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Kodali R, Parasar K, Anand U, Anwar S, Saha B, Singh BN, Kant K, Karthikeyan V. Enteral nutrition versus parenteral nutrition in the management of postoperative pancreatic fistula following pancreaticoduodenectomy: a prospective observational study. ANZ J Surg 2025. [PMID: 40105276 DOI: 10.1111/ans.70096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2025] [Revised: 03/06/2025] [Accepted: 03/07/2025] [Indexed: 03/20/2025]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) presents a significant challenge to oral intake after pancreaticoduodenectomy (PD). Strategies such as enteral feeding via nasojejunal tube, feeding jejunostomy (FJ), and total parenteral nutrition (TPN) are commonly used to optimize postoperative nutrition. However, the routine use of FJ in PD remains controversial. This study assesses the effectiveness of enteral feeding versus TPN in the management of POPF. METHODS A prospective observational study was conducted on 100 patients undergoing classical PD at a tertiary care centre in eastern India between July 2019 and July 2024. Patients were randomly allocated to FJ and non-FJ groups in a 1:1 ratio. The primary endpoints were procedure-related complications (POPF, delayed gastric emptying (DGE), post-pancreatectomy haemorrhage, bile leak, Clavien-Dindo grade ≥ 3), hospital stay, additional costs and 30-day mortality in patients with clinically relevant POPF. RESULTS Of the 100 patients, 50 underwent routine FJ placement, and 50 did not. Most POPF cases were Grade B (34% versus 24%). Subgroup analysis of patients with clinically relevant POPF revealed that FJ placement significantly reduced fistula duration (3.8 versus 5.2 weeks, P < 0.001), intra-abdominal drain duration (26.4 versus 34.9 days, P < 0.001), hospital stay (7.9 versus 9.9 days, P < 0.001) and cost expenses (1301 ± 524 versus 1982 ± 441, P < 0.001). There were no differences in complication rates, reoperations, readmissions or 30-day mortality. FJ placement was not associated with adverse events. CONCLUSION Routine FJ is a safe and cost-effective strategy for PD patients requiring prolonged nutritional support.
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Affiliation(s)
- Rohith Kodali
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Saad Anwar
- Department of Surgical Gastroenterology, Apollo Spectra Hospitals, Kanpur, India
| | - Bijit Saha
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Basant Narayan Singh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Kislay Kant
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Venkatesh Karthikeyan
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, India
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Marchetti A, Corvino G, Perri G, Marchegiani G, De Luca R. Reoperation for pancreatic fistula: a systematic review of completion pancreatectomy vs. pancreas-preserving-procedures and outcomes. HPB (Oxford) 2025; 27:240-249. [PMID: 39658409 DOI: 10.1016/j.hpb.2024.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 10/30/2024] [Accepted: 11/21/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND Consensus on the nomenclature and indications for reoperation for post-operative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is lacking. This study explores the available literature to classify the different types of reoperations and report outcomes. METHODS A systematic literature search was performed, including articles from 2010 to 2024 reporting reoperations for POPF after PD. The primary outcome was 30- or 90-day-mortality. Secondary outcomes included reoperation date, additional relaparotomy, ICU-admission, hospital stay, rate of pancreatic-exocrine-insufficiency, diabetes and long-term survivors. RESULTS Twenty-five studies were reviewed with 766 patients reoperated for POPF after PD, 283 (37 %) undergoing completion pancreatectomy (CP) and 483 (63 %) pancreas-preserving-procedures (PPPs). Among PPPs, drainage (30 %), wirsungostomy (14 %), pancreatic anastomosis repair (6 %), "sinking" of pancreatic stump (6 %) and re-do pancreatic anastomosis (4 %) were identified. The main indications for reoperation were post-pancreatectomy hemorrhage, necrotizing acute pancreatitis, sepsis and peritonitis. PPPs were preferred with severe hemodynamic instability. Mortality rates after CP and PPPs ranged from 20 to 56 % and 0-67 %, respectively. Early reoperation was associated with reduced ICU-recovery after "sinking" (p = 0.049). CONCLUSION Reoperation for POPF after PD is rarely needed. When it is, early timing seems critical for better outcomes, and PPPs seems to be the best bail out option in patients with severe hemodynamic instability.
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Affiliation(s)
- Alessio Marchetti
- Department of Pancreatic Surgery, Verona University Hospital, Piazzale Ludovico Antonio Scuro 10, 37134, Verona, VR, Italy; Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - Gaetano Corvino
- Department of Pancreatic Surgery, Verona University Hospital, Piazzale Ludovico Antonio Scuro 10, 37134, Verona, VR, Italy
| | - Giampaolo Perri
- Hepato Pancreato Biliary (HPB) and Liver Transplant Surgery, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Via Giustiniani 2, 35128, Padova, Italy
| | - Giovani Marchegiani
- Hepato Pancreato Biliary (HPB) and Liver Transplant Surgery, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Via Giustiniani 2, 35128, Padova, Italy.
| | - Raffaele De Luca
- Department of Surgical Oncology, I.R.C.C.S Istituto Tumori "Giovanni Paolo II", Viale Orazio Flacco 65, 70124, Bari, Italy
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Ju JW, Jang HS, Lee M, Lee HJ, Kwon W, Jang JY. Early postoperative fever as a predictor of pancreatic fistula after pancreaticoduodenectomy: a single-center retrospective observational study. BMC Surg 2024; 24:229. [PMID: 39134979 PMCID: PMC11318233 DOI: 10.1186/s12893-024-02521-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 07/30/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND The connection between early postoperative fever and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy remains unclear. This study aimed to investigate this association and assess the predictive value of early postoperative fever for CR-POPF. METHODS This retrospective observational study included adult patients who underwent pancreaticoduodenectomy at a tertiary teaching hospital between 2007 and 2019. Patients were categorized into those with early postoperative fever (≥ 38 °C in the first 48 h after surgery) and those without early postoperative fever groups. Weighted logistic regression analysis using stabilized inverse probability of treatment weighting (sIPTW) and multivariable logistic analysis were performed. The c-statistics of the receiver operating characteristic curves were calculated to evaluate the impact on the predictive power of adding early postoperative fever to previously identified predictors of CR-POPF. RESULTS Of the 1997 patients analyzed, 909 (45.1%) developed early postoperative fever. The overall incidence of CR-POPF among all the patients was 14.3%, with an incidence of 19.5% in the early postoperative fever group and 9.9% in the group without early postoperative fever. Early postoperative fever was significantly associated with a higher risk of CR-POPF after sIPTW (adjusted odds ratio [OR], 1.73; 95% confidence interval [CI], 1.34-2.22; P < 0.001) and multivariable logistic regression analysis (adjusted OR, 1.88; 95% CI, 1.42-2.49; P < 0.001). The c-statistics for the models with and without early postoperative fever were 0.76 (95% CI, 0.73-0.79) and 0.75 (95% CI, 0.72-0.78), respectively, showing a significant difference between the two (difference, 0.02; 95% CI, 0.00-0.03; DeLong's test, P = 0.005). CONCLUSIONS Early postoperative fever is a significant but not highly discriminative predictor of CR-POPF after pancreaticoduodenectomy. However, its widespread occurrence limits its applicability as a predictive marker.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hwan Suk Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Mirang Lee
- Department of Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Wooil Kwon
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Razjouyan H, Maranki JL. Endoscopic Retrograde Cholangiopancreatography for the Management of Pancreatic Duct Leaks and Fistulas. Gastrointest Endosc Clin N Am 2024; 34:405-416. [PMID: 38796289 DOI: 10.1016/j.giec.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pancreatic duct (PD) leaks are a common complication of acute and chronic pancreatitis, trauma to the pancreas, and pancreatic surgery. Diagnosis of PD leaks and fistulas is often made with contrast-enhanced pancreatic protocol computed tomography or magnetic resonance imaging with MRCP. Endoscopic retrograde pancreatography with pancreatic duct stenting in appropriately selected patients is often an effective treatment, helps to avoid surgery, and is considered first-line therapy in cases that fail conservative management.
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Affiliation(s)
- Hadie Razjouyan
- Division of Gastroenterology and Hepatology, Penn State College of Medicine, Penn State Health, 500 University Drive, HU850, Hershey, PA 17033, USA
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Penn State College of Medicine, Penn State Health, 500 University Drive, HU850, Hershey, PA 17033, USA.
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Biesel EA, Kuesters S, Chikhladze S, Ruess DA, Hipp J, Hopt UT, Fichtner-Feigl S, Wittel UA. Surgical complications requiring late surgical revisions after pancreatoduodenectomy increase postoperative morbidity and mortality. Scand J Surg 2024; 113:88-97. [PMID: 37962167 DOI: 10.1177/14574969231206132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Pancreatoduodenectomies are complex surgical procedures with considerable postoperative morbidity and mortality. Here, we describe complications and outcomes in patients requiring surgical revisions following pancreatoduodenectomy. METHODS A total of 1048 patients undergoing a pancreatoduodenectomy at our institution between 2002 and 2019 were analyzed retrospectively. All patients with surgical revisions were included. Revisions were divided into early and late using a cut-off of 5 days after the first surgery. Statistical significance was examined by using chi-square tests and Fisher's exact tests. Survival analysis was performed using Kaplan-Meier curves and log-rank tests. RESULTS A total of 150 patients with at least 1 surgical revision after pancreatoduodenectomy were included. Notably, 64 patients had a revision during the first 5 days and were classified as early revision. Compared with the 86 patients with late revisions, we found no differences concerning wound infections, delayed gastric emptying, or acute kidney failure. After late revisions, we found significantly more cases of sepsis (31.4% late versus 15.6% early, p = 0.020) and reintubation due to respiratory failure (33.7% versus 18.8%, p = 0.031). Postoperative mortality was significantly higher within the late revision group (23.2% versus 9.4%, p = 0.030). CONCLUSION Arising complications after pancreatoduodenectomy should be addressed as early as possible as patients requiring late surgical revisions frequently developed septic complications and multiorgan failure.
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Affiliation(s)
- Esther A Biesel
- Department of General and Visceral Surgery University Medical Center FreiburgUniversity of FreiburgHugstetter Str. 55 D-79106 Freiburg Germany
| | - Simon Kuesters
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Dietrich A Ruess
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Julian Hipp
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
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Wu AGR, Mohan R, Fong KY, Chen Z, Bonney GK, Kow AWC, Ganpathi IS, Pang NQ. Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis. Langenbecks Arch Surg 2023; 408:317. [PMID: 37587225 DOI: 10.1007/s00423-023-03053-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication. METHODS Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality. RESULTS Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed. CONCLUSION Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.
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Affiliation(s)
- Andrew Guan Ru Wu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ramkumar Mohan
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Zhaojin Chen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Glenn Kunnath Bonney
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Adult Liver Transplantation Programme, National University Centre for Organ Transplantation, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Alfred Wei Chieh Kow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Adult Liver Transplantation Programme, National University Centre for Organ Transplantation, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Iyer Shridhar Ganpathi
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Adult Liver Transplantation Programme, National University Centre for Organ Transplantation, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Ning Qi Pang
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital, Singapore, Singapore.
- Adult Liver Transplantation Programme, National University Centre for Organ Transplantation, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore.
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Jabłońska B, Mrowiec S. Pancreatectomy and Pancreatic Surgery. Life (Basel) 2023; 13:1400. [PMID: 37374182 DOI: 10.3390/life13061400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Pancreatectomy, including pancreaticoduodenectomy (PD), as well as central pancreatectomy (CP), distal pancreatectomy (DP) and total/subtotal pancreatectomy, is a major, complex and difficult surgical procedure performed for various benign and malignant pancreatic diseases: from chronic pancreatitis, through benign cystic tumors and neuroendocrine neoplasms to malignant neoplasms, including pancreatic ductal adenocarcinoma (PDAC) [...].
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Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, 40-752 Katowice, Poland
| | - Sławomir Mrowiec
- Department of Digestive Tract Surgery, Medical University of Silesia, 40-752 Katowice, Poland
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Pausch TM, Liu X, Dincher J, Contin P, Cui J, Wei J, Heger U, Lang M, Tanaka M, Heap S, Kaiser J, Klotz R, Probst P, Miao Y, Hackert T. Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003-2021. J Clin Med 2023; 12:jcm12052013. [PMID: 36902800 PMCID: PMC10003839 DOI: 10.3390/jcm12052013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Middle segment-preserving pancreatectomy (MPP) can treat multilocular diseases in the pancreatic head and tail while avoiding impairments caused by total pancreatectomy (TP). We conducted a systematic literature review of MPP cases and collected individual patient data (IPD). MPP patients (N = 29) were analyzed and compared to a group of TP patients (N = 14) in terms of clinical baseline characteristics, intraoperative course, and postoperative outcomes. We also conducted a limited survival analysis following MPP. Pancreatic functionality was better preserved following MPP than TP, as new-onset diabetes and exocrine insufficiency each occurred in 29% of MPP patients compared to near-ubiquitous prevalence among TP patients. Nevertheless, POPF Grade B occurred in 54% of MPP patients, a complication avoidable with TP. Longer pancreatic remnants were a prognostic indicator for shorter and less eventful hospital stays with fewer complications, whereas complications of endocrine functionality were associated with older patients. Long-term survival prospects after MPP appeared strong (median up to 110 months), but survival was lower in cases with recurring malignancies and metastases (median < 40 months). This study demonstrates MPP is a feasible treatment alternative to TP for selected cases because it can avoid pancreoprivic impairments, but at the risk of perioperative morbidity.
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Affiliation(s)
- Thomas M. Pausch
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-565150
| | - Xinchun Liu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Department of Gastrointestinal Surgery, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Josefine Dincher
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Pietro Contin
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jiaqu Cui
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Matthias Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Masayuki Tanaka
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Stephen Heap
- Study Center of the German Society of Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Jörg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Study Center of the German Society of Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Surgery, Cantonal Hospital Thurgau, 8501 Frauenfeld, Switzerland
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Swartling O, Evans M, Larsson P, Gilg S, Holmberg M, Klevebro F, Löhr M, Sparrelid E, Ghorbani P. Risk factors for acute kidney injury after pancreatoduodenectomy, and association with postoperative complications and death. Pancreatology 2023; 23:227-233. [PMID: 36639282 DOI: 10.1016/j.pan.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with increased morbidity and mortality after general surgery, although little is known among patients undergoing pancreatoduodenectomy. The objective was to investigate the association between AKI and postoperative complications and death after pancreatoduodenectomy. METHODS All patients ≥18 years who underwent a pancreatoduodenectomy 2008-2019 at the Karolinska University Hospital, Stockholm, Sweden, were included. Standardized criteria for AKI, including estimated glomerular filtration rate (eGFR) and urine volume measurements, were used to grade postoperative AKI. RESULTS In total, 970 patients were included with a median age of 68 years (IQR 61-74) of whom 517 (53.3%) were men. There were 137 (14.1%) patients who developed postoperative AKI. Risk factors for AKI included lower preoperative eGFR, cardiovascular disease and treatment with renin-angiotensin system inhibitors or diuretics. Those who developed AKI had a higher risk of severe postoperative complications, including Clavien-Dindo score ≥ IIIa (adjusted OR 3.35, 95% CI 2.24-5.01) and ICU admission (adjusted OR 7.83, 95% CI 4.39-13.99). In time-to-event analysis, AKI was associated with an increased risk for both 30-day mortality (adjusted HR 4.51, 95% CI 1.54-13.27) and 90-day mortality (adjusted HR 4.93, 95% CI 2.37-10.26). Patients with benign histology and AKI also had an increased 1-year mortality (HR 4.89, 95% CI 1.88-12.71). CONCLUSIONS Postoperative AKI was associated with major postoperative complications and an increased risk of postoperative mortality. Monitoring changes in serum creatinine levels and urine volume output could be important in the immediate perioperative period to improve outcomes after pancreatoduodenectomy.
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Affiliation(s)
- Oskar Swartling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Marie Evans
- Renal Unit, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Patrik Larsson
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Holmberg
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Matthias Löhr
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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10
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Clinically Relevant Pancreatic Fistula after Pancreaticoduodenectomy: How We Do It. BIOLOGY 2023; 12:biology12020178. [PMID: 36829457 PMCID: PMC9952935 DOI: 10.3390/biology12020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023]
Abstract
(1) Background: This study's goals were to investigate possible risk factors for clinically relevant postoperative pancreatic fistula (POPF) grade B/C according to the updated definitions of the International Study Group of Pancreatic Surgery and to analyze possible treatment strategies; (2) Methods: Between 2017 and 2021, 200 patients were analyzed regarding the development of POPF grade B/C with an emphasis on postoperative outcome and treatment strategies; (3) Results: POPF grade B/C was observed in 39 patients (19.5%). These patients were younger, mainly male, had fewer comorbidities and showed a higher body mass index. Also, they had lower CA-19 levels, a smaller tumor size and softer pancreatic parenchyma. They experienced a worse outcome without affecting the overall mortality rate (10% vs. 6%, p = 0.481), however, this lead to a prolonged postoperative stay (28 (32-36) d vs. 20 (15-28) d, p ≤ 0.001). The majority of patients with POPF grade B/C were able to receive conservative treatment, followed by drainage placement, endoscopic vacuum-assisted therapy (EVT) and surgery. Conservative treatment resulted in a shorter length of the postoperative stay (24 (22-28) d vs. 34 (26-43) d, p = 0.012); (4) Conclusions: Patients developing POPF grade B/C had a worse outcome; however, this did not affect the overall mortality rate. The majority of the patients were able to receive conservative treatment, resulting in a shorter length of their hospital stay.
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Krueger CM, Langheinrich M, Biesel EA, Kundel L, Krueger K, Adam U, Riediger H. Preoperative risk assessment for postoperative pancreatic fistula (POPF): Image-based calculation of duct-to-parenchyma (D/P) ratio and an Alignment of Duct and Mucosa (ADAM) anastomosis may lead to a low POPF rate—results from 386 patients. Front Surg 2022; 9:1039191. [DOI: 10.3389/fsurg.2022.1039191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative pancreatic fistula (POPF) is the most critical complication after pancreatoduodenectomy (PD). Preoperative identification of high-risk patients and optimal pancreatic reconstruction technique can be a way to reduce postoperative complications.MethodsA series of 386 patients underwent PD over a 10-year period (2009–2019). On routinely performed preoperative computed tomography (CT) images, the ventro-dorsal diameters of duct (D) and parenchyma (P) were measured in the cutting plane at the superior mesenteric vein. Then, the ratio of both values was calculated (D/P ratio) Double-layer pancreatojejunostomy with alignment of duct and mucosa (ADAM) by two monofilament threads (MFT) was performed in 359 patients and pancreatogastrostomy (PG) in 27 patients. The incidence of POPF was diagnosed according to the International Study Group for Pancreatic Fistula criteria.ResultsThe overall rate of POPF was 21% (n = 80), and the rate of clinically relevant type B/C fistulas 6.5% (n = 25). A D/P ratio of <0.2 was significantly associated with type B/C fistula (11%, p < 0.01). In low-risk patients (D/P ratio >0.2), type B/C fistula occurred only in 2%, and in high-risk patients (D/P ratio <0.2) in 9%. ADAM anastomosis was performed safely by two different surgeons. A PG anastomosis had double-digit POPF rates in all groups.ConclusionPreoperative CT imaging with D/P measurement may predict the risk of POPF development. A cut off D/P ratio of <0.2 was significantly associated with clinical relevant POPF. ADAM anastomosis may be an option for pancreatojejunostomy. However, preoperative knowledge of the D/P ratio could guide decision-making for primary pancreatectomy when pancreatic reconstruction is critical.
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review. World J Gastrointest Surg 2022; 14:1089-1106. [PMID: 36386401 PMCID: PMC9640330 DOI: 10.4240/wjgs.v14.i10.1089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/16/2022] [Accepted: 10/14/2022] [Indexed: 02/07/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.
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Affiliation(s)
| | - Jaswinder S Samra
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Sumit Sahni
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Anubhav Mittal
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
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13
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Florentin LM, Dulcich G, López Grove R, Paladini JI, Spina JC. Imaging assessment after pancreaticoduodenectomy: reconstruction techniques-normal findings and complications. Insights Imaging 2022; 13:170. [PMID: 36264369 PMCID: PMC9584030 DOI: 10.1186/s13244-022-01306-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/24/2022] [Indexed: 11/10/2022] Open
Abstract
Pancreaticoduodenectomy represents a major surgery for tumors located at the pancreatic head and the ampullary/periampullary region. This complex procedure is associated with a high morbidity rate. Many surgical techniques have been proposed in order to reduce mortality rates, although post-procedure complications represent a current problem. Different imaging findings and complications may appear depending on the surgical technique used. Hence, radiologists should be familiarized with them to distinguish normal findings from real complications. The most challenging scenarios are represented by abdominal fluid collections, and tumor recurrence, that may frequently mimic normal postsurgical changes.
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Affiliation(s)
| | - Gonzalo Dulcich
- Department of Radiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Roy López Grove
- Department of Radiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - José Ignacio Paladini
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Carlos Spina
- Department of Radiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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14
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Lee SJ, Choi IS, Moon JI. Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy. Ann Surg Treat Res 2022; 103:217-226. [PMID: 36304194 PMCID: PMC9582620 DOI: 10.4174/astr.2022.103.4.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/09/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy. Results A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months. Conclusion Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.
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Affiliation(s)
- Seung Jae Lee
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - In Seok Choi
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Ju Ik Moon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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15
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Hong SB, Lee NK, Kim S, Seo HI, Park YM, Noh BG, Kim DU, Han SY, Kim TU. Diagnostic performance of magnetic resonance image for malignant intraductal papillary mucinous neoplasms: the importance of size of enhancing mural nodule within cyst. Jpn J Radiol 2022; 40:1282-1289. [PMID: 35781178 DOI: 10.1007/s11604-022-01312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the clinical significance of enhancing mural nodules ≥ 5 mm by comparing the diagnostic performance of high-risk stigmata for diagnosing the malignant IPMN between the international consensus guideline (ICG) 2012 and 2017 in pancreatic magnetic resonance image (MRI). MATERIALS AND METHODS In this retrospective study, we reviewed preoperative pancreatic MRI with surgically confirmed IPMNs between May 2009 and April 2021. High-risk stigmata, defined by ICG 2012 and ICG 2017, associated with malignant IPMN were evaluated using logistic regression analysis. We calculated and compared the sensitivity and specificity of ICG 2012 and ICG 2017 for diagnosing malignant IPMNs. Receiver-operating characteristic (ROC) curves were used to compare ICG 2012 to ICG 2017. RESULTS A total of 73 patients (43 men and 30 women; mean age, 69 years; standard deviation, 8 years) with 34 malignant IPMNs and 39 benign IPMNs were included. Among high-risk stigmata, enhancing mural nodule ≥ 5 mm, and MPD diameter ≥ 10 mm were the significant predictor of malignant IPMN, in multivariate logistic regression (P < 0.001 for all). For the diagnosis of malignant IPMN, the specificity of ICG 2017 for enhancing mural nodules ≥ 5 mm as the high-risk stigmata was significantly higher than that of ICG 2012 (87.2% vs. 64.1%, P = 0.008). However, there was no significant difference in sensitivity between the two guidelines (94.1% vs. 97.1%, P = 1.0). The comparison of the ROC curves showed that the diagnostic performance of ICG 2017 for malignant IPMNs (AUC, 0.91) significantly improved when compared to that of ICG 2012 (AUC, 0.81) (P = 0.01). CONCLUSION When applying enhancing mural nodule ≥ 5 mm as a high-risk stigmata, ICG 2017 provided a significantly higher specificity than ICG 2012 without a reduction in sensitivity.
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Affiliation(s)
- Seung Baek Hong
- Department of Radiology and Biomedical Research Institute of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Nam Kyung Lee
- Department of Radiology and Biomedical Research Institute of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea.
| | - Suk Kim
- Department of Radiology and Biomedical Research Institute of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Hyung-Il Seo
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Young Mok Park
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byeong Gwan Noh
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Sung Yong Han
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Tae Un Kim
- Department of Radiology, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis. Langenbecks Arch Surg 2022; 407:2801-2810. [PMID: 35752718 DOI: 10.1007/s00423-022-02599-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.
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Stereotactic Irradiation of the Pancreas: Case Study of a Patient With Persistent Pancreatic Fistula. Pancreas 2022; 51:e62-e63. [PMID: 35584391 DOI: 10.1097/mpa.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Mohan A, Gupta R, Yadav TD, Gupta V, Sharma V, Mandavdhare H, Angrup A, Singh H. Association of Intra-Operative Bile Culture with Post-Operative Complications after Pancreaticoduodenectomy. Surg Infect (Larchmt) 2022; 23:351-356. [PMID: 35231198 DOI: 10.1089/sur.2021.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Infectious complications after pancreaticoduodenectomy (PD) are a major cause of morbidity. The association of bactibilia with the occurrence of surgical site infection (SSI) is debatable. Patients and Methods: Consecutive patients who underwent PD between July 2019 and December 2020 were included. All patients underwent standard pre-operative preparation and imaging. Pre-operative biliary drainage (PBD) was done as clinically indicated. A bile sample was collected just before the transection of common bile duct (CBD). Post-operative outcomes including SSI were analyzed. Results: Fifty-four patients were assessed for enrollment; 50 were found to be resectable during surgery and were included. The incidence of bactibilia was 46%. Nineteen (38%) patients developed SSIs and the occurrence was higher in patients who had positive bile culture (14 [60.8%] vs. 5 [18.5%]; p = 0.002). A similar organism between bile culture and SSI was seen in nine (64.2%) of 14 patients. Patients who had positive bile culture had more frequent change of antibiotic (16 [69%] vs. 8 [29.6%]; p = 0.005) and required prolonged duration of postoperative antibiotic agents (12 days [IQR, 8-14] vs. 8 days [IQR, 6-10]; p = 0.003). There was no association between bile culture growth and development of post-operative pancreatic fistula, delayed gastric emptying, and post-operative pancreatic hemorrhage. Patients with bactibilia had prolonged post-operative stay (17 days [IQR, 11-20] vs. 11 days [IQR, 8-14]; p = 0.010) and severe post-operative complications (8 [34.7%] vs. 2 [7.4%]; p = 0.008). Conclusions: Bactibilia is associated with the development of SSI and may provide a guide in selection of antibiotics.
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Affiliation(s)
- Anand Mohan
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Kaczmarek DJ, Heling DJ, Gonzalez-Carmona MA, Strassburg CP, Branchi V, Matthaei H, Kalff J, Manekeller S, Glowka TR, Weismüller TJ. Management of post-operative pancreatic fistulas following Longmire-Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy. BMC Gastroenterol 2021; 21:425. [PMID: 34772366 PMCID: PMC8588716 DOI: 10.1186/s12876-021-02000-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/28/2021] [Indexed: 01/08/2023] Open
Abstract
Background Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. Methods We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. Results PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. Conclusions EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.
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Affiliation(s)
| | - Dominik J Heling
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | | | - Vittorio Branchi
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Jörg Kalff
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Steffen Manekeller
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Tim R Glowka
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Tobias J Weismüller
- Department of Internal Medicine I, University of Bonn, Bonn, Germany. .,Department of Internal Medicine - Gastroenterology and Oncology, Vivantes Humboldt Hospital, Am Nordgraben 2, 13509, Berlin, Germany.
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Garnier J, Ewald J, Marchese U, Delpero JR, Turrini O. Standardized salvage completion pancreatectomy for grade C postoperative pancreatic fistula after pancreatoduodenectomy (with video). HPB (Oxford) 2021; 23:1418-1426. [PMID: 33832833 DOI: 10.1016/j.hpb.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/17/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Emergency completion pancreatectomy (CP) after pancreatoduodenectomy (PD) is a technically demanding procedure. We report our experiences with a four-step standardized technique used at our center since 2012. METHODS In the first step, the gastrojejunostomy is divided with a stapler to quickly access the pancreatic anastomosis and permit adequate exposure, especially in cases of active bleeding. Second, the bowel loops connected to the pancreatic anastomosis is divided in cases of pancreaticojejunostomy. Third, the pancreatectomy is completed with or without the splenic vessels and spleen conservation according to the local conditions. Finally, the fourth step reconstructs in a Roux-en-Y fashion and ensures drainage. RESULTS From January 2012 to December 2019, 450 patients underwent PD at our center. Reintervention for grade C postoperative pancreatic fistula was decided for 30 patients, and CP was performed in 21 patients. The mean intraoperative blood loss and operative duration were relatively low (600 ml and 240 min, respectively). During the perioperative period, three patients died from multiple organ failure, and two patients died intraoperatively from a cataclysmic hemorrhage originating from the superior mesenteric artery. DISCUSSION Our standardized procedure appears to be relatively safe, reproducible, and could be particularly useful for young surgeons.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France.
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | | | - Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CRCM, Marseille, France
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Kiełbowski K, Bakinowska E, Uciński R. Preoperative and intraoperative risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy – systematic review and meta-analysis. POLISH JOURNAL OF SURGERY 2021; 93:1-10. [DOI: 10.5604/01.3001.0014.9659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication after pancreaticoduodenectomy (PD). It is observed when the amylase activity in the drain fluid exceeds three times the normal upper value. Grades B and C of POPF are considered as clinically relevant. Fistula might originate due to failure of healing of a pancreatic anastomosis or from raw pancreatic surface.
Materials and methods: 18 retrospective and prospective studies published between 2015 and 2020 were included in this meta-analysis. Total number of patients was 5836. To investigate potential risk factors associated with the occurrence of POPF, odds ratios (OR) with 95% confidence intervals (CI) were calculated. To compare discontinuous data, mean differences (MD) were calculated.
Results: 13 factors were divided into preoperative and intraoperative groups. Male sex, higher BMI, soft pancreatic texture and small pancreatic duct were considered as significant risk factors while vascular resection lowered the risk of development pancreatic fistula.
Discussion: It is considered that the development of POPF is associated with intrapancreatic fat. More severe infiltration with fat tissue is responsible for soft texture of the gland, while higher BMI is one of the risk factors of increased pancreatic fat. On the contrary, diabetes is associated with fibrotic pancreas which could lower the risk of developing POPF.
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Affiliation(s)
- Kajetan Kiełbowski
- Student Scientific Society, Pomeranian Medical University, Szczecin, Poland
| | - Estera Bakinowska
- Student Scientific Society, Pomeranian Medical University, Szczecin, Poland
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22
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Proposal of a Preoperative CT-Based Score to Predict the Risk of Clinically Relevant Pancreatic Fistula after Cephalic Pancreatoduodenectomy. ACTA ACUST UNITED AC 2021; 57:medicina57070650. [PMID: 34202601 PMCID: PMC8307575 DOI: 10.3390/medicina57070650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Postoperative pancreatic fistula after cephalic pancreatoduodenectomy (CPD) is still the leading cause of postoperative morbidity, entailing long hospital stay and costs or even death. The aim of this study was to propose the use of morphologic parameters based on a preoperative multisequence computer tomography (CT) scan in predicting the clinically relevant postoperative pancreatic fistula (CRPF) and a risk score based on a multiple regression analysis. Materials and Methods: For 78 consecutive patients with CPD, we measured the following parameters on the preoperative CT scans: the density of the pancreas on the unenhanced, arterial, portal and delayed phases; the unenhanced density of the liver; the caliber of the main pancreatic duct (MPD); the preoperatively estimated pancreatic remnant volume (ERPV) and the total pancreatic volume. We assessed the correlation of the parameters with the clinically relevant pancreatic fistula using a univariate analysis and formulated a score using the strongest correlated parameters; the validity of the score was appreciated using logistic regression models and an ROC analysis. Results: When comparing the CRPF group (28.2%) to the non-CRPF group, we found significant differences of the values of unenhanced pancreatic density (UPD) (44.09 ± 6.8 HU vs. 50.4 ± 6.31 HU, p = 0.008), delayed density of the pancreas (48.67 ± 18.05 HU vs. 61.28 ± 16.55, p = 0.045), unenhanced density of the liver (UDL) (44.09 ± 6.8 HU vs. 50.54 ± 6.31 HU, p = 0.008), MPD (0.93 ± 0.35 mm vs. 3.14 ± 2.95 mm, p = 0.02) and ERPV (46.37 ± 10.39 cm3 vs. 34.87 ± 12.35 cm3, p = 0.01). Based on the odds ratio from the multiple regression analysis and after calculating the optimum cut-off values of the variables, we proposed two scores that both used the MPD and the ERPV and differing in the third variable, either including the UPD or the UDL, producing values for the area under the receiver operating characteristic curve (AUC) of 0.846 (95% CI 0.694-0.941) and 0.774 (95% CI 0.599-0.850), respectively. Conclusions: A preoperative CT scan can be a useful tool in predicting the risk of clinically relevant pancreatic fistula.
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Kushiya H, Nakamura T, Asano T, Okamura K, Tsuchikawa T, Murakami S, Kurashima Y, Ebihara Y, Noji T, Nakanishi Y, Tanaka K, Shichinohe T, Hirano S. Predicting the Outcomes of Postoperative Pancreatic Fistula After Pancreatoduodenectomy Using Prophylactic Drain Contrast Imaging. J Gastrointest Surg 2021; 25:1445-1450. [PMID: 32495135 DOI: 10.1007/s11605-020-04646-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a main cause of fatal complications post-pancreatoduodenectomy. However, no universally accepted drainage management exists for clinically relevant postoperative pancreatic fistulas. We retrospectively evaluated cases in which drain contrast imaging was used to determine its utility in identifying clinically relevant postoperative pancreatic fistulas post-pancreatoduodenectomy. METHODS Between January 2014 and December 2018, 209 consecutive patients who underwent pancreatoduodenectomy in our institute were retrospectively analyzed. Drain monitoring with contrast imaging was performed in 47 of the cases. We classified drain contrast type into three categories and evaluated postoperative outcome in each group: (1) fistulous tract group-only the fistula was contrasted; (2) fluid collection group - fluid collection connected to the drain fistula; and (3) pancreatico-anastomotic fistula group-fistula connected to the digestive tract. RESULTS The durations of postoperative hospital stay and drainage were significantly shorter in the fistulous tract group than in the fluid collection group (31 vs. 46 days, p = 0.0026; and 12 vs. 38 days, p < 0.0001, respectively). The cost and number of drain exchanges were significantly lower in the fistulous tract group than in the fluid collection group ($163.6 vs. 467.5, p < 0.0001; and 1 vs. 5.5, p < 0.0001, respectively). Notably, no patient had grade C postoperative pancreatic fistula. CONCLUSION Classification of prophylactic drain contrast type can aid in predicting outcomes of clinically relevant postoperative pancreatic fistulas and optimizing drainage management.
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Affiliation(s)
- Hiroki Kushiya
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
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Chen YF, Hsu CP, Hsu JT, Huang CW, Fu CY, Kuo IM, Chen MY, Chang SC, Wang SY, Yeh CN, Hwang TL. Impact of the highest amylase level in drain fluid on surgical outcomes and postoperative interventions in patients undergoing pancreaticoduodenectomy. Asian J Surg 2021; 44:1151-1157. [PMID: 33674183 DOI: 10.1016/j.asjsur.2021.01.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/06/2021] [Accepted: 01/31/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The clinical significance of the highest drain fluid amylase (DFA) level beyond pancreaticoduodenectomy (PD) postoperative day three (POD 3) remains unclear. This study investigated the impact of highest DFA level beyond POD 3 on postoperative pancreatic fistula (POPF) severity and outcomes of patients undergoing PD with POPF. METHODS Patient demographics of biochemical POPF and clinically relevant POPF (CR-POPF) were compared. Predictive factors were assessed using binary logistic regression. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of highest DFA (beyond POD 3). We compared length of hospital stay, surgical mortality rates, and need for postoperative interventions by highest DFA level. RESULTS Patients with CR-POPF had an older age (p = 0.039), required intraoperative blood transfusion (p = 0.006), and had greater highest DFA levels (p = 0.001) than those with biochemical POPF. The optimal highest DFA cutoff was 2014.5 U/L. Multivariate analysis showed that percentage of patients with intraoperative blood transfusion (p = 0.011; odds ratio, 3.716) and a highest DFA > 2014.5 U/L beyond POD 3 (p = 0.001; odds ratio, 5.722) was predictive of CR-POPF. CONCLUSION Highest DFA > 2014.5 U/L beyond POD 3 is an independent predictor for CR-POPF. At a highest DFA >2014.5 U/L, 30-day surgical mortality rate, length of stay, and need for postoperative interventions did not differ.
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Affiliation(s)
- Yi-Fu Chen
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Chun-Wei Huang
- Department of General Surgery, New Taipei Municipal Tucheng Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - I-Ming Kuo
- Department of General Surgery, New Taipei Municipal Tucheng Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Yang Chen
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shih-Chun Chang
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shang-Yu Wang
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Nan Yeh
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsann-Long Hwang
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Meng L, Cai H, Cai Y, Li Y, Peng B. Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center's preliminary experience. BMC Surg 2021; 21:70. [PMID: 33530951 PMCID: PMC7856715 DOI: 10.1186/s12893-021-01076-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/26/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD). METHODS We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications. RESULTS No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02). CONCLUSIONS Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.
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Affiliation(s)
- Lingwei Meng
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - He Cai
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Yongbin Li
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.
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Mutignani M, Bonato G, Dioscoridi L, Mazzola M, Cintolo M, Pugliese F, Rosa R, Italia A, Ferrari G, Forti E. Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience. Surg Endosc 2021; 35:1908-1914. [PMID: 33403464 DOI: 10.1007/s00464-020-08199-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/17/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIM Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions. METHODS It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted. RESULTS We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8 days (range 2-10). During the follow-up interval, no leak recurrences were observed. CONCLUSIONS Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.
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Affiliation(s)
- Massimiliano Mutignani
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giulia Bonato
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Lorenzo Dioscoridi
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Michele Mazzola
- Department of Oncologic and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marcello Cintolo
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Francesco Pugliese
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Roberto Rosa
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Angelo Italia
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giovanni Ferrari
- Department of Oncologic and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
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Chao J, Zhu C, Jia Z, Zhang X, Qin X. Prophylactic active irrigation drainage reduces the risk of post-operative pancreatic fistula-related complications in patients undergoing limited pancreatic resection. J Minim Access Surg 2021; 17:197-201. [PMID: 33047685 PMCID: PMC8083757 DOI: 10.4103/jmas.jmas_290_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective of this study is to evaluate the efficacy of prophylactic active irrigation drainage in preventing post-operative pancreatic fistula (POPF) and POPF-related complications in patients undergoing limited pancreatic resection (LPR). Materials and Methods: Patients who underwent LPR for benign or borderline pancreatic lesions between February 2014 and March 2019 were enroled in this retrospective study. Patients were divided into two groups according to the type of intraperitoneal drainage used: closed-suction drainage (CSD) or continuous active irrigation drainage (CAID). Data regarding the outcomes and complications of surgery were collected and analysed. Results: A total of 50 patients (33 women; age, 50.1 ± 10.8 years) were included in this study. Twenty-nine patients were treated with CSD, and 21 patients were treated with CAID. Clinically relevant POPF and POPF-related complications occurred in 11 patients in the CSD group and in two patients in the CAID group (P = 0.024). Patients in the CSD group demonstrated a longer tube indwelling time than those in the CAID group (17.1 ± 10.2 days vs. 13.7 ± 7.5 days; P = 0.044). Mean post-operative hospital stay was also longer in the CSD group than in the CAID group (20.6 ± 7.9 days vs. 16.1 ± 6.3 days; P = 0.039). Conclusions: Prophylactic CAID appears to be an effective alternative for the management of POPF and POPF-related complications in patients undergoing LPR.
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Affiliation(s)
- Jiadeng Chao
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Chunfu Zhu
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Zhongzhi Jia
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Xudong Zhang
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Xihu Qin
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
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Takeda Y, Saiura A, Inoue Y, Mise Y, Ishizawa T, Takahashi Y, Ito H. Early Fistulography Can Predict Whether Biochemical Leakage Develops to Clinically Relevant Postoperative Pancreatic Fistula. World J Surg 2020; 44:1252-1259. [PMID: 31820055 DOI: 10.1007/s00268-019-05315-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND As complete prevention of postoperative pancreatic fistula (POPF) after pancreatic surgery remains difficult, many risk factors for clinically relevant POPF (CR-POPF) have been reported. However, their clinical impact could be limited because all previous reports included patients without biochemical leakage (BL) that rarely developed to CR-POPF. Therefore, a new strategy for identifying high-risk patients who develop delayed complications from patients with confirmed BL and for implementing interventions for such patients in the early postoperative period is required. This study aimed to examine the role of fistulography in predicting CR-POPF from confirmed BL. METHODS Consecutive patients diagnosed with BL on postoperative day 3 after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from January 2013 to June 2015 in our institution were included. Fistulography was performed 1 week after the operation, and the associations between findings on fistulography and delayed complications associated with POPF were evaluated. RESULTS Eighty-four (37%) of 227 patients who underwent PD and 45 (48%) of 94 patients who underwent DP were included and divided to two groups according to fistulographic findings (simple type, n = 107, 83%; cavity type, n = 22, 17%). The latter finding was associated with a greater morbidity rate (Clavien-Dindo grade ≥ 2: 36% vs 59%, p = 0.018) and a worse final POPF grade (B/C 64% vs 95%, p = 0.003). In the multivariate analysis, cavity type on fistulography was a significant predictive factor for grade B/C POPF. CONCLUSIONS Fistulography is a useful examination for identifying patients with a high risk of developing delayed complications associated with POPF.
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Affiliation(s)
- Yoshinori Takeda
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akio Saiura
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan. .,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Yosuke Inoue
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan.,Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Takeaki Ishizawa
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Hiromichi Ito
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
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Takeda Y, Saiura A, Takahashi Y, Inoue Y, Mise Y, Ito H. Conservative drain management increases the incidence of grade B postoperative pancreatic fistula without increasing serious complications: Does persistent drainage reflect the quality of pancreatic surgery or institutional policy? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:1011-1018. [PMID: 33052623 DOI: 10.1002/jhbp.838] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/30/2020] [Accepted: 09/20/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Among grade B/C postoperative pancreatic fistula (POPF), the clinical burden of patients treated with persistent drainage alone was reported to be less. As the clinical difference might depend on drain management, we evaluated their clinical burden under conservative drain management. METHODS We included 292 patients who underwent pancreaticoduodenectomy or distal pancreatectomy between 2013 and 2015. Patients with grade B POPF were categorized into those receiving persistent drainage alone (B-drain) and those receiving other treatments (B-other). The clinical burden of these groups and patients with biochemical leakage (BL) was compared. RESULTS BL, grade B POPF, and grade C POPF occurred in 42 (14%), 93 (32%), and 4 (1.4%) patients, respectively. The B-drain group comprised 61% of grade B POPF. The overall major morbidity (Clavien-Dindo grade ≥ 3) in the B-drain group was significantly lower than in the B-other group (18% vs 50%, P = .001) but was comparable to that of the BL group (19%, P = .848). The POPF-related major morbidity in the B-drain and B-other group were 0% and 25%, respectively (P < .001). CONCLUSIONS Under conservative drain management, patients with grade B POPF frequently experienced persistent drainage alone and the clinical burden of B-drain group and BL group was comparable.
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Affiliation(s)
- Yoshinori Takeda
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary and Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary and Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Department of Hepatobiliary and Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiromichi Ito
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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30
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Caputo D, Angeletti S, Ciccozzi M, Cartillone M, Cascone C, La Vaccara V, Coppola A, Coppola R. Role of drain amylase levels assay and routinary postoperative day 3 abdominal CT scan in prevention of complications and management of surgical drains after pancreaticoduodenectomy. Updates Surg 2020; 72:727-741. [PMID: 32410161 DOI: 10.1007/s13304-020-00784-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/02/2020] [Indexed: 12/21/2022]
Abstract
To asses drains amylase (DA) cut-offs for the risk of clinically relevant postoperative pancreatic fistula (POPF) and define the optimal timing of drains removal based on daily DA assay and abdominal CT scan finding after pancreatoduodenectomy (PD). Different algorithms able to identify patients at higher risk of POPF and to assess the optimal time for drains removal after PD have been proposed. The most accurate DA cut-offs in the assessment of the risk of clinically relevant POPF were retrospectively identified. Data from a prospective trial for optimal timing of drains removal were analyzed. Then, to validate the cut-offs identified in the first phase, they were applied to the patients enrolled in the prospective trial. Patients with POD1 DA ≥ 666 U/L were at higher risk of clinically relevant POPF (p 0.0001). POD3 DA value ≥ 252 U/L predicted 88% of clinical relevant fistulas. POD3 DA level ≥ 207 U/L was able to predict 68% of biliary fistulas. Patients with abdominal collection ≥ 5 cm, showed a significantly higher rate (60% vs. 23%, p < 0.001) of biliary fistula. Timing of drains removal did not influence complications. Drains amylase levels predict clinically relevant POPF. Drains should be maintained up to POD3; in case of POD1 DA levels < 666 U/L and POD3 DA levels < 252 U/L drains could be removed. In case of POD3 DA levels, ≥ 207 the routine use of abdominal CT scan in the same day could be justified to detect collections ≥ 5 cm and maintain drains beyond the POD3.
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Affiliation(s)
- Damiano Caputo
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico of Rome, Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistic and Molecular Epidemiology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Mariacristina Cartillone
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Chiara Cascone
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Vincenzo La Vaccara
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Alessandro Coppola
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Roberto Coppola
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
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Smits FJ, Henry AC, van Eijck CH, Besselink MG, Busch OR, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IHM, Bosscha K, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IH, Kazemier G, Liem M, van der Kolk BM, de Meijer VE, Patijn GA, Roos D, Schreinemakers JM, Wit F, van Werkhoven CH, Molenaar IQ, van Santvoort HC. Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster-randomized trial. Trials 2020; 21:389. [PMID: 32381031 PMCID: PMC7206814 DOI: 10.1186/s13063-020-4167-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/12/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreatic resection is a major abdominal operation with 50% risk of postoperative complications. A common complication is pancreatic fistula, which may have severe clinical consequences such as postoperative bleeding, organ failure and death. The objective of this study is to investigate whether implementation of an algorithm for early detection and minimally invasive management of pancreatic fistula may improve outcomes after pancreatic resection. METHODS This is a nationwide stepped-wedge, cluster-randomized, superiority trial, designed in adherence to the Consolidated Standards of Reporting Trials (CONSORT) guidelines. During a period of 22 months, all Dutch centers performing pancreatic surgery will cross over in a randomized order from current practice to best practice according to the algorithm. This evidence-based and consensus-based algorithm will provide daily multilevel advice on the management of patients after pancreatic resection (i.e. indication for abdominal imaging, antibiotic treatment, percutaneous drainage and removal of abdominal drains). The algorithm is designed to aid early detection and minimally invasive step-up management of postoperative pancreatic fistula. Outcomes of current practice will be compared with outcomes after implementation of the algorithm. The primary outcome is a composite of major complications (i.e. post-pancreatectomy bleeding, new-onset organ failure and death) and will be measured in a sample size of at least 1600 patients undergoing pancreatic resection. Secondary endpoints include the individual components of the primary endpoint and other clinical outcomes, healthcare resource utilization and costs analysis. Follow up will be up to 90 days after pancreatic resection. DISCUSSION It is hypothesized that a structured nationwide implementation of a dedicated algorithm for early detection and minimally invasive step-up management of postoperative pancreatic fistula will reduce the risk of major complications and death after pancreatic resection, as compared to current practice. TRIAL REGISTRATION Netherlands Trial Register: NL 6671. Registered on 16 December 2017.
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Affiliation(s)
- F. Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | | | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark Arntz
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas L. Bollen
- Department of Radiology, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
| | - Otto M. van Delden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Krijn P. van Lienden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inne H. M. Borel Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Ziekenhuis, ´s-Hertogenbosch, The Netherlands
| | - R. M. van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - B. Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Mike Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs A. Patijn
- Department of Surgery, Isala Ziekenhuis, Zwolle, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
| | - C. Henri van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA The Netherlands
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Jeroen Bosch Ziekenhuis, ´s-Hertogenbosch, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, The Netherlands
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Surgery, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Isala Ziekenhuis, Zwolle, The Netherlands
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
- Department of Surgery, Amphia Ziekenhuis, Breda, The Netherlands
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Cai J, Ramanathan R, Zenati MS, Al Abbas A, Hogg ME, Zeh HJ, Zureikat AH. Robotic Pancreaticoduodenectomy Is Associated with Decreased Clinically Relevant Pancreatic Fistulas: a Propensity-Matched Analysis. J Gastrointest Surg 2020; 24:1111-1118. [PMID: 31267434 DOI: 10.1007/s11605-019-04274-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) is a major complication that adversely affects recovery. The robotic approach may decrease the incidence of this complication. This propensity-matched analysis evaluates the impact of robotic PD (RPD) on CR-POPF. METHODS Patients undergoing PD after the learning curve at a high-volume academic medical center were reviewed. CR-POPF outcomes after open PD (OPD) and RPD were compared. Logistic regression and propensity score matching (PSM) were used to define the independent effect of RPD on CR-POPF. RESULTS Of 865 PDs performed over the study period, 405 (46.8%) were OPD and 460 (53.2%) were RPD. RPD was associated with a similar overall POPF rate, but a lower incidence of CR-POPF (6.7% vs. 15.8%, p < 0.001). On multivariate analysis, RPD was an independent predictor of lower CR-POPF (OR 0.278, p < 0.001). Following propensity matching, RPD continued to be protective against the occurrence of CR-POPF (coefficient = - 0.113, p = 0.001). CONCLUSIONS This is the largest single-center PSM analysis to evaluate the impact of robotic approach on pancreatoduodenectomy and suggests that RPD can minimize the clinical impact of pancreatic leaks after PD.
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Affiliation(s)
- Jianpeng Cai
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rajesh Ramanathan
- Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA
| | - Mazen S Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amr Al Abbas
- Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore Hospital, Chicago, IL, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA.
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Xu W, Peng X, Jiang B. Hypoalbuminemia after pancreaticoduodenectomy does not predict or affect short-term postoperative prognosis. BMC Surg 2020; 20:72. [PMID: 32293409 PMCID: PMC7161192 DOI: 10.1186/s12893-020-00739-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 04/06/2020] [Indexed: 02/08/2023] Open
Abstract
Background Hypoalbuminemia (HA) is a risk factor for the complications following pancreaticoduodenectomy (PD). This study aimed to explore the factors that affect HA following PD and evaluate the influence of HA on the short-term postoperative prognosis. Methods: Total 163 patients who underwent PD and met inclusion criteria were subdivided into two groups according to the status of HA. The relationships of postoperative albumin (ALB) level and exogenous ALB infusion with postoperative responses and complications were assessed by correlation analysis. Results Preoperative ALB ≥35.0 g/L and postoperative complication grade were factors influencing HA after PD. Correlation analysis demonstrated significant negative correlation of postoperative ALB level with white blood cell (WBC) count and neutrophil count. Postoperative exogenous ALB infusion positively correlated with blood urea nitrogen, creatinine, complication grade, postoperative intraperitoneal hemorrhage and pancreatic fistula. No significant differences were observed between the complications and30-day mortality rates with and without postoperative HA. Conclusions HA after PD should not be considered as an indicator but rather a result of poor prognosis. WBCs, especially neutrophils, are involved in reducing postoperative ALB level. Infusion of exogenous ALB to maintain ALB > 30 g/L could not improve clinical outcomes.
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Affiliation(s)
- Wei Xu
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Hospital Affiliated with Hunan Normal University, No. 61 West Jiefang Road, Changsha, 410005, China
| | - Xiangqun Peng
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Hospital Affiliated with Hunan Normal University, No. 61 West Jiefang Road, Changsha, 410005, China
| | - Bo Jiang
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Hospital Affiliated with Hunan Normal University, No. 61 West Jiefang Road, Changsha, 410005, China.
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Handaya AY, Fauzi AR, Werdana VAP. Tapering pressure of wall vacuum-assisted closure for the treatment of patients with pancreatic fistula in traumatic pancreatic injury: Report of two cases. Int J Surg Case Rep 2020; 68:158-161. [PMID: 32163905 PMCID: PMC7063329 DOI: 10.1016/j.ijscr.2020.02.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
Postoperative pancreatic fistula is a nightmare for digestive surgeons. Requires complex treatment and a long duration of hospitalization of patients with a large cost burden. VAC using wall suction with NPWT principle can be used to treat patients with complex wounds. A simple and easy procedure with good outcomes. Introduction Traumatic injury to the pancreas is rare and difficult to diagnose, requiring immediate operative management. It also has high mortality and morbidity rates. Postoperative pancreatic fistula is one of the complications that is considered a nightmare for digestive surgeons. The prevalence of POPF is estimated at 13%–41%, with 28% of mortality rate and the most common cause of death is retroperitoneal sepsis and hemorrhage. It requires complex treatment and a long duration of hospitalization of patients with a large cost burden. Presentation of case Here we report 2 cases of POPF after pancreatic injury in abdominal trauma. The patients underwent emergency laparotomy. In the hospital ward, the patients developed wound dehiscence and a clear viscous pancreatic juice came out from the wound with high output. The installation of wall VAC using wall suction with pressure adjustments according to the number of products per day was performed. The patients showed good outcomes, the pancreatic juice output decreased and diminished, and the wound also narrowed and closed. Discussion VAC using wall suction is a device that applies the technique of NPWT and an emerging procedure used to treat patients with complex wounds. NPWT can reduce pooling of fluid, while reducing shear stress and tissue hypoxia at the wound edges, and stimulating the release of vascular endothelial growth factor in wound milieu. Conclusions Tapering pressure of VAC using wall suction for treatment of pancreatic fistula in post laparotomy pancreatic injury patients is a simple and easy procedure with good outcomes.
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Affiliation(s)
- Adeodatus Yuda Handaya
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta 55281, Indonesia.
| | - Aditya Rifqi Fauzi
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta 55281, Indonesia.
| | - Victor Agastya Pramudya Werdana
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta 55281, Indonesia.
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Shao X, Xie Y, Xu Q, Sun A, Wang Z, Tian Y. A New Feasible Technique for Polytetrafluoroethylene Suture Buttress-Reinforced Pancreaticojejunostomy (PBRP): Mechanical Analysis and a Prospective, Randomized Controlled Trial. J Gastrointest Surg 2019; 23:1825-1833. [PMID: 30511130 DOI: 10.1007/s11605-018-4059-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/15/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) is a major concern after pancreatoduodenectomy (PD). We recently designed a new anastomotic method to reduce the rate of pancreatic fistula: polytetrafluoroethylene suture buttress-reinforced pancreaticojejunostomy (PBRP). METHODS An animal model and a computer simulation were used to measure the maximum stress and tensile strength of the pancreas with and without the suture buttresses. Then, a randomized controlled trial (RCT) was performed to compare the outcome of PD between patients who underwent PBRP vs traditional pancreaticojejunostomy (TP). RESULTS The maximum load in the animal model was significantly higher with the suture buttresses than without (5.47 ± 1.67 N vs 3.72 ± 1.36 N, p < 0.01), and in the computer simulation, the peak stress was lower with the suture buttresses than without (54.86 vs 486.8 MPa). There were no significant differences between the two groups in the overall frequency of POPF, but the rate of clinically relevant POPF was significantly lower in the PBRP group (2.8 vs 22.8%, p = 0.028). The pancreaticojejunostomy time was significantly longer in the PBRP group (19.57 ± 3.31 vs 17.17 ± 4.83 min, p = 0.018), and the PBRP group showed a shorter drainage tube retention duration (10 vs 12 days, p = 0.006) and postoperative hospital stay (13 d vs 15 d, p = 0.031). CONCLUSIONS PBRP is a feasible and reliable procedure for preventing clinically relevant POPF. Additional multi-institution randomized trials should be conducted to confirm these results.
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Affiliation(s)
- Xinxin Shao
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Pan Jia Yuan Nan Li, Chaoyang District, Beijing, 100021, China
- Department of Oncological Surgery, Beijing Traditional Chinese Medicine Hospital, Capital Medical University, Beijing, 100010, China
| | - Yibin Xie
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Pan Jia Yuan Nan Li, Chaoyang District, Beijing, 100021, China
| | - Quan Xu
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Pan Jia Yuan Nan Li, Chaoyang District, Beijing, 100021, China
| | - Anqiang Sun
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Zhenze Wang
- National Research Center for Rehabilitation Technical Aids, Beijing, 100176, China
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, Beijing, 100176, China
- Key Laboratory of Rehabilitation Technical Aids Technology and System of the Ministry of Civil Affairs, Beijing, 100176, China
| | - Yantao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Pan Jia Yuan Nan Li, Chaoyang District, Beijing, 100021, China.
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Clinical Implications of the 2016 International Study Group on Pancreatic Surgery Definition and Grading of Postoperative Pancreatic Fistula on 775 Consecutive Pancreatic Resections. Ann Surg 2019; 268:1069-1075. [PMID: 28678062 DOI: 10.1097/sla.0000000000002362] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of the present study was to evaluate the clinical implications of the 2016 International Study Group for Pancreatic Surgery (ISGPS) definition and classification of postoperative pancreatic fistula (POPF) using a single high-volume institutional cohort of patients undergone pancreatic surgery. BACKGROUND The ISGPS definition and grading system of POPF has been recently updated. Although the rationale for the changes was supported by previous studies, the effect of the new definition and classification scheme on surgical series has not been established. METHODS A total of 775 patients undergone pancreatic surgery in our institute from 2013 to 2015 were reviewed. The parameters modified in the ISGPS classification were analyzed according to postoperative outcomes. Finally the classification was validated by external clinical and economical outcomes. RESULTS Applying the 2016 scheme, 17.5% of patients changed classification group compared to the 2015 system. Grade B increased from 11.5% to 22.1%, whereas grade C decreased from 15.2% to 4.6%. Biochemical leak occurred in 7% of patients, and it did not differ from the non-POPF condition in terms of surgical outcomes. Non-POPF group, grades B and C POPF differed significantly in terms of intensive care unit staying (P < 0.001), length of stay (P < 0.001), readmission rate (P < 0.001), and hospital costs (P < 0.001). CONCLUSIONS The present study has confirmed the pertinence of the changes introduced in the 2016 ISGPS POPF definition and grading. This updated classification is effective in identifying three conditions that differ in terms of clinical and economic outcomes. These results suggested the reliability of the new definition and scheme in classifying POPF-related outcomes.
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Ma T, Bai X, Chen W, Lao M, Jin G, Zheng K, Fu D, Yang F, Qin R, Li X, Lou W, Zhang L, Jiang K, Wu P, Shao C, Liu A, Yang Y, Ma Y, Wu H, Liang T. Surgical management and outcome of grade-C pancreatic fistulas after pancreaticoduodenectomy: A retrospective multicenter cohort study. Int J Surg 2019; 68:27-34. [PMID: 31195148 DOI: 10.1016/j.ijsu.2019.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/13/2019] [Accepted: 05/27/2019] [Indexed: 01/06/2023]
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Li YT, Zhang HY, Xing C, Ding C, Wu WM, Liao Q, Zhang TP, Zhao YP, Dai MH. Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy. World J Gastroenterol 2019; 25:2514-2523. [PMID: 31171894 PMCID: PMC6543243 DOI: 10.3748/wjg.v25.i20.2514] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/02/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence.
AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula.
METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and long-term follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.
RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031; and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration.
CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.
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Affiliation(s)
- Ya-Tong Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Han-Yu Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Cheng Xing
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Cheng Ding
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Wen-Ming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Tai-Ping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Meng-Hua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
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Yang YY, Zhao CQ, Wang LS, Lin JX, Zhu SZ, Huang HG. A novel biopolymer device fabricated by 3D printing for simplifying procedures of pancreaticojejunostomy. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 103:109786. [PMID: 31349454 DOI: 10.1016/j.msec.2019.109786] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 05/04/2019] [Accepted: 05/20/2019] [Indexed: 12/13/2022]
Abstract
The purpose of our research was to verify the feasibility and effectiveness of a novel three-dimensional printed biopolymer device (3DP-BPD) for duct-to-mucosa pancreaticojejunostomy (PJ) in minipigs. Polylactic acid (PLA) was selected as the raw materials for 3DP-BPD. Three components of a 3DP-BPD were designed and manufactured: hollow stent, supporting disk, and nut. A pancreatic duct dilation model was developed in six minipigs. After 4 weeks, minipigs underwent operations with duct-to-mucosa PJ using 3DP-BPD. The operation time and postoperative complications were analyzed. The anastomotic sites were evaluated grossly 4 weeks and 24 weeks after PJ, and the histological evaluation of anastomotic sites was performed 24 weeks after PJ. The operation time of six stitches duct-to-mucosa PJ was 9.1 ± 1.7 min. All minipigs survived without any adverse events like postoperative pancreatic fistula (POPF). Serum C reactive protein (CRP) and procalcitonin (PCT) levels were normal, and the anastomotic sites were connected tightly on gross observation and touch at 4 weeks and 24 weeks. Histological examinations indicated that the tissues were continuous between the pancreas and the jejunum. The use of 3DP-BPD did not increase the risk of severe local inflammation and POPF. 3DP-BPD used for duct-to-mucosa PJ is more convenient and clinically feasible for pancreatoenteric reconstruction.
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Affiliation(s)
- Yuan-Yuan Yang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, PR China
| | - Chao-Qian Zhao
- Key Laboratory of Optoelectronic Materials Chemistry and Physics, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences, Fuzhou 350001, PR China
| | - Lu-Sheng Wang
- School of Computer and Information Engineering, Xiamen University of Technology, Xiamen 361000, PR China
| | - Jin-Xin Lin
- Key Laboratory of Optoelectronic Materials Chemistry and Physics, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences, Fuzhou 350001, PR China
| | - Shun-Zhi Zhu
- School of Computer and Information Engineering, Xiamen University of Technology, Xiamen 361000, PR China
| | - He-Guang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, PR China.
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Appleby Procedure (Distal Pancreatectomy With Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Indications, Outcomes, and Imaging. AJR Am J Roentgenol 2019; 213:35-44. [PMID: 30917026 DOI: 10.2214/ajr.18.20887] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE. We describe the indications, surgical technique, outcome, and imaging findings in patients with pancreatic ductal adenocarcinoma (PDAC) treated with distal pancreatectomy and celiac artery resection (modified Appleby procedure). CONCLUSION. Distal pancreatectomy and celiac artery resection is a feasible surgery in selected patients with locally advanced PDAC. Knowledge of surgical technique and imaging features may aid radiologists in identifying patients with locally invasive PDAC who might benefit from resection and identifying characteristic distal pancreatectomy and celiac artery resection complications.
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Bacterial smear test of drainage fluid after pancreaticoduodenectomy can predict postoperative pancreatic fistula. Pancreatology 2019; 19:274-279. [PMID: 30718188 DOI: 10.1016/j.pan.2019.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/21/2019] [Accepted: 01/23/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES It is widely accepted that postoperative pancreatic fistula (POPF) accompanied by bacterial infection results in a worse outcome than POPF alone. However, few studies evaluating predictive indicators of POPF have focused on bacterial infection. METHODS A consecutive 100 patients who underwent pancreaticoduodenectomy at our institute for periampullary disease were enrolled. POPF was assessed according to the International Study Group of Pancreatic Fistula consensus guidelines; grades B and C were defined as clinically relevant POPF (CR-POPF). The patients' characteristics, perioperative surgical factors, and laboratory data including the results of culture and smear testing performed using drainage fluid on postoperative days (PODs) 1 and 3 were analyzed. RESULTS The overall incidence of CR-POPF was 25%. Univariate analyses revealed that the factors associated with CR-POPF were male sex, soft pancreas, MPD diameter, higher serum C-reactive protein concentration and white blood cell count on POD 3, higher amylase concentration in drainage fluid, and culture and/or smear positivity of drainage fluid. Multivariate analysis newly revealed that the smear positivity of drainage fluid on POD 3 was the independent risk factors for CR-POPF (p = 0.027). CONCLUSIONS Smear positivity of drainage fluid on POD 3 after pancreaticoduodenectomy may be a new predictor of CR-POPF.
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EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video). Gastrointest Endosc 2019; 89:311-319.e1. [PMID: 30179609 DOI: 10.1016/j.gie.2018.08.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Postoperative pancreatic leakage and fistulae (POPF) are a leading adverse event after partial pancreatic resection. Treatment algorithms are currently not standardized. Evidence regarding the role of endoscopy is scarce. METHODS One hundred ninety-six POPF patients with (n = 132) and without (n = 64) concomitant pancreatic fluid collections (PFCs) from centers in Berlin, Kiel, and Dresden were analyzed retrospectively. Clinical resolution was used as the primary endpoint of analysis. RESULTS Analysis was stratified by the presence or absence of a PFC because these patients differed in treatment pathway and the presence of systemic inflammation with a median C-reactive protein of 30.7 mg/dL in patients without a PFC versus 131.0 mg/dL in patients with a PFC (P = 3.4 × 10-4). In patients with PFCs, EUS-guided intervention led to resolution in a median of 8 days as compared with 25 days for percutaneous drainage and 248 days for surgery (P = 3.75 × 10-14). There was a trend toward a higher success rate of EUS-guided intervention as a primary treatment modality with 85% (P = .034), followed by percutaneous drainage (64%) and surgery (41%). When applied as a rescue intervention (n = 24), EUS led to clinical resolution in 96% of cases. In patients without PFCs, EUS-guided internalization in a novel endoscopic technique led to resolution after a median of 4 days as compared with 51 days for a remaining surgical drainage (P = 9.3 × 10-9). CONCLUSIONS In this retrospective analysis, EUS-guided drainage of POPF led to a more rapid resolution. EUS may be considered as a viable option in the management of PFCs and POPF and should be evaluated in prospective studies.
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Endoscopic Transgastric Versus Surgical Approach for Infected Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech 2019; 29:141-149. [PMID: 30676541 DOI: 10.1097/sle.0000000000000632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgical approach (SA) is the standard treatment for infected necrotizing pancreatitis (INP) and endoscopic transgastric approach (ETA) is a promising alternative treatment. This systematic review and meta-analysis aimed to compare the effectiveness and safety of ETA versus SA in INP. Several databases were systematically searched for eligible studies that compared ETA with SA for INP. Predefined criteria were used for study selection. Three reviewers independently assessed the risk of bias. Primary outcomes included clinical resolution rate, short-term mortality, major complications, and hospital stay. Study-specific effect sizes and their 95% confidence interval (CI) were combined to calculate the pooled value using fixed-effects or random-effects model. Six studies were included with 295 patients. Major complication rate [odds ratio (OR), 0.13; 95% CI, 0.06-0.29], new-onset organ failure rate (OR, 0.26; 95% CI, 0.12-0.54), postoperative pancreatic fistula rate (OR, 0.09; 95% CI, 0.03-0.28), and incisional hernia rate (OR, 0.10; 95% CI, 0.01-0.85) were lower in the ETA group. There was a shorter hospital stay (mean difference, -17.72; 95% CI, -21.30 to -14.13) in the ETA group. No differences were found in clinical resolution, short-term mortality, postoperative bleeding, perforation of visceral organ, and endocrine or exocrine insufficiency. Compared with SA, ETA showed comparable effectiveness and safety for the treatment of INP based on current evidence.
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Villafane-Ferriol N, Baugh KA, McElhany AL, Van Buren G, Fang A, Tashakori EK, Reyes JEM, Cao HST, Silberfein EJ, Massarweh N, Hsu C, Barakat O, Schmidt C, Zyromski NJ, Dillhoff M, Villarreal JA, Fisher WE. Evidence Versus Practice in Early Drain Removal After Pancreatectomy. J Surg Res 2019; 236:332-339. [PMID: 30694774 DOI: 10.1016/j.jss.2018.11.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/19/2018] [Accepted: 11/21/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes. METHODS We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5. RESULTS Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P < 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P < 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P < 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy. CONCLUSIONS Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.
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Affiliation(s)
| | - Katherine A Baugh
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Amy L McElhany
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - George Van Buren
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Andrew Fang
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Erisha K Tashakori
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Jose E Mendez Reyes
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Hop S Tran Cao
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Eric J Silberfein
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Nader Massarweh
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Cary Hsu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Omar Barakat
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - Carl Schmidt
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary Dillhoff
- Department of Surgery, Ohio State University, Columbus, Ohio
| | - Joshua A Villarreal
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX
| | - William E Fisher
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX.
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Liu P, Yang Q, Zhu L. The Effects of Different Treatments on Postoperative Pancreatic Fistula (POPF). J INVEST SURG 2018; 33:491-492. [PMID: 30395737 DOI: 10.1080/08941939.2018.1529840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qin Yang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Luhong Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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Xia W, Zhou Y, Lin Y, Yu M, Yin Z, Lu X, Hou B, Jian Z. A Predictive Risk Scoring System for Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy. Med Sci Monit 2018; 24:5719-5728. [PMID: 30113999 PMCID: PMC6108272 DOI: 10.12659/msm.911499] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Postoperative pancreatic fistula remains a challenge after pancreaticoduodenectomy (PD). This study aimed to establish a scoring system to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after PD. Material/Methods The clinical records of 361 consecutive patients who underwent PD between 2009 and 2017 were reviewed retrospectively. Patients were divided into a study group (225 patients) and a validation group (136 patients). CR-POPF was defined and classified based on the 2016 ISGPS definition and classification system. Univariate and multivariate logistic regression analyses were performed and we thus developed a scoring system based on the regression coefficient of the multivariate logistic regression model. The predictive value was determined using the receiver operating characteristic (ROC) curve. Results A predictive scoring system with a maximum of 6 points for CR-POPF was established using the following 4 factors: 1 point for soft pancreatic texture (OR 2.09, 95%CI 1.10–3.98, P=0.025), 1.5 points for main pancreatic duct diameter ≤2.5 mm (OR 2.72, 95%CI 1.23–5.99, P=0.013), 0.5 points for extended lymphadenectomy (OR 1.57, 95%CI 1.13–2.18, P=0.007), 0.5 points for a 25–30 g/L postoperative day 1 serum albumin (OR 1.43, 95%CI 1.02–2.00, P=0.037), and 3 points for postoperative day 1 serum albumin ≤25 g/L (OR 5.12, 95%CI 1.82–14.41, P=0.002). The ROC curve showed that this scoring system was highly predictive for CR-POPF in the validation group (AUC=0.806, 95%CI: 0.735–0.878). Conclusions This 6-point risk scoring system will be useful for perioperative risk management of CR-POPF.
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Affiliation(s)
- Wuzheng Xia
- Southern Medical University, Guangzhou, Guangdong, China (mainland).,Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Yu Zhou
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Ye Lin
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Min Yu
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Zi Yin
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Xin Lu
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Baohua Hou
- Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
| | - Zhixiang Jian
- Southern Medical University, Guangzhou, Guangdong, China (mainland).,Department of General Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China (mainland)
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Sahakian AB, Jayaram P, Marx MV, Matsushima K, Park C, Buxbaum JL. Metallic coil and N-butyl-2-cyanoacrylate for closure of pancreatic duct leak (with video). Gastrointest Endosc 2018; 87:1122-1125. [PMID: 28843585 DOI: 10.1016/j.gie.2017.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 08/06/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pancreatic fistula is a challenging yet common adverse event of partial pancreatectomy. Our objective is to determine the feasibility of endoscopic closure of a pancreatic fistula using a combination of a metallic coil and N-butyl-2-cyanoacrylate (NBCA) glue. METHODS A patient with a postoperative pancreatic stump leak recalcitrant to conservative management and pancreatic duct stent placement underwent endoscopic/fluoroscopic placement of a metallic coil in the pancreatic duct followed by injection of .5 mL NBCA and lipiodol mixture directed at the coil. The patient's clinical condition, Jackson-Pratt (JP) drain output, and pancreatic enzyme content were monitored daily after the procedure. RESULTS The patient's clinical condition improved. JP drain output and amylase/lipase levels progressively decreased to resolution within 7 days of the procedure. No adverse events occurred as a result of the procedure. CONCLUSIONS Endoscopic closure of pancreatic fistula with a metallic coil and NBCA glue is feasible and may be a useful modality for treatment of refractory postpancreatectomy-related fistula.
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Affiliation(s)
- Ara B Sahakian
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Preeth Jayaram
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - M Victoria Marx
- Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Caroline Park
- Division of Acute Care Surgery, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Major pancreatic resections: normal postoperative findings and complications. Insights Imaging 2018; 9:173-187. [PMID: 29450852 PMCID: PMC5893491 DOI: 10.1007/s13244-018-0595-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 12/11/2022] Open
Abstract
Objectives (1) To illustrate and describe the main types of pancreatic surgery; (2) to discuss the normal findings after pancreatic surgery; (3) to review the main complications and their radiological findings. Background Despite the decreased postoperative mortality, morbidity still remains high resulting in longer hospitalisations and greater costs. Imaging findings following major pancreatic resections can be broadly divided into “normal postoperative alterations” and real complications. The former should regress within a few months whereas complications may be life-threatening and should be promptly identified and treated. Imaging findings CT is the most effective postoperative imaging technique. MRI and fluoroscopy are used less often and only in specific cases such as assessing the gastro-intestinal function or the biliary tree. The most common normal postoperative findings are pneumobilia, perivascular cuffing, fluid collections, lymphadenopathy, acute anastomotic oedema and stranding of the peri-pancreatic/mesenteric fat. Imaging depicts the anastomoses and the new postoperative anatomy. It can also demonstrate early and late complications: pancreatic fistula, haemorrhage, delayed gastric emptying, hepatic infarction, acute pancreatitis of the remnant, porto-mesenteric thrombosis, abscess, biliary anastomotic leaks, anastomotic stenosis and local recurrence. Conclusions Radiologists should be aware of surgical procedures, postoperative anatomy and normal postoperative imaging findings to better detect complications and recurrent disease. Teaching Points • Morbidity after pancreatic resections is high. • CT is the most effective postoperative imaging technique. • Imaging depicts the anastomoses and the new postoperative anatomy. • Pancreatic fistula is the most common complication after partial pancreatic resection.
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Pulvirenti A, Ramera M, Bassi C. Modifications in the International Study Group for Pancreatic Surgery (ISGPS) definition of postoperative pancreatic fistula. Transl Gastroenterol Hepatol 2017; 2:107. [PMID: 29354764 DOI: 10.21037/tgh.2017.11.14] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 11/23/2017] [Indexed: 12/18/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) remains the major postoperative cause of morbidity and mortality following pancreatic surgery. Since 2005, the International Study Group of Pancreatic Fistula (ISGPF) definition and classification has been adopted worldwide allowing the comparison among different surgical approaches and mitigation strategies. Over the last 11 years, several limitations have emerged from clinical practice and in 2016 the International Study Group for Pancreatic Surgery (ISGPS) updated the POPF definition and grading system. Objectives of this review article were to summarize modifications in the updated ISGPS definition and to illustrate their clinical impact.
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Affiliation(s)
- Alessandra Pulvirenti
- Pancreas Surgery Unit of Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Marco Ramera
- Pancreas Surgery Unit of Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Pancreas Surgery Unit of Pancreas Institute, Verona University Hospital, Verona, Italy
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