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Cioltean CL, Bartoș A, Muntean L, Brânzilă S, Iancu I, Pojoga C, Breazu C, Cornel I. The Learning Curve for Pancreaticoduodenectomy: The Experience of a Single Surgeon. Life (Basel) 2024; 14:549. [PMID: 38792572 PMCID: PMC11122127 DOI: 10.3390/life14050549] [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: 03/24/2024] [Revised: 04/18/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND AND AIMS Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process. METHODS We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). RESULTS The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. CONCLUSIONS Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.
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Affiliation(s)
- Cristian Liviu Cioltean
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.L.C.); (I.C.)
- Department of Surgery, Satu Mare County Emergency Hospital, 440192 Satu Mare, Romania
| | - Adrian Bartoș
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.L.C.); (I.C.)
- Department of Surgery, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
- Medicover Hospital, 407062 Cluj-Napoca, Romania; (S.B.); (I.I.)
| | - Lidia Muntean
- Department of Gastroenterology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
| | - Sandu Brânzilă
- Medicover Hospital, 407062 Cluj-Napoca, Romania; (S.B.); (I.I.)
| | - Ioana Iancu
- Medicover Hospital, 407062 Cluj-Napoca, Romania; (S.B.); (I.I.)
| | - Cristina Pojoga
- Department of Gastroenterology, Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania;
- Department of Clinical Psychology and Psychotherapy, Babeș-Bolyai University (UBB Med), 400015 Cluj-Napoca, Romania
| | - Caius Breazu
- Department of ICU, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
- Department of ICU, Cluj-Napoca County Emergency Hospital, 400006 Cluj-Napoca, Romania
| | - Iancu Cornel
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania; (C.L.C.); (I.C.)
- Department of Surgery, Satu Mare County Emergency Hospital, 440192 Satu Mare, Romania
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Yu ZH, Du MM, Zhang X, Suo JJ, Zeng T, Xie XL, Xiao W, Lu QB, Liu YX, Yao HW. The impact of preoperative biliary drainage on postoperative healthcare-associated infections and clinical outcomes following pancreaticoduodenectomy: a ten-year retrospective analysis. BMC Infect Dis 2024; 24:361. [PMID: 38549089 PMCID: PMC10979617 DOI: 10.1186/s12879-024-09246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/22/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a complex procedure and easily accompanied by healthcare-associated infections (HAIs). This study aimed to assess the impact of PBD on postoperative infections and clinical outcomes in PD patients. METHODS The retrospective cohort study were conducted in a tertiary hospital from January 2013 to December 2022. Clinical and epidemiological data were collected from HAIs surveillance system and analyzed. RESULTS Among 2842 patients who underwent PD, 247 (8.7%) were diagnosed with HAIs, with surgical site infection being the most frequent type (n = 177, 71.7%). A total of 369 pathogenic strains were detected, with Klebsiella pneumoniae having the highest proportion, followed by Enterococcu and Escherichia coli. Although no significant association were observed generally between PBD and postoperative HAIs, subgroup analysis revealed that PBD was associated with postoperative HAIs in patients undergoing robotic PD (aRR = 2.174; 95% CI:1.011-4.674; P = 0.047). Prolonging the interval between PBD and PD could reduce postoperative HAIs in patients with cholangiocarcinoma (≥4 week: aRR = 0.292, 95% CI 0.100-0.853; P = 0.024) and robotic PD (≤2 week: aRR = 3.058, 95% CI 1.178-7.940; P = 0.022). PBD was also found to increase transfer of patients to ICU (aRR = 1.351; 95% CI 1.119-1.632; P = 0.002), extended length of stay (P < 0.001) and postoperative length of stay (P = 0.004). CONCLUSION PBD does not exhibit a significant association with postoperative HAIs or other outcomes. However, the implementation of robotic PD, along with a suitable extension of the interval between PBD and PD, appear to confer advantages concerning patients' physiological recuperation. These observations suggest potential strategies that may contribute to enhanced patient outcomes.
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Affiliation(s)
- Zheng-Hao Yu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
- Medical School of Chinese PLA, Beijing, P. R. China
| | - Ming-Mei Du
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Xuan Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
- Institute of Hepatobiliary Surgery of Chinese PLA, Beijing, P. R. China
| | - Ji-Jiang Suo
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China
| | - Tao Zeng
- Medical School of Chinese PLA, Beijing, P. R. China
- Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital, Beijing, P. R. China
| | - Xiao-Lian Xie
- Department of Central Sterile Supply, Ningxia People's Armed Police Corps Hospital, Yinchuan, P. R. China
| | - Wei Xiao
- Department Of Hospital Infection-Control, Lanzhou University Second Hospital, Gansu, P. R. China
| | - Qing-Bin Lu
- Department of Laboratorial Science and Technology, School of Public Health, Peking University, 38 Xue-Yuan Road, Haidian District, Beijing, 100191, P. R. China.
| | - Yun-Xi Liu
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
| | - Hong-Wu Yao
- Department of Disease Prevention and Control, The First Medical Center, Chinese PLA General Hospital, 28 Fu-Xing Road, Haidian District, Beijing, 100853, P. R. China.
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Ikuta S, Fujikawa M, Nakajima T, Kasai M, Aihara T, Yamanaka N. Machine learning approach to predict postpancreatectomy hemorrhage following pancreaticoduodenectomy: a retrospective study. Langenbecks Arch Surg 2024; 409:29. [PMID: 38183456 DOI: 10.1007/s00423-023-03223-6] [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: 08/18/2023] [Accepted: 12/29/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a rare yet dreaded complication following pancreaticoduodenectomy (PD). This retrospective study aimed to explore a machine learning (ML) model for predicting PPH in PD patients. METHODS A total of 284 patients who underwent open PD at our institute were included in the analysis. To address the issue of imbalanced data, the adaptive synthetic sampling (ADASYN) technique was employed. The best-performing ML model was selected using the PyCaret library in Python and evaluated based on recall, precision, and F1 score metrics. In addition to assessing the model's performance on the test data, bootstrap validation (n = 1000) with the original dataset was conducted. RESULTS PPH occurred in 11 patients (3.9%), with a median onset time of 22 days postoperatively. These minority cases were oversampled to 85 using ADASYN. The extra trees classifier demonstrated superior performance with recall, precision, and F1 score of 0.967, 0.914, and 0.937, respectively. Both validation using the test data and bootstrap resampling consistently demonstrated recall, precision, and F1 score exceeding 0.9. The model identified the peak value of C-reactive protein during the first 7 postoperative days as the most significant feature, followed by the preoperative neutrophil-to-lymphocyte ratio. CONCLUSIONS This study highlights the potential of the ML approach to predict PPH occurrence following PD. Vigilance and early interventions guided by such model predictions could positively impact outcomes for high-risk patients.
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Affiliation(s)
- Shinichi Ikuta
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan.
| | - Masataka Fujikawa
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Takayoshi Nakajima
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Tsukasa Aihara
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Naoki Yamanaka
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
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Jain AJ, Maxwell JE, Katz MHG, Snyder RA. Surgical Considerations for Neoadjuvant Therapy for Pancreatic Adenocarcinoma. Cancers (Basel) 2023; 15:4174. [PMID: 37627202 PMCID: PMC10453019 DOI: 10.3390/cancers15164174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a challenging disease process with a 5-year survival rate of only 11%. Neoadjuvant therapy in patients with localized pancreatic cancer has multiple theoretical benefits, including improved patient selection for surgery, early delivery of systemic therapy, and assessment of response to therapy. Herein, we review key surgical considerations when selecting patients for neoadjuvant therapy and curative-intent resection. Accurate determination of resectability at diagnosis is critical and should be based on not only anatomic criteria but also biologic and clinical criteria to determine optimal treatment sequencing. Borderline resectable or locally advanced pancreatic cancer is best treated with neoadjuvant therapy and resection, including vascular resection and reconstruction when appropriate. Lastly, providing nutritional, prehabilitation, and supportive care interventions to improve patient fitness prior to surgical intervention and adequately address the adverse effects of therapy is critical.
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Affiliation(s)
| | | | | | - Rebecca A. Snyder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.J.J.)
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Balzano G, Zerbi A, Aleotti F, Capretti G, Melzi R, Pecorelli N, Mercalli A, Nano R, Magistretti P, Gavazzi F, De Cobelli F, Poretti D, Scavini M, Molinari C, Partelli S, Crippa S, Maffi P, Falconi M, Piemonti L. Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial. Ann Surg 2023; 277:894-903. [PMID: 36177837 PMCID: PMC10174105 DOI: 10.1097/sla.0000000000005713] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with islet autotransplantation (IAT) in patients at high risk of postoperative pancreatic fistula (POPF). BACKGROUND Criteria to predict the risk of POPF occurrence after PD are available. However, even when a high risk of POPF is predicted, TP is not currently accepted as an alternative to PD, because of its severe consequences on glycaemic control. Combining IAT with TP may mitigate such consequences. METHODS Randomized, open-label, controlled, bicentric trial (NCT01346098). Candidates for PD at high-risk pancreatic anastomosis (ie, soft pancreas and duct diameter ≤3 mm) were randomly assigned (1:1) to undergo either PD or TP-IAT. The primary endpoint was the incidence of complications within 90 days after surgery. RESULTS Between 2010 and 2019, 61 patients were assigned to PD (n=31) or TP-IAT (n=30). In the intention-to-treat analysis, morbidity rate was 90·3% after PD and 60% after TP-IAT ( P =0.008). According to complications' severity, PD was associated with an increased risk of grade ≥2 [odds ratio (OR)=7.64 (95% CI: 1.35-43.3), P =0.022], while the OR for grade ≥3 complications was 2.82 (95% CI: 0.86-9.24, P =0.086). After TP-IAT, the postoperative stay was shorter [median: 10.5 vs 16.0 days; P <0.001). No differences were observed in disease-free survival, site of recurrence, disease-specific survival, and overall survival. TP-IAT was associated with a higher risk of diabetes [hazard ratio=9.1 (95% CI: 3.76-21.9), P <0.0001], but most patients maintained good metabolic control and showed sustained C-peptide production over time. CONCLUSIONS TP-IAT may become the standard treatment in candidates for PD, when a high risk of POPF is predicted.
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Affiliation(s)
- Gianpaolo Balzano
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Francesca Aleotti
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Molinari
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Partelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Maffi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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A novel refined pyroptosis and inflammasome-related genes signature for predicting prognosis and immune microenvironment in pancreatic ductal adenocarcinoma. Sci Rep 2022; 12:18384. [PMID: 36319832 PMCID: PMC9626462 DOI: 10.1038/s41598-022-22864-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 01/01/2023] Open
Abstract
Pyroptosis is an inflammatory form of cell death, which plays a key role in the development of auto-inflammation and cancer. This study aimed to construct a pyroptosis and inflammasome-related genes for predicting prognosis of the pancreatic ductal adenocarcinoma (PDAC). This study was based primarily on the one-way analysis of variance, univariate Cox regression analysis, Least absolute shrinkage and selection operator (LASSO) Cox regression, a risk-prognostic signature, gene set variation analysis (GSVA), and immune microenvironment analysis, using PDAC data from The Cancer Genome Atlas and International Cancer Genome Consortium databases for the analysis of the role of 676 pyroptosis and inflammasome-related genes in PDAC retrieved from the Reactome and GeneCards databases. Lastly, we collected six paired PDAC and matched normal adjacent tissue samples to verify the expression of signature genes by quantitative real-time PCR (qRT-PCR). We identified 18 candidate pyroptosis and inflammasome-related genes that differed significantly between pathologic grades (stages) of PDAC patients. The univariate Cox and LASSO analyses pointed to six genes as the best variables for constructing a prognostic signature, including ACTA2, C1QTNF9, DNAH8, GATM, LBP, and NGF. The results of the risk prognostic model indicated that the AUCs at 1, 3, and 5 years were greater than 0.62. GSVA revealed that 'GLYCOLYSIS', 'P53 PATHWAY', 'KRAS SIGNALING UP', and 'INFLAMMATORY RESPONSE' hallmark gene sets were associated with the risk score. The high-risk group was associated with poor prognosis and was characterized by a lower infiltration of cells involved in anti-tumor immunity; whereas the low-risk group with higher T cells, NK cells, and macrophages showed relatively better survival and significantly higher upregulation of cytolytic scores and inflammation scores. Additionally, crucial pyroptosis and inflammasome-related genes were further validated by qRT-PCR. Our study revealed the prognostic role of the pyroptosis and inflammasome-related genes in PDAC for the first time. Simultaneously, the biological and prognostic heterogeneity of PDAC had been demonstrated, deepening our molecular understanding of this tumor.
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Houghton EJ, Rubio JS. Surgical management of the postoperative complications of hepato-pancreato-biliary surgery. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220041] [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: 11/06/2022] Open
Affiliation(s)
- Eduardo Javier Houghton
- Teaching and Research Department, DAICIM Foundation, Buenos Aires, Argentina
- Surgery Division, B. Rivadavia Hospital, Buenos Aires, Argentina
- Department of Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Juan Santiago Rubio
- Solid Organ Transplant Service, Hospital de Alta Complejidad en Red El Cruce Dr. Néstor Carlos Kirchner, Buenos Aires, Argentina
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Lindholm E, Bergmann GB, Haugaa H, Labori KJ, Yaqub S, Bjørnbeth BA, Line PD, Grindheim G, Kjøsen G, Pischke SE, Tønnessen TI. Early detection of anastomotic leakage after pancreatoduodenectomy with microdialysis catheters: an observational Study. HPB (Oxford) 2022; 24:901-909. [PMID: 34836755 DOI: 10.1016/j.hpb.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 08/05/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Microdialysis catheters can detect focal inflammation and ischemia, and thereby have a potential for early detection of anastomotic leakages after pancreatoduodenectomy. The aim was to investigate whether microdialysis catheters placed near the pancreaticojejunostomy can detect leakage earlier than the current standard of care. METHODS Thirty-five patients with a median age 69 years were included. Two microdialysis catheters were placed at the end of surgery; one at the pancreaticojejunostomy, and one at the hepaticojejunostomy. Concentrations of glucose, lactate, pyruvate, and glycerol were analyzed hourly in the microdialysate during the first 24 h, and every 2-4 h thereafter. RESULTS Seven patients with postoperative pancreatic fistulae (POPF) had significantly higher glycerol levels (P < 0.01) in the microdialysate already in the first postoperative samples. Glycerol concentrations >400 μmol/L during the first 12 postoperative hours detected patients with POPF with a sensitivity of 100% and a specificity of 93% (P < 0.001). After 24 h, lactate and lactate-to-pyruvate ratio were significantly higher (P < 0.05) and glucose was significantly lower (P < 0.05) in patients with POPF. CONCLUSION High levels of glycerol in microdialysate was an early detector of POPF. The subsequent inflammation was detected as increase in lactate and lactate-to-pyruvate ratio and a decrease in glucose (NCT03627559).
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Affiliation(s)
- Espen Lindholm
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Clinic of Surgery, Vestfold Hospital Trust, 3103 Tønsberg, Norway
| | - Gisli Björn Bergmann
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway
| | - Håkon Haugaa
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Lovisenberg Diaconal University College, 0456 Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway
| | - Pål-Dag Line
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Guro Grindheim
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway
| | - Gisle Kjøsen
- Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway
| | - Søren Erik Pischke
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway; Department of Immunology, Oslo University Hospital, 0454 Oslo, Norway
| | - Tor Inge Tønnessen
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway.
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Barannikov AY, Sakhno VD, Durleshter VM, Andreev AV, Tokarenko EV. The first experience of applying a new pancreatoenteroanastomosis with a «soft» pancreatic stump in pancreatoduodenal resection. GREKOV'S BULLETIN OF SURGERY 2022. [DOI: 10.24884/0042-4625-2022-181-2-63-70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The OBJECTIVE was to improve the results of pancreatoduodenal resection by reducing the incidence of pancreatoenteroanastomotic leak and postoperative pancreatitis with a «soft» pancreatic stump.METHODS AND MATERIALS. A new method for the formation of pancreatoenteroanastomosis has been developed and implemented: precision wirsungojejunoanastomosis with additional wide atraumatic peritonization of the pancreatic stump cutoff with the loop of the small intestine. From February 2016 to March 2018, this method was tested in 18 patients.RESULTS. Pancreatoenteroanastomotic leak of class A was noted in 2 (11.1 %) patients, was transient, asymptomatic, did not require additional medical measures and did not extend the duration of the postoperative period. There were no pancreatoenteroanastomotic leak of classes B and C, pancreonecrosis of the stump, lethal outcomes. Objectively worst statistical results were obtained in the comparison group.CONCLUSION. The formation of the small intestine anastomosis with a «soft» pancreatic stump according to the proposed method for pancreatoduodenal resection reduces the incidence of postoperative pancreatitis of the stump and pancreatoenteroanastomotic leak.
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Affiliation(s)
| | - V. D. Sakhno
- Regional Clinical Hospital № 2; Kuban State Medical University
| | | | - A. V. Andreev
- Regional Clinical Hospital № 2; Kuban State Medical University
| | - E. V. Tokarenko
- Multidisciplinary Medical Center Sogaz of Gelendzhik (LLC «RN-modern technologies»)
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Lale A, Kirmizi I, Hark BD, Karahan V, Kurt R, Arikan TB, Yıldırım N, Aygen E. Predictors of Postoperative Pancreatic Fistula (POPF) After Pancreaticoduodenectomy: Clinical Significance of the Mean Platelet Volume (MPV)/Platelet Count Ratio as a New Predictor. J Gastrointest Surg 2022; 26:387-397. [PMID: 34545541 DOI: 10.1007/s11605-021-05136-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/21/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE In this study, it was aimed to determine the predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) and clinical significance of mean platelet volume (MPV)/total platelet count ratio (MPR) as a new predictor for CR-POPF. METHODS A total of 105 patients who underwent PD consecutively due to periampullary located diseases were included in the study. Patients were divided into two groups as CR-POPF and no postoperative pancreatic fistula (No-POPF). Demographic parameters, preoperative serum-based inflammatory indicators, surgical procedures, intraoperative findings, and histopathological parameters were recorded retrospectively from prospectively recorded patient files and compared between the groups. RESULTS CR-POPF occurred in 16 (15.2%) patients: 8 (7.6%) were grade B and 8 (7.6%) were grade C according to the ISGPF classification. In univariate analysis, intraoperative blood loss > 580 mL (OR: 5.25, p = 0.001), intraoperative blood transfusion (OR: 5.96, p = 0.002), intraoperative vasoconstrictor medication (OR: 4.17, p = 0.014), benign histopathology (OR: 3.51, p = 0.036), and poor differentiation in malignant tumors (OR: 4.07, p = 0.044) were significantly higher in the CR-POPF group, but not significant in multivariate analysis. Soft pancreatic consistency (OR: 6.08, p = 0.013), pancreatic duct diameter < 2.5 mm (OR: 17.15, p < 0.001), and MPR < 28.9 (OR: 13.91, p < 0.001) were the independent predictors of CR-POPF according to multivariate analysis. Neoadjuvant treatment history and simultaneous vascular resection were less likely to cause CR-POPF development; however, they were insignificant. CONCLUSION Soft pancreatic consistency, pancreatic duct diameter, and preoperative MPR were the independent predictors of CR-POPF following PD. Decreased MPR is a strong predictor for CR-POPF and should be considered when deciding treatment strategies.
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Affiliation(s)
- Azmi Lale
- Department of Surgical Oncology, Faculty of Medicine, Fırat University Medical Faculty Hospital, Elazig, 23200, Turkey.
| | - Ilter Kirmizi
- Department of Gastrointestinal Surgery, Aydin State Hospital, Aydin, Turkey
| | - Betul Dagoglu Hark
- Department of Biostatistics and Medical Informatics, School of Medicine, Firat University, Elazig, Turkey
| | - Veysel Karahan
- Department of Surgical Oncology, Faculty of Medicine, Fırat University Medical Faculty Hospital, Elazig, 23200, Turkey
| | - Remzi Kurt
- Department of Surgical Oncology, Faculty of Medicine, Fırat University Medical Faculty Hospital, Elazig, 23200, Turkey
| | - Turkmen Bahadir Arikan
- Department of General Surgery, Erciyes University Medical Faculty Hospital, Kayseri, Turkey
| | - Nilgün Yıldırım
- Department of Medical Oncology, Fırat University Medical Faculty Hospital, Elazig, Turkey
| | - Erhan Aygen
- Department of Surgical Oncology, Faculty of Medicine, Fırat University Medical Faculty Hospital, Elazig, 23200, Turkey
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Tewari M, Swain JR, Mahendran R. Update on Management Periampullary/Pancreatic Head Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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12
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Li Y, Chen L, Xing C, Ding C, Zhang H, Wang S, Long Y, Guo J, Liao Q, Zhang T, Zhao Y, Dai M. Changes in Serum Lactate Level Predict Postoperative Intra-Abdominal Infection After Pancreatic Resection. World J Surg 2021; 45:1877-1886. [PMID: 33604712 DOI: 10.1007/s00268-021-05987-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Postoperative intra-abdominal infection is one of the most serious complications after pancreatic resection. In this article, we investigated the relationship between serum lactate level and postoperative infection, to suggest a new predictor of potential infection risk after pancreatectomy. METHODS A retrospective analysis of 156 patients who underwent pancreatic surgery and admitted in the intensive care unit for recovery after surgery between August 2017 and August 2019 was performed. RESULTS The basic characteristics, preoperative information, pathological diagnoses, surgical methods, and intraoperative situations of patients in the postoperative intra-abdominal infection group (n = 52) and non-infection group (n = 104) showed no significant differences. With the same postoperative treatments and results of fluid balance, blood pressure maintenance, and laboratory tests, postoperative serum lactate level increased much higher in the infection group than non-infection group (P < 0.001), while the base excess level declined much lower (P = 0.002). Patients in the infection group needed more time to elute lactate (P < 0.001), and stayed longer in the intensive care unit after surgery (P = 0.007). The overall postoperative complications were certainly more in the infection group (P < 0.001), resulting in a longer hospitalization time (P < 0.001). CONCLUSIONS When patients recovered smoothly from anesthesia with a stable hemodynamics situation and normal results of laboratory tests, abnormally high serum lactate level could be a predictor of postoperative intra-abdominal infection after pancreatic resection.
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Affiliation(s)
- Yatong Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Lixin Chen
- 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
| | - Hanyu Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Shunda Wang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yun Long
- Department of Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Junchao Guo
- 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
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Beijing, 100730, China.
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Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis. Sci Rep 2020; 10:17896. [PMID: 33087777 PMCID: PMC7578105 DOI: 10.1038/s41598-020-74812-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/07/2020] [Indexed: 02/05/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.
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14
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Comparison of surgical outcomes between isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis. BMC Gastroenterol 2020; 20:279. [PMID: 32819274 PMCID: PMC7439684 DOI: 10.1186/s12876-020-01415-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aimed to compare the safety and effectiveness of the following procedures after pancreaticoduodenectomy: isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy. METHODS We performed a systematic search of the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 January 2020. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated using STATA 12.0 statistical software. RESULTS Thirteen studies involving 1942 patients were included in this study. Pooled analysis showed that reoperation rates following isolated pancreaticojejunostomy were lower reoperation than with conventional pancreaticojejunostomy (OR = 0.36, 95% CI: 0.15-0.86, p = 0.02, respectively), and that isolated pancreaticojejunostomy required longer operation time vs conventional pancreaticojejunostomy (WMD = 43.61, 95% CI: 21.64-65.58, P = 0.00). Regarding postoperative pancreatic fistula, clinically-relevant postoperative pancreatic fistula, delayed gastric emptying, clinically-relevant delayed gastric emptying, bile leakage, hemorrhage, reoperation, length of postoperative hospital stay, major complications, overall complications, and mortality, we found no significant differences for either isolated pancreaticojejunostomy versus conventional pancreaticojejunostomy or isolated gastrojejunostomy versus conventional pancreaticojejunostomy. CONCLUSIONS This study showed that isolated pancreaticojejunostomy was associated with a lower reoperation rate, but required longer operation time vs conventional pancreaticojejunostomy. Considering the limitations, high-quality randomized controlled trials are required.
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Hu B, Tan HY, Rao XW, Jiang JY, Yang K. A Scoring System for Surgical Site Infection after Pancreaticoduodenectomy Using Clinical Data. Surg Infect (Larchmt) 2020; 22:240-244. [PMID: 32543287 DOI: 10.1089/sur.2020.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Object: To analyze the factors influencing surgical site infection (SSI) after pancreaticoduodenectomy and to establish a scoring system for predicting such infections. Methods: Patients who underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of Chongqing Medical University from January 2015 to March 2019 were divided randomly into a model group and a test group in a proportion of 3:1. According to whether an SSI occurred after operation, the model group was divided into an incision-infection group and a non-infection group. Univariable analysis and multivariable regression analysis were used to analyze factors related to post-operative incision infection and to establish a clinical predictive scoring system. The scoring system was evaluated for the test group. Results: A total of 236 patients, 177 in the model group and 59 in the test group, were included. In the model group, univariable and logistic regression analysis showed that tumor nature (benign versus malignant), post-operative albumin concentration, pancreatic fistula formation, post-operative cough, and peri-operative blood transfusion were the independent risk factors for incision infection. Then we established a clinical predictive scoring system. In the test group, the area under the receiver operator characteristic curve of the system was 0.768 (p < 0.001, with sensitivity = 59.1% and specificity = 94.6%). Conclusion: The scoring system had good clinical prediction ability and high specificity, so it was worth using in the clinic.
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Affiliation(s)
- Bo Hu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hao-Yang Tan
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin-Wen Rao
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Yi Jiang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kang Yang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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16
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Araujo RLC, Silva RO, de Pádua Souza C, Milani JM, Huguet F, Rezende AC, Gaujoux S. Does neoadjuvant therapy for pancreatic head adenocarcinoma increase postoperative morbidity? A systematic review of the literature with meta-analysis. J Surg Oncol 2020; 121:881-892. [PMID: 31994193 DOI: 10.1002/jso.25851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Neoadjuvant treatment (NT) for pancreatic head cancer may allow some patients to undergo curative resection, but its impact on postoperative complications remains unclear. A systematic review and meta-analysis were performed to compare overall postoperative morbidity, pancreatic fistula, and mortality between patients who underwent upfront surgery and those who underwent neoadjuvant therapy first. Forty-five studies with 3359 patients were included. No significant differences in morbidity and mortality rates associated with NT for pancreatic head cancer were detected in this study.
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Affiliation(s)
- Raphael L C Araujo
- Department of Digestive Surgery, Escola Paulista de Medicina (UNIFESP), São Paulo, São Paulo, Brazil.,Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil.,Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Raphael O Silva
- Department of Surgical Oncology, Hospital Santa Casa, Campo Mourão, Paraná, Brazil
| | | | - Jean M Milani
- Post-graduation Program, Barretos Cancer Hospital, Barretos, São Paulo, Brazil
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon AP-HP, Sorbonne University, Paris, France
| | - Ana C Rezende
- Department of Oncology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Hôpital Cochin AP-HP, Paris, France
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17
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Shark mouth pancreaticojejunostomy: a new enteric reconstruction procedure of pancreatic stump. Chin Med J (Engl) 2019; 132:1354-1358. [PMID: 30896569 PMCID: PMC6629351 DOI: 10.1097/cm9.0000000000000219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: The enteric reconstruction procedure of pancreatic stump after pancreaticoduodenectomy remains to be the critical factor influencing the mortality and morbidity. No widely accepted surgical procedure for the pancreaticojejunostomy has been erected yet. We have developed a new technique of pancreaticojejunostomy named “shark mouth pancreaticojejunostomy.” The aim of this study is to assess the efficacy of “shark mouth pancreaticojejunostomy.” Methods: This is a prospective single-arm observational study to evaluate the clinical efficacy of “shark mouth pancreaticojejunostomy.” Patients with diseases, in whom a pancreaticoduodenectomy is indicated, would be recruited from Peking University Third Hospital. The hypothesis to be tested is that a “shark mouth pancreaticojejunostomy” will reduce fistula rate from around 20% to less than 10%. A sample size of 120 patients will be needed. The primary endpoint is the incidence rate of postoperative pancreatic fistula (POPF). The secondary endpoints of the study are anastomosis time, postoperative hospital stay, and morbidities besides the POPF such as the hemorrhage. Enrolled patients will undergo pancreaticoduodenectomy and be followed up for 3 months. The relevant data will be monitored and recorded. Conclusions: The current trial will explore the therapeutic value of the newly raised pancreaticojejunostomy procedure as the “shark mouth pancreaticojejunostomy.” Its theoretical base and pragmatic feature will promise high external validity. Trial registration: Clinical Trials.gov: NCT03366038; https://www.clinicaltrials.gov.
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18
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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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Mahendran R, Tewari M, Dixit VK, Shukla HS. Enhanced recovery after surgery protocol enhances early postoperative recovery after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2019; 18:188-193. [PMID: 30573300 DOI: 10.1016/j.hbpd.2018.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 12/06/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocol is a multimodal, multidisciplinary and evidence-based approach to reduce surgical stress and enhance recovery in the postoperative period. This study aimed to analyze the outcome of ERAS protocol in patients after pancreaticoduodenectomy (PD). METHODS A total of 50 consecutive patients with pancreatic/periampullary cancer who underwent PD between January 2016 to August 2017 were included in the study. As per the institute ERAS protocol, nasogastric tube (NGT) was removed on postoperative day (POD) 1 if output was less than 200 mL and oral sips were allowed; oral liquids were allowed on POD2; semisolid diet by POD3; abdominal drain was removed on POD 4 if output was less than 100 mL with no evidence of postoperative pancreatic fistula (POPF); normal diet was allowed on POD5. Discharge criteria on POD6 were afebrile, tolerating oral normal diet, pain free and no surgery related complications (defined as per the ISGPS definitions). RESULTS NGT was removed on POD1 in 45 (90%) patients, abdominal drain removed by POD4 in 41 (82%) and 43 (86%) patients were discharged on POD6. There was no 30-day postoperative mortality. Three (6%) patients had delayed gastric emptying (DGE). None had postoperative hemorrhage and POPF. Readmission rate was 8%. A significant relation was found between the length of hospital stay (LOS) with age (P < 0.05) and a marginal relation between LOS and postoperative albumin (P = 0.05). CONCLUSIONS ERAS protocol can be safely followed in the perioperative care of patients who undergo PD. Early removal of NGT and allowing oral diet restore bowel function early. ERAS decreases the LOS and postoperative complications.
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Affiliation(s)
- Ramasamy Mahendran
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India
| | - Mallika Tewari
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India.
| | - Vinod Kumar Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India
| | - Hari Shankar Shukla
- Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP 221005, India
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Multidetector CT findings differ between surgical grades of pancreatic fistula after pancreaticoduodenectomy. Eur Radiol 2019; 29:2399-2407. [DOI: 10.1007/s00330-018-5916-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 10/26/2018] [Accepted: 11/23/2018] [Indexed: 12/18/2022]
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Yamamoto M, Kawaguchi Y, Ichida A, Matsumura M, Sakamoto Y, Arita J, Akamatsu N, Kaneko J, Kokudo N, Hasegawa K. Evaluation of preoperative nutritional variables to predict postoperative complications after pancreaticoduodenectomy. Nutrition 2019; 67-68S:100006. [PMID: 34332712 DOI: 10.1016/j.nutx.2020.100006] [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: 07/30/2019] [Revised: 11/30/2019] [Accepted: 12/20/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Perioperative malnutrition reportedly increases postoperative morbidity and mortality rates after abdominal surgery, including pancreaticoduodenectomy (PD). However, few studies have focused on the association between preoperative nutritional variables and the incidence of postoperative complications. The present study aimed to evaluate preoperative nutritional parameters to predict the incidence of postoperative complications after PD. METHODS A total of 140 consecutive patients underwent PD between May 2012 and April 2015. Preoperative nutritional variables included body mass index, total lymphocyte count, albumin, total cholesterol, cholinesterase, and transthyretin. The rates of Clavien-Dindo (C-D) grade ≥II complications were evaluated for each nutritional variable. Predictive factors for the incidence of C-D grade ≥II complications were evaluated by assessing pre- and intraoperative factors. RESULTS Of the 140 patients, 108 were included in the study after excluding 32 patients with missing data on preoperative nutritional variables. A cholinesterase concentration of <250 IU/L (odds ratio: 2.82; 95% confidence interval, 1.12-7.80; P = 0.028) was the only independent predictive factor for the incidence of C-D grade ≥II postoperative complications. CONCLUSIONS Low cholinesterase concentrations were significantly associated with a higher incidence of postoperative morbidity in patients undergoing PD. Preoperative nutritional variables can be used as predictors of postoperative complications after PD.
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Affiliation(s)
- Masaki Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masaru Matsumura
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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Outcome of 150 Consecutive Blumgart's Pancreaticojejunostomy After Pancreaticoduodenectomy. Indian J Surg Oncol 2018; 10:65-71. [PMID: 30948875 DOI: 10.1007/s13193-018-0821-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is the most feared complication after pancreaticoduodenectomy (PD) that leads to intra-abdominal abscess, sepsis, or bleeding and remains the single most important source of morbidity and mortality after PD. To minimize this dreaded complication, various surgical techniques and modifications of pancreaticoenteric reconstruction have been proposed. However, still POPF does occur even in experienced hands. We herein describe the outcome of 150 post PD patients who underwent duct-to-mucosa (DM) pancreaticojejunostomy (PJ) using a special technique, Blumgart's "through & through" U transpancreatic sutures. The technique is described in detail. Postoperative octreotide and metoclopramide were used in all patients for 3 days. An enhanced recovery (ERAS) protocol was followed in a subset of patients. All patients were ASA grade 1 and had adenocarcinoma of the periampullary region/pancreatic head and underwent standard pylorus resecting PD after due optimization. Eighty-eight (58.7%) patients had pancreatic duct < 3 mm and pancreatic texture was soft to very soft in 112 (74.6%) patients. There was only one International Study Group of Pancreatic Surgery (ISGPS) grade C POPF with concomitant hemorrhage. Five patients developed ISGPS grade B and two grade C, delayed gastric emptying (DGE). There was no 30-day mortality. The average length of hospital stay was 7.3 ± 4.2 days with a median of 6 days in the ERAS subset of patients. Blumgart's "through & through" DMPJ technique is very helpful in reducing the POPF and other complications even in high-risk pancreas (i.e., soft with a small pancreatic duct) and is easy to learn and perform.
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Lavu H, McCall N, Keith SW, Kilbane EM, Parmar AD, Hall BL, Pitt HA. Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality. J Pancreat Cancer 2018; 4:45-51. [PMID: 30631858 PMCID: PMC6145537 DOI: 10.1089/pancan.2018.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses. Results: Invagination patients had higher serum albumin (p < 0.01) and lower body mass index (p < 0.01), were less likely to have a preoperative biliary stent (p < 0.01), and were more likely to have a soft gland (p < 0.01). PJ anastomosis type was not associated with morbidity but was associated with mortality (duct-to-mucosa vs. invagination, odds ratio = 0.22, p < 0.01). Among patients who developed a clinically relevant pancreatic fistula, none of the 119 duct-to-mucosa, compared with 5 of 21 invagination, patients died (p < 0.01). Conclusion: Patients who undergo a PJ by duct-to-mucosa or invagination differ with respect to preoperative and intraoperative variables. When an invagination PJ leaks, there may be a greater influence on mortality than when a duct-to-mucosa PJ leaks.
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Affiliation(s)
- Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Neal McCall
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott W Keith
- Department of Biostatistics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Bruce L Hall
- Washington University, School of Medicine, St. Louis, Missouri
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Surgery, Philadelphia, Pennsylvania
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Number of acinar cells at the pancreatic stump predicts pancreatic fistula after pancreaticoduodenectomy. Surg Today 2018; 48:790-795. [DOI: 10.1007/s00595-018-1656-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/13/2018] [Indexed: 12/28/2022]
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Xu J, Ji SR, Zhang B, Ni QX, Yu XJ. Strategies for pancreatic anastomosis after pancreaticoduodenectomy: What really matters? Hepatobiliary Pancreat Dis Int 2018; 17:22-26. [PMID: 29428099 DOI: 10.1016/j.hbpd.2018.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/28/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The postoperative pancreatic fistula rate remains approximately 10-20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate. DATA SOURCES Studies were identified by searching PubMed for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: "duct-to-mucosa", "invagination", "pancreaticojejunostomy", "pancreaticogastrostomy," and "pancreaticoduodenectomy". The search was limited to English publications. RESULTS Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy. CONCLUSION Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.
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Affiliation(s)
- Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Shun-Rong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Bo Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Quan-Xing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China.
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Positron emission tomography modalities prevent futile radical resection of pancreatic cancer: A meta-analysis. Int J Surg 2017; 46:119-125. [DOI: 10.1016/j.ijsu.2017.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/15/2017] [Accepted: 09/02/2017] [Indexed: 02/06/2023]
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Bin X, Lian B, Jianping G, Bin T. Comparison of patient outcomes with and without stenting tube in pancreaticoduodenectomy. J Int Med Res 2017; 46:403-410. [PMID: 28718685 PMCID: PMC6011316 DOI: 10.1177/0300060517717400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate the clinical effect of different pancreaticojejunostomy techniques in the treatment of pancreaticoduodenectomy and investigate the applicability of pancreaticojejunostomy without pancreatic duct stenting. Methods From January 2012 to December 2015, 87 patients who underwent pancreaticoduodenectomy were randomly assigned to either Group A (duct-to-mucosa anastomosis with pancreatic duct stenting, n = 43) or Group B (pancreas-jejunum end-to-side anastomosis without stenting (n = 44). The operative duration of pancreaticojejunostomy, postoperative hospital stay, and incidence of postoperative complications were compared between the two methods. Results The operative duration of pancreaticojejunostomy without use of the pancreatic duct stent was significantly shorter in Group B than in Group A (t = 7.137). The postoperative hospital stay was significantly shorter in Group B than in Group A (t = 2.408). The differences in the incidence of postoperative complications such as pancreatic fistula, abdominal bleeding, abdominal infection and delayed gastric emptying were not significantly different between the two groups (χ2 = 0.181, 0.322, 0.603, and 0.001, respectively). Conclusion Pancreaticoduodenectomy without pancreatic duct stenting is safe and reliable and can reduce the operative time and hospital stay. No significant differences were observed in the incidence of postoperative complications.
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Affiliation(s)
- Xiong Bin
- 2 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China
| | - Bai Lian
- 1 The Second Department of General Surgery, Yongchuan Hospital of Chongqing Medical University, Chong Qing, China
| | - Gong Jianping
- 2 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China
| | - Tu Bin
- 2 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China
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Deng LH, Xiong JJ, Xia Q. Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis. J Evid Based Med 2017; 10:37-45. [PMID: 27314553 DOI: 10.1111/jebm.12202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/07/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the advantage between isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). METHODS Comparative studies on this topic published between January 1976 and April 2015 in PubMed, EMbase, EBSCO, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched, and selected based on specific inclusion and exclusion criteria. Perioperative outcomes such as postoperative pancreatic fistula, delayed gastric emptying, operation time, intraoperative blood loss, intraoperative blood transfusion, postoperative bleeding, intra-abdominal abscess, bile leakage, wound infection, morbidity and mortality were compared. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence interval (CI) were calculated using either fixed- or random-effects model. RESULTS Six studies were included with two randomized controlled and four nonrandomized trials. A total of 712 patients (359 patients from the IPJ group and 353 patients from the CPJ group) were analyzed. The pooled results revealed that IPJ had longer operation time (WMD = 36.55, 95% CI 6.98 to 66.11, P = 0.02). However, there were no significant differences between both groups in postoperative pancreatic fistula, intraoperative blood loss, blood transfusion, delayed gastric emptying, postoperative bleeding, intra-abdominal abscess, bile leakage, wound infection, morbidity, mortality and postoperative hospital stay. CONCLUSIONS PD with IPJ was comparable to CPJ in intraoperative outcomes and postoperative complications. However, further randomized controlled trials should be undertaken to ascertain these findings.
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Affiliation(s)
- Li Hui Deng
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Systematic review and meta-analysis of robotic versus open pancreaticoduodenectomy. Surg Endosc 2016; 31:3085-3097. [PMID: 27928665 DOI: 10.1007/s00464-016-5371-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 11/21/2016] [Indexed: 02/06/2023]
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Tewari M. Significance of pathological positive superior mesenteric/portal venous invasion in pancreatic cancer. Hepatobiliary Pancreat Dis Int 2016; 15:572-578. [PMID: 27919845 DOI: 10.1016/s1499-3872(16)60156-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy with superior mesenteric/portal venous resection for pancreatic ductal adenocarcinoma (PDAC) is frequently performed with no added morbidity or mortality in case of tumor abutment to the superior mesenteric or portal vein so as to obtain a margin negative resection. True histopathological portal vein invasion is found only in a small subset of such patients. The aim of this review aimed to discuss the significance of histopathological venous invasion in PDAC. DATA SOURCES For this review available data was searched from PubMed and analyzed. No randomized trials have been published on this topic. RESULTS Existing data on prognostic factors in histopathological venous invasion by PDAC are limited and recent studies indicate worse survival in this subgroup of patients. In addition, venous invasion in PDAC has been associated with large tumors, involved lymph nodes, perineural invasion and R1 resection. The survival of patients with portal venous resection but without histologic venous invasion is reportedly better than those with histopathological venous invasion; though conflicting studies do exist on the subject. Some studies also relate the depth of venous invasion to prognosis after surgical resection of PDAC. CONCLUSIONS Frank/'histopathological' invasion of superior mesenteric/portal venous and R1 resection indicate a very poor survival. Such patients may be given the opportunity of benefit of neoadjuvant treatment.
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Affiliation(s)
- Mallika Tewari
- Hepato Pancreatico Biliary and Gastrointestinal Division, Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005 U.P., India.
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A comparative study on the complications of conventional and end-to-side inserting pancreatojejunostomy after pancreaticoduodenectomy. Surg Today 2016; 47:238-244. [DOI: 10.1007/s00595-016-1364-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/15/2016] [Indexed: 12/19/2022]
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Hsu CW, Lin LF, Law MK. Purse-string suture without pancreatic parenchymal stitches in pancreaticojejunostomy during laparoscopic pancreaticoduodenectomy. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Chih-Wei Hsu
- Division of General Surgery, Department of Surgery; Tungs' Taichung MetroHarbor Hospital; Taichung Taiwan
| | - Lien-Fu Lin
- Division of Gastroenterology, Department of Internal Medicine; Tungs' Taichung MetroHarbor Hospital; Taichung Taiwan
| | - Ming-Ko Law
- Division of General Surgery, Department of Surgery; Tungs' Taichung MetroHarbor Hospital; Taichung Taiwan
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Palani Velu LK, McKay CJ, Carter CR, McMillan DC, Jamieson NB, Dickson EJ. Serum amylase and C-reactive protein in risk stratification of pancreas-specific complications after pancreaticoduodenectomy. Br J Surg 2016; 103:553-63. [PMID: 26898605 DOI: 10.1002/bjs.10098] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 01/08/2023]
Abstract
Abstract
Background
Pancreas-specific complications (PSCs), comprising postoperative pancreatic fistula, haemorrhage and intra-abdominal collections, are drivers of morbidity and mortality after pancreaticoduodenectomy (PD). A serum amylase concentration of 130 units/l or more on postoperative day (POD) 0 has been shown to be an objective surrogate of pancreatic texture, a determinant of PSCs. This study evaluated serial measurements of C-reactive protein (CRP) to refine PSC risk stratification.
Methods
Consecutive patients undergoing PD between 2008 and 2014, with vascular resection if required and without preoperative chemoradiotherapy, had serum investigations from the day before operation until discharge. Receiver operating characteristic (ROC) curve analysis was used to identify a threshold value of serum CRP with clinically relevant PSCs for up to 30 days after discharge as outcome measure.
Results
Of 230 patients, 95 (41·3 per cent) experienced a clinically relevant PSC. A serum CRP level of 180 mg/l or higher on POD 2 was associated with PSCs, prolonged critical care stay and relaparotomy (all P < 0·050). Patients with a serum amylase concentration of 130 units/l or more on POD 0 who developed a serum CRP level of at least 180 mg/l on POD 2 had a higher incidence of morbidity. Patients were stratified into high-, intermediate- and low-risk groups using these markers. The low-risk category was associated with a negative predictive value of 86·5 per cent for development of clinically relevant PSCs. There were no deaths among 52 patients in the low-risk group, but seven deaths among 79 (9 per cent) in the high-risk group.
Conclusion
A serum amylase level below 130 units/l on POD 0 combined with a serum CRP level under 180 mg/l on POD 2 constitutes a low-risk profile following PD, and may help identify patients suitable for early discharge.
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Affiliation(s)
- L K Palani Velu
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Academic Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - C J McKay
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - C R Carter
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - D C McMillan
- Academic Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - N B Jamieson
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
- Academic Department of Surgery, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - E J Dickson
- West of Scotland Pancreatic Unit, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
Pancreatic ductal adenocarcinoma (PDA) is a challenging disease, as overall survival has not improved over the last several decades. The disease is characterized by late diagnosis, difficult major surgery in resectable patients, and a biologically chemoresistant tumor. Intense research in the field is ongoing to develop biomarkers for early detection and prognostication. Surgery is presently the crux of the management of PDA and has been standardized over the years with high-volume centers reporting <5 % operative mortality. The biggest problem is to overcome the inherent chemoresistance of the tumor that is densely fibrotic and hypoxic and has a tendency to invade surrounding neuronal plexuses. This review attempts to summarize in brief the reasons why PDA is difficult to treat, and provides a glimpse of the ongoing research in the field.
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Zhou Y, Lin J, Wu L, Li B, Li H. Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis. BMC Gastroenterol 2015; 15:68. [PMID: 26076690 PMCID: PMC4467059 DOI: 10.1186/s12876-015-0300-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 06/05/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most frequent complications after pancreaticoduodenectomy (PD). This meta-analysis aimed to evaluate the effect of antecolic versus retrocolic reconstruction of gastro/duodenojejunostomy on DGE after PD. METHODS Randomized controlled trials (RCTs) comparing antecolic versus retrocolic reconstruction of gastro/duodenojejunostomy on DGE after PD were eligible for inclusion. Pooled estimates of treatment effect were calculated using either the fixed effects model or random effects model. RESULTS Five RCTs involving 534 randomized patients were eligible. The comparison of DGE showed no significant difference (odds ratio, 0.66; 95% confidence interval, 0.32 to 1.33; P = 0.24). The antecolic and retrocolic groups also had comparable outcomes for clinical parameters related to DGE, other complications, hospital mortality, and length of hospital stay. CONCLUSIONS The route of gastro/duodenojejunostomy reconstruction has no impact on DGE after PD. Therefore, the choice of reconstruction route should be selected according to the surgeon's preference.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University; Oncologic Center of Xiamen, Xiamen, China.
| | - Jincan Lin
- Department of Digestive Diseases, First Xiamen Hospital, Fujian Medical University, Xiamen, China.
| | - Lupeng Wu
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University; Oncologic Center of Xiamen, Xiamen, China.
| | - Bin Li
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University; Oncologic Center of Xiamen, Xiamen, China.
| | - Hua Li
- Department of Digestive Diseases, First Xiamen Hospital, Fujian Medical University, Xiamen, China.
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Beisani M, Dopazo C, Blanco L, Caralt M, Sapisochín G, Olsina JJ, Balsells J. Antecolic anastomosis and delayed gastric emptying: still a benefit in patients without intra-abdominal complications? Eur Surg 2015. [DOI: 10.1007/s10353-015-0311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Čečka F, Loveček M, Jon B, Skalický P, Šubrt Z, Ferko A. DRAPA trial--closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial. Trials 2015; 16:207. [PMID: 25947117 PMCID: PMC4470087 DOI: 10.1186/s13063-015-0706-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 04/07/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The morbidity of pancreatic resection remains high, with pancreatic fistula being the most common cause. The important question is whether any postoperative treatment adjustment may prevent the development of clinically significant postoperative pancreatic fistulae. Recent studies have shown that intraabdominal drains and manipulation using them are of great importance. Although authors of a few retrospective reports have described good results of pancreatic resection without the use of intraabdominal drains, a recent prospective randomized trial showed that routine elimination of drains in pancreaticoduodenectomy is associated with poor outcome. An important issue arises as to which type of drain is most suitable for pancreatic resection. Two types of surgical drains exist: open drains and closed drains. Open drains are considered obsolete nowadays because of frequent retrograde infection. Closed drains include two types: passive gravity drains and closed-suction drains. Closed-suction drains are more effective, as they remove fluid from the abdominal cavity under light pressure. However, some surgeons believe that closed-suction drains represent a potential hazard to patients and that negative pressure might increase the risk of pancreatic fistulae. Nobody has yet specifically dealt with the question of which kind of drainage is most appropriate in pancreatic surgery. METHODS/DESIGN The aim of the DRAins in PAncreatic surgery (DRAPA) trial is to compare the closed-suction drain versus the closed passive gravity drain in pancreatic resection. DRAPA is a dual-centre, prospective, randomized controlled trial. The primary endpoint is the rate of postoperative pancreatic fistula; the secondary endpoint is postoperative morbidity with follow-up of 3 months. DISCUSSION No study to date has compared different types of drains in pancreatic surgery. This study is designed to answer the question whether any particular type of drain might lower the rate of postoperative pancreatic fistula or other complications. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01988519. Registered 13 November 2013.
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Affiliation(s)
- Filip Čečka
- Department of Surgery, Faculty of Medicine, University Hospital Hradec Králové, Sokolská 581, 500 05, Hradec Králové, Czech Republic.
| | - Martin Loveček
- First Department of Surgery, Faculty of Medicine, University Hospital Olomouc, IP Pavlova 6, 779 00, Olomouc, Czech Republic.
| | - Bohumil Jon
- Department of Surgery, Faculty of Medicine, University Hospital Hradec Králové, Sokolská 581, 500 05, Hradec Králové, Czech Republic.
| | - Pavel Skalický
- First Department of Surgery, Faculty of Medicine, University Hospital Olomouc, IP Pavlova 6, 779 00, Olomouc, Czech Republic.
| | - Zdeněk Šubrt
- Department of Surgery, Faculty of Medicine, University Hospital Hradec Králové, Sokolská 581, 500 05, Hradec Králové, Czech Republic. .,Department of Field Surgery, Faculty of Military Health Sciences, University of Defence, Třebešská 1575, 500 02, Hradec Králové, Czech Republic.
| | - Alexander Ferko
- Department of Surgery, Faculty of Medicine, University Hospital Hradec Králové, Sokolská 581, 500 05, Hradec Králové, Czech Republic.
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Zhang L, Li Z, Wu X, Li Y, Zeng Z. Sealing Pancreaticojejunostomy in Combination with Duct Parenchyma to Mucosa Seromuscular One-Layer Anastomosis: A Novel Technique to Prevent Pancreatic Fistula after Pancreaticoduodenectomy. J Am Coll Surg 2015; 220:e71-7. [DOI: 10.1016/j.jamcollsurg.2014.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/07/2014] [Accepted: 12/08/2014] [Indexed: 12/15/2022]
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Zhou Y, Yu J, Wu L, Li B. Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy on occurrences of postoperative pancreatic fistula after pancreaticoduodenectomy. Asian J Surg 2015; 38:155-60. [PMID: 25913732 DOI: 10.1016/j.asjsur.2015.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 02/10/2015] [Accepted: 02/12/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND/OBJECTIVE Pancreatic fistula (PF) is the most common and challenging complication after pancreaticoduodenectomy (PD). This meta-analysis aimed to evaluate the impact of pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) on occurrences of postoperative PF. METHODS A systematic literature search in the Medline, EMBASE, OVID, and Cochrane databases was performed to identify all eligible randomized controlled trials (RCTs). Pooled estimates were presented with 95% confidence intervals (CI). RESULTS Six RCTs involving 1005 patients met the inclusion criteria. The incidence of PF [odds ratio (OR) 0.58, 95% CI, 0.42-0.81; p = 0.001], intra-abdominal abscess or collections (OR 0.43, 95% CI, 0.28-0.65; p < 0.001), and biliary fistula (OR 0.28, 95% CI, 0.11-0.74; p = 0.01) were found to be significantly lower in the PG group than in the PJ group. There was no significant difference in overall morbidity, other complications, hospital mortality, or length of hospital stay between the two groups. CONCLUSION The meta-analysis showed that PG following PD represents a safe procedure associated with fewer PFs compared with PJ.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China.
| | - Jianhua Yu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China
| | - Lupeng Wu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China
| | - Bin Li
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China
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Gómez T, Palomares A, Serradilla M, Tejedor L. Reconstruction after pancreatoduodenectomy: Pancreatojejunostomy vs pancreatogastrostomy. World J Gastrointest Oncol 2014; 6:369-376. [PMID: 25232462 PMCID: PMC4163735 DOI: 10.4251/wjgo.v6.i9.369] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 03/18/2014] [Indexed: 02/05/2023] Open
Abstract
Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy (PD) in order to decrease postoperative complications, mainly pancreatic fistulas (PF). In this work, we compare the two most frequent techniques of reconstruction after PD, pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), in order to determine which of the two is better. A systematic review of the literature was performed, including major meta-analysis articles, clinical randomized trials, systematic reviews, and retrospective studies. A total of 64 articles were finally included. PJ and PG are usually responsible for most of the postoperative morbidity, mainly due to the onset of PF, being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia. The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG. PF, delayed gastric emptying and mortality were not different. Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons, and the surgical care was likely to be similar for all the studies. The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa. Exocrine function appears to be worse after PG than after PJ, resulting in severe atrophic changes in the remnant pancreas. Depending on the type of PJ or PG used, the PF rate and other complications can also be different. The best method to deal with the pancreatic stump after PD remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon’s preference and adherence to basic principles such as good exposure and visualization. In conclusion, up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD.
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Abstract
OBJECTIVE Pulmonary embolism (PE) after major abdominal surgery is a serious and potentially lethal complication. The purpose of the present study was to identify risk factors for postoperative PE after pancreas resection. METHODS Our prospective database for pancreatic surgery was retrospectively analyzed for patients treated between January 2006 and August 2012 in a tertiary care Swiss hospital. Risk factors for PE were identified in univariate and multivariate analyses that included preoperative, intraoperative, and postoperative variables. RESULTS Among 251 patients, 187 underwent pancreato-duodenectomy (PD), 62 underwent distal pancreatectomy, and 2 underwent other types of pancreas resections. PE was diagnosed in 13 patients (7.0%) after PD and none after other procedures. Compared with the non-PE group, the PE group had higher body mass indices (≥25 kg/m, P = 0.04), longer median operation times (P = 0.009), higher rates of severe abdominal complications (P < 0.001), longer median intensive care unit stays (P = 0.003), and longer hospital stays (P = 0.01). Multivariate analyses identified the following independent predictors for PE: a history of thromboembolic events (odds ratio [OR], 22.3), prolonged operation time (OR, 5.76), and major abdominal complications (OR, 10.8). CONCLUSIONS Prolonged operation times and major postoperative abdominal complications were strong risk factors for PE after PD, in both univariate and multivariate analyses.
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Meng G, Xing Q, Yuan Q, Du Z, Wang Y, Meng H. Internal compared with external drainage of pancreatic duct during pancreaticoduodenectomy: a retrospective study. Chin J Cancer Res 2014; 26:277-84. [PMID: 25035654 DOI: 10.3978/j.issn.1000-9604.2014.06.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/06/2014] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To compare internal with external drainage of the pancreatic duct during pancreaticoduodenectomy with regard to the incidence of postoperative pancreatic fistula (POPF) and other complications. METHODS We retrospectively analyzed 316 patients who underwent pancreaticoduodenectomy with a placed drainage tube (external, n=128; internal, n=188) in the pancreatic duct from 1 January 1999 to 31 December 2011 in Tianjin Third Central Hospital of China. The incidence of POPF and some other complications were compared. RESULTS There was no difference in the incidence rates of POPF between those given an internal or external drainage tube (P=0.788), but POPF was more severe in the former (P=0.014). Intraperitoneal bleeding rate was also higher in the patients with internal drainage (P=0.040), but operative time and postoperative hospitalization were longer in those with external drainage (P=0.002 and P=0.007, respectively). There was no difference between the groups with regard to the incidence rates of gastrointestinal bleeding, delayed gastric emptying, pulmonary infection, or incision infection and in-hospital mortality. CONCLUSIONS External drainage of the pancreatic duct during pancreaticoduodenectomy can decrease the severity of POPF, but operative time and postoperative hospitalization will be extended.
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Affiliation(s)
- Guangxing Meng
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Qianzhe Xing
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Qiang Yuan
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi Du
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yijun Wang
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hua Meng
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Kanda M, Fujii T, Suenaga M, Takami H, Hattori M, Inokawa Y, Yamada S, Nakayama G, Sugimoto H, Koike M, Nomoto S, Kodera Y. Estimated pancreatic parenchymal remnant volume accurately predicts clinically relevant pancreatic fistula after pancreatoduodenectomy. Surgery 2014; 156:601-10. [PMID: 24998158 DOI: 10.1016/j.surg.2014.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/14/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) leads to prolonged hospitalization and potentially fatal complications. We sought to determine whether estimated pancreatic parenchymal remnant volume (EPPRV) on preoperative computed tomography (CT) predicts clinically relevant POPF. METHODS This retrospective study included 246 patients who underwent PD between 2008 and 2013. Pancreatic thickness, pancreatic width, and main pancreatic duct (MPD) diameter at the estimated transection line in addition to estimated whole pancreatic remnant volume (EWPRV) were measured on preoperative CT images. MPD volume was subtracted from EWPRV to determine EPPRV. The predictive ability of preoperative CT parameters for POPF was evaluated. RESULTS EPPRV was an independent predictor of POPF and had a stronger association with POPF than EWPRV. Receiver operating characteristic curve analysis showed that EPPRV had the greatest area under the curve (0.885) for predicting POPF. EPPRV ≥25.5 cm(3) was the best cutoff value for predicting POPF, with a high negative predictive value (0.934) and low likelihood ratio of a negative result (0.235). Multivariate analysis including the preoperative CT parameters and well-known risk factors for POPF showed that EPPRV ≥25.5 cm(3) had the greatest odds ratio for POPF. EPPRV was correlated with pancreatic juice volume. Patients with EPPRV ≥25.5 cm(3) had a greater drainage fluid amylase concentration and greater duration of drainage tube placement than those with EPPRV <25.5 cm(3). CONCLUSION EPPRV from preoperative CT was highly predictive of POPF and may help in development of management for POPF after PD.
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Affiliation(s)
- Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masaya Suenaga
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Takami
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Hattori
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshikuni Inokawa
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Sugimoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuji Nomoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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Chen YJ, Lai ECH, Lau WY, Chen XP. Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature. Int J Surg 2014; 12:706-11. [PMID: 24851718 DOI: 10.1016/j.ijsu.2014.05.060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/11/2014] [Accepted: 05/14/2014] [Indexed: 01/15/2023]
Abstract
Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.
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Affiliation(s)
- Yong-jun Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, China.
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Xiao-ping Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
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Araujo RLC, Karkar AM, Allen PJ, Gönen M, Chou JF, Brennan MF, Blumgart LH, D'Angelica MI, DeMatteo RP, Coit DG, Fong Y, Jarnagin WR. Timing of elective surgery as a perioperative outcome variable: analysis of pancreaticoduodenectomy. HPB (Oxford) 2014; 16:250-62. [PMID: 23600897 PMCID: PMC3945851 DOI: 10.1111/hpb.12107] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 02/21/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The timing of major elective operations is a potentially important but rarely examined outcome variable. This study examined elective pancreaticoduodenectomy (PD) timing as a perioperative outcome variable. METHODS Consecutive patients submitted to PD were identified. Determinants of 90-day morbidity (prospectively graded and tracked), anastomotic leak or fistula, and mortality, including operation start time (time of day), day of week and month, were assessed in univariate and multivariate analyses. Operation start time was analysed as a continuous and a categorical variable. RESULTS Of the 819 patients identified, 405 (49.5%) experienced one or more complications (total number of events = 684); 90-day mortality was 3.5%. On multivariate analysis, predictors of any morbidity included male gender (P = 0.009) and estimated blood loss (P = 0.017). Male gender (P = 0.002), benign diagnosis (P = 0.002), presence of comorbidities (P = 0.002), American Society of Anesthesiologists (ASA) score (P = 0.025), larger tumour size (P = 0.013) and positive resection margin status (P = 0.005) were associated with the occurrence of anastomotic leak or fistula. Cardiac and pulmonary comorbidities were the only variables associated with 90-day mortality. Variables pertaining to procedure scheduling were not associated with perioperative morbidity or mortality. Operation start time was not significant when analysed as a continuous or a categorical variable, or when stratified by surgeon. CONCLUSIONS Perioperative outcome after PD is determined by patient, disease and operative factors and does not appear to be influenced by procedure timing.
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Affiliation(s)
- Raphael L C Araujo
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Ami M Karkar
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Joanne F Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Murray F Brennan
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Leslie H Blumgart
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | | | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Daniel G Coit
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - Yuman Fong
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan–Kettering Cancer CenterNew York, NY, USA
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Figueras J, Sabater L, Planellas P, Muñoz-Forner E, Lopez-Ben S, Falgueras L, Sala-Palau C, Albiol M, Ortega-Serrano J, Castro-Gutierrez E. Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy. Br J Surg 2014; 100:1597-605. [PMID: 24264781 DOI: 10.1002/bjs.9252] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anastomotic leakage of pancreaticojejunostomy (PJ) remains the single most important source of morbidity after pancreaticoduodenectomy (PD). The primary aim of this randomized clinical trial comparing PG with PJ after PD was to test the hypothesis that invaginated PG would result in a lower rate and severity of pancreatic fistula. METHODS Patients undergoing PD were randomized to receive either a duct-to-duct PJ or a double-layer invaginated PG. The primary endpoint was the rate of pancreatic fistula, using the definition of the International Study Group on Pancreatic Fistula. Secondary endpoints were the evaluation of severe abdominal complications (Clavien-Dindo grade IIIa or above), endocrine and exocrine function. RESULTS Of 123 patients randomized, 58 underwent PJ and 65 had PG. The incidence of pancreatic fistula was significantly higher following PJ than for PG (20 of 58 versus 10 of 65 respectively; P = 0.014), as was the severity of pancreatic fistula (grade A: 2 versus 5 per cent; grade B-C: 33 versus 11 per cent; P = 0.006). The hospital readmission rate for complications was significantly lower after PG (6 versus 24 per cent; P = 0.005), weight loss was lower (P = 0.025) and exocrine function better (P = 0.022). CONCLUSION The rate and severity of pancreatic fistula was significantly lower with this PG technique compared with that following PJ. REGISTRATION NUMBER ISRCTN58328599 (http://www.controlled-trials.com).
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Affiliation(s)
- J Figueras
- Departments of Hepatobiliary and Pancreatic Surgery, 'Dr Josep Trueta' Hospital, Institute of Biomedical Research of Girona (IDIBGI), Girona
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Gerstenhaber F, Grossman J, Lubezky N, Itzkowitz E, Nachmany I, Sever R, Ben-Haim M, Nakache R, Klausner JM, Lahat G. Pancreaticoduodenectomy in elderly adults: is it justified in terms of mortality, long-term morbidity, and quality of life? J Am Geriatr Soc 2013; 61:1351-7. [PMID: 23865843 DOI: 10.1111/jgs.12360] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate long-term morbidity, mortality, and quality of life (QoL) after pancreaticoduodenectomy (PD) in elderly adults. DESIGN Retrospective cohort study. SETTING Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel. PARTICIPANTS One hundred and sixty-eight individuals aged 70 and older who underwent PD between 1995 and 2010. MEASUREMENTS A prospective pancreatic surgery database was analyzed for postoperative morbidity; mortality; intensive care unit (ICU), hospital, and rehabilitation facility stay; and readmissions after surgery. QoL was assessed using a validated questionnaire completed 3, 6, and 12 months after surgery. RESULTS Seventy-two percent of the participants had an American Society of Anesthesiologists score of 3 or greater. There was no intraoperative death. Thirty- and 60-day postoperative mortality rates were 5.9% and 6.5%, respectively. Median ICU stay was 2 days, and median hospital stay was 22 days. Sixty-four participants (37.5%) were discharged to a rehabilitation facility. The first-year readmission rate was 31%. One- and 2-year overall survival rates were 58% and 36%, respectively. Global QoL scores 3 and 12 months after surgery were 68% and 73%, respectively. Scores were lower yet comparable with those of matched individuals undergoing laparoscopic cholecystectomy. CONCLUSION Most elderly adults with pancreatic cancer survive longer than 1 year after PD; 36% survive longer than 2 years. These individuals are likely to have acceptable long-term morbidity and overall good QoL, corresponding with their age.
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CT After Pancreaticoduodenectomy: Spectrum of Normal Findings and Complications. AJR Am J Roentgenol 2013; 201:2-13. [DOI: 10.2214/ajr.12.9647] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Ke S, Ding XM, Gao J, Zhao AM, Deng GY, Ma RL, Xin ZH, Ning CM, Sun WB. A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy. Surgery 2013; 153:743-52. [PMID: 23601899 DOI: 10.1016/j.surg.2013.02.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/05/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a major and serious complication after pancreaticoduodenectomy (PD). There have been no prospective randomized trials evaluating POPF rates in Roux-en-Y reconstruction (RYR) with isolated pancreatic drainage versus conventional loop reconstruction (CLR). The authors hypothesized that RYR decreases the incidence and severity of POPF in patients after PD. METHODS Between January 2006 and April 2012, the findings for 216 patients were analyzed in this multicenter, prospective trial in China. After providing appropriate preoperative informed consent, patients were randomly assigned to either RYR or CLR after completion of pancreaticoduodenal resection. We referred to the Johns Hopkins fistula definition and classified POPF as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. RESULTS The incidence of POPF was similar in the RYR (15.7%, 17/107) and CLR (17.6%, 19/109) groups. Both univariate and multivariate logistic regression analyses revealed that the factor most highly associated with POPF was ampullary or duodenal disease (P < .05). The incidence of type B POPF was higher in the CLR than in the RYR group. Furthermore, patients with POPF in the CLR group had a significantly longer postoperative hospital stay (31.9 ± 6.9 days) and higher total hospital costs than did the patients in the RYR group (P < .05). CONCLUSION These data do not support the hypothesis that RYR is associated with a lower incidence of POPF than is CLR. However, they do indicate that RYR may contribute to decreasing fistula severity, duration of stay, and hospital expense.
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Affiliation(s)
- Shan Ke
- Department of Hepatobiliary Surgery, Beijing Chao-yang Hospital Affiliated to Capital Medical University, Beijing, China
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Warschkow R, Ukegjini K, Tarantino I, Steffen T, Müller SA, Schmied BM, Marti L. Diagnostic study and meta-analysis of C-reactive protein as a predictor of postoperative inflammatory complications after pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:492-500. [PMID: 22038499 DOI: 10.1007/s00534-011-0462-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Although C-reactive protein (CRP) can be measured by a standard blood test, its diagnostic value for distinguishing patients with inflammatory complications after pancreatic surgery from patients with normal postoperative inflammatory responses has not been adequately investigated. This study aimed to assess the diagnostic accuracy of CRP levels for the occurrence of postoperative inflammatory complications after pancreatic surgery. METHODS Clinical data and CRP levels measured in 280 patients after pancreatic surgeries (performed between 1998 and 2010) until postoperative day 10 (POD 10) were retrospectively analyzed. Using the receiver operating characteristic method, diagnostic accuracy was evaluated by an area under the curve (AUC) analysis. Furthermore, the results of the present study were compared to previously published reports by applying diagnostic meta-analysis techniques. RESULTS The 30-day mortality rate was 3.9% (95% CI 2.1-7.0%). Inflammatory complications occurred in 153 of 280 patients (54.6%; 95% CI 48.8-60.4%). On POD 4, the AUC was 0.67 (95% CI 0.58-0.76). The highest diagnostic accuracy was observed on POD 7 (AUC 0.77; 95% CI 0.68-0.85). In a diagnostic meta-analysis that included two additional studies, the diagnostic sensitivity on POD 4 was 0.63 (95% CI 0.50-0.76), and the specificity was 0.79 (95% CI 0.71-0.88). The highest sensitivity occurred on POD 6 (0.75; 95% CI 0.68-0.82). Considerable statistical heterogeneity was observed in the analysis of PODs 3, 4 and 5. CONCLUSION According to this limited evidence, CRP levels had a low to moderate diagnostic accuracy. Large, blinded studies are warranted for a more precise estimation of CRP's diagnostic value.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland.
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