Abstracts / PancreatologS112

of AKT, a pro-survival kinase that may promote resistance to RAD001. Thus,PI3K may represent a novel potential therapeutic target for PETs.

Aims: Identification of novel therapy that overcomes resistance toRAD001 treatment.

Patients & methods: Western Blot to analyze PI3K/AKT/mTOR path-way; Colony Assay to analyze cell survival; Protein Synthesis Assay and 7-mGTP Cap Assay to evaluate protein synthesis.

Results: We tested the impact of novel PI3K inhibitors (BEZ235,BKM120 and BYL719) on cell proliferation and survival in two PET cell lines:BON-1 (responsive to RAD001) and QGP-1 (unresponsive to RAD001).BEZ235 was the most efficient drug in inhibiting PET cell proliferation.Furthermore, combination of BEZ235 with RAD001 exhibited additiveeffects on cell survival. Combined therapy was effective also in BON-1 thatacquired resistance to RAD001 after a chronic exposure to this inhibitor(BON-1 RR). Finally, we found that combined therapy was more efficientthan single agents in inhibiting the PI3K/AKT/mTOR axis.

Conclusion: Co-treatment with RAD001 and BEZ235 may represent asuitable therapy to counteract primary and acquired resistance to RAD001 inPETs.

F-086.

Laparoscopic distal pancreatectomy: Analysis of trends in surgicaltechniques, patient selection, and outcomes.

Giuseppe Malleo, Giovanni Marchegiani, Isacco Damoli, AlessandroEsposito, Tiziana Marchese, Roberto Salvia, Claudio Bassi, GiovanniButturini

Department of Surgery, The Pancreas Institute, University of VeronaHospital Trust, Italy

Background: Laparoscopic distal pancreatectomy (LDP) is increasinglybeing performed.

Aims: This study analyzed the time trends of demographic, operative,and pathologic variables, assessed the parameters potentially related to thelearning curve, and evaluated the long-term outcomes.

Patients & methods: LDP performed between 1999 and 2012 wereincluded in the study. The time trends were studied categorizing theoperative sequence in three equal groups, and the parameters related to thelearning curve were assessed using local regression techniques. All theanalyses were stratified by operation type (associated splenectomy vs.spleen-preserving procedures).

Results: The study population consisted of 100 patients. There were 57LDP with associated splenectomy and 41 spleen-preserving LDP, con-versionwas necessary in 2 cases. The time trend analysis showed that therewas not a tendency towards broadening the indications or selecting moredifficult cases. Similarly, the study of the learning curve components didnot show any variation over time. Only 78.9% of splenectomized patientsreceived prophylactic vaccinations, and one unvaccinated patient devel-oped an overwhelming post-splenectomy infection. At a median follow-upof 72.5 months the incidence of newly diagnosed diabetes was 13%, while21.6% of patients undergoing spleen-preserving LDP developed gastric andperigastric varices.

Conclusion: We weren’t able to identify parameters related to thepatient selection process and to the learning curve in LDP. These aremultidimensional phenomena that can be hardly inferred by singlemetrics. In the long-term, the results were satisfactory. The possibility ofserious infections following splenectomy has to be taken into account,such that a strict adherence to vaccine protocols is strongly recom-mended.

F-087.

Sixty total laparoscopic pancreaticoduodenectomies

Khatkov Igor, Tsvirkun Victor, Izrailov Roman, Tyutyunnik Pavel,Atroshchenko Andrey, Feydorov Ilia, Khisamov Artur, Andrianov Aleksey

MCSC, Russia

Background: Nowadays progress in pancreatic surgery is related withsuccessful applying of minimally invasive technology for periampullarearea’s cancer patients. Total laparoscopic pancreaticoduodenectomy (LPD)is still technically challenging. As a result just several centers in the worldhave experience more than 30 e 40 procedures.

Aims: to estimate our results of performing LPDPatients&methods: Single surgical team performed all procedures. 60

patients underwent LPD. There were 37 females and 23 males. Mean agewas 59,09 (range, 45-76) years. In a retrospective study we analyzed themain outcome measures: conversion rate, blood loss, operative time,length of hospital stay, number of lymph nodes, TNM stage, postoperativemorbidity and mortality.

Results:Median operative timewas 445min (range, 255e705min) andmedian blood loss was 300ml (range, 10 e 2100 ml). Diagnosis: benign andmalignant 6,6% (n¼4) and 93,4% (n¼56) respectively. The final pathologyexamination results: Pancreatic adenocarcinoma (n-51), seal ring cancer1,6% (n¼1), indifferent cancer 3,3% (n¼2), neuroendocrine tumor of theduodenum 1,6% (n¼1), chronic pancreatitis 3,3% (n¼2). Mean number oflymph nodes e 19. TNM: I e 30%; II e 46,1%; III e 17,3%. The complicationrate (Clavien-Dindo Classification) 38,3%: I or II e 11,6%; IIIA e 13,3%; IIIB e

6,6%; IV e 1,6%; V e 5%. Resected margins were positive in three cases.Conclusion: Laparoscopic approach permits to perform pan-

creaticoduodenectomy as open procedure. Time of procedure is decreasingwith growing of experience.

y 14 (2014) S1eS129

F-088.

Laparoscopic spleen-preserving distal pancreatectomy: Our techni-ques and outcomes

Hajime Matsushima, Tomohiko Adachi, Amane Kitasato, MasatakaHirabaru, Masaaki Hidaka, Akihiko Soyama, Kengo Kanetaka, MitsuhisaTakatsuki, Tamotsu Kuroki, Susumu Eguchi

Department of Surgery, Nagasaki University Graduate School ofBiomedical Sciences, Japan

Background: We select two procedures, Warshaw technique (WT) orsplenic vessels preservation procedure (SVP) for laparoscopic spleen-pre-serving distal pancreatectomy (LSPDP) according to the location andmalignant degree of pancreas tumors. In cases the tumor close to splenicvessels, WT is selected.

Aims: This study aimed to analyze the safety of each procedure, espe-cially regarding long-term outcomes.

Patients & methods: In both procedures, the pancreas was mobilizedfrom the median toward the splenic hilum following the dissection ofpancreas. In WT, the splenocolic ligament and left gastroepiploic vesselswere preserved as well as the short gastric vessels. The splenic circulationwas confirmed using laparoscopic ultrasonography. Between September2005 and January 2014, a total of 25 (7 males) patients diagnosed withbenign or low malignant tumors underwent WT (n¼18) or SVP (n¼7).

Results: The mean periods of postoperativemonitoring was 42months.The mean operative time, blood loss, and hospital stay inWT/SVP were 310

Abstracts / Pancreatology 14 (2014) S1eS129 S113

min (168-512)/316 min (238-376), 443 gr (5-3250)/96 gr (9-210), and 16days (8-29)/16 days (5-24), respectively. There was no grade B or C pan-creatic fistula in both procedures. The postoperative maximum plateletcounts in WT/SVP were 36.3/10.9�104/ml. Five patients (28%) with splenicpartial infarction and 2 patients (11%) with gastric varices in WT wereobserved without any treatments. In SVP, There were no complications inthe splenic circulation. No local recurrences were seen in both procedures.

Conclusion: Two procedures of LSPDP for benign and low-grademalignant tumors are safe and effective.

F-089.

Surgical outcome of pancreaticoduodenectomy with a total meso-pancreatoduodenum excision for pancreatic head cancer

Yasunari Kawabata, Takeshi Nishi, Akihiko Kidani, Yoshitsugu Tajima

Shimane University faculty of Medicine, Department of Digestive andGeneral Surgery, Japan

Background: Lymph node and surgical margin status are the mostpowerful prognostic factors for pancreatic head cancer (PHC) receivingpancreaticoduodenectomy (PD). Achievement of curative surgical margin(R0) and en bloc lymphadenectomy around the pancreatic head is man-datory to contribute the improvement of survival.

Aims: To reduce the microscopic residual tumor resection (R1) and thelocal recurrence, we devised a pancreaticoduodenectomy with total meso-pancreatoduodenum excision (tMPDe) as complete mesentery resectionand SMA first approach. We herein propose a concept of surgical anatomy,i.e., meso-pancreatoduodenum, and report an outcome of new surgicaltechnique, i.e., tMPDe.

Patients&methods: A total of 52 consecutive patients underwent a PDfor PHC between May 2006 and December 2013 at Shimane UniversityHospital. Of these, 27 patients received a conventional PD (cPD), while 25patients underwent a tMPDe.

Results: The estimated blood loss (cPD,1370ml; tMPDe 950ml; median,p¼0.017) was significantly decreased in tPMDe. Morbidity had no sig-nificant different in two group, and tPMDe showed no characteristicscomplications. The total number of lymph node dissected (cPD, 20; tMPDe31; median, p<0.001) was significantly improved with increasing aroundSMA lymph node harvest (cPD, 2; tMPDe, 5; median) in tMPDe. In tMPDe,lymph node metastasis around the SMA was significantly increased (cPD,11%; tMPDe, 40%; p¼0.014), however, R1 resection (cPD, 33.4%; tMPDe, 4%;p¼0.013) was significantly improved. No local recurrence was foundaround the SMA in tMPDe.

Conclusion: Our surgical procedure, tMPDe, is a safe because it is abloodless operation with improving oncological outcome.

F-090.

Laparoscopic pancreaticoduodenectomy: Our techniques andoutcomes

Tamotsu Kuroki, Amane Kitasato, Tomohiko Adachi, Masataka Hirabaru,Hajime Matsushima, Akihiko Soyama, Masaaki Hidaka, Kengo Kanetaka,Mitsuhisa Takatsuki, Susumu Eguchi

Department of Surgery, Nagasaki University, Japan

Background: Laparoscopic surgery for pancreatic and periampullarydisease is still a challenging operation.

Aims: The aim of this study was to reveal the clinical outcomes ofpatients undergoing laparoscopic pancreaticoduodenectomy (LPD).

Patients & methods: Forty-three patients with benign or malignant dis-ease in the pancreatic head or periampullary lesion underwent LPD betweenNovember2008andDecember2013.Weanalyzed theclinical outcomesof LPDin a single institutional study.Weperformedapancreaticoduodenectomywithlymph node dissection laparoscopically, and a reconstruction through a mid-line minilaparotomy required for sample removal.

Results: There were a total of 43 (25 males) patients with a mean age of70 (range, 54-85). Pathologic diagnosis confirmed IPMN of the pancreas

(n¼13), bile duct carcinoma (n¼11), ampullary arcinoma (n¼10), pancre-atic ductal carcinoma (n¼7), and neuro-endocrine tumor (n¼2). Themedian operative time was 526 minutes (range, 360-988), and blood losswas 300 mL (range, 30-920). No mortality was seen. Pancreatic fistulaoccurred in 7patients (16%). For the 28 patients with malignant diseases, 27patients had margin-negative R0 resection (96%), the mean number ofretrieved lymph nodes for the malignant lesions was 20 (range, 4-36). Aftera median follow-up of 28 months, 5-years all over survival is 77%.

Conclusion: LPD is a feasible and safe surgical procedure that providesthe advantages expected from a minimally invasive surgery including lessblood loss, and can achieve similar long-term results to conventional openPD.

F-091.

Division of the surgeons workloads in pancreaticoduodenectomy

Seong Ho Choi a, Dong Hun Kim a, Jaehong Jeong a, Huisong Lee a, Jin SeokHeo a, Dong Wook Choi a, Min Jung Kim b

a Samsung Medical Center, Sungkyunkwan University School ofMedicine, South Koreab Jeju National University Hospital, Jeju National University School ofMedicine, South Korea

Background: Many authors have suggested factors that affect pancre-atic leakage after pancreatoduodenectomy (PD), but there was little reportfor surgeon’s factor to predominate in pancreatic fistula.

Aims: This study was conducted to determine if surgeon’s workload ofPD could impact on postoperative pancreatic fistula (POPF).

Patients & methods: We retrospectively analyzed a total of 270 con-secutive patients who underwent PD between January 2008 and June 2013by an experienced single surgeon. These patients were divided into thoseunderwent PD totally by a single operator (Group 1) and just recon-structions by other training surgeons (Group 2). Duct-to-mucosa pan-creaticojejunostomy was performed on all patients. The POPF was definedby the International Study Group on Pancreatic Fistula criteria.

Results: There were 157 patients (58.1%) in Group 1 and 113 patients(41.9%) in Group 2. Postoperative morbidity rate was comparable betweenthe two groups (55.4% vs. 52.2%; P ¼ 0.603), but clinical pancreatic fistula(grade B/C) rate was significantly different (10.8% vs. 2.7%; P ¼ 0.011).Postoperative mortality was one patient (0.4%) in all. A significant associ-ationwith clinical pancreatic fistulawas found for soft pancreas (P¼ 0.021),preoperative serum albumin levels � 3.5 g/dL (P ¼ 0.012), other patholo-gies except pancreatic cancer (P¼ 0.027) and a single operator (P¼0.019). Amultivariate logistic regression analysis revealed that a single operator[odds ratio (OR) 4.2, P ¼ 0.029] was the significant predictive risk factor forclinical pancreatic fistula.

Conclusion: Division of the surgeon’s workloads in PD is associatedwith a lower rate of pancreatic fistula.

F-092.

Antecolic reconstruction during pancreatoduodenectomy

Dezs€o Kelemen, B�alint Kasz�as, €Ors P�eter Horv�ath, Andr�as Vereczkei

Department of Surgery, School of Medicine, University of P�ecs, P�ecs,Hungary

Background: Operative mortality related to pancreatic resections hasdropped below 5% in specialized centres. However, morbidity rates are stillhigh and one of the most common complications is delayed gastric emp-tying (DGE).

Aims: In the present study the effect of a modified antecolic recon-struction on the occurrence of DGE is investigated and the results areretrospectively compared to those gained by the traditional retrocolicprocedure.

Patients&methods: Between 1998 and 2014, 274 consecutive patientswere radically operated on for pancreatic or periampullary malignancies.