Although fluorescence guidance during various surgical procedures has been shown to be safe and have possible better clinical outcomes than without the guidance, the use of fluorophores in pancreatic surgery is novel and not yet well described. This scoping review involved a systematic methodology of the currently available literature and aimed to illuminate the use of fluorophores in pancreatic surgery from a clinical view.

The PRISMA and the PRISMA-ScR guidelines were used when appropriate and the following databases were searched: PubMed, Embase, Scopus, The Cochrane Collection, and Web of Science. Human original articles and case reports were included. Bias was assessed with the Newcastle-Ottawa Scale and the IDEAL framework was used for evaluation of surgical innovation.

A total of 5,565 search hits were screened, and 23 original articles and 24 case reports consisting of 754 patients met the inclusion criteria. The use of indocyanine green was both the most prominent and the most promising method for securing sufficient perfusion of neighboring organs, enhancing the detection and distinguishing of neuroendocrine tumors, and assisting in the identification of hepatic micrometastases.

The included studies were generally heterogenic, exploratory, and small. Indocyanine green was used in several ways, and it may add clinical value in different settings during pancreatic surgery. Tumor-targeted probes are a rapidly developing and promising field of research.

Applying indocyanine green (ICG) fluorescence in surgery has created a new dimension of navigation surgery to advance in various disciplines. The research in this field is nascent and fragmented, necessitating academic efforts to gain a comprehensive understanding. The present review aims to integrate diverse perspectives and recent advances in its application in gastrointestinal surgery. The relevant articles were selected by using the appropriate keyword search in PubMed. The angiography and cholangiography property of ICG fluorescence is helpful in various hepatobiliary disorders. In gastroesophageal and colorectal surgery, the lymphangiography and angiography property of ICG is applied to evaluate bowel vascularity and guide lymphadenectomy. The lack of objective parameters to assess ICG fluorescence has been the primary limitation when ICG is used to evaluate bowel perfusion. The optimum dose and timing of ICG administration need to be standardized in some new application areas in gastrointestinal surgery. Binding tumor-specific ligands with fluorophores can potentially widen the fluorescence application to detect primary and metastatic gastrointestinal tumors. The narrative review outlines prior contributions, limitations, and research opportunities for future studies across gastrointestinal sub-specialty. The findings of the present review would be helpful for scholars and practitioners to explore and progress in this exciting domain of gastrointestinal surgery.

Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest.

To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF.

A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications.

Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified.

The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.

This study aimed to explore the risk factors of clinically relevant pancreatic fistulas (PF) after laparoscopic pancreaticoduodenectomy (LPD). The clinical data of 80 patients who underwent pancreaticoduodenectomy in our hospital were retrospectively analyzed. The potential risk factors for PF after LPD were determined using univariate and multivariate logistic regression analyses. Results from the univariate analyses showed that the pancreatic duct diameter (P < .001), pancreatic texture (P < .001), abdominal infection (P = .002), and reoperation (P < .001) were associated with clinically relevant PF. Results from the multivariate logistic regression analysis showed that the pancreatic duct diameter (P = .002) and pancreatic texture (P = .016) were significant risk factors for clinically relevant PF. Based on this study, the pancreatic duct diameter and pancreatic texture are independent risk factors for clinically relevant PF after LPD.

Postoperative acute pancreatitis (POAP) emerges as a distinct pancreas-specific complication increasing both the risk and the burden of POPF after pancreatoduodenectomy. Among various risk factors, pancreas stump (PS) hypoperfusion might play a role in POAP occurrence but has never been investigated. The current study aimed at evaluating the feasibility of intraoperative fluorescence angiography (IOFA) of the PS using ICG and its association with POAP.

Consecutive patients who underwent pancreatoduodenectomy for a periampullary tumor with pancreatojejunostomy and PS perfusion assessment using IOFA between January 2020 and November 2020 were prospectively included. Perioperative management and surgical strategy were standardized. IOFA of the pancreas stump was performed before fashioning pancreatojejunostomy. POAP was defined according to the Connor definition and was confirmed upon radiological blind review. Outcomes between patients with normally perfused and hypoperfused PS were compared. POAP was the primary endpoint.

Among 30 patients, nine patients (30%) developed POAP according to the Connor definition, and six patients (20%) had CT-confirmed POAP. Upon IOFA, six patients (20%) presented PS hypoperfusion; of which one patient underwent extended pancreatectomy further to the left. PS hypoperfusion was statistically associated with the occurrence of POAP (80% vs. 16%; p = 0.011) and CT-confirmed POAP (60% vs. 12%; p = 0.041). Clinically relevant POPF rate was 40% in case of PS hypoperfusion and 4% in case of normal PS perfusion (p = 0.064).

PS perfusion assessment using IOFA seems safe and reliable to anticipate POAP. PS IOFA could be considered as a potential tool for perioperative assessment of surgical risk after pancreatoduodenectomy.

Clinically relevant pancreatic fistula (CRPF) is a serious complication following laparoscopic pancreaticoduodenectomy (LPD). This study aimed to determine if C-reactive protein (CRP) and procalcitonin (PCT) serum levels could be used as early biomarkers to predict CRPF after LPD.

In this retrospective study, we collected peri-operative data of patients who underwent LPD between January 2019 and November 2019. We compared serum levels of white blood cells (WBC), CRP, and PCT on post-operative days (POD) 1, 2, 3, 5, and 7 between the CRPF and non-CRPF groups and analyzed the predictive risk factors for CRPF.

Among the 186 patients included in this study, 18 patients (9.7%) developed CRPF, including 15 and 3 patients with grade B and C fistulas, respectively. The mean WBC, CRP, and PCT levels were higher on most PODs in the CRPF group compared to the non-CRPF group. Receiver operating characteristic (ROC) analysis indicated that CRP levels on POD 2, 5, and 7 can predict CRPF development after LPD, with the area under the curve (AUC) value reaching the highest level on POD 2 (AUC 0.794). PCT levels on POD 2, 3, 5, and 7 were highly predictive of CRPF after LPD. The highest AUC value was achieved on POD 3 [PCT > 2.10 ng/ml (AUC 0.951; sensitivity 88.2%, specificity 92.9%, P < 0.001)].

Both CRP and PCT levels can be used to predict CRPF development after LPD, with PCT having a higher predictive value.

Because of today's advancements in surgical techniques and perioperative management skills, surgeons are beginning to explore the usefulness of the laparoscopic approach in managing periampullary tumors. However, as a result of its innate complexity and associated high surgery-related complications, its applicability to the general surgical community remains controversial. To date, only retrospective data from high-volume centers support the safety and feasibility of laparoscopic pancreaticoduodenectomy (Lap PD) for the treatment of benign conditions and malignant periampullary tumors. In addition, various surgical techniques in terms of port placement, dissection, and reconstruction have evolved in different centers depending on the preferred method commonly used by the surgeon through accumulated experience. In our center, we used a stepwise approach and standardized our surgical technique to overcome this technically demanding procedure. A collaborative implementation of video review and analysis, practice training and simulation, operating room didactics, and strict adherence to our stepwise approach in Lap PD, might potentially improve the surgical skills of young hepatobiliary surgeons and possibly overcome the volume-based learning curve of Lap PD.