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Highlights • Hemodynamically stable gunshot wound patients may be managed without retrieval of the bullet. • Nearly 90% of patients with cardiac bullet emboli on initial presentation are hemodynamically stable. • Non-operative management of stable patients includes intensive observation and additional imaging to localize the bullet., Gunshot wounds to the cardiac region usually result in devastating injuries. However, if bullets embolize into the myocardium without significant damage to the organ, optimal evaluation and management remains unclear. We present the case of a hemodynamically stable gunshot wound patient who presented with a bullet to the heart. Sternotomy revealed that the bullet had embolized through the superior vena cava and embedded into the apex of the right ventricle. The patient was managed without retrieval of the bullet and continues to be well despite a retained intracardiac bullet. We discuss cases of bullet embolization to the heart and the emergence of minimally-invasive approaches for management.

Background: Few studies exist regarding the state of robotic transaxillary thyroidectomy (RT) and its outcomes at high-volume institutions. Methods: Eighty-nine patients underwent RT between January 2009 and September 2015 at two tertiary centers. Data were collected from prospectively-maintained IRB-approved databases. Patient demographic and clinical data, and trends were evaluated. Results: Indications for RT included biopsy-proven or suspicion for malignancy in 20.2%, atypical cells or follicular neoplasm in 27.7%, multinodular goiter in 26.6%, thyrotoxicosis in 8.5%, need for completion thyroidectomy in 5.3%, and non-diagnostic FNA in 3.2%. 56% underwent total thyroidectomy and 44% lobectomy. Operative time (OT) was 153.5 minutes for lobectomies and 192.6 minutes for total thyroidectomy. The complication rate was 11.7%: temporary RLN neuropraxia in 2 patients, permanent hypoparathyroidism in 1 patient, temporary hypoparathyroidism in 6 patients, flap seroma in 1 patient, and flap hematoma in 1 patient. Pathology showed malignancy in 43 patients. At a mean follow-up of 31.9 months, there were no recurrences. Since 2013, the number of RTs performed has risen. The number of out-of-state patients increased from 18% to 37% after 2011. Conclusions: RT was performed without compromising outcomes in selected patients. There remains interest among patients seeking this procedure in expert centers.

Minimally invasive surgery for liver resections has a defined role and represents an accepted alternative to open techniques for selected cases. Robotic technology can overcome some of the disadvantages of the laparoscopic technique, mainly in the most complex cases. Precise dissection and microsuturing is possible, even in narrow operative fields, allowing for a better dissection of the hepatic hilum, fine lymphadenectomy, and biliary reconstruction even with small bile ducts and easier bleeding control. This technique has the potential to allow for a greater number of major resections and difficult segmentectomies to be performed in a minimally invasive fashion. The implementation of near-infrared fluorescence with indocyanine green (ICG) also allows for a more accurate recognition of vascular and biliary anatomy. The perspectives of this kind of virtually implemented imaging are very promising and may be reflected in better outcomes. The overall data present in current literature suggests that robotic liver resections are at least comparable to both open and laparoscopic surgery in terms of perioperative and postoperative outcomes. This article provides technical details of robotic liver resections and a review of the current literature.

Die roboterassistierte hepatobiliare Chirurgie ist in den letzten Jahren stetig gewachsen. Sie stellt bei ausgewahlten Patienten eine Alternative zu den offenen und laparoskopischen Verfahren dar. Die Endowrist-Instrumente und die verbesserte Visualisierung bieten einen wichtigen Vorteil bezuglich Blutungskontrolle, Mikronahten und Dissektion. Cholezystektomien und kleinere Hepatektomien werden mit vergleichbaren Ergebnissen durchgefuhrt wie offene und laparoskopische Operationen. Auch komplexe Verfahren, wie z. B. schwere und erweiterte Hepatektomien zeigen exzellente Ergebnisse, sofern sie von Experten durchgefuhrt werden. Der zusatzlich verwendete fluoreszierende Farbstoff Indozyaningrun bietet einen weiteren Vorteil zur Erkennung der vaskularen und biliaren Anatomie. Zukunftige Innovationen werden es ermoglichen, die Anwendung und Indikationsgebiete fur dieses Verfahren zu erweitern. Die roboterassistierte Operation ist zu einem sehr wichtigen Teil der modernen minimal-invasiven Chirurgie geworden, und die Entwicklung neuer Robotertechnologien werden eine breitere Anwendung dieser Technik fordern.

Although minimally invasive pancreatectomy has been performed increasingly for pancreatic malignancies, many authors feel that a history of pancreatitis is a contraindication to either laparoscopic or robotic-assisted pancreatectomy. Shown here is a video (Supplemental Digital Content 1, http://links.lww.com/SLE/A172) of a laparoscopic total pancreatectomy with splenectomy for chronic pancreatitis. This patient was denied auto-islet cell transplantation because of insurance restraints. In total, 4 laparoscopic total pancreatectomies have been attempted and completed. Indications for laparoscopic total pancreatectomy have been 2 for diffuse intraductal papillary mucinous neoplasm, 1 for pancreatic adenocarcinoma, and the above-mentioned patient. No patient suffered a biliary leak, and the average length of stay was 5 days (range, 4 to 8 d). History of pancreatitis is a relative contraindication to minimally invasive pancreatectomy. It should be performed by surgeons with expertise in both open and minimally invasive pancreatic surgery.

About 50 cases of azygos venous system injuries following civilian trauma have been published in current literature. The purpose of our study was to investigate the incidence of these injuries, the causative mechanism and type of trauma, the co-existing injuries, and the mortality rate in our institution. We performed a retrospective review of all trauma patients who were admitted to the surgical department of the General Hospital of Rethymno during an 11-year period. Our study included patients arriving at our institution dead or alive with an azygos venous system injury following blunt or penetrating civilian trauma. Seven patients—five men and two women—were identified with azygos venous system injuries. Five had an azygos vein laceration, one suffered from both azygos and hemiazygos vein lacerations, and the last one had sustained hemiazygos and accessory hemiazygos vein injuries. All of them suffered from a blunt trauma. Three arrived at our hospital in extremis, and all died within 24 h despite our resuscitation attempts. All of our patients were polytrauma patients. All of them had co-existing torso injuries which were severe in all but one case, three of them suffered also from serious head injuries, and all but one had at least serious extremity’s injuries. Azygos venous system injuries are rare, although it seems that they are more frequent than current literature would indicate. Blunt trauma mechanism seems to be predominant in civilian trauma setting, and the patients have usually sustained a lot of serious and severe co-existing injuries with high resultant lethality.

Currently, there are several clinical applications for intraoperative ICG, such as identification of vascular and biliary anatomy, assessment of organ and tissue perfusion, lymph node mapping, and real-time identification of lesions. In this paper we present a review of the available literature related to the use of ICG fluorescence in robotic surgery in order to provide a better understanding of the current applications, show the rapid growth of this technique, and demonstrate the potential future applications.

According to the lung cancer staging project, T1a (≤ 2 cm) non-small-cell lung cancer (NSCLC) should be additionally classified into ≤ 1 cm and1 to 2 cm groups. This study aimed to investigate the surgical procedure for NSCLC ≤ 1 cm and1 to 2 cm.We identified 15,760 patients with T1aN0M0 NSCLC after surgery from the Surveillance, Epidemiology, and End Results database. Overall survival (OS) and lung cancer-specific survival (LCSS) were compared among patients after lobectomy, segmentectomy, or wedge resection. The proportional hazards model was applied to evaluate multiple prognostic factors.OS and LCSS favored lobectomy compared with segmentectomy or wedge resection in patients with NSCLC ≤ 1 cm and1 to 2 cm. Multivariable analysis showed that segmentectomy and wedge resection were independently associated with poorer OS and LCSS than lobectomy for NSCLC ≤ 1 cm and1 to 2 cm. With sublobar resection, lower OS and LCSS emerged for NSCLC1 to 2 cm after wedge resection, whereas similar survivals were observed for NSCLC ≤ 1 cm. Multivariable analyses showed that wedge resection is an independent risk factor of survival for NSCLC1 to 2 cm but not for NSCLC ≤ 1 cm.Lobectomy showed better survival than sublobar resection for patients with NSCLC ≤ 1 cm and1 to 2 cm. For patients in whom lobectomy is unsuitable, segmentectomy should be recommended for NSCLC1 to 2 cm, whereas surgeons could rely on surgical skills and the patient profile to decide between segmentectomy and wedge resection for NSCLC ≤ 1 cm.

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.

Background: One of the perceived major drawbacks of minimally invasive techniques has always been its cost. This is especially true for the robotic approach and is one of the main reasons that has prevented its wider acceptance among hospitals and surgeons. The aim of our study was to evaluate the clinical outcomes and economic impact of robotic and open liver surgery in a single institution. Methods: Sixty-eight robotic and 55 open hepatectomies were performed at our institution between January 1, 2009 and December 31, 2013. Demographics, perioperative data, and postoperative outcomes were collected and compared between the two groups. An independent company performed the financial analysis. The economic parameters comprised direct variable costs, direct fixed costs, and indirect costs. Results: Mean estimated blood loss was significantly less in the robotic group (438 versus 727.8 mL; P = .038). Overall morbidity was significantly lower in the robotic group (22% versus 40%; P = .047). Clavien III/IV complications were also lower, with 4.4% in the robotic versus 16.3% in the open group (P = .043). The length of stay in the intensive care unit (ICU) was shorter for patients who underwent a robotic procedure (2.1 versus 3.3 days; P = .004). The average total cost, including readmissions, was $37,518 for robotic surgery and $41,948 for open technique. Conclusions: Robotic liver resections had less overall morbidity, ICU, and hospital stay. This translates into decreased average costs for robotic surgery. These procedures are financially comparable to open resections and do not represent a financial burden to the hospital.

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

Background We describe our experience with what is, to our knowledge, the first case of robotic assisted ex vivo partial splenectomy with auto-transplantation for a benign non parasitic cyst. Materials and Methods The patient is a 32 year-old female with a giant, benign splenic cyst causing persistent abdominal pain. Preoperative imaging showed a cystic lesion measuring 8.3 × 7.6 cm, in the middle portion of the spleen. Due to the central location of the bulky lesion a partial splenectomy was not feasible. As an alternative to a total splenectomy, a possible reimplantation of hemi-spleen after bench surgery was offered. We proceeded with a robotic total splenectomy and bench hemisplenectomy, preserving the lower pole and a portion of the middle segment of the organ. A robotic reconstruction of the splenic vessels was then performed intra-abdominally. The reperfusion was optimal. Results The total operative time was 305 min, with 78 min of robotic time. Postoperative ultrasound confirmed a patent arterial and venous flow. The postoperative course was uneventful and the patient was discharged on postoperative day 4. The pathology report was consistent with epithelial cyst of the spleen. The patient is doing well at 6-month follow-up. Conclusions The optimized vision and dexterity provided by the robotic system allowed a safe and precise reconstruction of the splenic vessels, even in a deep and narrow operative field. Partial splenectomy with autotransplantation of the organ was thus achieved, avoiding a total splenectomy in a young patient.

Obesity has been steadily increasing in the United States. The effect of body mass index (BMI) on surgical outcomes in pancreatic surgery is still controversial. Currently, there is no report related to obesity and robotic pancreatic surgery. The purpose of this study was to evaluate the impact of BMI on the surgical outcomes of both nonobese and obese patients undergoing robot-assisted distal pancreatectomy (RADP).A prospectively collected database for RADP was retrieved for analysis. Patients were categorized as obese (BMI ≥30 kg/m(2)) and nonobese (BMI30 kg/m(2)). Demographics, perioperative data, American Society of Anesthesiologists score, diagnosis, conversion rate, morbidity, surgical mortality, pancreatic fistula rate, and length of stay were compared.A total for 85 RADP were included, with 57 (67%) in the nonobese group and 28 (33%) in the obese group. No differences were found between nonobese and obese patients regarding demographic, preoperative risk, and perioperative parameters and mortality. There was a trend in the obese group associated with a higher rate of postoperative complications, but it was statistically insignificant. Clinically significant pancreatic fistula (grade B) occurred in 28.5% of obese patients and in 7% of nonobese patients, but without statistical significance (P = .064).Obesity does not have a significant impact on the perioperative outcomes and surgical risks for patients undergoing RADP, but high BMI may be a predictor for pancreatic fistula after RADP.

Pancreatic cancer is the fourth leading cause of cancer-related death in the United States, with more than 45,000 estimated new cases per year [1]. The only potentially curative treatment is surgery, but unfortunately only 10–20% of patients have a resectable disease at the time of diagnosis [2]. The most important factors that can improve the oncologic outcome after surgery are an adequate lymphadenectomy and a negative resection margin [3]. Even though the overall morbidity and mortality rates after pancreatic surgery have been progressively decreasing over the past twenty years, pancreas-related complications are still a major concern.

Bile duct tumors can be broadly classified into benign, premalignant and malignant tumors as per the histologic findings, and into intrahepatic and extrahepatic tumors based on their location [1]. Most of these tumors are malignant. Bile duct adenoma is the most common benign neoplasm of the bile ducts, though it is rare. Premalignant bile duct tumors include biliary intraepithelial neoplasia (Bi1IN) and intraductal papillary neoplasm of the bile duct (IPN-B). Cholangiocarcinoma (CC) is the commonest primary malignancy of the bile ducts [2]. It is predominantly adenocarcinoma (95% of cases), although other histologic types including squamous cell carcinoma, small cell carcinoma and sarcomas have been described.

Laparoscopic distal pancreatectomy (LDP) is increasing in popularity thanks to the benefits that have been recently demonstrated by many authors. The Da Vinci(®) Surgical System could overcome some limits of laparoscopy, helping the surgeons to perform safer and faster difficult procedures. Nowadays, prospective clinical trials comparing LDP to robotic distal pancreatectomy (RDP) are lacking. The aim of this study is to present a prospective comparison between the two techniques.Since November 2011, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP, depending on the availability of the Da Vinci(®) Surgical System for our Surgical Unit. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Follow-up included cross-sectional imaging ended on April 2014.Twenty-two patients underwent RDP and 21 LDP; patients' characteristics were similar. The median operative time was longer and procedures' cost was double in RDP group. The conversion to open rate and the median length of postoperative hospital stay were 4.5 % and 7 days, respectively, in both groups. Pancreatic fistula developed in 57.1 % (12/21) and 50 % (11/22) of LDP and RDP, respectively (p = 0.870), being grade A the most frequent. Mortality was nil and an R0 resection was achieved in all Patients. The overall number of lymph nodes harvested was similar between the two groups.Both RDP and LDP are valid techniques for the treatment of distal pancreatic tumors. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot: we continue to perform both approaches choosing upon single patient's characteristics.

Background/Aim. Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. Methods. A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. Results. No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. Conclusions. ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

Approximately 20 % of patients affected by pancreatic ductal adenocarcinoma are amenable to surgical resection. Several tumours are reported as “borderline resectable” because of their proximity to the major vessels. In the effort to achieve a radical tumour removal, vein resection has been proposed, but its oncological benefits remain debated. Our aim is to investigate morbidity, mortality and survival after pancreatectomy with vein resection. Forty patients underwent pancreatectomy and vein resection (group A), and 20 patients (group B) underwent bilio-enteric and/or gastro-entero bypass. In group A, cancer vein invasion was microscopically proven in 14 cases (35 %). Vein infiltration, tumour differentiation and node-positive disease were not adverse prognostic variables. No difference in survival was seen over a 1-year follow-up. After this period, group A showed significant survival benefits with a longer stabilisation of the disease (p = 0.005). Tumour-free resection margins and adjuvant chemoradiotherapy were the most important prognostic factors (p

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

Postoperative pancreatic fistula (POPF) has a wide range of clinical and economical implications due to the difference of the associated complications and management. The aim of this study is to verify the applicability of the International Study Group of Pancreatic Fistula (ISGPF) definition and its capability to predict hospital costs. This is a retrospective study based on prospectively collected data of 755 patients who underwent pancreaticoduodenectomy in our institution between November 1996 and October 2006. A number of 147 patients (19.5%) have developed a POPF according to ISGPF definition. Grade A fistula, which has no clinical impact, occurred in 19% of all cases. Grade B occurred in 70.7% and was successfully managed with conservative therapy or mini-invasive procedures. Grade C (8.8%) was associated to severe clinical complications and required invasive therapy. Pulmonary complications were statistically higher in the groups B and C rather than the group A POPFs (p

Solid pseudopapillary tumors (SPTs) are rare pancreatic neoplasms of low malignant potential that occur mainly in young women. Only 17 cases of SPT treated laparoscopically have been published in the literature and long-term follow-up data are still lacking. Retrospective analysis of ten patients (8 women, 2 men; mean age, 25.4 years) (DS: 12.1; minimum 11, maximum 51) who underwent laparoscopic distal pancreatectomy with a definitive histological diagnosis of SPT. Long-term follow-up data were collected. The average tumor size was 43.8 mm (minimum 20, maximum 65 mm). The mean operative time was 177.5 minutes (DS: 53.7; minimum 120, maximum 255). In all, five patients underwent distal splenopancreatectomy; five patients underwent spleen-preserving distal pancreatectomy of whom three with splenic vessel preservation and two with the Warshaw technique. The conversion rate was nil and no case of perioperative mortality was recorded. The mean hospital stay was 7 days (DS: 2.7; minimum 4, maximum 12). Six patients had an uneventful postoperative course and four had postoperative complications. Two of them underwent reoperation, and the other two had nonsurgical complications. After a median follow-up of 47 (range, 5–98) months, all patients were alive and disease-free. Laparoscopic pancreatic resection is a safe and feasible procedure that could become the treatment of choice for patients affected by pancreatic SPT. Distal pancreatectomy should be performed, if possible, with spleen-preserving technique, especially in young patients. To avoid metastatic spread, laparoscopic or laparotomic biopsy should not be performed in patients affected by SPT.

Pancreatic fistula is defined as an abnormal communication between the pancreatic ductal system and any other space, internal or external to the peritoneal cavity, caused by an interruption to the integrity of the ductal epithelium itself [1]. Pancreatic fistulas are thus divided into internal and external, the former being by far the most frequent and almost the only ones that occur after pancreatic resection. In fact, whenever a postoperative fistula develops, in the absence of adequate drainage the result will be an abdominal collection that evolves into an abscess or a pseudocyst rather than an internal fistula.

Postoperative pancreatic fistula (POPF) is the most common major complication after pancreatoduodenectomy (PD) and it can lead to prolonged hospital stay, increased costs, and mortality. The POPF rate is strictly correlated to the definition applied, but there are so many different definitions in the literature that comparison between published series of patients is difficult. The International Study Group of Pancreatic Fistula (IGSPF) has developed a new definition, with a grading system able to stratify complicated patients into three groups, based upon the clinical implications and costs of their postoperative course. The most important risk factors identified are a soft pancreatic texture and a main pancreatic duct diameter of 3 mm or less. Several surgical techniques have been studied in order to prevent anastomotic leakage, but none has been demonstrated to be superior to others. The use of somatostatin analogues is still matter of controversy. Conservative management of POPF is usually effective, but in patients with deteriorating clinical status with evidence of sepsis, surgical management is needed.

s / Pancreatology 13 (2013) S2–S98 S52 Patients & methods: Radiology data were compared with the findings from 51 standard, 58 extended and 17 total pancreaticoduodenectomies; 9 distal resections with CA excision; and 28 palliations for PC. The survival of 11 patients with controversial CT and EUS data with regard to arterial invasion, after R0/R1 procedures (false-positive CT results, Group A), was compared to survival after eight R2 resections (false-negative CT results, Group B) and after 12 bypass procedures for locally advanced cancer (truepositive CT results, Group C) Results: In all of the cases in group A, operative exploration revealed no arterial invasion, as predicted by CT. The one-year survival in Group A was 88.9%, and the two-year survival was 26.7%, with a median follow-up of 22 months. One-year survival was not attained in groups B and C, with a significant difference in survival (Pa-b 1⁄4 0.0029, Pb-c 1⁄4 0.003). Conclusion: In all of the cases in group A, operative exploration revealed no arterial invasion, as predicted by CT. The one-year survival in Group A was 88.9%, and the two-year survival was 26.7%, with a median follow-up of 22 months. One-year survival was not attained in groups B and C, with a significant difference in survival (Pa-b 1⁄4 0.0029, Pb-c 1⁄4 0.003). PI-117 Abstract id: 299. Laparoscopic enucleation of benign and borderline pancreatic neoplasms Giuseppe Malleo, Giovanni Marchegiani, Despoina Daskalaki, Isacco Damoli, Claudio Bassi, Giovanni Butturini. Department of Surgery, University of Verona, Italy Introduction:Minimally invasive enucleation of pancreatic neoplasms is a very uncommon procedure. Aims: Here we describe the shortand long-term results of laparoscopic enucleations performed at our institution for benign to borderline lesions of the pancreas. Patients m median KPS 90 (range 80-100) received trabectedin. Prior therapy consisted of adjuvant gemcitabine (N1⁄43); adjuvant PEXG (cisplatin, epirubicin, capecitabine, gemcitabine; N1⁄42); PEXG (N1⁄419) or gemcitabine (N1⁄41) for mPA. Median prior PFS was 9 months; maximum response to prior chemotherapy in 20 mPA pts was PR in 14 (70%) and SD in 6 (30%). Only 1 pt completed all the planned 9 cycles; 23 interrupted trabectedin due to PD, and 1 due to toxicity. Only 2 pts (8%) were PFS-6. Median PFS was 1.9 months (range 0.7-7.4). Median OSwas 4.7 months (range 1.1-13.9) and 1-yr OS was 24%. No PR and 6 SD (24%) were observed. Grade 3-4 toxicity consisted of neutropenia (44%); fatigue (16%); anemia, thrombocytopenia and transaminitis (8% each); febrile neutropenia (4%). Conclusion: This study showed that trabectedin has a limited activity compared to other drugs used as salvage therapy in mPA. PI-119 Abstract id: 46. Pancreaticojejunostomy with duct-to-mucosa improves the incidence of over grade B pancreatic fistula in patients with soft pancreas compared with total diversion Satoshi Mizutani , Hideyuki Suzuki , Takayuki Aimoto , Seiji Yamagishi , Akira Muraki , Arichika Hoshino , Masanori Yoshino , Masanori Watanabe , Eiji Uchida . 1 Institute of Gastroenterology, Nippon Medical School, Japan Department of Surgery, Nippon Medical School, Japan Introduction: Pancreatic fistula (PF) is the most critical complication after pancreaticoduodenectomy (PD). Although pancreaticojejunostomy with total diversion (PJ-TD) is technically easy, this reconstruction method often results in high incidence of PF. On the other hand, pancreaticojejunostomy with duct-to-mucosa anastomosis (PJ-DM) has been recently established as the standard procedure despite technical difficulty. Aims: The aim is to compare clinical outcomes after the procedure between cases receiving PJ-DM and PJ-TD, especially focusing on the incidence of PF. Patients & methods: Thirty two patients with periampular cancer underwent PD. Remnant pancreas in all cases showed soft texture. Patients were divided into two groups: receiving PJ-TD (n1⁄415) and PJ-DM (n1⁄417). We compared patient backgrounds, perioperative factors, and postoperative complications between both groups. PF was assessed according to the definition of PF by International Study Group of Pancreatic Fistula. Results: There were no differences in patient backgrounds and perioperative factors. The incidence rate of all grades PF was relatively high, 41% in the PJ-DM group and 67% in the PJ-TD group. However, PF with over grade B were detected in only 1 patient (6%) of the PJ-DM group while 6 patients (40%) of the PJ-TD showed grade B&C PF. There was no surgeryrelated death in both groups. Conclusion: The PJ-DM procedure seems to be superior to the PJ-TD method in terms of decrease in the incidence rate of PF.