Although the use of the minimally invasive approach is expanding in pancreatic surgery, indications and results of laparoscopic reinterventions after pancreatectomy are unknown.

Based on the multicenter AFC (Association Française de Chirurgie) cohort (2010-2021), patients who underwent open (open reoperation group) or laparoscopic (laparoscopic reoperation group) reoperation within 90 days after minimally invasive pancreatectomy were included and compared. Inverse probability of treatment weighting analysis was performed to determine the impact of laparoscopic reoperation on postoperative mortality.

Of the 3,412 patients who underwent minimally invasive pancreatectomy, 298 (8.7%) underwent reoperation, with a median delay of 9 days (interquartile range: 4-19 days). Most frequent causes of reintervention were pancreatic fistula with uncontrolled sepsis (postoperative pancreatic fistula) (23%) and hemorrhage (postpancreatectomy hemorrhage) (46%). Sixty-five patients (22%) underwent laparoscopic and 233 (78%) open reoperation. Laparoscopic reoperation was mostly performed for postoperative pancreatic fistula drainage (43%), postpancreatectomy hemorrhage (26%), bowel obstruction (20%), or peritonitis (8%). Patients in the laparoscopic reoperation group were more often reoperated on after distal pancreatectomy (54% vs 36% in open reoperation group, P = .017). After pancreatoduodenectomy, laparoscopic reoperation was more often performed for bowel obstruction compared with open reoperation (20% vs 4%, P = .005). After reintervention, the postoperative mortality rate was 13%. Hospital stay was significantly shorter after laparoscopic reoperation (28 vs 36 days, P = .037). After adjustment for inverse probability of treatment weighting, laparoscopic revision was statistically associated with less postoperative mortality (odds ratio = 0.81, 95% confidence interval: 0.81-0.95).

The laparoscopic approach may be an option for surgical reintervention after minimal invasive pancreatectomy in non-life-threatening indications, mainly after distal pancreatectomy for postoperative pancreatic fistula drainage or after pancreatoduodenectomy for occlusion.

Postoperative pancreatic fistula remains a challenging complication after pancreaticoduodenectomy. Addressing this issue requires effective strategies to promote anastomotic healing. In this study, we developed a novel hydrogel designed to close pancreaticoenteric anastomosis after pancreaticoduodenectomy. The hydrogel-composed of polyvinyl alcohol, chitosan, and dopamine-modified oxidized hyaluronic acid-exhibited excellent antibacterial, anti-inflammatory, and wound healing properties. It was designed to conform well to the anastomotic site for clinical application. The hydrogel demonstrated good biocompatibility, appropriate mechanical strength, low swelling, and strong adhesive properties, meeting specific requirements for pancreaticoenteric anastomosis environments. Moreover, by activating the cell cycle, it promoted cell proliferation and migration, thereby accelerating anastomotic closure. Addition of the potent broad-spectrum antibiotic meropenem further enhanced its antibacterial efficacy, targeting common microbial species involved in delayed healing and fistula formation after pancreatic surgery. In a rat model of pancreatic fistula, the hydrogel effectively sealed the anastomosis, filled potential suture gaps, and exerted antibacterial, anti-inflammatory, and tissue regeneration-promoting effects around the anastomotic site. Therefore, this hydrogel, with its ideal degradation properties, shows promising application prospects in closing pancreaticoenteric anastomosis following pancreaticoduodenectomy, thereby offering an effective solution to reduce complications such as pancreatic fistula after pancreatic surgery.

Postpancreatectomy hemorrhage is one of the most severe and life-threatening complications after pancreaticoduodenectomy. We present four cases of gastrointestinal bleeding patients to clarify its appropriate treatment and prevention.

The main symptoms included black stool, hematochezia, haematemesis, blood in the nasogastric tube, and hemorrhagic shock. The mean age was 66.25 years old and the median onset time was 340 d after the surgery. The bleeding location comprised gastrointestinal anastomosis, bile duct-jejunum anastomosis, and extraluminal bleeding. The possible causes included marginal ulcer, jejunal varix, and abdominal infection. Endoscopic hemostatic clips, as well as a covered stent using angiography, were utilized to stop the bleeding and three patients survived. Only one patient died of gastrointestinal bleeding, abdominal bleeding, abdominal infection, hypovolemic shock, and disseminated intravascular coagulation.

Early and effective endoscopic intervention is the key to successful hemostasis in patients with gastrointestinal bleeding after pancreatoduodenectomy.

Objective: Postoperative pancreatic fistula (POPF) is a common and challenging complication following pancreaticoduodenectomy (PD), occurring in 2% to 46% of cases. Despite various pancreaticojejunostomy techniques, an effective method to prevent POPF has not been established. This study aimed to develop and evaluate a novel 3D-printed biodegradable pancreatic duct stent to simplify the surgical process of pancreaticojejunostomy, reduce anastomotic complexity, and minimize postoperative complications. Methods: Data from 32 patients undergoing total laparoscopic pancreaticoduodenectomy were utilized. Preoperative CT scans were transformed into 3D reconstructions to guide the design and printing of customized stents using polylactic acid (PLA). The stents were assessed for mechanical integrity, surface texture, and thermal stability. Animal experiments were conducted on 16 mini pigs, with the experimental group receiving the novel stent and the control group receiving traditional silicone stents. Results: The 3D-printed stents demonstrated accurate dimensional replication and mechanical reliability. In the animal experiments, the experimental group showed no significant difference in postoperative complications compared to the control group. At 4 weeks post-surgery, CT scans revealed well-healed anastomoses in both groups, with no significant inflammation or other complications. Histological examination and 3D reconstruction models confirmed good healing and device positioning in the experimental group. Conclusion: The 3D-printed biodegradable pancreatic duct stent offers a promising solution for pancreaticojejunostomy, with comparable safety and efficacy to traditional methods. Further research is needed to validate its clinical application.

The coronavirus disease 2019 (COVID-19) pandemic greatly impacted medical resources such as cancer screening, diagnosis, and treatment given to people for various diseases. We surveyed the impacts of the pandemic on the incidence of complications and mortality following pancreaticoduodenectomy for pancreatic cancer in Japan.

Data on patients who underwent pancreaticoduodenectomy for pancreatic cancer were extracted from the Japanese National Clinical Database (NCD) between 2018 and 2021. The number of the pancreaticoduodenectomy for pancreatic cancer were obtained and then the morbidity and mortality rates were evaluated using a standardized morbidity/mortality ratio (SMR), which is the ratio of the observed number of incidences to the expected number of incidences calculated by the risk calculator previously developed by the NCD.

This study included 22 255 cases. The number of pancreaticoduodenectomies exhibited an increasing trend even during the COVID-19 pandemic. The mean observed incidence rates of Grade C pancreatic fistula and Clavien-Dindo grade ≥4 complications, and the 30-day mortality and surgical mortality rates were 0.8%, 1.8%, 0.8% and 0.9%, respectively. The standardized morbidity ratios did not increase during the COVID-19 pandemic. The standardized mortality ratios remained within the range of variations observed before the COVID-19 pandemic.

The increasing trend in the number of pancreaticoduodenectomies and favorable short-term outcomes even in the COVID-19 pandemic suggest the medical care for pancreatic cancer in Japan functioned well during the pandemic.

The connection between early postoperative fever and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy remains unclear. This study aimed to investigate this association and assess the predictive value of early postoperative fever for CR-POPF.

This retrospective observational study included adult patients who underwent pancreaticoduodenectomy at a tertiary teaching hospital between 2007 and 2019. Patients were categorized into those with early postoperative fever (≥ 38 °C in the first 48 h after surgery) and those without early postoperative fever groups. Weighted logistic regression analysis using stabilized inverse probability of treatment weighting (sIPTW) and multivariable logistic analysis were performed. The c-statistics of the receiver operating characteristic curves were calculated to evaluate the impact on the predictive power of adding early postoperative fever to previously identified predictors of CR-POPF.

Of the 1997 patients analyzed, 909 (45.1%) developed early postoperative fever. The overall incidence of CR-POPF among all the patients was 14.3%, with an incidence of 19.5% in the early postoperative fever group and 9.9% in the group without early postoperative fever. Early postoperative fever was significantly associated with a higher risk of CR-POPF after sIPTW (adjusted odds ratio [OR], 1.73; 95% confidence interval [CI], 1.34-2.22; P < 0.001) and multivariable logistic regression analysis (adjusted OR, 1.88; 95% CI, 1.42-2.49; P < 0.001). The c-statistics for the models with and without early postoperative fever were 0.76 (95% CI, 0.73-0.79) and 0.75 (95% CI, 0.72-0.78), respectively, showing a significant difference between the two (difference, 0.02; 95% CI, 0.00-0.03; DeLong's test, P = 0.005).

Early postoperative fever is a significant but not highly discriminative predictor of CR-POPF after pancreaticoduodenectomy. However, its widespread occurrence limits its applicability as a predictive marker.

Introduction Postoperative pancreatic fistula (POPF) is a common complication of pancreatoduodenectomy (PD) that may cause lethal complications. Therefore, it is important to properly treat POPF and prevent its aggravation during the postoperative management of PD. We have used a combination of open drainage, in which the wound above the fluid collection is opened, and negative pressure wound therapy with instillation and dwell time (NPWTi-d) to manage POPF after PD. To evaluate the feasibility and efficacy of this combination treatment, we analyzed the outcomes of patients with POPF after PD. Methods Patients who underwent PD were reviewed and those who developed POPF were extracted and divided into three groups according to the management of POPF: N group (patients treated with open drainage and NPWTi-d), O group (patients treated with open drainage without NPWTi-d), and C group (patients treated with catheter drainage). The perioperative outcomes were compared among the three groups. Results During the study period, 133 patients underwent PD, out of which 39 (29%) developed POPF (≥grade B). Among the 39 patients with POPF, eight, four, and 27 were classified into the N, O, and C group, respectively. No mortality was observed in the patients with POPF. No severe complications were observed in the patients who underwent open drainage (N and O groups), while two patients in the C group developed severe complications. Among the patients who underwent open drainage, the N group tended to have a shorter postoperative hospital stay than the O group. Conclusions The current study suggests that open drainage safely and effectively healed POPF and NPWTi-d promoted wound closure. The combination of open drainage and NPWTi-d may prevent the aggravation of POPF, reduce failure to rescue, and shorten hospital stay after PD.

Anastomotic leakage (AL) is the leaking of non-sterile gastrointestinal contents into a patient's abdominal cavity. AL is one of the most dreaded complications following gastrointestinal surgery, with mortality rates reaching up to 27%. The current diagnostic methods for anastomotic leaks are limited in sensitivity and specificity. Since the timing of detection directly impacts patient outcomes, developing new, fast, and simple methods for early leak detection is crucial. Here, a naked eye-readable, electronic-free macromolecular network drain fluid sensor is introduced for continuous monitoring and early detection of AL at the patient's bedside. The sensor array comprises three different macromolecular network sensing elements, each tailored for selectivity toward the three major digestive enzymes found in the drainage fluid during a developing AL. Upon digestion of the macromolecular network structure by the respective digestive enzymes, the sensor produces an optical shift discernible to the naked eye. The diagnostic efficacy and clinical applicability of these sensors are demonstrated using clinical samples from 32 patients, yielding a Receiver Operating Characteristic Area Under the Curve (ROC AUC) of 1.0. This work has the potential to significantly contribute to improved patient outcomes through continuous monitoring and early, low-cost, and reliable AL detection.

Pancreatic fistula is a very difficult complication after pancreatic surgery(1). Endoscopic ultrasound guided drainage of pancreatic duct (EUS-PD)was a challenging endoscopic procedure that can solve the problem of postoperative pancreatic fistula. However, EUS-PD cannot be completed in patients with undilated pancreatic ducts. Here, we present a case of fistula-digestive anastomosis in the treatment of postoperative pancreatic fistula.

Meta-analysis of 10 randomized prospective trials demonstrated a higher risk of postoperative bleeding from pancreaticogastrostomy (PG) compared with pancreatojejunostomy following pancreatoduodenectomy (PD). This study evaluated the incidence, risk factors, and treatment of anastomotic bleeding from invaginated PG.

We retrospectively evaluated all consecutive PDs performed between April 1, 2011 and December 31, 2022 using invaginated PG by the double purse-string technique. Multivariate analysis identified risk factors for anastomotic PG bleeding.

During the study, 695 consecutive patients with a median age of 66 years underwent PD; the majority was performed for ductal pancreatic adenocarcinomas. Simultaneous vascular resections were performed in 328 patients. Postoperative mortality was 4.1%. Bleeding from PG occurred in 33(4.6%) patients at a median interval of 5 days (range, 1-14) from surgery, leading to reoperation in 21(63%). PG bleeding-related mortality was 9.0%. Multivariate analyses identified a soft pancreatic texture and Wirsung duct > 3 or ≤ 3 mm (Class C and D, respectively, of the ISGPS) (odds ratio [OR]: 2.17, 95% confidence interval [95% CI]: 1.38-3.44; P = 0.0009) and wrapping of the invaginated pancreas (OR: 0.37, 95% CI: 0.17-0.84; P = 0.01) as independent risk factors for PG bleeding.

In a large volume setting, anastomotic bleeding from invaginated PG occurred in ~ 5% of patients and was associated with soft pancreatic parenchyma and small wirsung duct. The reduced rate of PG bleeding observed with wrapping of the invaginated pancreatic stump warrants further evaluation in a prospective randomized study.

Several guidelines exist for minimally invasive pancreatoduodenectomy (MIPD) regarding its prerequisites and learning curve. However, these guidelines are based on the experience of the pioneers of MIPD; minimal data exist on the experience of the next generation of surgeons. The aim of this study was to compare the two surgeon types (veteran and junior) for MIPD in terms of immediate postoperative outcomes.

The postoperative outcomes of 22 patients who underwent robot-assisted pancreatoduodenectomy (RAPD) by a junior surgeon from July 2021 to December 2022 were retrospectively reviewed. The outcomes were compared with the initial postoperative outcomes and the contemporary postoperative outcomes of RAPD by a veteran surgeon.

In comparing the initial outcomes between the two surgeon types, the veteran surgeons showed a shorter operation time (junior surgeon vs. veteran surgeon: 606 ± 89 vs. 467 ± 77 min, p < 0.001). However, there was no significant difference in terms of postoperative outcomes, such as blood loss (300 [200-600] ml. vs. 200 [100-500] ml, p = 0.208), major complications (≥CDC IIIa: 4 (18.2%) vs. 4 (18.2%), p = 1.000), postoperative pancreatic fistula (POPF; ≥ISGPF Grade B: 2 (9.1%) vs. 3 (13.6%), p > 0.999), and length of hospital stay (18.0 ± 8.9 days vs. 18.3 ± 7.9 days, p = 0.915), between the two surgeon types. In addition, in a comparison of the contemporary outcomes, there was no significant difference in terms of postoperative outcome (complications: 4 (18.2%) vs 11 (11.1%), p = 0.580; POPF: 2 (9.1%) vs. 3 (3.0%), p = 0.484; length of hospital stay: 18.0 ± 8.9 vs. 15.0 ± 6.5 days, p = 0.065).

The initial outcomes of MIPD by a well-trained junior surgeon were found to be comparable to those of MIPD by a veteran surgeon.

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk.

Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139).

We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF.

Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.

Postoperative pancreatic fistula (POPF) is responsible of most major complications and fatalities after PD. By avoiding POPF, TP may improve operative outcomes in high-risk patients. The aim was to compare total pancreatectomy (TP) and pancreatoduodenectomy (PD) in high-risk patients and evaluate results of implementing a risk-tailored strategy in clinical practice.

Between 2014 and 2023, 139 patients (76 men, median age 67 years) underwent resection of disease located in the head of the pancreas. Starting January 1, 2022, we offered TP to patients at high POPF risks (fistula risk score (FRS) ≥7) and to patients with intermediate POPF risks (FRS: 3-6) and high risks of failure to rescue (age> 75 years, ASA score ≥3). We compared outcomes of TP and PD and evaluated the results of the new strategy implementation on operative outcomes. Propensity score-based analysis was performed to limit bias of between-group comparison.

Eventually, 26 (19%) patients underwent TP and 113 (81%) patients underwent PD. Severe complications occurred in 42 (30%) patients and 13 (9%) patients died. TP resulted in shorter lengths of hospital stay (median: 14 days [11; 18] vs. 17 days [13; 24], p = 0.016) and less risks of post-pancreatectomy hemorrhage (PPH) (0% vs. 20%, p < 0.001) compared to PD. Crude and propensity match analysis showed that the implementation of a risk-tailored strategy led to significant reduction of reoperation, POPF, PPH and mortality rates.

The use of TP as part of a risk-tailored strategy in high-risk patients can be lifesaving.

Managing postoperative pancreatic fistula (POPF) presents a formidable challenge after pancreatoduodenectomy. Some centers consider pancreatic duct occlusion (PDO) in reoperations following pancreatoduodenectomy as a pancreas-preserving procedure, aiming to control a severe POPF. The aim of the current study was to evaluate the short- and long-term outcomes of employing PDO for the management of the pancreatic stump during relaparotomy for POPF subsequent to pancreatoduodenectomy.

Retrospective review of consecutive patients at Oslo University Hospital undergoing pancreatoduodenectomy and PDO during relaparotomy. Pancreatic stump management during relaparotomy consisted of occlusion of the main pancreatic duct with polychloroprene Faxan-Latex, after resecting the dehiscent jejunal loop previously constituting the pancreaticojejunostomy.

Between July 2005 and September 2015, 826 pancreatoduodenectomies were performed. Overall reoperation rate was 13.2% (n = 109). POPF grade B/C developed in 113 (13.7%) patients. PDO during relaparotomy was performed in 17 (2.1%) patients, whereas completion pancreatectomy was performed in 22 (2.7%) patients. Thirteen (76%) of the 17 patients had a persistent POPF after PDO, and the time from PDO until removal of the last abdominal drain was median 35 days. Of the PDO patients, 13 (76%) patients required further drainage procedures (n = 12) or an additional reoperation (n = 1). In-hospital mortality occurred in one patient (5.9%). Five (29%) patients developed new-onset diabetes mellitus, and 16 (94%) patients acquired exocrine pancreatic insufficiency.

PDO is a safe and feasible approach for managing severe POPF during reoperation following pancreatoduodenectomy. A significant proportion of patients experience persistent POPF post-procedure, necessitating supplementary drainage interventions. The findings suggest that it is advisable to explore alternative pancreas-preserving methods before opting for PDO in the management of POPF subsequent to pancreatoduodenectomy.

Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors.

The PubMed database was searched for papers published in the English language no earlier than January 2018.

We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective.

It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.

Pancreatectomy, including pancreaticoduodenectomy (PD), as well as central pancreatectomy (CP), distal pancreatectomy (DP) and total/subtotal pancreatectomy, is a major, complex and difficult surgical procedure performed for various benign and malignant pancreatic diseases: from chronic pancreatitis, through benign cystic tumors and neuroendocrine neoplasms to malignant neoplasms, including pancreatic ductal adenocarcinoma (PDAC) [...].