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Shahbaz NK, Verhoeff K, Wees T, Jatana S, Quan D, Glinka J, Skaro A, Tang ES. Laparoscopic versus open pancreaticoduodenectomy outcomes in patients ≥ 75 years old: an NSQIP analysis of 4343 patients. HPB (Oxford) 2025; 27:696-705. [PMID: 39965982 DOI: 10.1016/j.hpb.2025.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Revised: 01/19/2025] [Accepted: 01/28/2025] [Indexed: 02/20/2025]
Abstract
BACKGROUND The benefits of MIS in older adults are conflicting. This study evaluates demographics and early outcomes, for older patients (≥75) undergoing minimally invasive (MIS) versus open pancreaticoduodenectomy (PD). METHOD We categorized elderly patients who underwent PD from 2017 to 2021 NSQIP databases by surgical approach (open vs MIS). Baseline characteristics were examined with bivariate analysis, and multivariate logistic regression assessed the independent effect of minimally invasive surgery on 30-day serious complications and mortality. RESULTS Amongst 4137 patients, 150 (3.63 %) underwent MIS PD. Patients demographics were similar. Open cohorts were older (79.1 vs 78.4 years; p = 0.011) with greater tumor invasion (36.6 % vs. 27.0 %; p = 0.018). MIS had longer operations (133.1 vs 119.6 min; p < 0.001). Multivariate analysis demonstrated that MIS approach was associated with increased serious complications (OR 2.21; p < 0.001), but not mortality (OR 2.11; p = 0.173). Post hoc analysis excluding cases converted to open demonstrated no difference in serious complications (OR 1.94; p = 0.070) or mortality (OR 3.58; p = 0.094). PSM analysis estimated a 14.7 % higher rate of serious complications in MIS but similar mortality (p = 0.291). CONCLUSIONS MIS PD uptake in elderly patients remains limited, with early findings indicating longer operations and higher complications. Further research on patient selection differences, technique modifications, and center expertise is required.
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Affiliation(s)
- Nazgol K Shahbaz
- Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Tyrell Wees
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sukhdeep Jatana
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | | | - Juan Glinka
- Department of Surgery, London, Ontario, Canada
| | - Anton Skaro
- Department of Surgery, London, Ontario, Canada
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Okui N, Furukawa K, Shirai Y, Onda S, Haruki K, Chiba M, Kato M, Torisu Y, Gocho T, Ikegami T. Safe and beneficial outcomes of pancreaticogastrostomy with endoscopic transgastric drainage for pancreatic fistula after pancreaticoduodenectomy. Surg Oncol 2024; 57:102141. [PMID: 39326127 DOI: 10.1016/j.suronc.2024.102141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/26/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
PURPOSES The optimal surgical technique and perioperative management to prevent postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy have not yet been established. This study examined the perioperative outcomes of pancreaticogastrostomy with endoscopic transgastric drainage. METHODS We performed a retrospective analysis of 191 patients who underwent pancreaticoduodenectomy between 2016 and 2023. They were divided into two groups: pancreaticojejunostomy group (n = 135) and pancreaticogastrostomy group (n = 56). We compared preoperative factors and postoperative outcomes. We performed endoscopic drainage only in the pancreaticogastrostomy group. RESULTS Preoperative factors were similar between the two groups. Operative time [480 (404-542) vs. 382 (346-458) minutes], blood loss [505 (270-850) vs. 315 (145-535) g], pseudoaneurysm formation (7 % vs. 0 %), and postoperative hospital stay [28 (22-38) vs. 19 (17-24) days] were significantly lower in the pancreaticogastrostomy group. In the analysis of 41 patients with POPF, postoperative hospital stay [40 (23-108) vs. 27 (18-54) days] and hospital stay after POPF diagnosis [30 (10-99) vs. 15 (5-35) days] were significantly shorter in the pancreaticogastrostomy group. Endoscopic transgastric drainage was performed in 77 % of patients in the pancreaticogastrostomy group, and drainage was successfully completed in all patients. CONCLUSION Pancreaticogastrostomy with endoscopic transgastric drainage could be effective for the safe management of pancreaticoduodenectomy.
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Affiliation(s)
- Norimitsu Okui
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masafumi Chiba
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Gocho
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Ghimire R, Limbu Y, Regmee S, Maharjan DK, Mishra A, Pahari R, Thapa PB. Indocyanine green fluorescence imaging: Assessment of perfusion at pancreatic resection margin during pancreatoduodenectomy: A cross sectional study. Health Sci Rep 2024; 7:e70153. [PMID: 39444730 PMCID: PMC11497489 DOI: 10.1002/hsr2.70153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/30/2024] [Accepted: 10/08/2024] [Indexed: 10/25/2024] Open
Abstract
Background Clinically relevant-postoperative pancreatic fistula (CR-POPF) is one of the dreaded complications of pancreatoduodenectomy. Vascularity of the stump of the pancreas during pancreatico-enteric anastomosis is considered one of the major determinants of POPF. Indocyanine green (ICG) is one of the modality for vascular assessment; hence, we aimed to evaluate the role of ICG fluorescence imaging to assess the vascularity of the pancreatic stump during pancreatoduodenectomy. Methodology The study was conducted at Kathmandu Medical College, Kathmandu, Nepal, during the period of 1 year (June 01, 2022-July 31, 2023). All of the patients who were undergoing pancreatoduodenectomy were included in the study. In all cases, intraoperatively, ICG fluorescence detection at the pancreatic stump margin was evaluated using near-infrared light. Results A total of 28 patients underwent PD during this period. The ICG fluorescence imaging was positive at the pancreatic stump margin in 25 out of the 28 patients (89%), and in three cases, the florescence was negative. In patients who had negative fluorescence, revision of the stump margin was performed. Clinically relevant POPF was noted in 2 out of 28 cases, which had a soft pancreas with a small duct, although the pancreatic stump margin had good ICG florescence per-operatively. Conclusion ICG is inexpensive and a safe dye to use in clinical practice. We can objectively assess the pancreatic stump vascularity using intraoperative ICG fluorescence imaging, thereby potentially decreasing postoperative pancreatic fistula.
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Affiliation(s)
- Roshan Ghimire
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Yugal Limbu
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Sujan Regmee
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Dhiresh Kumar Maharjan
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Aakash Mishra
- Kathmandu Medical College Teaching HospitalKathmanduNepal
| | - Rabin Pahari
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
| | - Prabin Bikram Thapa
- Department of Gastrointestinal and General SurgeryKathmandu Medical College Teaching HospitalKathmanduNepal
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Chauhan SSB, Vierra B, Park JO, Pillarisetty VG, Davidson GH, Sham JG. Prophylactic somatostatin analogs for postoperative pancreatic fistulas: a cross-sectional survey of AHPBA surgeons. HPB (Oxford) 2024; 26:1229-1236. [PMID: 38971667 DOI: 10.1016/j.hpb.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/13/2024] [Accepted: 06/12/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Postoperative pancreatic fistulas lead to substantially increased morbidity, mortality, and healthcare costs after pancreatectomy. Studies have reported conflicting data on the role of prophylactic somatostatin analogs in the reduction of postoperative pancreatic fistula. Current practice patterns, surgeon beliefs, and barriers to using these drugs in the Americas is not known. METHODS An online 26-question cross-sectional survey was distributed via email to the members of the Americas Hepato-Pancreato-Biliary Association in April 2023. RESULTS One hundred and two surgeons responded in spring 2023. 48.0% of respondents reported using prophylactic SSAs during their surgical training, however, only 29.4% do so in their current practice, most commonly when performing Whipple procedures. Octreotide was the most frequently used SSA (34.3%), followed by octreotide LAR (12.7%) and pasireotide (11.8%). Reasons for not prescribing included a lack of high-quality data (62.7%), perception of limited efficacy (34.3%) and high cost (30.4%). CONCLUSION These results highlight key areas for future study including understanding surgeon rationale for patient and drug selection. Variable practice patterns amongst surgeons also underscore the importance of generalizability in the design of future clinical trials in order to maximize impact.
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Affiliation(s)
| | - Benjamin Vierra
- University of Washington Department of Surgery, Seattle, WA, USA
| | - James O Park
- University of Washington Department of Surgery, Seattle, WA, USA; Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Venu G Pillarisetty
- University of Washington Department of Surgery, Seattle, WA, USA; Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Giana H Davidson
- University of Washington Department of Surgery, Seattle, WA, USA; Surgical Outcomes Research Center, University of Washington Seattle, WA, USA
| | - Jonathan G Sham
- University of Washington Department of Surgery, Seattle, WA, USA; Surgical Outcomes Research Center, University of Washington Seattle, WA, USA; Fred Hutchinson Cancer Center, Seattle, WA, USA.
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Addeo P, Gussago S, De Mathelin P, Averous G, Paul C, Bachellier P. Anastomotic bleeding from invaginated pancreaticogastrostomy following pancreatoduodenectomy: incidence, risk factors, treatment and prevention. Langenbecks Arch Surg 2024; 409:229. [PMID: 39066838 DOI: 10.1007/s00423-024-03400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/30/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives et Hépatiques, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Stefano Gussago
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives et Hépatiques, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Pierre De Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives et Hépatiques, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Chloé Paul
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives et Hépatiques, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives et Hépatiques, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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6
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Salman MA, Elewa A, Elsherbiny M, Tourkey M, Emechap EN, Chikukuza S, Salman A. Postoperative pancreatic fistula after pancreaticogastrostomy versus pancreatojejunostomy after pancreatic resection, a comparative systematic review and meta-analysis. World J Surg 2024; 48:1467-1480. [PMID: 38629863 DOI: 10.1002/wjs.12173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/22/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND In patients undergoing pancreaticoduodenectomy (PD), there has been some evidence favoring pancreaticogastrostomy (PG) over pancreatojejunostomy (PJ) in the occurrence of postoperative pancreatic fistulas (POPF) and considering PG as a safer anastomotic technique. However, other publications revealed comparable incidences of POPF attributed to both techniques. The current work attempts to reach a more consolidated conclusion about such an issue. METHODS This is a systematic review and meta-analysis that analyzed the studies comparing PG and PJ during PD in terms of the rate of POPF occurrence. Studies were obtained by searching the Scopus, PubMed Central, and Cochrane Central Register of Controlled Trials databases. RESULTS 35 articles published between 1995 and 2022 presented data from 14,666 patients; 4547 underwent PG and 10,119 underwent PJ. Statistically significant lower rates of POPF (p = 0.044) and clinically relevant CR-POPF (p = 0.043) were shown in the PG group. The post-pancreatectomy hemorrhage (PPH) was significantly higher in the PG group, while no significant difference was found between the two groups in the clinically significant PPH. No statistically significant differences were found regarding the amount of intraoperative blood loss, length of hospital stay, DGE, overall morbidity rates, reoperation rates, or mortality rates. The percentage of male sex in the PG group and the percentage of soft pancreas in the PJ group seem to influence the odds ratio of CR-POPF (p = 0.076 and 0.074, respectively). CONCLUSION The present study emphasizes the superiority of PG over PJ regarding CR-POPF rates. Higher rates of postoperative hemorrhage were associated with PG. Yet, the clinically significant hemorrhage rate was comparable between the two groups.
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Affiliation(s)
- Mohamed AbdAlla Salman
- General Surgery Department, Kasralainy School of Medicine, Cairo University, Giza, Egypt
| | - Ahmed Elewa
- General Surgery Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | | | - Mohamed Tourkey
- General Surgery Department, Great Western Hospital, Swindon, UK
| | | | | | - Ahmed Salman
- Internal Medicine Department, Kasralainy School of Medicine, Cairo University, Giza, Egypt
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Wang TG, Tian L, Zhang XL, Zhang L, Zhao XL, Kong DS. Gradient inflammation in the pancreatic stump after pancreaticoduodenectomy: Two case reports and review of literature. World J Clin Cases 2024; 12:1649-1659. [PMID: 38576729 PMCID: PMC10989426 DOI: 10.12998/wjcc.v12.i9.1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/26/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) contributes significantly to morbidity and mortality after pancreaticoduodenectomy (PD). However, the underlying mechanisms remain unclear. This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD. CASE SUMMARY Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD. Gradient inflammation is present in the pancreatic stump. The apoptosis was lower than that in the normal pancreas. Moreover, neutrophil-dominated inflammatory cells are concentrated in the ductal system. Notably, neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts. Additionally, evidence indicates that gut microbes migrate from the digestive tract. Gradient inflammation occurs in pancreatic stumps after PD. CONCLUSION The mechanisms underlying POPF include high biochemical activity in the pancreas, mechanical injury, and digestive reflux. To prevent POPF and address pancreatic inflammation and reflux, breaking the link with anastomotic dehiscence is practical.
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Affiliation(s)
- Tie-Gong Wang
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Liang Tian
- Department of Pathology, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Xiao-Ling Zhang
- Department of Pathology, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Lei Zhang
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Xiu-Lei Zhao
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - De-Shuai Kong
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
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Bellotti R, Cardini B, Strolz CJ, Stättner S, Oberhuber R, Braunwarth E, Resch T, Scheidl S, Margreiter C, Schneeberger S, Öfner D, Maglione M. Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy. J Clin Med 2023; 12:3318. [PMID: 37176758 PMCID: PMC10179219 DOI: 10.3390/jcm12093318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques. METHODS This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used. RESULTS Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015). CONCLUSION Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.
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Affiliation(s)
- Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Carola J. Strolz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergut Hospital, 4840 Vöcklabruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
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9
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Sattari SA, Sattari AR, Makary MA, Hu C, He J. Laparoscopic Versus Open Pancreatoduodenectomy in Patients With Periampullary Tumors: A Systematic Review and Meta-analysis. Ann Surg 2023; 277:742-755. [PMID: 36519444 DOI: 10.1097/sla.0000000000005785] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of randomized controlled trials compared laparoscopic pancreatoduodenectomy (LPD) versus open pancreatoduodenectomy (OPD) in patients with periampullary tumors. BACKGROUND LPD has gained attention; however, its safety and efficacy versus OPD remain debatable. METHODS We searched PubMed and Embase. Primary outcomes were the length of hospital stay (LOS) (day), Clavien-Dindo grade ≥III complications, and 90-day mortality. Secondary outcomes were blood loss (milliliter), blood transfusion, duration of operation (minute), readmission, reoperation, comprehensive complication index score, bile leak, gastrojejunostomy or duodenojejunostomy leak, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, surgical site infection, intra-abdominal infection, number of harvested lymph nodes, and R0 resection. Pooled odds ratio (OR) or mean difference (MD) of data was calculated using the random-effect model. The grading of recommendations, assessment, development and evaluation approach was used for grading the level of evidence. RESULTS Four randomized controlled trials yielding 818 patients were included, of which 411 and 407 patients underwent LPD and OPD, respectively. The meta-analysis concluded that 2 approaches were similar, except in the LPD group, the LOS tended to be shorter [MD=-2.54 (-5.17, 0.09), P =0.06], LOS in ICU was shorter [MD=-1 (-1.8, -0.2), P =0.01], duration of operation was longer [MD=75.16 (23.29, 127.03), P =0.005], blood loss was lower [MD=-115.40 (-152.13, -78.68), P <0.00001], blood transfusion was lower [OR=0.66 (0.47, 0.92), P =0.01], and surgical site infection was lower [OR=0.35 (0.12, 0.96), P =0.04]. The overall certainty of the evidence was moderate. CONCLUSIONS Within the hands of highly skilled surgeons in high-volume centers, LPD is feasible and as safe and efficient as OPD.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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10
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Giuliani T, Perri G, Kang R, Marchegiani G. Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge. Cancers (Basel) 2023; 15:2499. [PMID: 37173964 PMCID: PMC10177600 DOI: 10.3390/cancers15092499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/23/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.
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Affiliation(s)
- Tommaso Giuliani
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (T.G.); (R.K.)
| | | | - Ravinder Kang
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (T.G.); (R.K.)
| | - Giovanni Marchegiani
- Verona University Hospital, 37134 Verona, Italy;
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, 35122 Padua, Italy
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11
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Clinically Relevant Pancreatic Fistula after Pancreaticoduodenectomy: How We Do It. BIOLOGY 2023; 12:biology12020178. [PMID: 36829457 PMCID: PMC9952935 DOI: 10.3390/biology12020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023]
Abstract
(1) Background: This study's goals were to investigate possible risk factors for clinically relevant postoperative pancreatic fistula (POPF) grade B/C according to the updated definitions of the International Study Group of Pancreatic Surgery and to analyze possible treatment strategies; (2) Methods: Between 2017 and 2021, 200 patients were analyzed regarding the development of POPF grade B/C with an emphasis on postoperative outcome and treatment strategies; (3) Results: POPF grade B/C was observed in 39 patients (19.5%). These patients were younger, mainly male, had fewer comorbidities and showed a higher body mass index. Also, they had lower CA-19 levels, a smaller tumor size and softer pancreatic parenchyma. They experienced a worse outcome without affecting the overall mortality rate (10% vs. 6%, p = 0.481), however, this lead to a prolonged postoperative stay (28 (32-36) d vs. 20 (15-28) d, p ≤ 0.001). The majority of patients with POPF grade B/C were able to receive conservative treatment, followed by drainage placement, endoscopic vacuum-assisted therapy (EVT) and surgery. Conservative treatment resulted in a shorter length of the postoperative stay (24 (22-28) d vs. 34 (26-43) d, p = 0.012); (4) Conclusions: Patients developing POPF grade B/C had a worse outcome; however, this did not affect the overall mortality rate. The majority of the patients were able to receive conservative treatment, resulting in a shorter length of their hospital stay.
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12
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Kazantsev GB, Spitzer AL, Peng PD, Ramirez RM, Chang CK, Tsai S, Aldakkak M, Huyser MR, Dominguez DA. Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy. HPB (Oxford) 2023; 25:124-135. [PMID: 36323594 DOI: 10.1016/j.hpb.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hypothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF. METHODS Review of prospective database of all PD's performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed "high risk" if soft gland and/or small duct were present. RESULTS PJ was performed in 199 (147 "low-risk" and 52 "high-risk") cases, and 110 patients (all "high-risk") had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in "low-risk" versus "high risk" scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively. CONCLUSION Selective use of PG after PD in "high-risk" scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.
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Affiliation(s)
- George B Kazantsev
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA.
| | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Rene M Ramirez
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed Aldakkak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michelle R Huyser
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA, USA
| | - Dana A Dominguez
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA, USA
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13
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Yang J, Luo P, Wang Z, Shen J. Simulation training of laparoscopic pancreaticojejunostomy and stepwise training program on a 3D-printed model. Int J Surg 2022; 107:106958. [PMID: 36283653 DOI: 10.1016/j.ijsu.2022.106958] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/29/2022] [Accepted: 10/11/2022] [Indexed: 10/31/2022]
Abstract
AIM Laparoscopic pancreaticojejunostomy is among the most difficult and high-risk operations. Surgeons with low or moderate seniority rarely are allowed to perform this surgery in clinics. Therefore, there is an urgent need to develop a reliable simulation training model focused on laparoscopic pancreaticojejunostomy and an effective stepwise training program. METHODS Surgeons with different working experiences or exposure to different training programs at Sir Run Run Shaw Hospital were divided into four groups. Each was required to perform laparoscopic pancreaticojejunostomy using a designed three-dimensional dry lab model. All surgeons' baseline characteristics and surgical performance, including operation time and score, were recorded and analysed. The authenticity of the model was evaluated by four senior surgeons. RESULTS The surgeon group with higher seniority had an older average age, longer working time, and had completed more laparoscopic cholecystectomy and laparoscopic common bile duct exploration procedures. Meanwhile, the surgeon group with higher seniority presented better operation performance, including shorter operation time and higher operation score in their initial simulation training. Resident surgeons who underwent stepwise training with the laparoscopic biliary-enteric anastomosis training program showed better initial performance than resident surgeons who underwent stepwise training with the laparoscopic basic suture training program. After repeated training, the surgeons showed improved surgical performance. CONCLUSION Our pancreaticojejunostomy model showed a good degree of discernibility, as surgeons with more experience performed better with the model for their initial simulation training in laparoscopic pancreaticojejunostomy. Stepwise training of the laparoscopic biliary-enteric anastomosis training program helped surgeons obtain a better initial performance, and repeated simulation training on this model improved the surgeon's operative performance.
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Affiliation(s)
- Jin Yang
- Department of General Surgery, Sir Run-Run Shaw Hospital, School of Medical College, Zhejiang University, Hangzhou, 310016, China Key Laboratory of Laparoscopic Technology of Zhejiang Province, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China Department of Hepatobiliary and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang Province, China
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14
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Fan ST. Binding pancreaticogastrostomy after pancreaticoduodenectomy and central pancreatectomy. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sheung Tat Fan
- Liver Surgery and Transplant Centre Hong Kong Sanatorium and Hospital Hong Kong China
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15
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He YG, Yang XM, Peng XH, Li J, Huang W, Jian GC, Wu J, Tang YC, Wang L, Huang XB. Association of a Modified Blumgart Anastomosis With the Incidence of Pancreatic Fistula and Operation Time After Laparoscopic Pancreatoduodenectomy: A Cohort Study. Front Surg 2022; 9:931109. [PMID: 35832498 PMCID: PMC9271827 DOI: 10.3389/fsurg.2022.931109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To explore the association between a modified Blumgart anastomosis technique and the operative time and surgical complications. METHODS This is a retrospective cohort study that analyzed the data of patients who underwent laparoscopic pancreaticoduodenectomy from January 2015 to March 2021. The primary outcome was to explore the association between the modified Blumgart anastomosis technique and operative time. RESULTS A total of 282 patients were enrolled. There were 177 cases of pancreatic duct-to-mucosa anastomosis in the traditional surgery group, and 105 cases of the modified three-step Blumgart anastomosis in the modified group. There were no statistically significant differences in the general and intraoperative characteristics found between the two groups (P > 0.05). The surgical method was an independent predictor of operative time. Overall complications postsurgery were less common in the modified group than in the traditional group. The incidence of postoperative pancreatic fistula was higher in the traditional group than in the modified group (45 cases (25.4%) and 11 cases (10.5%), respectively). Fourteen cases (7.9%) in the traditional group and four case (3.8%) in the modified group had postoperative pancreatic fistula of grades B + C. The two groups had statistically significant differences (P < 0.05). The results of the linear regression showed that the type of surgical method was associated with operation time (95% CI, -73.074 to -23.941, β: -0.438, P < 0.001). CONCLUSION This modified three-step Blumgart pancreaticojejunostomy was associated with the operation time.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Liang Wang
- Correspondence: Xiaobing Huang Liang Wang
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16
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Zheng M, Liu A, Li J, Liang X, Peng J, Chen D, Shi L, Fu Z, Ji M, Yang G, Yang T, Tang L, Shao C. Comparison of early postoperative outcomes between omega-like duct-to-mucosa pancreatojejunostomy and conventional duct-to-mucosa pancreatojejunostomy after pancreaticoduodenectomy. HPB (Oxford) 2022; 24:606-615. [PMID: 34872867 DOI: 10.1016/j.hpb.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic fistula is a life-threatening complication of pancreaticoduodenectomy. Omega-like duct-to-mucosa pancreatojejunostomy is a novel technique which helps reduce the risk of fistulation. This study aimed to compare early postoperative outcomes of omega-like and conventional pancreatojejunostomy. METHODS A retrospective single-centre cohort study comparing outcomes of adult patients who underwent open pancreatoduodenectomy with conventional (CDMP) or omega-like duct-to-mucosa pancreatojejunostomy (ODMP) between 1 January 2015 and 31 December 2019. The primary outcome measure was the pancreatic fistula rate. RESULTS 440 patients were included in this study of whom 233 underwent CDMP and 207 ODMP. The rate of clinically relevant pancreatic fistula (grade B/C) was significantly higher after CDMP than ODMP (18.5% vs. 10.6%, P = 0.021). 153 patients in CDMP group and 99 patients in ODMP group developed one or more complications (65.7% vs. 47.8%, P = 0.004). The average hospitalization expenses were numerically decreased in ODMP group, although this was not statistically significant (120,000 ± 42,000 [Chinese Yuan] vs. 100,000 ± 40,000 [Chinese Yuan] or 18,581 ± 6503 [United States Dollar] vs. 15,484 ± 6194 [United States Dollar], P = 0.402). CONCLUSION ODMP may reduce the incidence of pancreatic fistula and other early postoperative complications after pancreatoduodenectomy.
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Affiliation(s)
- Minghui Zheng
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Anan Liu
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Judong Li
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xing Liang
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Junfeng Peng
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Danlei Chen
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ligang Shi
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Zhiping Fu
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Meng Ji
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Guang Yang
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Tianbo Yang
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Liang Tang
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China.
| | - Chenghao Shao
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China.
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Vilhav C, Fagman JB, Holmberg E, Naredi P, Engström C. C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage. Langenbecks Arch Surg 2022; 407:1949-1959. [PMID: 35306601 PMCID: PMC9399186 DOI: 10.1007/s00423-022-02440-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
Background Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C. Methods Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C. Results High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started. Discussion High postoperative CRP levels are related to an increased risk of PPH C.
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Affiliation(s)
- C Vilhav
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J B Fagman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Holmberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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18
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OUP accepted manuscript. Br J Surg 2022; 109:812-821. [DOI: 10.1093/bjs/znac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/07/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022]
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Grego A, Friziero A, Serafini S, Belluzzi A, Moletta L, Saadeh LM, Sperti C. Does Pancreatic Fistula Affect Long-Term Survival after Resection for Pancreatic Cancer? A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:5803. [PMID: 34830957 PMCID: PMC8616191 DOI: 10.3390/cancers13225803] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/03/2021] [Accepted: 11/17/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The impact of postoperative pancreatic fistula (POPF) on survival after resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear. METHODS The MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting on survival in patients with and without POPF. A meta-analysis was performed to investigate the impact of POPF on disease-free survival (DFS) and overall survival (OS). RESULTS Sixteen retrospective cohort studies concerning a total of 5019 patients with an overall clinically relevant POPF (CR-POPF) rate of 12.63% (n = 634 patients) were considered. Five of eleven studies including DFS data reported higher recurrence rates in patients with POPF, and one study showed a higher recurrence rate in the peritoneal cavity. Six of sixteen studies reported worse OS rates in patients with POPF. Sufficient data for a meta-analysis were available in 11 studies for DFS, and in 16 studies for OS. The meta-analysis identified a shorter DFS in patients with CR-POPF (HR 1.59, p = 0.0025), and a worse OS in patients with POPF, CR-POPF (HR 1.15, p = 0.0043), grade-C POPF (HR 2.21, p = 0.0007), or CR-POPF after neoadjuvant therapy. CONCLUSIONS CR-POPF after resection for PDAC is significantly associated with worse overall and disease-free survival.
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Affiliation(s)
| | | | | | | | | | | | - Cosimo Sperti
- Department of Surgery, Oncology and Gastroenterology, 3rd Surgery Clinic, University of Padua, Via Giustiniani 2, 35128 Padua, Italy; (A.G.); (A.F.); (S.S.); (A.B.); (L.M.); (L.M.S.)
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Blanco-Fernández G, Jaén-Torrejimeno I, De-Armas-Conde N, Rojas-Holguín A, Naharro JS, Castillo-Tuñón JM, López-Guerra D. Prospective Study Correlating External Biliary Stenting and Pancreatic Fistula Following Pancreaticoduodenectomy. J Gastrointest Surg 2021; 25:2881-2888. [PMID: 33768426 DOI: 10.1007/s11605-021-04983-6] [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: 01/10/2021] [Accepted: 03/10/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most common complication of pancreaticoduodenectomy (PD). Sometimes POPF is associated with biliary fistula (BF) or "mixed" fistula. The purpose of this study is to assess whether the severity of the fistulae, when present, is decreased with an external biliary stent in place. METHODS In this single-center study, we assessed patients who underwent elective PD from January 2014 to December 2017. Patients were divided into two groups: standard PD (ST-PD) vs. PD with external biliary stent (PD-BS). Demographic, preoperative, intraoperative, and postoperative variables were analyzed, including complications according to the Clavien-Dindo classification, and those specific to pancreatic surgeries, and mortality rates within 90 days of operation. RESULTS A total of 128 patients were included (65 in ST-PD group and 63 in PD-BS group). Postoperative complications occurred in 61.7% of patients (32.8%, Clavien-Dindo ≥ III) and were more common among patients in the PD-BS group (44.4% vs. 23.1%; p = 0.03). POPF was also more common among patients in the PD-BS group (39.7% vs. 18.5%; p = 0.008). No statistically significant differences were found for any other complications. CONCLUSION Based on the results of our study, placement of a transanastomotic external biliary stent does not reduce the rate of pancreatic or biliary fistulae, or their severity; in fact, POPF is more likely when biliary exteriorization is present. TRIAL REGISTRATION NCT04654299.
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Affiliation(s)
- Gerardo Blanco-Fernández
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain
| | - Isabel Jaén-Torrejimeno
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain.
| | - Noelia De-Armas-Conde
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain
| | - Adela Rojas-Holguín
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain
| | - Jesús Santos Naharro
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain
| | - Juan Manuel Castillo-Tuñón
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain
| | - Diego López-Guerra
- Department of HBP and Liver Transplant Surgery, University Hospital Complex of Badajoz, University of Extremadura, Avda de Elvas, s/n, 06080, Badajoz, Spain
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Outcome of pancreatic anastomoses during pancreatoduodenectomy in two national audits. Surgery 2021; 170:1799-1806. [PMID: 34373107 DOI: 10.1016/j.surg.2021.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evidence on the optimal pancreatic anastomosis during pancreatoduodenectomy is inconclusive. Large multicenter and nationwide registries may provide additional insights. The study compared the practice and outcome of different pancreatic anastomoses during pancreatoduodenectomy, focusing on the rate of postoperative pancreatic fistula, in two large audits of pancreatic surgery. METHODS Posthoc analysis of patients after pancreatoduodenectomy in the Dutch Pancreatic Cancer Audit and the German DGAV StuDoQ|Pancreas registries (January 2014 to December 2017). Postoperative pancreatic fistula (International Study Group of Pancreatic Surgery B/C), postpancreatectomy hemorrhage (International Study Group of Pancreatic Surgery B/C) and Clavien-Dindo ≥3 complications rates were compared for the three most common anastomoses: duct-to-mucosa pancreatojejunostomy, non-duct-to-mucosa pancreatojejunostomy, and non-duct-to-mucosa pancreatogastrostomy. Multivariable adjustment for potential confounders was performed. RESULTS Overall, 6,149 patients were included. The most common anastomosis was duct-to-mucosa pancreatojejunostomy (duct-to-mucosa pancreatojejunostomy 59.8%, non-duct-to-mucosa pancreatojejunostomy 21.1%, non-duct-to-mucosa pancreatogastrostomy 12.4%). The overall postoperative pancreatic fistula rate was 14%: duct-to-mucosa pancreatojejunostomy 12.9%, non-duct-to-mucosa pancreatojejunostomy 14.4% (P = .162), non-duct-to-mucosa pancreatogastrostomy 18.3% (P < .001). The rate of postpancreatectomy hemorrhage was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 6.9%, non-duct-to-mucosa pancreatojejunostomy 10% (P < .001), non-duct-to-mucosa pancreatogastrostomy 17.9% (P < .001). The rate of Clavien-Dindo ≥3 complications was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 28%, non-duct-to-mucosa pancreatojejunostomy 32.7% (P = .002), non-duct-to-mucosa pancreatogastrostomy 43.1% (P < .001). In the multivariable analysis, the risk of postoperative pancreatic fistula did not differ significantly between the three anastomoses. The risk of hemorrhage (odds ratio 2.4, 95% confidence interval 1.6-3.5, P < .001) and Clavien-Dindo ≥3 (odds ratio 1.6, 95% confidence interval 1.2-2.1, P = .001) remained significantly higher only for non-duct-to-mucosa pancreatogastrostomy. CONCLUSION Data from two national audits showed no difference in the risk-adjusted postoperative pancreatic fistula rate among the three most used pancreatic anastomoses during pancreatoduodenectomy. Pancreatogastrostomy was inferior to pancreatojejunostomy regarding bleeding and overall major complications.
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22
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Tewari M, Swain JR, Mahendran R. Update on Management Periampullary/Pancreatic Head Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Brunner M, Krautz C, Maak M, Weber GF, Grützmann R. [Pylorus-Preserving Pancreaticoduodenectomy (PPPD) with Segmental Portal Vein Resection]. Zentralbl Chir 2021; 147:233-241. [PMID: 34318466 DOI: 10.1055/a-1528-7927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pylorus-preserving partial pancreatoduodenectomy is a complex visceral operation, especially when simultaneous resection and reconstruction of the portal venous axis is necessary. Pancreatic anastomosis plays a decisive role in this procedure, since postoperative pancreatic fistula (POPF) is a frequent complication, with serious consequences (morbidity and mortality) for the affected patient. Various techniques are available for anastomosing the residual pancreas: the duct-to-mucosa pancreaticojejunostomy, invaginating pancreatojejunostomy, Blumgart anastomosis and pancreatogastrostomy. INDICATION Adenocarcinoma of the pancreatic head with portal vein infiltration. PROCEDURE Pylorus-preserving pancreaticoduodenectomy (PPPD) with portal vein resection. CONCLUSION A standardised and structured approach to pylorus-preserving partial pancreatoduodenectomy helps the surgeon to perform this procedure safely. Performing a simultaneous portal vein resection increases the complexity of the procedure, but nonetheless, if infiltration of the portal venous axis is suspected, the indication for en-bloc resection should be given generously, as intraoperatively it is not possible to differentiate reliably between inflammatory adherence and tumour infiltration and portal vein/V.-mesenterica-superior-resection does not increase morbidity and mortality. The choice of the surgical technique for anastomosing the residual pancreas should be made by the surgeon on the basis of his expertise and, if necessary, adapted to the patient's situs, since the most important pancreatic anastomosis techniques appear to be equivalent according to the current evidence.
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Affiliation(s)
- Maximilian Brunner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
| | - Christian Krautz
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
| | - Matthias Maak
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
| | - Georg F Weber
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
| | - Robert Grützmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
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Bizzoca C, Fedele S, Lippolis AS, Aquilino F, Castellana M, Basile MR, Lucarelli G, Vincenti L. Modified Technique for Wirsung-Pancreatogastric Anastomosis after Pancreatoduodenectomy: A Single Center Experience and Systematic Review of the Literature. J Clin Med 2021; 10:3064. [PMID: 34300229 PMCID: PMC8303560 DOI: 10.3390/jcm10143064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/03/2021] [Accepted: 07/06/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The mortality rate following pancreaticoduodenectomy (PD) has been decreasing over the past few years; nonetheless, the morbidity rate remains elevated. The most common complications after PD are post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) syndrome. The issue as to which is the best reconstruction method for the treatment of the pancreatic remnant after PD is still a matter of debate. The aim of this study was to retrospectively analyze the morbidity rate in 100 consecutive PD reconstructed with Wirsung-Pancreato-Gastro-Anastomosis (WPGA), performed by a single surgeon applying a personal modification of the pancreatic reconstruction technique. METHODS During an 8-year period (May 2012 to March 2020), 100 consecutive patients underwent PD reconstructed with WPGA. The series included 57 males and 43 females (M/F 1.32), with a mean age of 68 (range 41-86) years. The 90-day morbidity and mortality were retrospectively analyzed. Additionally, a systematic review was conducted, comparing our technique with the existing literature on the topic. RESULTS We observed eight cases of clinically relevant POPF (8%), three cases of "primary" DGE (3%) and four patients suffering "secondary" DGE. The surgical morbidity and mortality rate were 26% and 6%, respectively. The median hospital stay was 13.6 days. The systematic review of the literature confirmed the originality of our modified technique for Wirsung-Pancreato-Gastro-Anastomosis. CONCLUSIONS Our modified double-layer WPGA is associated with a very low incidence of POPF and DGE. Also, the technique avoids the risk of acute hemorrhage of the pancreatic parenchyma.
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Affiliation(s)
- Cinzia Bizzoca
- Department of General Surgery “Ospedaliera”, Polyclinic Hospital of Bari, Piazza G. Cesare 11, 70124 Bari, Italy;
| | - Salvatore Fedele
- General Surgery Unit, National Institute of Gastroenterology Saverio de Bellis, Research Hospital, via Turi 27, Castellana Grotte, 70013 Bari, Italy; (S.F.); (F.A.)
| | - Anna Stella Lippolis
- Department of General Surgery, San Paolo Hospital, via Capo Scardicchio, 70123 Bari, Italy; (A.S.L.); (M.R.B.)
| | - Fabrizio Aquilino
- General Surgery Unit, National Institute of Gastroenterology Saverio de Bellis, Research Hospital, via Turi 27, Castellana Grotte, 70013 Bari, Italy; (S.F.); (F.A.)
| | - Marco Castellana
- Unit of Research Methodology and Data Sciences for Population Health, National Institute of Gastroenterology Saverio de Bellis, Research Hospital, via Turi 27, Castellana Grotte, 70013 Bari, Italy;
| | - Maria Raffaella Basile
- Department of General Surgery, San Paolo Hospital, via Capo Scardicchio, 70123 Bari, Italy; (A.S.L.); (M.R.B.)
| | - Giuseppe Lucarelli
- Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation-Urology, University of Bari, 70124 Bari, Italy;
| | - Leonardo Vincenti
- Department of General Surgery “Ospedaliera”, Polyclinic Hospital of Bari, Piazza G. Cesare 11, 70124 Bari, Italy;
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Wang XX, Yan YK, Dong BL, Li Y, Yang XJ. Pancreatic outflow tract reconstruction after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg Oncol 2021; 19:203. [PMID: 34229720 PMCID: PMC8262038 DOI: 10.1186/s12957-021-02314-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To evaluate the outcomes of pancreaticogastrostomy and pancreaticojejunostomy after pancreatoduodenectomy with the help of a meta-analysis. METHODS Randomized controlled trials comparing pancreaticogastrostomy and pancreaticojejunostomy were searched electronically using PubMed, The Cochrane Library, and EMBASE. Fixed and random-effects were used to measure pooled estimates. Research indicators included pancreatic fistula, delayed gastric emptying, postoperative hemorrhage, intraperitoneal fluid collection, wound infection, overall postoperative complications, reoperation, and mortality. RESULTS Overall, 10 randomized controlled trials were included in this meta-analysis, with a total of 1629 patients. The overall incidences of pancreatic fistula and intra-abdominal collections were lower in the pancreaticogastrostomy group than in the pancreaticojejunostomy group (OR=0.73, 95% CI 0.55~0.96, p=0.02; OR=0.59, 95% CI 0.37~0.96, p=0.02, respectively). The incidence of B/C grade pancreatic fistula in the pancreaticogastrostomy group was lower than that in the pancreaticojejunostomy group, but no significant difference was observed (OR=0.61, 95%CI 0.34~1.09, p=0.09). Postoperative hemorrhage was more frequent in the pancreaticogastrostomy group than in the pancreaticojejunostomy group (OR=1.52; 95% CI 1.08~2.14, p=0.02). No significant differences in terms of delayed gastric emptying, wound infection, reoperation, overall postoperative complications, mortality, exocrine function, and hospital readmission were observed between groups. CONCLUSION This meta-analysis suggests that pancreaticogastrostomy reduces the incidence of postoperative pancreatic fistula and intraperitoneal fluid collection but increases the risk of postoperative hemorrhage compared with pancreaticojejunostomy.
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Affiliation(s)
- Xin Xin Wang
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
- The 1st Clinical Medicine College, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu Province, China
| | - Yu Ke Yan
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
| | - Bao Long Dong
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
| | - Yuan Li
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
| | - Xiao Jun Yang
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China.
- Peoples Clinical Medicine College, Lanzhou University, Lanzhou, 730000, Gansu Province, China.
- Gansu key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China.
- Gansu Research Center of Prevention and Control Project for Digestive Oncology, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China.
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Li Y, Hua R. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis. Minerva Surg 2021; 77:65-71. [PMID: 34160171 DOI: 10.23736/s2724-5691.21.08802-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. EVIDENCE ACQUISITION A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula(ISGPF) definition of POPF. The main outcomes were POPF and clinically relevant POPF. RESULTS Three techniques of pancreatic anastomosis following PD were directly compared in 16 RCTs comprising 2365 patients. EVIDENCE SYNTHESIS Overall, 929 patients underwent duct-to-mucosa pancreaticojejunostomy(PJ DTM), 760 patients invagination pancreaticojejunostomy(PJ Inv), and 676 patients underwent pancreatogastrostomy(PG). The results of comparisons of POPF, clinically relevant POPF, biliary leakage, delayed gastric emptying(DGE), in hospital mortality, internal hemorrhage, reoperation in our network meta-analysis suggested there were no significant differences among the 3 procedures. CONCLUSIONS There are no significant differences among PJ DTM, PJ Inv and PG in the prevention of POPF, clinically relevant POPF, biliary leakage, DGE, internal hemorrhage and reoperation. However, further randomized controlled trials should be undertaken to ascertain these findings.
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Affiliation(s)
- Yujie Li
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Rong Hua
- Department of Pancreaticobiliary Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China -
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Bhoriwal SK, Kumar S, Deo S, Sharma J, Mishra A, Kumar N, Saikia J, Dhall K. Clinical outcomes and technical description of unstented end to side pancreaticogastrostomy by small posterior gastrotomy. Ann Hepatobiliary Pancreat Surg 2021; 25:251-258. [PMID: 34053928 PMCID: PMC8180407 DOI: 10.14701/ahbps.2021.25.2.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/09/2022] Open
Abstract
Backgrounds/Aims Morbidity following Whipple’s surgery largely depends upon the pancreatic stump anastomosis leak. Pancreaticogastrostomy is one of the techniques of pancreatic stump reconstruction and is described variously in the literature. Duct to mucosa pancreaticogastrostomy is described either by a large 3-4 cm posterior gastrotomy or by small gastrotomy of 2-3 mm with the use of internal stents along with. We describe clinical outcomes and technique of 2 layer end to side pancreatico-gastrostomy by a small posterior gastrotomy without the use of internal stents. Methods Hospital records of 35 patients where the technique of, small posterior gastrotomy end to side duct to mucosa pancreatico-gastrostomy without internal stents, was used for pancreatic stump reconstruction were studied retrospectively. The data were analyzed for demographic details, stage of the disease, and short term outcomes related to surgical procedure. Results The mean duration of surgery was 7.4 hours. Grade A, B, and C POPF were observed in 10 (28.5%), 3 (8.5%), and 1 (2.8%) of patients respectively. The mean time to remove pancreatic drain was 9 days, and the mean time to start oral feeds was 8.9 days. The mean hospital stay was 12.9 days (07-26). Thirty days mortality was 2.8%. Conclusions Unstented duct to mucosa end to side pancreatico-gastrostomy technique is comparable with other pancreatico-gastrostomy techniques in outcomes in terms of POPF, morbidity, mortality, and hospital stay. However, to establish the superiority or inferiority of this technique, a larger study is recommended.
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Affiliation(s)
- Sandeep Kumar Bhoriwal
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Sunil Kumar
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Svs Deo
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Jyoti Sharma
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Ashutosh Mishra
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Naveen Kumar
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Jyoutishman Saikia
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
| | - Kunal Dhall
- Department of Surgical Oncology, All India Institute of Medical Science, New Delhi, India
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Rate of Post-Operative Pancreatic Fistula after Robotic-Assisted Pancreaticoduodenectomy with Pancreato-Jejunostomy versus Pancreato-Gastrostomy: A Retrospective Case Matched Comparative Study. J Clin Med 2021; 10:jcm10102181. [PMID: 34070025 DOI: 10.3390/jcm10102181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/08/2021] [Accepted: 05/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. METHODS The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. RESULTS Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. CONCLUSIONS The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula.
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Casciani F, Bassi C, Vollmer CM. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021; 170:889-909. [PMID: 33892952 DOI: 10.1016/j.surg.2021.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula. METHODS A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon. RESULTS Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula. CONCLUSION A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, University of Verona, Italy. https://twitter.com/F_Casciani
| | - Claudio Bassi
- Department of Surgery, University of Verona, Italy. https://twitter.com/pennsurgery
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Kumar S, Chandra A, Madhavan SM, Kumar D, Chauhan S, Pandey A, Masood S. Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience. Indian J Surg Oncol 2021; 12:22-30. [PMID: 33814828 DOI: 10.1007/s13193-020-01195-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/19/2020] [Indexed: 01/04/2023] Open
Abstract
Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.
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Affiliation(s)
- Suneed Kumar
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George Medical University, Lucknow, Uttar Pradesh India
| | - Shibumon M Madhavan
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Dinesh Kumar
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Smita Chauhan
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Anshuman Pandey
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Shakeel Masood
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
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Ibrahim R, Abounozha S, Nawara H, Alawad A. In Whipple's procedure, which anastomotic technique has lower leak rate; Pancreaticogastostomy or Pancreatojejunostomy? Ann Med Surg (Lond) 2021; 61:158-160. [PMID: 33425350 PMCID: PMC7782191 DOI: 10.1016/j.amsu.2020.12.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 01/11/2023] Open
Abstract
A best evidence topic has been constructed using a described protocol. The three-part question addressed was: in patient with Whipple's procedure which anastomotic technique has lower leak rate pancreaticogastostomy (PG) or pancreatojejunostomy (PJ)? Using the reported search, 38 articles were found; out of this six studies were deemed to be suitable to answer the question. The outcomes assessed were incidence of anastomotic leaks (pancreatic fistula) in both techniques PG and PJ. In conclusion, the best evidence showed that PG anastomosis has lower incidence of pancreatic fistula in comparison to PJ anastomosis.
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Affiliation(s)
- Rashid Ibrahim
- University Hospitals Plymouth NHS Trust, Plymouth, UK
- Corresponding author.
| | - Sabry Abounozha
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | - Hossam Nawara
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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Maehira H, Iida H, Mori H, Yasukawa D, Maekawa T, Muramoto K, Takebayashi K, Kaida S, Miyake T, Tani M. Superior perianastomotic fluid collection in the early postoperative period affects pseudoaneurysm occurrence after pancreaticoduodenectomy. Langenbecks Arch Surg 2021; 406:1461-1468. [PMID: 33389107 DOI: 10.1007/s00423-020-02072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Pseudoaneurysm (PA) after pancreaticoduodenectomy (PD) is a harmful complication due to postoperative pancreatic fistula. However, the preventive method for PA is unclear. This study aimed to assess the risk factors for PA after PD and to evaluate the clinical features of patients with PA. METHODS Medical records of 54 patients who underwent PD and developed clinically relevant postoperative pancreatic fistula (POPF) were retrospectively reviewed. We evaluated postoperative computed tomography (CT) findings, including the perianastomotic fluid collection (PFC) location on postoperative day 4. Perioperative findings and postoperative CT findings were compared between patients with and without PA after PD. RESULTS The PA group included nine patients (17%). The median postoperative day of diagnosis of PA was 17 (range, 7-33). The PA locations were the gastroduodenal artery stump (n = 3), dorsal pancreatic artery (DPA) stump from the common hepatic artery (n = 4), DPA stump from the replaced right hepatic artery (n = 1), and inferior pancreaticoduodenal artery stump (n = 1). The prevalence of falciform ligament wrap to the hepatic artery was lower (33% vs. 78%, p = 0.014) and superior PFC prevalence was higher (100% vs. 58%, p = 0.019) in the PA group than in the non-PA group. Superior PFC reached the dorsal part of the caudate lobe of the liver in all patients with PA. Furthermore, all PAs occurred at the arteries that could not be wrapped by the falciform ligament. CONCLUSION Prevention of superior PFC and falciform ligament wrapping may reduce PA occurrence after PD with clinically relevant POPF.
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Affiliation(s)
- Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Daiki Yasukawa
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Keiji Muramoto
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Katsushi Takebayashi
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Setatsukinowa-cho, Otsu, Shiga, 520-2192, Japan
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Williamsson C, Stenvall K, Wennerblom J, Andersson R, Andersson B, Tingstedt B. Predictive Factors for Postoperative Pancreatic Fistula-A Swedish Nationwide Register-Based Study. World J Surg 2020; 44:4207-4213. [PMID: 32816084 PMCID: PMC7599162 DOI: 10.1007/s00268-020-05735-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND A serious complication after pancreatoduodenectomy (PD) is postoperative pancreatic fistula (POPF). The aim of this study was to analyse the incidence and predictive factors for POPF by using a large nationwide cohort. METHODS Data from the Swedish National Registry for Pancreatic and Periampullary Cancer for all patients undergoing a PD from 2010 until 30th June 2018 were collected. The material was analysed in two groups, no POPF and clinically relevant (grade B and C) POPF. RESULTS A total of 2503 patients underwent PD, of which 245 (10%) developed POPF. Patients with POPF had significantly more overall complications (Clavien Dindo ≥3a, 75% vs. 21%, p < 0.001) and longer hospital stay (median 23 [16-35] vs. 11 [8-15], p < 0.001) than patients without POPF. The risk of POPF was higher with increased BMI (OR 1.08, p < 0.001). Preoperative presence of diabetes (OR 0.52, p = 0.012) and preoperative biliary drainage (OR 0.34, p < 0.001) reduced the risk of POPF. Reconstruction with pancreaticojejunostomy caused a more than two folded increase in POPF compared with pancreaticogastrostomy (OR 2.41, p < 0.001). Weight gain ≥2 kg on postoperative day 1 was also a risk factor (OR 1.76, p < 0.001). CONCLUSION A high BMI, a pancreaticojejunostomy and postoperative weight gain were risk factors for developing POPF. Diabetes or preoperative biliary drainage was protective.
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Affiliation(s)
- C Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden.
| | - K Stenvall
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - J Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - R Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
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Kawaida H, Kono H, Amemiya H, Hosomura N, Watanabe M, Saito R, Nakata Y, Shoda K, Shimizu H, Furuya S, Akaike H, Kawaguchi Y, Sudo M, Matusda M, Itakura J, Fujii H, Ichikawa D. Anastomosis technique for pancreatojejunostomy and early removal of drainage tubes may reduce postoperative pancreatic fistula. World J Surg Oncol 2020; 18:295. [PMID: 33183313 PMCID: PMC7661166 DOI: 10.1186/s12957-020-02067-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background Postoperative pancreatic fistula (POPF) is one of the most serious complications after pancreaticoduodenectomy (PD). Various factors have been reported as POPF risks, but the most serious of these is soft pancreas. To reduce POPF occurrences, many changes to the PD process have been proposed. This study evaluates short-term results of anastomosis technique for PD. Methods In total, 123 patients with soft pancreases who had undergone PD at Yamanashi University between January 2012 and August 2020 were retrospectively analyzed. We divided these patients into two groups depending on the time PD was performed: a conventional group (n = 67) and a modified group (n = 56). Results The rate of clinically relevant POPF was significantly lower in the modified group than that in the conventional group (5.4% vs 22.4%, p value < 0.001), with there being only one case of POPF in the modified group. There were no cases of POPF-related hemorrhaging in the modified group. On the third day after the operation, the amylase levels in the drainage fluid for the modified group became less than half (1696 vs 650 U/L). Multivariate analysis showed that the modified method was the independent predictors to prevent clinical POPF (p value = 0.002). Conclusions Our novel anastomosis technique for pancreatojejunostomy reduced POPF in PD, especially in cases where the patient had a soft pancreas.
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Affiliation(s)
- Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan.
| | - Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Naohiro Hosomura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Mitsuaki Watanabe
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Ryo Saito
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Yuuki Nakata
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Katsutoshi Shoda
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hiroki Shimizu
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Shinji Furuya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hidenori Akaike
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Yoshihiko Kawaguchi
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Makoto Sudo
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Masanori Matusda
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Jun Itakura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hideki Fujii
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
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Yang JX, Ye SY, Dai D. Risk factors and preventive measures for postoperative pancreatic fistula after pancreaticoduodenectomy. Shijie Huaren Xiaohua Zazhi 2020; 28:914-919. [DOI: 10.11569/wcjd.v28.i18.914] [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] [Indexed: 02/06/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD), which can lead to slow recovery, deterioration, and even reoperation and death. At present, the mortality rate after PD has decreased, but the incidence of POPF is still high. Therefore, exploring the risk factors and prevention strategies for pancreatic fistula has become a hot research topic in pancreatic surgery. This paper summarizes the nature, risk factors, and preventive measures for POPF.
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Affiliation(s)
- Jun-Xing Yang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524000, Guangdong Province, China
| | - Si-Yan Ye
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524000, Guangdong Province, China
| | - Dong Dai
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524000, Guangdong Province, China
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36
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Eguchi H, Iwagami Y, Matsushita K, Tomimaru Y, Akita H, Noda T, Gotoh K, Kobayashi S, Nagano H, Mori M, Doki Y. Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy regarding incidence of delayed gastric emptying after pancreaticoduodenectomy. Langenbecks Arch Surg 2020; 405:921-928. [PMID: 32901299 DOI: 10.1007/s00423-020-01982-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/01/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Delayed gastric emptying (DGE) is an important postoperative complication after pancreaticoduodenectomy (PD), and its incidence may be associated with the utilized surgical procedures. Compared with pancreaticojejunostomy (PJ) after PD, it may be speculated that pancreaticogastrostomy (PG) is a risk factor for DGE, because it needs an anastomosis of the remnant pancreas to the back wall of the stomach. This study aimed to compare PG and PJ with regard to the incidence of DGE after PD. METHODS We performed a prospective open-label randomized clinical trial (RCT) including patients undergoing elective pancreaticoduodenectomy, who were randomly assigned PG or PJ the day before surgery. The primary endpoint was incidence of DGE. RESULTS The study included 60 patients (30 PG, 30 PJ), of whom seven were deemed unresectable, one was enucleated, and one was switched from PJ to PG during surgery according to the surgeon's decision. Thus, modified intention-to-treat analyses were performed in 27 PG patients and 26 PJ patients. DGE occurred in three patients in the PG group and six patients in the PJ group, which did not constitute a significant between-group difference (P = 0.42). In the PG group, two cases were ISGPS grade A DGE and one was grade C. In the PJ group, one case was grade A, two grade B, and three grade C. The two groups also did not significantly differ in the incidence of other morbidities or postoperative hospital stay. CONCLUSIONS Post-PD DGE incidences were similar after PG and PJ.
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Affiliation(s)
- Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan. .,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan.
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Katsunori Matsushita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
| | - Hiroaki Nagano
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan.,Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Masaki Mori
- Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan.,Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Clinical Study Group of Osaka University, Hepato-Biliary-Pancreatic Group, Osaka, Japan
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Klotz R, Larmann J, Klose C, Bruckner T, Benner L, Doerr-Harim C, Tenckhoff S, Lock JF, Brede EM, Salvia R, Polati E, Köninger J, Schiff JH, Wittel UA, Hötzel A, Keck T, Nau C, Amati AL, Koch C, Eberl T, Zink M, Tomazic A, Novak-Jankovic V, Hofer S, Diener MK, Weigand MA, Büchler MW, Knebel P. Gastrointestinal Complications After Pancreatoduodenectomy With Epidural vs Patient-Controlled Intravenous Analgesia: A Randomized Clinical Trial. JAMA Surg 2020; 155:e200794. [PMID: 32459322 PMCID: PMC7254441 DOI: 10.1001/jamasurg.2020.0794] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/01/2020] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. Evidence from a post hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications. OBJECTIVE To determine whether postoperative PCIA decreases the occurrence of gastrointestinal complications after pancreatic surgery compared with EDA. DESIGN, SETTING, AND PARTICIPANTS In this adaptive, pragmatic, international, multicenter, superiority randomized clinical trial conducted from June 30, 2015, to October 1, 2017, 371 patients at 9 European pancreatic surgery centers who were scheduled for elective pancreatoduodenectomy were randomized to receive PCIA (n = 185) or EDA (n = 186); 248 patients (124 in each group) were analyzed. Data were analyzed from February 22 to April 25, 2019, using modified intention to treat and per protocol. INTERVENTIONS Patients in the PCIA group received general anesthesia and postoperative PCIA with intravenous opioids with the help of a patient-controlled analgesia device. In the EDA group, patients received general anesthesia and intraoperative and postoperative EDA. MAIN OUTCOMES AND MEASURES The primary end point was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. Secondary end points included 30-day mortality, other complications, postoperative pain levels, intraoperative or postoperative use of vasopressor therapy, and fluid substitution. RESULTS Among the 248 patients analyzed (147 men; mean [SD] age, 64.9 [10.7] years), the primary composite end point did not differ between the PCIA group (61 [49.2%]) and EDA group (57 [46.0%]) (odds ratio, 1.17; 95% CI, 0.71-1.95 P = .54). Neither individual components of the primary end point nor 30-day mortality, postoperative pain levels, or intraoperative and postoperative substitution of fluids differed significantly between groups. Patients receiving EDA gained more weight by postoperative day 4 than patients receiving PCIA (mean [SD], 4.6 [3.8] vs 3.4 [3.6] kg; P = .03) and received more vasopressors (46 [37.1%] vs 31 [25.0%]; P = .04). Failure of EDA occurred in 23 patients (18.5%). CONCLUSIONS AND RELEVANCE This study found that the choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications because the 2 procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings. TRIAL REGISTRATION German Clinical Trials Register: DRKS00007784.
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Larmann
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Laura Benner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Colette Doerr-Harim
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Solveig Tenckhoff
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Johan F. Lock
- Department of General, Visceral, Transplant, Vascular and Paediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Elmar-Marc Brede
- Department of Anaesthesiology and Critical Care, University Hospital of Würzburg, Würzburg, Germany
| | - Roberto Salvia
- Surgical and Oncological Department, Pancreas Institute, University Hospital Trust, Verona, Italy
| | - Enrico Polati
- Department of Anaesthesiology and Intensive Care, Verona University Hospital, Verona, Italy
| | - Jörg Köninger
- Department of General, Visceral, Thorax and Transplantation Surgery, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany
| | - Jan-Henrik Schiff
- Department of Anaesthesiology and Operative Intensive Care, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany
- Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Marburg, Germany
| | - Uwe A. Wittel
- Department of General and Visceral Surgery, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Alexander Hötzel
- Department of Anaesthesiology and Critical Care, Medical Centre, University of Freiburg, Freiburg, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Carla Nau
- Department of Anaesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Anca-Laura Amati
- Department of Visceral, Thoracic, Transplant and Paediatric Surgery, Justus Liebig University of Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Thomas Eberl
- Department of Surgery, General Public Hospital of the Brothers of St John of God, St Veit/Glan, Austria
| | - Michael Zink
- Department of Anaesthesiology and Intensive Care Medicine, General Public Hospital of the Brothers of St John of God, St Veit/Glan, Austria
| | - Ales Tomazic
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vesna Novak-Jankovic
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Stefan Hofer
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K. Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A. Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- The Study Centre of the German Surgical Society, Heidelberg University Hospital, Heidelberg, Germany
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Gavrila D, Lacatus M, Beger HG, Tudor S, Vasilescu C. Limited Parenchyma-Sparing Pancreatic Head Resection for Benign Neuroendocrine Tumors and Cystic Neoplasms—the Use of Duodenum-Preserving Head Resection. Indian J Surg 2020. [DOI: 10.1007/s12262-019-01971-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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39
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Andrianello S, Marchegiani G, Malleo G, Masini G, Balduzzi A, Paiella S, Esposito A, Landoni L, Casetti L, Tuveri M, Salvia R, Bassi C. Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis: A Single-Center, Phase 3, Randomized Clinical Trial. JAMA Surg 2020; 155:313-321. [PMID: 32101272 PMCID: PMC7160692 DOI: 10.1001/jamasurg.2019.6035] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022]
Abstract
IMPORTANCE The operative scenarios with the highest postoperative pancreatic fistula (POPF) risk represent situations in which fistula prevention and mitigation strategies have the strongest potential to affect surgical outcomes after pancreaticoduodenectomy. Evidence from studies providing risk stratification is lacking. OBJECTIVE To investigate whether pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG), both with externalized transanastomotic stent, is the best reconstruction method for patients at high risk of POPF after pancreaticoduodenectomy. DESIGN, SETTING, AND PARTICIPANTS A single-center, phase 3, randomized clinical trial was conducted at the Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy, from July 12, 2017, through March 15, 2019, among adults undergoing elective pancreaticoduodenectomy and considered at high risk for pancreatic fistula after intraoperative assessment of the fistula risk score, some of whom were randomized to undergo PG or PJ. All analyses were performed on an intention-to-treat basis. INTERVENTIONS Intervention consisted of PJ or PG, both with externalized transanastomotic stent and octreotide omission. MAIN OUTCOMES AND MEASURES The primary end point was POPF. The secondary end points were Clavien-Dindo grade 3 or higher morbidity, postpancreatectomy hemorrhage, delayed gastric emptying, and average complication burden. RESULTS A total of 604 patients were screened for eligibility; 82 were at high risk for POPF (fistula risk score, 7-10), and 72 were randomized undergo PG (n = 36; 20 men and 16 women; median age, 65 years [interquartile range, 23-82]) or PJ (n = 36; 26 men and 10 women; median age, 63 years [interquartile range, 35-79]). There was no significant difference in the incidence of POPF between patients who underwent PG and patients who underwent PJ (18 [50.0%] vs 14 [38.9%]; P = .48), but for patients who developed a POPF, the mean (SD) average complication burden was lower for those who underwent PJ than for those who underwent PG (0.25 [0.13] vs 0.39 [0.17]; P = .04). The rates of postpancreatectomy hemorrhage (14 [38.9%] in the PG group vs 9 [25.0%] in the PJ group; P = .31) and delayed gastric emptying (16 [44.4%] in the PG group vs 18 [50.0%] in the PJ group; P = .81) were similar, but patients who underwent PG presented with a significantly higher incidence of Clavien-Dindo grade 3 or higher morbidity than those who underwent PJ (17 [47.2%] vs 8 [22.2%]; P = .047). CONCLUSIONS AND RELEVANCE Among patients at the highest risk for POPF, those who underwent PG or PJ experienced similar rates of POPF. However, PG was associated with an increased incidence of Clavien-Dindo grade 3 or higher morbidity and with an increased average complication burden for the patients who developed a POPF. For patients at high risk for pancreatic fistula, PJ with the use of externalized stent and octreotide omission should be considered the most appropriate technical strategy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03212196.
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Affiliation(s)
- Stefano Andrianello
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Gaia Masini
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alberto Balduzzi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
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40
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Ratnayake CBB, Wells CI, Kamarajah SK, Loveday B, Sen G, French JJ, White S, Pandanaboyana S. Critical appraisal of the techniques of pancreatic anastomosis following pancreaticoduodenectomy: A network meta-analysis. Int J Surg 2020; 73:72-77. [PMID: 31843679 DOI: 10.1016/j.ijsu.2019.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/22/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. METHODS A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula (ISGPF) definition of POPF. The primary outcome was clinically relevant POPF. RESULTS Five techniques of pancreatic anastomosis following PD were directly compared in 15 RCTs comprising 2428 patients. Panreatojejunostomy (PJ) end-to-side invagination vs. PJ end-to-side duct-to-mucosa was the most frequent comparison (n = 7). Overall, 971 patients underwent PJ end-to-side duct-to-mucosa, 791 patients PJ end-to-side invagination, 505 patients pancreatogastrostomy (PG) end-to-side invagination, 98 patients PG end-to-side duct-to-mucosa, and 63 patients PJ end-to-side single layer. PG duct-to-mucosa was associated with the lowest rates of clinically relevant POPF, delayed gastric emptying, intra-abdominal abscess, all postoperative morbidity and postoperative mortality, the shortest operative time and postoperative hospital stay and the lowest volume of intra-operative blood loss. CONCLUSION Duct-to-mucosa pancreaticogastrostomy was associated with the lowest rates of clinically relevant POPF and had the best outcome profile among all techniques of pancreatico-anastomosis following PD.
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Affiliation(s)
- Chathura B B Ratnayake
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Benjamin Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Surgery, The Royal Melbourne Hospital, Melbourne, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Gourab Sen
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Steve White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK.
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41
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Modified Blumgart Mattress Suture Versus Conventional Interrupted Suture in Pancreaticojejunostomy During Pancreaticoduodenectomy: Randomized Controlled Trial. Ann Surg 2019; 269:243-251. [PMID: 29697455 PMCID: PMC6325750 DOI: 10.1097/sla.0000000000002802] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: This study used a randomized controlled trial (RCT) to evaluate whether mattress suture of pancreatic parenchyma and the seromuscular layer of jejunum (modified Blumgart method) during pancreaticojejunostomy (PJ) decreases the incidence of clinically relevant postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). Background: Several studies reported that mattress suture of Blumgart anastomosis in PJ could reduce POPF rate. This, however, is the first RCT. Methods: Between June, 2013 and May, 2017, 224 patients scheduled for PD were enrolled in this study in Wakayama Medical University Hospital. Enrolled patients were randomized to either interrupted suture or modified Blumgart mattress suture. The primary endpoint was the incidence of grade B/C POPF based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01898780). Results: Patients were randomized to either interrupted suture (103 patients) or modified Blumgart mattress suture (107 patients) and were analyzed by intention-to-treat. Grade B/C POPF occurred in 7 patients (6.8%) in the interrupted suture group and 11 (10.3%) in the mattress suture group (P = 0.367). Mortality within 90 days was 0 in both groups. There were no significant differences in all postoperative complications between the interrupted suture group and the modified Blumgart mattress suture group. Conclusions: Mattress suture of pancreatic parenchyma and the jejunal seromuscular layer during PJ (modified Blumgart technique) did not reduce clinically relevant POPF compared with interrupted suture.
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Krishna A, Bansal VK, Kumar S, Garg P, Kapoor BML, Misra MC. Pancreaticogastrostomy After Whipple’s Surgery Avoids Pancreatic Fistula—a Large Case Series Analysis. Indian J Surg 2019. [DOI: 10.1007/s12262-019-01991-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Factibilidad y morbimortalidad en doscientos casos consecutivos de pancreaticogastrostomía después de duodenopancreatectomía. Cir Esp 2019; 97:501-509. [DOI: 10.1016/j.ciresp.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/30/2019] [Accepted: 04/06/2019] [Indexed: 12/19/2022]
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Liu Q, Zhao Z, Gao Y, Zhao G, Tan X, Wang C, Liu R. Novel single-layer continuous suture of pancreaticojejunostomy for robotic pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 27:56-63. [PMID: 31562793 DOI: 10.1002/jhbp.682] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The best technique for pancreatic anastomosis after pancreaticoduodenectomy (PD) remains controversial, and the procedure for robotic PD (RPD) has not been previously reported. This study aimed to evaluate the safety and feasibility of a novel technique of pancreaticojejunostomy (PJ) for RPD. METHODS The demographics and perioperative outcomes of a consecutive series of RPD patients who underwent single-layer continuous suture (SCS) for PJ between September 2018 and November 2018 were analyzed. RESULTS Thirty patients were included in the study. Twenty patients had a soft pancreas, and 15 patients had a small main pancreatic duct (MPD) (<3 mm). The mean operative time was 234.1 min, the mean duration of PJ was 14.9 min, and the median estimated blood loss was 100.0 ml. No patients required conversion to laparotomy. Postoperative pancreatic fistula (POPF) included seven cases of Grade A and two cases of Grade B. No case of Grade C POPF occurred. The mean postoperative hospital stay was 12.3 days. No 90-day readmission or mortality was observed. Neither pancreatic texture nor MPD size affected the perioperative outcomes. CONCLUSIONS Single-layer continuous suture is easy to perform and is associated with favorable clinical outcomes, regardless of the pancreatic duct size and texture.
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Affiliation(s)
- Qu Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhiming Zhao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yuanxing Gao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Guodong Zhao
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xianglong Tan
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Chihyuan Wang
- Department of General Surgery, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan, China
| | - Rong Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, 28 Fuxing Road, Beijing, 100853, China
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Serra F, Barbato G, Tazzioli G, Gelmini R. Pancreaticogastrostomy as reconstruction choice in pancreatic trauma surgery: Case report and review of the literature. Int J Surg Case Rep 2019; 65:102-106. [PMID: 31704658 PMCID: PMC6920313 DOI: 10.1016/j.ijscr.2019.10.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Due to its retroperitoneal location and its proximity to major vascular structures and other organs, isolated pancreatic injuries are rare. The optimal management for pancreatic injuries of grades III and IV, where a main ductal transection is present, remains controversial. Isolated complete traumatic transection of the pancreatic neck is uncommon, but this condition is associated with some peculiar technical aspects that allow more conservative treatments. PRESENTATION OF THE CASE A closed abdominal blunt trauma in a young patient underwent emergency surgery for suspect hemoperitoneum. Intraoperatively evidence of complete traumatic transection of the pancreatic neck treated with pancreas tissue debridement, suture of the cephalic stump and pancreaticogastrostomy reconstruction. DISCUSSION Preservation of pancreatic volume and avoidance of adjacent organ resection is associated with lesser mortality and morbidity rate. The advantages of conservative treatments are related to reductions in the postoperative exocrine and endocrine insufficiencies. CONCLUSION In selected cases of complete neck transection with preserved pancreatic parenchyma in a stable patient, parenchymal-sparing interventions should be considered. Pancreaticogastrostomy offers an easier to learn and faster technique also suited for less experienced surgeons.
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Affiliation(s)
- Francesco Serra
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
| | - Giuseppe Barbato
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
| | - Giovanni Tazzioli
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
| | - Roberta Gelmini
- Department of Surgery, University of Modena and Reggio Emilia - Policlinico of Modena, Via del Pozzo, 71, 41100 Modena, Italy.
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Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial. Ann Surg 2019; 268:731-739. [PMID: 30138162 DOI: 10.1097/sla.0000000000002893] [Citation(s) in RCA: 261] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare perioperative outcomes of pancreatoduodenectomy (PD) performed through the laparoscopic route or by open surgery. SUMMARY BACKGROUND DATA Laparoscopic PD is being progressively performed in selected patients. METHODS An open-label single-center RCT was conducted between February 2013 and September 2017. The primary endpoint was the length of hospital stay (LOS). Secondary endpoints were operative time, transfusion requirements, specific pancreatic complications (pancreatic or biliary fistula, pancreatic hemorrhage, and delayed gastric emptying), Clavien-Dindo grade ≥ 3 complications, comprehensive complication index (CCI) score, poor quality outcome (PQO), and the quality of pathologic resection. Analyses were performed on an intention to treat basis. RESULTS Of 86 patients assessed for PD, 66 were randomized (34 laparoscopic approach, 32 open surgery). Conversion to an open procedure was needed in 8 (23.5%) patients. Laparoscopic versus open PD was associated with a significantly shorter LOS (median 13.5 vs. 17 d; P = 0.024) and longer median operative time (486 vs. 365 min; P = 0.0001). The laparoscopic approach was associated with significantly better outcomes regarding Clavien-Dindo grade ≥ 3 complications (5 vs. 11 patients; P = 0.04), CCI score (20.6 vs. 29.6; P = 0.038), and PQO (10 vs. 14 patients; P = 0.041). No significant differences in transfusion requirements, pancreas-specific complications, the number of lymph nodes retrieved, and resection margins between the two approaches were found. CONCLUSIONS Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological standards of a curative-intent surgical resection. TRIAL REGISTRY ISRCTN93168938.
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Xiang Y, Wu J, Lin C, Yang Y, Zhang D, Xie Y, Yao X, Zhang X. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol 2019; 13:797-806. [PMID: 31282769 DOI: 10.1080/17474124.2019.1640601] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Postoperative pancreatic fistula is the most troublesome complication after pancreaticoduodenectomy, and is an on-going area of concern for pancreatic surgeons. The specific pancreatic reconstruction technique is an important factor influencing the development of postoperative pancreatic fistula after pancreaticoduodenectomy. Areas covered: In this paper, we briefly introduced the definition and relevant influencing factors of postoperative pancreatic fistula. We performed a search of all meta-analyses published in the last 5 years and all published randomized controlled trials comparing different pancreatic anastomotic techniques, and we evaluated the advantages and disadvantages of different techniques. Expert opinion: No individual anastomotic method can completely avoid postoperative pancreatic fistula. Selecting specific techniques tailored to the patient's situation intraoperatively may be key to reducing the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Yien Xiang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Jiacheng Wu
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Chao Lin
- b Department of Hepatobiliary and Pancreatic Surgery, Jilin University Third Affiliated Hospital , Changchun , Jilin , CN
| | - Yongsheng Yang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Dan Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Yingjun Xie
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xiaoxiao Yao
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xuewen Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
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Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, Ichikawa D. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol 2019; 25:3722-3737. [PMID: 31391768 PMCID: PMC6676555 DOI: 10.3748/wjg.v25.i28.3722] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.
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Affiliation(s)
- Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Naohiro Hosomura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Jun Itakura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hideki Fujii
- Department of Surgery, Kofu Manicipal Hospital, Yamanashi 400-0832, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
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Pancreaticogastrostomy after pancreaticoduodenectomy without suturing the pancreas. Surg Today 2019; 50:200-204. [PMID: 31346811 DOI: 10.1007/s00595-019-01854-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
The aim of the present paper was to describe a new and easy technique for performing pancreaticogastrostomy (PG) through simple pancreatic invagination by a single binding suture without suturing the pancreatic parenchyma. The present study included all consecutive patients who underwent elective pancreaticoduodenectomy from 2007 to 2015. The intraoperative and postoperative outcomes after PG (PG group) were compared with those of patients who underwent pancreaticojejunostomy (PJ) (PJ group). Out of 270 patients, 88 PG and 182 PJ patients were assessed. The rate of clinically significant PF was similar between the PG and PJ groups (10.2% vs. 13.2%, respectively; p = 0.487), despite the risk of pancreatic fistula being higher in the PG group. There were no significant differences in the intraoperative and postoperative outcomes or mortality between the groups. This easy invagination technique for PG is simple, safe and reproducible with a low risk of postoperative pancreatic fistula.
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Jin Y, Feng YY, Qi XG, Hao G, Yu YQ, Li JT, Peng SY. Pancreatogastrostomy vs pancreatojejunostomy after pancreaticoduodenectomy: An updated meta-analysis of RCTs and our experience. World J Gastrointest Surg 2019; 11:322-332. [PMID: 31602291 PMCID: PMC6783689 DOI: 10.4240/wjgs.v11.i7.322] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/11/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is one of the most important operations in hepatobiliary and pancreatic surgery. AIM To evaluate the advantages and disadvantages of pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG). METHODS This meta-analysis was performed using Review Manager 5.3. All clinical randomized controlled trials, in which patients underwent PD with pancreatico-digestive tract reconstruction via PJ or PG, were included. RESULTS The search of PubMed, Wanfang Data, EMBASE, and the Cochrane Library provided 125 citations. After further analysis, 11 trials were included from nine counties. In all, 909 patients underwent PG and 856 underwent PJ. Meta-analysis showed that pancreatic fistula (PF) was a significantly lower morbidity in the PG group than in the PJ group (odds ratio [OR] = 0.67, 95% confidence interval [CI]: 0.53-0.86, P = 0.002); however, grades B and C PF was not significantly different between the two groups (OR = 0.61, 95%CI: 0.34-1.09, P = 0.09). Postoperative hemorrhage showed a significantly lower morbidity in the PJ group than in the PG group (OR = 1.47, 95%CI: 1.05-2.06, P = 0.03). Delayed gastric emptying was not significantly different between the two groups (OR = 1.09, 95%CI: 0.83-1.41, P = 0.54). CONCLUSION There is no difference in the incidence of grades B and C PF between the two groups. However, postoperative bleeding is significantly higher in PG than in PJ. Binding PJ or binding PG is a safe and secure technique according to our decades of experience.
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Affiliation(s)
- Yun Jin
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Yang-Yang Feng
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Xiao-Gang Qi
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Geng Hao
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Yuan-Quan Yu
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Jiang-Tao Li
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Shu-You Peng
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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