404 Dissect, Resect, Reconstruct: Intra-operative Technical Variation in Open Pancreatoduodenectomy Among UK HPB Surgeons

Abstract Aim To evaluate technical variability in open pancreatoduodenectomy (PD) among hepatobiliary and pancreatic (HPB) surgeons in the United Kingdom (UK) and Ireland. Method A national cross-sectional survey was distributed to consultant HPB surgeons across the UK and Ireland. Questions ranged across technical factors including operation type, operative sequence, dissection technique, resection strategy and the three reconstructions. Responses were analysed descriptively. Results 38 responses were received, from across 30 hospitals. 20/38 (52.6%) perform a pylorus-preserving pancreaticoduodenectomy (PPPD) vs 18/38 (47.4%) Whipple’s. Marked variation in operative sequence was seen(n=36), with 24/36 (66.7%) starting with kocherisation. Extent of kocherisation, lesser sac entry and approach to superior mesenteric artery showed marked variation. 19/38 (50%) performed en-bloc cholecystectomy. Division of the stomach was unanimously performed with a stapler, whilst the CBD was divided mostly with the scalpel (18/38,47.4%). The pancreatic neck was more varied, with most using diathermy (25/38,65.8%), with 9/25 (36%) further specifying knife/scissors used to divide the duct. Pancreatico-enterostomy technique varied; most performed modified-Blumgart (14/38,36.8%) or Cattell-Warren (10/38,26.3%). 6/38 (15.8%) specified a PJ technique: 3/38 (7.9%) duct-to-mucosa and 3/38 (7.9%) dunking. 3/38 (7.9%) performed PG and 3/38 (7.9%) highlighted a modifiable technique depending on gland texture and duct size. Internal stents were used by 33/38 (86.8%): mostly infant feeding-tubes (29/38,65.8%) though 5/38 (13.1%) detailed trialing biodegradable stents. Conclusions: This national survey highlights wide variation in keystone-steps of a PD. Whilst such variation may just reflect difference in training and operator preference, further work to understand the impact of such variation on patient outcomes is necessary.