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Chen J, Song C, Guo X. Effects of seamless care in the perioperative management of laparoscopic pancreatoduodenectomy on patients' quality of life and postoperative complications. Sci Rep 2025; 15:8726. [PMID: 40082622 PMCID: PMC11906768 DOI: 10.1038/s41598-025-92871-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2024] [Accepted: 03/03/2025] [Indexed: 03/16/2025] Open
Abstract
This study investigates the efficacy of the seamless care model in operative management for patients who have undergone laparoscopic Pancreatoduodenectomy, evaluating its potential effects on postoperative quality of life (QOL) and complications. This study encompassed patients who underwent LPD at our institution between February 2022 and May 2023. Patients were randomly allocated to either the standard care group(control group) or the seamless care group(intervention group) using a random number table method. QOL was assessed both preoperatively and postoperatively. The incidence of adverse events before to discharge was evaluated. No significant changes in preoperative QOL measures were seen between the two groups (P > 0.05). Postoperatively, the intervention group exhibited markedly superior physiological function scores and overall quality of life (P < 0.05), as well as a considerably reduced frequency of adverse events (P < 0.05). The intervention group exhibited significantly shorter times to first postoperative flatus and shortened hospital stays relative to the control group (P < 0.05), times to ambulation demonstrated no significant difference (P > 0.05). Seamless care significantly enhances quality of life and reduces adverse events following LPD, warranting its broader clinical implementation.
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Affiliation(s)
- Jingtao Chen
- Nursing Department, First Hospital of Jilin University, Changchun, 130000, China.
| | - Chengcheng Song
- Nursing Department, First Hospital of Jilin University, Changchun, 130000, China
| | - Xun Guo
- Nursing Department, First Hospital of Jilin University, Changchun, 130000, China
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Ma JM, Wang PF, Yang LQ, Wang JK, Song JP, Li YM, Wen Y, Tang BJ, Wang XD. Machine learning model-based prediction of postpancreatectomy acute pancreatitis following pancreaticoduodenectomy: A retrospective cohort study. World J Gastroenterol 2025; 31:102071. [DOI: 10.3748/wjg.v31.i8.102071] [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: 10/07/2024] [Revised: 11/07/2024] [Accepted: 01/03/2025] [Indexed: 01/23/2025] Open
Abstract
BACKGROUND The International Study Group of Pancreatic Surgery has established the definition and grading system for postpancreatectomy acute pancreatitis (PPAP). There are no established machine learning models for predicting PPAP following pancreaticoduodenectomy (PD).
AIM To explore the predictive model of PPAP, and test its predictive efficacy to guide the clinical work.
METHODS Clinical data from consecutive patients who underwent PD between 2016 and 2024 were retrospectively collected. An analysis of PPAP risk factors was performed, various machine learning algorithms [logistic regression, random forest, gradient boosting decision tree, extreme gradient boosting, light gradient boosting machine, and category boosting (CatBoost)] were utilized to develop predictive models. Recursive feature elimination was employed to select several variables to achieve the optimal machine algorithm.
RESULTS The study included 381 patients, of whom 88 (23.09%) developed PPAP. PPAP patients exhibited a significantly higher incidence of postoperative pancreatic fistula (55.68% vs 14.68%, P < 0.001), grade C postoperative pancreatic fistula (9.09% vs 1.37%, P = 0.001). The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve of 0.859 [95% confidence interval (CI): 0.814-0.905] in the training cohort and 0.822 (95%CI: 0.717-0.927) in the testing cohort. According to shapley additive explanations analysis, pancreatic texture, main pancreatic duct diameter, body mass index, estimated blood loss, and surgery time were the most important variables based on recursive feature elimination. The CatBoost algorithm based on selected variables demonstrated superior performance, with an area under the receiver operating characteristic curve of 0.837 (95%CI: 0.788-0.886) in the training cohort and 0.812 (95%CI: 0.697-0.927) in the testing cohort.
CONCLUSION We developed the first machine learning-based predictive model for PPAP following PD. This predictive model can assist surgeons in anticipating and managing this complication proactively.
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Affiliation(s)
- Ji-Ming Ma
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Peng-Fei Wang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Liu-Qing Yang
- Department of Information Administration, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Jun-Kai Wang
- Department of Radiology, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Jian-Ping Song
- Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong Province, China
| | - Yu-Mei Li
- Department of Otorhinolaryngology, Xiangyang No. 1 People’s Hospital, Xiangyang 441000, Hubei Province, China
| | - Yan Wen
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Bing-Jun Tang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
| | - Xue-Dong Wang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Beijing 102218, China
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Bruna CL, Emmen AMLH, Wei K, Sutcliffe RP, Shen B, Fusai GK, Shyr YM, Khatkov I, White S, Jones LR, Manzoni A, Kerem M, Groot Koerkamp B, Ferrari C, Saint-Marc O, Molenaar IQ, Bnà C, Dokmak S, Boggi U, Liu R, Jang JY, Besselink MG, Abu Hilal M. Effects of Pancreatic Fistula After Minimally Invasive and Open Pancreatoduodenectomy. JAMA Surg 2025; 160:190-198. [PMID: 39630441 PMCID: PMC11618579 DOI: 10.1001/jamasurg.2024.5412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 09/28/2024] [Indexed: 12/08/2024]
Abstract
Importance Postoperative pancreatic fistulas (POPF) are the biggest contributor to surgical morbidity and mortality after pancreatoduodenectomy. The impact of POPF could be influenced by the surgical approach. Objective To assess the clinical impact of POPF in patients undergoing minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD). Design, Setting, and Participants This cohort study was conducted from 2007 to 2020 in 36 referral centers in Europe, South America, and Asia. Participants were patients with POPF (grade B/C as defined by the International Study Group of Pancreatic Surgery [ISGPS]) after MIPD and OPD (MIPD-POPF, OPD-POPF). Propensity score matching was performed in a 1:1 ratio based on the variables age (continuous), sex, body mass index (continuous), American Society of Anesthesiologists score (dichotomous), vascular involvement, neoadjuvant therapy, tumor size, malignancy, and POPF grade C. Data analysis was performed from July to October 2023. Exposure MIPD and OPD. Main Outcomes and Measures The primary outcome was the presence of a second clinically relevant (ISGPS grade B/C) complication (postpancreatic hemorrhage [PPH], delayed gastric emptying [DGE], bile leak, and chyle leak) besides POPF. Results Overall, 1130 patients with POPF were included (558 MIPD and 572 OPD), of whom 336 patients after MIPD were matched to 336 patients after OPD. The median (IQR) age was 65 (58-73) years; there were 703 males (62.2%) and 427 females (37.8%). Among patients who had MIPD-POPF, 129 patients (55%) experienced a second complication compared with 95 patients (36%) with OPD-POPF (P < .001). The rate of PPH was higher with MIPD-POPF (71 patients [21%] vs 22 patients [8.0%]; P < .001), without significant differences for DGE (65 patients [19%] vs 45 patients [16%]; P = .40), bile leak (43 patients [13%] vs 52 patients [19%]; P = .06), and chyle leak (1 patient [0.5%] vs 5 patients [1.9%]; P = .39). MIPD-POPF was associated with a longer hospital stay (median [IQR], 27 [18-38] days vs 22 [15-30] days; P < .001) and more reoperations (67 patients [21%] vs 21 patients [7%]; P < .001) but comparable in-hospital/30-day mortality (25 patients [7%] vs 7 patients [5%]; P = .31) with OPD-POPF, respectively. Conclusions and Relevance This study found that for patients after MIPD, the presence of POPF is more frequently associated with other clinically relevant complications compared with OPD. This underscores the importance of perioperative mitigation strategies for POPF and the resulting PPH in high-risk patients.
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Affiliation(s)
- Caro L. Bruna
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Anouk M. L. H. Emmen
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Kongyuan Wei
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People’s Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Robert P. Sutcliffe
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guiseppe K. Fusai
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Yi-Ming Shyr
- General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, Republic of China
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Steve White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Leia R. Jones
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Alberto Manzoni
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Mustafa Kerem
- Department of General Surgery, Gazi University, School of Medicine, Ankara, Turkey
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Clarissa Ferrari
- Research and Clinical Trials Office, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional Orleans, Orleans, France
| | - I. Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Claudio Bnà
- Department of Radiology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris Cite, Clichy, France
| | - Ugo Boggi
- Department of Surgery, University Hospital of Pisa, Pisa, Italy
| | - Rong Liu
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People’s Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing, China
| | - Jin-Young Jang
- Departments of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Lee JW, Kwon JH, Lee JW. Impact of Modified Blumgart Anastomosis on Pancreatic Fistula and Pancreaticojejunostomy Time During Laparoscopic Pancreaticoduodenectomy: Single-Center Experience. J Clin Med 2024; 14:90. [PMID: 39797173 PMCID: PMC11722071 DOI: 10.3390/jcm14010090] [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: 12/02/2024] [Revised: 12/21/2024] [Accepted: 12/26/2024] [Indexed: 01/13/2025] Open
Abstract
Background/Objectives: The aim of this study is to evaluate the impact of modified Blumgart anastomosis methods during pancreaticojejunostomy (PJ) on the incidence of clinically relevant postoperative pancreatic fistula (POPF) after laparoscopic pancreaticoduodenectomy (LPD). Methods: This is a retrospective cohort study analyzing data of patients who underwent LPD from 2018 to 2022. The primary endpoint was the incidence of grade B and C POPF based on the International Study Group on Pancreatic Fistula criteria and PJ anastomosis time. Incidence of postoperative complications (Clavien-Dindo classification grade ≥ III) was also investigated. Results: A total of 148 patients, 99 patients in a modified Blumgart group and 49 patients in a continuous suture group, were enrolled. There were no statistically significant differences in the general and intraoperative characteristics found between the two groups (p > 0.05). There was no significant difference in pancreas texture (p = 0.397) and diameter of pancreatic duct (p = 0.845). Grade B and C POPF occurred in five patients (5.1%) in the modified Blumgart group and three patients (6.1%) in the continuous suture group with no statistical difference (p = 0.781). A total of eleven patients (11.1%) in the modified Blumgart group and four patients (8.2%) in the continuous suture group had postoperative complication (Clavien-Dindo Classification grade 3 or more). Mortality within 90 days was 2 (2%) and 0 (0%), respectively. The PJ anastomosis times in the modified Blumgart group and continuous suture group were 28.8 ± 5.94 min and 35 ± 7.71 min, respectively (p = 0.003). Conclusions: This study suggests that modified Blumgart PJ showed shorter anastomosis time with comparable outcome to continuous suture methods in LPD.
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Affiliation(s)
| | | | - Jung-Woo Lee
- Department of Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea; (J.W.L.); (J.H.K.)
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Birgin E, Heil J, Walter B, Wagner M, Müssle B, Kornmann M, Seufferlein T, Rahbari NN. [Anastomotic leakage in hepato-pancreato-biliary surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:887-894. [PMID: 39340543 DOI: 10.1007/s00104-024-02176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/30/2024]
Abstract
Severe complications following hepato-pancreato-biliary surgery are frequently due to leakage of anastomoses. Local intraoperative and systematic measures can reduce the incidence of leaks and leak-related sequelae. The early identification of leak-related sequelae, such as hemorrhage is pivotal to reduce the mortality risk. Therefore, perioperative risk stratification incorporating surgical and patient risk factors is crucial. The management of anastomotic leaks is complex and an interdisciplinary treatment is therefore recommended. The treatment depends on the institutional expertise, localization, characteristic features of the anastomosis and the onset of insufficiency. This article describes the different concepts of the diagnostics, prevention, consequences and management of anastomotic leakage in hepato-pancreato-biliary surgery in more detail.
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Affiliation(s)
- Emrullah Birgin
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
| | - Jan Heil
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - Benjamin Walter
- Klinik für Innere Medizin 1, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Martin Wagner
- Klinik für Innere Medizin 1, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Benjamin Müssle
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - Marko Kornmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | | | - Nuh N Rahbari
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
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6
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Behrman SW. The Grade C Pancreatic Fistula. Surg Clin North Am 2024; 104:1113-1120. [PMID: 39237167 DOI: 10.1016/j.suc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
Grade C pancreatic fistulas are associated with severe morbidity and a significant risk of mortality. High-risk pancreatic anastomoses can be predicted to allow best practice fistula mitigation techniques. In these high-risk glands, any deviation from a stable postoperative clinical course should prompt early computed tomography and aggressive, percutaneous drainage of the operative bed. If salvage surgery is necessary, drainage of the operative bed and/or external diversion of pancreatic juice via stenting while completion pancreatectomy should be avoided. Senior mentorship in the perioperative period offers an opportunity to decrease this complication even in early career surgeons.
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Affiliation(s)
- Stephen W Behrman
- Surgical Oncology, Baptist Memorial Medical Education, Baptist Health Sciences University College of Osteopathic Medicine.
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Symeonidis D, Zacharoulis D, Tzovaras G, Kissa L, Samara AA, Petsa E, Tepetes K. Stent A pancreaticojejunostomy after pancreatoduodenectomy: Is it always necessary? World J Methodol 2024; 14:90164. [PMID: 39310242 PMCID: PMC11230077 DOI: 10.5662/wjm.v14.i3.90164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 02/19/2024] [Accepted: 04/07/2024] [Indexed: 06/25/2024] Open
Abstract
The establishment of a postoperative pancreatic fistula (POPF) is considered the most common and, concomitantly, the most serious complication associated with pancreaticoduodenectomy (PD). The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified. The stenting of the pancreatic duct, with the use of either internal or external stents, has been evaluated in this direction. In theory, it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF. The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF, after PD, by using PubMed and Reference Citation Analysis. In general, previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF; this is at the cost, however, of increased morbidity associated mainly with the stent removal. Certainly, the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract. Bearing in mind the scarcity of high-quality data on the subject, an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.
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Affiliation(s)
| | | | - Georgios Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Labrini Kissa
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Athina A Samara
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Eleana Petsa
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Konstantinos Tepetes
- Department of General Surgery, University Hospital of Larissa, Larissa 41110, Greece
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Marique L, Codjia T, Dembinski J, Dokmak S, Aussilhou B, Jehaes F, Cauchy F, Lesurtel M, Sauvanet A. Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage. Surgery 2024; 176:440-446. [PMID: 38760227 DOI: 10.1016/j.surg.2024.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/30/2023] [Accepted: 03/24/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy. METHODS This single-center retrospective study included 812 open pancreaticoduodenectomies (2012-2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification. RESULTS There were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12-0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1-20.3, P < .001) was predictive of this complication. CONCLUSION Arterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.
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Affiliation(s)
- Lancelot Marique
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Tatiana Codjia
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Jeanne Dembinski
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Beatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - François Jehaes
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France.
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9
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Gaujoux S, Regimbeau JM, Piessen G, Truant S, Foissac F, Barbier L, Buc E, Adham M, Fuks D, Deguelte S, Muscari F, Sulpice L, Vaillant JC, Schwarz L, Sa Cunha A, Muzzolini M, Dousset B, Sauvanet A. Somatostatin Versus Octreotide for Prevention of Postoperative Pancreatic Fistula: The PREFIPS Randomized Clinical Trial: A FRENCH 007-ACHBT Study. Ann Surg 2024; 280:179-187. [PMID: 38662619 DOI: 10.1097/sla.0000000000006313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
OBJECTIVE Pharmacological prevention of postoperative pancreatic fistula (POPF) after pancreatectomy is open to debate. The present study compares clinically significant POPF rates in patients randomized between somatostatin versus octreotide as prophylactic treatment. METHODS Multicentric randomized controlled open study in patient's candidate for pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) comparing somatostatin continuous intravenous infusion for 7 days versus octreotid 100 μg, every 8 hours subcutaneous injection for 7 days, stratified by procedure (PD vs DP) and size of the main pancreatic duct (>4 mm) on grade B/C POPF rates at 90 days based on an intention-to-treat analysis. RESULTS Of 763 eligible patients, 651 were randomized: 327 in the octreotide arm and 324 in the somatostatin arm, with comparable the stratification criteria - type of surgery and main pancreatic duct dilatation. Most patients had PD (n=480; 73.8%), on soft/normal pancreas (n=367; 63.2%) with a nondilated main pancreatic duct (n=472; 72.5%), most often for pancreatic adenocarcinoma (n=311; 47.8%). Almost all patients had abdominal drainage (n=621; 96.1%) and 121 (19.5%) left the hospital with the drain in place (median length of stay=16 days). A total of 153 patients (23.5%) developed a grade B/C POPF with no difference between both groups: 24.1%: somatostatin arm and 22.9%: octreotide arm (χ 2 test, P =0.73, ITT analysis). Absence of statistically significant difference persisted after adjustment for stratification variables and in per-protocol analysis. CONCLUSION Continuous intravenous somatostatin is not statistically different from subcutaneous octreotide in the prevention of grade B/C POPF after pancreatectomy. FINDINGS In the PREFIPS Randomized Clinical Trial including 651 patients, a total of 153 patients (23.5%) developed a grade B/C POPF with no significant difference between both groups: 24.1%: somatostatin arm and 22.9%: octreotide arm (χ 2 test, P =0.73, ITT analysis). Absence of statistically significant difference persisted after adjustment for stratification variables and in per-protocol analysis.
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Affiliation(s)
- Sébastien Gaujoux
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Jean-Marc Regimbeau
- Department of Oncology and Digestive Surgery, CHU Amiens-Picardie, Amiens, France
- University of Picardie Jules-Vernes, Amiens, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, CHU Lille, Lille, France
- University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| | - Stéphanie Truant
- University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
- Department of Digestive Surgery and Transplantation, CHU Lille, Lille, France
| | - Frantz Foissac
- Clinical Research Unit Necker Cochin Hospital, APHP, Paris, France
| | - Louise Barbier
- Department of Digestive Surgery and Liver Transplantation, CHU Tours Trousseau, Tours, France
- University of Tours, Tours, France
| | - Emmanuel Buc
- Department of Digestive and Hepatobiliary Surgery, Estaing Hospital, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Clermont-Ferrand Faculty of Medicine, Clermont-Ferrand, France
| | - Mustapha Adham
- Digestive Surgery Unit, Edouard Herriot Hospital, Lyon, France
- Hospices Civils of Lyon University, Lyon, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepatobiliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
- University of Paris, Paris, France
| | - Sophie Deguelte
- Digestive Surgery Department, Reims University Hospital, Robert Debré Hospital, Reims, France
- Reims University Hospital, Robert Debré Hospital, Reims, France
| | - Fabrice Muscari
- Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
- Toulouse University, Toulouse, France
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive Surgery Hospital Rennes, Rennes, France
- Rennes University, Rennes, France
| | - Jean-Christophe Vaillant
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Charles Nicolle Hospital, Rouen, France
- Rouen University, Rouen, France
| | - Antonio Sa Cunha
- Department of Hepatobiliary Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
- Paris-Saclay University, Saclay, France
| | - Milena Muzzolini
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Pancreatic, Hepatobiliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
- University of Paris, Paris, France
| | - Alain Sauvanet
- Department of Hepatobiliary Surgery, Beaujon Hospital, Clichy, France
- University Paris Cité, Paris, France
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10
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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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11
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Cannas S, Casciani F, Vollmer CM. Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor. Ann Surg 2024; 279:1036-1045. [PMID: 37522844 DOI: 10.1097/sla.0000000000006060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). BACKGROUND Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined. METHODS Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. RESULTS Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). CONCLUSIONS At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.
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Affiliation(s)
- Samuele Cannas
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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12
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Tang B, Wang P, Ma J, Shi J, Yang S, Zeng J, Xiang C, Wang X. Comparing the distal pancreatectomy fistula risk score (D-FRS) and DISPAIR-FRS for predicting pancreatic fistula after distal pancreatectomy. ANZ J Surg 2024; 94:667-673. [PMID: 38062615 DOI: 10.1111/ans.18819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 04/17/2024]
Abstract
BACKGROUNDS Distal pancreatectomy fistula risk score (D-FRS) and DISPAIR-FRS has not been widely validated for predicting postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP). METHODS We retrospectively analysed 104 patients undergoing DP. The predictive value of the D-FRS and DISPAIR-FRS were compared. Risk factors associated with POPF were investigated by multivariate analysis. RESULTS Of the 104 patients, 23 (22.1%) were categorized into the POPF group (all grade B). The areas under the ROC (AUCs) of the D-FRS (preoperative), D-FRS (intraoperative), and DISPAIR-FRS were 0.737, 0.809, and 0.688, respectively. Stratified by the D-FRS (preoperative), the POPF rates in low-risk, intermediate-risk, and high-risk groups were 5%, 22.6%, and 36.4%, respectively. By the D-FRS (intraoperative), the POPF rates in low-risk, intermediate-risk, and high-risk groups were 8.8%, 47.1%, and 47.4%, respectively. By the DISPAIR-FRS, the POPF rates in low-risk, intermediate-risk, and extreme-high-risk groups were 14.8%, 23.8% and 62.5%, respectively. Body mass index and main pancreatic duct diameter were independent risk factors of POPF both in preoperative (P = 0.014 and P = 0.033, respectively) and intraoperative (P = 0.015 and P = 0.039) multivariate analyses. CONCLUSION Both the D-FRS (preoperative), D-FRS (intraoperative), and DISPAIR-FRS has good performance in POPF prediction after DP. The risk stratification was not satisfactory in current Asian cohort.
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Affiliation(s)
- Bingjun Tang
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Pengfei Wang
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Jiming Ma
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Jun Shi
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Shizhong Yang
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Jianping Zeng
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Canhong Xiang
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
| | - Xuedong Wang
- Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Medicine, Tsinghua University, Beijing, China
- Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing, China
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13
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Mazzola M, Giani A, Calcagno P, Benedetti A, Zironda A, Gualtierotti M, De Martini P, Ferrari G. Pancreatojejunostomy: standing on the shoulders of giants. A single centre retrospective analysis. Updates Surg 2024; 76:97-106. [PMID: 37679576 DOI: 10.1007/s13304-023-01643-z] [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: 03/27/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023]
Abstract
Gaining experience in pancreatic surgery could be demanding especially when minimally invasive approach is used. Pancreatojejunostomy (PJ) is one of the most critical steps during pancreatoduodenectomy (PD). Our aim was to investigate the impact of a surgeon's experience in performing PJ, especially in a subgroup of patients undergoing laparoscopic PD (LPD). Data of consecutive patients undergoing PD from 2017 to 2022 were prospectively collected and retrospectively analyzed. Patients were divided into two groups: M group included patients in which PJ was performed by an experienced surgeon, D group included those receiving PJ by a less experienced one. The groups were compared in terms of postoperative outcomes. 187 patients were selected (157 in group M and 30 in group D). The cohorts differed in terms of median age (68 vs 74 years, p = 0.016), and previous abdominal surgery (41.4% vs 66.7%, p = 0.011), while no difference was found regarding risk of postoperative pancreatic fistula (POPF). The groups did not differ in terms of surgical outcomes. POPF rate was 15.9% and 10% in the M and D group (p = 0.578), respectively. Among patients undergoing laparoscopic PJ POPF rate was 16.0% and 17.7% in the M and D group (p = 0.867), respectively, without difference. No difference was found in terms of POPF in patients undergoing PD independently from the surgeon who performed the PJ, even during LPD. Moderate/high FRS, BMI > 30 kg/m2 and male sex, but not the surgeon who performed the PJ anastomosis, were independent predictors of POPF.
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Affiliation(s)
- Michele Mazzola
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Alessandro Giani
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Pietro Calcagno
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Antonio Benedetti
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Andrea Zironda
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Monica Gualtierotti
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Paolo De Martini
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
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14
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Li J, Niu HY, Meng XK. Novel invagination procedure for pancreaticojejunostomy using double purse string sutures: A technical note. World J Gastrointest Surg 2023; 15:2792-2798. [PMID: 38222010 PMCID: PMC10784842 DOI: 10.4240/wjgs.v15.i12.2792] [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: 10/30/2023] [Revised: 11/14/2023] [Accepted: 12/08/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most serious complications after pancreaticoduodenectomy (PD), and the choice of pancreaticojejunostomy (PJ) is considered a key factor affecting the occurrence of POPF. Numerous anastomotic methods and their modifications have been proposed, and there is no method that can completely avoid the occurrence of POPF. Based on our team's experience in pancreatic surgery and a review of relevant literature, we describe a novel invagination procedure for PJ using double purse string sutures, which has resulted in favourable outcomes. AIM To describe the precise procedural steps, technical details and clinical efficacy of the novel invagination procedure for PJ. METHODS This study adopted a single-arm retrospective cohort study methodology, involving a total of 65 consecutive patients who underwent PD with the novel invagination procedure for PJ, including the placement of a pancreatic stent, closure of the residual pancreatic end, and two layers of purse-string suturing. Baseline data included age, sex, body mass index (BMI), pancreatic texture, pancreatic duct diameter, operation time, and blood loss. Clinical outcomes included the operation time, blood loss, and incidence of POPF, postoperative haemorrhage, delayed gastric emptying, postoperative pulmonary infection, postoperative abdominal infection, and postoperative pulmonary infection. RESULTS The mean age of the patients was 59.12 (± 8.08) years. Forty males and 25 females were included, and the mean BMI was 21.61 kg/m2 (± 2.74). A total of 41.53% of patients had a pancreatic duct diameter of 3 mm or less. The mean operation time was 263.83 min (± 59.46), and the mean blood loss volume was 318.4 mL (± 163.50). Following the surgical intervention, only three patients showed grade B POPF (4.62%), while no patients showed grade C POPF. Five patients (5/65, 7.69%) were diagnosed with postoperative haemorrhage. Six patients (6/65, 9.23%) experienced delayed gastric emptying. Four patients (4/65, 6.15%) developed postoperative pulmonary infection, while an equivalent number (4/65, 6.15%) exhibited postoperative abdominal infection. Additionally, two patients (2/65, 3.08%) experienced postoperative pulmonary infection. CONCLUSION The novel invagination technique for PJ is straightforward, yields significant outcomes, and has proven to be safe and feasible for clinical application.
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Affiliation(s)
- Jun Li
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, Inner Mongolia Autonomous Region, China
| | - He-Yuan Niu
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, Inner Mongolia Autonomous Region, China
| | - Xing-Kai Meng
- Department of Hepatobiliary, Pancreatic and Splenic Surgery, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010010, Inner Mongolia Autonomous Region, China
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15
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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16
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Theijse RT, Stoop TF, Hendriks TE, Suurmeijer JA, Smits FJ, Bonsing BA, Lips DJ, Manusama E, van der Harst E, Patijn GA, Wijsman JH, Meerdink M, den Dulk M, van Dam R, Stommel MW, van Laarhoven K, de Wilde RF, Festen S, Draaisma WA, Bosscha K, van Eijck CH, Busch OR, Molenaar IQ, Groot Koerkamp B, van Santvoort HC, Besselink MG. Nationwide Outcome after Pancreatoduodenectomy in Patients at very High Risk (ISGPS-D) for Postoperative Pancreatic Fistula. Ann Surg 2023; 281:00000658-990000000-00717. [PMID: 38073575 PMCID: PMC11723487 DOI: 10.1097/sla.0000000000006174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D. SUMMARY BACKGROUND DATA Morbidity and mortality after ISGPS-D PD is perceived so high that a recent randomized trial advocated prophylactic total pancreatectomy (TP) as alternative aiming to lower this risk. However, current outcomes of ISGPS-D PD remain unknown as large nationwide series are lacking. METHODS Nationwide retrospective analysis including consecutive patients undergoing ISGPS-D PD (i.e., soft texture and pancreatic duct ≤3 mm), using the mandatory Dutch Pancreatic Cancer Audit (2014-2021). Primary outcome was in-hospital mortality and secondary outcomes included major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and POPF (ISGPS grade B/C). The use of prophylactic TP to avoid POPF during the study period was assessed. RESULTS Overall, 1402 patients were included. In-hospital mortality was 4.1% (n=57), which decreased to 3.7% (n=20/536) in the last 2 years. Major morbidity occurred in 642 patients (45.9%) and POPF in 410 (30.0%), which corresponded with failure to rescue in 8.9% (n=57/642). Patients with POPF had increased rates of major morbidity (88.0% vs. 28.3%; P<0.001) and mortality (6.3% vs. 3.5%; P=0.016), compared to patients without POPF. Among 190 patients undergoing TP, prophylactic TP to prevent POPF was performed in 4 (2.1%). CONCLUSION This nationwide series found a 4.1% in-hospital mortality after ISGPS-D PD with 45.9% major morbidity, leaving little room for improvement through prophylactic TP. Nevertheless, given the outcomes in 30% of patients who develop POPF, future randomized trials should aim to prevent and mitigate POPF in this high-risk category.
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Affiliation(s)
- Rutger T. Theijse
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Thomas F. Stoop
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Division of Surgical Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Tessa E. Hendriks
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - J. Annelie Suurmeijer
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - F. Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Eric Manusama
- Department of Surgery, Medisch Centrum Leeuwarden, the Netherlands
| | | | - Gijs A. Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Jan H. Wijsman
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Mark Meerdink
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany
- NUTRIM-School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Germany
| | - Martijn W.J. Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kees van Laarhoven
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Roeland F. de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | | | - Werner A. Draaisma
- Department of Surgery, Jeroen Bosch Hospital, ‘s Hertogenbosch, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, ‘s Hertogenbosch, the Netherlands
| | - Casper H.J. van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
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17
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Perri G, Marchegiani G, Partelli S, Andreasi V, Luchini C, Bariani E, Bannone E, Fermi F, Mattiolo P, Falconi M, Salvia R, Bassi C. Either High or Low Risk: The Acinar Score at the Resection Margin Dichotomizes the Risk Spectrum of Pancreas-specific Complications After Pancreatoduodenectomy. Ann Surg 2023; 278:e1242-e1249. [PMID: 37325905 DOI: 10.1097/sla.0000000000005943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Pancreatic acinar content (Ac) has been associated with pancreas-specific complications after pancreatoduodenectomy. The aim of this study was to improve the prediction ability of intraoperative risk stratification by integrating the pancreatic acinar score. METHODS A training and validation cohort underwent pancreatoduodenectomy with a subsequent histologic assessment of pancreatic section margins for Ac, fibrosis (Fc), and fat. Intraoperative risk stratification (pancreatic texture, duct diameter) and pancreas-specific complications (postoperative hyperamylasemia [POH], postpancreatectomy acute pancreatitis [PPAP], pancreatic fistula [POPF]) were classified according to ISGPS definitions. RESULTS In the validation cohort (n= 373), the association of pancreas-specific complications with higher Ac and lower Fc was replicated (all P <0.001). In the entire cohort (n= 761), the ISGPS classification allocated 275 (36%) patients into intermediate-risk classes B (POH 32%/PPAP 3%/POPF 17%) and C (POH 36%/PPAP 9%/POPF 33%). Using the acinar score (Ac ≥60% and/or Fc ≤10%), intermediate-risk patients could be dichotomized into a low-risk (POH 5%/PPAP 1%/POPF 6%) and a high-risk (POH 51%/PPAP 9%/POPF 38%) group (all P <0.001). The acinar score AUC for POPF prediction was 0.70 in the ISGPS intermediate-risk classes. Overall, 239 (31%) patients were relocated into the high-risk group from lower ISGPS risk classes using the acinar score. CONCLUSIONS The risk of pancreas-specific complications appears to be dichotomous-either high or low-according to the acinar score, a tool to better target the application of mitigation strategies in cases of intermediate macroscopic features.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Valentina Andreasi
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Luchini
- Division of Pathology, Verona University Hospital, Verona, Italy
| | - Elena Bariani
- Division of Pathology, Verona University Hospital, Verona, Italy
| | - Elisa Bannone
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Francesca Fermi
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Mattiolo
- Division of Pathology, Verona University Hospital, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
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18
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Ferguson BD. Toward Better Prediction of Postpancreatectomy Hemorrhage. JAMA Netw Open 2023; 6:e2346069. [PMID: 38055282 DOI: 10.1001/jamanetworkopen.2023.46069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
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19
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Angrisani M, Meniconi RL, Sandini M, Colasanti M, Ferretti S, Guglielmo N, Berardi G, Mariano G, Usai S, Braga M, Gianotti L, Ettorre GM. External validation of scores predicting postoperative fistula after pancreatogastrostomy for pancreatoduodenectomy reconstruction. A single center experience. Pancreatology 2023; 23:852-857. [PMID: 37827971 DOI: 10.1016/j.pan.2023.10.004] [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: 04/01/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent complication of pancreatic surgery and can be fatal. Selection and stratification of patients according to the risk of POPF are important for the perioperative management. Predictive metrics have been developed and validated in pancreatojejunostomy. Aim of this study is to assess whether the most used prognostic scores can be predictive of fistula following Wirsung-pancreaticogastrostomy (WPG) for pancreatoduodenectomy (PD)reconstruction. METHOD This single-center prospective observational study included 212 PDs between January 2008 and October 2022 with a standardized WPG. All component variables of the six scores were separately validated in our cohort. The overall predictive ability of the six fistula scores was measured and compared with the receiver operating characteristics curves (ROC) method and expressed by the area under the ROC-curve (AUC). Univariate and multivariate logistic regression analyses were performed considering all risk factors in the scores in order to identify variables independently correlated with POPF in the WPG. RESULTS CR-POPF occurred in 36 of 212 (17 %) patients. All scores showed poor prognostic stratification for the development of CR-POPF. The occurrence of CR-POPF was associated with nine factors: male gender (p = 0.003); BMI (kg/m2) (p = 0.005); ASA (%) (p = 0.003); Soft pancreatic texture (%) (p = 0.003), Pathology (p = 0.008); MPD (p = 0.011); EBL (mL) (p = 0.021); Preop. Bilirubin (mg/dl) (p = 0.038); Preop. Glucose (mg/dl) (p = 0.0369). Male gender (OR: 5.54, CI 1.41-21.3) and soft consistency of the remnant pancreas (OR: 3.83, CI 1.14-12.8) were the only independent prognostic factors on multivariate analysis. CONCLUSIONS Our study including exclusively pancreatogastrostomies failed to validate the most used predictive scores for POPF. We found that only male gender and soft pancreatic texture are associated with POPF. Specific predictive scores following pancreatogasgtrostomy are needed.
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Affiliation(s)
- Marco Angrisani
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy; School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy.
| | - Roberto Luca Meniconi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Marta Sandini
- Department of Medical, Surgical, and Neurologic Sciences, University of Siena, Siena, Italy
| | - Marco Colasanti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Stefano Ferretti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Nicola Guglielmo
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Giammauro Berardi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Germano Mariano
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Sofia Usai
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
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20
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Matsui H, Shindo Y, Yamada D, Ogihara H, Tokumitsu Y, Nakajima M, Iida M, Suzuki N, Takeda S, Nakagami Y, Kobayashi S, Eguchi H, Ioka T, Hamamoto Y, Nagano H. A novel prediction model of pancreatic fistula after pancreaticoduodenectomy using only preoperative markers. BMC Surg 2023; 23:310. [PMID: 37828597 PMCID: PMC10571374 DOI: 10.1186/s12893-023-02213-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Since clinically relevant postoperative pancreatic fistula (CR-POPF) can cause intra-abdominal hemorrhage and abscesses, leading to surgery-related deaths after pancreaticoduodenectomy (PD), its preoperative prediction is important to develop strategies for surgical procedures and perioperative management. This study aimed to establish a novel prediction model for CR-POPF using preoperative markers. METHODS On a training set of 180 patients who underwent PD at the Yamaguchi University Hospital, a combination of CR-POPF predictors were explored using the leave-one-out method with a unique discrete Bayes classifier. This predictive model was confirmed using a validation set of 366 patients who underwent PD at the Osaka University Hospital. RESULTS In the training set, CR-POPF occurred in 60 (33%) of 180 patients and 130 (36%) of 366 patients in the validation set using selected markers. In patients with pancreatic ductal adenocarcinoma (PDAC), the main pancreatic duct (MPD) index showed the highest prognostic performance and could differentiate CR-POPF with 87% sensitivity and 81% specificity among 84 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index-based model for 130 PDAC samples were 93% and 87%, respectively. In patients with non-PDAC, the MPD index/body mass index (BMI) combination showed the highest prognostic performance and could differentiate CR-POPF with 84% sensitivity and 57% specificity among 96 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index/BMI-based model for 236 non-PDAC samples were 85% and 53%, respectively. CONCLUSION We developed a novel prediction model for pancreatic fistulas after PD using only preoperative markers. The MPD index and MPD index/BMI combination will be useful for CR-POPF assessment in PDAC and non-PDAC samples, respectively.
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Affiliation(s)
- Hiroto Matsui
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Yoshitaro Shindo
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hiroyuki Ogihara
- Department of Computer Science and Electronic Engineering, National Institute of Technology, Tokuyama College, Shunan, Yamaguchi, Japan
| | - Yukio Tokumitsu
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Masao Nakajima
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Michihisa Iida
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Nobuaki Suzuki
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Shigeru Takeda
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan
| | - Yuki Nakagami
- Department of Data Science, Graduate School of Economics, Shimonoseki City University, Shimonoseki, Yamaguchi, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tatsuya Ioka
- Oncology Center, Yamaguchi University Hospital, Ube, Yamaguchi, Japan
| | - Yoshihiko Hamamoto
- Division of Electrical, Electronic and Information Engineering, Graduate School of Sciences and Technology for Innovation, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, Ube, 755-8505, Yamaguchi, Japan.
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21
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Stoop TF, Bergquist E, Theijse RT, Hempel S, van Dieren S, Sparrelid E, Distler M, Hackert T, Besselink MG, Del Chiaro M, Ghorbani P. Systematic Review and Meta-analysis of the Role of Total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula: Is it a Justifiable Indication? Ann Surg 2023; 278:e702-e711. [PMID: 37161977 PMCID: PMC10481933 DOI: 10.1097/sla.0000000000005895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF). SUMMARY BACKGROUND DATA TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking. METHODS Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥IIIa) on the short-term and quality of life. RESULTS After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR=1.04 [95%CI 0.56-1.93]). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR=0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [±15] vs. 76% [±20]; P =0.857). CONCLUSIONS This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bail-out procedure, the comparable long-term quality of life is reassuring.
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Affiliation(s)
- Thomas F. Stoop
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Erik Bergquist
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Rutger T. Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
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22
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Chui JN, Sahni S, Samra JS, Mittal A. Postoperative pancreatitis and pancreatic fistulae: a review of current evidence. HPB (Oxford) 2023; 25:1011-1021. [PMID: 37301633 DOI: 10.1016/j.hpb.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies. METHODS A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset. RESULTS A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury. CONCLUSIONS The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.
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Affiliation(s)
- Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
| | - Sumit Sahni
- Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia; School of Medicine, The University of Notre Dame, Sydney, Australia.
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Lim CSH, Mittal A, Samra JS. How i do it: microscope augmented pancreaticojejunostomy. Langenbecks Arch Surg 2023; 408:327. [PMID: 37610436 DOI: 10.1007/s00423-023-03055-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 08/09/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE Post-operative pancreatic fistula (POPF) is perhaps one of most dreaded pancreatoduodenectomy-related complications. Various approaches to mitigate this risk have been explored, with conflicting results and no clear consensus on the comparative superiority of any one technique. We postulate that regardless of technique, the key to reducing POPF is a robust pancreatic anastomosis with careful apposition of tissues, in particular the duct-to-mucosa anastomosis. METHOD We describe the fashioning of a pancreatojejunostomy with an external pancreatic stent in the setting of a high-risk anastomosis with help of a 10 × magnification surgical microscope. A technical description with a short, edited video is presented.
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Affiliation(s)
- Christopher Seng Hong Lim
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Centre, Sydney, Australia
- Notre Dame University of Australia, Sydney, Australia
| | - Jaswinder Singh Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Centre, Sydney, Australia
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24
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Loos M, König AK, von Winkler N, Mehrabi A, Berchtold C, Müller-Stich BP, Schneider M, Hoffmann K, Kulu Y, Feisst M, Hinz U, Lang M, Goeppert B, Albrecht T, Strobel O, Büchler MW, Hackert T. Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It? Ann Surg 2023; 278:e87-e93. [PMID: 35781509 PMCID: PMC10249602 DOI: 10.1097/sla.0000000000005494] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to identify the indications for and report the outcomes of completion pancreatectomy (CPLP) in the postoperative course after pancreatoduodenectomy (PD). BACKGROUND CPLP may be considered or even inevitable for damage control after PD. METHODS A prospectively maintained database of all patients undergoing PD between 2001 and 2019 was searched for patients who underwent CPLP in the postoperative course after PD. Baseline characteristics, perioperative details, and outcomes of CPLP patients were analyzed and specific indications for CPLP were identified. RESULTS A total of 3953 consecutive patients underwent PD during the observation period. CPLP was performed in 120 patients (3%) after a median of 10 days following PD. The main indications for CPLP included postpancreatectomy acute necrotizing pancreatitis [n=47 (39%)] and postoperative pancreatic fistula complicated by hemorrhage [n=41 (34%)] or associated with uncontrollable leakage of the pancreatoenteric anastomosis [n=23 (19%)]. The overall 90-day mortality rate of all 3953 patients was 3.5% and 37% for patients undergoing CPLP. CONCLUSIONS Our finding that only very few patients (3%) need CPLP suggests that conservative, interventional, and organ-preserving surgical measures are the mainstay of complication management after PD. Postpancreatectomy acute necrotizing pancreatitis, uncontrollable postoperative pancreatic fistula, and fistula-associated hemorrhage are highly dangerous and represent the main indications for CPLP after PD.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anna-Katharina König
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Nikolai von Winkler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P. Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Goeppert
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Albrecht
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General Surgery, Vienna University Hospital, Vienna, Austria
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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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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Codjia T, Roussel E, Papet E, Pinson J, Monge M, Tortajada P, Tuech JJ, Schwarz L. Can the Realization of an External Wirsungostomy be an Option for High-Risk Pancreatic Anastomosis After Pancreaticoduodenectomy? World J Surg 2023; 47:1533-1539. [PMID: 36884081 DOI: 10.1007/s00268-023-06927-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (POPF) occurs in 15-20% of patients after pancreaticoduodenectomy (PD) and reintervention in the setting of Grade C POPF remains associated with a mortality rate of up to 25%. In patients at high risk of POPF, PD with external wirsungostomy (EW) could be a safe alternative that avoids pancreatico-enteric anastomosis while preserving the remnant pancreas. METHODS Of the 155 consecutive patients who underwent PD from November 2015 to December 2020, 10 patients were managed using an EW, all with a fistula risk score (FRS) ≥ 7 and BMI ≥30 kg/m2, and/or major associated abdominal surgery. The pancreatic duct was cannulated with a polyethylene tube to allow good external drainage of the pancreatic fluid. We retrospectively analyzed postoperative complications and endocrine and exocrine insufficiencies. RESULTS The median alternative FRS was 36.9% [22.1-45.2]. There was no postoperative death. The 90-day overall severe complication (grade ≥3) rate was 30% (n = 3 patients), no patient required reoperation, and 2 hospital readmissions occurred. 3 patients experienced Grade B POPF (30%), managed using image-guided drainage for 2 patients. The external pancreatic drain was removed after a median drainage time of 75 days [63-80]. Two patients presented with late symptoms (> 6 months) warranting interventional management (pancreaticojejunostomy and transgastric drainage). Six patients experienced significant weight loss (> 2 kg) 3 months after surgery. One year after surgery, 4 patients still complained of diarrhea and were treated with transit-delaying drugs. One patient presented new-onset diabetes one year after surgery, and 1 of the 4 patients with preexisting diabetes experienced worsening disease. CONCLUSION EW after PD might be a solution to reduce post-operative mortality following PD in high-risk patients.
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Affiliation(s)
- Tatiana Codjia
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Edouard Roussel
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Eloise Papet
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Matthieu Monge
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Pauline Tortajada
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, UNIROUEN, UMR 1245 INSERM, Normandie ROUEN University, 76000, Rouen, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France.
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, UNIROUEN, UMR 1245 INSERM, Normandie ROUEN University, 76000, Rouen, France.
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Schuh F, Mihaljevic AL, Probst P, Trudeau MT, Müller PC, Marchegiani G, Besselink MG, Uzunoglu F, Izbicki JR, Falconi M, Castillo CFD, Adham M, Z'graggen K, Friess H, Werner J, Weitz J, Strobel O, Hackert T, Radenkovic D, Kelemen D, Wolfgang C, Miao YI, Shrikhande SV, Lillemoe KD, Dervenis C, Bassi C, Neoptolemos JP, Diener MK, Vollmer CM, Büchler MW. A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg 2023; 277:e597-e608. [PMID: 33914473 PMCID: PMC9891297 DOI: 10.1097/sla.0000000000004855] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). SUMMARY BACKGROUND DATA Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. METHODS A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. RESULTS Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001). CONCLUSION For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
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Affiliation(s)
- Fabian Schuh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maxwell T Trudeau
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Faik Uzunoglu
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, ''Vita-Salute'' University, Milan, Italy
| | | | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, Lyon, France
| | | | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dezso Kelemen
- Department of Surgery, University of Pécs, Medical School, Pécs, Hungary
| | - Christopher Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Y I Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA
| | | | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Charles M Vollmer
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Malgras B, Dokmak S, Aussilhou B, Pocard M, Sauvanet A. Management of postoperative pancreatic fistula after pancreaticoduodenectomy. J Visc Surg 2023; 160:39-51. [PMID: 36702720 DOI: 10.1016/j.jviscsurg.2023.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.
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Affiliation(s)
- B Malgras
- Digestive and endocrine surgery department, Bégin Army Training Hospital, 69, avenue de Paris, 94160 Saint-Mandé, France; Val de Grâce School, 1, place Alphonse-Lavéran, 75005 Paris, France
| | - S Dokmak
- Hepatobiliary and pancreatic surgery department, Paris-Cité University, Beaujon Hospital, AP-HP, 92110 Clichy, France
| | - B Aussilhou
- Hepatobiliary and pancreatic surgery department, Paris-Cité University, Beaujon Hospital, AP-HP, 92110 Clichy, France
| | - M Pocard
- Department of pancreatic and hepatobiliary digestive surgery and liver transplantation, Pitié Salpêtrière Hospital, 41-83, boulevard de l'Hôpital, 75013 Paris, France; UMR 1275 CAP Paris-Tech, Paris-Cité University, Lariboisière Hospital, 2, rue Ambroise-Paré, 75010 Paris, France
| | - A Sauvanet
- Hepatobiliary and pancreatic surgery department, Paris-Cité University, Beaujon Hospital, AP-HP, 92110 Clichy, France.
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30
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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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Bassi C, Marchegiani G, Giuliani T, Di Gioia A, Andrianello S, Zingaretti CC, Brentegani G, De Pastena M, Fontana M, Pea A, Paiella S, Malleo G, Tuveri M, Landoni L, Esposito A, Casetti L, Butturini G, Falconi M, Salvia R. Pancreatoduodenectomy at the Verona Pancreas Institute: the Evolution of Indications, Surgical Techniques, and Outcomes: A Retrospective Analysis of 3000 Consecutive Cases. Ann Surg 2022; 276:1029-1038. [PMID: 33630454 DOI: 10.1097/sla.0000000000004753] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the present study was to critically reappraise the experience at our high-volume institution to obtain new insights for future directions. SUMMARY BACKGROUND DATA The indications, surgical techniques, and perioperative management of pancreatoduodenectomy (PD) have profoundly evolved over the last 20 years. METHODS All consecutive PDs performed during the last 20 years at the Verona Pancreas Institute were divided into four 5-year timeframes and retrospectively analyzed in terms of indications, intraoperative features, and surgical outcomes. Significant milestones were provided to understand practice changes using a before-after analysis method. RESULTS The study population consisted of 3000 patients. The median age, ASA ≥ 3 and number of nonbenchmark cases significantly increased over time ( P < 0.005). Pancreatic cancer was the leading indication, representing 60% of patients/year in the last timeframe, 40% of whom received neoadjuvant treatment. Conversely, after the development of International Guidelines, the proportion of resected cystic neoplasms progressively and thoroughly decreased. Given the increased complexity of surgery for pancreatic cancer, the evolution of technologies, surgical techniques, and postoperative management allowed the maintenance of favorable surgical outcomes over time, with a stable 20.0% of patients with a Clavien-Dindo grade ≥ 3, an 11.7% failure to rescue and a 2.3% in-hospital mortality rate. The incidence of postoperative pancreatic fistula, hemorrhage, and delayed gastric emptying was 22.4%, 13.4%, and 12.4%, respectively. CONCLUSIONS PD significantly evolved in Verona over the past 2 decades. Surgeries of greater complexity are currently performed on increasingly frailer patients, mostly for pancreatic cancer and often after neoadjuvant chemotherapy. However, the progression of all fields of pancreatic surgery, including the expanding use of postoperative pancreatic fistula mitigation strategies, has allowed satisfactory outcomes to be maintained.
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Affiliation(s)
- Claudio Bassi
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Tommaso Giuliani
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Caterina Costanza Zingaretti
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Giacomo Brentegani
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Martina Fontana
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Antonio Pea
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
| | | | - Massimo Falconi
- Pancreatic Surgery, IRCCS San Raffaele Hospital, University ''Vita e Salute,'' Milano, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Verona Pancreas, Institute, University of Verona, Verona, Italy
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Wei JP, Tai S, Su ZL. One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced: A valuable anastomosis technique. World J Clin Cases 2022; 10:9276-9284. [PMID: 36159416 PMCID: PMC9477674 DOI: 10.12998/wjcc.v10.i26.9276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/26/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). To effectively reduce the incidence of POPF, we designed a new type of pancreaticojejunostomy (PJ), which was termed one-half layer PJ with the rear wall of the pancreas reinforced.
AIM To explore the clinical application value of this new technique.
METHODS We compared 62 patients who had undergone PD by either the traditional duct-to-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019. All 62 patients were operated by the same surgeon experienced in both procedures. We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.
RESULTS There was no significant difference between the two groups in basic information except the postoperative hospital stays, 14.7 ± 5.4 d in the traditional duct-to-mucosa anastomoses group and 12.0 ± 4.2 d in the one-half layer PJ group (P = 0.042). In terms of postoperative complications, the one-half layer PJ group had a lower rate of POPF than the traditional group. The overall number of cases with POPF was 8 (24.2%) in the traditional group and 2 (6.9%) in the one-half layer group (P = 0.017). Additionally, the rate of grades B and C POPF was lower in the one-half layer group (3.4%) compared with that (12.1%) in the traditional group (P = 0.010). One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.
CONCLUSION One-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF. It may be a promising technique for PJ after PD.
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Affiliation(s)
- Jin-Ping Wei
- Department of General Surgery, Beijing Chuiyangliu Hospital, Beijing 100022, China
| | - Sheng Tai
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Zhi-Lei Su
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
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Total pancreatectomy as an alternative to high-risk pancreatojejunostomy after pancreatoduodenectomy: a propensity score analysis on surgical outcome and quality of life. HPB (Oxford) 2022; 24:1261-1270. [PMID: 35031280 DOI: 10.1016/j.hpb.2021.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/10/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Total pancreatectomy (TP) is mentioned as alternative to pancreatoduodenectomy (PD) with high-risk pancreatojejunostomy (PJ) to avoid severe pancreatic fistula-related complications, but its benefit is controversial and comparative studies are scarce. METHODS Cross-sectional single-center study among patients after PD with high-risk PJ versus patients after single-stage elective TP for any indication (2015-2017), using propensity scores to evaluate surgical outcomes and long-term quality of life (QoL) in three risk strata. EORTC QLQ-C30 and EQ-5D-5L were used for QoL assessment. RESULTS Overall, 77 patients after TP (68.8%) and 102 patients after high-risk PD (34.5%) were included. Major morbidity (29.9% vs. 41.2%; p = 0.119) and 90-day mortality (5.2% vs. 8.8%; p = 0.354) did not differ significantly between TP and high-risk PD. Interventions for intra-abdominal fluid collections (9.1% vs. 23.5%, p = 0.011) and postpancreatectomy haemorrhage (6.5% vs. 18.6%; p = 0.018) were more often required after high-risk PD, but these differences did not remain after stratification. QoL was comparable after TP and high-risk PD (75% vs. 83%; p = 0.720), even after stratification. CONCLUSIONS TP seems not to be inferior to high-risk PD regarding surgical outcomes and QoL. TP could be considered as an alternative to a very high-risk PD, but reluctance persists since TP does not appear to reduce mortality.
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Mazzola M, Bertoglio CL, Giani A, Zironda A, Carnevali P, Lombardi PM, De Martini P, Magistro C, Ferrari G. Novel biodegradable internal stent as a mitigation strategy in high-risk pancreaticojejunostomy: technical notes and preliminary results. Surg Today 2022; 52:1115-1119. [PMID: 35301554 DOI: 10.1007/s00595-022-02488-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 11/24/2022]
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most feared complication after pancreaticoduodenectomy (PD), as it can lead to extremely poor outcomes. We herein report the preliminary results of an anastomotic technique based on the use of a novel internal biodegradable stent (IBS) to mitigate POPF sequelae. Between October 2020 and May 2021, all patients undergoing PD with high-risk pancreatic anastomosis received a pancreato-jejunal (PJ) anastomosis with an Archimedes™ IBS placement. Fifteen patients comprised our study cohort. In 11 cases, a 2-mm Archimedes™ stent was used, and in the remaining four patients, a 2.6-mm stent was used. Overall postoperative complications occurred in eight patients, with four cases being severe. Two patients developed CR-POPF, with one of them dying. In our small preliminary series, PJ anastomosis with an Archimedes™ IBS showed encouraging results in terms of CR-POPF incidence. Further studies are needed to confirm these findings.
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Affiliation(s)
- Michele Mazzola
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Camillo Leonardo Bertoglio
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Alessandro Giani
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Andrea Zironda
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Pietro Carnevali
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Pietro Maria Lombardi
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Paolo De Martini
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Carmelo Magistro
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
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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] [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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36
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Adamenko O, Ferrari C, Porreca A, Seewald S, Groth S, Gutzwiller JP, Kulaksiz H, Schmidt J. Perianastomotic Irrigation With Passive Drainage Dramatically Decreases POPF Rate After High-risk Pancreaticoduodenectomy. ANNALS OF SURGERY OPEN 2022; 3:e154. [PMID: 37601610 PMCID: PMC10431367 DOI: 10.1097/as9.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To assess whether prophylactic irrigation and passive drainage of pancreatico-jejunal anastomosis could reduce leak and mortality rates after high-risk pancreaticoduodenectomies. Background Postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreaticoduodenectomy. Several risk factors have been proposed likewise potential mitigation strategies. Regarding the latter, surgical drain policy remains a "hot topic." We propose an innovative approach to mitigate POPF and POPF-related mortality following high-risk pancreaticoduodenectomies. Methods One hundred fifty-seven patients undergoing pancreaticoduodenectomy between January 2012 and November 2021 were included in the study. Subjects with main pancreatic duct ≤ 3 mm and soft parenchyma were classified as high-risk for POPF development. Since August 2015, high-risk patients received prophylactic irrigation and drainage of the perianastomotic area. These patients were compared with risk-matched historical controls. Results We identified 73 high-risk patients. Of these, the 47 subjects receiving prophylactic perianastomotic irrigation showed significantly lower POPF rates (12.7% vs 69.2%, P < 0.001). Multivariate regression analysis confirmed the significant association between irrigation drainages and POPF (odds ratio 0.014, P = 0.01). Although not significant, mortality was lower in the irrigation group (4.2% vs 13.0%, P = 0.340). However, none of the fatalities in the irrigation-drainage group were POPF-related. No significant difference in length of hospital stay was observed between the 2 groups (18.0 vs 21.0 days, P = 0.091). Conclusions Irrigation and drainage of the perianastomotic area represents a powerful approach to reduce POPF and, potentially, mortality after high-risk pancreaticoduodenectomies.
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Affiliation(s)
| | - Carlo Ferrari
- From the Hirslanden Hospitals, Zürich, Switzerland
- Università degli Studi di Milano, Milan, Italy
| | - Annamaria Porreca
- Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio,” Chieti, Italy
| | - Stefan Seewald
- From the Hirslanden Hospitals, Zürich, Switzerland
- GastroZentrum Hirslanden, Zürich, Switzerland
| | - Stefan Groth
- From the Hirslanden Hospitals, Zürich, Switzerland
- GastroZentrum Hirslanden, Zürich, Switzerland
| | - Jean-Pierre Gutzwiller
- From the Hirslanden Hospitals, Zürich, Switzerland
- Magendarm Thalwil AG, Thalwil, Switzerland
| | | | - Jan Schmidt
- From the Hirslanden Hospitals, Zürich, Switzerland
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37
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Development of a prediction model of pancreatic fistula after duodenopancreatectomy and soft pancreas by assessing the preoperative image. Langenbecks Arch Surg 2022; 407:2363-2372. [DOI: 10.1007/s00423-022-02564-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
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Lim CSH, Chui JN, Sharma V, Samra JS, Mittal A. Construction of a pancreatojejunostomy with an external stent: A technical description. J Surg Oncol 2022; 125:976-981. [PMID: 35099826 DOI: 10.1002/jso.26808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/30/2021] [Accepted: 01/18/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Christopher S H Lim
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Varsha Sharma
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Australian Pancreatic Centre, Sydney, Australia.,Notre Dame University of Australia, Fremantle, Western Australia, Australia
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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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Chikhladze S, Hipp J, Biesel E, Weckler M, Ruess D, Kousoulas L, Hopt U, Fichtner-Feigl S, Wittel U. High serum CA19–9 preoperatively reduces POPF risk after pancreatoduodenectomy in PDAC. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2021.100051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Yu H, Yu T, Wang J, Wei F, Gong H, Dong H, He X, Wang Z, Yang J. Validation of a three-dimensional printed dry lab pancreaticojejunostomy model in surgical assessment: a cross-sectional study. BMJ Open 2022; 12:e052295. [PMID: 35105574 PMCID: PMC8808463 DOI: 10.1136/bmjopen-2021-052295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Until now, there have been few tools to evaluate whether a surgeon was technically ready to perform a safe pancreaticojejunostomy (PJ). In the current study, we aimed to evaluate whether a three-dimensional model could mimic a real surgical situation and distinguish between surgeons of different levels of experiences. DESIGN A three-dimensional PJ dry laboratory model was printed. Eight experienced pancreatic surgeons were tasked to evaluate the appearance and tactile sensation of the model. Proficiency was scored based on 15 surgeons with various levels of pancreatic experience performing a PJ on the three-dimensional model. Additionally, the time of manipulation and NASA Task Load Index (NASA-TLX) scores were recorded for each operation. SETTING Our study was conducted in multimedical centre in China. RESULTS Compared with real surgical situations, this model had similar appearance (3.96±0.55 out of five points) and tactile sensation (3.85±0.46 out of five points) according to the expert evaluation. Additionally, the chief surgeon group scored the best in proficiency (based on NASA-TLX scores and operative time), and there were statistical differences for performances among surgeons of various levels (p<0.05). CONCLUSION The three-dimensional PJ model could mimic a real surgical situation and can distinguish between surgeons of different levels of experiences.
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Affiliation(s)
- Hao Yu
- Key Laboratory of Laparoscopic Technology of Zhejiang Province, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
- Department of Thoracic Surgery, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Tunan Yu
- Key Laboratory of Laparoscopic Technology of Zhejiang Province, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
- Department of General Surgery, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Jiulong Wang
- Department of General Surgery, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Fangqiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou Medical College, Hangzhou, China
| | - Haibo Gong
- Department of Research and Development, Ningbo Trandomed 3D Medical Technology Co., Ltd, Ningbo, Zhejiang, China
| | - Haiying Dong
- Department of Oncology, Hangzhou Medical College, Hangzhou, China
| | - Xinzhong He
- Department of Hepatobiliary and Pancreatic Surgery, The First People's Hospital of Tongxiang City, Jiaxing, Zhejiang, China
| | - Zhifei Wang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou Medical College, Hangzhou, China
| | - Jin Yang
- Key Laboratory of Laparoscopic Technology of Zhejiang Province, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
- Department of General Surgery, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
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Valero Liñán AS, Miota De Llama JI, González Masiá JA, Conde Inarejos B. Reinforced duct-mucosa anastomosis (REDMA). New alternative after cephalic duodepancreatectomy. Cir Esp 2022; 100:95-101. [PMID: 35123940 DOI: 10.1016/j.cireng.2022.01.001] [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: 05/04/2020] [Accepted: 11/02/2020] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Of the possible complications after a cephalic duodenopancreatectomy (CPD), the clinically relevant postoperative pancreatic fistula (PPF) is the most important, especially in patients with pancreas of a soft consistency. The main objective of this work is to analyze the different postsurgical complications, with special emphasis on the rate of PPF on soft pancreas with a risk of moderate/high PPF, and its incidence between the two different types of sutures used by our group (classic vs reinforced duct-mucosa anastomosis [REDMA]). METHODS Retrospective observational study, between January 2017 and March 2020, of patients undergoing CPD in our unit after applying the inclusion and exclusion criteria. Analysis of preoperative, intraoperative factors and postoperative complications observed during follow-up. RESULTS Sample of 34 patients; 67.6% (n = 23) of them under the classic protocol and 32.4% (n = 11) with REDMA. The only post-surgical complication in which we obtained statistical repercussion, without differences between cases and controls in terms of the risk of FPP, in favor of the REDMA anastomosis is that of FPP. Thanks to this surgical innovation, both the complications from stage IIIb, according to the Clavien-Dindo classification, and the mean hospital stay have also been reduced with statistical significance. CONCLUSIONS When REDMA reduces the rate of PPF in patients with moderate/high surgical risk of it, we consider it to be a useful alternative to consider in the reconstruction of transit after CPD.
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Affiliation(s)
- Antonio Serafín Valero Liñán
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Albacete, Albacete, Spain.
| | - José Ignacio Miota De Llama
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Albacete, Albacete, Spain
| | - José Antonio González Masiá
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Albacete, Albacete, Spain
| | - Belén Conde Inarejos
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario de Albacete, Albacete, Spain
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Trudeau MT, Casciani F, Ecker BL, Maggino L, Seykora TF, Puri P, McMillan MT, Miller B, Pratt WB, Asbun HJ, Ball CG, Bassi C, Behrman SW, Berger AC, Bloomston MP, Callery MP, Castillo CFD, Christein JD, Dillhoff ME, Dickson EJ, Dixon E, Fisher WE, House MG, Hughes SJ, Kent TS, Malleo G, Salem RR, Wolfgang CL, Zureikat AH, Vollmer CM. The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg 2022; 275:e463-e472. [PMID: 32541227 DOI: 10.1097/sla.0000000000004068] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. BACKGROUND The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. METHODS FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches. RESULTS The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). CONCLUSION Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.
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Affiliation(s)
- Maxwell T Trudeau
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Fabio Casciani
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Brett L Ecker
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laura Maggino
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Thomas F Seykora
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Priya Puri
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Matthew T McMillan
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Benjamin Miller
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wande B Pratt
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | - Adam C Berger
- Jefferson Medical College, Philadelphia, Pennsylvania
| | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - John D Christein
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Mary E Dillhoff
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | | | - Michael G House
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven J Hughes
- University of Florida College of Medicine, Jacksonville, Florida
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | | | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charles M Vollmer
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Fernandez-Placencia RM, Montenegro P, Guerrero M, Serrano M, Ortega E, Bravo M, Huanca L, Bertani S, Trejo JM, Webb P, Malca-Vasquez J, Taxa L, Lachos-Davila A, Celis-Zapata J, Luque-Vasquez C, Payet E, Ruiz E, Berrospi F. Survival after curative pancreaticoduodenectomy for ampullary adenocarcinoma in a South American population: A retrospective cohort study. World J Gastrointest Surg 2022; 14:24-35. [PMID: 35126860 PMCID: PMC8790327 DOI: 10.4240/wjgs.v14.i1.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/28/2021] [Accepted: 01/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ampullary adenocarcinoma (AAC) is a rare neoplasm that accounts for only 0.2% of all gastrointestinal cancers. Its incidence rate is lower than 6 cases per million people. Different prognostic factors have been described for AAC and are associated with a wide range of survival rates. However, these studies have been exclusively conducted in patients originating from Asian, European, and North American countries. AIM To evaluate the histopathologic predictors of overall survival (OS) in South American patients with AAC treated with curative pancreaticoduodenectomy (PD). METHODS We analyzed retrospective data from 83 AAC patients who underwent curative (R0) PD at the National Cancer Institute of Peru between January 2010 and October 2020 to identify histopathologic predictors of OS. RESULTS Sixty-nine percent of patients had developed intestinal-type AAC (69%), 23% had pancreatobiliary-type AAC, and 8% had other subtypes. Forty-one percent of patients were classified as Stage I, according to the AJCC 8th Edition. Recurrence occurred primarily in the liver (n = 8), peritoneum (n = 4), and lung (n = 4). Statistical analyses indicated that T3 tumour stage [hazard ratio (HR) of 6.4, 95% confidence interval (CI) of 2.5-16.3, P < 0.001], lymph node metastasis (HR: 4.5, 95%CI: 1.8-11.3, P = 0.001), and pancreatobiliary type (HR: 2.7, 95%CI: 1.2-6.2, P = 0.025) were independent predictors of OS. CONCLUSION Extended tumour stage (T3), pancreatobiliary type, and positive lymph node metastasis represent independent predictors of a lower OS rate in South American AAC patients who underwent curative PD.
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Affiliation(s)
| | - Paola Montenegro
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Melvy Guerrero
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Mariana Serrano
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Emperatriz Ortega
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Mercedes Bravo
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Lourdes Huanca
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Stéphane Bertani
- International Joint Laboratory of Molecular Anthopological Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
- Unite Pharmacochim & Pharmacol Dev, UMR152, F-31062 Toulouse, France
| | - Juan Manuel Trejo
- Department of Radiation Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Patricia Webb
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Jenny Malca-Vasquez
- Department of Radiation Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Luis Taxa
- Department of Pathology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Alberto Lachos-Davila
- Department of Radiation Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Juan Celis-Zapata
- Hepato-Pancreato-Biliary Section, Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Carlos Luque-Vasquez
- Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Eduardo Payet
- Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Eloy Ruiz
- Hepato-Pancreato-Biliary Section, Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
| | - Francisco Berrospi
- Hepato-Pancreato-Biliary Section, Department of Abdominal Surgery, Instituto Nacional de Enfermedades Neoplasicas, Lima 15038, Peru
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Marchegiani G, Crippa S, Perri G, Rancoita PMV, Caravati A, Belfiori G, Dall'Olio T, Aleotti F, Partelli S, Bassi C, Falconi M, Salvia R. Surgery for Intraductal Papillary Mucinous Neoplasms of the Pancreas: Preoperative Factors Tipping the Scale of Decision-Making. Ann Surg Oncol 2022; 29:3206-3214. [PMID: 35072863 PMCID: PMC8989932 DOI: 10.1245/s10434-022-11326-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/27/2021] [Indexed: 12/14/2022]
Abstract
Background Decision-making in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas depends on scaling the risk of malignancy with the surgical burden of a pancreatectomy. This study aimed to develop a preoperative, disease-specific tool to predict surgical morbidity for IPMNs. Methods Based on preoperative variables of resected IPMNs at two high-volume institutions, classification tree analysis was applied to derive a predictive model identifying the risk factors for major morbidity (Clavien–Dindo ≥3) and postoperative pancreatic insufficiency. Results Among 524 patients, 289 (55.2%) underwent pancreaticoduodenectomy (PD), 144 (27.5%) underwent distal pancreatectomy (DP), and 91 (17.4%) underwent total pancreatectomy (TP) for main-duct (18.7%), branch-duct (12.6%), or mixed-type (68.7%) IPMN. For 98 (18.7%) of the patients, major morbidity developed. The classification tree distinguished different probabilities of major complications based on the type of surgery (area under the surve [AUC] 0.70; 95% confidence interval [CI], 0.63–0.77). Among the DP patients, the presence of preoperative diabetes identified two risk classes with respective probabilities of 5% and 25% for the development of major morbidity, whereas among the PD/TP patients, three different classes with respective probabilities of 15%, 20%, and 36% were identified according to age and body mass index (BMI). Overall, history of diabetes, age, and cyst size segregated three different risk classes for new-onset/worsening diabetes. Conclusions In presumed IPMNs, the disease-specific risk of major morbidity and pancreatic insufficiency can be determined in the preoperative setting and used to personalize the possible surgical indication. Age and overweight status in case of PD/TP and diabetes in case of DP tip the scale toward less aggressive clinical management in the absence of features suggestive for malignancy. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-11326-5.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy.
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Paola M V Rancoita
- University Centre of Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Tommaso Dall'Olio
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
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Connor S. OUP accepted manuscript. BJS Open 2022; 6:6573989. [PMID: 35470379 PMCID: PMC9039119 DOI: 10.1093/bjsopen/zrac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Saxon Connor
- Department of Surgery, Canterbury District Health Board, Christchurch, New Zealand
- Correspondence to: Saxon Connor (e-mail: )
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Commentary on Brief Clinical Report: "Coronary Artery Stent for Securing High-risk Pancreatico-jejunal Anastomosis After Pancreaticoduodenectomy: A pilot series". Ann Surg 2021; 275:e669. [PMID: 34913892 DOI: 10.1097/sla.0000000000005344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Protective peritoneal patch for arteries during pancreatoduodenectomy: good value for money. Langenbecks Arch Surg 2021; 407:377-382. [PMID: 34812937 DOI: 10.1007/s00423-021-02345-z] [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: 05/04/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study proposes and details a simple and inexpensive protective technique of wrapping the hepatic and gastroduodenal artery stumps with a peritoneal patch during pancreatoduodenectomy (PD) in order to decrease post-pancreatectomy hemorrhage (PPH). METHODS Among the 85 patients who underwent PD between July 2020 and March 2021, 16 patients with high-risk pancreatic anastomosis received a peritoneal patch. The Updated Alternative Fistula Risk Score (ua-FRS) was calculated. Post-operative pancreatic fistula (POPF) and PPH were diagnosed and graded according to the International Study Group of Pancreatic Surgery. The mortality rate was calculated up to 90 days after PD. RESULTS The mean ua-FRS of the 16 patients was 43% (range: 21-63%). Among them, 6 (38%) experienced clinically relevant-POPF, and a PPH was observed in two patients (13%). In these two patients who required re-intervention, the peritoneal patch was remarkably intact, and neither the gastroduodenal stump nor hepatic artery was involved. None of the patients experienced 90-day mortality. CONCLUSION Although the outcomes are encouraging, the evaluation of a larger series to assess the effectiveness of the peritoneal protective patch for arteries in a high-risk pancreatic anastomosis is ongoing.
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Coronary Artery Stent for Securing High-risk Pancreatico-jejunal Anastomosis After Pancreatoduodenectomy: A Pilot Series. Ann Surg 2021; 275:e665-e668. [PMID: 34793356 DOI: 10.1097/sla.0000000000005316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the feasibility and clinical utility of coronary artery stent (CAS) in securing pancreatico-jejunal anastomosis (PJ) and avoid stent displacement after pancreatoduodenectomy (PD). SUMMARY BACKGROUND DATA Externalized trans-anastomotic stent (ETS) is a standard mitigation strategy for postoperative pancreatic fistula (POPF) in high-risk patients. However, major morbidity remains extremely elevated, especially in case of ETS malfunction due to displacement. METHODS A pilot series of 72 patients underwent PD and PJ with CAS positioning between January 2016 and December 2019. All patients were at high-risk for POPF (soft pancreatic texture; main pancreatic duct diameter ≤ 3 mm) and underwent a CT-scan at postoperative day 5 and 10 to assess the correct CAS positioning. Postoperative outcomes were analyzed, and displacement rates were compared with a cohort of 141 patients with the same high-risk characteristics, undergoing PD with PJ and externalized trans-anastomotic stent (ETS). RESULTS No CAS-related complications were registered in the study group. In particular, no CAS displacement was registered, compared to a 28% ETS malfunction (either displacement or occlusion). The POPF rate, major morbidity, and mortality were 11%, 6%, and 0% respectively. CONCLUSIONS The CAS positioning appears to be a feasible and safe mitigation strategy to secure PJ anastomosis after PD with high POPF risk avoiding stent displacement. Further validation and comparison with current standard of care is required in a prospective controlled setting.
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Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study. Langenbecks Arch Surg 2021; 407:1073-1081. [PMID: 34782930 DOI: 10.1007/s00423-021-02376-6] [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: 05/30/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). METHODS From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. RESULTS The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence. CONCLUSIONS For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.
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