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de Oliveira Silva Nascimento A, Silva ODC, Duarte BN, de Carvalho Baptista Barbosa I, Bajou CMO, Taba JV, Pipek LZ, Iuamoto LR, Hsing WT, Carneiro-D'Albuquerque LA, Andraus W, Meyer A. Suture versus stapler in distal pancreatectomy and its impact on postoperative pancreatic fistula. Sci Rep 2025; 15:6052. [PMID: 39972194 PMCID: PMC11840080 DOI: 10.1038/s41598-025-90617-9] [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: 07/05/2024] [Accepted: 02/14/2025] [Indexed: 02/21/2025] Open
Abstract
Postoperative pancreatic fistula is a critical complication after distal pancreatectomy. The aim of this systematic review is to assess new reports on the main pancreatic stump closure techniques (stapler and hand-sewn suture) in distal pancreatectomy, to define their influence on postoperative pancreatic fistula rates. A literature review was performed following PRISMA guidelines (PROSPERO: CRD42023408181). The survey was conducted in Medline (via PubMed) and EMBASE. Clinical trials and cohorts were included if they assessed pancreatic fistula rates after distal pancreatectomy, and excluded if they used a fistula rating system other than the ISGPF one. The risk of bias was assessed using the Study Quality Assessment Tools | NHLBI, NIH. A meta-analysis was presented as forest-plots. Eleven articles were included, representing 1498 patients. No significant difference was found between Suture and Bare stapler (95% CI 0.91-1.68) or Bare stapler and Reinforced stapler for A-graded fistula rates (95% CI 0.78-1.28) and B-graded fistula rates (I-squared = 0.0%, p = 0.784). Most articles showed unclear risk of detection bias. This meta-analysis found no difference in fistula rates between stump closure techniques. This choice should be made by surgeons' and hospital administration's preferences.
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Affiliation(s)
| | | | | | | | | | - João Victor Taba
- Faculty of Medicine FMUSP, University of São Paulo, São Paulo, SP, Brazil
| | - Leonardo Zumerkorn Pipek
- Department of Neurology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, São Paulo, Brazil
| | - Leandro Ryuchi Iuamoto
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
| | - Wu Tu Hsing
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Department of Gastroenterology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, Avenida Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, Avenida Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil
| | - Alberto Meyer
- Department of Gastroenterology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, Avenida Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil.
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Chen H, Jiang K, Li X, Ye Q, Wang J, Zhou S, Wang H, Qiu K. Application and advantage analysis of triangular gastric suspension technique in laparoscopic distal pancreatectomy. Surg Endosc 2025; 39:1372-1378. [PMID: 39806175 DOI: 10.1007/s00464-024-11505-3] [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: 09/20/2024] [Accepted: 12/23/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy is a safe and effective surgical method for treating benign and malignant tumors of the pancreatic body and tail. However, laparoscopic surgery requires good intraoperative exposure, and since the pancreas is obstructed by the stomach and duodenum, making surgical operations and the management of intraoperative emergencies challenging. Therefore, gastric traction is crucial in laparoscopic distal pancreatectomy. Common gastric suspension techniques include single and double gastric suspension. Here, we propose a new, simple, and effective gastric suspension method called the triangular gastric suspension. METHODS We retrospectively analyzed the clinical data of 62 patients who underwent laparoscopic distal pancreatectomy at the Hepatobiliary and Pancreatic Surgery Department, The Affiliated LiHuiLi Hospital of Ningbo University from February 2017 to March 2024. The patients were divided into two groups based on whether triangular gastric suspension with silk sutures was used during surgery: the suspension group (28 cases) and the control group (34 cases). We analyzed various perioperative indicators between the two groups both before and after propensity score matching (PSM). RESULTS With or without PSM, there were no statistically significant differences between the two groups in terms of age, gender, body mass index, American Society of Anesthesiologists classification, surgical approach, tumor pathological type and tumor length. Meanwhile, there were no statistically significant differences between the two groups in terms of pancreatic stump anastomosis, intraoperative transfusion, intraoperative R0 rate, postoperative pancreatic fistula grade, postoperative severe hemorrhage, reoperation, and delayed gastric emptying rate. However, the differences in operative time, intraoperative blood loss, and total hospital stay were statistically significant, with the suspension group showing better outcomes. CONCLUSION The triangular gastric suspension method provides significant advantages in reducing intraoperative blood loss and shortening operative time during laparoscopic distal pancreatectomy. It is a new, simple, and effective suspension method.
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Affiliation(s)
- Hao Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Keting Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Xing Li
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Qiong Ye
- Department of Orthopaedic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Jie Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Songsheng Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Haibiao Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China.
| | - Kaijie Qiu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China.
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Sadek K, Shaker A, Tice M, Stauffer JA. Combined division of the splenic vessels and pancreatic parenchyma during laparoscopic distal pancreatectomy is a safe alternative to separate division: a single-institution retrospective study. HPB (Oxford) 2025; 27:80-86. [PMID: 39521694 DOI: 10.1016/j.hpb.2024.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/28/2024] [Accepted: 10/08/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Limited data exists regarding the safety and outcomes of combined division of the splenic vessels with the pancreatic parenchyma during laparoscopic distal pancreatectomy (LDP). This study aims to evaluate the combined division technique. METHODS Patients who underwent LDP for pancreatic cancer from April 2011 to December 2022 were retrospectively reviewed and categorized into the following groups: combined (CV) versus separate (SV) division of the splenic vein; combined (CA) versus separate (SA) division of the splenic artery; and combined (CAV) versus separate (SAV) division of the splenic artery and vein, with or without the pancreatic parenchyma. RESULTS Among the 80 patients included, 44 underwent CV and 36 underwent SV. Operative time and major morbidity were significantly lower in CV compared with SV. Similar findings were observed in CAV versus SAV, as well as lower blood loss in CAV. Operative time was significantly lower in CA versus SA. Pancreatic fistula and postpancreatectomy hemorrhage rates showed no significant differences between groups. No patient developed splenic arteriovenous fistula in follow-up. CONCLUSION Combined division of the splenic vessels with the pancreatic parenchyma during LDP is safe and associated with improved outcomes compared with separate division.
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Affiliation(s)
- Kareem Sadek
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Andrew Shaker
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Mary Tice
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - John A Stauffer
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.
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Jiang K, Chen H, Wang J, Zhou S, Qiu K, Wang H. Laparoscopic distal pancreatectomy with pancreatic remnant-gastric coverage: a modified technique to reduce postoperative pancreatic fistula. Surg Endosc 2025; 39:368-375. [PMID: 39548006 PMCID: PMC11666661 DOI: 10.1007/s00464-024-11386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Accepted: 10/26/2024] [Indexed: 11/17/2024]
Abstract
BACKGROUND To evaluate the efficacy and safety of a modified pancreatic remnant-gastric coverage technique in laparoscopic distal pancreatectomy (LDP). METHODS This retrospective study analyzed clinical data from 63 patients who underwent LDP between March 2017 and April 2024 at the Hepatobiliary and Pancreatic Surgery Department, The Affiliated LiHuiLi Hospital of Ningbo University. Patients were divided into two groups based on the pancreatic remnant management method: the experimental group (n = 28) underwent pancreatic remnant-gastric coverage, while the control group (n = 35) had the pancreatic remnant closed using a stapler followed by hand-sewn reinforcement. The parameters observed included general patient characteristics, intraoperative data, and postoperative data. We compared and analyzed all the above data between the two groups of patients both before and after propensity score matching (PSM). RESULTS All 63 patients were successfully operated. Before PSM, the incidence of POPF (Grade B/C) in the experimental group was significantly lower than in the control group (14.3% vs 34.3%, P < 0.05). And the incidence of POPF (BL) in the experimental group was lower than in the control group (39.3% vs 51.4%). After PSM, the difference in the incidence of POPF (Grade B/C) between the two groups remained statistically significant (16.0% vs 32.0%, P < 0.05). The incidence of POPF (BL) in the experimental group was also lower than in the control group (36.0% vs 56.0%). There were no statistically significant differences between the two groups in terms of operation time, pancreatic texture, thickness of pancreatic stump, intraoperative bleeding, intraoperative transfusion, post-pancreatectomy hemorrhage, abdominal infection, encapsulated effusion, or delayed gastric emptying both before and after PSM (P > 0.05). CONCLUSION The use of the modified pancreatic remnant-gastric coverage in LDP effectively reduces the incidence of POPF and is both safe and feasible, making it a technique worth promoting.
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Affiliation(s)
- Keting Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Hao Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Jie Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Songsheng Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China
| | - Kaijie Qiu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China.
| | - Haibiao Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Lihuili Hospital of Ningbo University, 57 Xingning Road, Ningbo, Zhejiang, China.
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Imamura M, Kimura Y, Kukita K, Murakami T, Kato T, Kyuno D, Takemasa I. Powered stapler and polyglycolic acid sheet for pancreatic fistula after distal pancreatectomy. J Gastrointest Surg 2024; 28:2008-2014. [PMID: 39326510 DOI: 10.1016/j.gassur.2024.09.020] [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: 07/02/2024] [Revised: 08/20/2024] [Accepted: 09/21/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Although distal pancreatectomy (DP) is crucial for the treatment of pancreatic diseases, it often leads to postoperative pancreatic fistula (POPF), a complication with significant management challenges and health effects. Despite the use of various techniques, including suturing methods, staplers, and biodegradable materials, the optimal strategy to reduce POPF remains unclear. This study investigated the combined use of powered staplers and polyglycolic acid (PGA) sheets to mitigate POPF. METHODS This study retrospectively analyzed the data of 165 patients who underwent DP at Sapporo Medical University Hospital between January 2013 and August 2023. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients treated without (group O, n = 50) and with powered staplers and PGA sheets (group P, n = 115). In addition, the surgical techniques, patient demographics, and postoperative outcomes were examined. RESULTS This study found no significant difference in the overall incidence of POPF between the groups. However, group P had a significantly lower incidence of CR-POPF than group O (20.9% vs 40.0%, respectively; P = .011). Multivariate analysis demonstrated that male sex (odds ratio [OR], 2.81; 95% CI, 1.26-6.26; P = .012) and pancreatic thickness of more than 14 mm (OR, 2.85; 95% CI, 1.17-6.95; P = .021) were independent risk factors for CR-POPF. The use of powered staplers and PGA sheets (OR, 0.38; 95% CI, 0.17-0.85; P = .017) was associated with reduced CR-POPF risk. CONCLUSION The combined use of powered staplers and PGA sheets can significantly decrease the incidence of CR-POPF in patients with DP.
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Affiliation(s)
- Masafumi Imamura
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan.
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Kazuharu Kukita
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Murakami
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Toru Kato
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Daisuke Kyuno
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
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Naito K, Shinmura K, Suzuki T, Maeda S, Kuboki S, Ohtsuka M. Appropriate linear stapler selection for avoiding postoperative pancreatic fistula after distal pancreatectomy: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e39954. [PMID: 39465759 PMCID: PMC11460885 DOI: 10.1097/md.0000000000039954] [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: 12/22/2023] [Indexed: 10/29/2024] Open
Abstract
BACKGROUND Despite the progress in surgical techniques and perioperative managements, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Recently, pancreatic dissection using a linear stapler has been widely performed; however, risk factors influencing the occurrence of POPF after DP using a liner stapler is not fully understood. The purpose of this paper was to evaluate whether the relations between staple height and pancreatic thickness or main pancreatic duct (MPD) diameter influenced the incidence of POPF. METHODS Patients who underwent DP without other organ resections between 2015 and 2022 were retrospectively reviewed. Compression Index (CI) was defined as staple height/pancreatic thickness, and Suturing Index (SI) was defined as staple height/ MPD diameter. RESULTS In 51 patients undergoing DP, 16 patients (31.4%) developed POPF. ROC analyses revealed that lower CI and higher SI significantly increased the incidence of POPF, and the cutoff values were 0.186 and 0.821, respectively. Univariate and multivariate analyses revealed that CI ≤ 0.186 and SI ≥ 0.821 were independent risk factors for POPF after DP. Moreover, the incidence of POPF in patients fulfilling both CI > 0.186 and SI < 0.821 was 5.9%, which was extremely lower than in those without fulfilling the criteria (44.1%), suggesting that this new criteria in combination with CI and SI was an excellent predictor of POPF. CONCLUSIONS It is possible that stapler cartridge selection using our new criteria in combination with CI and SI may reduce the incidence of POPF.
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Affiliation(s)
- Kei Naito
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Kazuyasu Shinmura
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Takayuki Suzuki
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Shintaro Maeda
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Fuchs J, Loos M, Kinny-Köster B, Hackert T, Schneider M, Mehrabi A, Berchtold C, Al-Saeedi M, Müller BP, Strobel O, Feißt M, Kessler M, Günther P, Büchler MW. Pancreatic Surgery in Children: Complex, Safe, and Effective. Ann Surg 2024; 280:332-339. [PMID: 38386903 PMCID: PMC11224565 DOI: 10.1097/sla.0000000000006125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
OBJECTIVE The aim of this study was to assess indications for and report outcomes of pancreatic surgery in pediatric patients. BACKGROUND Indications for pancreatic surgery in children are rare and data on surgical outcomes after pediatric pancreatic surgery are scarce. METHODS All children who underwent pancreatic surgery at a tertiary hospital specializing in pancreatic surgery between 2003 and 2022 were identified from a prospectively maintained database. Indications, surgical procedures, and perioperative as well as long-term outcomes were analyzed. RESULTS In total, 73 children with a mean age of 12.8 years (range: 4 mo to 18 y) underwent pancreatic surgery during the observation period. Indications included chronic pancreatitis (n=35), pancreatic tumors (n=27), and pancreatic trauma (n=11). Distal pancreatectomy was the most frequently performed procedure (n=23), followed by pancreatoduodenectomy (n=19), duodenum-preserving pancreatic head resection (n=10), segmental pancreatic resection (n=7), total pancreatectomy (n=3), and others (n=11). Postoperative morbidity occurred in 25 patients (34.2%), including 7 cases (9.6%) with major complications (Clavien-Dindo≥III). There was no postoperative (90-d) mortality. The 5-year overall survival was 90.5%. The 5-year event-free survival of patients with chronic pancreatitis was 85.7%, and 69.0% for patients with pancreatic tumors. CONCLUSION This is the largest single-center study on pediatric pancreatic surgery in a Western population. Pediatric pancreatic surgery can be performed safely. Centralization in pancreatic centers with high expertise in surgery of adult and pediatric patients is important as it both affords the benefits of pancreatic surgery experience and ensures that surgical management is adapted to the specific needs of children.
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Affiliation(s)
- Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benedict Kinny-Köster
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Beat P. Müller
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Manuel Feißt
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Markus Kessler
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Coinsin B, Durin T, Marchese U, Sauvanet A, Dokmak S, Cherkaoui Z, Fuks D, Laurent C, Magallon C, Turrini O, Sulpice L, Robin F, Bachellier P, Addeo P, Birnbaum DJ, Roussel E, Schwarz L, Regimbeau JM, Piessen G, Liddo G, Girard E, Cailliau É, Truant S, El Amrani M. The impact of cirrhosis on short and long postoperative outcomes after distal pancreatectomy. Surgery 2024; 176:447-454. [PMID: 38811323 DOI: 10.1016/j.surg.2024.03.038] [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: 07/27/2023] [Revised: 03/18/2024] [Accepted: 03/24/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The impact of cirrhosis on the postoperative outcomes of distal pancreatectomy is yet to be reported. We aimed to evaluate the outcomes of distal pancreatectomy in patients with cirrhosis. METHODS We conducted a retrospective, multicentric study patients with cirrhosis who underwent planned distal pancreatectomy between 2008 and 2020 in French high volume centers. Patients with cirrhosis were matched 1:4 for demographic, surgical, and histologic criteria with patients without cirrhosis. The primary endpoint was severe morbidity (Clavien-Dindo grade ≥III). The secondary endpoints were postoperative complications, specifically related to cirrhosis and pancreatic surgery, and survival for patients with pancreatic adenocarcinoma. RESULTS Overall, 32 patients with cirrhosis were matched with 128 patients without cirrhosis. Most patients (93.5%) had Child-Pugh A cirrhosis. The severe morbidity rate after distal pancreatectomy was higher in patients with cirrhosis than in those without cirrhosis (28.13% vs 25.75%, P = .11. The operative time was significantly longer in the cirrhotic group compared with controls (P = .01). However, patients with and without cirrhosis had comparable blood loss and conversion rates. Postoperatively, the two groups had similar rates of pancreatic fistula, hemorrhage, reoperation, postoperative mortality, and survival rates at 1, 3, and 5 years. CONCLUSION The current study suggests that distal pancreatectomy in high-volume centers is feasible for patients with compensated cirrhosis.
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Affiliation(s)
- Benjamin Coinsin
- Department of Digestive Surgery and Transplantation, Lille University Hospital, France
| | - Thibault Durin
- Department of Digestive Surgery and Transplantation, Lille University Hospital, France
| | - Ugo Marchese
- Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Teaching Hospital, AP-HP, Université de Paris, France
| | - Alain Sauvanet
- AP-HP, Department of HBP Surgery, Hôpital Beaujon, University of Paris, Clichy, France
| | - Safi Dokmak
- AP-HP, Department of HBP Surgery, Hôpital Beaujon, University of Paris, Clichy, France
| | - Zineb Cherkaoui
- AP-HP, Department of HBP Surgery, Hôpital Beaujon, University of Paris, Clichy, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Teaching Hospital, AP-HP, Université de Paris, France
| | | | - Cloe Magallon
- Institut Paoli Calmettes, Marseille University, department of Oncological Surgery, France
| | - Olivier Turrini
- Institut Paoli Calmettes, Marseille University, department of Oncological Surgery, France
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive Surgery, University Hospital, Rennes 1 University, France
| | - Fabien Robin
- Department of Hepatobiliary and Digestive Surgery, University Hospital, Rennes 1 University, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Piettro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Chemin des Bourrely, France
| | - Edouard Roussel
- Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Medical Center and Jules Verne University of Picardie, 1 rue du Professeur Christian Cabrol, 80054, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Guido Liddo
- Department of Digestive Surgery, Valenciennes Hospital, France
| | - Edouard Girard
- Department of Digestive and Emergency Surgery, Grenoble Alpes University Hospital, France
| | | | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, Lille University Hospital, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Lille University Hospital, France.
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Mihara F, Takemura N, Yoshizaki Y, Nakamura M, Kokudo T, Ito K, Inagaki F, Saiura A, Kokudo N. Middle-segment preserving pancreatectomy: a literature review and case report. Langenbecks Arch Surg 2024; 409:177. [PMID: 38847851 DOI: 10.1007/s00423-024-03370-4] [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: 01/16/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Middle segment-preserving pancreatectomy (MSPP) is a relatively new parenchymal-sparing surgery that has been introduced as an alternative to total pancreatectomy (TP) for multicentric benign and borderline pancreatic diseases. To date, only 36 cases have been reported in English. METHODS We reviewed 22 published articles on MSPP and reported an additional case. RESULTS Our patient was a 49-year-old Japanese man diagnosed with Zollinger-Elison syndrome (ZES) caused by duodenal and pancreatic gastrinoma associated with multiple endocrine neoplasia syndrome type 1. We avoided TP and chose MSPP as the operative technique due to his relatively young age. The patient developed a grade B postoperative pancreatic fistula (POPF), which improved with conservative treatment. He was discharged without further treatment. To date, no tumor has recurred, and pancreatic function seems to be maintained. According to a literature review, the morbidity rate of MSPP is as high as 54%, mainly due to the high incidence of POPF (32%). In contrast, there was no perioperative mortality, and postoperative pancreatic function was comparable to that after conventional pancreatectomy. CONCLUSIONS Despite the high incidence of POPF, MSPP appears to be safe, with low perioperative mortality and good postoperative pancreatic sufficiency.
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Affiliation(s)
- Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Yuhi Yoshizaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Mai Nakamura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Takashi Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2- 1-1 Hongou, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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10
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Izumi H, Yoshii H, Fujino R, Takeo S, Nomura E, Mukai M, Makuuchi H. Efficacy of Pancreatic Dissection With a Triple-row Stapler in Laparoscopic Distal Pancreatectomy: A Retrospective Observational Study. Surg Laparosc Endosc Percutan Tech 2024; 34:295-300. [PMID: 38736396 DOI: 10.1097/sle.0000000000001284] [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: 11/02/2023] [Accepted: 03/21/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Postoperative pancreatic fistulas (POPFs) occur after 20% to 30% of laparoscopic distal pancreatectomies. This study aimed to evaluate the clinical efficacy of laparoscopic distal pancreatectomy using triple-row staplers in preventing POPFs. METHODS Between April 2016 and May 2023, 59 patients underwent complete laparoscopic distal pancreatectomies. There were more females (n=34, 57.6%) than males (n=25, 42.4%). The median age of the patients was 68.9 years. The patients were divided into slow-compression (n=19) and no-compression (n=40) groups and examined for pancreatic leakage. Both groups were examined with respect to age, sex, body mass index (BMI), pancreatic thickness at the pancreatic dissection site, pancreatic texture, diagnosis, operative time, blood loss, presence of POPF, date of drain removal, and length of hospital stay. In addition, risk factors for POPF were examined in a multivariate analysis. RESULTS Grade B POPFs were found in 9 patients (15.3%). Using univariate analysis, the operative time, blood loss, postoperative pancreatic fluid leakage, day of drain removal, and hospital stay were shorter in the no-compression group than in the slow-compression group. Using multivariate analysis, the absence of POPFs was significantly more frequent in the no-compression group (odds ratio, 5.69; 95% CI, 1.241-26.109; P =0.025). The no-compression pancreatic dissection method was a simple method for reducing POPF incidence. CONCLUSIONS The method of quickly dissecting the pancreas without compression yielded better results than the method of slowly dissecting the pancreas with slow compression. This quick dissection without compression was a simple and safe method that minimized postoperative pancreatic fluid leakage, shortened the operative time and length of hospital stay, and reduced medical costs. Therefore, this method might be a clinically successful option.
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Affiliation(s)
- Hideki Izumi
- Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, Hachioji, Tokyo, Japan
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11
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Maino C, Cereda M, Franco PN, Boraschi P, Cannella R, Gianotti LV, Zamboni G, Vernuccio F, Ippolito D. Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon. Eur J Radiol Open 2024; 12:100544. [PMID: 38304573 PMCID: PMC10831502 DOI: 10.1016/j.ejro.2023.100544] [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: 11/05/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 02/03/2024] Open
Abstract
Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.
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Affiliation(s)
- Cesare Maino
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Marco Cereda
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Paolo Niccolò Franco
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Piero Boraschi
- Radiology Unit, Azienda Ospedaliero-Universitaria Pisana, 56124 Pisa, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Luca Vittorio Gianotti
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
| | - Giulia Zamboni
- Institute of Radiology, Department of Diagnostics and Public Health, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Federica Vernuccio
- University Hospital of Padova, Institute of Radiology, 35128 Padova, Italy
| | - Davide Ippolito
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
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12
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Qian T, Huang K, Chen W, Bai X, Gao S, Shen Y, Zhang M, Wu J, Yu J, Ma T, Liang T. Comparison of outcomes with stapler versus hand-sewn closure of the pancreatic stump following minimally invasive distal pancreatectomy: a retrospective cohort study. JOURNAL OF PANCREATOLOGY 2024; 7:106-110. [DOI: 10.1097/jp9.0000000000000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2025] Open
Abstract
Background:
Pancreatic fistula after distal pancreatectomy is a common and potentially lethal complication. The optimal closure method for the pancreatic remnant during minimally invasive distal pancreatectomy (MDP) remains unclear.
Methods:
Data of consecutive patients who underwent MDP in our institution between July 2018 and June 2021 were collected. The outcomes of MDP with stapler and hand-sewn closure were compared. The primary outcome was clinically relevant postoperative pancreatic fistula (CR-POPF) per the International Study Group of Pancreatic Surgery definition.
Results:
Of the 384 patients (stapler closure, 339; hand-sewn closure, 45) enrolled, 249 developed CR-POPF (grades B and C: 242 and 7 patients, respectively). The rates of grade B and grade C POPF in the stapler group were similar to the corresponding rates in the hand-sewn group (64.6% and 1.5% vs 51.1% and 4.4%, P = .078 and P = .223, respectively). No differences between the stapler and hand-sewn groups were observed regarding the median operation time (207 vs 222 minutes, P = .139), incidence of major complications (16.5% vs 20.0%, P = .559), and mortality (0.2% vs 0%, P = 1.000). The independent risk factors of CR-POPF were abdominal abscess, prolonged operation time, and transection site (P = .004, .006, and .001, respectively).
Conclusion:
The incidence and severity of CR-POPF by stapler closure of the pancreatic stump were comparable to those associated with hand-sewn closure in MDP in this retrospective cohort. Randomized controlled trials are needed to verify this finding.
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Affiliation(s)
- Tao Qian
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Kaiquan Huang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Chen
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | | | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Wu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Yu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
- Cancer Center, Zhejiang University, Hangzhou, China
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13
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Hirashita T, Fujinaga A, Nagasawa Y, Orimoto H, Amano S, Kawamura M, Kawasaki T, Kawano Y, Masuda T, Endo Y, Inomata M. Efficacy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy. Langenbecks Arch Surg 2024; 409:145. [PMID: 38687358 DOI: 10.1007/s00423-024-03335-7] [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: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult. METHODS Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated. RESULTS In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure. CONCLUSIONS PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.
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Affiliation(s)
- Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan.
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuiko Nagasawa
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Hiroki Orimoto
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Shota Amano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yoko Kawano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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14
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Timmerhuis HC, Jensen CW, Ngongoni RF, Baiocchi M, DeLong JC, Ohkuma R, Dua MM, Norton JA, Poultsides GA, Worth PJ, Visser BC. Postoperative outcomes and costs of laparoscopic versus robotic distal pancreatectomy: a propensity-matched analysis. Surg Endosc 2024; 38:2095-2105. [PMID: 38438677 DOI: 10.1007/s00464-024-10728-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/28/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) has established advantages over the open approach. The costs associated with robotic DP (RDP) versus laparoscopic DP (LDP) make the robotic approach controversial. We sought to compare outcomes and cost of LDP and RDP using propensity matching analysis at our institution. METHODS Patients undergoing LDP or RDP between 2000 and 2021 were retrospectively identified. Patients were optimally matched using age, gender, American Society of Anesthesiologists status, body mass index, and tumor size. Between-group differences were analyzed using the Wilcoxon signed-rank test for continuous data, and the McNemar's test for categorical data. Outcomes included operative duration, conversion to open surgery, postoperative length of stay, pancreatic fistula rate, pseudocyst requiring intervention, and costs. RESULTS 298 patients underwent MIDP, 180 (60%) were laparoscopic and 118 (40%) were robotic. All RDPs were matched 1:1 to a laparoscopic case with absolute standardized mean differences for all matching covariates below 0.10, except for tumor type (0.16). RDP had longer operative times (268 vs 178 min, p < 0.01), shorter length of stay (2 vs 4 days, p < 0.01), fewer biochemical pancreatic leaks (11.9% vs 34.7%, p < 0.01), and fewer interventional radiological drainage (0% vs 5.9%, p = 0.01). The number of pancreatic fistulas (11.9% vs 5.1%, p = 0.12), collections requiring antibiotics or intervention (11.9% vs 5.1%, p = 0.12), and conversion rates (3.4% vs 5.1%, p = 0.72) were comparable between the two groups. The total direct index admission costs for RDP were 1.01 times higher than for LDP for FY16-19 (p = 0.372), and 1.33 times higher for FY20-22 (p = 0.031). CONCLUSIONS Although RDP required longer operative times than LDP, postoperative stays were shorter. The procedure cost of RDP was modestly more expensive than LDP, though this was partially offset by reduced hospital stay and reintervention rate.
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Affiliation(s)
- Hester C Timmerhuis
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Christopher W Jensen
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rejoice F Ngongoni
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Baiocchi
- Stanford Prevention Research Center and Departments of Statistics and Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Jonathan C DeLong
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rika Ohkuma
- Department of Quality, Stanford University School of Medicine, Stanford, CA, USA
| | - Monica M Dua
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeffrey A Norton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Patrick J Worth
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Surgery, Stanford Health Care & Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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15
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Loos M, Mack CE, Xu ATL, Hassenpflug M, Hinz U, Mehrabi A, Berchtold C, Schneider M, Al-Saeedi M, Roth S, Hackert T, Büchler MW. Distal Pancreatectomy: Extent of Resection Determines Surgical Risk Categories. Ann Surg 2024; 279:479-485. [PMID: 37259852 PMCID: PMC10829897 DOI: 10.1097/sla.0000000000005935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Recently, subclassification of pancreatoduodenectomy in 4 differing types has been reported, because additional major vascular and multivisceral resections have been shown to be associated with an increased risk of postoperative morbidity and mortality. OBJECTIVE To classify distal pancreatectomy (DP) based on the extent of resection and technical difficulty and to evaluate postoperative outcomes with regards to this classification system. METHODS All consecutive patients who had undergone DP between 2001 and 2020 in a high-volume pancreatic surgery center were included in this study. DPs were subclassified into 4 distinct categories reflecting the extent of resection and technical difficulty, including standard DP (type 1), DP with venous (type 2), multivisceral (type 3), or arterial resection (type 4). Patient characteristics, perioperative data, and postoperative outcomes were analyzed and compared among the 4 groups. RESULTS A total of 2135 patients underwent DP. Standard DP was the most frequently performed procedure (64.8%). The overall 90-day mortality rate was 1.6%. Morbidity rates were higher in patients with additional vascular or multivisceral resections, and 90-day mortality gradually increased with the extent of resection from standard DP to DP with arterial resection (type 1: 0.7%; type 2: 1.3%; type 3: 3%; type 4: 8.7%; P <0.0001). Multivariable analysis confirmed the type of DP as an independent risk factor for 90-day mortality. CONCLUSIONS Postoperative outcomes after DP depend on the extent of resection and correlate with the type of DP. The implementation of the 4-type classification system allows standardized reporting of surgical outcomes after DP improving comparability of future studies.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudia E. Mack
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - An Ting L. Xu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Matthias Hassenpflug
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General and Visceral Surgery, GRN Klinik Sinsheim, Sinsheim, Germany
| | - Ulf Hinz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Susanne Roth
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral, and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus W. Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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16
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Huang JM, Chen SH, Chen TH. Short-Term Outcomes of Conventional Laparoscopic versus Robot-Assisted Distal Pancreatectomy for Malignancy: Evidence from US National Inpatient Sample, 2005-2018. Cancers (Basel) 2024; 16:1003. [PMID: 38473361 DOI: 10.3390/cancers16051003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The primary treatment for pancreatic cancer is surgical resection, and laparoscopic resection offers benefits over open surgery. This study aimed to compare the short-term outcomes of robot-assisted vs. conventional laparoscopic distal pancreatectomy. METHODS Data of adults ≥ 20 years old with pancreatic cancer who underwent conventional laparoscopic or robot-assisted laparoscopic distal pancreatectomy were extracted from the United States (US) Nationwide Inpatient Sample (NIS) 2005-2018 database. Comorbidities and complications were identified through the International Classification of Diseases (ICD) codes. Short-term outcomes were compared using logistic regression and included length of hospital stay (LOS), perioperative complications, in-hospital mortality, unfavorable discharge, and total hospital costs. RESULTS A total of 886 patients were included; 27% received robot-assisted, and 73% received conventional laparoscopic surgery. The mean age of all patients was 65.3 years, and 52% were females. Multivariable analysis revealed that robot-assisted surgery was associated with a significantly reduced risk of perioperative complications (adjusted odds ratio (aOR) = 0.61, 95% confidence interval (CI): 0.45-0.83) compared to conventional laparoscopic surgery. Specifically, robot-assisted surgery was associated with a significantly decreased risk of VTE (aOR = 0.35, 95% CI: 0.14-0.83) and postoperative blood transfusion (aOR = 0.37, 95% CI: 0.23-0.61). Robot-assisted surgery was associated with a significantly shorter LOS (0.76 days shorter, 95% CI: -1.43--0.09) but greater total hospital costs (18,284 USD greater, 95% CI: 4369.03-32,200.70) than conventional laparoscopic surgery. CONCLUSIONS Despite the higher costs, robot-assisted distal pancreatectomy is associated with decreased risk of complications and shorter hospital stays than conventional laparoscopic distal pancreatectomy.
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Affiliation(s)
- Jyun-Ming Huang
- Department of Surgery, China Medical University Hospital, No. 2, Yude Rd., North Dist., Taichung City 404327, Taiwan
- School of Medicine, China Medical University, No. 2, Yude Rd., North Dist., Taichung City 404, Taiwan
| | - Sheng-Hsien Chen
- Department of Surgery, China Medical University Hospital, No. 2, Yude Rd., North Dist., Taichung City 404327, Taiwan
- School of Medicine, China Medical University, No. 2, Yude Rd., North Dist., Taichung City 404, Taiwan
| | - Te-Hung Chen
- Department of Surgery, China Medical University Hospital, No. 2, Yude Rd., North Dist., Taichung City 404327, Taiwan
- School of Medicine, China Medical University, No. 2, Yude Rd., North Dist., Taichung City 404, Taiwan
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17
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Xia N, Li J, Huang X, Tian B, Xiong J. Reinforced stapling does not reduce postoperative pancreatic fistula in distal pancreatectomy: a systematic review and meta-analysis. Updates Surg 2023; 75:2063-2074. [PMID: 37950142 DOI: 10.1007/s13304-023-01691-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
Postoperative pancreatic fistula (POPF) is a severe complication after distal pancreatectomy (DP); however, it is unclear how to effectively reduce the incidence. The purpose of this meta-analysis is to determine whether reinforced stapling reduces POPF after DP. From February 2007 to April 2023, a comprehensive search of electronic data and references was conducted in PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. In this study, the perioperative outcomes were evaluated for the reinforced stapler (RS) group and the standard stapler (SS) group in DP using Review Manager Software. Using fixed- or random-effects models, pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. In total, three randomized clinical trials (RCTs) with 425 patients and five observational clinical studies (OCS) with 318 patients were included. In pooled meta-analyses from RCTs, there was no difference between the two groups in the incidence of POPF (OR = 0.79; 95% CI [0.47,1.35]; P = 0.39), intraoperative blood loss (MD = 10.66; 95% CI [- 28.83,50.16]; P = 0.6), operative time (MD = 9.88; 95% CI [- 8.92,28.67]; P = 0.3), major morbidity (OR = 1.12; 95% CI [0.67,1.90]; P = 0.66), reoperation (OR = 0.97; 95% CI [0.41,2.32]; P = 0.95), readmission (OR = 0.99; 95% CI [0.57,1.72]; P = 0.97) or hospital stay (MD = - 0.95; 95% CI [- 5.22,3.31]; P = 0.66). However, the results of POPF and readmission were favorable for RS in the OCS group.
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Affiliation(s)
- Ning Xia
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Jiao Li
- Department of Emergency Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
- Disaster Medical Center, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Xing Huang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Bole Tian
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Junjie Xiong
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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18
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Inoue K, Morikawa T, Ishida M, Miura T, Kashiwagi R, Kokumai T, Aoki S, Iseki M, Nakayama S, Douchi D, Ohtsuka H, Mizuma M, Nakagawa K, Kamei T, Unno M. Chronic Glucocorticoid Use is a Potential Risk Factor for Delayed Pancreatic Fistula after Laparoscopic Distal Pancreatectomy: A Retrospective Analysis. TOHOKU J EXP MED 2023; 261:221-228. [PMID: 37648507 DOI: 10.1620/tjem.2023.j072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Pancreatic fistula is a potentially morbid complication after distal pancreatectomy. Chronic glucocorticoid use is one of the risk factors for pancreatic fistula in pancreaticoduodenectomy, though it has not been reported in distal pancreatectomy. We explored whether chronic glucocorticoid use can be a risk factor for pancreatic fistula in distal pancreatectomy. We reviewed 408 consecutive patients who underwent elective distal pancreatectomy from 2011 to 2021. We evaluated two kinds of pancreatic fistula (postoperative pancreatic fistula and delayed pancreatic fistula). We defined delayed pancreatic fistula as a patient who was re-admitted for pancreatic fistula after the first discharge from the hospital. Preoperative characteristics and postoperative outcomes were analyzed. Two hundred sixty-seven patients underwent open distal pancreatectomy, while 141 patients had laparoscopic distal pancreatectomy. A comparison of patient with and without chronic glucocorticoid use showed that only patients with chronic glucocorticoid use developed delayed pancreatic fistula (0% vs. 16.7%; p < 0.001). In addition, delayed pancreatic fistula occurred in only laparoscopic distal pancreatectomy patients with chronic glucocorticoid use (0% vs. 25.0%; p < 0.001). Although sample size is small, it is reasonable to presume that chronic glucocorticoid use is a potential risk factor for delayed pancreatic fistula in laparoscopic distal pancreatectomy.
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Affiliation(s)
- Koetsu Inoue
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takanori Morikawa
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Masaharu Ishida
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takayuki Miura
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Ryosuke Kashiwagi
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takashi Kokumai
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Shuichi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Masahiro Iseki
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Shun Nakayama
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Daisuke Douchi
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Hideo Ohtsuka
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine
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19
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Ding H, Kawka M, Gall TMH, Wadsworth C, Habib N, Nicol D, Cunningham D, Jiao LR. Robotic Distal Pancreatectomy Yields Superior Outcomes Compared to Laparoscopic Technique: A Single Surgeon Experience of 123 Consecutive Cases. Cancers (Basel) 2023; 15:5492. [PMID: 38001752 PMCID: PMC10669937 DOI: 10.3390/cancers15225492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/03/2023] [Accepted: 11/18/2023] [Indexed: 11/26/2023] Open
Abstract
Technical limitations of laparoscopic distal pancreatectomy (LDP), in comparison to robotic distal pancreatectomy (RDP), may translate to high conversion rates and morbidity. LDP and RDP procedures performed between December 2008 and January 2023 in our tertiary referral hepatobiliary and pancreatic centres were analysed and compared with regard to short-term outcomes. A total of 62 consecutive LDP cases and 61 RDP cases were performed. There was more conversion to open surgeries in the laparoscopic group compared with the robotic group (21.0% vs. 1.6%, p = 0.001). The LDP group also had a higher rate of postoperative complications (43.5% vs. 23.0%, p = 0.005). However, there was no significant difference between the two groups in terms of major complication or pancreatic fistular after operations (p = 0.20 and p = 0.71, respectively). For planned spleen-preserving operations, the RDP group had a shorter mean operative time (147 min vs. 194 min, p = 0.015) and a reduced total length of hospital stay compared with the LDP group (4 days vs. 7 days, p = 0.0002). The failure rate for spleen preservation was 0% in RDP and 20% (n = 5/25) in the LDP group (p = 0.009). RDP offered a better method for splenic preservation with Kimura's technique compared with LDP to avoid the risk of splenic infarction and gastric varices related to ligation and division of splenic pedicles. RDP should be the standard operation for the resection of pancreatic tumours at the body and tail of the pancreas without involving the celiac axis or common hepatic artery.
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Affiliation(s)
- Hao Ding
- Department of Surgery and Cancer, Imperial College London, Exhibition Road, South Kensington, London SW7 2BU, UK; (H.D.); (M.K.); (T.M.H.G.)
| | - Michal Kawka
- Department of Surgery and Cancer, Imperial College London, Exhibition Road, South Kensington, London SW7 2BU, UK; (H.D.); (M.K.); (T.M.H.G.)
| | - Tamara M. H. Gall
- Department of Surgery and Cancer, Imperial College London, Exhibition Road, South Kensington, London SW7 2BU, UK; (H.D.); (M.K.); (T.M.H.G.)
- Department of Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK; (D.N.); (D.C.)
| | - Chris Wadsworth
- Department of Gastroenterology and Surgery, The Hammersmith Hospital, Du Cane Road, London W12 0HS, UK; (C.W.); (N.H.)
| | - Nagy Habib
- Department of Gastroenterology and Surgery, The Hammersmith Hospital, Du Cane Road, London W12 0HS, UK; (C.W.); (N.H.)
| | - David Nicol
- Department of Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK; (D.N.); (D.C.)
| | - David Cunningham
- Department of Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK; (D.N.); (D.C.)
| | - Long R. Jiao
- Department of Surgery and Cancer, Imperial College London, Exhibition Road, South Kensington, London SW7 2BU, UK; (H.D.); (M.K.); (T.M.H.G.)
- Department of Surgery and Oncology, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK; (D.N.); (D.C.)
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20
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Yin T, Yuan J, Wu Y, Li S, Wang M, He R, Qin R. Retroperitonealization of the pancreatic stump in distal pancreatectomy: a novel technique to reduce postoperative pancreatic fistula. Langenbecks Arch Surg 2023; 408:425. [PMID: 37914974 DOI: 10.1007/s00423-023-03138-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of retroperitonealization of the pancreatic stump in distal pancreatectomy. METHODS Clinical data from the Tongji Hospital pancreatic database were retrospectively reviewed in this study. The data of 68 patients who underwent retroperitonealized distal pancreatectomy from January, 2019, to April, 2021, were collected and analyzed. Sixty-four patients who underwent conventional distal pancreatectomy during the same period were matched. We compared and analyzed the operative outcomes and postoperative complications between the patients in the two groups before and after propensity score matching (PSM). RESULTS Before PSM, the operative outcomes and postoperative complications were comparable between the two groups. After PSM, the retroperitonealized group had a lower incidence of postoperative pancreatic fistula (POPF) (10.53% vs 31.58%, P = 0.047) and shorter time until drainage removal (10.00, 8.00-13.00 days vs 13.00, 10.00-18.00 days, P = 0.005). In the univariate and multivariate regression analyses, non-retroperitonealization and intra-abdominal infection were found to be independent risk factors for postoperative pancreatic fistula (POPF). CONCLUSION Retroperitonealization of the pancreatic stump can reduce the incidence of POPF after distal pancreatectomy.
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Affiliation(s)
- Taoyuan Yin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Jingxiong Yuan
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Yi Wu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Shizhen Li
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China
| | - Ruizhi He
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China.
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, Hubei, China.
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21
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Nagamori M, Igarashi T, Kimura N, Fukasawa M, Watanabe T, Hirano K, Tanaka H, Shibuya K, Yoshioka I, Fujii T. Laparoscopic distal pancreatectomy for pancreatic tail cancer in a 100-year-old patient. Clin J Gastroenterol 2023; 16:779-784. [PMID: 37486542 DOI: 10.1007/s12328-023-01834-6] [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: 03/23/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Abstract
We present the case of a 100-year-old man with no specific symptoms. Computed tomography (CT) revealed a 34 mm tumor in the pancreatic tail, which was diagnosed as pancreatic cancer by biopsy. CT and magnetic resonance imaging showed that the tumor was resectable, and there were no noncurative factors on staging laparoscopy (cT3N0M0: cStage IIA). His performance status was good, and hypertension was the only comorbidity. A cardiologist, respiratory physician, and anesthesiologist examined the patient and determined that his condition was suitable for surgery. His postoperative predicted mortality rate was 0.9% using the American College of Surgeons risk calculator. We administered synbiotics and nutrients before surgery and introduced preoperative rehabilitation to improve his activities of daily living (ADL) as well as respiratory training to prevent postoperative pneumonia. Regarding the invasiveness of the surgery, we performed laparoscopic distal pancreatectomy with D1 lymphadenectomy. The patient was discharged on postoperative day 17, without any major complications. When performing pancreatectomy in older adults, it is important to fully assess preoperative tolerance and perioperative risk and prevent worsening of ADL by introducing nutritional therapy and rehabilitation.
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Affiliation(s)
- Masakazu Nagamori
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Takamichi Igarashi
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Nana Kimura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Mina Fukasawa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Katsuhisa Hirano
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Haruyoshi Tanaka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Isaku Yoshioka
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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22
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Kaneda Y, Kimura Y, Saito A, Ae R, Kawahira H, Sata N. Pancreas Ligation Device for Distal Pancreatectomy: An Ex Vivo Follow-Up Porcine Study. Cureus 2023; 15:e44771. [PMID: 37692176 PMCID: PMC10484152 DOI: 10.7759/cureus.44771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction Postoperative pancreatic fistula (POPF) is a critical complication occurring with a high incidence after distal pancreatectomy. To minimize the risk of POPF, we developed an innovative pancreas ligation device capable of closing the pancreatic stump without causing traumatic injury to the pancreatic duct and artery. We conducted an ex vivo follow-up study to compare the pressure resistance of the pancreas ligation device with that of a regular linear stapler. Materials and methods The pancreases were excised from 20 pigs and divided into two groups: ligation group (n = 10) and stapler group (n = 10). Distal pancreatectomy was performed, and the pancreatic stump was closed using either a pancreas ligation device or a regular linear stapler. The main pancreatic duct was cannulated with a 4-French catheter connected to a cannula and syringe filled with contrast medium. Using fluoroscopy detection, pressure resistance was defined as the maximum pressure without leakage from the pancreatic stump. Results No significant differences were found between the two groups regarding sex, age, body weight, or pancreatic thickness. In the ligation group, no leakage was observed at the stump in any pancreas. However, in the stapler group, six of 10 pancreases showed leakage at the staple line or into the parenchyma. Pressure resistance was significantly higher in the ligation group than in the stapler group (median: 42.8 vs. 34.3 mmHg, P = 0.023). Conclusions These findings suggest the effectiveness of a pancreas ligation device in reducing the incidence of POPF after distal pancreatectomy. Our ligation device is expected to be a useful alternative to a linear stapler for pancreatic stump closure.
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Affiliation(s)
- Yuji Kaneda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
- Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Yuki Kimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Akira Saito
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, JPN
| | - Hiroshi Kawahira
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
- Medical Simulation Center, Jichi Medical University, Shimotsuke, JPN
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, JPN
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23
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Poddar P, Shylasree TS, Bhandare M. Splenectomy and Distal Pancreaticosplenectomy: Surgical Anatomy and Technique Specific to Advanced Ovarian Cancer. Indian J Surg Oncol 2023; 14:252-263. [PMID: 36891436 PMCID: PMC9986191 DOI: 10.1007/s13193-021-01412-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 07/28/2021] [Indexed: 10/20/2022] Open
Abstract
Ovarian cancer is one of the most aggressive malignancies in women and usually presents at an advanced stage. Complete tumor debulking and platinum sensitivity are the two important determinants of survival in ovarian cancer. Upper abdominal surgery with bowel resections and peritonectomy are usually needed to achieve optimal cytoreduction. Splenic disease in the form of diaphragmatic peritoneal disease or omental caking at the splenic hilum is not infrequent. Around 1-2% of these require distal pancreaticosplenectomy (DPS) and the decision to perform DPS versus splenectomy should be made early in the intraoperative period to prevent unnecessary hilar dissection and bleeding. We hereby describe the surgical anatomy of the spleen and pancreas and point of technique of splenectomy and DPS specific to advanced ovarian cancers.
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Affiliation(s)
- Pabashi Poddar
- Department of Gynecological Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernst Borges Marg, Parel, Mumbai, 400012 Maharashtra India
| | - T. S. Shylasree
- Department of Gynecological Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernst Borges Marg, Parel, Mumbai, 400012 Maharashtra India
| | - Manish Bhandare
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernst Borges Marg, Parel, Mumbai, 400012 Maharashtra India
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24
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Palmeri M, Furbetta N, Di Franco G, Gianardi D, Guadagni S, Bianchini M, Fatucchi LM, Comandatore A, Moglia A, Di Candio G, Morelli L. Comparison of different pancreatic stump management strategies during robot-assisted distal pancreatectomy. Int J Med Robot 2023; 19:e2470. [PMID: 36256862 DOI: 10.1002/rcs.2470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/14/2022] [Accepted: 10/13/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) represents the most feared complication after distal pancreatectomy, and the possible role of robotic assistance in this setting is poorly investigated so far. METHODS We analysed short-term outcomes of 88 patients who had undergone robot-assisted distal pancreatectomy (RDP), dividing them according to pancreatic stump management: selective Wirsung duct ligation/hand sewn suture (WirsLIG group), use of robotic EndoWrist staplers (RobSTAP group), and use of laparoscopic staplers (LapSTAP group). RESULTS Mean operative time resulted significantly longer in WirsLIG group (291.1 ± 77.21 min vs. 245 ± 56.22 min in RobSTAP group vs. 221.77 ± 64.64 min in LapSTAP group). No significant differences were found in median hospital stay and in POPF occurrence. CONCLUSIONS No strategy for pancreatic stump management during RDP has proven superior to the others in reducing POPF rates. The hand-sewn technique resulted more time consuming, nevertheless it remains essential where there is not enough space to insert the stapler.
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Affiliation(s)
- Matteo Palmeri
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Desirée Gianardi
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Simone Guadagni
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Matteo Bianchini
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Lorenzo Maria Fatucchi
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Annalisa Comandatore
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Andrea Moglia
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
| | - Giulio Di Candio
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Luca Morelli
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,Multidisciplinary Center for Robotic Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.,EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy
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25
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Luo D, Li Y, Ji L, Gong X. Novel end-to-side one-layer continuous pancreaticojejunostomy vs. end-to-end invaginated pancreaticojejunostomy in pancreatoduodenectomy: A single-center retrospective study. Front Surg 2023; 9:980056. [PMID: 36684316 PMCID: PMC9852522 DOI: 10.3389/fsurg.2022.980056] [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: 06/28/2022] [Accepted: 10/18/2022] [Indexed: 01/09/2023] Open
Abstract
Background and Objective Postoperative pancreatic fistula (POPF) is the most common critical complication after pancreatoduodenectomy (PD) and is the primary reason for increased mortality and morbidity after PD. We aim to investigate the clinical significance of a novel approach, i.e., end-to-side one-layer continuous pancreaticojejunostomy, for patients with PD. Methods The clinical data of 65 patients who underwent pancreatoduodenectomy at the Xiangya Hospital, Central South University, from September 2020 to December 2021 were retrospectively analyzed. Results Forty patients underwent end-to-end invaginated pancreaticojejunostomy, and 25 underwent the novel end-to-side one-layer continuous pancreaticojejunostomy. No significant differences were observed in pancreatic fistula, intraperitoneal infection, intraperitoneal bleeding, reoperation, postoperative hospital stay, or perioperative death between the two groups. However, the novel end-to-side one-layer continuous pancreaticojejunostomy group had significantly shorter operation duration (32.6 ± 5.1 min vs. 8.3 ± 2.2 min, p < 0.001). The incidence of pancreatic fistula in the novel pancreaticojejunostomy group was 12%, including two cases of grade A POPF and only one case of grade B POPF. No cases of grade C POPF occurred. No deaths were observed during the perioperative period. Conclusions The novel anastomosis method leads to a shorter operation duration than the traditional anastomosis method and does not increase postoperative complications. In conclusion, it is a simplified and feasible method for pancreatic anastomosis.
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Affiliation(s)
- Dong Luo
- Department of Hepatopancreatobiliary Surgery II, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yixiong Li
- Department of General Surgery (Pancreatic Surgery), Xiangya Hospital, Central South University, Changsha, China
| | - Liandong Ji
- Department of General Surgery (Pancreatic Surgery), Xiangya Hospital, Central South University, Changsha, China,Correspondence: LianDong Ji Xuejun Gong
| | - Xuejun Gong
- Department of General Surgery (Pancreatic Surgery), Xiangya Hospital, Central South University, Changsha, China,Correspondence: LianDong Ji Xuejun Gong
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26
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Masuda H, Kotecha K, Gall T, Gill AJ, Mittal A, Samra JS. Transition from open to robotic distal pancreatectomy in a low volume pancreatic surgery country: a single Australian centre experience. ANZ J Surg 2023; 93:151-159. [PMID: 36511144 DOI: 10.1111/ans.18199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/14/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advances in technology and techniques have allowed for robotic distal pancreatectomies to be readily performed in patients at high volume centres. This study describes the experience of a single surgeon during the learning curve and transition from open to robotic distal pancreatectomy in Australia, a traditionally low volume pancreatic surgery country. METHODS All patients undergoing distal pancreatectomy at an Australian-based tertiary referral centre between 2010 and 2021 were reviewed retrospectively. Demographic, clinicopathologic and survival data were analysed to compare perioperative and oncological outcomes between patients who underwent open, laparoscopic and robotic distal pancreatectomies. RESULTS A total of 178 distal pancreatectomies were identified for analysis during the study period. Ninety-one open distal pancreatectomies (ODP), 48 laparoscopic distal pancreatectomies (LDP), and 39 robotic distal pancreatectomies (RDP) were performed. Robotic distal pancreatectomy was non-inferior with respect to perioperative outcomes and yielded statistically non-significant advantages over LDP and ODP. CONCLUSION RDP is feasible and can be performed safely in well-selected patients during the learning phase at large pancreatic centres in a traditionally low-volume country like Australia. Referral to large pancreatic centres where access to the robotic platform and surgeon experience is not a barrier, and where a robust multidisciplinary team meeting can take place, remains pivotal in the introduction and transition toward the robotic approach for management of patients with pancreatic body or tail lesions.
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Affiliation(s)
- Hiro Masuda
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tamara Gall
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony J Gill
- Northern Clinical School, University of Sydney, Camperdown, New South Wales, Australia.,NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Camperdown, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Northern Clinical School, University of Sydney, Camperdown, New South Wales, Australia
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27
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Sheen AJ, Bandyopadhyay S, Baltatzis M, Deshpande R, Jamdar S, Carino NDL. Preliminary experience in laparoscopic distal pancreatectomy using the AEON™ endovascular stapler. Front Oncol 2023; 13:1146646. [PMID: 37124511 PMCID: PMC10130406 DOI: 10.3389/fonc.2023.1146646] [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: 01/17/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background The aim of this study is to investigate the effects of using a new innovative endovascular stapler, AEON™, on the pancreatic leak rates and other outcome measures. Methods In a retrospective review of prospectively collected data from a secure tertiary unit registry, patients undergoing distal or lateral pancreatectomy were analyzed for any differences on pancreatic fistula rates, length of stay, comprehensive complication index (CCI), and demographics after using AEON™ compared with other commonly used staplers. Statistical significance was defined as <0.05. Results There were no differences in the demographics between the two groups totaling 58 patients over 2 years from 2019 to 2021. A total of 43 and 15 patients underwent pancreatic transection using other staplers and AEON™ endovascular stapler, respectively. The comparison of the two groups revealed a significantly reduced rate of mean drain lipase at postoperative day 3 with AEON™ (446 U/L) versus the other staplers (4,208 U/L) (p = 0.018) and a subsequent reduction of postoperative pancreatic fistula (POPF) from 65% to 20%. A reduction in the mean CCI, from 13.80 when other staplers were used to 4.97 when AEON™ was used, was also observed (p = 0.087). Mean length of stay was shorter by 3 days in the AEON™ group compared with that in the other staplers (6 and 9 days, respectively; p = 0.018). Conclusion AEON™ stapler when used to transect the pancreas demonstrated a significantly reduced pancreatic fistula rate, length of stay in hospital, and a leaning towards a reduced CCI. Its use should be further evaluated in larger cohorts with the encouraging results to determine whether this is possibly related to the technology used in the design of the AEON™ stapler.
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Affiliation(s)
- Aali J. Sheen
- Manchester University Foundation National Health Service (NHS) Trust, Department of Surgery, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health (FBMH), University of Manchester, Manchester, United Kingdom
- Faculty of Bioscience, Manchester Metropolitan University, Manchester, United Kingdom
- *Correspondence: Aali J. Sheen,
| | - Samik Bandyopadhyay
- Manchester University Foundation National Health Service (NHS) Trust, Department of Surgery, Manchester, United Kingdom
| | - Minas Baltatzis
- Department of General Surgery, Salford Royal Foundation Trust, Salford, United Kingdom
| | - Rahul Deshpande
- Manchester University Foundation National Health Service (NHS) Trust, Department of Surgery, Manchester, United Kingdom
| | - Saurabh Jamdar
- Manchester University Foundation National Health Service (NHS) Trust, Department of Surgery, Manchester, United Kingdom
| | - Nicola de Liguori Carino
- Manchester University Foundation National Health Service (NHS) Trust, Department of Surgery, Manchester, United Kingdom
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Shah P, Patel V, Ashkar M. De novo non-alcoholic fatty liver disease after pancreatectomy: A systematic review. World J Clin Cases 2022; 10:12946-12958. [PMID: 36569000 PMCID: PMC9782952 DOI: 10.12998/wjcc.v10.i35.12946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/10/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As operative techniques and mortality rates of pancreatectomy have improved, there has been a shift in focus to maintaining and improving the nutritional status of these patients as we continue to learn more about post-operative complications. Although pancreatic endocrine and exocrine insufficiencies are known complications of pancreatectomy, increased longevity of these patients has also led to a higher incidence of de novo fatty liver disease which differs from traditional fatty liver disease given the lack of metabolic syndrome. AIM To identify and summarize patterns and risk factors of post-pancreatectomy de novo fatty liver disease to guide future management. METHODS We performed a database search on PubMed selecting papers published between 2001 and 2022 in the English language. PubMed was last accessed 1 June 2022. RESULTS Various factors influence the development of de novo fatty liver including indication for surgery (benign vs malignant), type of pancreatectomy, amount of pancreas remnant, and peri-operative nutritional status. With an incidence rate up to 75%, de novo non-alcoholic fatty liver disease (NAFLD) can develop within 12 mo after pancreatectomy and various risk factors have been established including pancreatic resection line and remnant pancreas volume, peri-operative malnutrition and weight loss, pancreatic exocrine insufficiency (EPI), malignancy as the indication for surgery, and postmenopausal status. CONCLUSION Since majority of risk factors leads to EPI and malnutrition, peri-operative focus on nutrition and enzymes replacement is key in preventing and treating de novo NAFLD after pancreatectomy.
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Affiliation(s)
- Parth Shah
- Gastroenterology, Washington University in Saint Louis, Saint Louis, MO 63110, United States
| | - Vanisha Patel
- Internal Medicine, Washington University in Saint Louis, Saint Louis, MO 63110, United States
| | - Motaz Ashkar
- Gastroenterology, Washington University in Saint Louis, Saint Louis, MO 63110, United States
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Kokkinakis S, Kritsotakis EI, Maliotis N, Karageorgiou I, Chrysos E, Lasithiotakis K. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 21:527-537. [PMID: 35513962 DOI: 10.1016/j.hbpd.2022.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 04/13/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.
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Affiliation(s)
- Stamatios Kokkinakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, Division of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete 71110, Greece
| | - Neofytos Maliotis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Ioannis Karageorgiou
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece.
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30
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Hedges EA, Khan TM, Babic B, Nilubol N. Predictors of post-operative pancreatic fistula formation in pancreatic neuroendocrine tumors: A national surgical quality improvement program analysis. Am J Surg 2022; 224:1256-1261. [PMID: 35999087 PMCID: PMC9700260 DOI: 10.1016/j.amjsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/04/2022] [Accepted: 07/14/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a serious complication following pancreas surgery. We aimed to establish factors associated with POPF specifically in patients with pancreatic neuroendocrine tumors (PNET). METHODS The 2014-2018 American College of Surgeons National Surgical Quality Improvement Program database was querried for patients undergoing resection for PNET. The impact of patient, tumor, and operative factors on POPF formation was evaluated. RESULTS 3532 patient underwent resections for PNET. The POPF rate was significantly higher in patients with PNET (24.8%) versus non-PNET (16.4%) (p < 0.0001). Male sex (OR 1.45, 95% CI 1.11-1.89), enucleation (OR 3.14, 95% CI 1.10-8.98), pancreaticoduodenectomy (OR 1.51, 95% CI 1.13-2.03), small duct size <3 mm (OR 3.24, 95% CI 1.62-6.48), and soft gland texture (OR 1.81, 95% CI 1.18-2.77) were independently associated with POPF in PNET patients on multivariable analysis. CONCLUSIONS POPF is more common in patients undergoing resection for PNET and is dictated primarily by surgical approach and gland characteristics.
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Affiliation(s)
- Elizabeth A Hedges
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tahsin M Khan
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bruna Babic
- Division of Endocrine Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review. World J Gastrointest Surg 2022; 14:1089-1106. [PMID: 36386401 PMCID: PMC9640330 DOI: 10.4240/wjgs.v14.i10.1089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/16/2022] [Accepted: 10/14/2022] [Indexed: 02/07/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.
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Affiliation(s)
| | - Jaswinder S Samra
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Sumit Sahni
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Anubhav Mittal
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
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Drake JA, Fleming AM, Behrman SW, Glazer ES, Deneve JL, Yakoub D, Tsao MW, Dickson PV. Tumor Location in the Pancreatic Tail Is Associated with Decreased Likelihood of Receiving Chemotherapy for Pancreatic Adenocarcinoma. J Gastrointest Surg 2022; 26:2136-2147. [PMID: 35768717 DOI: 10.1007/s11605-022-05381-2] [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: 01/18/2022] [Accepted: 04/02/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chemotherapy (CTX) is associated with improved survival for patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC). The current study evaluated the influence of tumor location on receipt of CTX. METHODS The NCDB (2006-2017) was queried to identify patients with clinical stage I-III PDAC. Predictors of receipt of CTX, sequencing of CTX, and overall survival (OS) were analyzed. RESULTS Among 14,557 patients who underwent resection for PDAC 3,453 (24%) did not receive CTX. On multivariable analysis, patients with tail tumors were 15% less likely to receive CTX (OR 0.85, 95% CI 0.747-0.968) and 58% less likely to receive neoadjuvant CTX (OR 0.42, 95% CI 0.351-0.509) relative to patients with head/neck tumors. For patients with body tumors, there was no difference in rates of administration or sequence of CTX. For patients with resected tail tumors, median OS was 29.9 vs 18.9 months (p < 0.001) between those who did and did not receive CTX. For patients with tail tumors, independent predictors of not receiving CTX, regardless of sequence, were increasing age (OR 0.95, 95% CI 0.935-0.965), increasing post-op length of stay (OR 0.95, 95% CI 0.932-0.968), and 30-day post-op readmission (OR 0.46, 95% CI 0.315-0.670). CONCLUSIONS In patients with clinical stage I-III PDAC, tumor location within the tail was independently associated with not receiving CTX. Given the marked improvement in OS when CTX is administered, strategies aimed at increasing the number of these patients who receive CTX are necessary.
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Affiliation(s)
- Justin A Drake
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Andrew M Fleming
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Stephen W Behrman
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Evan S Glazer
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Jeremiah L Deneve
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Danny Yakoub
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Miriam W Tsao
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA
| | - Paxton V Dickson
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Ave., 3rdFloor, Memphis, TN, 38163, USA.
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Vissers FL, Balduzzi A, van Bodegraven EA, van Hilst J, Festen S, Hilal MA, Asbun HJ, Mieog JSD, Koerkamp BG, Busch OR, Daams F, Luyer M, De Pastena M, Malleo G, Marchegiani G, Klaase J, Molenaar IQ, Salvia R, van Santvoort HC, Stommel M, Lips D, Coolsen M, Bassi C, van Eijck C, Besselink MG. Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial. Trials 2022; 23:809. [PMID: 36153559 PMCID: PMC9509576 DOI: 10.1186/s13063-022-06736-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C. METHODS/DESIGN Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality. DISCUSSION PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).
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Affiliation(s)
- F. L. Vissers
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - A. Balduzzi
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - E. A. van Bodegraven
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - J. van Hilst
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands ,grid.440209.b0000 0004 0501 8269Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - S. Festen
- grid.440209.b0000 0004 0501 8269Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - M. Abu Hilal
- grid.430506.40000 0004 0465 4079Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK ,grid.415090.90000 0004 1763 5424Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - H. J. Asbun
- grid.418212.c0000 0004 0465 0852Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, USA
| | - J. S. D. Mieog
- grid.10419.3d0000000089452978Department of Surgery, LUMC, Leiden, the Netherlands
| | - B. Groot Koerkamp
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - O. R. Busch
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - F. Daams
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - M. Luyer
- grid.413532.20000 0004 0398 8384Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - M. De Pastena
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Malleo
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Marchegiani
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - J. Klaase
- grid.4494.d0000 0000 9558 4598Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - I. Q. Molenaar
- grid.7692.a0000000090126352Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R. Salvia
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - H. C. van Santvoort
- grid.415960.f0000 0004 0622 1269Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - M. Stommel
- grid.10417.330000 0004 0444 9382Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
| | - D. Lips
- grid.415214.70000 0004 0399 8347Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M. Coolsen
- grid.412966.e0000 0004 0480 1382Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
| | - C. Bassi
- grid.411475.20000 0004 1756 948XDepartment of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - C. van Eijck
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M. G. Besselink
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
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Risk Factor Identification for Delayed Gastric Emptying after Distal Pancreatectomy-An Evaluation of 1688 Patients Based on the German StuDoQ|Pancreas Registry. J Clin Med 2022; 11:jcm11195539. [PMID: 36233403 PMCID: PMC9572291 DOI: 10.3390/jcm11195539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/17/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.
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Comparison of splenic vessel preserving distal pancreatectomy and the Warshaw technique for solid pseudopapillary neoplasm in children. Pediatr Surg Int 2022; 38:1143-1148. [PMID: 35633409 DOI: 10.1007/s00383-022-05134-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Spleen-preserving distal pancreatectomy (SPDP) such as splenic vessel preservation (SVP) for solid pseudopapillary neoplasms (SPNs) in the body or tail of the pancreas in children prevents post-splenectomy infection and hematologic disorders. However, SVP could be technically challenging, and the Warshaw technique (WT) could be an alternative technique that has been reported to be safe and effective in adults. We, therefore, compared the perioperative outcomes of SVP and WT in pediatric patients. METHODS We retrospectively reviewed the medical records of pediatric patients with SPN who underwent SPDP using SVP or WT between November 2002 and November 2018 at a large-sized tertiary referral center. RESULTS Twenty-eight patients were included. Sixteen (57.1%) patients underwent SVP and 12 (42.9%) patients underwent WT. There were no significant differences in the baseline characteristics between the two groups. Postoperative complications occurred in 8 patients each in the SVP (50%), and the WT (66.7%) groups. Two (12.5%) in the SVP group and 1 (8.3%) in the WT group required additional intervention. During a median follow-up duration of 49 months, there were no significant differences in the incidence of splenic infarctions or perigastric varices between the two groups. CONCLUSIONS There were no significant differences in the surgical outcomes between WT and SVP in pediatric patients with SPN. WT could be a safe and feasible alternative technique for SVP in challenging cases.
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Segmentation of Pancreatic Subregions in Computed Tomography Images. J Imaging 2022; 8:jimaging8070195. [PMID: 35877639 PMCID: PMC9317715 DOI: 10.3390/jimaging8070195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
The accurate segmentation of pancreatic subregions (head, body, and tail) in CT images provides an opportunity to examine the local morphological and textural changes in the pancreas. Quantifying such changes aids in understanding the spatial heterogeneity of the pancreas and assists in the diagnosis and treatment planning of pancreatic cancer. Manual outlining of pancreatic subregions is tedious, time-consuming, and prone to subjective inconsistency. This paper presents a multistage anatomy-guided framework for accurate and automatic 3D segmentation of pancreatic subregions in CT images. Using the delineated pancreas, two soft-label maps were estimated for subregional segmentation—one by training a fully supervised naïve Bayes model that considers the length and volumetric proportions of each subregional structure based on their anatomical arrangement, and the other by using the conventional deep learning U-Net architecture for 3D segmentation. The U-Net model then estimates the joint probability of the two maps and performs optimal segmentation of subregions. Model performance was assessed using three datasets of contrast-enhanced abdominal CT scans: one public NIH dataset of the healthy pancreas, and two datasets D1 and D2 (one for each of pre-cancerous and cancerous pancreas). The model demonstrated excellent performance during the multifold cross-validation using the NIH dataset, and external validation using D1 and D2. To the best of our knowledge, this is the first automated model for the segmentation of pancreatic subregions in CT images. A dataset consisting of reference anatomical labels for subregions in all images of the NIH dataset is also established.
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Elkomos BE, Elkomos PE, Salem AA, Adly PB. The outcome of bioabsorbable staple line reinforcement versus standard stapler for distal pancreatectomy: A systematic review and meta-analysis. J Minim Access Surg 2022; 18:338-345. [PMID: 35708377 PMCID: PMC9306122 DOI: 10.4103/jmas.jmas_47_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/15/2022] [Accepted: 04/22/2022] [Indexed: 01/08/2023] Open
Abstract
Background and Aim In the era of minimally invasive procedures and as a way to decrease the incidence of post-operative pancreatic fistula (POPF), the use of staplers for distal pancreatectomy (DP) has increased dramatically. Our aim was to investigate whether reinforced staplers decrease the incidence of clinically relevant PF after DP compared with staplers without reinforcement. Methods PubMed, Scopus, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 November 2021, and a systematic review and a meta-analysis were done to detect the outcomes after using reinforced staplers versus standard stapler for DP. Results Seven studies with a total of 681 patients were included. The overall incidence of POPF and the incidence of Grade A POPF after DP are similar for the two groups (overall POPF, risk ratio [RR] = 0.85, 95% confidence interval [CI] = 0.71-1.01, P = 0.06; I2 = 38% and Grade A POPF, RR = 1.15, 95% CI = 0.78-1.69, P = 0.47; I2 = 49%). However, the incidence of clinically significant POPF (Grades B and C) is significantly lower in DP with reinforced staplers than DP with bare staplers (Grades B and C, RR = 0.45, 95% CI = 0.29-0.71, P = 0.0005; I2 = 17%). Nevertheless, the time of the operation, the blood loss during surgical procedure, the hospital stay after the surgery and the thickness of the pancreas are similar for both techniques. Conclusion Although staple line reinforcement after DP failed to prevent biochemical PF, it significantly reduced the rate of clinically relevant POPF in comparison to standard stapling.
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Affiliation(s)
- Beshoy Effat Elkomos
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
| | | | - Amir Ali Salem
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
| | - Philobater Bhgat Adly
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
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Pueyo-Périz E, Téllez-Marquès C, Radosevic A, Morató O, Visa L, Ilzarbe L, Berjano E, de Vicente E, Poves I, Ielpo B, Grande L, Burdío F, Sánchez-Velázquez P. Radiofrequency-assisted transection of the pancreas vs stapler in distal pancreatectomy: a propensity score matched cohort analysis. Sci Rep 2022; 12:7486. [PMID: 35523857 PMCID: PMC9076639 DOI: 10.1038/s41598-022-11583-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 04/25/2022] [Indexed: 12/20/2022] Open
Abstract
To demonstrate the efficacy of radiofrequency for pancreatic stump closure in reducing the incidence of postoperative pancreatic fistula (POPF) in distal pancreatectomy (DP) compared with mechanical transection methods. Despite all the different techniques of pancreatic stump closure proposed for DP, best practice for avoiding POPF remains an unresolved issue, with an incidence of up to 30% regardless of center volume or surgical expertise. DP was performed in a cohort of patients by applying radiofrequency to stump closure (RF Group) and compared with mechanical closure (Control Group). A propensity score (PS) matched cohort study was carried out to minimize bias from nonrandomized treatment assignment. Cohorts were matched by PS accounting for factors significantly associated with either undergoing RF transection or mechanical closure through logistic regression analysis. The primary end-point was the incidence of clinically relevant POPF (CR-POPF). Of 89 patients included in the whole cohort, 13 case patients from the RF-Group were 1:1 matched to 13 control patients. In both the first independent analysis of unmatched data and subsequent adjustment to the overall propensity score-matched cohort, a higher rate of CR-POPF in the Control Group compared with the RF-Group was detected (25.4% vs 5.3%, p = 0.049 and 53.8% vs 0%; p = 0.016 respectively). The RF Group showed better outcomes in terms of readmission rate (46.2% vs 0%, p = 0.031). No significant differences were observed in terms of mortality, major complications (30.8% vs 0%, p = 0.063) or length of hospital stay (5.7 vs 5.2 days, p = 0.89). Findings suggest that the RF-assisted technique is more efficacious in reducing CR-POPF than mechanical pancreatic stump closure.
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Affiliation(s)
- E Pueyo-Périz
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain.
| | - C Téllez-Marquès
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - A Radosevic
- Department of Radiology, Hospital del Mar, Passeig Maritim 25-29, Barcelona, Spain
| | - O Morató
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - L Visa
- Department of Oncology, Hospital del Mar-IMIM-CIBERONC, Passeig Maritim 25-29, Barcelona, Spain
| | - L Ilzarbe
- Department of Gastroenterology, Hospital del Mar, Passeig Maritim 25-29, Barcelona, Spain
| | - E Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - E de Vicente
- Department of Surgery, Hospital Sanchinarro, Madrid, Spain
| | - I Poves
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - B Ielpo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - L Grande
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - F Burdío
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - P Sánchez-Velázquez
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain.
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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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Samanta J, Dhar J, Muktesh G, Gupta P, Kumar-M P, Das A, Agarwala R, Bellam BL, Chauhan R, Kumar KH, Yadav TD, Gupta V, Sinha SK, Kochhar R, Facciorusso A. Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis. Expert Rev Gastroenterol Hepatol 2022; 16:297-305. [PMID: 35227141 DOI: 10.1080/17474124.2022.2047649] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Comparative data on percutaneous catheter drainage (PCD) vs EUS-guided drainage (EUS-D) for management of symptomatic walled-off-necrosis (WON), specially infected WON with/without organ failure(OF) is limited. METHODS Patients with symptomatic WON were divided into two groups of PCD and EUS-D, depending on the modality of drainage. Resolution of OF, adverse events, and other outcome measures were recorded. The two modalities were compared among infected WON sub-cohort and also degree of solid component (SC). RESULTS 218 patients (175 males; 80.3%) were included who underwent either PCD (n = 102) or EUS-D (n = 116). Clinical success was significantly higher in the EUS-D group (92.1% vs 64.6%; p < 0.0001) and even for infected WON (n = 128) (p = 0.004), with higher (p = 0.007) and faster (p < 0.0001) OF resolution. Other outcome measures including mortality were significantly higher in the PCD group. Among subgroups, PCD with >40% SC had the worst clinical success/OF resolution rates, while EUS-D with <40% SC had the best outcomes. CONCLUSION EUS-D should be preferred over PCD in the management of WON, infected or otherwise, for higher clinical success, and higher/faster resolution of OF. PCD should be avoided in WON with>40% SC.
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Affiliation(s)
- Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Muktesh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar-M
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aritra Das
- Expert epidemiologist, CARE India Solutions, New Delhi, India
| | - Roshan Agarwala
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Balaji L Bellam
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Hemanth Kumar
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj K Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy
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An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Surg Today 2022; 52:1430-1437. [PMID: 35138460 DOI: 10.1007/s00595-022-02470-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
PURPOSES Postoperative pancreatic fistula is the most common and severe postoperative complication of distal pancreatectomy. Treatment of pancreatic stump to reduce the incidence of postoperative pancreatic fistula is crucial. This study evaluated the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. METHODS Prospectively collected data of consecutive patients who underwent distal pancreatectomy from April 2013 to May 2020 with pancreatic transection performed by the bare stapler method (131 patients), stapler + hand-sewn closure method (199 patients), and stapler + titanium clip method (209 patients) were reviewed retrospectively and compared between groups. RESULTS No statistically significant differences were observed in basic data among the three groups. There were also no significant differences among the three groups in terms of the intraoperative data or tumor pathological types, except for the number of laparoscopic treatment cases (23, 53, and 80 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and pancreatic neuroendocrine tumor cases (15, 29, and 12, respectively; P < 0.05). There were no significant differences in postoperative complications or parameters, except for the number of clinical pancreatic fistula cases (31, 27, and 13 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and postoperative length of hospital stay (11.6 ± 8.3, 10.6 ± 9.7, and 9.3 ± 6.9 days, respectively; P < 0.05). The stapler + titanium clip group had a significantly lower number of clinical pancreatic fistula cases and shorter postoperative length of hospital stay than the other groups. The univariate analysis showed that pancreatic resection line thickness was an independent risk factor for clinical pancreatic fistula after operation. CONCLUSION Stapler closure combined with titanium clips to reinforce the pancreatic stump is simple and easy to implement, effectively reduces the incidence of clinical pancreatic fistula, and shortens the postoperative length of hospital stay.
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Toya K, Tomimaru Y, Kobayashi S, Sasaki K, Iwagami Y, Yamada D, Noda T, Takahashi H, Doki Y, Eguchi H. Preoperative neutrophil-to-lymphocyte ratio predicts healing time for postoperative pancreatic fistula after distal pancreatectomy. Ann Gastroenterol Surg 2022; 6:169-175. [PMID: 35106427 PMCID: PMC8786688 DOI: 10.1002/ags3.12510] [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: 07/26/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Postoperative pancreatic fistula is a serious complication of distal pancreatectomy. Although many studies have described the incidence and risk factors associated with postoperative pancreatic fistula (POPF), few have focused on the healing time. This study investigated the healing time and potential factors associated with the healing time of POPF after distal pancreatectomy (DP). METHODS Among 114 patients that underwent DP in our hospital from January 2010 to December 2020, we included 88 that developed POPF. The healing time for a postoperative pancreatic fistula was defined as the interval between the completion of DP and the removal of all drains related to the treatment for POPF. Based on the definition, three cases who required additional treatment after removal of all drains were excluded from this study. Clinical factors associated with the fistula healing times were investigated in the 85 patients. RESULTS The average POPF healing time was 11 ± 10 days (median: 6 days, range: 3-57). We found that the neutrophil-to-lymphocyte ratio, a marker of inflammatory and nutritional status, was the only factor independently associated with the POPF healing time; the mean healing time was significantly shorter in patients with neutrophil-to-lymphocyte ratio ≤2.1 (8 ± 6 days) than in those with neutrophil-to-lymphocyte ratio >2.1 (13 ± 12 days; P = .0139). CONCLUSION We demonstrated that the neutrophil-to-lymphocyte ratio could independently predict the POPF healing time after DP. These findings suggested that improving the neutrophil-to-lymphocyte ratio might shorten the healing times for POPF after DP.
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Affiliation(s)
- Keisuke Toya
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yoshito Tomimaru
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Shogo Kobayashi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Kazuki Sasaki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yoshifumi Iwagami
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Daisaku Yamada
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Takehiro Noda
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Hidenori Takahashi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Hidetoshi Eguchi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
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A randomized controlled trial of stapled versus ultrasonic transection in distal pancreatectomy. Surg Endosc 2022; 36:4033-4041. [PMID: 34518950 PMCID: PMC9085691 DOI: 10.1007/s00464-021-08724-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The pancreatic transection method during distal pancreatectomy is thought to influence postoperative fistula rates. Yet, the optimal technique for minimizing fistula occurrence is still unclear. The present randomized controlled trial compared stapled versus ultrasonic transection in elective distal pancreatectomy. METHODS Patients undergoing distal pancreatectomy from July 2018 to July 2020 at two high-volume institutions were considered for inclusion. Exclusion criteria were contiguous organ resection and a parenchymal thickness > 17 mm on intraoperative ultrasound. Eligible patients were randomized in a 1:1 ratio to stapled transection (Endo GIA Reinforced Reload with Tri-Staple Technology®) or ultrasonic transection (Harmonic Focus® + or Harmonic Ace® + shears). The primary endpoint was postoperative pancreatic fistula. Secondary endpoints included overall complications, abdominal collections, and length of hospital stay. RESULTS Overall, 72 patients were randomized in the stapled transection arm and 73 patients in the ultrasonic transection arm. Postoperative pancreatic fistula occurred in 23 patients (16%), with a comparable incidence between groups (12% in stapled transection versus 19% in ultrasonic dissection arm, p = 0.191). Overall complications did not differ substantially (35% in stapled transection versus 44% in ultrasonic transection arm, p = 0.170). There was an increased incidence of abdominal collections in the ultrasonic dissection group (32% versus 14%, p = 0.009), yet the need for percutaneous drain did not differ between randomization arms (p = 0.169). The median length of stay was 8 days in both groups (p = 0.880). Intraoperative blood transfusion was the only factor independently associated with postoperative pancreatic fistula on logistic regression analysis (OR 4.8, 95% CI 1.2-20.0, p = 0.032). CONCLUSION The present randomized controlled trial of stapled versus ultrasonic transection in elective distal pancreatectomy demonstrated no significant difference in postoperative pancreatic fistula rates and no substantial clinical impact on other secondary endpoints.
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van der Heijde N, Lof S, Busch OR, de Hingh I, de Kleine RH, Molenaar IQ, Mungroop TH, Stommel MW, Besselink MG, van Eijck C. Incidence and impact of postoperative pancreatic fistula after minimally invasive and open distal pancreatectomy. Surgery 2021; 171:1658-1664. [PMID: 34906371 DOI: 10.1016/j.surg.2021.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/21/2021] [Accepted: 11/11/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Previous studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is unknown whether the clinical impact of postoperative pancreatic fistula after minimally invasive distal pancreatectomy is comparable with that after open distal pancreatectomy. We aimed to compare not only the incidence of postoperative pancreatic fistula, but more importantly, also its clinical impact. METHODS This is a post hoc analysis of a multicenter randomized trial investigating a possible beneficial impact of a fibrin patch on the rate of clinically relevant postoperative pancreatic fistula (International Study Group for Pancreatic Surgery grade B/C) after distal pancreatectomy. Primary outcomes of the current analysis are the incidence and clinical impact of postoperative pancreatic fistula after both minimally invasive distal pancreatectomy and open distal pancreatectomy. RESULTS From October 2010 to August 2017, 252 patients undergoing distal pancreatectomy were randomized, and data of 247 patients were available for analysis: 87 minimally invasive distal pancreatectomy and 160 open distal pancreatectomies. The postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was significantly higher than that after open distal pancreatectomy (28.7% vs 16.9%, P = .029). More patients were discharged with an abdominal surgical drain after minimally invasive distal pancreatectomy compared to open distal pancreatectomy (30/87, 34.5% vs 26/160, 16.5%, P = .001). In patients with postoperative pancreatic fistula, additional percutaneous catheter drainage procedures were performed less often (52% vs 84.6%, P = .012), with fewer drainage procedures (median [range], 2 [1-4] vs 2, [1-7], P = .014) after minimally invasive distal pancreatectomy. CONCLUSION In this post hoc analysis, the postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was higher than that after open distal pancreatectomy, whereas the clinical impact was less.
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Affiliation(s)
- Nicky van der Heijde
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Sanne Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht and St Antonius Hospital Nieuwegein, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Chhabra P, Maher B, Trivedi D, Karavias D, Arshad A, Wright M, Tehami N. Management of infected post-pancreatic resection fluid collections under endoscopic ultrasound guidance using lumen apposing metal stent: A case series and review of the literature. Ann Hepatobiliary Pancreat Surg 2021; 25:500-508. [PMID: 34845122 PMCID: PMC8639308 DOI: 10.14701/ahbps.2021.25.4.500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 01/08/2023] Open
Abstract
Backgrounds/Aims Post-operative pancreatic fistulas (POPF) and fluid collections (POPFC) remain significant sources of morbidity and mortality after pancreatic resections. There remains a paucity of literature describing endoscopic ultrasound (EUS) guided drainage of POPFC using a Hot AXIOS™ lumen apposing metal stent (LAMS). Methods We conducted a retrospective study, encompassing all consecutive patients with POPFC managed using Hot AXIOS™ LAMS at our institution between January 2017 and December 2019. Primary outcome measures were technical and clinical success. Secondary outcome measures were adverse events and recurrence rates. Results Five patients underwent EUS guided drainage using Hot AXIOS™ LAMS during the study period. Mean age of patients was 67.8 ± 2.16 years. The majority (60.0%) of patients were males. Median duration of symptom onset after surgery was 9 days. All patients presented with abdominal pain. Median size of the collection measured on computed tomography was 91 mm. Median interval time between symptom onset and EUS drainage was 30 days. Two patients required percutaneous drainage prior to EUS guided drainage. Technical and clinical success were achieved for all patients. No adverse events were observed. Median duration of follow-up was 90 days. No recurrence of collection occurred during the follow-up period. Conclusions EUS guided drainage of POPFC using Hot AXIOS™ LAMS is a safe and effective treatment modality with technical and clinical success rates of 100% in our experience.
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Affiliation(s)
- Puneet Chhabra
- Department of Gastroenterology, Southampton General Hospital, Southampton, United Kingdom
| | - Ben Maher
- Department of Interventional Radiology, Southampton General Hospital, Southampton, United Kingdom
| | - Dharmadev Trivedi
- Department of Hepatobiliary and Pancreatic Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Dimitrios Karavias
- Department of Hepatobiliary and Pancreatic Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Ali Arshad
- Department of Hepatobiliary and Pancreatic Surgery, Southampton General Hospital, Southampton, United Kingdom
| | - Mark Wright
- Department of Gastroenterology, Southampton General Hospital, Southampton, United Kingdom
| | - Nadeem Tehami
- Department of Gastroenterology, Southampton General Hospital, Southampton, United Kingdom
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Karunakaran M, Barreto SG. Surgery for pancreatic cancer: current controversies and challenges. Future Oncol 2021; 17:5135-5162. [PMID: 34747183 DOI: 10.2217/fon-2021-0533] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta-The Medicity, Gurugram 122001, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurugram 122001, India
| | - Savio George Barreto
- College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
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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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Wennerblom J, Ateeb Z, Jönsson C, Björnsson B, Tingstedt B, Williamsson C, Sandström P, Ansorge C, Blomberg J, Del Chiaro M. Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial. Br J Surg 2021; 108:265-270. [PMID: 33793753 DOI: 10.1093/bjs/znaa113] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/11/2020] [Accepted: 11/06/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is the leading cause of morbidity after distal pancreatectomy. Strategies investigated to reduce the incidence have been disappointing. Recent data showed a reduction in postoperative pancreatic fistula with the use of synthetic mesh reinforcement of the staple line. METHODS An RCT was conducted between May 2014 and February 2016 at four tertiary referral centres in Sweden. Patients scheduled for distal pancreatectomy were eligible. Enrolled patients were randomized during surgery to stapler transection with biological reinforcement or standard stapler transection. Patients were blinded to the allocation. The primary endpoint was the development of any postoperative pancreatic fistula. Secondary endpoints included morbidity, mortality, and duration of hospital stay. RESULTS Some 107 patients were randomized and 106 included in an intention-to-treat analysis (56 in reinforced stapling group, 50 in standard stapling group). No difference was demonstrated in terms of clinically relevant fistulas (grade B and C): 6 of 56 (11 per cent) with reinforced stapling versus 8 of 50 (16 per cent) with standard stapling (P = 0.332). There was no difference between groups in overall postoperative complications: 45 (80 per cent) and 39 (78 per cent) in reinforced and standard stapling groups respectively (P = 0.765). Duration of hospital stay was comparable: median 8 (range 2-35) and 9 (2-114) days respectively (P = 0.541). CONCLUSION Biodegradable stapler reinforcement at the transection line of the pancreas did not reduce postoperative pancreatic fistula compared with regular stapler transection in distal pancreatectomy. Registration number: NCT02149446 (http://www.clinicaltrials.gov).
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Affiliation(s)
- J Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Z Ateeb
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - C Jönsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - B Björnsson
- Department of Surgery in Linköping, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - B Tingstedt
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital at Lund and Lund University, Lund, Sweden
| | - C Williamsson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital at Lund and Lund University, Lund, Sweden
| | - P Sandström
- Department of Surgery in Linköping, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - C Ansorge
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J Blomberg
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgical Oncology, Department of Surgery, University of Colorado at Denver-Anschutz Medical Campus, Aurora, Colorado, USA
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49
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Ielpo B, Pueyo-Périz EM, Radosevic A, Andaluz A, Berjano E, Grande L, Sánchez-Velázquez P, Burdío F. Clinical case report: endoluminal thermal ablation of main pancreatic duct for patients at high risk of postoperative pancreatic fistula after pancreaticoduodenectomy. Int J Hyperthermia 2021; 38:755-759. [PMID: 33941013 DOI: 10.1080/02656736.2021.1917703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Multiple attempts have been made to manage the pancreatic stump and the pancreatic duct in order to reduce the rate of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), however radiofrequency-based technologies could help to achieve this goal. Previous encouraging clinical and experimental results support the use of endoluminal thermal ablation (ETHA) of the main pancreatic duct to reduce pancreatic exocrine secretion and hence POPF. We here describe our initial clinical experience with ETHA of the main pancreatic duct in two cases at high risk of POPF. METHODS Two cases underwent PD for malignancy with a high risk of POPF (adenocarcinoma, obese patients, surgical difficulties with heavy intraoperative blood loss, soft pancreas or walled-off pancreatitis and a tight small pancreatic main duct). In both cases, ETHA of the main pancreatic duct was conducted intraoperatively just before Blumgart-type pancreatic-jejunal anastomosis using a ClosureFast catheter (Medtronic, Mansfield, MA, USA) normally used for varicose vein treatment (therefore an off-label use). RESULTS Although a clear radiological POPF was detected in the second case, the clinical postoperative course in both cases was uneventful. Little pancreatic fluid collected in the abdominal drainage with low levels of amylase enzyme, confirming low exocrine pancreatic function. No other procedure-related complications were detected. CONCLUSION Endoluminal thermal ablation of the main pancreatic duct may be a feasible and safe technique to reduce the adverse effects of POPF after PD.
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Affiliation(s)
- Benedetto Ielpo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Eva M Pueyo-Périz
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | - Anna Andaluz
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Luis Grande
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Patricia Sánchez-Velázquez
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Fernando Burdío
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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50
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Dhayat SA, Tamim ANJ, Jacob M, Ebeling G, Kerschke L, Kabar I, Senninger N. Postoperative pancreatic fistula affects recurrence-free survival of pancreatic cancer patients. PLoS One 2021; 16:e0252727. [PMID: 34086792 PMCID: PMC8177431 DOI: 10.1371/journal.pone.0252727] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Postoperative pancreatic fistula (POPF) with reported incidence rates up to 45% contributes substantially to overall morbidity. In this study, we conducted a retrospective evaluation of POPF along with its potential perioperative clinical risk factors and its effect on tumor recurrence. METHODS Clinical data on patients who had received pancreatoduodenectomy (PD), distal pancreatectomy (DP), or duodenum-preserving pancreatic head resection (DPPHR) were prospectively collected between 2007 and 2016. A Picrosirius red staining score was developed to enable morphological classification of the resection margin of the pancreatic stump. The primary end point was the development of major complications. The secondary end points were overall and recurrence-free survival. RESULTS 340 patients underwent pancreatic resection including 222 (65.3%) PD, 87 (25.6%) DP, and 31 (9.1%) DPPHR. Postoperative major complications were observed in 74 patients (21.8%). In multivariable logistic regression analysis, POPF correlated with body mass index (BMI) (p = 0.025), prolonged stay in hospital (p<0.001), high Picrosirius red staining score (p = 0.049), and elevated postoperative levels of amylase or lipase in drain fluid (p≤0.001). Multivariable Cox regression analysis identified UICC stage (p<0.001), tumor differentiation (p<0.001), depth of invasion (p = 0.001), nodal invasion (p = 0.001), and the incidence of POPF grades B and C (p = 0.006) as independent prognostic markers of recurrence-free survival. CONCLUSION Besides the known clinicopathological risk factors BMI and amylase in the drain fluid, the incidence of POPF correlates with high Picrosirius red staining score in the resection margins of the pancreatic stumps of curatively resected pancreatic ductal adenocarcinoma (PDAC). Furthermore, clinically relevant POPF seems to be a prognostic factor for tumor recurrence in PDAC.
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Affiliation(s)
- Sameer A. Dhayat
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Ahmad N. J. Tamim
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Marius Jacob
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Georg Ebeling
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Laura Kerschke
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Iyad Kabar
- Department of Internal Medicine B, Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
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