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Zou J, Sun D, Zhang W, Wang D, Shen D, Qin L, Xue X. An improved invagination pancreaticojejunostomy technique associated with a lower incidence of pancreatic fistula: A single-center study. Pancreatology 2024; 24:1355-1359. [PMID: 39521719 DOI: 10.1016/j.pan.2024.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 09/05/2024] [Accepted: 10/31/2024] [Indexed: 11/16/2024]
Abstract
PURPOSE This study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure. METHODS Clinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed. RESULTS There were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001). CONCLUSION The improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis.
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Affiliation(s)
- Jiayue Zou
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
| | - Ding Sun
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
| | - Weigang Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
| | - Daobin Wang
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
| | - Danyang Shen
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
| | - Lei Qin
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
| | - Xiaofeng Xue
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu Province, China.
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Aghamaliyev U, Cepele G, Hofmann FO, Knoblauch M, Kessler C, Crispin A, Weniger M, Andrassy J, Renz BW, Werner J. Hyperlipasemia in the immediate postoperative period predicts postoperative pancreatic fistula after pancreatic resections. Surgery 2024; 176:1732-1738. [PMID: 39375065 DOI: 10.1016/j.surg.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 07/31/2024] [Accepted: 09/09/2024] [Indexed: 10/09/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula is the most common severe complication after pancreatic surgery. It associated with increased morbidity and prolonged hospital stay. Identifying patients at low risk for postoperative pancreatic fistula is essential to enable timely removal of drains and facilitate early discharge. Although postoperative hyperamylasemia is linked to postoperative pancreatic fistula, the role of postoperative hyperlipasemia remains unclear. This study aims to investigate the role of postoperative hyperlipasemia in predicting postoperative pancreatic fistula B/C pancreaticoduodenectomy and distal pancreatectomy. MATERIAL AND METHODS The study included 471 patients who underwent pancreaticoduodenectomy and distal pancreatectomy at our institution between January 1, 2019, and February 28, 2023. Postoperative hyperamylasemia and postoperative hyperlipasemia were defined as values above the upper limit of normal established at our institution. RESULTS In univariate analysis, postoperative hyperlipasemia and postoperative hyperamylasemia on postoperative day 0 demonstrated the strongest association with postoperative pancreatic fistula B/C. Consequently, a subset of 177 patients with available serum lipase and amylase data underwent further investigation. Besides body mass index and high-risk pathology, both postoperative hyperlipasemia and postoperative hyperamylasemia on postoperative day 0 emerged as independent risk factors for postoperative pancreatic fistula B/C in univariate analysis. In multivariate analysis, postoperative hyperlipasemia on postoperative day 0 emerged as a significant predictor of postoperative pancreatic fistula B/C, with body mass index as independent risk factor of postoperative pancreatic fistula B/C. CONCLUSION The absence of postoperative hyperlipasemia on postoperative day 0 could potentially serve as an effective diagnostic tool for identifying patients who are at a low risk of developing postoperative pancreatic fistula B/C after pancreaticoduodenectomy and distal pancreatectomy. Consequently, not only serum amylase, but also serum lipase can be integrated into clinical practice alongside other relevant parameters.
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Affiliation(s)
- Ughur Aghamaliyev
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany. https://twitter.com/draghamaliyev
| | - Ganildo Cepele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Felix O Hofmann
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany; German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Mathilda Knoblauch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany; German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Claudius Kessler
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Crispin
- BE-Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Maximilian Weniger
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Bernhard W Renz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany; German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany. https://twitter.com/renzbr
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.
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Limbu Y, Acharya BP, Raut S, Regmee S, Ghimire R, Maharjan DK, Thapa PB. Validation of the Updated Alternate Fistula Risk Score for Prediction of Postoperative Pancreatic Fistula After Pancreatoduodenectomy. JGH Open 2024; 8:e70053. [PMID: 39605900 PMCID: PMC11598738 DOI: 10.1002/jgh3.70053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 10/20/2024] [Accepted: 11/03/2024] [Indexed: 11/29/2024]
Abstract
Background and Aim Postoperative pancreatic fistula (POPF) remains a significant challenge following pancreatoduodenectomy (PD), contributing to morbidity and mortality. Various risk assessment models have been established to predict the likelihood of POPF. An updated alternate fistula risk score (ua-FRS) has been recently refined and validated within European cohorts. However, the validation of this score in South Asian cohorts remains relatively unexplored. This study aims to validate the applicability of ua-FRS for the prediction of POPF in patients undergoing PD in the South Asian population, particularly Nepal. Methods This cross-sectional, observational study was conducted by a single team across three tertiary care centers in Kathmandu, Nepal from July 2021 to October 2023. A total of 98 patients were studied in terms of their sex, body mass index (BMI), diameter of the main pancreatic duct (MPD), pancreatic consistency, pathological site, and estimated blood loss. The accuracy of ua-FRS for the prediction of postoperative pancreatic fistula after pancreatoduodenectomy was evaluated using the receiver operative characteristics curve. Results Univariate analysis revealed that sex, pancreatic gland texture, the diameter of the main pancreatic duct, the site of pathology, and BMI were statistically significant factors. However, in the multivariate analysis, only BMI and the diameter of the MPD retained their statistical significance, with p-values less than 0.005. The ua-FRS demonstrated high sensitivity and specificity in predicting postoperative pancreatic fistula, as evidenced by an area under the curve (AUC) of 0.802. Conclusion The ua-FRS has validation in the context of the South Asian population to predict POPF following PD, offering a reliable tool to guide perioperative management.
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Affiliation(s)
- Yugal Limbu
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Bidur Prasad Acharya
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Sneha Raut
- Kathmandu Medical College Teaching HospitalKathmanduNepal
| | - Sujan Regmee
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Roshan Ghimire
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Dhiresh Kumar Maharjan
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Prabin Bikram Thapa
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
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Vaidya K, Shinde RK, Nagtode T, Jivani A, Goel S, Samuel J. Role of Necrosectomy in Necrotizing Pancreatitis: A Narrative Review. Cureus 2024; 16:e70470. [PMID: 39479145 PMCID: PMC11522170 DOI: 10.7759/cureus.70470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Accepted: 09/29/2024] [Indexed: 11/02/2024] Open
Abstract
Necrotizing pancreatitis (NP) is a severe complication of acute pancreatitis, characterized by necrosis of pancreatic and peripancreatic tissues, leading to significant morbidity and mortality. The role of necrosectomy, the surgical removal of necrotic tissue, in the management of NP has evolved over the past few decades, moving from early aggressive surgical intervention to a more conservative and stepwise approach. This narrative review explores the historical perspectives, current practices, and future trends in the role of necrosectomy in NP. Early studies favored open surgical debridement; however, high mortality rates associated with early intervention prompted a shift towards minimally invasive techniques, delayed interventions, and the "step-up approach," combining percutaneous drainage with minimally invasive surgery. We also review the indications for surgery, optimal timing, and various techniques, including video-assisted retroperitoneal debridement and endoscopic transluminal necrosectomy. The review highlights the benefits of these strategies in reducing complications, improving patient outcomes, and minimizing hospital stays. Ongoing research into patient selection, timing, and procedural refinement will continue to shape the role of necrosectomy in NP management. Understanding the evolving role of necrosectomy is crucial for optimizing care and reducing the burden of this life-threatening condition.
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Affiliation(s)
- Khushbu Vaidya
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Raju K Shinde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tushar Nagtode
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ashish Jivani
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Somya Goel
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Joben Samuel
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Researc, Wardha, IND
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He W, Wang Y, Li X, Ji Y, Yuan J, Yang W, Yan S, Yan J. Sealing the Pandora's vase of pancreatic fistula through entrapping the digestive enzymes within a dextrorotary (D)-peptide hydrogel. Nat Commun 2024; 15:7235. [PMID: 39174548 PMCID: PMC11341566 DOI: 10.1038/s41467-024-51734-7] [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: 11/09/2023] [Accepted: 08/16/2024] [Indexed: 08/24/2024] Open
Abstract
A variety of therapeutic possibilities have emerged for skillfully regulating protein function or conformation through intermolecular interaction modulation to rectify abnormal biochemical reactions in diseases. Herein, a devised strategy of enzyme coordinators has been employed to alleviate postoperative pancreatic fistula (POPF), which is characterized by the leakage of digestive enzymes including trypsin, chymotrypsin, and lipase. The development of a dextrorotary (D)-peptide supramolecular gel (CP-CNDS) under this notion showcases its propensity for forming gels driven by intermolecular interaction. Upon POPF, CP-CNDS not only captures enzymes from solution into hydrogel, but also effectively entraps them within the internal gel, preventing their exchange with counterparts in the external milieu. As a result, CP-CNDS completely suppresses the activity of digestive enzymes, effectively alleviating POPF. Remarkably, rats with POPF treated with CP-CNDS not only survived but also made a recovery within a mere 3-day period, while mock-treated POPF rats had a survival rate of less than 5 days when experiencing postoperative pancreatic fistula, leak or abscess. Collectively, the reported CP-CNDS provides promising avenues for preventing and treating POPF, while exemplifying precision medicine-guided regulation of protein activity that effectively targets specific pathogenic molecules across multiple diseases.
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Affiliation(s)
- Wangxiao He
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, PR China.
- Department of Medical Oncology and Department of Talent Highland, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, PR China.
| | - Yang Wang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, PR China
- Department of Tumor and Immunology in Precision Medical Institute, Western China Science and Technology Innovation Port, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Xiao Li
- Department of General Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Yanlin Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, PR China
- Department of Tumor and Immunology in Precision Medical Institute, Western China Science and Technology Innovation Port, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Juzheng Yuan
- Department of Tumor and Immunology in Precision Medical Institute, Western China Science and Technology Innovation Port, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
- Department of General Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Wenguang Yang
- Department of Medical Oncology and Department of Talent Highland, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, PR China
| | - Siqi Yan
- Department of Tumor and Immunology in Precision Medical Institute, Western China Science and Technology Innovation Port, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China
| | - Jin Yan
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, PR China.
- Department of Tumor and Immunology in Precision Medical Institute, Western China Science and Technology Innovation Port, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, China.
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Machado MC, Machado MA. How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy. Updates Surg 2024; 76:1265-1270. [PMID: 38724873 DOI: 10.1007/s13304-024-01867-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/03/2024] [Indexed: 08/24/2024]
Abstract
Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.
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7
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Mukai Y, Asukai K, Akita H, Kubo M, Hasegawa S, Wada H, Miyata H, Ohue M, Sakon M, Takahashi H. Assessing Intra-abdominal status for clinically relevant postoperative pancreatic fistula based on postoperative fluid collection and drain amylase levels after distal pancreatectomy. Ann Gastroenterol Surg 2024; 8:321-331. [PMID: 38455495 PMCID: PMC10914692 DOI: 10.1002/ags3.12741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/26/2023] [Accepted: 09/05/2023] [Indexed: 03/09/2024] Open
Abstract
Aim The aim of this study was to evaluate the intra-abdominal status related to postoperative pancreatic fistula by combining postoperative fluid collection and drain amylase levels. Methods We retrospectively reviewed the data of 203 patients who underwent distal pancreatectomy and classified their postoperative abdominal status into four groups based on postoperative fluid collection size and drain amylase levels. We also evaluated the incidence of clinically relevant postoperative pancreatic fistula in each group according to C-reactive protein values. Results The incidence of clinically relevant postoperative pancreatic fistula in the entire cohort (n = 203) was 28.1%. Multivariate analysis revealed that postoperative fluid collection, drain amylase levels, and C-reactive protein levels are considerable risk factors for clinically relevant postoperative pancreatic fistula. In the subgroup with large postoperative fluid collection and high drain amylase levels, 65.9% of patients developed clinically relevant postoperative pancreatic fistula. However, no significant difference was observed in C-reactive protein levels between patients with clinically relevant postoperative pancreatic fistula and those without it. In contrast, in the subgroup with a large postoperative fluid collection size or a high amylase level alone, a significant difference was observed in C-reactive protein values between the patients with clinically relevant postoperative pancreatic fistula and those without it. Conclusion Postoperative fluid collection status and the C-reactive protein value provide a more precise assessment of intra=abdominal status related to postoperative pancreatic fistula after distal pancreatectomy. This detailed analysis may be a clinically reasonable approach to individual drain management.
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Affiliation(s)
- Yosuke Mukai
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kei Asukai
- Department of SurgeryYao Municipal HospitalOsakaJapan
| | - Hirofumi Akita
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masahiko Kubo
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | | | - Hiroshi Wada
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Miyata
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayuki Ohue
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masato Sakon
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hidenori Takahashi
- Department of SurgeryOsaka International Cancer InstituteOsakaJapan
- Department of Gastroenterological Surgery, Graduate School of MedicineOsaka UniversityOsakaJapan
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8
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Ingwersen EW, Rijssenbeek PMW, Marquering HA, Kazemier G, Daams F. Radiomics for the prediction of a postoperative pancreatic fistula following a pancreatoduodenectomy: A systematic review and radiomic score quality assessment. Pancreatology 2024; 24:306-313. [PMID: 38238193 DOI: 10.1016/j.pan.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a severe complication following a pancreatoduodenectomy. An accurate prediction of POPF could assist the surgeon in offering tailor-made treatment decisions. The use of radiomic features has been introduced to predict POPF. A systematic review was conducted to evaluate the performance of models predicting POPF using radiomic features and to systematically evaluate the methodological quality. METHODS Studies with patients undergoing a pancreatoduodenectomy and radiomics analysis on computed tomography or magnetic resonance imaging were included. Methodological quality was assessed using the Radiomics Quality Score (RQS) and Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement. RESULTS Seven studies were included in this systematic review, comprising 1300 patients, of whom 364 patients (28 %) developed POPF. The area under the curve (AUC) of the included studies ranged from 0.76 to 0.95. Only one study externally validated the model, showing an AUC of 0.89 on this dataset. Overall adherence to the RQS (31 %) and TRIPOD guidelines (54 %) was poor. CONCLUSION This systematic review showed that high predictive power was reported of studies using radiomic features to predict POPF. However, the quality of most studies was poor. Future studies need to standardize the methodology. REGISTRATION not registered.
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Affiliation(s)
- Erik W Ingwersen
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, the Netherlands
| | - Pieter M W Rijssenbeek
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Henk A Marquering
- Amsterdam UMC, Location University of Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Biomedical Engineering and Physics Department, the Netherlands
| | - Geert Kazemier
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Freek Daams
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands.
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Pacella G, Brunese MC, D’Imperio E, Rotondo M, Scacchi A, Carbone M, Guerra G. Pancreatic Ductal Adenocarcinoma: Update of CT-Based Radiomics Applications in the Pre-Surgical Prediction of the Risk of Post-Operative Fistula, Resectability Status and Prognosis. J Clin Med 2023; 12:7380. [PMID: 38068432 PMCID: PMC10707069 DOI: 10.3390/jcm12237380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors. METHODS The PubMed database was searched for papers published in the English language no earlier than January 2018. RESULTS We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective. CONCLUSIONS It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.
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Affiliation(s)
- Giulia Pacella
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | - Maria Chiara Brunese
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | | | - Marco Rotondo
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
| | - Andrea Scacchi
- General Surgery Unit, University of Milano-Bicocca, 20126 Milan, Italy
| | - Mattia Carbone
- San Giovanni di Dio e Ruggi d’Aragona Hospital, 84131 Salerno, Italy;
| | - Germano Guerra
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (G.P.)
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Tian F, Luo MJ, Sun MQ, Lu J, Huang BW, Guo JC. Staple line lockstitch reinforcement decreases clinically relevant pancreatic fistula following distal pancreatectomy: Results of a propensity score matched retrospective analysis. Front Oncol 2022; 12:999002. [PMID: 36338750 PMCID: PMC9634739 DOI: 10.3389/fonc.2022.999002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Postoperative pancreatic fistula (POPF) remains the primary complication of distal pancreatectomies. We aimed to review whether staple line reinforcement with continuous lockstitches would lead to decreased grade B and C pancreatic fistula in patients undergoing distal pancreatectomy. Methods This retrospective study enrolled consecutive patients scheduled to undergo distal pancreatectomy at a large tertiary hospital. A comparison was conducted between lockstitch reinforcement and non-reinforcement for remnant closure during distal pancreatectomies from August 2016 to February 2021. Propensity score matching was applied to balance the two groups with covariates including abdominal and back pain, diabetes mellitus, and estimated blood loss. The primary outcome was POPF rate. Results A total of 153 patients were enrolled in the study (89 lockstitch reinforcements, 64 non-reinforcements), of whom 128 patients (64 per group) were analyzed after propensity score matching (1:1). The total POPF rate was 21.9%. POPF was identified in 12.5% (8/64) of the patients who underwent resection with lockstitch reinforcement and 31.2% (20/64) of the patients without reinforcement (odds ratio 0.314, 95% confidence interval 0.130-0.760, P=0.010). No deaths occurred in either group. Neither the major complication rate nor the length of hospital stay after surgery differed between the groups. Conclusions Compared with the use of stapler alone, staple line lockstitch reinforcement for remnant closure during distal pancreatectomy could reduce the POPF rate. Further multicenter randomized clinical trials are required to confirm these results.
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Affiliation(s)
- Feng Tian
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming-jie Luo
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Meng-qing Sun
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Lu
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo-wen Huang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun-chao Guo
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Jun-chao Guo,
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11
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Brajcich BC, Platoff RM, Thompson VM, Hall B, Ko CY, Pitt HA. Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes? HPB (Oxford) 2022; 24:1252-1260. [PMID: 35034836 DOI: 10.1016/j.hpb.2021.12.017] [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: 06/22/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1). METHODS Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1. RESULTS POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039). CONCLUSION POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.
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Affiliation(s)
- Brian C Brajcich
- American College of Surgeons, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | | | | | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University in Saint Louis School of Medicine, and BJC Healthcare, St Louis, MO USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA, USA; The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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12
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Torres OJM, Moraes-Junior JMA, Fernandes EDSM, Hackert T. Surgical Management of Postoperative Grade C Pancreatic Fistula following Pancreatoduodenectomy. Visc Med 2022; 38:233-242. [PMID: 36160826 PMCID: PMC9421704 DOI: 10.1159/000521727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/19/2021] [Indexed: 08/03/2023] Open
Abstract
Background The incidence of Grade C postoperative pancreatic fistula ranges from 2 to 11% depending on the type of pancreatic resection. This complication may frequently require early relaparotomy and the surgical approach remains technically challenging and is still associated with a high mortality. Infectious complications and post-operative hemorrhage are the two most common causes of reoperation. Summary The best management of grade C pancreatic fistulas remains controversial and ranges from conservative approaches up to completion pancreatectomy. The choice of the technique depends on the patient's conditions, intraoperative findings, and surgeon's discretion. A pancreas-preserving strategy appears to be attractive, including from simple to more complex procedures such as debridement and drainage, and external wirsungostomy. Completion pancreatectomy should be reserved for selected cases, including stable patients with severe infection complication or hemorrhage after pancreatic fistula who do not respond to pancreas-preserving procedures. Key Messages This review describes the current options for management of grade C pancreatic fistula after pancreatoduodenectomy with regard to indication, choice of procedure and outcomes of the different approaches.
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Affiliation(s)
- Orlando Jorge Martins Torres
- Department of Surgery, Hepatopancreatobiliary Unit, Presidente Dutra University Hospital − Maranhão Federal University, São Luiz, Brazil
| | - José Maria Assunção Moraes-Junior
- Department of Surgery, Hepatopancreatobiliary Unit, Presidente Dutra University Hospital − Maranhão Federal University, São Luiz, Brazil
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Abstract
OBJECTIVES Delayed gastric emptying (DGE) is a complication that affects the length of hospitalization and associated cost after pancreaticoduodenectomy (PD). The reported risk factors for DGE were controversial. This study aimed to identify risk factors for the development of DGE after PD. METHODS The patients who underwent PD between October 2010 and October 2020 were retrospectively examined. Multivariate analysis was performed to predict the variables causing DGE. RESULTS In total, 225 patients underwent PD. The pylorus preserving PD was applied to 151 patients (67%), whereas standard PD to 74 (33%). The DGE was detected in 26 patients (11.5%). The majority of cases were classified as grade A (57.7%), whereas 38.4% as grade B and 3.9% as grade C. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 3.48; 95% confidence interval [CI], 1.45-8.34; P = 0.05), the preoperative biliary stent (OR, 2.5; 95% CI, 1.04-5.99; P = 0.039), and the pylorus resection (OR, 3.05; 95% CI, 1.28-7.25; P = 0.012) were independently associated with DGE. CONCLUSIONS We demonstrated that implementation of the preoperative stent, pylorus resection, and diabetes mellitus are independent risk factors for DGE. Pylorus preservation should remain the standard of care in PD.
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Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2022; 3:CD013462. [PMID: 35289922 PMCID: PMC8923262 DOI: 10.1002/14651858.cd013462.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. OBJECTIVES To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. SEARCH METHODS We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. MAIN RESULTS We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.
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Affiliation(s)
- Hua Hai
- Department of Operating Room, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziwei Zhang
- Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Tsunematsu M, Shirai Y, Hamura R, Taniai T, Yanagaki M, Haruki K, Furukawa K, Onda S, Toyama Y, Gocho T, Ikegami T. The clinical management of peripancreatic fluid collection after distal pancreatectomy. Surg Today 2022; 52:1524-1531. [DOI: 10.1007/s00595-022-02483-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/03/2022] [Indexed: 12/01/2022]
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He S, Xia J, Zhang W, Lai M, Cheng N, Liu Z, Cheng Y. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2021; 12:CD010583. [PMID: 34921395 PMCID: PMC8683710 DOI: 10.1002/14651858.cd010583.pub5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. This is the third update of a previously published Cochrane Review to address the uncertain benifits of prophylactic abdominal drainage in pancreatic surgery. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS In this updated review, we re-searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and the Chinese Biomedical Literature Database (CBM) on 08 February 2021. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We conducted the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) or standardized mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. We used GRADE to assess the certainty of the evidence for important outcomes. MAIN RESULTS We identified a total of nine RCTs with 1892 participants. Drain use versus no drain use We included four RCTs with 1110 participants, randomised to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. Low-certainty evidence suggests that drain use may reduce 90-day mortality (RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants). Compared with no drain use, low-certainty evidence suggests that drain use may result in little to no difference in 30-day mortality (RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants), wound infection rate (RR 0.98, 95% CI 0.68 to 1.41; four studies, 1055 participants), length of hospital stay (MD -0.14 days, 95% CI -0.79 to 0.51; three studies, 876 participants), the need for additional open procedures for postoperative complications (RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants), and quality of life (105 points versus 104 points; measured with the pancreas-specific quality of life questionnaire (scale 0 to 144, higher values indicating a better quality of life); one study, 399 participants). There was one drain-related complication in the drainage group (0.2%). Moderate-certainty evidence suggests that drain use probably resulted in little to no difference in morbidity (RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants). The evidence was very uncertain about the effect of drain use on intra-abdominal infection rate (RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-certainty evidence), and the need for additional radiological interventions for postoperative complications (RR 0.87, 95% CI 0.40 to 1.87; three studies, 660 participants; very low-certainty evidence). Active versus passive drain We included two RCTs involving 383 participants, randomised to the active drain group (N = 194) and the passive drain group (N = 189) after pancreatic surgery. Compared with a passive drain, the evidence was very uncertain about the effect of an active drain on 30-day mortality (RR 1.23, 95% CI 0.30 to 5.06; two studies, 382 participants; very low-certainty evidence), intra-abdominal infection rate (RR 0.87, 95% CI 0.21 to 3.66; two studies, 321 participants; very low-certainty evidence), wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; two studies, 321 participants; very low-certainty evidence), morbidity (RR 0.97, 95% CI 0.53 to 1.77; two studies, 382 participants; very low-certainty evidence), length of hospital stay (MD -0.79 days, 95% CI -2.63 to 1.04; two studies, 321 participants; very low-certainty evidence), and the need for additional open procedures for postoperative complications (RR 0.44, 95% CI 0.11 to 1.83; two studies, 321 participants; very low-certainty evidence). There was no drain-related complication in either group. Early versus late drain removal We included three RCTs involving 399 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 200) and the late drain removal group (N = 199) after pancreatic surgery. Compared to late drain removal, the evidence was very uncertain about the effect of early drain removal on 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; three studies, 399 participants; very low-certainty evidence), wound infection rate (RR 1.32, 95% CI 0.45 to 3.85; two studies, 285 participants; very low-certainty evidence), hospital costs (SMD -0.22, 95% CI -0.59 to 0.14; two studies, 258 participants; very low-certainty evidence), the need for additional open procedures for postoperative complications (RR 0.77, 95% CI 0.28 to 2.10; three studies, 399 participants; very low-certainty evidence), and the need for additional radiological procedures for postoperative complications (RR 1.00, 95% CI 0.21 to 4.79; one study, 144 participants; very low-certainty evidence). We found that early drain removal may reduce intra-abdominal infection rate (RR 0.44, 95% CI 0.22 to 0.89; two studies, 285 participants; very low-certainty evidence), morbidity (RR 0.49, 95% CI 0.30 to 0.81; two studies, 258 participants; very low-certainty evidence), and length of hospital stay (MD -2.20 days, 95% CI -3.52 to -0.87; three studies, 399 participants; very low-certainty evidence), but the evidence was very uncertain. None of the studies reported on drain-related complications. AUTHORS' CONCLUSIONS Compared with no drain use, it is unclear whether routine drain use has any effect on mortality at 30 days or postoperative complications after pancreatic surgery. Compared with no drain use, low-certainty evidence suggests that routine drain use may reduce mortality at 90 days. Compared with a passive drain, the evidence is very uncertain about the effect of an active drain on mortality at 30 days or postoperative complications. Compared with late drain removal, early drain removal may reduce intra-abdominal infection rate, morbidity, and length of hospital stay for people with low risk of postoperative pancreatic fistula, but the evidence is very uncertain.
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Affiliation(s)
- Sirong He
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jie Xia
- The Key Laboratory of Molecular Biology on Infectious Diseases, Chongqing Medical University, Chongqing, China
| | - Wei Zhang
- Department of Hepatopancreatobiliary Surgery, The People's Hospital of Jianyang City, Jianyang, China
| | - Mingliang Lai
- Department of Clinical Laboratory, Jiangjin Central Hospital, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Schmuck RB, Lippens E, Wulsten D, Garske DS, Strönisch A, Pratschke J, Sauer IM, Duda GN, Bahra M, Cipitria A. Role of extracellular matrix structural components and tissue mechanics in the development of postoperative pancreatic fistula. J Biomech 2021; 128:110714. [PMID: 34534790 DOI: 10.1016/j.jbiomech.2021.110714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/28/2021] [Accepted: 08/23/2021] [Indexed: 01/04/2023]
Abstract
Radical resection remains the only curative treatment option in pancreatic cancer. Postoperative pancreatic fistulas (POPF) occur in up to 30% of patients leading to prolonged hospital-stay, increased cost of care and morbidity and mortality. Mechanical properties of the pancreas are associated with POPF. The aim of this study is to analyze the role of extracellular matrix (ECM) and tissue mechanics in the risk of POPF. Biopsies of 41 patients receiving a partial pancreas-resection are analyzed. Clinical data, ECM components and mechanical properties are correlated with POPF. Preoperative cholestasis is correlated with reduced risk of POPF, which comes along with a dilatation of the pancreatic duct and significantly higher content of collagen I. Patients developing POPF exhibited a degenerated tissue integrity, with significantly lower content of fibronectin and a trend for lower collagen I, III, IV and hyaluronic acid. This correlated with a soft tactile sensation of the surgeon during the intervention. However, this was not reflected with tissue mechanics evaluated by ex vivo uniaxial compression testing, where a significantly higher elastic modulus and no effect on the stress relaxation time were found. In conclusion, patients with cholestasis seem to have a lower risk for POPF, and an increase in collagen I. A degenerated matrix with lower content of structural ECM components correlates with increased risk of POPF. However, ex vivo uniaxial compression testing failed to clearly explain the link of ECM properties and POPF.
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Affiliation(s)
- Rosa B Schmuck
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow-Klinikum, Berlin 10117, Germany.
| | - Evi Lippens
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, Berlin 13353, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, GermanyBerlin Institute of Health Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin 13353, Germany
| | - Dag Wulsten
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, Berlin 13353, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, GermanyBerlin Institute of Health Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin 13353, Germany
| | - Daniela S Garske
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, Berlin 13353, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, GermanyBerlin Institute of Health Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin 13353, Germany; Max Planck Institute of Colloids and Interfaces, Department of Biomaterials, Potsdam 14476, Germany
| | - Annika Strönisch
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow-Klinikum, Berlin 10117, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow-Klinikum, Berlin 10117, Germany
| | - Igor M Sauer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow-Klinikum, Berlin 10117, Germany
| | - Georg N Duda
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, Berlin 13353, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, GermanyBerlin Institute of Health Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin 13353, Germany
| | - Marcus Bahra
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte I Campus Virchow-Klinikum, Berlin 10117, Germany
| | - Amaia Cipitria
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Augustenburger Platz 1, Berlin 13353, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, GermanyBerlin Institute of Health Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin 13353, Germany; Max Planck Institute of Colloids and Interfaces, Department of Biomaterials, Potsdam 14476, Germany
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18
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Rollin N, Cassese G, Pineton DE Chambrun G, Serrand C, Navarro F, Blanc P, Panaro F, Valats JC. An easy-to-use score to predict Clinically Relevant Post-Operative Pancreatic Fistula after distal pancreatectomy. Minerva Surg 2021; 77:354-359. [PMID: 34693675 DOI: 10.23736/s2724-5691.21.09001-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Postoperative Pancreatic Fistula (POPF) is a common and serious complication after Distal Pancreatectomy (DP). An effective and accepted score to predict the occurrence of Clinically Relevant (CR-) POPF does not exist. METHODS Data regarding 103 consecutive patients undergoing DP from 2015 to 2019 were collected. A multivariate logistic regression was performed, in order to build a simplified score. The accuracy in predicting a categorical outcome was evaluated using the Receiver Operating Characteristic (ROC) curves. Youden's J test was performed to evaluate the performance of a positive score on the POPF occurrence. RESULTS 33 patients developed a CR-POPF. Based on multivariate analysis results, a 4 points score was created by assigning 1 point if operation time was >4 hours, amylase levels on drains' fluid >500 UI on POD 3, pancreatic thickness >10mm and if the BMI was > 30. The discriminating ability was tested on the ROC curve, showing an area under the curve of 0.83 (CI 95%=0.75 - 0.92). The score threshold was determined at 2 points/4, the highest value according to the Youden index (0.53). The sensitivity is calculated at 82% (CI95% 69-95) and the specificity at 71 (CI95% 61 - 82). A threshold of 3 points/4 allows to reach a specificity of 99% (CI95% 99 - 100). CONCLUSIONS An easy to use post-operative score based on operation time, obesity, amylase level on drains on POD3 and pancreatic thickness on preoperative CT seems to predict the risk of developing CR-POPF.
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Affiliation(s)
- Nicolas Rollin
- Department of Gastroenterology and Hepatology, Montpellier University Hospital, Montpellier, France
| | - Gianluca Cassese
- Department of HPB surgery and liver transplantation, Montpellier University Hospital, Montpellier, France.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Chris Serrand
- Department of Statistics, Montpellier University, Montpellier, France
| | - Francis Navarro
- Department of HPB surgery and liver transplantation, Montpellier University Hospital, Montpellier, France
| | - Pierre Blanc
- Department of Gastroenterology and Hepatology, Montpellier University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of HPB surgery and liver transplantation, Montpellier University Hospital, Montpellier, France -
| | - Jean Christoph Valats
- Department of Gastroenterology and Hepatology, Montpellier University Hospital, Montpellier, France
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Postoperative single-sequence (PoSSe) MRI: imaging work-up for CT-guided or endoscopic drainage indication of collections after hepatopancreaticobiliary surgery. Abdom Radiol (NY) 2021; 46:3418-3427. [PMID: 33590307 PMCID: PMC8215044 DOI: 10.1007/s00261-021-02955-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 11/25/2022]
Abstract
Purpose Fluid collections due to anastomotic leakage are a common complication after hepatopancreaticobiliary (HPB) surgery and are usually treated with drainage. We conducted a study to evaluate imaging work-up with a postoperative single-sequence (PoSSe) MRI for the detection of collections and indication of drainage. Material and methods Forty-six patients who developed signs of leakage (fever, pain, laboratory findings) after HPB surgery were prospectively enrolled. Each patient was examined by abdominal sonography and our PoSSe MRI protocol (axial T2-weighted HASTE only). PoSSe MRI examination time (from entering to leaving the MR scanner room) was measured. Sonography and MRI were evaluated regarding the detection and localization of fluid collections. Each examination was classified for diagnostic sufficiency and an imaging-based recommendation if CT-guided or endoscopic drainage is reasonable or not was proposed. Imaging work-up was evaluated in terms of feasibility and the possibility of drainage indication. Results Sonography, as first-line modality, detected 21 focal fluid collections and allowed to decide about the need for drainage in 41% of patients. The average time in the scanning room for PoSSe MRI was 9:23 min [7:50–13:32 min]. PoSSe MRI detected 46 focal collections and allowed therapeutic decisions in all patients. Drainage was suggested based on PoSSe MRI in 25 patients (54%) and subsequently indicated and performed in 21 patients (100% sensitivity and 84% specificity). No patient needed further imaging to optimize the treatment. Conclusions The PoSSe MRI approach is feasible in the early and intermediate postoperative setting after HPB surgery and shows a higher detection rate than sonography. Imaging work-up regarding drainage of collections was successful in all patients and our proposed PoSSe MRI algorithm provides an alternative to the standard work-up.
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Kuscher S, Kiehl T, Kronberger IE, Moser P, Maier H, Maier S, Hautz T, Öfner D, Schneeberger S, Troppmair J. Distal Pancreatic Resection with Splenectomy in the Rat: A Pancreatic Fistula Model to Investigate Postsurgical Damage? Eur Surg Res 2021; 62:97-104. [PMID: 34023826 DOI: 10.1159/000515867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a major complication in pancreatic surgery and can cause considerable postoperative morbidity. Advanced surgical-technical approaches to prevent POPF did not yield a substantial improvement. To investigate innovative treatments, experimental animal models of distal pancreatic resection and pancreaticoduodenectomy are of fundamental importance. After a failed attempt to replicate a previously described rat model for pancreatic fistula induction, we proceeded to distal pancreatic resection with splenectomy to provoke pancreatic leakage and generate a suitable animal model. METHODS Distal pancreatic resection with splenectomy was performed in 40 rats. The rats were sacrificed on postoperative day (POD) 1, 2, 4, 6, 8, or 10, and the abdominal cavity was explored. Ascites probes were collected pre- and postoperatively for the detection of pancreas amylase and lipase. Tissue samples from the naïve pancreas (POD 0) and the postoperatively harvested remnant were evaluated histologically. The extent of necrosis was determined, and samples were examined for neutrophil infiltration. TUNEL staining served for the verification of necrosis in distinct cases. Immunohistochemistry of Ki67, von Willebrand factor, and CD68 was performed to evaluate proliferation, blood-vessel sprouting, and macrophage invasion. RESULTS The rats showed no clinical symptoms or severe complications in the postoperative course up to 10 days. Abdominal exploration revealed adhesions in the upper abdomen, but no intra-abdominal fluid accumulations were found. Signs of inflammation and tissue damage were evident at the pancreatic resection margin on histological examination whereas the naïve pancreatic tissue was widely unaffected. Statistically significant differences were seen between the preoperative and postoperative extent of necrosis, the presence of neutrophil infiltrate, and levels of ascitic amylase and lipase. Immunohistochemical staining on Ki67, von Willebrand factor, and CD68 did not reveal any workable results on nonstatistical examination, and it was therefore not considered for further analyses. CONCLUSION Creating a functional animal model of pancreatic fistula that reflects the clinical and pathophysiological impact of pancreatic leakage in humans has not been achieved. Our approach of left pancreatic resection recapitulated inflammation and tissue damage, early events in the development of fistulas, and it could be suitable for the experimental testing of novel targeting methods.
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Affiliation(s)
- Stefanie Kuscher
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Kiehl
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Irmgard Elisabeth Kronberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrizia Moser
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Hans Maier
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Sarah Maier
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Troppmair
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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21
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Mungroop TH, Klompmaker S, Wellner UF, Steyerberg EW, Coratti A, D'Hondt M, de Pastena M, Dokmak S, Khatkov I, Saint-Marc O, Wittel U, Abu Hilal M, Fuks D, Poves I, Keck T, Boggi U, Besselink MG. Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation. Ann Surg 2021; 273:334-340. [PMID: 30829699 DOI: 10.1097/sla.0000000000003234] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort. BACKGROUND MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted, and hybrid MIPD. METHODS A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (International Study Group on Pancreatic Surgery grade B/C). Model performance was assessed using the area under the receiver operating curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance. RESULTS Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (odds ratio 4.6, 95 confidence interval [CI] 2.8-7.6) and male sex (odds ratio 1.9, 95 CI 1.4-2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95 CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD and open pancreatoduodenectomy. CONCLUSIONS The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.
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Affiliation(s)
- Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Ulrich F Wellner
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) Studien-, Dokumentations- und Qualitätszentrum (StuDoQ|Pancreas), Germany
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrea Coratti
- Department of Oncology and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Matteo de Pastena
- Department of Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Régional Orleans, Orleans, France
| | - Uwe Wittel
- Department of Visceral and General Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Ignasi Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Tobias Keck
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) Studien-, Dokumentations- und Qualitätszentrum (StuDoQ|Pancreas), Germany
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
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22
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Maatman TK, Weber DJ, Qureshi B, Ceppa EP, Nakeeb A, Schmidt CM, Zyromski NJ, House MG. Does the Microbiology of Bactibilia Drive Postoperative Complications After Pancreatoduodenectomy? J Gastrointest Surg 2020; 24:2544-2550. [PMID: 31745903 DOI: 10.1007/s11605-019-04432-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/18/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The influence of bile microflora, particularly with broad antimicrobial resistance patterns, on postoperative outcomes after pancreatoduodenectomy (PD), is poorly understood. The aim of this study was to determine the influence of the microbiology of bactibilia on postoperative outcomes following PD. METHODS Intraoperative bile cultures were obtained in 162 patients undergoing PD between 2015 and 2017. Intraoperative bile cultures were analyzed and correlated with short-term outcomes after PD. Independent groups t test, Pearson's correlation, or Fisher's exact tests were performed. Hazard ratios (HR) are reported with 95% confidence intervals (CI). Statistical significance was defined as P value of < 0.05. RESULTS Intraoperative bile cultures were positive in 89/162 patients (55%). The most common bacteria were Enterococcus spp. (n = 48, 54%), Klebsiella spp. (n = 24, 27%), and Enterobacter spp. (n = 17, 19%). Bactibilia was not associated with increased infectious complications, postoperative pancreatic fistula (POPF), or mortality. Enterococcus and Enterobacter were associated with higher rates of incisional (HR, 6.5; 95% CI, 1.2-34.8; P = 0.03) and organ-space surgical site infection (HR, 4.9; 95% CI, 1.1-22.0; P = 0.03), respectively. No single bacterium was associated with POPF, bile leak, cholangitis, 30- or 90-day mortality. CONCLUSION Bactibilia, in general, does not increase the risk of developing a postoperative complication following pancreatoduodenectomy; however, Enterococcus and Enterobacter increase the likelihood of developing incisional and organ-space surgical infections, respectively.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - Daniel J Weber
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - Beenish Qureshi
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., 5th floor, Indianapolis, IN, 46202, USA.
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Klaiber U, Sauer P, Martin E, Bruckner T, Luntz S, Tjaden C, Probst P, Knebel P, Diener MK, Buchler MW, Hackert T. Protocol of a randomised controlled phase II clinical trial investigating PREoperative endoscopic injection of BOTulinum toxin into the sphincter of Oddi to reduce postoperative pancreatic fistula after distal pancreatectomy: the PREBOT Pilot trial. BMJ Open 2020; 10:e036815. [PMID: 32878758 PMCID: PMC7470495 DOI: 10.1136/bmjopen-2020-036815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) is still the most frequently occurring and clinically relevant complication after distal pancreatectomy (DP). Preoperative endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi represents an innovative approach to prevent POPF. The aim of this project (PREBOTPilot) is to generate the first randomised controlled trial data on the safety, feasibility and efficacy of preoperative endoscopic BTX injection into the sphincter of Oddi to prevent clinically relevant POPF following DP. METHODS AND ANALYSIS PREBOTPilot is an investigator-initiated, single-centre, randomised, controlled, open-label, phase II clinical trial with two parallel study groups and an exploratory study design. 60 patients scheduled for DP will be randomised to intervention and control group. In the intervention group, patients will undergo preoperative endoscopic injection of BTX into the sphincter of Oddi, whereas in the control group no preoperative endoscopy will be performed. The combined primary endpoint is the occurrence of clinically relevant POPF and/or death within 30 days after DP. The secondary endpoints comprise further postoperative outcome parameters and quality of life up to 3 months after DP as well as safety and feasibility of the procedure. Statistical analysis is based on the modified intention-to-treat population, excluding patients without status post DP. For safety analysis, rates of adverse events (AEs) and serious AEs will be calculated with 95% CIs for group comparisons. ETHICS, FUNDING AND DISSEMINATION PREBOTPilot has been approved by the German Federal Institute for Drugs and Medical Devices (reference number 4043654) and the Ethics Committee of Heidelberg University (reference number AFmo-523/2019). This trial is supported by the German Federal Ministry of Education and Research (BMBF). The results of the trial will be presented at national and international conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER DRKS00020401.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Peter Sauer
- Interdisciplinary Centre of Endoscopy, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Eike Martin
- Patient Advocacy, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Steffen Luntz
- Coordination Centre for Clinical Trials (KKS), University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Christine Tjaden
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus W Buchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
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Shinde RS, Acharya R, Chaudhari VA, Bhandare MS, Mungroop TH, Klompmaker S, Besselink MG, Shrikhande SV. External validation and comparison of the original, alternative and updated-alternative fistula risk scores for the prediction of postoperative pancreatic fistula after pancreatoduodenectomy. Pancreatology 2020; 20:751-756. [PMID: 32340876 DOI: 10.1016/j.pan.2020.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many postoperative pancreatic fistula (POPF) predictions models were developed and validated in western populations. Direct use of these models in the large Indian/Asian population, however, requires proper validation. OBJECTIVE To validate the original, alternative and updated alternative fistula risk score (FRS) models. METHODS A validation study was performed in consecutive patients undergoing pancreatoduodenectomy (PD) from January 2011 to March 2018. The area under the receiver operating curve (ROC) and calibration plots were used to assess the performance of original-FRS (o-FRS), alternative FRS (a-FRS) and updated alternative FRS (ua-FRS) models. RESULTS This cohort consisted of 825 patients of which 66% were males with a median age of 55 years and mean body mass index of 22.6. The majority of tumors (61.8%) were of periampullary origin. Clinically relevant POPF was observed in 16.8% patients. Area under curve (AUC) of ROC for the o-FRS was 0.65, 0.69 for a-FRS and 0.70 for ua-FRS, respectively (p = 0.006). CONCLUSIONS In this large Indian cohort of predominantly periampullary tumors, the ua-FRS performed better than the a-FRS and o-FRS, although differences were small. Since the AUC value of the ua-FRS is at the accepted threshold there might be room for improvement for a FRS.
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Affiliation(s)
- Rajesh S Shinde
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajgopal Acharya
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vikram A Chaudhari
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Manish S Bhandare
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Shailesh V Shrikhande
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.
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Gupta S, Attri AK, Sharma R, Gureh M, Nasir MI. Binding Pancreaticojejunostomy: Is It Safe? Niger J Surg 2020; 26:48-52. [PMID: 32165836 PMCID: PMC7041346 DOI: 10.4103/njs.njs_17_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/20/2019] [Accepted: 09/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background: Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ. Methods: The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality. Results: A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality. Conclusion: BPJ is safe and is associated with a low incidence of POPF.
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Affiliation(s)
- Sanjay Gupta
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Ashok K Attri
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Rajeev Sharma
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Monika Gureh
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Md Imran Nasir
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
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Deng Y, He S, Cheng Y, Cheng N, Gong J, Gong J, Zeng Z, Zhao L. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2020; 3:CD009621. [PMID: 32157697 PMCID: PMC7064369 DOI: 10.1002/14651858.cd009621.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019). SELECTION CRITERIA We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Yilei Deng
- The First Affiliated Hospital of Zhengzhou UniversityDepartment of Hepatopancreatobiliary SurgeryNo. 1, Jianshe East RoadZhengzhouHenan ProvinceChina450000
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 74, Lin Jiang Road, ChongqingChongqingChina400010
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 74, Lin Jiang Road, ChongqingChongqingChina400010
| | - Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingYunnanChina650032
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingYunnanChina650032
| | - Longshuan Zhao
- The First Affiliated Hospital of Zhengzhou UniversityDepartment of Hepatopancreatobiliary SurgeryNo. 1, Jianshe East RoadZhengzhouHenan ProvinceChina450000
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Lee SC, Hong TH, Kim OH, Cho SJ, Kim KH, Song JS, Hwang KS, Jung JK, Hong HE, Seo H, Choi HJ, Ahn J, Lee TY, Rim E, Jung KY, Kim SJ. A Novel Way of Preventing Postoperative Pancreatic Fistula by Directly Injecting Profibrogenic Materials into the Pancreatic Parenchyma. Int J Mol Sci 2020; 21:ijms21051759. [PMID: 32143463 PMCID: PMC7084673 DOI: 10.3390/ijms21051759] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 12/13/2022] Open
Abstract
This paper aims to validate if intrapancreatic injection of penicillin G can enhance hardness and suture holding capacity (SHC) of the pancreas through prompting the fibrosis process. Soft pancreatic texture is constantly mentioned as one of the most contributory predictors of postoperative pancreatic fistula (POPF). Soft pancreas has poor SHC and higher incidence of parenchymal tearing, frequently leading to POPF. From a library of 114 antibiotic compounds, we identified that penicillin G substantially enhanced pancreatic hardness and SHC in experimental mice. Specifically, we injected penicillin G directly into the pancreas. On determined dates, we measured the pancreatic hardness and SHC, respectively, and performed molecular and histological examinations for estimation of the degree of fibrosis. The intrapancreatic injection of penicillin G activated human pancreatic stellate cells (HPSCs) to produce various fibrotic materials such as transforming growth factor-β1 (TGF-β1) and metalloproteinases-2. The pancreatic hardness and SHC were increased to the maximum at the second day after injection and then it gradually subsided demonstrating its reversibility. Pretreatment of mice with SB431542, an inhibitor of the TGF-β1 receptor, before injecting penicillin G intrapancreatically, significantly abrogated the increase of both pancreatic hardness and SHC caused by penicillin G. This suggested that penicillin G promotes pancreatic fibrosis through the TGF-β1 signaling pathway. Intrapancreatic injection of penicillin G promotes pancreatic hardness and SHC by enhancing pancreatic fibrosis. We thus think that penicillin G could be utilized to prevent and minimize POPF, after validating its actual effectiveness and safety by further studies.
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Affiliation(s)
- Sang Chul Lee
- Department of Surgery, Daejeon St. Mary’s Hospital, College of Medicine, the Catholic University of Korea, Daejeon 34943, Korea;
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
| | - Tae Ho Hong
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Ok-Hee Kim
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Suk Joon Cho
- College of Pharmacy, Chungbuk National University, Cheongju 28644, Korea; (S.J.C.); (J.-K.J.)
| | - Kee-Hwan Kim
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
- Department of Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 11765, Korea
| | - Jin Sook Song
- Bio & Drug Discovery Division, Korea Research Institute of Chemical Technology, Daejeon 34114, Korea; (J.S.S.); (K.-S.H.); (K.-Y.J.)
| | - Kyu-Seok Hwang
- Bio & Drug Discovery Division, Korea Research Institute of Chemical Technology, Daejeon 34114, Korea; (J.S.S.); (K.-S.H.); (K.-Y.J.)
| | - Jae-Kyung Jung
- College of Pharmacy, Chungbuk National University, Cheongju 28644, Korea; (S.J.C.); (J.-K.J.)
| | - Ha-Eun Hong
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Haeyeon Seo
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Joseph Ahn
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Tae Yoon Lee
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
| | - Eunyoung Rim
- Deparpment of Medicinal Chemistry and Pharmacology, University of Science & Technology, Daejeon 34113, Korea;
| | - Kwan-Young Jung
- Bio & Drug Discovery Division, Korea Research Institute of Chemical Technology, Daejeon 34114, Korea; (J.S.S.); (K.-S.H.); (K.-Y.J.)
- Deparpment of Medicinal Chemistry and Pharmacology, University of Science & Technology, Daejeon 34113, Korea;
| | - Say-June Kim
- Catholic Central Laboratory of Surgery, Institute of Biomedical Industry, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (T.H.H.); (O.-H.K.); (K.-H.K.); (H.-E.H.); (H.S.)
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.J.C.); (J.A.); (T.Y.L.)
- Correspondence: ; Fax: +822-535-0070
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Li T, D'Cruz RT, Lim SY, Shelat VG. Somatostatin analogues and the risk of post-operative pancreatic fistulas after pancreatic resection - A systematic review & meta-analysis. Pancreatology 2020; 20:158-168. [PMID: 31980352 DOI: 10.1016/j.pan.2019.12.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a common complication of pancreatic resection. Somatostatin analogues (SA) have been used as prophylaxis to reduce its incidence. The aim of this study is to appraise the current literature on the effects of SA prophylaxis on the prevention of POPF following pancreatic resection. METHODS The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from studies that reported the effects of SA prophylaxis on POPF following pancreatic resection were extracted, to determine the effect of SA on POPF morbidity and mortality. RESULTS A total of 15 studies, involving 2221 patients, were included. Meta-analysis revealed significant reductions in overall POPF (Odds ratio: 0.65 (95% CI 0.53-0.81, p < 0.01)), clinically significant POPF (Odds ratio: 0.53 (95% CI 0.34-0.83, p < 0.01)) and overall morbidity (OR: 0.69 (95% CI: 0.50-0.95, p = 0.02)) following SA prophylaxis. There is no evidence that SA prophylaxis reduces mortality (OR: 1.10 (95%CI: 0.68-1.79, p = 0.68)). CONCLUSION SA prophylaxis following pancreatic resection reduces the incidence of POPF. However, mortality is unaffected.
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Affiliation(s)
- Tianpei Li
- Yong Loo Lin School of Medicine, National University, Singapore.
| | - Reuban Toby D'Cruz
- Department of General Surgery, National University Health System, Singapore
| | - Sheng Yang Lim
- Yong Loo Lin School of Medicine, National University, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Müssle B, Oehme F, Schade S, Sommer M, Bogner A, Hempel S, Pochhammer J, Kahlert C, Distler M, Weitz J, Welsch T. Drain Amylase or Lipase for the Detection of POPF-Adding Evidence to an Ongoing Discussion. J Clin Med 2019; 9:jcm9010007. [PMID: 31861508 PMCID: PMC7019284 DOI: 10.3390/jcm9010007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives: A postoperative pancreatic fistula (POPF) is defined as a threefold increase in the amylase concentration in abdominal drains on or after the third postoperative day (POD). However, additional lipase fluid analysis is widely used despite lacking evidence. In this study, drain amylase and lipase levels were compared regarding their value in detecting POPF. Methods: We conducted a retrospective study including all patients who underwent pancreatic resections at our center between 2005 and 2016. Drain fluid analysis was performed from day 2 to 5. Results: 990 patients were included in the analysis. Overall, 333 (34%) patients developed a POPF. The median amylase and lipase concentrations at POD 3 in cases with POPF were 11.55 µmol/(s·L) (≈13 ×-fold increase) and 39 µmol/(s·L) (≈39 ×-fold increase), respectively. Seven patients with subsequent POPF (2%) were missed with amylase analysis on POD 3, but detected using 3-fold lipase analysis. The false-positive rate of lipase was 51/424 = 12%. A cutoff lipase value at POD 3 of > 4.88 yielded a specificity of 94% and a sensitivity of 89% for development of a POPF. Increased body mass index turned out as risk factor for the development of POPF in a multivariable model. Conclusions: Threefold-elevated lipase concentration may be used as an indicator of a POPF. However, the additional detection of POPF using simultaneous lipase analysis is marginal. Therefore, assessment of lipase concentration does not provide added clinical value and only results in extra costs.
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Affiliation(s)
- Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Stephanie Schade
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Marian Sommer
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Julius Pochhammer
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
- Correspondence: ; Tel.: +49-(0)351-458-18283
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Ratnayake CBB, Wells C, Hammond J, French JJ, Windsor JA, Pandanaboyana S. Network meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy. Br J Surg 2019; 106:1580-1589. [PMID: 31626341 DOI: 10.1002/bjs.11291] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/27/2019] [Accepted: 05/30/2019] [Indexed: 01/04/2025]
Abstract
BACKGROUND The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy remains high, and different pancreatic stump closure techniques have been used to reduce the incidence. A network meta-analysis was undertaken to compare the most frequently performed pancreatic stump closure techniques after distal pancreatectomy and determine the technique associated with the lowest POPF rate. METHODS A systematic search of the Scopus, PubMed, MEDLINE and Embase databases was conducted to identify eligible RCTs. The primary outcome was the occurrence of clinically relevant POPF. Secondary outcomes were duration of operation, blood loss, intrabdominal collections, postoperative complications and 30-day mortality. RESULTS Sixteen RCTs including 1984 patients and eight different pancreatic stump closure techniques were included in the network meta-analysis. Patch coverage of the pancreatic stump (round ligament or seromuscular patch) after stapler or suture closure ranked best, with the lowest rates of clinically relevant POPF, lowest volume of intraoperative blood loss, fewer intra-abdominal abscesses, and lower rates of overall complications and 30-day mortality. Round ligament patch closure outperformed seromuscular patch closure in preventing clinically relevant POPF with a significantly larger cohort for comparative analysis. Pancreaticoenteric anastomotic closure consistently ranked poorly for most reported postoperative outcomes. CONCLUSION Patch coverage after stapler or suture closure has the lowest POPF rate and best outcomes among stump closure techniques after distal pancreatectomy.
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Affiliation(s)
- C B B Ratnayake
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Hepatopancreatobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - C Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Hepatopancreatobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - J Hammond
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - J J French
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - J A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Hepatopancreatobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - S Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
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Cheng Y, He S, Xia J, Ding X, Liu Z, Gong J. Duct-to-mucosa pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Sirong He
- Chongqing Medical University; Department of Immunology, College of Basic Medicine; No. 1 Yixue Road Chongqing China 450000
| | - Jie Xia
- Chongqing Medical University; The Key Laboratory of Molecular Biology on Infectious Diseases; Chongqing China 450000
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
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Yoshino J, Ban D, Ogura T, Ogawa K, Ono H, Mitsunori Y, Kudo A, Tanaka S, Tanabe M. The Clinical Implications of Peripancreatic Fluid Collection After Distal Pancreatectomy. World J Surg 2019; 43:2069-2076. [PMID: 31004209 DOI: 10.1007/s00268-019-05009-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Pancreatic fistula after distal pancreatectomy (DP) remains an unsolved problem, and postoperative CT imaging often demonstrates fluid collection (FC) around the pancreatic remnant. This study sought to clarify the clinical implications of FC. METHODS This study enrolled 146 patients who underwent DP. FC was defined as a cyst-like lesion ≥ 10 mm in diameter on CT imaging at postoperative day (POD) 7. FC size, irregularity of FC margin, and air bubbles in FC were investigated. In addition, clinical data were retrospectively collected, and useful predictive factors for postoperative pancreatic fistula (POPF) were analyzed. RESULTS Clinically relevant POPF was observed in 26 patients (17.8%), and FC was detected in 136 patients (94.4%). Multivariate analysis identified FC size and drain amylase levels on POD3 as significant risk factors for POPF. Cutoff values were determined by ROC analyses, and the levels of the FC size and drain amylase on POD3 were determined as 41 mm and 1026 IU/L, respectively. The sensitivity and specificity of FC diameters > 41 mm were 76.9% and 75.0%, respectively, while those of drain amylase levels > 1026 IU on POD3 were 73.1% and 75.8%, respectively. CONCLUSIONS While treating some FCs after DP was necessary for the management of POPF, others did not require any intervention since most of them spontaneously disappeared. FC size and drain amylase levels on POD3 were found to be significantly associated with POPF and could potentially help to determine appropriate treatment.
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Affiliation(s)
- Jun Yoshino
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Toshiro Ogura
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kosuke Ogawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroaki Ono
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Mitsunori
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Shinji Tanaka
- Department of Molecular Oncology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Lower phosphate levels following pancreatectomy is associated with postoperative pancreatic fistula formation. HPB (Oxford) 2019; 21:834-840. [PMID: 30503649 DOI: 10.1016/j.hpb.2018.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/16/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Whereas hypophosphatemia following hepatectomy is associated with decreased morbidity, hypophosphatemia following pancreatectomy may be associated with increased morbidity, including the development of postoperative pancreatic fistula (POPF). This study aimed to evaluate the relationship between postoperative hypophosphatemia and POPF formation. METHODS Patients from our institutional Research Patient Data Registry who underwent pancreatectomy from 2001 to 2017 were included. POPF was defined according to the International Study Group for Pancreatic Fistulas (ISGPF) criteria and according to internal criteria for drain removal. Postoperative serum phosphate levels, demographics, and comorbidities were evaluated. Unadjusted and adjusted analyses were performed. RESULTS 2342 patients underwent pancreatic resection. Mean age was 63.0 years (SD 14.3), 51.2% were male, and 58.7% had pancreatic cancer. Of all resections, 67.7% were pancreaticoduodenectomies. In unadjusted analysis, phosphate levels were significantly and persistently lower on POD 0 and POD 2-5 in patients who developed POPF's. In adjusted analysis, POD 2 phosphate <1.75 predicted an additional 46% increased odds of POPF (OR 1.46 95% CI 1.06-2.01; p = 0.02). Distal pancreatectomy was independently associated with POPF formation when compared to pancreaticoduodenectomy (OR 1.72 95% CI 1.18-2.51; p = 0.005). CONCLUSION Lower phosphate levels in the early post-operative period following both proximal and distal pancreatectomies is associated with increased risk of POPF.
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Outcomes and Complications of Double Roux Loop Reconstruction in Pancreaticoduodenectomy: A Single Center Experience. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2019. [DOI: 10.5812/ijcm.91388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Suyama Y, Hoshikawa M, Yoshikawa H, Murakami W, Soga S, Aosasa S, Yamamoto J, Shinmoto H. Restoration of Dehiscent Pancreaticojejunostomy Causing a Major Postoperative Pancreatic Fistula by Reinsertion of a Pancreatic Duct Tube Using the Rendezvous Technique. Cardiovasc Intervent Radiol 2019; 42:1358-1362. [DOI: 10.1007/s00270-019-02228-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/19/2019] [Indexed: 12/28/2022]
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36
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Outcomes following pancreatic resections—results and challenges of an Austrian university hospital compared to nationwide data and international centres. Eur Surg 2019. [DOI: 10.1007/s10353-019-0585-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Lin J, Ni B, Liu G. Percutaneous Endoscopic Necrosectomy (PEN) Combined with Percutaneous Catheter Drainage (PCD) and Irrigation for the Treatment of Clinically Relevant Pancreatic Fistula after Pancreatoduodenectomy. J INVEST SURG 2018; 33:317-324. [PMID: 30587050 DOI: 10.1080/08941939.2018.1511014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose: This study aimed to evaluate the efficacy of percutaneous endoscopic necrosectomy (PEN) combined with percutaneous catheter drainage (PCD) and irrigation versus PCD for the treatment of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). Materials and Methods: A total of 34 consecutive patients who suffered from CR-POPF after PD were enrolled in this retrospective cohort study. 12 patients received PEN combined with PCD and irrigation, and 22 patients received PCD. The complications and outcomes of the treatments were compared. Results: No patients suffered from severe PCD- or PEN-related complications. Compared with those treated with PCD, the patients treated with PEN combined with PCD and irrigation had a lower incidence of postoperative delayed severe intraabdominal hemorrhage (31.8% vs. 0%; p = 0.04). During the follow-up period, no patients in either group suffered from collection recurrence or external pancreatic fistula requiring surgical intervention.Conclusions: PEN combined with PCD and irrigation was safe and effective for reducing postoperative delayed severe intraabdominal hemorrhage in patients with CR-POPF after PD.
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Affiliation(s)
- Jian Lin
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, PR China
| | - Biqing Ni
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, PR China
| | - Guozhong Liu
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, PR China
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Loos M, Strobel O, Legominski M, Dietrich M, Hinz U, Brenner T, Heininger A, Weigand MA, Büchler MW, Hackert T. Postoperative pancreatic fistula: Microbial growth determines outcome. Surgery 2018; 164:1185-1190. [PMID: 30217397 DOI: 10.1016/j.surg.2018.07.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is a dangerous complication in pancreatic surgery. This study assessed the impact of microbiologic pathogens detected in postoperative pancreatic fistula on clinical outcomes after partial pancreatoduodenectomy and distal pancreatectomy. METHODS Microorganisms in postoperative pancreatic fistula were identified by microbiologic analyses from abdominal drains or intraoperative swabs during relaparotomy. Demographic, operative, and microbiologic data, as well as postoperative outcomes were examined. RESULTS Of 2,752 patients undergoing partial pancreatoduodenectomy and distal pancreatectomy, 256 patients with clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grades B and C) were identified (9.3%) and microbiologic cultures were positive in 210 patients (82.0%), with a higher rate after partial pancreatoduodenectomy (95.8%) than after distal pancreatectomy (64.3%; P < .001). Microbiologic spectra differed distinctively between partial pancreatoduodenectomy and distal pancreatectomy. Detection of microorganisms in postoperative pancreatic fistula resulted in a higher morbidity and mortality, including postpancreatectomy hemorrhage (42.4% vs 21.7%; P = .009), sepsis (38.1% vs 6.5%; P < .001), wound infection (30.0% vs 6.5%; P = .001), reoperation (48.1% vs 10.9%; P < .001), hospital stay (median 42 vs 26 days; P < .001), and overall 90-day mortality (19.5% vs 4.3%; P = .013) and was identified as an independent risk factor for sepsis, wound infection, and reoperation in the multivariate analysis. CONCLUSION Detection of microorganisms in postoperative pancreatic fistula is frequent after pancreatic resection and indicates a turning point in the development of postoperative pancreatic fistula into a life-threatening condition. Whether early anti-infective therapy in combination with interventional measures or a surgical reintervention are warranted, has yet to be elucidated.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Matthias Legominski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Maximilian Dietrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Alexandra Heininger
- Department of Infectious Diseases, Institute of Medical Microbiology and Hygiene, University of Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Torres OJM, Costa RCNDC, Costa FFM, Neiva RF, Suleiman TS, Souza YLMS, Shrikhande SV. MODIFIED HEIDELBERG TECHNIQUE FOR PANCREATIC ANASTOMOSIS. ACTA ACUST UNITED AC 2018; 30:260-263. [PMID: 29340550 PMCID: PMC5793144 DOI: 10.1590/0102-6720201700040008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/21/2017] [Indexed: 12/17/2022]
Abstract
Background: Pancreatic fistula is a major cause of morbidity and mortality after
pancreatoduodenectomy. To prevent this complication, many technical
procedures have been described. Aim: To present a novel technique based on slight modifications of the original
Heidelberg technique, as new pancreatojejunostomy technique for
reconstruction of pancreatic stump after pancreatoduodenectomy and present
initial results. Method: The technique was used for patients with soft or hard pancreas and with duct
size smaller or larger than 3 mm. The stitches are performed with 5-0 double
needle prolene at the 2 o’clock, 4 o’clock, 6 o’clock, 8 o’clock, 10
o’clock, and 12 o’clock, positions, full thickness of the parenchyma. A
running suture is performed with 4-0 single needle prolene on the posterior
and anterior aspect the pancreatic parenchyma with the jejunal seromuscular
layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and
extended into the jejunal lumen. Two previously placed hemostatic sutures on
the superior and inferior edges of the remnant pancreatic stump are passed
in the jejunal seromuscular layer and tied. Results: Seventeen patients underwent pancreatojejunostomy after
pancreatoduodenectomy for different causes. None developed grade B or C
pancreatic fistula. Biochemical leak according to the new definition
(International Study Group on Pancreatic Surgery) was observed in four
patients (23.5%). No mortality was observed. Conclusion: Early results of this technique confirm that it is simple, reliable, easy to
perform, and easy to learn. This technique is useful to reduce the incidence
of pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- Orlando Jorge M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Federal University of Maranhão, São Luiz, MA, Brazil
| | - Roberto C N da Cunha Costa
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Federal University of Maranhão, São Luiz, MA, Brazil
| | - Felipe F Macatrão Costa
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Federal University of Maranhão, São Luiz, MA, Brazil
| | - Romerito Fonseca Neiva
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Federal University of Maranhão, São Luiz, MA, Brazil
| | - Tarik Soares Suleiman
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Federal University of Maranhão, São Luiz, MA, Brazil
| | - Yglésio L Moyses S Souza
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Federal University of Maranhão, São Luiz, MA, Brazil
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Vass DG, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts K, Sutcliffe RP. Utility of drain fluid amylase measurement on the first postoperative day after distal pancreatectomy. HPB (Oxford) 2018; 20:803-808. [PMID: 29802050 DOI: 10.1016/j.hpb.2017.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 06/29/2017] [Accepted: 08/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early exclusion of a postoperative pancreatic fistula (POPF) may facilitate earlier drain removal in selected patients after distal pancreatectomy. The purpose of this study was to evaluate the role of first postoperative day drain fluid amylase (DFA1) measurement to predict POPF. METHODS Patients in whom DFA1 was measured after distal pancreatectomy were identified from a prospectively maintained database over a five-year period. A cut-off value of DFA1 was derived using ROC analysis, which yielded sensitivity and negative predictive value of 100% for excluding POPF. RESULTS DFA1 was available in 53 of 138 (38%) patients who underwent distal pancreatectomy. 19 of 53 patients (36%) developed a pancreatic fistula (Grade A - 15, Grade B - 3, Grade C - 1). Median DFA1 was significantly higher in those who developed a pancreatic fistula (5473; range 613-28,450) compared those without (802; range 57-2350). p < 0.0001. Using ROC analysis, a DFA1 less than 600 excluded pancreatic fistula with a sensitivity of 100% (AUROC of 0.91; SE = 0.04, p < 0.001). CONCLUSION First postoperative day drain fluid amylase measurement may have a role in excluding pancreatic fistula after distal pancreatectomy. Such patients may be suitable for earlier drain removal.
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Affiliation(s)
- David G Vass
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, UK
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
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Gong J, He S, Cheng Y, Cheng N, Gong J, Zeng Z. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2018; 6:CD009621. [PMID: 29934987 PMCID: PMC6513198 DOI: 10.1002/14651858.cd009621.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018). SELECTION CRITERIA We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
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Zhang W, He S, Cheng Y, Xia J, Lai M, Cheng N, Liu Z. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2018; 6:CD010583. [PMID: 29928755 PMCID: PMC6513487 DOI: 10.1002/14651858.cd010583.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS For the last version of this review, we searched CENTRAL (2016, Issue 8), and MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database (CBM) to 28 August 2016). For this updated review, we searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2016 to 15 November 2017. SELECTION CRITERIA We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled studies that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS We identified six studies (1384 participants). Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. MAIN RESULTS Drain use versus no drain useWe included four studies with 1110 participants, who were randomized to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. There was little or no difference in mortality at 30 days between groups (1.5% with drains versus 2.3% with no drains; RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants; moderate-quality evidence). Drain use probably slightly reduced mortality at 90 days (0.8% versus 4.2%; RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants; moderate-quality evidence). We were uncertain whether drain use reduced intra-abdominal infection (7.9% versus 8.2%; RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-quality evidence), or additional radiological interventions for postoperative complications (10.9% versus 12.1%; RR 0.87, 95% CI 0.79 to 2.23; three studies, 660 participants; very low-quality evidence). Drain use may lead to similar amount of wound infection (9.8% versus 9.9%; RR 0.98 , 95% CI 0.68 to 1.41; four studies, 1055 participants; low-quality evidence), and additional open procedures for postoperative complications (9.4% versus 7.1%; RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants; low-quality evidence) when compared with no drain use. There was little or no difference in morbidity (61.7% versus 59.7%; RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants; moderate-quality evidence), or length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies, 711 participants; moderate-quality evidence) between groups. There was one drain-related complication in the drainage group (0.2%). Health-related quality of life was measured with the pancreas-specific quality-of-life questionnaire (FACT-PA; a scale of 0 to 144 with higher values indicating a better quality of life). Drain use may lead to similar quality of life scores, measured at 30 days after pancreatic surgery, when compared with no drain use (105 points versus 104 points; one study, 399 participants; low-quality evidence). Hospital costs and pain were not reported in any of the studies.Type of drainWe included one trial involving 160 participants, who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. An active drain may lead to similar mortality at 30 days (1.2% with active drain versus 0% with passive drain; low-quality evidence), and morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15; low-quality evidence) when compared with a passive drain. We were uncertain whether an active drain decreased intra-abdominal infection (0% versus 2.6%; very low-quality evidence), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05; very low-quality evidence), or the number of additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29; very low-quality evidence). Active drain may reduce length of hospital stay slightly (MD -1.90 days, 95% CI -3.67 to -0.13; one study; low-quality evidence; 14.1% decrease of an 'average' length of hospital stay). Additional radiological interventions, pain, and quality of life were not reported in the study.Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula, who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no mortality in either group. Early drain removal may slightly reduce morbidity (38.6% with early drain removal versus 61.4% with late drain removal; RR 0.63, 95% CI 0.43 to 0.93; low-quality evidence), length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; low-quality evidence; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (MD -EUR 2069.00, 95% CI -3872.26 to -265.74; low-quality evidence; 17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33, 95% CI 0.01 to 8.01; one study; very low-quality evidence). Intra-abdominal infection, wound infection, additional radiological interventions, pain, and quality of life were not reported in the study. AUTHORS' CONCLUSIONS It was unclear whether routine abdominal drainage had any effect on the reduction of mortality at 30 days, or postoperative complications after pancreatic surgery. Moderate-quality evidence suggested that routine abdominal drainage probably slightly reduced mortality at 90 days. Low-quality evidence suggested that use of an active drain compared to the use of a passive drain may slightly reduce the length of hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.
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Affiliation(s)
- Wei Zhang
- The People's Hospital of Jianyang CityDepartment of Hepatopancreatobiliary SurgeryNo. 180, Hospital RoadJianyangSichuanChina641499
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Jie Xia
- Chongqing Medical UniversityThe Key Laboratory of Molecular Biology on Infectious DiseasesChongqingChina450000
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
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Xu SB, Jia CK, Wang JR, Zhang RC, Mou YP. Do patients benefit more from robot assisted approach than conventional laparoscopic distal pancreatectomy? A meta-analysis of perioperative and economic outcomes. J Formos Med Assoc 2018; 118:268-278. [PMID: 29798819 DOI: 10.1016/j.jfma.2018.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/10/2017] [Accepted: 05/03/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/PURPOSE Robotic approach has improved the ergonomics of conventional laparoscopic distal pancreatectomy (LDP), but whether patients benefit more from robot assisted distal pancreatectomy (RADP) is still controversial. This meta-analysis aims to compare the perioperative and economic outcomes of RADP with LDP. METHODS A systematic review of the literature was carried out on PubMed, EMBASE, and the Cochrane Library between January 1990 and March 2017. All eligible studies comparing RADP versus LDP were included. Perioperative and economic outcomes constituted the end points. RESULTS 13 English studies with 1396 patients were included. Regarding to intraoperative outcomes, RADP was associated with a significant decrease in conversion rate (OR = 0.52; 95%CI: 0.34, 0.78; P = 0.002). Although the spleen-preserving rates were comparable between RADP and LDP, a significant higher splenic vessels conservation rate was observed in the RADP group (OR = 4.71; 95%CI: 1.77, 12.56; P = 0.002). No statistically significant differences were found at operation time, estimated blood loss and blood transfusion rate. Concerning postoperative outcomes, pooled data indicated the overall morbidity, pancreatic fistula and the length of hospital stay did not differ significantly between the RADP and LDP groups. And concerning pathological outcomes, positive margin rate and the number of lymph nodules harvested were comparable between the two groups. The operative cost of RADP was almost double that of LDP (WMD = 2350.2 US dollars; 95%CI: 1165.62, 3534.78; P = 0.0001). CONCLUSION RADP showed a slight technical advantage. But whether this benefit is worth twofold cost should be considered by patient's individuation.
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Affiliation(s)
- Sun-Bing Xu
- Department of Hepatobiliary Pancreatic Surgery, Hangzhou First People's Hospital, Nanjing Medical University, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou 310006, China.
| | - Chang-Ku Jia
- Department of Hepatobiliary Pancreatic Surgery, Hangzhou First People's Hospital, Nanjing Medical University, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou 310006, China
| | - Jing-Rui Wang
- Department of Hepatobiliary Pancreatic Surgery, Hangzhou First People's Hospital, Nanjing Medical University, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou 310006, China
| | - Ren-Chao Zhang
- Department of Gastrointestinal Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou 310014, China
| | - Yi-Ping Mou
- Department of Gastrointestinal Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou 310014, China
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[Closure of pancreas stump after distal and segmental resection : Suture, stapler, coverage or anastomosis?]. Chirurg 2018; 88:25-29. [PMID: 27778058 DOI: 10.1007/s00104-016-0301-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Postoperative pancreatic fistulas represent the most frequent complication after distal and segmental pancreatectomy and occur with a frequency of up to 50 %. There are many technical variations of pancreatic stump treatment for reduction of fistula rates after distal resection. Most of these techniques have only been analyzed in retrospective studies and the evidence for or against a specific technique is low. Several retrospective trials have been conducted with good results to compare suturing with stapled closure of the remnant and to assess the effect of a vascularized falciform ligament patch in reducing postoperative pancreatic fistula; however, in a recently published randomized trial, which analyzed closure of the remnant with a pancreaticojejunostomy compared to standard closure, these results could not be confirmed. Because stapler resection and closure is the most commonly used technique in laparoscopic distal pancreatectomy, there are a large number of studies which assessed various novel methods of improving stapling. Extended stapler compression time and mesh augmentation of the stapler line can be valid methods to reduce fistula rates. Central pancreatectomy is a relatively rarely used procedure where the right-sided pancreatic remnant is closed in the same fashion as during distal pancreatectomy and the left-sided remnant is connected to the intestines with a pancreaticojejunostomy or pancreaticogastrostomy. In conclusion, postoperative pancreatic fistula rates are still a relevant clinical problem after distal pancreatectomy and further studies on potentially improved novel techniques are required.
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Hempel S, Wolk S, Kahlert C, Kersting S, Weitz J, Welsch T, Distler M. Outpatient Drainmanagement of patients with clinically relevant Postoperative Pancreatic Fistula (POPF). Langenbecks Arch Surg 2017; 402:821-829. [PMID: 28597036 DOI: 10.1007/s00423-017-1595-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/29/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Postoperative pancreatic fistula (POPF) is a common complication after pancreatic surgery associated with extended hospitalization, increased medical costs, and reduced quality of life. The aim of the present study was to analyze the feasibility of ambulatory drainage and develop an ambulatory management algorithm. METHODS Patients with POPF grade B or C (according to the ISGPF classification) between Jan. 2005 and Dec. 2014 that required persistent drainage were identified from a prospectively collected database. Postoperative events and clinical outcomes were retrospectively analyzed. RESULTS A total of 132 out of 887 patients (14.8%) developed a POPF (grade B or C), and 45 (34.1%) were discharged from the hospital with percutaneous drainage. For patients with grade B fistulas, the mean hospital stay was significantly shorter compared to patients with grade C fistulas (mean 27.7 vs. 40 days; p = 0.0285). About 40% of patients with ambulatory drainage developed a complication, but only 28.9% required readmission. Of those, 52.9% did not require specific treatment and 26.3% were treated with a new drain placement. None of the patients developed major complications, and there was no difference in the frequency of complications between the two groups (p = 0.872). The duration of drain persistence was significantly shorter for patients with grade B fistulas than for those with grade C fistulas (52.2 vs. 85.9 days; p = 0.0007). CONCLUSIONS Ambulatory drainage management is feasible in selected patients. No severe complications occurred during ambulatory drainage management. A management algorithm is recommended as this could possibly reduce medical costs and improve quality of life.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Stephan Kersting
- Department of General and Vascular Surgery, St. Josefs Hospital, Freiburg, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
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Smits FJ, van Santvoort HC, Besselink MG, Batenburg MCT, Slooff RAE, Boerma D, Busch OR, Coene PPLO, van Dam RM, van Dijk DPJ, van Eijck CHJ, Festen S, van der Harst E, de Hingh IHJT, de Jong KP, Tol JAMG, Borel Rinkes IHM, Molenaar IQ. Management of Severe Pancreatic Fistula After Pancreatoduodenectomy. JAMA Surg 2017; 152:540-548. [PMID: 28241220 PMCID: PMC5831426 DOI: 10.1001/jamasurg.2016.5708] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
Abstract
Importance Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking. Objective To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy. Design, Setting, and Participants A multicenter, retrospective, propensity-matched cohort study was conducted in 9 centers of the Dutch Pancreatic Cancer Group from January 1, 2005, to September 30, 2013. From a cohort of 2196 consecutive patients who underwent pancreatoduodenectomy, 309 patients with severe pancreatic fistula were included. Propensity score matching (based on sex, age, comorbidity, disease severity, and previous reinterventions) was used to minimize selection bias. Data analysis was performed from January to July 2016. Exposures First intervention for pancreatic fistula: catheter drainage or relaparotomy. Main Outcomes and Measures Primary end point was in-hospital mortality; secondary end points included new-onset organ failure. Results Of the 309 patients included in the analysis, 209 (67.6%) were men, and mean (SD) age was 64.6 (10.1) years. Overall in-hospital mortality was 17.8% (55 patients): 227 patients (73.5%) underwent primary catheter drainage and 82 patients (26.5%) underwent primary relaparotomy. Primary catheter drainage was successful (ie, survival without relaparotomy) in 175 patients (77.1%). With propensity score matching, 64 patients undergoing primary relaparotomy were matched to 64 patients undergoing primary catheter drainage. Mortality was lower after catheter drainage (14.1% vs 35.9%; P = .007; risk ratio, 0.39; 95% CI, 0.20-0.76). The rate of new-onset single-organ failure (4.7% vs 20.3%; P = .007; risk ratio, 0.15; 95% CI, 0.03-0.60) and new-onset multiple-organ failure (15.6% vs 39.1%; P = .008; risk ratio, 0.40; 95% CI, 0.20-0.77) were also lower after primary catheter drainage. Conclusions and Relevance In this propensity-matched cohort, catheter drainage as first intervention for severe pancreatic fistula after pancreatoduodenectomy was associated with a better clinical outcome, including lower mortality, compared with primary relaparotomy.
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Affiliation(s)
- F. Jasmijn Smits
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | | | - Robbert A. E. Slooff
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | | | - Ronald M. van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - David P. J. van Dijk
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | | | - Koert P. de Jong
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Johanna A. M. G. Tol
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | | | - I. Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Hackert T, Klaiber U, Hinz U, Kehayova T, Probst P, Knebel P, Diener MK, Schneider L, Strobel O, Michalski CW, Ulrich A, Sauer P, Büchler MW. Sphincter of Oddi botulinum toxin injection to prevent pancreatic fistula after distal pancreatectomy. Surgery 2017; 161:1444-1450. [DOI: 10.1016/j.surg.2016.09.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/20/2016] [Accepted: 09/07/2016] [Indexed: 01/23/2023]
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Marino M, Gulotta G, Komorowski AL. Robotic Pancreaticoduodenectomy: Technical Considerations. Indian J Surg 2017; 80:118-122. [PMID: 29915476 DOI: 10.1007/s12262-017-1628-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/13/2017] [Indexed: 01/30/2023] Open
Abstract
Robotic surgery can help to overcome some technical limitations of laparoscopic pancreaticoduodenectomy thanks to EndoWrist instrumentations and the 3D view. Despite the potential benefits, its employment is still low and controversial. We focused on some important technical details crucial for a safe robotic pancreatectomy. After performing 52 robotic pancreatic resections that included 10 pancreatoduodenectomies, the authors describe their technique. The review of literature on robotic and laparoscopic duodenopancreatectomy is also performed in order to evaluate possible benefits of the robotic platform. We describe the step-by-step surgical procedure, analyzing all possible troubleshooting occurring in an initial center experience. The estimated blood loss as well as the length of stay was reduced by the robotic approach. We did not observe any significant increase of pancreatic fistula rate and all other postoperative complications despite our initial learning curve. Robotic pancreatoduodenectomy is a technically advanced procedure that requires important laparoscopic and robotic skills but it shows to be safe, feasible with some clear advantages in the bleeding control and in the reconstructive phase of the procedure.
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Affiliation(s)
- Marco Marino
- 1Department of Emergency and General Surgery, P. Giaccone Hospital, University of Palermo. Giuffrè L. str. 5, 90127 Palermo, Italy
| | - Gaspare Gulotta
- 1Department of Emergency and General Surgery, P. Giaccone Hospital, University of Palermo. Giuffrè L. str. 5, 90127 Palermo, Italy
| | - Andrzej L Komorowski
- 2Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology Cancer Centre, Garncarska str. 11, 31-115 Kraków, Poland
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49
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Reply to Comment on "Teres Ligament Patch Reduces Relevant Morbidity After Distal Pancreatectomy (the DISCOVER Randomized Controlled Trial)". Ann Surg 2017; 267:e94. [PMID: 28257329 DOI: 10.1097/sla.0000000000002202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Fang CH, Chen QS, Yang J, Xiang F, Fang ZS, Zhu W. Body Mass Index and Stump Morphology Predict an Increased Incidence of Pancreatic Fistula After Pancreaticoduodenectomy. World J Surg 2017; 40:1467-76. [PMID: 26796886 DOI: 10.1007/s00268-016-3413-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND A majority of factors associated with the occurrence of clinical relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) can only be identified intra- or postoperatively. There are no reports for assessing the morphological features of pancreatic stump and analyzing its influence on CR-POPF risk after PD preoperatively. METHOD A total of 90 patients underwent PD between April 2012 and May 2014 in our hospital were included. Preoperative computed tomographic (CT) images were imported into the Medical Image Three-Dimensional Visualization System (MI-3DVS) for acquiring the morphological features of pancreatic stump. The demographics, laboratory test and morphological features of pancreatic stump were recorded prospectively. The clinical course was evaluated focusing on the occurrence of pancreatic fistula as defined by the International Study Group on Pancreatic Fistula (ISGPF). Logistic regression analysis was used to identify independent predictors of CR-POPF. RESULTS CR-POPF occurred in 18 patients (14 grade B, 4 grade C). In univariate analysis, male gender (P = 0.026), body mass index (BMI) ≥ 25.3 kg/m(2) (P = 0.002), main pancreas duct diameter (MPDD) < 3.1 mm (P = 0.005), remnant pancreatic parenchymal volume (RPPV) > 27.8 mL (P < 0.001), and area of cut surface (AOCS) > 222.3 mm(2) (P < 0.001) were associated with an increased risk of CR-POPF. In multivariate analysis, BMI ≥ 25.3 kg/m(2) (OR 12.238, 95 % CI 1.822-82.215, P = 0.010) and RPPV > 27.8 mL (OR 12.907, 95 % CI 1.602-104.004, P = 0.016) were the only independent risk factors associated with CR-POPF. A cut-off value of 27.8 mL for RPPV established based on the receiver operating characteristic (ROC) curve, which was the strongest single predictive factor for CR-POPF, with a sensitivity and specificity of 77.8 and 86.1 %, respectively. The area under the ROC curve of RPPV was 0.770 (95 % CI 0.629-0.911, P < 0.001). CONCLUSIONS Our study demonstrated that CR-POPF is correlated with BMI and RRPV. MI-3DVS provides us a novel and convenient method for measuring the RPPV. Preoperative acquisition of RPPV and BMI may help the surgeons in fitting postoperative management to patient's individual risk after PD.
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Affiliation(s)
- Chi-Hua Fang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China.
| | - Qing-Shan Chen
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Jian Yang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Fei Xiang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Zhao-Shan Fang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Wen Zhu
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
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