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Mahamid A, Gerszman E, Kazlow E, Abu Shtaya A, Goldberg N, Froylich D, Haddad R. Serosal Patching with Glubran ®2 on the Pancreatic Stump for Reducing Postoperative Pancreatic Fistulae After Robot-Assisted Distal Pancreatectomy: A Single-Center Retrospective Study. Cancers (Basel) 2025; 17:502. [PMID: 39941869 PMCID: PMC11816142 DOI: 10.3390/cancers17030502] [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: 12/13/2024] [Revised: 01/24/2025] [Accepted: 01/31/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND Postoperative pancreatic fistulae (POPFs) are a significant cause of morbidity following left pancreatectomy. We hypothesized that incorporating serosal patching with the application of a synthetic sealant, a modified cyanoacrylate (Glubran®2), to the pancreatic stump, would decrease the incidence rate of clinically significant POPFs. METHODS This is a retrospective study of consecutive patients who underwent robot-assisted left pancreatectomy. The primary outcome was clinically significant POPFs within 90 days of surgery. Secondary outcomes included the incidence rate of POPFs (all the grades), 90-day morbidity, and 90-day mortality. RESULTS We compared outcomes between Glubran®2 sealant with serosal patching (GSP, n = 6) and Glubran®2 sealant without serosal patching (GNSP, n = 12) groups. The GSP group had significantly lower incidence rates of clinically significant POPFs (grades B/C) (p = 0.034) and overall POPFs (all the grades) (p = 0.046). No significant differences in 90-day postoperative morbidity were observed between the two groups (p = 0.56), and no 90-day mortality occurred in either group. CONCLUSIONS Incorporating serosal patching along with Glubran®2 sealant in the management of the pancreatic stump during left pancreatectomy demonstrates promising results in reducing the incidence rate of clinically significant POPFs. This finding highlights the need for further research with larger sample sizes in order to confirm the observed outcomes and explore the long-term implications for postoperative complications and recovery in patients undergoing this procedure during pancreatic surgery.
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Affiliation(s)
- Ahmad Mahamid
- Divion of Surgery, Carmel Medical Center, Haifa 3436212, Israel; (E.G.); (E.K.); (D.F.); (R.H.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
| | - Eden Gerszman
- Divion of Surgery, Carmel Medical Center, Haifa 3436212, Israel; (E.G.); (E.K.); (D.F.); (R.H.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
| | - Esther Kazlow
- Divion of Surgery, Carmel Medical Center, Haifa 3436212, Israel; (E.G.); (E.K.); (D.F.); (R.H.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
| | - Aasem Abu Shtaya
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
- Department of Gastroenterology, Carmel Medical Center, Haifa 3436212, Israel
| | - Natalia Goldberg
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
- Department of Radiology, Carmel Medical Center, Haifa 3436212, Israel
| | - Dvir Froylich
- Divion of Surgery, Carmel Medical Center, Haifa 3436212, Israel; (E.G.); (E.K.); (D.F.); (R.H.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
| | - Riad Haddad
- Divion of Surgery, Carmel Medical Center, Haifa 3436212, Israel; (E.G.); (E.K.); (D.F.); (R.H.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3525433, Israel; (A.A.S.); (N.G.)
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Jivani A, Shinde RK, Nagtode T, Vaidya K, Goel S. The Surgical Management of Pancreatic Pseudocysts: A Narrative Review. Cureus 2024; 16:e69055. [PMID: 39391462 PMCID: PMC11465202 DOI: 10.7759/cureus.69055] [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: 08/26/2024] [Accepted: 09/10/2024] [Indexed: 10/12/2024] Open
Abstract
Pancreatic pseudocysts, commonly arising as a complication of acute or chronic pancreatitis, present a significant clinical challenge. This narrative review explores the surgical management of pancreatic pseudocysts, emphasizing advancements, techniques, and outcomes. We examine the indications for surgical intervention, including symptomatic pseudocysts, complications such as infection or hemorrhage, and pseudocysts resistant to conservative treatment. Various surgical approaches are discussed, including open surgery, laparoscopic techniques, and endoscopic interventions. The review highlights the evolution of surgical strategies, from traditional cystogastrostomy to minimally invasive methods, and assesses their efficacy and safety. Additionally, we address patient selection criteria, preoperative assessment, and postoperative care. By synthesizing current evidence and clinical experiences, this review aims to provide a comprehensive overview of the best practices in the surgical management of pancreatic pseudocysts, offering valuable insights for clinicians in optimizing patient outcomes.
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Affiliation(s)
- Ashish Jivani
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Raju K Shinde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tushar Nagtode
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Khushbu Vaidya
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Somya Goel
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hajibandeh S, Hajibandeh S, Hablus MA, Bari H, Pathanki AM, Ali M, Ahmad J, Marangoni G, Khan S, Lam FT. Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2024; 28:302-314. [PMID: 38522846 PMCID: PMC11341886 DOI: 10.14701/ahbps.24-015] [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] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement. Future randomized research is needed to provide stronger evidence.
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Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohammed Abdallah Hablus
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
- Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hassaan Bari
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Adithya Malolan Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Majid Ali
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Jawad Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Gabriele Marangoni
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Saboor Khan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - For Tai Lam
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
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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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Ninomiya R, Komagome M, Nagata R, Kimura A, Takemura N, Maki A, Beck Y. Innovative staple line reinforcement and suturing technique: impact on postoperative pancreatic fistula rates in distal pancreatectomy. J Gastrointest Surg 2024; 28:945-947. [PMID: 38594166 DOI: 10.1016/j.gassur.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Riki Ninomiya
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
| | - Masahiko Komagome
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Rihito Nagata
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Akifumi Kimura
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Nobuyuki Takemura
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Akira Maki
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yoshifumi Beck
- Department of Hepato-Biliary-Pancreatic Surgery and Pediatric Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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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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8
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Sugumar K, Naik L, Hue JJ, Ammori JB, Hardacre JM, Ocuin LM, Winter JM. Risk factors of developing nonalcoholic fatty liver disease after pancreatic resection: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:983-992. [PMID: 38552899 DOI: 10.1016/j.gassur.2024.03.025] [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: 11/27/2023] [Revised: 02/19/2024] [Accepted: 03/22/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) occurs in 10% to 40% of patients after pancreatic resection. Pancreatic exocrine insufficiency (PEI) is thought to be closely associated with NAFLD; however, the mechanism of NAFLD is not clearly understood. We perform a systematic review and meta-analysis to better understand the risk factors of NAFLD. METHODS A systematic literature search was performed in the MEDLINE database. Studies focused on the risk factors associated with NAFLD in patients undergoing pancreatectomy. The odds ratios (ORs) denoting the association of risk factors with NAFLD after resection were curated. RESULTS Of 814 published articles, 26 studies met the inclusion criteria. Combined, these studies included clinical data on 4055 patients. The pooled incidence of NAFLD was 29% (23%-35%). Among the various risk factors analyzed, the following had a significant likelihood of NAFLD on forest plot analysis: female gender (OR, 2.44), pancreatic ductal adenocarcinoma (OR, 2.11), portal vein or superior mesenteric vein resection (OR, 1.99), dissection of nerve plexus around the superior mesenteric artery (OR, 1.93), and adjuvant chemotherapy (OR, 1.58). Only 2 studies investigated 2 different measurements of quantitative PEI, which could not be used for analysis. Owing to heterogeneity of studies, pancreatic remanent volume, which is considered a marker for PEI could not be evaluated. Pancreatic enzyme replacement therapy (PERT) was not associated with NAFLD. CONCLUSION Numerous factors are associated with NAFLD after pancreatectomy. Previous research shows that PEI may be associated with NAFLD; however, this could not be compared in our meta-analysis. Further research is required to study the role of PERT in NAFLD.
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Affiliation(s)
- Kavin Sugumar
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Lora Naik
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States
| | - Jonathan J Hue
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - John B Ammori
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Jeffrey M Hardacre
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Lee M Ocuin
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States
| | - Jordan M Winter
- Department of Surgery, University Hospitals Seidman Cancer Center and Case Comprehensive Cancer Center, Cleveland, Ohio, United States.
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9
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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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10
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Zou J, Xue X, Qin L. Development of a Nomogram to Predict Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy on the Basis of Visceral Fat Area and Magnetic Resonance Imaging. Ann Surg Oncol 2023; 30:7712-7719. [PMID: 37530992 DOI: 10.1245/s10434-023-13943-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The aim of this study was to develop a nomogram to predict the risk of developing clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) using preoperative clinical and imaging data. METHODS The data of 205 patients were retrospectively analyzed, randomly divided into training (n = 125) and testing groups (n = 80). The patients' preoperative laboratory indicators, preoperative clinical baseline data, and preoperative imaging data [enhanced computed tomography (CT), enhanced magnetic resonance imaging (MRI)] were collected. Univariate analyses combined with multivariate logistic regression were used to identify the independent risk factors for CR-POPF. These factors were used to train and validate the model and to develop the risk nomogram. The area under the curve (AUC) was used to measure the predictive ability of the models. The integrated discrimination improvement index (IDI) and decision curve analysis (DCA) were used to assess the clinical feasibility of the nomogram in relation to five other models established in literature. RESULTS CT visceral fat area (P = 0.014), the pancreatic spleen signal ratio on T1 fat-suppressed MRI sequences (P < 0.001), and CT main pancreatic duct diameter (P = 0.001) were identified as independent prognostic factors and used to develop the model. The final nomogram achieved an AUC of 0.903. The IDI and DCA showed that the nomogram outperformed the other five CR-POPF models in the training and testing cohorts. CONCLUSION The nomogram achieved a superior predictive ability for CR-POPF following PD than other models described in literature. Clinicians can use this simple model to optimize perioperative planning according to the patient's risk of developing CR-POPF.
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Affiliation(s)
- Jiayue Zou
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Xiaofeng Xue
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Lei Qin
- Department of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
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11
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De Pastena M, van Bodegraven EA, Mungroop TH, Vissers FL, Jones LR, Marchegiani G, Balduzzi A, Klompmaker S, Paiella S, Tavakoli Rad S, Groot Koerkamp B, van Eijck C, Busch OR, de Hingh I, Luyer M, Barnhill C, Seykora T, Maxwell T T, de Rooij T, Tuveri M, Malleo G, Esposito A, Landoni L, Casetti L, Alseidi A, Salvia R, Steyerberg EW, Abu Hilal M, Vollmer CM, Besselink MG, Bassi C. Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation. Ann Surg 2023; 277:e1099-e1105. [PMID: 35797608 DOI: 10.1097/sla.0000000000005497] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. BACKGROUND POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. METHODS Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure. RESULTS Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85). CONCLUSIONS The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Leia R Jones
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alberto Balduzzi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Shazad Tavakoli Rad
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Caleb Barnhill
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Thomas Seykora
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Massimiliano Tuveri
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Casetti
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery, University of California, San Francisco, CA
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
- Department of Surgery, Southampton University, Southampton, UK
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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12
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Xinyang Z, Taoying L, Xuli L, Jionghuang C, Framing Z. Comparison of the complications of passive drainage and active suction drainage after pancreatectomy: A meta-analysis. Front Surg 2023; 10:1122558. [PMID: 37151863 PMCID: PMC10157543 DOI: 10.3389/fsurg.2023.1122558] [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: 12/13/2022] [Accepted: 03/13/2023] [Indexed: 05/09/2023] Open
Abstract
Objective This study aimed to compare the effect of passive drainage and active suction drainage on complications after pancreatectomy. Methods The databases were searched and covered in this study on the comparison of passive and active suction drainage after pancreatectomy from the database establishment to Feb. 2023. A meta-analysis was conducted with the RevMan5.3 software. Results On the whole, 1,903 cases were included in eight studies, including 994 cases in the passive drainage group, 909 in the active suction drainage group, 1,224 in the pancreaticoduodenectomy group, as well as 679 in the distal pancreatectomy group. No statistically significant difference was identified between the two groups in the incidence of total complications, the rate of abdominal hemorrhage, the rate of abdominal effusion, the death rate and the length of stay after pancreatectomy (all P > 0.05), whereas the difference in the incidence of pancreatic fistula after distal pancreatectomy between the two groups was of statistical significance (OR = 3.35, 95% CI = 1.12-10.07, P = 0.03). No significant difference was reported in pancreatic fistula between the two groups after pancreaticoduodenectomy. Conclusion After distal pancreatectomy, active suction drainage might down-regulate the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Zhou Xinyang
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
| | - Lei Taoying
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
| | - Lan Xuli
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
| | - Chen Jionghuang
- Department of General Surgery, Sir Run Run Shaw Hospital, The Affiliated Hospital of the Medical College, ZheJiang University, Hangzhou, China
| | - Zhong Framing
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
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13
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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, for the Dutch Pancreatic Cancer Group. 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] [MESH Headings] [Grants] [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
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A. Balduzzi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - E. A. van Bodegraven
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J. van Hilst
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - S. Festen
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - M. Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - H. J. Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, USA
| | | | | | - O. R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - F. Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - M. De Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Marchegiani
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - J. Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - I. Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R. Salvia
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - H. C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - M. Stommel
- Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
| | - D. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M. Coolsen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
| | - C. Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - C. van Eijck
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M. G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
- Department of Surgery, OLVG, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, USA
- Department of Surgery, LUMC, Leiden, the Netherlands
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
- Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
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14
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Using a Reinforced Stapler Decreases the Incidence of Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:1969-1979. [PMID: 35525852 DOI: 10.1007/s00268-022-06572-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is no consensus on the pancreatic transection during distal pancreatectomy (DP) to reduce postoperative pancreatic fistula (POPF). This meta-analysis aimed to evaluate the effects of a reinforced stapler on the postoperative outcomes of DP. METHODS We systematically searched electronic databases and bibliographic reference lists in The PubMed/MEDLINE, Google Scholar, Cochrane Library's Controlled Trials Registry and Database of Systematic Reviews, Embase, and Scopus. Review Manager Software was used for pooled estimates. RESULTS Seven eligible studies published between 2007 and 2021 were included with 553 patients (267 patients in the reinforced stapler group and 286 patients in the standard stapler group). The reinforced stapler reduced the POPF grade B and C (OR = 0.33; 95% CI [0.19, 0.57], p < 0.01). There was no difference between the reinforced stapler group and standard stapler group in terms of mortality rate (OR = 0.39; 95% CI [0.04, 3.57], p = 0.40), postoperative haemorrhage (OR = 0.53; 95% CI [0.20, 1.43], p = 0.21), and reoperation rate (OR = 0.91; 95% CI [0.40, 2.06], p = 0.82). CONCLUSIONS Reinforced stapling in DP is safe and seems to reduce POPF grade B/C with similar mortality rates, postoperative bleeding, and reoperation rate. The protocol of this systematic review with meta-analysis was registered in PROSPERO (ID: CRD42021286849).
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15
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Bubis LD, Behman R, Roke R, Serrano PE, Khalil JA, Coburn NG, Law CH, Bertens K, Martel G, Hallet J, Marcaccio M, Balaa F, Quan D, Gallinger S, Nanji S, Leslie K, Tandan V, Luo Y, Beck G, Skaro A, Dath D, Moser M, Karanicolas PJ. PATCH-DP: a single-arm phase II trial of intra-operative application of HEMOPATCH™ to the pancreatic stump to prevent post-operative pancreatic fistula following distal pancreatectomy. HPB (Oxford) 2022; 24:72-78. [PMID: 34176743 DOI: 10.1016/j.hpb.2021.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/21/2021] [Accepted: 05/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is the most significant cause of morbidity following distal pancreatectomy. Hemopatch™ is a thin, bovine collagen-based hemostatic sealant. We hypothesized that application of Hemopatch™ to the pancreatic stump following distal pancreatectomy would decrease the incidence of clinically-significant POPF. METHODS We conducted a prospective, single-arm, multicentre phase II study of application of Hemopatch™ to the pancreatic stump following distal pancreatectomy. The primary outcome was clinically-significant POPF within 90 days of surgery. A sample size of 52 patients was required to demonstrate a 50% relative reduction in Grade B/C POPF from a baseline incidence of 20%, with a type I error of 0.2 and power of 0.75. Secondary outcomes included incidence of POPF (all grades), 90-day mortality, 90-day morbidity, re-interventions, and length of stay. RESULTS Adequate fixation Hemopatch™ to the pancreatic stump was successful in all cases. The rate of grade B/C POPF was 25% (95%CI: 14.0-39.0%). There was no significant difference in the incidence of grade B/C POPF compared to the historical baseline (p = 0.46). The 90-day incidence of Clavien-Dindo grade ≥3 complications was 26.9% (95%CI: 15.6-41.0%). CONCLUSION The use of Hemopatch™ was not associated with a decreased incidence of clinically-significant POPF compared to historical rates. (NCT03410914).
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Affiliation(s)
- Lev D Bubis
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Ramy Behman
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Rachel Roke
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Pablo E Serrano
- Department of Surgery, Juravinski Hospital, McMaster University, Hamilton, Canada
| | - Jad A Khalil
- Division of General Surgery, The Ottawa Hospital, Ottawa, Canada
| | - Natalie G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Calvin H Law
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kimberly Bertens
- Division of General Surgery, The Ottawa Hospital, Ottawa, Canada
| | - Guillaume Martel
- Division of General Surgery, The Ottawa Hospital, Ottawa, Canada
| | - Julie Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Michael Marcaccio
- Department of Surgery, Juravinski Hospital, McMaster University, Hamilton, Canada
| | - Fady Balaa
- Division of General Surgery, The Ottawa Hospital, Ottawa, Canada
| | - Douglas Quan
- London Health Sciences, University of Western Ontario, London, Canada
| | - Steven Gallinger
- Department of Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, Canada
| | - Ken Leslie
- London Health Sciences, University of Western Ontario, London, Canada
| | - Ved Tandan
- Department of Surgery, Juravinski Hospital, McMaster University, Hamilton, Canada
| | - Yigang Luo
- Department of Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Gavin Beck
- Department of Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Anton Skaro
- London Health Sciences, University of Western Ontario, London, Canada
| | - Deepak Dath
- Department of Surgery, Juravinski Hospital, McMaster University, Hamilton, Canada
| | - Michael Moser
- Department of Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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16
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Chong E, Ratnayake B, Lee S, French JJ, Wilson C, Roberts KJ, Loveday BPT, Manas D, Windsor J, White S, Pandanaboyana S. Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition. HPB (Oxford) 2021; 23:1139-1151. [PMID: 33820687 DOI: 10.1016/j.hpb.2021.02.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016 International Study Group of Pancreatic Fistula (ISGPF) definition. METHODS A systemic search of MEDLINE, Pubmed, Scopus, and EMBASE were conducted using the PRISMA framework. Studies were evaluated for risk factors for the development CR-POPF after DP using the 2016 ISGPF definition. Further subgroup analysis was undertaken on studies ≥10 patients in exposed and non-exposed subgroups. RESULTS Forty-three studies with 8864 patients were included in the meta-analysis. The weighted rate of CR-POPF was 20.4% (95%-CI: 17.7-23.4%). Smoking (OR 1.29, 95%-CI: 1.08-1.53, p = 0.02) and open DP (OR 1.43, 95%-CI: 1.02-2.01, p = 0.04) were found to be significant risk factors of CR-POPF. Diabetes (OR 0.81, 95%-CI: 0.68-0.95, p = 0.02) was a significant protective factor against CR-POPF. Substantial heterogeneity was observed in the comparisons of pancreatic texture and body mass index. Seventeen risk factors achieved significance in a univariate or multivariate comparison as reported by individual studies in the narrative synthesis, however, they remain difficult to interpret as statistically significant comparisons were not uniform. CONCLUSION This meta-analysis found smoking and open DP to be risk factors and diabetes to be protective factor of CR-POPF in the era of 2016 ISGPF definition.
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Affiliation(s)
- Eric Chong
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Shiela Lee
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Colin Wilson
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Keith J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Benjamin P T Loveday
- Hepatobiliary and Upper Gastrointestinal Unit, Royal Melbourne Hospital, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - Derek Manas
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Steve White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom; Population Health Sciences Institute, Newcastle University, Newcastle, United Kingdom.
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17
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Mungroop TH, van der Heijde N, Busch OR, de Hingh IH, Scheepers JJ, Dijkgraaf MG, Groot Koerkamp B, Besselink MG, van Eijck CH. Randomized clinical trial and meta-analysis of the impact of a fibrin sealant patch on pancreatic fistula after distal pancreatectomy: CPR trial. BJS Open 2021; 5:zrab001. [PMID: 34137446 PMCID: PMC8262074 DOI: 10.1093/bjsopen/zrab001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains the main cause of morbidity in patients after distal pancreatectomy. The objective of this study was to investigate whether an absorbable fibrin sealant patch could prevent POPF after distal pancreatectomy. METHODS A multicentre, patient-blinded, parallel-group randomized superiority trial was performed in seven Dutch hospitals. Allocation was done using a computer-generated randomization list with a 1 : 1 allocation ratio and concealed varying permuted block sizes. Pancreatic stump closure with a fibrin patch was compared with standard treatment in patients undergoing distal pancreatectomy. The primary endpoint was the development of grade B/C POPF. A systematic review and meta-analysis was performed which combined the present findings with all available evidence. RESULTS Between October 2010 and August 2017, 247 patients were enrolled. Fifty-four patients (22.2 per cent) developed a POPF, 25 of 125 patients in the patch group versus 29 of 122 in the control group (20.0 versus 23.8 per cent; P = 0·539). No related adverse effects were observed. In the meta-analysis, no significant difference was seen between the patch and control groups (19.7 versus 22.0 per cent; odds ratio 0.89, 95 per cent c.i. 0.60 to 1.32; P = 0·556). CONCLUSION Application of a fibrin patch to the pancreatic stump does not reduce the incidence of POPF in distal pancreatectomy. Future studies should focus on alternative fistula mitigation strategies, considering pancreatic neck thickness and duct size as risk factors. Trial registration number NL5876 (Netherlands Trial Registry).
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Affiliation(s)
- T H Mungroop
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University
of Amsterdam, Amsterdam, the
Netherlands
| | - N van der Heijde
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University
of Amsterdam, Amsterdam, the
Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University
of Amsterdam, Amsterdam, the
Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven,
the Netherlands
| | - J J Scheepers
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M G Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics,
Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University
of Amsterdam, Amsterdam, the
Netherlands
| | - C H van Eijck
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
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18
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Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Retrospective Study. Can J Gastroenterol Hepatol 2021; 2021:8874504. [PMID: 33542910 PMCID: PMC7840268 DOI: 10.1155/2021/8874504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/15/2020] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Clinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discuss the risk factors of pancreatic fistula in order to interpret the clinical importance. METHODS In this retrospective study, 263 patients who underwent DP at Ningbo Medical Center Li Huili Hospital between January 2011 and January 2020 were reviewed in accordance with relevant guidelines and regulations. Patients' demographics and clinical parameters were evaluated using univariate and multivariate analyses to identify the risk factors contributing to CR-POPF. P < 0.05 was considered statistically significant. RESULTS In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication (19.0%). The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct were more likely to develop pancreatic fistula. However, on multivariate analysis, the soft texture of the pancreas (OR = 2.381, 95% CI = 1.271-4.460, P=0.001) and the ligation of the main pancreatic duct (OR = 0.388, 95% CI = 0.207-0.726, P=0.002) were only an independent influencing factor for CR-POPF. CONCLUSIONS As a conclusion, pancreatic fistula was the most common surgical complication after DP. The soft texture of the pancreas and the absence of ligation of the main pancreatic duct can increase the risk of CR-POPF.
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19
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Eshmuminov D, Karpovich I, Kapp J, Töpfer A, Endhardt K, Oberkofler C, Petrowsky H, Lenggenhager D, Tschuor C, Clavien PA. Pancreatic fistulas following distal pancreatectomy are unrelated to the texture quality of the pancreas. Langenbecks Arch Surg 2021; 406:729-734. [PMID: 33420516 DOI: 10.1007/s00423-020-02071-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The relevance of pancreatic texture for pancreatic fistula (POPF) formation after distal pancreatectomy (DP) remains ill defined. Recent POPF definition adjustments and common subjective pancreatic texture assessment are further drawbacks in the investigation of pancreatic texture as a factor for POPF development after DP. METHODS The predictive value of pancreatic texture by histologic assessment was investigated for POPF formation after DP, respecting the updated 2016 fistula definition. Histologic evaluation at the resection margin included amount of steatosis, degree of fibrosis, and pancreatic duct size. RESULTS A total of 102 patients who underwent DP were included. Thirty-six patients developed POPF. There was no difference in histologic variables in patients with and without POPF. In the univariate analysis, none of the three histologic features showed significant correlation with POPF formation. The ROC (receiver operating characteristic) curve demonstrated poor utility for the grade of steatosis 0.481 ± 0.058 (p = 0.75) and grade of fibrosis 0.466 ± 0.058 (p = 0.57) as predictive factors for POPF formation. CONCLUSION Results indicate that pancreatic texture does not predict POPF formation following DP. This is particularly relevant in the context of the increasing use of robotic and laparoscopic approaches for DPs with limited clinical pancreatic texture assessment by palpation.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | | | - Joshua Kapp
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Antonia Töpfer
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Katharina Endhardt
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Christian Oberkofler
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Daniela Lenggenhager
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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20
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Illuminati G, Cerasari S, Pasqua R, Nardi P, Fratini C, Frey S, Iannelli A, Marini P. Results of Standard Stapler Closure of Pancreatic Remnant After Distal Spleno-Pancreatectomy for Adenocarcinoma. Front Surg 2020; 7:596580. [PMID: 33251244 PMCID: PMC7674636 DOI: 10.3389/fsurg.2020.596580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023] Open
Abstract
Background/Aim: The purpose of this study was to evaluate the results of stapled closure of the pancreatic remnant after cold-knife section of the pancreatic isthmus and distal pancreatectomy for adenocarcinoma. Methods: A retrospective evaluation of 57 consecutive patients undergoing distal spleno-pancreatectomy for adenocarcinoma was performed. The pancreatic isthmus was systematically straight-sectioned with a cold knife, and the remnant was stapled close without additional stitches or adjuncts. The study's main endpoints were postoperative mortality, the occurrence of a pancreatic fistula, the need for a re-operation, the postoperative length of stay in the hospital, the rate of re-admission, and late survival. Results: Postoperative mortality was absent. Seventeen patients (29.8%) presented a pancreatic fistula of grade A in seven cases (41.2%), grade B in eight cases (47.1%), and grade C in two cases (11.8%). Re-operation was required in the two patients (3.5%) with grade C fistula in order to drain an intra-abdominal abscess. The mean postoperative length of stay in the hospital was 15 days (range, 6-62 days). No patient required re-admission. Twenty-nine patients (50.8%) were alive and free from disease, respectively, 12 patients (21.1%) at 12 months, 13 patients (22.8%) at 60 months, and four patients (7.0%) at 120 months from the operation. The remaining patients died of metastatic disease 9-37 months from the operation. Lastly, disease-related mortality was 49.1%. Conclusion: Stapler closure of the pancreatic remnant allows good postoperative results, limiting the formation of pancreatic fistula to the lower limit of its overall reported incidence.
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Affiliation(s)
- Giulio Illuminati
- The Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy
| | - Saverio Cerasari
- The Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy
| | - Rocco Pasqua
- The Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy
| | - Priscilla Nardi
- The Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy
| | - Chiara Fratini
- The Department of Surgical Sciences, The University of Rome "La Sapienza", Rome, Italy
| | - Sébastien Frey
- The Department of Digestive Surgery and Liver Transplantation Unit, University Hospital of Nice Archet, University of Cote d'Azur, Nice, France
| | - Antonio Iannelli
- The Department of Digestive Surgery and Liver Transplantation Unit, University Hospital of Nice Archet, University of Cote d'Azur, Nice, France
| | - Pierluigi Marini
- The Department of General and Emergency Surgery, San Camillo-Forlanini Regional Hospital, Rome, Italy
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21
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Effect of Flowable Thrombin-Containing Collagen-Based Hemostatic Matrix for Preventing Pancreatic Fistula after Pancreatectomy: A Randomized Clinical Trial. J Clin Med 2020; 9:jcm9103085. [PMID: 32987876 PMCID: PMC7601002 DOI: 10.3390/jcm9103085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 01/08/2023] Open
Abstract
Background: The aim of this study was to evaluate the safety and efficacy of a flowable hemostatic matrix, and their effects for postoperative pancreatic fistula (POPF) after pancreatectomy. Methods: This was a randomized, clinical, single-center, single-blind (participant), non-inferiority, phase IV, and parallel-group trial. The primary endpoint was the incidence of POPF. The secondary endpoints were risk factors for POPF, drain removal days, incidence of complication, 90-day mortality, and length of hospital stay. Results: This study evaluated a total of 53 patients, of whom 26 patients were in the intervention group (flowable hemostatic matrix) and 27 patients were in the control group (thrombin-coated collagen patch). POPF was more common in the control group than in the intervention group (59.3% vs. 30.8%, p = 0.037). Among participants who underwent distal pancreatectomy, POPF (33.3% vs. 92.3%, p = 0.004), and clinically relevant POPF (8.3% vs. 46.2%, p = 0.027) was more common in the control group. A multivariate logistic regression model identified flowable hemostatic matrix use as an independent negative risk factor for POPF, especially in cases of distal pancreatectomy (DP) (odds ratio 17.379, 95% confidential interval 1.453–207.870, p = 0.024). Conclusion: Flowable hemostatic matrix application is a simple, feasible, and effective method of preventing POPF after pancreatectomy, especially for patients with DP. Non-inferiority was demonstrated in the efficacy of preventing POPF in the intervention group compared to the control group.
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22
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Wong P, White M, Tozzi F, Warner SG, Woo Y, Singh G, Fong Y, Melstrom L. Implications of Postpancreatectomy Hypophosphatemia. Am Surg 2020; 87:61-67. [PMID: 32924538 DOI: 10.1177/0003134820949517] [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: 11/17/2022]
Abstract
BACKGROUND Electrolyte abnormalities are commonly found after major abdominal surgery for malignancy. We hypothesized that the severity of hypophosphatemia developed in pancreatectomy patients would be associated with the incidence of complications postoperatively. METHODS A retrospective analysis of an institutional database was conducted for all pancreatic resections (2009-2017). Patient charts were reviewed for demographics, clinicopathologic factors, and perioperative outcomes. RESULTS In a cohort of 283 pancreatectomy patients, 107 (37.8%) and 134 (47.3%) developed mild (2.0-2.5 mg/dL) and moderate/severe hypophosphatemia (<2.0 mg/dL), respectively. Nadir serum phosphate levels were shown to occur on postoperative day (POD) 2 for patients without complications and POD3 for patients who had at least 1 complication. Patients who developed severe hypophosphatemia were significantly more likely to suffer fistula-related complications (P = .0401). CONCLUSIONS Assessing the severity and timing of postpancreatectomy hypophosphatemia presents an opportunity for early detection of impending fistula-related complications.
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Affiliation(s)
- Paul Wong
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Michael White
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Federico Tozzi
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA.,14742Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Susanne G Warner
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yanhgee Woo
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Gagandeep Singh
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh Melstrom
- 20220Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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23
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Igarashi T, Harimoto N, Matsui Y, Muranushi R, Yamanaka T, Hagiwara K, Hoshino K, Ishii N, Tsukagoshi M, Watanabe A, Kubo N, Araki K, Saito S, Shirabe K. Association between intraoperative and postoperative epidural or intravenous patient-controlled analgesia and pancreatic fistula after distal pancreatectomy. Surg Today 2020; 51:276-284. [PMID: 32734348 DOI: 10.1007/s00595-020-02087-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/12/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to elucidate the association between postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) and clinicopathological factors and intraoperative and postoperative epidural or intravenous patient-controlled analgesia (IV-PCA). METHODS We reviewed data of 116 patients who underwent distal pancreatectomy at Gunma University Hospital from October 2000 to October 2019. Clinical POPF was defined as the International Study Group of Pancreatic Fistula grade B or C. RESULTS Intraoperative and postoperative analgesia included fentanyl-mediated IV-PCA (n = 37, 32%), fentanyl-mediated epidural analgesia (n = 39, 34%), and morphine-mediated epidural analgesia (n = 40, 34%). All patients had received analgesia. Clinical POPF occurred in 34 of the 116 (29%) DP cases. Male sex (P = 0.035) and the length of operation time (P = 0.0070) were significant risk factors of clinical POPF. Furthermore, a thick pancreas was more likely to cause clinical POPF than a thin one (P = 0.052). No statistically significant difference was found between other factors, including intraoperative and postoperative analgesia (P = 0.95), total median oral morphine equivalents (P = 0.23), and clinical POPF. CONCLUSION Intraoperative and postoperative epidural analgesia and IV-PCA are not associated with clinical POPF after DP. Our results suggest that morphine and fentanyl can be used as IV-PCA or epidural analgesia.
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Affiliation(s)
- Takamichi Igarashi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Yusuke Matsui
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Ryo Muranushi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takahiro Yamanaka
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Kouki Hoshino
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Norihiro Ishii
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Akira Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Norio Kubo
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Kenichiro Araki
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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24
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Should all pancreatic surgery be centralized regardless of patients' comorbidity? HPB (Oxford) 2020; 22:1057-1066. [PMID: 31784212 DOI: 10.1016/j.hpb.2019.10.2443] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship. METHODS Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:<10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI). RESULTS The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates. CONCLUSION The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.
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25
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Miao Y, Lu Z, Yeo CJ, Vollmer CM, Fernandez-Del Castillo C, Ghaneh P, Halloran CM, Kleeff J, de Rooij T, Werner J, Falconi M, Friess H, Zeh HJ, Izbicki JR, He J, Laukkarinen J, Dejong CH, Lillemoe KD, Conlon K, Takaori K, Gianotti L, Besselink MG, Del Chiaro M, Montorsi M, Tanaka M, Bockhorn M, Adham M, Oláh A, Salvia R, Shrikhande SV, Hackert T, Shimosegawa T, Zureikat AH, Ceyhan GO, Peng Y, Wang G, Huang X, Dervenis C, Bassi C, Neoptolemos JP, Büchler MW. Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2020; 168:72-84. [PMID: 32249092 DOI: 10.1016/j.surg.2020.02.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
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Affiliation(s)
- Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China.
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jörg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Keith D Lillemoe
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Montorsi
- Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, HCL, UCBL1, Lyon, France
| | | | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Güralp O Ceyhan
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Yunpeng Peng
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Guangfu Wang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xumin Huang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - John P Neoptolemos
- 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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Liver metastases from pancreatic ductal adenocarcinoma: is there a place for surgery in the modern era? JOURNAL OF PANCREATOLOGY 2020. [DOI: 10.1097/jp9.0000000000000042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Endoscopic Transpapillary Pancreatic Duct Stent Placement for Symptomatic Peripancreatic Fluid Collection Caused by Clinically Relevant Postoperative Pancreatic Fistula After Distal Pancreatectomy. Surg Laparosc Endosc Percutan Tech 2020; 29:261-266. [PMID: 31206421 DOI: 10.1097/sle.0000000000000694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study aimed to evaluate the safety and efficacy of endoscopic transpapillary pancreatic duct stent placement (ETPS) for symptomatic peripancreatic fluid collection caused by postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP). ETPS was also compared with percutaneous drainage (PTD). Retrospectively 38 patients were studied who developed clinically relevant POPF. Of 38 patients, 4 underwent PTD and 11 underwent ETPS. Technical and clinical success rates of ETPS (100% and 91%, respectively) were comparable with PTD (100% and 75%, respectively). The tip of a pancreatic stent was placed over the pancreatic stump in 4 patients and draining of pus through the pancreatic stent was observed. The hospital stay after DP and the interval from intervention to discharge were significantly shorter in the ETPS group than in the PTD group. ETPS is safe and successful for managing peripancreatic fluid collection caused by POPF after DP and should be considered as a therapeutic option.
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Miyamoto R, Sano N, Maeda M, Inagawa S, Ohkohchi N. Modified Reinforced Staple Closure Technique Decreases Postoperative Pancreatic Fistula After Distal Pancreatectomy. Indian J Surg Oncol 2019; 10:587-593. [PMID: 31866728 DOI: 10.1007/s13193-019-00958-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 08/06/2019] [Indexed: 01/02/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is a serious complication that can occur following distal pancreatectomy (DP). Recent studies demonstrated that the use of reinforced staplers with bioabsorbable mesh significantly reduced the incidence of POPF, although the safety and efficacy of this approach remain controversial. Therefore, we originally developed a modified closure technique that combines the use of a reinforced stapler with bioabsorbable mesh with suture closure of the main pancreatic duct. The aim of this study was to determine whether our closure technique is predictive of POPF after DP. Fifty-nine consecutive patients who underwent DP were retrospectively enrolled. Based on the closure technique, we divided the cohort into a suture group (group A; n = 39) and a modified closure group (group B; n = 20). Using multivariate analysis, surgical closure techniques, including our method, and other well-known POPF risk factors were independently assessed. Multivariate logistic regression analysis identified no pathological fibrosis (odds ratio [OR], 5.41; p < 0.01), body mass index (> 25 kg/m2) (OR, 3.01; p = 0.02), and pancreatic stump closure technique (group A) (OR, 2.04; p = 0.01) as independent risk factors for POPF. The present study indicated that our modified closure technique is an additional useful technique to reduce POPF after DP.
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Affiliation(s)
- Ryoichi Miyamoto
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
- 2Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Naoki Sano
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Michihiro Maeda
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Satoshi Inagawa
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Nobuhiro Ohkohchi
- 2Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
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Keung EZ, Asare EA, Chiang YJ, Prakash LR, Rajkot N, Torres KE, Hunt KK, Feig BW, Cormier JN, Roland CL, Katz MHG, Lee JE, Tzeng CWD. Postoperative pancreatic fistula after distal pancreatectomy for non-pancreas retroperitoneal tumor resection. Am J Surg 2019; 220:140-146. [PMID: 31843190 DOI: 10.1016/j.amjsurg.2019.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/18/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Short-term outcomes after distal pancreatectomy (DP) for retroperitoneal (RP) tumors are unknown. We sought to identify rates of postoperative pancreatic fistula (POPF) and morbidity after en bloc DP with RP tumor resection. METHODS A retrospective review of 43 patients who underwent DP with RP tumor resection (1/2011-12/2017) was performed. RESULTS Seventeen patients had RP sarcoma, 12 renal cell carcinoma, 11 gastrointestinal stromal tumor, and 3 adrenocortical carcinoma. Grade III-IV complications occurred in 7 patients. Grade B POPF occurred in 14 patients, grade C POPF in none, and biochemical leak in 6. Of 22 patients who developed radiographically evident peri-pancreatic fluid collections, 7 required percutaneous drainage. The 90-day readmission rate was 33%. CONCLUSIONS DP with RP tumor resection is associated with high rates of clinically relevant POPF compared to historical results for DP for primary pancreatic tumors. Multi-center studies to identify targetable predictors and risk mitigation strategies for POPF in this rare high-risk population are needed.
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Affiliation(s)
- Emily Z Keung
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Elliot A Asare
- Department of Surgery, University of Utah and Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Nikita Rajkot
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Keila E Torres
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Barry W Feig
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Janice N Cormier
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, TX, USA.
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Pulvirenti A, Landoni L, Borin A, De Pastena M, Fontana M, Pea A, Esposito A, Casetti L, Tuveri M, Paiella S, Marchegiani G, Malleo G, Salvia R, Bassi C. Reinforced stapler versus ultrasonic dissector for pancreatic transection and stump closure for distal pancreatectomy: A propensity matched analysis. Surgery 2019; 166:271-276. [PMID: 30975498 DOI: 10.1016/j.surg.2019.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is the primary contributor to morbidity after distal pancreatectomy. To date, no techniques used for the transection and closure of the pancreatic stump have shown clear superiority over the others. This study aimed to compare the rate of postoperative pancreatic fistula after pancreatic transection conducted with a reinforced stapler versus an ultrasonic dissector after a distal pancreatectomy. METHOD Prospectively collected data of consecutive patients who underwent distal pancreatectomy from 2014 to 2017 were reviewed retrospectively. We included distal pancreatectomies in which pancreatic transection was performed by reinforced stapler or ultrasonic dissector; we excluded extended distal pancreatectomies. To overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for postoperative pancreatic fistula. RESULTS Overall, 200 patients met the inclusion criteria. The reinforced stapler was employed in 108 patients and the ultrasonic dissector in 92 cases. After one-to-one propensity matching, 92 patients were selected from each group. The matched reinforced stapler and ultrasonic dissector cohort had no differences in baselines characteristics except for the mini-invasive approach, which was more common in the ultrasonic dissector group (34% vs 51%, P = .025). Overall, 48 patients (26%) developed a postoperative pancreatic fistula, 46 (25%) a grade B postoperative pancreatic fistula, and 2 (1%) a grade C postoperative pancreatic fistula. In the reinforced stapler group, the rate of postoperative pancreatic fistula was 12% (n = 11) and in the ultrasonic dissector group 40% (n = 37) with a P < .001. CONCLUSION The results of this study suggest that the use of reinforced stapler for pancreatic transection decreases the risk of postoperative pancreatic fistula. A randomized trial is required to confirm these preliminary data.
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Affiliation(s)
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Alex Borin
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Matteo De Pastena
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Martina Fontana
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Massimiliano Tuveri
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy.
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
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Machado MC, Machado MAC. Drainage after distal pancreatectomy: Still an unsolved problem. Surg Oncol 2019; 30:76-80. [DOI: 10.1016/j.suronc.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/10/2019] [Accepted: 06/04/2019] [Indexed: 02/07/2023]
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Antila A, Siiki A, Sand J, Laukkarinen J. Perioperative hydrocortisone treatment reduces postoperative pancreatic fistula rate after open distal pancreatectomy. A randomized placebo-controlled trial. Pancreatology 2019; 19:786-792. [PMID: 31153781 DOI: 10.1016/j.pan.2019.05.457] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/30/2019] [Accepted: 05/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most common complication after distal pancreatectomy (DP). In a recent RCT on pancreaticoduodenectomy (PD), perioperative hydrocortisone (HC) treatment reduced Clavien-Dindo (C-D) III-V complications. The aim of this study was to investigate whether perioperative HC treatment reduces the overall complications and clinically significant POPF after distal pancreatectomy (DP). METHODS Fourty consecutive patients undergoing DP were randomized to receive intravenous HC 100mg/placebo every eight hours until the second postoperative day. Thirty-one patients were completed with DP and received HC/placebo every 8 h for two days postoperatively. The primary endpoint was overall complications (C-D III-V) and the secondary endpoint was the development of clinically significant POPF. RESULTS Pancreatic duct diameter, operative time and blood loss were similar in the groups. Ninety-day mortality was zero. With HC treatment the rates of C-D III-V complications tended to be lower compared to the placebo group (5.9% vs 21.4%, p = 0.034). The rate of grade B/C POPF was significantly reduced with HC treatment compared to the placebo group (5.9% vs. 42.9%, p = 0.028). CONCLUSION Perioperative HC treatment may have a favourable effect on overall major complications after open DP. HC treatment reduces the incidence of clinically significant POPF after open DP.
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Affiliation(s)
- Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Antti Siiki
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Päijät-Häme Central Hospital, Lahti, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland.
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Daniel F, Tamim H, Hosni M, Ibrahim F, Mailhac A, Jamali F. Validation of day 1 drain fluid amylase level for prediction of clinically relevant fistula after distal pancreatectomy using the NSQIP database. Surgery 2019; 165:315-322. [DOI: 10.1016/j.surg.2018.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/11/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
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Dumitrascu T, Eftimie M, Aiordachioae A, Stroescu C, Dima S, Ionescu M, Popescu I. Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy. World J Gastrointest Surg 2018; 10:84-89. [PMID: 30510633 PMCID: PMC6259023 DOI: 10.4240/wjgs.v10.i8.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/24/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP. METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo. RESULTS Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP. CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.
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Affiliation(s)
- Traian Dumitrascu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihai Eftimie
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Andra Aiordachioae
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Cezar Stroescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Simona Dima
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihnea Ionescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Irinel Popescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
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Choron RL, Efron DT. Isolated and Combined Duodenal and Pancreatic Injuries: A Review and Update. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0216-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. PLoS One 2018; 13:e0203841. [PMID: 30212577 PMCID: PMC6136772 DOI: 10.1371/journal.pone.0203841] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. METHODS All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. RESULTS A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001). CONCLUSIONS Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.
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Affiliation(s)
- Allison N. Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
| | - Todd W. Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Reid B. Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
- * E-mail:
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Kang WS, Park YC, Jo YG, Kim JC. Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center. Ann Surg Treat Res 2018; 95:29-36. [PMID: 29963537 PMCID: PMC6024086 DOI: 10.4174/astr.2018.95.1.29] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022] Open
Abstract
Purpose Pancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation. Methods We reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses. Results Data from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%. Conclusion The pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.
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Affiliation(s)
- Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience. PLoS One 2018; 13:e0197553. [PMID: 29897920 PMCID: PMC5999073 DOI: 10.1371/journal.pone.0197553] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 05/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP. Methods We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques. Results 8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02). Conclusion After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.
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Yüksel A, Bostancı EB, Çolakoğlu MK, Ulaş M, Özer İ, Karaman K, Akoğlu M. Pancreatic stump closure using only stapler is associated with high postoperative fistula rate after minimal invasive surgery. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:XXXX. [PMID: 29749326 DOI: 10.5152/tjg.2018.17567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS Postoperative pancreatic fistula (POPF) is the most common cause of morbidity and mortality after distal pancreatectomy (DP). The aim of the present study is to determine the risk factors that can lead to POPF. MATERIALS AND METHODS The study was conducted between January 2008 and December 2012. A total of 96 patients who underwent DP were retrospectively analyzed. RESULTS Overall, 24 patients (25%) underwent laparoscopic distal pancreatectomy (LDP) and 72 patients (75%) open surgery. The overall morbidity rate was 51% (49/96). POPF (32/96, 33.3%) was the most common postoperative complication. Grade B fistula (18/32, 56.2%) was the most common fistula type according to the International Study Group on Pancreatic Fistula definition. POPF rate was significantly higher in the minimally invasive surgery group (50%, p=0.046). POPF rate was 58.6% (17/29) in patients whose pancreatic stump closure was performed with only stapler, whereas POPF rate was 3.6% (1/28) in the group where the stump was closed with stapler plus oversewing sutures. Both minimally invasive surgery (OR: 0.286, 95% CI: 0.106-0.776, p=0.014) and intraoperative blood transfusion (OR: 4.210, 95% CI: 1.155-15.354, p=0.029) were detected as independent risk factors for POPF in multi-variety analysis. CONCLUSION LDP is associated with a higher risk of POPF when stump closure is performed with only staplers. Intraoperative blood transfusion is another risk factor for POPF. On the other hand, oversewing sutures to the stapler line reduces the risk of POPF.
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Affiliation(s)
- Adem Yüksel
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Erdal Birol Bostancı
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Muhammet Kadri Çolakoğlu
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Murat Ulaş
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - İlter Özer
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Kerem Karaman
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
| | - Musa Akoğlu
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey
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Satoi S, Yamamoto T, Motoi F, Matsumoto I, Yoshitomi H, Amano R, Tahara M, Murakami Y, Arimitsu H, Hirono S, Sho M, Ryota H, Ohtsuka M, Unno M, Takeyama Y, Yamaue H. Clinical impact of developing better practices at the institutional level on surgical outcomes after distal pancreatectomy in 1515 patients: Domestic audit of the Japanese Society of Pancreatic Surgery. Ann Gastroenterol Surg 2018; 2:212-219. [PMID: 29863185 PMCID: PMC5980579 DOI: 10.1002/ags3.12066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 02/05/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND AIM Institutional standardization in the perioperative management of distal pancreatectomy (DP) has not been evaluated in a multicenter setting. The aim of the present study was to assess the influence of institutional standardization on the development of postoperative complications after DP. METHODS Data were collected from 1515 patients who underwent DP in 2006, 2010, and 2014 at 53 institutions in Japan. A standardized institution (SI) was defined as one that implemented ≥6 of 11 quality initiatives according to departmental policy. There were 541 patients in the SI group and 974 in the non-SI group. Clinical parameters were compared between groups. Risk factors for morbidity and mortality were assessed by logistic regression analysis with a mixed-effects model. RESULTS Proportion of patients who underwent DP in SI increased from 16.5% in 2006 to 46.4% in 2014. The SI group experienced an improved process of care and a lower frequency of severe complications vs the non-SI group (grade III/IV Clavien-Dindo; 22% vs 29%, respectively, clinically relevant postoperative pancreatic fistula; 22% vs 31%, respectively, P < .05 for both). Duration of in-hospital stay in the SI group was significantly shorter than that in the non-SI group (16 [5-183] vs 20 postoperative days [5-204], respectively; P = .002). Multivariate analysis with a mixed-effects model showed that soft pancreas, late drain removal, excess blood loss and long surgical time were risk factors for post-DP complications (P < .05). Pancreatic texture, drain management and surgical factors, but not standardization of care, were associated with a lower incidence of post-DP complications.
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Affiliation(s)
- Sohei Satoi
- Department of SurgeryKansai Medical UniversityHirakataJapan
| | | | - Fuyuhiko Motoi
- Department of SurgeryTohoku University Graduate School of MedicineSendaiJapan
| | - Ippei Matsumoto
- Department of SurgeryFaculty of MedicineKindai UniversityOsaka‐SayamaJapan
| | - Hideyuki Yoshitomi
- Department of General SurgeryChiba University Graduate School of MedicineChibaJapan
| | - Ryosuke Amano
- Department of Surgical OncologyOsaka City UniversityOsakaJapan
| | | | - Yoshiaki Murakami
- Department of SurgeryInstitute of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Hidehito Arimitsu
- Division of Gastroenterological SurgeryChiba Cancer Center HospitalChibaJapan
| | - Seiko Hirono
- Second Department of SurgerySchool of MedicineWakayama Medical UniversityWakayamaJapan
| | - Masayuki Sho
- Department of SurgeryNara Medical UniversityKashiharaJapan
| | - Hironori Ryota
- Department of SurgeryKansai Medical UniversityHirakataJapan
| | - Masayuki Ohtsuka
- Department of General SurgeryChiba University Graduate School of MedicineChibaJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineSendaiJapan
| | - Yoshifumi Takeyama
- Department of SurgeryFaculty of MedicineKindai UniversityOsaka‐SayamaJapan
| | - Hiroki Yamaue
- Second Department of SurgerySchool of MedicineWakayama Medical UniversityWakayamaJapan
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Eguia E, Hwalek AE, Martin B, Abood G, Aranha GV. What are the predictors that can help identify safe removal of drains following pancreatectomy? Am J Surg 2018; 216:955-958. [PMID: 29559084 DOI: 10.1016/j.amjsurg.2018.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/15/2018] [Accepted: 03/03/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND The management of a drain after Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) remains a controversial issue. Our aim in this study was to identify a safe time for drain removal. STUDY DESIGN This is a retrospective study, of a prospective database, of patients who underwent a PD or DP at two tertiary care institutions. RESULTS A total of 180 patients underwent PD and DP during the observation period. Seventeen patients developed fistulas (9.4%), with 70.6% (n = 12) developing in soft pancreatic remnants vs. 29.4% (n = 5) in firm pancreatic remnants. Patients with amylase levels greater than 173 U/L on a postoperative day three were 11.46 times more likely to form a fistula compared to those with an amylase level at or below 173 U/L (p < .001). CONCLUSION Fistula formation is associated with pancreas texture, duct size, and drain amylase following PD or DP. Patients with firm pancreatic texture and large ducts are less likely to develop fistulas than those with soft pancreatic texture and small ducts.
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Affiliation(s)
- Emanuel Eguia
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA.
| | - Ann E Hwalek
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Brendan Martin
- Clinical Research Office, Loyola University of Chicago, Maywood, Illinois, USA
| | - Gerard Abood
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Gerard V Aranha
- Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
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Wang X, Tan CL, Zhang H, Chen YH, Yang M, Ke NW, Liu XB. Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: A single-center experience of 142 patients. J Surg Oncol 2018; 117:182-190. [PMID: 29281757 DOI: 10.1002/jso.24804] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 07/18/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enucleation is increasingly used for benign or low-grade pancreatic neoplasms. Enucleation preserves the pancreatic parenchyma as well as decreases the risk of long-term endocrine and exocrine dysfunction, but may be associated with a higher rate of postoperative pancreatic fistula (POPF). The aim of this study was to assess short-term outcomes, in particular, POPF. METHODS Data were collected retrospectively from all 142 patients who underwent pancreatic enucleation between 2009 and 2014 in our institution were analyzed. RESULTS Lesions were most frequently located in the head and uncinate process of the pancreas (60.6%), and the most common types were neuroendocrine neoplasms (52.1%). Overall morbidity was 66%, mainly due to POPF (53.5%), and severe morbidity was only 8.4%, including one death (0.7%). Clinical POPF (Grade B or C) occurred in 22 patients (15.5%). Independent risk factors for clinical POPF were age ≥60 years, an episode of acute pancreatitis, and cystic morphology. Tumor size, coverage, histological differentiation, and prolonged operative time were not associated with the risk of POPF. CONCLUSIONS Enucleation is a safe and feasible procedure for benign or low-grade pancreatic neoplasms. The rate of clinical POPF is acceptable, and clinical POPF occurs more frequently in elderly patients (≥60 years of age), patients with cystic neoplasms, or patients with an episode of acute pancreatitis.
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Affiliation(s)
- Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Chun-Lu Tan
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yong-Hua Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Min Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Neng-Wen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Pancreatic parenchymal injection of ethanol and octreotide to induce focal pancreatic fibrosis in rats: Strategies to eliminate postoperative pancreatic fistula. Hepatobiliary Pancreat Dis Int 2018; 17:81-85. [PMID: 29428110 DOI: 10.1016/j.hbpd.2018.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 08/11/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is more likely to occur in a soft pancreas compared to a hard pancreas in which fibrosis has progressed. There is almost no leakage at the anastomosis site or cut surface of a hard pancreas. The aim of this study was to induce localized fibrosis at the cut surface of the pancreas in a rat model. METHODS Thirty-six rats were divided into three groups (group S: normal saline group; group E: ethanol group; and group O: octreotide group). Each rat was directly injected with a particular compound at the duodenal lobe of the pancreatic parenchyma. Each group was divided into three subgroups according to the time of post-injection sacrifice (1, 2, or 4 weeks). The hardness, suture holding capacity (SHC), and histological fibrosis grade of each pancreas were measured. RESULTS The hardness, SHC, and fibrosis grade of groups E and O were increased at week 1, with greater increases in group E (all P < 0.001). In a subgroup comparison, the hardness, SHC, and fibrosis grade of group E tended to decrease gradually over time, with no regular pattern evident in group O. A comparison between the injected site (duodenal lobe) and non-injected site (splenic lobe) of the pancreas revealed increases in the three parameters of group E only in the duodenal lobe, with increases in group O at both the duodenal and splenic lobes. CONCLUSIONS Parenchymal injection of ethanol and octreotide increased pancreatic fibrosis. Unlike octreotide, ethanol provoked localized fibrosis that was maintained over time. It is expected that ethanol injection could eliminate POPF during pancreatic surgery.
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Juo YY, King JC. Robotic-assisted spleen preserving distal pancreatectomy: a technical review. J Vis Surg 2018; 3:139. [PMID: 29302415 DOI: 10.21037/jovs.2017.08.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/07/2017] [Indexed: 11/06/2022]
Abstract
Minimally-invasive spleen-preserving distal pancreatectomy is indicated for benign or borderline malignant lesions confined to the pancreatic body and tail. With the introduction of the da Vinci robotic system, preliminary case series have suggested an improved spleen preservation rate, higher rate of margin negative resections and improved lymph node yield versus the standard laparoscopic approach. In this article, we described our approach to robotic-assisted distal pancreatectomy with both vessel-conserving (Kimura) and vessel-sacrificing (Warshaw) variations.
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Affiliation(s)
- Yen-Yi Juo
- Department of Surgery, Center for Advanced Surgical and Interventional Technology (CASIT) at UCLA, Los Angeles, CA, USA.,Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jonathan C King
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Sun N, Lu G, Zhang L, Wang X, Gao C, Bi J, Wang X. Clinical efficacy of spleen-preserving distal pancreatectomy with or without splenic vessel preservation: A Meta-analysis. Medicine (Baltimore) 2017; 96:e8600. [PMID: 29310334 PMCID: PMC5728735 DOI: 10.1097/md.0000000000008600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The meta-analysis was performed to investigate the clinical efficacy of spleen-preserving distal pancreatectomy with splenic vessel preservation (SPDP-SVP) and spleen-preserving distal pancreatectomy with splenic vessel resection (SPDP-SVR). METHODS Potential articles were searched on the databases of Pubmed, Embase, and Chinese National Knowledge Infrastructure (CNKI) from January 1988 until March 2017. Weight mean difference (WMD) with 95% confidence interval (CI) was applied to compare the efficacy of SPDP-SVP and SPDP-SVR. Odds ratio (OR) with 95% CI was calculated to figure out the risks for complications. P< .05 or I>50% indicated significant heterogeneity. The random-effects model is used to pool data if significant heterogeneity exists; otherwise, the fixed-effects model is used. Publication bias was evaluated by Begg's funnel plot. RESULTS Thirteen eligible articles were obtained in the meta-analysis. SPDP-SVP seemed to relate with reduced operative time and blood loss, prolonged hospital stay, and less complications; however, the effects were not statistically significant. Meanwhile, we found that SPDP-SVP was closely related with the reduced rate of splenic infarction and gastric varices (OR = 0.16, 95% CI = 0.09-0.29; OR = 0.08, 95% CI = 0.02-0.35). No publication bias was observed in the analysis (P = .636). CONCLUSIONS SPDP-SVP seems to show superiority than SPDP-SVR in reducing the rate of splenic infarction and gastric varices.
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Hou B, Xiong D, Chen S, Ma T, Zhang C, Zhou Y, Yin Z. Splenic vessel preservation versus splenic vessel resection in laparoscopic spleen-preserving distal pancreatectomy. ANZ J Surg 2017; 88:E532-E538. [PMID: 29124843 DOI: 10.1111/ans.14190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic spleen-preserving distal pancreatectomy for low-grade malignant pancreas tumours was recently demonstrated and can be performed with splenic vessel preservation (SVP) or splenic vessel resection (SVR). Whether one approach is superior to another is still a matter of debate. METHODS A systematic literature search (PubMed, Embase, Science Citation Index, Springer-Link and Cochrane Central Register of Controlled Trials) was performed. Pooled intra- and post-operative outcomes were evaluated. Stratified and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of the study qualities. RESULTS A total of six studies were included. There was no significant difference for SVR and SVP in terms of overall post-operative complications and the pooled odds ratio (OR) was 0.87 (95% confidence interval (CI) 0.55-1.38, I2 = 25%). Meta-analysis on the pooled outcome of intraoperative operative time and blood loss favoured SVR; the mean differences were 18.64 min (95% CI 6.91-30.37 min, I2 = 21%) and 65.67 mL (95% CI 18.88-112.45 mL, I2 = 48%), respectively. Subgroup analysis showed a decrease incidences in perigastric varices (OR = 0.07, 95% CI 0.03-0.18, I2 = 29%) and splenic infarction (OR = 0.16, 95% CI 0.08-0.32, I2 = 0%) in SVP. CONCLUSION For selected patients who underwent laparoscopic spleen-preserving distal pancreatectomy, an increased preference for the SVP technique should be suggested considering its short-term benefits. However, in case of large tumours that distort and compress vessel course, SVR could be applied with acceptable splenic ischaemia and perigastric varices.
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Affiliation(s)
- Baohua Hou
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dailan Xiong
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sheng Chen
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tingting Ma
- Gynaecology and Obstetrics Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuanzhao Zhang
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yu Zhou
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zi Yin
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Halle-Smith JM, Vinuela E, Brown RM, Hodson J, Zia Z, Bramhall SR, Marudanayagam R, Sutcliffe RP, Mirza DF, Muiesan P, Isaac J, Roberts KJ. A comparative study of risk factors for pancreatic fistula after pancreatoduodenectomy or distal pancreatectomy. HPB (Oxford) 2017; 19:727-734. [PMID: 28522378 DOI: 10.1016/j.hpb.2017.04.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/30/2017] [Accepted: 04/21/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Evidence associates various biometric and histological variables such as steatosis and absence of fibrosis as risk factors for post-operative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Following distal pancreatectomy (DP), the association between these factors and POPF is less clear. This study of patients, drawn from the same background population, undergoing PD or DP at a single centre is a comparative study of the risk factors for POPF after these two operations. METHODS Associations between POPF and patient characteristics, pre-operative blood tests, data from pre-operative computed tomography (CT) imaging, assessment of histological steatosis and fibrosis were explored. RESULTS 26/107 (24%) and 26/90 (29%) patients developed POPF after PD and DP respectively. Absence of fibrosis was associated with POPF (p < 0.001) after PD and its presence correlated with pancreatic duct width (p < 0.001). Steatosis was not associated with POPF (p = 0.910). Multivariable analysis showed pancreatic duct width (p = 0.016) and fibrosis (p = 0.025) to be independent predictors of POPF after PD. The only variable associated with POPF after DP was underlying pathology (p = 0.005). CONCLUSION Pancreatic duct width is the most important variable related to POPF after PD and is correlated with fibrosis. Steatosis was not related to POPF. In contrast, after DP POPF appears to be related to the underlying disease.
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Affiliation(s)
| | - Eduardo Vinuela
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - Rachel M Brown
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - James Hodson
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - Zergham Zia
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - Simon R Bramhall
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | | | | | - Darius F Mirza
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - Paolo Muiesan
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - John Isaac
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
| | - Keith J Roberts
- Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, UK
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Guilbaud T, Birnbaum DJ, Loubière S, Bonnet J, Chopinet S, Grégoire E, Berdah S, Hardwigsen J, Moutardier V. Comparison of different feeding regimes after pancreatoduodenectomy - a retrospective cohort analysis. Nutr J 2017; 16:42. [PMID: 28676052 PMCID: PMC5496601 DOI: 10.1186/s12937-017-0265-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/25/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the most frequent pancreatic specific complication (PSC) after pancreaticoduodenectomy (PD). Several gastric decompression systems exist to manage DGE. Patients with a pancreatic tumor require prolonged nutrition; however, controversies exist concerning nutrition protocol after PD. The aim of the study was to assess the safety and efficacy of nasogastric (NG), gastrostomy (GT), and gastrojejunostomy (GJ) tubes with different feeding systems on postoperative courses. METHODS Between January 2013 and March 2016, 86 patients underwent PD with pancreaticogastrostomy. Patients were divided into three groups: GJ group with enteral nutrition (EN, n = 12, 14%), NG (n = 31, 36%) and GT groups (n = 43, 50%), both with total parenteral nutrition (TPN). RESULTS Patients in the GJ (n = 9, 75%) and GT (n = 18, 42%) groups had an American Society of Anesthesiologists (ASA) score of 3 more often than those in the NG group (n = 5, 16%, p ≤ 0.01). Multivariate analysis identified the GT tube with TPN as an independent risk factor of severe morbidity (p = 0.02) and DGE (p < 0.01). An ASA score of 3, jaundice, common pancreatic duct size ≤3 mm and soft pancreatic gland texture (p < 0.05) were found as independent risk factors of PSCs. Use of a GJ tube with EN, GT tube with TPN, jaundice, and PSCs were identified as independent risk factors for greater postoperative length of hospital stay (p < 0.01). Mean global hospitalization cost did not differ between groups. CONCLUSION GT tube insertion with TPN was associated with increased severe postoperative morbidity and DGE and should not be recommended. EN through a GJ tube after PD is feasible but does not have clear advantages on postoperative courses compared to an NG tube.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - Sandrine Loubière
- Self perceived Health Assessment Research Unit and Department of Public health, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005, cedex 20 Marseille, France
| | - Julien Bonnet
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery and Liver Transplantation, Hôpital La Timone, Aix-Marseille University, 264 Rue Saint-Pierre 13385, cedex 20 Marseille, France
| | - Emilie Grégoire
- Department of Digestive Surgery and Liver Transplantation, Hôpital La Timone, Aix-Marseille University, 264 Rue Saint-Pierre 13385, cedex 20 Marseille, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - Jean Hardwigsen
- Department of Digestive Surgery and Liver Transplantation, Hôpital La Timone, Aix-Marseille University, 264 Rue Saint-Pierre 13385, cedex 20 Marseille, France
| | - Vincent Moutardier
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
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Intra-Operative Amylase Concentration in Peri-Pancreatic Fluid Predicts Pancreatic Fistula After Distal Pancreatectomy. J Gastrointest Surg 2017; 21:1031-1037. [PMID: 28321709 DOI: 10.1007/s11605-017-3395-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/06/2017] [Indexed: 01/31/2023]
Abstract
Post-operative pancreatic fistula (POPF) is a potentially severe complication following distal pancreatectomy. The aim of this study was to assess the predictive value of intra-operative amylase concentration (IOAC) in peri-pancreatic fluid after distal pancreatectomy for the diagnosis of POPF. Consecutive patients who underwent a distal pancreatectomy between November 2014 and September 2016 were included in the analysis. IOAC was measured, followed by drain fluid analysis for amylase on post-operative days (PODs) 1, 3, and 5. Receiver operator characteristic (ROC) analysis was performed to evaluate the discriminative capacity of IOAC as a predictor of POPF. IOAC was measured after distal pancreatectomy in 26 patients. The IOAC correlated significantly with (i) PODs 1, 3, and 5 drain amylase (p < 0.01); (ii) the development of POPF (p < 0.01); and (iii) the Clavien-Dindo grade of surgical complications (p = 0.02). Eighty-three percent of patients with an IOAC > 1000 experienced a post-operative complication (OR 18.3, 95% CI 2.51-103, p < 0.01). ROC curve analysis confirmed the predictive relationship of IOAC and POPF as an excellent test with an area under the curve of 0.92 (95% CI 0.81-0.99, p < 0.01). Measurement of IOAC allows early and accurate categorization of patients at risk for POPF in distal pancreatectomy.
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50
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Lu F, Soares KC, He J, Javed AA, Cameron JL, Rezaee N, Pawlik TM, Wolfgang CL, Weiss MJ. Neoadjuvant therapy prior to surgical resection for previously explored pancreatic cancer patients is associated with improved survival. Hepatobiliary Surg Nutr 2017; 6:144-153. [PMID: 28652997 DOI: 10.21037/hbsn.2016.08.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with pancreatic ductal adenocarcinoma (PDAC) are frequently referred to tertiary centers after unsuccessful attempted resections at other institutions. The outcome of these patients who are ultimately resected is not well understood. METHODS We performed a retrospective review of patients with PDAC who underwent re-exploration between 1995 and 2013 at a single high volume tertiary care institution. We aimed to evaluate the association of neoadjuvant therapy prior to re-exploration on pathologic findings and clinical outcome in previously explored patients with PDAC. RESULTS Between 1995 and 2013, 50 of the 2,062 patients who were surgically explored underwent pancreatic resection following a previous exploration where they were deemed unresectable. The most common reason for unresectability at initial operation was vascular invasion (80%) and a presumed R2 resection. Thirty-seven (74%) patients received neoadjuvant therapy. Neoadjuvant therapy was associated with improved TNM stage (P=0.002), fewer positive lymph nodes (0 vs. 2, P=0.025), and improved median survival (24 vs. 13 months, P=0.044). Compared to R2 resected patients with PDAC who had not previously been explored, re-explored patients had significantly lower pathologic T and N stages (P<0.001) and a longer median survival (19 vs. 10 months, P<0.001). CONCLUSIONS Patients with PDAC deemed unresectable may warrant re-exploration. Treatment with neoadjuvant therapy between operations is associated with improved pathological stage and survival. In this highly selected group of patients, successful resection is associated with improved survival compared to R2 resections.
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Affiliation(s)
- Fengchun Lu
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Union Hospital, Fujian Medical University, Fuzhou 350001, China
| | - Kevin C Soares
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Rezaee
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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