• pancreatic fistula
• pancreaticoduodenectomy
• morbidity
• fístula pancreática
• pancreaticoduodenectomia
• morbidade

• Humans
• Pancreatic Fistula/etiology
• Pancreatic Fistula/epidemiology
• Male
• Female
• Pancreaticoduodenectomy/adverse effects
• Retrospective Studies
• Risk Factors
• Tunisia
• Middle Aged
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Aged
• Adult
• Aged, 80 and over

• Pancreatectomy
• Pancreatic fistula
• Pancreaticojejunostomy
• Pancreatitis, chronic

• Roux-en-Y
• pancreatic fistula
• pancreaticoduodenectomy
• whipple

• Contrast media
• Fibrosis
• Multidetector computed tomography
• Pancreas

• Aged
• Fibrosis
• Humans
• Male
• Pancreas/diagnostic imaging
• Pancreas/surgery
• Pancreatic Fistula/diagnostic imaging
• Pancreaticoduodenectomy
• Postoperative Complications/diagnostic imaging
• Retrospective Studies
• Risk Factors
• Tomography, X-Ray Computed

• POPF
• Pancreatoduodenectomy
• Somatostatin analogues
• Somatostatin prophylaxis

• Aged
• Aged, 80 and over
• Anesthesiologists/organization & administration
• Body Mass Index
• Case-Control Studies
• Female
• Humans
• Male
• Middle Aged
• Pancreatic Fistula/classification
• Pancreatic Fistula/etiology
• Pancreatic Fistula/prevention & control
• Pancreaticoduodenectomy/adverse effects
• Pancreaticoduodenectomy/methods
• Pancreaticojejunostomy/adverse effects
• Pancreaticojejunostomy/methods
• Postoperative Care
• Postoperative Complications/classification
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Retrospective Studies
• Risk Factors
• Societies, Medical/organization & administration
• Somatostatin/administration & dosage

• Università di Pisa

• Computed tomography
• Pancreaticoduodenectomy
• Postoperative pancreatic fistula
• Risk prediction

• Aged
• Female
• Humans
• Logistic Models
• Male
• Middle Aged
• Pancreatic Fistula/diagnostic imaging
• Pancreatic Fistula/etiology
• Pancreaticoduodenectomy/adverse effects
• Perioperative Period
• Postoperative Complications/diagnostic imaging
• Prognosis
• ROC Curve
• Retrospective Studies
• Risk Assessment
• Risk Factors
• Tomography, X-Ray Computed/methods

Rationale: Clinically relevant postoperative pancreatic fistula (CR-POPF) is among the most formidable complications after pancreatoduodenectomy (PD), heightening morbidity/mortality rates. Fistula Risk Score (FRS) is a well-developed predictor, but it is an intraoperative predictor and quantifies >50% patients as intermediate risk. Therefore, an accurate and easy-to-use preoperative index is desired. Herein, we test the hypothesis that quantitative analysis of contrast-enhanced computed tomography (CE-CT) with deep learning could predict CR-POPFs.

Methods: A group of 513 patients underwent pancreatico-enteric anastomosis after PD at three institutions between 2006 and 2019 was retrospectively collected, and formed a training (70%) and a validation dataset (30%) randomly. A convolutional neural network was trained and generated a deep-learning score (DLS) to identify the patients with higher risk of CR-POPF preoperatively using CE-CT images, which was further externally tested in a prospective cohort collected from August 2018 to June 2019 at the fourth institution. The biological underpinnings of DLS were assessed using histomorphological data by multivariate linear regression analysis.

Results: CR-POPFs developed in 95 patients (16.3%) in total. Compared to FRS, the DLS offered significantly greater predictability in training (AUC:0.85 [95% CI, 0.80-0.90] vs. 0.78 [95% CI, 0.72-0.84]; P = 0.03), validation (0.81 [95% CI, 0.72-0.89] vs. 0.76 [95% CI, 0.66-0.84], P = 0.05) and test (0.89 [95% CI, 0.79-0.96] vs. 0.73 [95% CI, 0.61-0.83], P < 0.001) cohorts. Especially in the challenging patients of intermediate risk (FRS: 3-6), the DLS showed significantly higher accuracy (training: 79.9% vs. 61.5% [P = 0.005]; validation: 70.3% vs. 56.3% [P = 0.04]; test: 92.1% vs. 65.8% [P = 0.013]). Additionally, DLS was independently associated with pancreatic fibrosis (coefficients: -0.167), main pancreatic duct (coefficients: -0.445) and remnant volume (coefficients: 0.138) in multivariate linear regression analysis (r² = 0.512, P < 0.001). The user satisfaction score in the test cohort was 4 out of 5.

Conclusions: Preoperative CT based deep-learning model provides a promising novel method for predicting CR-POPF occurrences after PD, especially at intermediate FRS risk level. This has a potential to be integrated into radiologic reporting system or incorporated into surgical planning software to accommodate the preferences of surgeons to optimize preoperative strategies, intraoperative decision-making, and even postoperative care.

• Pancreatic fistula
• computed tomography (CT)
• deep learning
• fistula risk score
• pancreatoduodenectomy

• Biomechanics
• Finite element modeling
• Pancreaticojejunostomy
• Pancreatoduodenectomy
• Postoperative pancreatic fistula

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Animals
• China/epidemiology
• Computer Simulation
• Equipment Design
• Feasibility Studies
• Female
• Humans
• Length of Stay
• Male
• Middle Aged
• Pancreatic Fistula/epidemiology
• Pancreatic Fistula/etiology
• Pancreatic Fistula/prevention & control
• Pancreatic Neoplasms/surgery
• Pancreaticojejunostomy/methods
• Polytetrafluoroethylene
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Prospective Studies
• Suture Techniques/instrumentation
• Sutures
• Swine
• Treatment Outcome
• Young Adult

• Duct-to-mucosa
• invagination
• pancreaticoduodenectomy
• pancreaticogastrostomy
• pancreaticojejunostomy
• postoperative pancreatic fistula
• stent

Hemorrhage is the most serious complication after pancreatic surgery and is also the main cause of clinical death. With the progress of surgical methods and the rapid development of minimally invasive techniques, surgeons have more technical means to deal with postoperative hemorrhage. It is still inconsistent in terms of taking effective therapeutic measures according to different causes of bleeding. And this has long plagued every pancreatic surgeon. This article reviews the location, causes, preventive measures, and treatment of hemorrhage after pancreatectomy, in order to provide some guidance to clinicians.

• Post pancreatectomy hemorrhage
• Sentinel bleed
• Surgical operation
• Interventional operation

• Octreotide
• Pancreatic fistula
• Pancreaticoduodenectomy

Postoperative complications, especially postoperative pancreatic fistulas, remain the major concern following pancreaticoduodenectomy (PD). Mesh-reinforced pancreatic anastomoses, including pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), are a new effective technique in PD. This study was conducted to analyze the safety and efficacy of this new technique and to compare the results of mesh-reinforced PJ vs PG.

A total of 110 patients who underwent PD between August 2005 and January 2016 were eligible in this study. Perioperative and postoperative data of patients with a mesh-reinforced technique were analyzed. Data were also grouped according to the procedure performed: mesh-reinforced PJ and mesh-reinforced PG.

Among patients undergoing PD with the mesh-reinforced technique, 42 had postoperative complications, and the comprehensive complication index (CCI) was 32.7 ± 2.5. Only 10% of patients had pancreatic fistula; three were grade A, six were grade B, and two were grade C. Biliary fistula occurred in only 8.2% of patients. Patients undergoing mesh-reinforced PG showed a significantly lower rate of CCI than did mesh-reinforced PJ patients (27.0 ± 2.1 vs 37.0 ± 3.9, p < 0.05). The mesh-reinforced PG was also favored over mesh-reinforced PJ because of significant differences in intra-abdominal fluid collection (5.9% vs 18.6%, p < 0.05) and delayed gastric emptying (3.9% vs 15.3%, p < 0.05).

PD with the mesh-reinforced technique was a safe and effective method of decreasing postoperative pancreatic fistula. Compared with mesh-reinforced PJ, mesh-reinforced PG did not show significant differences in the rates of pancreatic fistula or biliary fistula. However, CCI, intra-abdominal fluid collection, and delayed gastric emptying were significantly reduced in patients with mesh-reinforced PG.

• Mesh
• Pancreatic fistula
• Pancreaticoduodenectomy
• Pancreatogastrostomy
• Pancreatojejunostomy

• End to side dunking
• Pancreatic fistula
• Whipple’s operation

• Image guided drainage
• Pancreatic duct drainage
• Pancreatic duct obstruction

• Adult
• Aged
• Aged, 80 and over
• Drainage/methods
• Female
• Humans
• Male
• Middle Aged
• Pancreatic Diseases/diagnostic imaging
• Pancreatic Diseases/therapy
• Pancreatic Ducts/diagnostic imaging
• Pancreatic Neoplasms
• Prospective Studies
• Radiography, Interventional/methods
• Tomography, X-Ray Computed/methods
• Treatment Outcome
• Ultrasonography, Interventional/methods

• Computed tomography
• Pancreas
• Pancreatic neoplasm
• Pancreatic surgery
• Postoperative

• Duodenopancreatectomy
• Pancreas
• Pancreatic fistula

• Pancreaticoduodenectomy
• complications
• drainage
• pancreatic fistula

• Duct-to-mucosa pancreatico-jejunostomy
• Pancreatic stump
• Pancreatico-gastrostomy
• Pancreatico-jejunostomy
• Pancreato-duodenectomy

• Humans
• Pancreas/surgery
• Pancreatic Diseases/surgery
• Pancreaticoduodenectomy/methods
• Pancreaticojejunostomy
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Risk Factors

• Octreotide
• Pancreatic fistula
• Pancreaticoduodenectomy
• Randomized controlled trial

• Pancreatic duct stent
• meta-analysis
• pancreaticoduodenectomy (PD)

Various pancreaticojejunostomy (PJ) techniques have been devised to minimize the rate of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). This study describes a modification of the mattress suture PJ technique, which we call "inverted mattress PJ (IM)". The results of an IM group and a historical consecutive control group were compared to determine how the IM technique affected POPF.

From 2003 to 2010, 186 consecutive patients underwent PD. A former group of 52 consecutive patients who underwent conventional duct-to-mucosa PJ (DM) was used as a historical control group. The IM technique was utilized for the IM group (134 patients). The clinicopathological features and surgical outcomes of the 2 groups were compared, with a particular focus on postoperative POPFs.

The average surgery duration was shorter in the IM group (580.3 minutes vs. 471 minutes, P < 0.001). Grades B and C POPFs occurred less frequently in the IM group, but the difference was not statistically significant (17.3% vs. 9.7%, P = 0.200). However, no grade C POPF occurred in the IM group compared with 5.8% of grade C POPFs (3/52) in the DM group (P = 0.020). Three patients died (1 in the DM group and 2 in the IM group). The causes of death were arrhythmia in 2 cases and Candida sepsis in 1 case. POPF was not causally related to the 3 deaths.

IM end-to-side PJ shortened operation time and increased safety with no incidence of grade C POPF.

• Pancreatic fistula
• Pancreaticojejunostomy

Risk factors for anastomotic leaks of pancreaticojejunostomy have been well described. We present a technique using indocyanine green dye (ICG) and a near-infrared (NIR) capable laparoscope to assess blood supply to the transected margin of the pancreas before pancreaticojejunal anastomosis. A 39-year-old female patient underwent a laparoscopic-assisted pancreaticoduodenectomy (Whipple's procedure) for an invasive ampullary adenocarcinoma. Before construction of the pancreaticojejunal anastomosis, the viability of the margin of the remnant pancreas was assessed with infrared scanning of injected ICG. The NIR identified an ischaemic segment of the margin, which was further resected. The patient had no postoperative evidence of a pancreatic leak and was discharged home on postoperative day 18. Ischaemia of the remnant pancreas is a risk factor for pancreaticojejunostomy leak. Infrared ICG testing might help to identify these ischaemic segments, which can be excised before anastomosis, and reduce failure rates.

• Laparoscopic central pancreatectomy
• median pancreatectomy
• pancreaticojejunal anastomosis

• Cancer
• Cirugía
• Cirugía pancreática
• Cáncer
• Evidence-based
• Evidencia
• Pancreas
• Pancreatic surgery
• Pancreaticogastric anastomosis
• Pancreaticogastrostomía
• Páncreas
• Surgery

• pancreatic fistula
• pancreaticoduodenectomy
• pancreaticogastrostomy
• pancreaticojejunostomy

• Drain amylase concentration
• Drain removal
• Enhanced recover
• Pancreaticoduodenectomy
• Postoperative pancreatic fistula
• Whipples resection

• Pancreatic cancer
• pancreatic anastomosis
• pancreatic fistula
• pancreatic resection
• total pancreatectomy

Background/Objectives. Postoperative pancreatic fistula (POPF) remains the main problem after pancreaticoduodenectomy and determines to a large extent the final outcome. We describe a new modification of pancreaticogastrostomy which combines duct to mucosa anastomosis with suturing the pancreatic capsule to posterior gastric wall and then invaginating the pancreatic remnant into the posterior gastric wall. This study was designed to assess the results of this new modification of pancreaticogastrostomy. Methods. The newly modified pancreaticogastrostomy was applied to 37 consecutive patients after pancreaticoduodenectomy for periampullary cancer (64.86%) or cancer head of the pancreas (35.14%). Eighteen patients (48.65%) had a soft pancreatic remnant, 13 patients (35.14%) had firm pancreatic remnant, and 6 patients (16.22%) had intermediate texture of pancreatic remnant. Rate of mortality, early postoperative complications, and hospital stay were also reported. Results. Operative mortality was zero and morbidity was 29.73%. Only three patients (8.11%) developed pancreatic leaks; they were treated conservatively. Eight patients (16.1%) had delayed gastric emptying, one patient (2.70%) had minor hemorrhage, one patient (2.70%) had biliary leak, and four patients (10.81%) had superficial wound infection. Conclusions. The new modified pancreatogastrostomy seems safe and reliable with low rate of POPF. However, further prospective controlled trials are essential to support these results.

We investigated the clinical application of extended distal pancreatectomy in patients with pancreatic neck cancer accompanied by distal pancreatic atrophy. In this study, we have emphasized on the technical aspects of using the linear stapling device for a bulky target organ.

From March 2010 to September 2013, 46 patients with pancreatic adenocarcinoma, who underwent pancreatic resection with radical intent at our institute, were reviewed retrospectively. Among them, three patients (6.5%) underwent extended distal pancreatectomy. A linear stapling device and vise-grip locking pliers were used for en bloc resection of the distal pancreas, first duodenal portion, and distal common bile duct. The results were compared with those after standard pancreatectomy.

All three patients presented with jaundice, and the ratio of pancreatic duct to parenchymal thickness of the pancreatic body was greater than 0.5. Grade A pancreatic fistula developed in all of the cases, but none of these fistulae were lethal. Pathological staging was T3N1M0 in all of the patients. The postoperative daily serum glucose fluctuations and insulin requirements were comparable to those in patients who received pancreaticoduodenectomy or distal pancreatectomy. At the last follow-up, two patients were alive with liver metastasis at 4 and 10 months postoperatively, respectively, and one patient died of liver metastasis at 5 months postoperatively.

While the prognosis of advanced pancreatic neck adenocarcinoma is still dismal, extended distal pancreatectomy is a valid treatment option, especially when there is atrophy of the distal pancreas. Also, the procedure is technically feasible, and further refinement is necessary to improve patient survival.

• Adenocarcinoma
• Atrophy
• Neck
• Pancreas
• Pancreatectomy

Introduction. Pancreatic surgery is challenging and associated with high morbidity, mainly represented by postoperative pancreatic fistula (POPF) and its further consequences. Identification of risk factors for POPF is essential for proper postoperative management. Aim of the Study. Evaluation of the role of morphological and histological features of pancreatic stump, other than main pancreatic duct diameter and glandular texture, in POPF occurrence after pancreaticoduodenectomy. Patients and Methods. Between March 2011 and April 2013, we performed 145 consecutive pancreaticoduodenectomies. We intraoperatively recorded morphological features of pancreatic stump and collected data about postoperative morbidity. Our dedicated pathologist designed a score to quantify fibrosis and inflammation of pancreatic tissue. Results. Overall morbidity was 59,3%. Mortality was 4,1%. POPF rate was 28,3%, while clinically significant POPF were 15,8%. Male sex (P = 0.009), BMI ≥ 25 (P = 0.002), prolonged surgery (P = 0.001), soft pancreatic texture (P < 0.001), small pancreatic duct (P < 0.001), pancreatic duct decentralization on stump anteroposterior axis, especially if close to the posterior margin (P = 0.031), large stump area (P = 0.001), and extended stump mobilization (P = 0.001) were related to higher POPF rate. Our fibrosis-and-inflammation score is strongly associated with POPF (P = 0.001). Discussion and Conclusions. Pancreatic stump features evaluation, including histology, can help the surgeon in fitting postoperative management to patient individual risk after pancreaticoduodenectomy.

• acoustic radiation force impulse elastography
• gastrointestinal ultrasound
• pancreas
• pancreatectomy
• pancreatic fistula

• Adult
• Aged
• Elasticity Imaging Techniques
• Feasibility Studies
• Female
• Humans
• Image Interpretation, Computer-Assisted/methods
• Male
• Middle Aged
• Pancreatectomy/adverse effects
• Pancreatic Fistula/diagnostic imaging
• Pancreatic Fistula/etiology
• Prognosis
• Reproducibility of Results
• Risk Assessment
• Sensitivity and Specificity
• Treatment Outcome

Surgery remains the mainstay of therapy for pancreatic head (PH) and periampullary carcinoma (PC) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience and advances in anesthesia, intensive care and parenteral nutrition have substantially decreased surgical complications and increased survival. We evaluate the effects of reconstruction type, complications and pathological factors on survival and quality of life.

This is a prospective study to evaluate the impact of various reconstruction methods of the pancreatic remnant after pancreaticoduodenectomy and the pathological characteristics of PC patients over 3.5 years. Patient characteristics and descriptive analysis in the three variable methods either with or without stent were compared with Chi-square test. Multivariate analysis was performed with the logistic regression analysis test and multinomial logistic regression analysis test. Survival rate was analyzed by use Kaplan-Meier test.

Forty-one consecutive patients with PC were enrolled. There were 23 men (56.1%) and 18 women (43.9%), with a median age of 56 years (16 to 70 years). There were 24 cases of PH cancer, eight cases of PC, four cases of distal CBD cancer and five cases of duodenal carcinoma. Nine patients underwent duct-to-mucosa pancreatico jejunostomy (PJ), 17 patients underwent telescoping pancreatico jejunostomy (PJ) and 15 patients pancreaticogastrostomy (PG). The pancreatic duct was stented in 30 patients while in 11 patients, the duct was not stented. The PJ duct-to-mucosa caused significantly less leakage, but longer operative and reconstructive times. Telescoping PJ was associated with the shortest hospital stay. There were 5 postoperative mortalities, while postoperative morbidities included pancreatic fistula-6 patients, delayed gastric emptying in-11, GI fistula-3, wound infection-12, burst abdomen-6 and pulmonary infection-2. Factors that predisposed to development of pancreatic leakage included male gender, preoperative albumin < 30g/dl, pre-operative hemoglobin < 10g/dl and non PJ-duct to mucosa type of reconstruction. The ampullary cancers presented at an earlier stage and had a better prognosis than pancreatic cancer and cholangiocarcinoma. Early stage (I and II), negative surgical margin, well and moderate differentiation and absence of lymph node involvement significantly predicted for longer survival.

PJ duct-to-mucosa anastomosis was safe, caused least pancreatic leakage and least blood loss compared with the other methods of reconstruction and was associated with early return back to home and prolonged disease free and overall survival.

• Complication
• mortality and survival
• pancreaticojujenostomy duct to mucosa
• periampullary cancer
• postoperative pancreatic fistula
• reconstruction

• Classification
• Complications
• Haemorrhage
• Pancreatic fistula
• Pancreatoduodenectomy
• Prevention