Somatostatin Versus Octreotide for Prevention of Postoperative Pancreatic Fistula: The PREFIPS Randomized Clinical Trial: A FRENCH 007-ACHBT Study

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.

[Robotic Pancreatoduodenectomy: Variations of Modified Blumgarts Pancreatojejunostomy]

Die wichtigste Komplikation nach Pankreatoduodenektomie ist die klinisch relevante Pankreasfistel. Um die Rate an Komplikationen zu senken, ist eine routinierte und standardisierte Operationstechnik zur Anlage der Pankreatojejunostomie notwendig.

Die Pankreatoduodenektomie ist im multimodalen Setting der Goldstandard zur Behandlung des lokal begrenzten Pankreaskopfkarzinoms und weiterer Pathologien. Das robotische Verfahren bietet als innovatives minimalinvasives Verfahren Vorteile bez. Morbidität und Ergonomie.

Nach der Resektionsphase folgt die Rekonstruktion beginnend mit der Pankreatojejunostomie. Die aktuell meistverbreitete robotische Technik ist die Anastomose nach Blumgart: Dabei wird eine äußere Naht transpankreatisch zwischen Jejunalwand und dem gesamten Pankreasparenchym in ventrodorsaler Ausrichtung angelegt, die Spannungs- und Scherkräfte verteilt. Die innere Naht wird durch eine Duct-to-Mucosa-Naht des Pankreasganges mit einer kleinen Jejujunostomie erreicht. In diesem Manuskript werden verschiedene Varianten dieser Rekonstruktion in robotischer Technik gezeigt.

Hinsichtlich der wissenschaftlichen Evidenz zeigt keine Anastomosenvariante einen Vorteil. Das Outcome ist abhängig von der Expertise des Operateurs, entsprechend sollte diejenige Anastomosentechnik angewendet werden, für die am meisten Erfahrung verfügbar ist. Die in diesem Beitrag gezeigten Variationen sollen für Anwender den Fokus auf wichtige Details legen sowie Tipps und Tricks zur Durchführung geben.

Survival outcomes after caudate lobectomy for hepatocellular carcinoma: systematic review and meta-analysis

BACKGROUND

Caudate lobectomy (CLB) remains the most effective treatment for caudate lobe hepatocellular carcinoma (CL-HCC). However, there is controversy regarding the survival after CLB. This meta-analysis aims to investigate the survival outcomes following CLB for the treatment of CL-HCC.

METHODS

In line with PRISMA and MOOSE guidelines, a search for all eligible studies was performed. The pooled estimates of survival rates and hazard ratios (HRs) with their 95% confidence intervals (CIs) were calculated using fixed- or random-effects models.

RESULTS

Sixteen studies comprising 864 patients met the inclusion criteria. The pooled estimates of 3- and 5-year overall survival (OS) rates were 62.3% and 42.9% respectively and the pooled estimate of 3- and 5-year recurrence-free survival (RFS) rates were 39.3% and 24.4% respectively. CL-HCC showed inferior OS (HR:1.39, 95% CI: 0.91-1.88, P < 0.001) and RFS (HR:1.33, 95% CI: 1.10-1.56, P < 0.001) than other sites HCC. Isolated CLB showed better OS (HR:0.9, 95% CI:0.39-1.41, p < 0.001) and RFS (HR:0.76, 95% CI: 0.03-1.5, P = 0.04) than combined CLB.

CONCLUSIONS

The survival outcomes for CL-HCC after CLB are lower compared to other sites HCC. Isolated CLB offers better survival outcomes compared to combined CLB. However, choosing isolated or combined approaches should be prioritized according to patient and tumour characteristics.

Real-time fluorescence imaging with indocyanine green during laparoscopic duodenum-preserving pancreatic head resection

BACKGROUND

Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) is a surgical method used to treat benign and low-grade malignant pancreatic head tumors. This study aimed to determine the protective effect of common bile duct in LDPPHR using indocyanine green (ICG) fluorescence imaging.

METHODS

A retrospective analysis of 30 patients treated with LDPPHR at the Second Affiliated Hospital of Nanchang University between January 2015 and November 2022 was performed. Patients were divided into two groups based on ICG use: ICG and non-ICG.

RESULTS

Thirty patients received LDPPHR, 11 males and 19 females, and the age was 50.50 (M (IQR)) years (range: 19-76 years). LDPPHR was successfully performed in 27 (90 %) patients, LPD was performed in 1 (3 %) patient, and laparotomy conversion was performed in 2 (7 %) patients. One patient (3 %) died 21 days after surgery. The incidence of intraoperative bile duct injury in the ICG group was lower than that in the non-ICG group (10 % vs 60 %, P = 0.009), and the operation time in the ICG group was shorter than that in the non-ICG group (311.9 ± 14.97 vs 338.05 ± 18.75 min, P < 0.05). Postoperative pancreatic fistula occurred in 16 patients (53 %), including 10 with biochemical leakage (62.5 %), four with grade B (25 %), and two with grade C (12.5 %). Postoperative bile leakage occurred in four patients (13 %).

CONCLUSIONS

The ICG fluorescence imaging technology in LDPPHR helps protect the integrity of the common bile duct and reduce the occurrence of intraoperative bile duct injury, postoperative bile leakage, and bile duct stenosis.

Surgical Perspectives of Open vs. Laparoscopic Approaches to Lateral Pancreaticojejunostomy: A Comprehensive Review

Pancreaticojejunostomy, a critical step in pancreatic surgery, has significantly evolved surgical approaches, including open, laparoscopic, and robotic techniques. This comprehensive review explores open surgery's historical success, advantages, and disadvantages, emphasizing surgeons' accrued experience and familiarity with this approach. However, heightened morbidity and prolonged recovery associated with open pancreaticojejunostomy underscore the need for a nuanced evaluation of alternatives. The advent of robotic-assisted surgery introduces a paradigm shift in pancreatic procedures. Enhanced dexterity, facilitated by wristed instruments, allows intricate suturing and precise tissue manipulation crucial in pancreatic surgery. Three-dimensional visualization augments surgeon perception, improving spatial orientation and anastomotic alignment. Moreover, the potential for a reduced learning curve may enhance accessibility, especially for surgeons transitioning from open techniques. Emerging technologies, including advanced imaging modalities and artificial intelligence, present promising avenues for refining both open and minimally invasive approaches. The ongoing pursuit of optimal outcomes mandates a judicious consideration of surgical techniques, incorporating technological advancements to navigate challenges and enhance patient care in pancreaticojejunostomy.

Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study

BACKGROUND

Pancreatoduodenectomy (PD) is the most effective surgical procedure to remove a pancreatic tumor, but the prevalent postoperative complications, including postoperative pancreatic fistula (POPF), can be life-threatening. Thus far, there is no consensus about the prevention of POPF.

AIM

To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy (PJ) on POPF development.

METHODS

We retrospectively collected and analyzed the data of 215 patients who underwent PD between January 2017 and February 2022 in our surgery center. The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis. Then, we stratified patients by anastomotic technique (end-to-side invagination PJ vs modified duct-to-mucosa PJ) to conduct a comparative study.

RESULTS

A total of 108 patients received traditional end-to-side invagination PJ, and 107 received modified duct-to-mucosa PJ. Overall, 58.6% of patients had various complications, and 0.9% of patients died after PD. Univariate and multivariate logistic regression analyses showed that anastomotic approaches, main pancreatic duct (MPD) diameter and pancreatic texture were significantly associated with the incidence of POPF. Additionally, the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2% and 283.4 min, respectively, which were significantly lower than those in patients receiving traditional end-to-side invagination PJ (27.8% and 333.2 minutes).

CONCLUSION

Anastomotic approach, MPD diameter and pancreatic texture are major risk factors for POPF development. Compared with traditional end-to-side invagination PJ, modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF. Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

Postoperative pancreatitis and pancreatic fistulae: a review of current evidence

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.

Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience

OBJECTIVE

Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage.

METHODS

We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group).

RESULTS

There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding).

CONCLUSION

Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.

Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy

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.

Comparisons of short-term outcomes of anastomotic methods of duct-to-mucosa pancreaticojejunostomy: out-layer continuous suture versus modified Blumgart method

Purpose

Postoperative pancreatic fistula (POPF) is the most troublesome complication after pancreaticojejunostomy (PJ). This study aimed to compare the short-term outcomes of 2 different methods of duct-to-mucosa PJ; out-layer continuous suture anastomosis (OCA) and the modified Blumgart method (mBM).

Methods

This retrospective cohort study enrolled patients who underwent curative-intent, open PD between 2015 and 2020. In mBM, 2 transpancreatic U-sutures were performed between the pancreatic margin and jejunum, with reinforced sutures in the central region. Patient demographics, diagnosis, intraoperative factors, postoperative complications, and POPF defined by the International Study Group on Pancreatic Fistula were investigated. Clinically relevant POPF (CR-POPF) included grades B and C POPF.

Results

A total of 184 patients underwent OCA, and 96 patients underwent mBM. The mBM group had more patients who underwent neoadjuvant therapy. The fistula risk scores were comparable between the 2 groups. Both groups showed no significant differences in CR-POPF and overall surgical complication rates. The total operation time was comparable, although the operation time for PJ was shorter in mBM.

Conclusion

No significant differences were observed in the postoperative outcomes between each group; the operation time for PJ in mBM was shorter. Therefore, mBM may be considered for utilization in duct-to-mucosa PJ.

Modified binding pancreaticogastrostomy vs modified Blumgart pancreaticojejunostomy after laparoscopic pancreaticoduodenectomy for pancreatic or periampullary tumors

BACKGROUND

Laparoscopic pancreaticoenteric anastomosis is one of the technically challenging steps of minimally invasive pancreaticoduodenectomy (PD), especially during the learning curve. Despite multiple randomized controlled trials and meta-analyses, the type of pancreatico-enteric anastomosis as a risk factor for post-pancreatectomy complications is debatable. Also, the ideal technique of pancreatic reconstruction during the learning curve of laparoscopic PD has not been well studied.

AIM

To compare the short-term outcomes of modified binding pancreaticogastrostomy (PG) and Blumgart pancreaticojejunostomy (PJ) during learning curve of laparoscopic PD.

METHODS

The first 25 patients with resectable pancreatic or periampullary tumors who underwent laparoscopic PD with modified binding PG or modified Blumgart PJ between January 2015 and May 2020 were retrospectively analyzed to compare perioperative outcomes during the same learning curve. A single layer of the full-thickness purse-string suture was placed around the posterior gastrotomy in the modified binding PG. In the modified Blumgart technique, only a single transpancreatic horizontal mattress suture was placed on either side of the pancreatic duct (total two sutures) to secure the pancreatic parenchyma to the jejunum. Also, on the ventral surface, the knot is tied on the jejunal wall without going through the pancreatic parenchyma. Post pancreatectomy complications are graded as per the International Study Group for Pancreatic Surgery criteria.

RESULTS

During the study period, modified binding PG was performed in 27 patients and modified Blumgart PJ in 29 patients. The demographic and clinical parameters of the first 25 patients included in both groups were comparable. Lower end cholangiocarcinoma and ampullary adenocarcinoma were the primary indications for laparoscopic PD in both groups (32/50, 64%). The median operative time for pancreatic reconstruction was significantly lower in the binding PG group (42 vs 58 min, P = 0.01). The clinically relevant (Grade B/C) postoperative pancreatic fistula (POPF) was significantly more in the modified PJ group (28% vs 4%, P = 0.04). In contrast, intraluminal postpancreatectomy hemorrhage (PPH) was more in the binding PG group (32% vs 4%, P = 0.02). There was no significant difference in the incidence of delayed gastric emptying between the two groups.

CONCLUSION

During the learning curve of laparoscopic PD, modified binding PG reduces POPF but is associated with increased intraluminal PPH compared to PJ using the modified Blumgart technique.

Comparison of early postoperative outcomes between omega-like duct-to-mucosa pancreatojejunostomy and conventional duct-to-mucosa pancreatojejunostomy after pancreaticoduodenectomy

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.

Incidence of postoperative pancreatic fistula after using a defined pancreaticojejunostomy technique for laparoscopic pancreaticoduodenectomy: A prospective multicenter study on 1033 patients

OBJECTIVE

This prospective multicenter study aimed to study the incidence of postoperative pancreatice fistula using a defined technique of pancreaticojejunostomy (PJ) in laparoscopic pancreaticoduodenectomy (LPD).

BACKGROUND

PJ is a technically challenging and time-consuming procedure in LPD. Up to now, only a few small sample size studies have been reported on various PJ techniques in LPD, none of which has widely been accepted by surgeons.

METHODS

This prospective study enrolled consecutive patients who underwent LPD using a defined technique of PJ at four institutions in China between January 2017 and December 2020.

RESULTS

Of 1045 patients, after excluding 12 patients (1.2%) due to conversion to open surgery, 1033 patients were analysed. The males comprised of 57.12% (590/1033), and females 42.88% (443/1033), with a mean age of 59.00 years. The mean ± s.d. operation time was (270.2 ± 101.8) min. The median time for PJ was 24min (IQR = 20.0-30.0). The overall incidence of postoperative pancreatic fistula was 12.6%, including 67 patients (6.5%) with Grade A biochemical leak, 50 patients (4.8%) with Grade B, and 13 patients (1.3%) with Grade C pancreatic fistulas. The overall incidence of major complications (Clavien-Dindo score ≥3) was 6.3% and the 30-day mortality was 2.8%.

CONCLUSION

The pancreaticojejunostomy technique for LPD was safe, simple and reproduceable with favorable clinical outcomes. However, further validations using high-quality RCTs are still required to confirm the findings of this study.

Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain.

OBJECTIVES

To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques.

SEARCH METHODS

We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes.

MAIN RESULTS

We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.

Surgical Strategy for Resecting Hepatocellular Carcinoma in the Caudate Lobe: Isolated or Combined Lobectomy? A Single-Center Study and Meta-Analysis

Background

Resection of hepatocellular carcinoma (HCC) originating in the caudate lobe remains challenging, while the optimal extent of resection is debated. We aimed to evaluate the relative benefits of combined caudate lobectomy (CCL) versus isolated caudate lobectomy (ICL) for caudate HCC.

Methods

Patients who underwent curative-intent resection for caudate HCC between January 2010 and December 2018 were identified from a single-center database. Surgical outcomes of the two strategy groups were analyzed before and after propensity score matching. A systematic review with meta-analysis was also performed to compare outcomes of CCL versus ICL for caudate HCC.

Results

A total of 28 patients were included: 11 in the CCL and 17 in the ICL group. Compared with ICL, the CCL group contained patients with larger tumors and a higher incidence of vascular invasion. After propensity score matching, 6 pairs of patients were selected. In the well-matched cohort, CCL demonstrated significantly improved recurrence-free survival (RFS) (P = 0.047) compared with ICL; no significant differences were noted for overall survival (OS), operation time, blood loss and morbidity rate. A total of 227 patients from nine eligible studies and ours were involved in the systematic review. Meta-analysis revealed that CCL provided better RFS (hazard ratio 0.54, 95% confidence interval 0.31–0.92) than ICL; no significant differences were observed in OS, operation time, blood loss and morbidity rate.

Conclusion

CCL confers superior RFS over ICL without compromise of perioperative outcomes and should be prioritized for patients with caudate HCC when feasible, especially for those with large-sized tumors.

Invaginated duct to mucosa pancreaticojejunostomy reduce postoperative pancreatic leakage: A matched case-controlled study

Postoperative pancreatic leakage is an obstacle in pancreaticoduodenectomy, which always follows pancreaticojejunostomy (PJ) failure. Dozens of PJ procedures have been reported, and none have shown superiority over others. Therefore, the present study is conducted to assess the potential advantages of invaginated duct-to-mucosa (D-M) PJ.We retrospectively analyze the related data from patients who underwent pancreaticodedunostomy due to malignant tumors at the First Affiliated Hospital of Henan University of Science and Technology from January 2017 to August 2019. According to the different PJ procedures, the patients are divided into custom D-M group and invaginated D-M group. Matching by sex, age, pancreatic duct size, and pancreatic texture is performed. Pancreatic leakage and other complications are compared, and SPSS 16.0 is employed for analysis.A total of 48 pairs of patients are included. Patients in both groups has almost the same baseline characteristics in terms of sex (P = 1.000), age (P = .897), American Society of Anesthesiologists status (P = .575), body mass index (P = .873), pancreatic duct size (P = .932), pancreatic texture (P = 1.000) and tumor origin (P = .686). No significant difference is observed in operative outcomes, such as operative duration (P = .632), PJ duration (P = .748), blood loss (P = .617) and number of required transfusions (P = .523). Pancreatic leakage is significantly decreased in the invaginated D-M group (P = .005). The differences in other complications, such as bleeding (P = .617), biliary leakage (P = .646), pneumonia (P = .594) and thrombosis (P = .714), do not reach statistical significance. The postoperative hospitalization duration is almost the same for both groups (P = .764).Invaginated D-M PJ may reduce pancreatic leakage following pancreaticoduodenectomy.

A novel anastomosis technique facilitates pancreaticojejunostomy in total laparoscopic pancreaticoduodenectomy (with video)

BACKGROUND

While the best technique for pancreatic anastomosis during Whipple's procedure remains controversial, laparoscopic pancreaticoduodenectomy (LPD) has been rapidly increasing in popularity. Because of their feasibility and reliability, new pancreatic anastomosis techniques may have vital roles when adapted for LPD. Here, we describe a new pancreaticojejunostomy (PJ) technique using three sutures (termed the "three sutures" PJ technique), which facilitates pancreatic anastomosis during total LPD.

METHODS

A total of 149 patients who underwent LPD using the "three sutures" PJ technique at three hospitals were included in this study (81 patients at Guangdong Provincial People's Hospital [GDPH], 60 patients at Sun Yat-Sen Memorial Hospital [SMH], and 8 patients at Affiliated Hospital of Guangdong Medical University [AHGMU]). Data on the demographic characteristics, operative outcomes, and postoperative results (pancreatic fistula rate, mortality rate, and length of hospital stay) of these patients were collected and analyzed.

RESULTS

A surgical video showing the details of the "three sutures" PJ method was included. The mean operation times at GDPH, SMH, and AHGMU were 4.08 ± 0.99 h, 4.65 ± 1.53 h, and 4.67 ± 0.64 h, respectively, and the average PJ times were 17.96 ± 3.49 min, 18.19 ± 2.63 min, and 22.5 ± 3.96 min, respectively. The numbers of grade B pancreatic fistulas were 9 (11.11%), 2 (3.33%), and 1 (12.50%), respectively, and two patients had grade C fistulas, one each at GDPH and SMH. The numbers of clinically relevant postoperative pancreatic fistula (CR-POPF) were 10 (12.35%), 3 (5.00%), and 1 (12.50%) in each center, respectively. The overall rate of CR-POPF was 9.40% (14/149) among patients of all three centers. The perioperative mortality rate was 0%.

CONCLUSIONS

The "three sutures" PJ technique for total LPD is a safe and reliable method, with a low risk of pancreatic fistula, short anastomosis time, and steep learning curve.

Long-term clinical outcomes of patients receiving proton beam therapy for caudate lobe hepatocellular carcinoma

Hepatocellular carcinoma (HCC) located in the caudate lobe (caudate HCC) is rare; however, patients with this type of tumour have poorer prognoses than those with HCC in other segments. Despite many published reports on the clinical usefulness of proton beam therapy (PBT) for HCC, data on the clinical outcomes of patients undergoing PBT for caudate HCC remain scarce. Therefore, the present study aimed to investigate the outcomes of this group of patients. Thirty patients with caudate HCC who underwent definitive PBT between February 2002 and February 2014 were retrospectively analysed. The total irradiation doses ranged from 55 to 77 (median 72.6) Gy relative biological dose. The median follow-up period was 37.5 (range, 3.0-152.0) months. The overall survival (OS) rates at one, three and five years were 86.6%, 62.8% and 46.1%, respectively. According to univariate and multivariate analyses, Child-Pugh A (P < 0.01), having a single tumour (P = 0.02) and a low serum alpha-fetoprotein level (AFP; P < 0.01) were significant factors predicting longer survival. The local control (LC) rates at one, three and five years were 100%, 85.9% and 85.9%, respectively, while the corresponding progression-free survival (PFS) rates were 65%, 27.5% and 22%, respectively. No grade 3 or worse adverse events were observed. PBT is effective and safe for the treatment of caudate HCC, and should therefore be considered a feasible option for intervention in patients with this disease.

Pancreatic adenocarcinoma: A review of recent paradigms and advances in epidemiology, clinical diagnosis and management

Pancreatic cancer is one of the dreaded malignancies for both the patient and the clinician. The five-year survival rate of pancreatic adenocarcinoma (PDA) is as low as 2% despite multimodality treatment even in the best hands. As per the Global Cancer Observatory of the International Agency for Research in Cancer estimates of pancreatic cancer, by 2040, a 61.7% increase is expected in the total number of cases globally. With the widespread availability of next-generation sequencing, the entire genome of the tumors is being sequenced regularly, providing insight into their pathogenesis. As invasive PDA arises from pancreatic intraepithelial neoplasia and mucinous neoplasm and intraductal papillary neoplasm, screening for them can be beneficial as the disease is curable with resection at an early stage. Routine preoperative biliary drainage has no role in patients suffering from PDA with obstructive jaundice. If performed, metallic stents are preferred over plastic ones. Minimally invasive procedures are preferred to open procedures as they have less morbidity. The duct-to-mucosa technique for pancreaticojejunostomy is presently widely practiced. The role of intraperitoneal drains after surgery for PDA is controversial. Neoadjuvant chemoradiotherapy has been proven to have a significant role both in locally advanced as well as in resectable PDA. Many new regimens and drugs have been added in the arsenal of chemoradiotherapy for metastatic disease. The roles of immunotherapy and gene therapy in PDA are being investigated. This review article is intended to improve the understanding of the readers with respect to the latest updates of PDA, which may help to trigger new research ideas and make better management decisions.

Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases

INTRODUCTION

There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique.

PATIENTS AND METHODS

A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting.

RESULTS

Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively.

CONCLUSIONS

Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Rate of Post-Operative Pancreatic Fistula after Robotic-Assisted Pancreaticoduodenectomy with Pancreato-Jejunostomy versus Pancreato-Gastrostomy: A Retrospective Case Matched Comparative Study

BACKGROUND

Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported.

METHODS

The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula.

RESULTS

Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients.

CONCLUSIONS

The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula.

New score for prediction of morbidity in patients undergoing open pancreaticoduodenectomy

Objective

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is commonly used to predict the risk of postoperative complications in general surgery. However, use of the POSSUM is not absolutely suitable for open pancreaticoduodenectomy (OPD), which has unique complications such as pancreatic fistula formation. This study was performed to establish a new risk score for assessing the incidence of postoperative complications of OPD.

Methods

This retrospective case-control study involved 159 patients who underwent standard OPD from 2 January 2017 to 1 February 2019. The risk factors for post-OPD complications were statistically investigated, and a risk score model was established by multivariate logistic regression.

Results

Among all 159 patients, 72 (42.28%) developed complications. A scoring system was developed based on the following five independent variables: sodium concentration of <141.20 mmol/L, white blood cell count of >6.35 × 10⁹/L, pancreatic texture grade, body mass index of >25.06 kg/m², and basic respiratory diseases. Our risk score model demonstrated better discriminating power, prediction power, and prediction probability than the POSSUM model in the receiver operating characteristic curve analysis.

Conclusion

This novel risk score may help to predict postoperative complications after OPD with higher accuracy than the POSSUM system.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BACKGROUND

Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.

METHODS

A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon.

RESULTS

Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.

CONCLUSION

A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

Blumgart Anastomosis After Pancreaticoduodenectomy. A Comprehensive Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

The superiority of Blumgart anastomosis (BA) over non-BA duct to mucosa (non-BA DtoM) still remains under debate.

METHODS

We performed a systematic search of studies comparing BA to non-BA DtoM. The primary endpoint was CR-POPF. Postoperative morbidity and mortality, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), reoperation rate, and length of stay (LOS) were evaluated as secondary endpoints. The meta-analysis was carried out using random effect. The results were reported as odds ratio (OR), risk difference (RD), weighted mean difference (WMD), and number needed to treat (NNT).

RESULTS

Twelve papers involving 2368 patients: 1075 BA and 1193 non-BA DtoM were included. Regarding the primary endpoint, BA was superior to non-BA DtoM (RD = 0.10; 95% CI: -0.16 to -0.04; NNT = 9). The multivariate ORs' meta-analysis confirmed BA's protective role (OR 0.26; 95% CI: 0.09 to 0.79). BA was superior to DtoM regarding overall morbidity (RD = -0.10; 95% CI: -0.18 to -0.02; NNT = 25), PPH (RD = -0.03; 95% CI -0.06 to -0.01; NNT = 33), and LOS (- 4.2 days; -7.1 to -1.2 95% CI).

CONCLUSION

BA seems to be superior to non-BA DtoM in avoiding CR-POPF.

Ultrasound-guided percutaneous microwave ablation for hepatocellular carcinoma originating in the caudate lobe: A pilot clinical study

Objective

This study aimed to evaluate the efficacy, feasibility, and tolerability of ultrasound (US)-guided percutaneous microwave ablation (MWA) for treating hepatocellular carcinoma (HCC) originating in the caudate lobe.

Materials and Methods

The treatment and survival parameters of 32 patients with HCC in the caudate lobe, who met the inclusion criteria and had received US-guided percutaneous MWA in our department from November 2010 to October 2015, were retrospectively analyzed. Imaging examination (contrast-enhanced computed tomography or magnetic resonance) 1 month after MWA was used to evaluate the efficacy of US-guided MWA.

Results

Thirty-two patients underwent percutaneous MWA for caudate lobe HCC. The average tumor size was 3.42 ± 0.27 (range: 1-6.8) cm. The initial complete ablation (CA) rate was 87.5% (28/32), and the total CA rate was 96.88% (31/32). Furthermore, the median length of hospitalization was 4 days (range: 2-10 days), and no major complication was observed in this study. The overall survival rates were 87.5%, 50%, and 28.13% at 1, 2, and 3 years, respectively. The progression-free survival after MWA was 93.75%, 53.15%, and 28.13% at 6, 12, and 18 months, respectively.

Conclusions

US-guided percutaneous MWA was a safe and effective treatment. It is a promising alternative therapy for HCC originating in the caudate lobe.

What should we trust to define, predict and assess pancreatic fistula after pancreatectomy?

OBJECTIVE

The ISGPF postoperative pancreatic fistula (POPF) definition using amylase drain concentration is widely used. However, the interest of lipase drain concentration, daily drain output and absolute enzyme daily production (concentration x daily drain volume) have been poorly investigated.

MATERIAL AND METHODS

These predictive on postoperative day (POD) 1, 3, 5 and 7 were analyzed in a development cohort, and subsequently tested in an independent validation cohort.

RESULTS

Of the 227 patients of the development cohort, 17% developed a biochemical fistula and 34% a POPF (Grade B/C). Strong correlation was found between amylase/lipase drain concentration at all postoperative days (ρ = 0.90; p = 0.001). Amylase and lipase were both significantly higher in patients with a POPF (p < 0.001) presenting an equivalent under the ROC curve area (0.85 vs 0.84; p = 0.466). Combining POD1 and POD3 threefold enzyme cut-off value increased significantly POPF prediction sensibility (97.4% vs 77.8%) and NPV (97.1% vs 86.3%). These results were also confirmed in the validation cohort of 554 patients. Finally, absolute enzyme daily production and daily drain output were significantly higher in patients with a POPF (p < 0.001) but did not add clinical value when compared to drain enzyme concentration.

CONCLUSION

Lipase is as effective as amylase drain concentration to define POPF. Absolute enzyme daily production or daily drain output do not help to better predict clinically significant POPF occurrence and severity. Lipase and amylase should mainly be used for their negative predictive value to predict the absence of clinically significant POPF and could allow early drain removal and hospital discharge.

Pancreaticoduodenectomy and external Wirsung stenting: our outcomes in 80 cases

INTRODUCTION

There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique.

PATIENTS AND METHODS

A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting.

RESULTS

Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively.

CONCLUSIONS

Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas

INTRODUCTION

Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear.

AREAS COVERED

This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications.

EXPERT OPINION

No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.

The individualized selection of Pancreaticoenteric anastomosis in Pancreaticoduodenectomy

Background

The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula.

Methods

Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group.

Results

From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3 mm, BMI ≥ 25, operation time > 330 min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p < 0.05).

Conclusions

Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.

Surgical indication and strategy for liver hemangioma in the caudate lobe: a multi-institutional retrospective analysis with 137 patients

Objective

To investigate the surgical indication and tactics for liver hemangioma in the caudate lobe

Methods

From January 1994 to July 2019, 137 patients, including 51 males and 86 females with the average age of 49.2 years old were diagnosed with liver hemangioma in caudate lobe and received treatment at five tertiary referral hospitals. Clinical features, correlations between tumor size and clinical manifestations, treatments, and prognosis were analyzed.

Results

Of the 137 patients identified, 40 (29.20%) patients were asymptomatic, whereas other 94 patients had clinical symptoms mainly presented as upper abdominal discomfort, epigastric distention, upper abdominal dull pain, nausea, and vomiting. Fifteen (93.75%), 18 (39.13%), and 7 (10.45%) patients presented no clinical symptoms among those tumor size was less than 3 cm (D ≤ 3 cm, n = 16), 3 cm < D ≤ 6 cm (n = 46), and 6 cm < D ≤ 9 cm (n = 67), respectively, while all 8 patients with tumor larger than 9 cm were symptomatic. Tumor diameter was obviously associated with the presence of clinical symptoms. In follow-up period, 7 patients in the conservative group (n = 39) received surgery because of tumor growth or symptom appearance. Totally 105 patients received operation including partial resection or isolated complete resection of caudate lobe and caudate lobe resection combined with liver segment resection, right liver resection, or left liver resection. All operations went smoothly, and no severe complications appeared.

Conclusion

Tumor diameter was obviously associated with the presence of clinical symptoms in patients with hemangioma in caudate lobe. Surgical therapy is not recommended for asymptomatic patients and available for patient who has symptoms. Effective surgical strategies should be put into use to reduce operative bleeding.

Binding Pancreaticojejunostomy: Is It Safe?

Background:

Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ.

Methods:

The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality.

Results:

A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality.

Conclusion:

BPJ is safe and is associated with a low incidence of POPF.

Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) remains the main cause of surgery related mortality after pancreaticoduodenectomy. Various pancreatoenteric anastomosis methods have been developed to reduce the POPF rate. However, the optimum choice has not been clarified. A literature search is performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing modified Blumgart anastomosis with interrupted transpancreatic suture are included in this meta-analysis. Grade B/C POPF, overall POPF rate and overall sever complication rate (Clavien-Dindo classification IIIa or more) are measured as primary outcomes. Revman 5.3 was used to perform the analysis. Five retrospective comparative studies and 1 randomized controlled trial with a total number of 1409 patients are included in our analysis. Meta-analysis revealed that modified Blumgart anastomosis is associated with lower rate of grade B/C POPF [Odds Ratio (OR) 95% confidence interval (CI),0.32 (0.12-0.84); P = 0.02] and intra-abdominal abscess [OR 95%CI, 0.43 (0.29-0.65); P < 0.01] comparing with interrupted transpancreatic suture. However, this procedure could not reduce overall POPF [OR 95%CI,0.70 (0.34-1.44); P = 0.34] and overall sever complication rate [OR 95%CI,0.91 (0.48-1.72); P = 0.77]. At current level of evidence, modified Blumgart anastomosis is superior to interrupted transpancreatic suture in terms of grade B/C POPF and intra-abdominal abscess. However, high-grade evidence will be necessary to confirm these results.

Stereotactic radiofrequency ablation of primary liver tumors in the caudate lobe

BACKGROUND

The encasement of the caudate lobe by a vascular ring of large vessels may apart from the technical difficulties in needle placement increase the probability of local recurrence after thermal ablation due to cooling effects. This single-center retrospective study evaluates the results after multiprobe stereotactic radiofrequency ablation (SRFA) of hepatocellular carcinoma (HCC) in the caudate lobe.

METHODS

Twenty patients underwent 24 multiple-probe SRFA sessions for the treatment of 24 HCCs in the caudate lobe. Eight of twenty patients had initially solitary tumors, the remaining 12 patients suffered from multifocal disease.

RESULTS

The median tumor size was 1.5 cm (range: 1-8 cm). After a mean follow-up of 21 months one local recurrence in the caudate lobe was observed resulting in a local recurrence rate of 4.2% (1/24). The overall survival rates at 1, 3, and 5 years from the date of the first SRFA were 95%, 59%, and 44%, respectively, with a median overall survival of 51.3 months. The disease-free survival after SRFA was 48%, 24% and 24%, at 1, 3 and 5 years, respectively. One patient suffering from Child C liver cirrhosis died due to septic shock 26 days after SRFA and one postinterventional complication required minimal invasive interventional treatment.

CONCLUSION

Multiprobe SRFA for HCC in the caudate lobe appears to be safe and feasible. The overall outcome is at least comparable to that of surgical resection, with low perioperative mortality and only minimal morbidity.

Factors associated with failure of enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy

BACKGROUND

The enhanced recovery after surgery (ERAS) protocol is an evidence-based perioperative care program aimed at reducing surgical stress response and accelerating recovery. However, a small proportion of patients fail to benefit from the ERAS program following pancreaticoduodenectomy. This study aimed to identify the risk factors associated with failure of ERAS program in pancreaticoduodenectomy.

METHODS

Between May 2014 and December 2017, 176 patients were managed with ERAS program following pancreaticoduodenectomy. ERAS failure was indicated by prolonged hospital stay, unplanned readmission or unplanned reoperation. Demographics, postoperative recovery and compliance were compared of those ERAS failure groups to the ERAS success group.

RESULTS

ERAS failure occurred in 59 patients, 33 of whom had prolonged hospital stay, 18 were readmitted to hospital within 30 days after discharge, and 8 accepted reoperation. Preoperative American Society of Anesthesiologists (ASA) score of ≥III (OR = 2.736; 95% CI: 1.276-6.939; P = 0.028) and albumin (ALB) level of <35 g/L (OR = 3.589; 95% CI: 1.403-9.181; P = 0.008) were independent risk factors associated with prolonged hospital stay. Elderly patients (>70 years) were on a high risk of unplanned reoperation (62.5% vs. 23.1%, P = 0.026). Patients with prolonged hospital stay and unplanned reoperation had delayed intake and increased intolerance of oral foods. Prolonged stay patients got off bed later than ERAS success patients did (65 h vs. 46 h, P = 0.012). Unplanned reoperation patients tended to experience severer pain than ERAS success patients did (3 score vs. 2 score, P = 0.035).

CONCLUSIONS

Patients with high ASA score, low ALB level or age >70 years were at high risk of ERAS failure in pancreaticoduodenectomy. These preoperative demographic and clinical characteristics are important determinants to obtain successful postoperative recovery in ERAS program.

Pancreaticojejunostomy-a review of modern techniques

Background

Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods.

Purpose

The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF.

Conclusions

Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.

Critical appraisal of the techniques of pancreatic anastomosis following pancreaticoduodenectomy: A network meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile.

METHODS

A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula (ISGPF) definition of POPF. The primary outcome was clinically relevant POPF.

RESULTS

Five techniques of pancreatic anastomosis following PD were directly compared in 15 RCTs comprising 2428 patients. Panreatojejunostomy (PJ) end-to-side invagination vs. PJ end-to-side duct-to-mucosa was the most frequent comparison (n = 7). Overall, 971 patients underwent PJ end-to-side duct-to-mucosa, 791 patients PJ end-to-side invagination, 505 patients pancreatogastrostomy (PG) end-to-side invagination, 98 patients PG end-to-side duct-to-mucosa, and 63 patients PJ end-to-side single layer. PG duct-to-mucosa was associated with the lowest rates of clinically relevant POPF, delayed gastric emptying, intra-abdominal abscess, all postoperative morbidity and postoperative mortality, the shortest operative time and postoperative hospital stay and the lowest volume of intra-operative blood loss.

CONCLUSION

Duct-to-mucosa pancreaticogastrostomy was associated with the lowest rates of clinically relevant POPF and had the best outcome profile among all techniques of pancreatico-anastomosis following PD.

Pancreatogastrostomy vs pancreatojejunostomy after pancreaticoduodenectomy: An updated meta-analysis of RCTs and our experience

BACKGROUND

Pancreatoduodenectomy (PD) is one of the most important operations in hepatobiliary and pancreatic surgery.

AIM

To evaluate the advantages and disadvantages of pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG).

METHODS

This meta-analysis was performed using Review Manager 5.3. All clinical randomized controlled trials, in which patients underwent PD with pancreatico-digestive tract reconstruction via PJ or PG, were included.

RESULTS

The search of PubMed, Wanfang Data, EMBASE, and the Cochrane Library provided 125 citations. After further analysis, 11 trials were included from nine counties. In all, 909 patients underwent PG and 856 underwent PJ. Meta-analysis showed that pancreatic fistula (PF) was a significantly lower morbidity in the PG group than in the PJ group (odds ratio [OR] = 0.67, 95% confidence interval [CI]: 0.53-0.86, P = 0.002); however, grades B and C PF was not significantly different between the two groups (OR = 0.61, 95%CI: 0.34-1.09, P = 0.09). Postoperative hemorrhage showed a significantly lower morbidity in the PJ group than in the PG group (OR = 1.47, 95%CI: 1.05-2.06, P = 0.03). Delayed gastric emptying was not significantly different between the two groups (OR = 1.09, 95%CI: 0.83-1.41, P = 0.54).

CONCLUSION

There is no difference in the incidence of grades B and C PF between the two groups. However, postoperative bleeding is significantly higher in PG than in PJ. Binding PJ or binding PG is a safe and secure technique according to our decades of experience.

WITHDRAWN: Individualized and pancreatic duct diameter-based strategy for pancreaticoenteric anastomosis during pancreaticoduodenectomy

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An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION

Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies.

METHODS

We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured.

RESULTS

We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9).

CONCLUSION

CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries.

LEVEL OF EVIDENCE

Epidemiologic/Diagnostic study, level III.

Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes

BACKGROUND

Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes.

METHODS

We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors.

RESULTS

The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay.

CONCLUSION

Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.

Modified duct-to-mucosa versus conventional pancreaticoenterostomy for pancreaticoduodenectomy: a retrospective cohort study based on propensity score matching analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common neopathy after pancreatoduodenectomy (PD). An ideal pancreaticoenterostomy (PE) which can effectively reduce the incidence of CR-POPF and its potential neopathy is needed. We aimed to assess the efficacy of our modified duct-to-mucosa PE in the PD.

METHOD

From January 2011 to December 2017, 233 consecutive patients with PD were retrospectively included from Shenzhen People's Hospital. After propensity score matching (PSM), there were 82 patients in both the modified duct-to-mucosa PE group (group A) and the conventional end-to-side inserting PE group (group B), respectively. The clinical course and the incidence of postoperative neopathy were compared between groups. Logistic regression method was utilized to analyze the association between PE approach and CR-POPF.

RESULTS

The PE time was shorter in group A (9.3 ± 1.8 min vs. 21.5 ± 2.8 min, P < 0.001). The group A had significantly lower incidence of severe neopathy (Clavien-Dindo grade > II) [7.3% (5/82) vs. 17.1% (14/82), P = 0.028] and incidence of CR-POPF [1.2% (1/82) vs. 19.5% (12/82), P < 0.001] than the group B. Our modified duct-to-mucosa PE technique was associated with a reduced risk for CR-POPF (OR, 0.11 [95% CI, 0.02-0.57]; P = 0.009) as compared with the conventional end-to-side inserting PE.

CONCLUSION

Compared with conventional end-to-side inserting PE, our modified duct-to-mucosa PE technique can effectively reduce the incidences of postoperative neopathy and CR-POPF.

TRIAL REGISTRATION

Researchregistry3877 . Registered 24 March 2018. Retrospectively registered.

Clinical significance of drain fluid culture after pancreaticoduodenectomy

BACKGROUND

The mechanism of infected postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD) is undefined. Drain amylase has been used to predict POPF, whereas little data are available about the value of drain fluid culture. The aim was to investigate the incidence, risk factors and association with surgical outcomes of positive drainage culture (PDC) after PD.

METHODS

A single-center retrospective analysis was conducted of prospectively collected data from patients who underwent PD between January 2005 and December 2015. Drain fluid samples were obtained for microbiological analysis after surgery. Risk factors for PDC were evaluated, and its influence on surgical outcomes was explored.

RESULTS

Of 768 patients, 261 (34%) had PDC during the postoperative period. Among them, a total of 434 isolates were yielded. One hundred and seven (24.7%) were Gram-positive, 283 (65.2%) Gram-negative, and 44 (10.1%) fungi. Multivariate analysis revealed that body mass index (BMI) ≥25 kg/m² , preoperative chemoradiation and intra-operative red blood cell transfusion were independent risk factors for PDC. PDC was associated with higher incidences of complications including POPF, major complications and reoperation, but with no correlation between the day of PDC and complications. BMI ≥25 kg/m² , early PDC (≤3 days), main pancreatic duct <3 mm, and soft pancreas were revealed as independent predictors for POPF. There was a correlation between type of microorganisms and complications.

CONCLUSION

Considering the correlation between PDC and postoperative complications, preventive measures are crucial to improve outcomes after PD. Whether antibiotic treatment for early PDC will alter the clinical course of POPF needs further evaluation.

Polyester sutures for pancreaticojejunostomy protect against postoperative pancreatic fistula: a case-control, risk-adjusted analysis

BACKGROUND

There is wide variability in the use of suture material for pancreatic anastomosis after pancreaticoduodenectomy (PD). This study evaluates the role of suture material on clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticojejunostomy (PJ) in a risk-adjusted setting.

METHODS

A retrospective study comparing (polyester) PE with polydioxanone (PDO) in 520 PDs. Patients were matched for risk for CR-POPF according to the fistula risk score (FRS) with the propensity score.

RESULTS

The matched PE and PDO groups consisted of 232 patients. The incidence of CR-POPF was lower for PE group (11.6 vs. 22%, p<0.01), with a lower rate of grade B (10.3 vs. 15.5%, p<0.01) and C (1.3 vs. 6.5%, p<0.01). After stratifying by fistula risk zone, PE suture remained associated with a reduced incidence of CR-POPF (9.4 vs. 15.6% low-, p = 0.04; 15.6 vs. 28.1% intermediate-, p = 0.02; 16.7 vs. 83.3% high-risk zone, p<0.01, respectively). Multivariable analysis demonstrated that pancreatic texture, preoperative diagnosis, FRS and the use of PE sutures were independent predictors of CR-POPF.

CONCLUSIONS

In the setting of a case-control matched for risk analysis, the use of PE suture for PJ is associated with a significant reduction of CR-POPF.