomy with pancreaticogastrostomy. Aim: To look for
feasibility of parenchymal preserving resection in cases of large pancreatic tumours
without any vascular involvement . Methods: In view of well encapsulated mass
arising from the mid body of the pancreas with no vascular invasion ,she underwent
central pancreatectomy . The proximal stump was transected with a stapler and
the tail end was reconstructed with pancreaticogastrostomy. Results: The
histopathology report and immunohistochemistry markers was suggestive of
inflammatory tumour of pancreas as CD 45, CD 68 were positive and SMA and AIK-1
were negative. A review of the literature for inflammatory pancreatic tumours was
done which showed it to be a very rare tumour with only 25 such cases reported in
the English literature. The presentation with fever is seen only in 8 % of the cases.
This is the first report of pancreatic parenchymal conservative surgery for
inflammatory tumour of the pancreas. Conclusion: Large solid tumour of the
pancreatic body may not always mean a neoplasm and a end of the road.
Preoperative diagnosis of a inflammatory pseudotumour of the pancreas is difficult.
Resection should be attempted at all costs, especially if the CECT shows no signs of
inoperability. Surgery is both diagnostic and therapeutic .If feasible these tumours
can be successfully treated even with a pancreatic parenchymal preservation .
Reconstruction with a pancreaticogastrostomy is feasible and can avoid an extra
anastomosis.
P 42
Early results of non operative management in Severe Acute Pancreatitis.
BY Raghavendra, R Gupta, M Kang, SS Rana, DK Bhasin, R Singh, PGI, Chandigarh.
Background: The initial treatment of Severe Acute Pancreatitis (SAP) is
conservative. The standard management was operative intervention in patients with
(suspected) infected necrotizing pancreatitis. Mode of intervention depends on
various factors. The aim of the present study was to evaluate the effectiveness of
non-operative management in patients with SAP. Methods: Ongoing prospective
study carried out from April 2008 onwards. All consecutive patients (50) with SAP
were recruited in the study. Patients were initially managed conservatively and as
per the indication underwent intervention. The outcome in patients managed with
different modalities was compared. Results: Of the 50 consecutive patients with
SAP, 31 patients were managed non-operatively. Out of which 12 patients were
managed conservatively, 19 patients underwent PCD alone and the remaining 19
patients underwent initial PCD followed by surgery. There was no mortality in
patients managed conservatively and one mortality in those managed by PCD alone.
Mortality was 8/19 (42%) in patients requiring surgery. Overall mortality in the
whole group was 9/50 (18%). Hypocalcemia was present in all patients who died,
while 7/9 patients had respiratory and renal failure each. CTSI was >8 in 8 patients
and <8 in one patient. There was no association of CTSI with type of management.
Conclusions: Overall mortality in this group of SAP was 18%. Patients with nonoperative management had one mortality. Surgery was required in 38% patients in
this series with a mortality of 42%.
P 43
The value of drain fluid amylase measurement in identifying pancreatic
leak after pancreaticoduodenectomy. G Sood, A Saha, AK Sharma, JK Banerjee,
CS Naidu, AK Sinha, Army Hospital Research and Referral, Delhi Cantt.
Introduction: Pancreatic anastomotic leak remains a major complication following
pancreaticoduodenectomy. If not recognized and treated, this can increase the
morbidity and mortality associated with Pancreoduodenectomy. Aim: The aim of this
study is to use actual case drain data and the clinical outcomes to determine if drain
volume and/or amylase levels are helpful to detect a leak and to find out which is
more important-the drain volume or its amylase concentration, or both, and on
which postoperative days (PODs). We did a retrospective review of 25 patients
including all patients who had undergone PD at a tertiary care referral multispecialty
resident training centre between January 2006 and Sep 2007. Criteria for leak were
met if: the volume from all of the drains was > 50 ml/day and If drain amylase was
greater than five times the upper limit of normal of the serum amylase value (>750
u/ml). Results: Of 8 patients with a pancreatic anastomotic leak, 3 (12%) were
asymptomatic and were placed into the chemical leak only group, 5 (20%) met the
criteria for both chemical leak and clinical leak and were placed into the clinical leak
group. 17 patients remained in the no leak group. The amylase of the drainage fluid
was significantly higher in the clinical leak group versus the no leak group on all
days and the amylase in the chemical leak group was significantly higher than the
no leak group on POD 3 -7. The drainage fluid volume was significantly greater on
POD 5-13 in the clinical leak group compared with the other two groups.
Conclusion: We conclude that monitoring drain volume and its amylase
concentration after POD 5 should provide an early detection of a clinically relevant
pancreatic leak in most patients, enabling the timely use of conservative measures.
P 44
Gastroduodenal artery pseudoaneurysm in chronic pancreatitis. V Gupta,
TD Yadav, RP Doley, R Kochhar, M Kang, V Gupta, JD Wig, PGI, Chandigarh.
Background: Pseudoaneurysms in patients with chronic pancreatitis is a rare and
potentially lethal complication. Gastroduodenal artery pseudoaneurysms pose a
significant challange. Optimal management of these aneurysms presenting with
hematemesis and/ or melena remains controversial. Methods: The medical records
of six patients with gastroduodenal artery pseudoaneurysms associated with chronic
pancreatitis managed by us were retrospectively reviewed. Alcoholic chronic calcific
pancreatitis was the predisposing factor in four, pancreas divisum in one and
idiopathic in another. The diagnosis of pseudoaneurysm was made on computed
tomographic and angiographic findings. Results: All the six patients (males 6, age
range, 24 – 62 years) presented with gastrointestinal bleeding – hematemesis in two
and melena in four patients. Computed tomography (CT) angiography revealed
features of chronic pancreatitis and visceral angiography demonstrated the
aneurysms at the origin of gastroduodenal artery – their size ranging from 10 mm to
30 mm. Angio-embolization in three patients could arrest the bleeding in two.
Percutaneous thrombin injection was successful in three patients. Urgent surgical
intervention was required in one patient following unsuccessful control of bleeding
with angioembolization and percutaneous thrombin injection. One patient died
following urgent surgical intervention. Five patients are well on follow up ranging
from 6 months to 8 years. Conclusion: Patients with pseudoaneurysms secondary
to chronic pancreatitis should undergo prompt initial evaluation and embolization
and/or image-guided percutaneous thrombin injection. These patients should
subsequently be operated upon and a careful evaluation of chronic pancreatitis is
mandatory in determining the timing of surgery.
P 45
Severe acute pancreatitis following blunt pancreatic trauma. V Gupta,TD
Yadav, RP Doley, Kishore GSB, JD Wig, R Kochhar, M Kang, PGI, Chandigarh.
Background: Acute necrotizing pancreatitis following blunt pancreatic injury is
uncommon in adults and carries a high mortality. Methods: The experience with
10 patients of post traumatic acute pancreatitis is the basis of this report. This is a
retrospective chart review of patients managed in our unit during the last 5 years. All
except two patients were males. Based on the timing of presentation, these patients
were divided into two groups– early presentation (five patients), and delayed
presentation group (five patients). Early presentation group had evidence of acute
pancreatitis at laparotomy. The delayed presentation group had severe acute
pancreatitis on imaging. At operation all had pancreatic necrosis. We performed a
wide opening of lesser sac, pancreatic necrosectomy and drainage of lesser sac and
peritoneal cavity. A jejunostomy tube was placed for postoperative nutritional
support. Results : Five patients presented early within 1-4 days of injury (4males,
one female, age range 16-35 years), two had associated injuries (fracture shaft
femur, haemopneumothorax), three underwent CECT (partial transection of
pancreas in 3). They were operated within 24 hours of presentation, all had acute
pancreatitis, one had liver injury, and one splenic injury. Three patients developed
recurrent collections needing percutaneous image guided drainage. One patient died
owing to progressive respiratory failure. Five patients presented after 6-13 days of
injury (4 males, one female, age range 22-32 years, three had associated injuries –
two had haemopneumothorax and one fracture both bones forearm. CECT in all
patients revealed acute necrotizing pancreatitis, CTSI 9-10. Three patients had
image-guided drainage of collection. All had systemic sepsis, one developed a colon
fistula and one had lower gastrointestinal. bleeding. All underwent pancreatic
necrosectomy, in addition one underwent segmental colon resection and
exteriorization and another a right hemicolectomy. Four patients died. Conclusion :
Acute necrotizing pancreatitis following blunt abdominal trauma is a highly fatal
condition. Surgical necrosectomy is the treatment modality of choice even though
associated with high morbidity and poor outcome.
P 46
Pancreas preserving approach for isolated pancreatic neck transection
RP Doley, TD Yadav, JD Wig, M Kang, R Sharma, A Dalal, M Jayant, PGI,
Chandigarh.
Background: Complete pancreatic transection following blunt abdominal trauma is
uncommon.We preserved the distal pancreatic tissue by incorporating it into a rouxen-Y pancreaticojejunostomy. Methods: Clinical records of four patients seen over a
period of three years were studied retrospectively..Three patients had a CT
performed.. Two patients underwent left pancreatectomy and splenectomy. In two
patients , a Roux-en-Y pancreaticojejunostomy to distal remnant was performed.
Three patients had a feeding jejunostomy tube placed for post operative nutritional
support. All patients received prophylactic Octreotide ( 300µgm/day). Results: All
patients were males, age range 15 years to 60 years, motor vehicle accident in two,
and two had a bicycle handlebar injury. All had complete pancreatic transection at
the neck. One had associated portal vein injury and one had massive ascites.. Two
patient had a distal pancreatectomy and splenectomy, and repair of portal vein in
one patient. Two patients underwent a pancreas preserving surgery- internal
drainage of the left remnant in a Roux-en-Y jejunal loop, two patients died-one
because of persistent sepsis, and the second owing to persistent hemodynamic
instability. Conclusion: Pancreas preserving approach-suture closure of proximal
remnant and Roux-en-Y pancreaticojejunostomy on distal segment is feasible and
safe. Substantial amount of normal pancreatic parenchyma is preserved.
P 47
Cystic lesions of pancreas – management options. A Sivasankar, GMKMCH,
Salem.
Background: Cystic lesions of Pancreas are on the rise consequent to increased
alcohol consumption and excellent widespread CT scan facility & availability. We
present the diverse mode of treatment for our patients during the last one year
period. Methods & Results: 37 Cases of Cystic lesions of pancreas presented to
our department between June 2008 and June 2009. 31 were males and 6 were
females. 20 cases of pseudocyst of Pancreas, all of them following ethanol induced
pancreatitis were managed conservatively. 9 cases of Pseudocysts were managed
with Cystogastrostomy including a patient who developed pseudocyst following
resection of Cystic tumour of pancreas (done elsewhere) and a patient who
developed pseudocyst following CA. head of pancreas with CCP. One patient
underwent Frey’s procedure for CCP with Pseudocyst. Two patients underwent
External drainage of Pseudocyst. Of them, one patient developed persistent
pancreatic fistula, drainage output decreased gradually and managed conservatively.
One patient underwent distal pancreatectomy and Splenectomy for severely
symptomatic pseudocyst of Tail of Pancreas. 4 cases of Cystic Neoplasm of pancreas
underwent resection. 2 patients having Solid Pseudo papillary neoplasm of Pancreas
arising from Body region of Pancreas underwent Distal Pancreatectomy and
Splenectomy. 2 cases of serous cystadenoma of Body of Pancreas underwent Distal
Pancreatectomy and Splenectomy. One patient had minimal pancreatic fistula,
managed conservatively. All the other patients had uneventful postoperative period.
Conclusion: Cystic lesions of Pancreas do not follow a uniform mode of treatment.
In this study, Solid pseudopapillary tumour came as surprise package with a novelty.