Pancreatic fistula rate after pancreatic resection. The importance of definitions

Assessment of acute obstructive pancreatitis by magnetic resonance imaging: Predicting the occurrence of pancreatic fistula following pancreatoduodenectomy

The aim of the present study was to assess the effect of preoperative acute obstructive pancreatitis on the risk of the occurrence of pancreatic fistula (PF) following pancreaticoduodenectomy. A total of 22 patients who developed postoperative PF were carefully matched with 22 control patients without PF according to demographic data, pancreatic pathology, presenting symptoms and other surgery-associated parameters. These parameters were compared between these two groups. The mean pancreatic apparent diffusion coefficient (ADC) values in the fistula group were 1.14±0.31×10^-3 mm²/s, which was significantly decreased compared with the non-fistula group (1.48±0.44×10^-3 mm²/s) (P=0.005). The pancreas-muscle signal intensity (SI) ratio on fat-suppressed T1 weighted image (rT1) in the fistula group was 1.71±0.25, which was significantly increased compared with the non-fistula group (1.25±0.29) (P<0.001). The pancreas-muscle SI ratios on fat-suppressed T2 weighted image (T2WI) in the fistula group and the non-fistula group were 0.72±0.08 and 0.62±0.07, respectively (P=0.79). There was no significant difference in pancreas-muscle SI ratio on fat-suppressed T2-weighted image (rT2) value between these two groups. Based on the receiver operating characteristic curve, the optimal cut-off value of ADC as a criterion for prediction of pancreatic fistula was 1.29×10^-3 mm²/s, which yielded a sensitivity of 77.3% and a specificity of 63.6%. In conclusion, the severity of acute obstructive pancreatitis was negatively associated with ADC values and pancreas-muscle SI ratio on rT1 images, which may be useful for predicting the occurrence of PF preoperatively.

Magnetic compression anastomosis for biliojejunostomy and pancreaticojejunostomy in Whipple's procedure: An initial clinical study

BACKGROUND AND AIM

Magnetic anastomosis has been attempted in biliary and intestinal reconstruction. The objective of the current study was to introduce an initial clinical use of magnetic compression anastomosis for pancreaticojejunostomy and biliojejunostomy in Whipple's procedure.

METHODS

Patients with peri-ampullary carcinoma and dilated bile and pancreatic ducts were prospectively enrolled from 2016 to 2017. After pancreaticoduodenectomy, an appropriate mother magnet and drainage tube was placed in the proximal bile duct and pancreatic duct. The daughter magnets were introduced to mate with the mother magnets at the anastomotic sites. A close postoperative surveillance and routine cholangiopancreaticography via the drainage tube were performed.

RESULTS

One female and three male patients with a median age of 69 years (range, 57-77) were included. The diameter of the common bile ducts and pancreatic ducts ranged from 8 to 15 mm, and 7 to 10 mm, respectively. The median time duration for biliojejunostomy and pancreaticojejunostomy was 7 (range, 5-8 min) min and 9 (range, 8-10 min) min, respectively. The median time of biliojejunostomy and pancreaticojejunostomy formation was 17 (range, 15-21 days) days and 11 (range, 10-18 days), respectively. With a median follow up of 313 days, one patient developed biliary anastomotic stricture at 11 months after surgery, and underwent stent placement via percutaneous transhepatic drainage sinus, and recovered well.

CONCLUSIONS

Magnetic anastomosis is safe, effective, and simple for both biliojejunostomy and pancreaticojejunostomy in Whipple's procedure.

Neoadjuvant FOLFIRINOX for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer: Results of a Decision Analysis

Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial between competing strategies. This article analyzes a mathematical decision‐analytic model to estimate the long‐term clinical outcomes and cost‐effectiveness of neoadjuvant FOLFIRINOX compared with surgery followed by adjuvant gemcitabine monotherapy or gemcitabine/capecitabine for patients with potentially resectable pancreatic ductal adenocarcinoma.

Background.

The effectiveness and cost‐effectiveness of using neoadjuvant FOLFIRINOX (nFOLFIRINOX) for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC) are unknown. Our objective was to determine whether nFOLFIRINOX is more effective or cost‐effective for patients with BR/LA PDAC compared with upfront resection surgery and adjuvant gemcitabine plus capecitabine (GEM/CAPE) or gemcitabine monotherapy (GEM).

Materials and Methods.

We performed a decision‐analysis to assess the value of nFOLFIRINOX versus GEM/CAPE or GEM using a mathematical simulation model. Model transition probabilities were estimated using published and institutional clinical data. Model outcomes included overall and disease‐free survival, quality‐adjusted life‐years (QALYs), cost in U.S. dollars, and cost‐effectiveness expressed as an incremental cost‐effectiveness ratio. Deterministic and probabilistic sensitivity analyses explored the uncertainty of model assumptions.

Results.

Model results found median overall survival (34.5/28.0/22.0 months) and disease‐free survival (15.0/14.0/13.0 months) were better for nFOLFIRINOX compared with GEM/CAPE and GEM. nFOLFIRINOX was the optimal strategy on an efficiency frontier, resulting in an additional 0.35 life‐years, or 0.30 QALYs, at a cost of $46,200/QALY gained compared with GEM/CAPE. Sensitivity analysis found that cancer recurrence and complete resection rates most affected model results, but were otherwise robust. Probabilistic sensitivity analyses found that nFOLFIRINOX was cost‐effective 92.4% of the time at a willingness‐to‐pay threshold of $100,000/QALY.

Conclusion.

Our modeling analysis suggests that nFOLFIRINOX is preferable to upfront surgery for patients with BR/LA PDAC from both an effectiveness and cost‐effectiveness standpoint. Additional clinical data that further define the long‐term effectiveness of nFOLFIRINOX are needed to confirm our results.

Implications for Practice.

Increasingly, neoadjuvant FOLFIRINOX has been used for borderline resectable and locally advanced pancreatic cancer with the goal of rendering them resectable and decreasing risk of recurrence. Despite many efforts to show the benefits of neoadjuvant over adjuvant therapies, clinical evidence to guide this decision is largely lacking. Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial. This modeling analysis suggests that neoadjuvant FOLFIRINOX is preferable to upfront surgery and adjuvant therapies by various outcome metrics including quality‐adjusted life years, overall survival, and incremental cost‐effectiveness ratio.

WITHDRAWN: A personal technical experience and results of a modified end-to-side technique of pancreatojejunostomy: A 350 patients retrospective cohort study

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Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-analysis of RCTs Applying the ISGPS (2016) Criteria

The goal of our study was to compare the impact of pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) on the incidence of complications after pancreaticoduodenectomy. A systematic search was performed using RevMan 5.3 software. A meta-analysis showed that PG was not superior to PJ in terms of postoperative pancreatic fistula (POPF). In multicenter randomized controlled trials, the incidence of POPF was lower in patients undergoing PG than in those undergoing PJ. However, PG was associated with an increased risk of postoperative intraluminal hemorrhage, but no significant difference was observed between 2-layer PG and PJ. No significant differences were found in the rate of overall delayed gastric emptying, biliary fistula, reoperation, mortality, and morbidity. PG and PJ have similar incidences of POPF, but PG could be slightly superior to PJ in multicenter trials. However, this analysis verifies that PG has a higher rate of postpancreatectomy hemorrhage. Of note, a 2-layer anastomosis could reduce the occurrence of postpancreatectomy hemorrhage.

Selection of pancreaticojejunostomy technique after pancreaticoduodenectomy: duct-to-mucosa anastomosis is not better than invagination anastomosis: A meta-analysis

BACKGROUND

One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD.

METHODS

A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software.

RESULTS

Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89-1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups.

CONCLUSION

The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.

A novel technique of pancreaticojejunostomy for laparoscopic pancreaticoduodenectomy

BACKGROUND

Pancreaticojejunostomy (PJ) reconstruction is the Achilles' heel of laparoscopic pancreaticoduodenectomy (LPD). However, only a few studies have focused on the performance of this difficult procedure laparoscopically.

METHODS

We present a safe and feasible technique of duct-to-mucosa pancreaticojejunostomy for LPD, named Bing's anastomosis. Our study included 238 cases of LPDs that underwent Bing's anastomosis. Data on the demographic characteristics, operative outcomes (total operative time, PJ duration, and estimated blood loss), and postoperative results (length of hospital stay, recovery of bowel function, and rates of postoperative morbidity and mortality) of the cases were prospectively collected and retrospectively analyzed.

RESULTS

Only one patient (0.4%) in our series required conversion to open surgery as a result of uncontrolled bleeding from the superior mesenteric artery. The average operative time was 358 min (220 min to 495 min). The mean duration for PJ was 23 min (19 min to 33 min). The mean estimated blood loss was 112 ml (50 ml to 800 ml). The overall incidence of pancreatic fistula was 21.4% and included 42 cases (17.6%) of biochemical leak, eight cases (3.4%) of Grade B, and one case (0.4%) of Grade C pancreatic fistulas. The 90-day mortality was 0.4%.

CONCLUSIONS

Bing's anastomosis is a safe, reliable, and rapid PJ technique for LPD that is associated with favorable outcomes and a low risk of pancreatic fistula. However, its safety and feasibility should be verified by performing prospective randomized controlled trials at different institutions.

A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy

BACKGROUND

Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is lacking. This systematic review and meta-analysis aims to provide an online overview of all pancreatic anastomosis techniques and to evaluate the incidence of clinically relevant POPF in randomized controlled trials (RCTs).

METHODS

A literature search was performed to December 2017. Included were studies giving a detailed description of the pancreatic anastomosis after open pancreatoduodenectomy and RCTs comparing techniques for the incidence of POPF (International Study Group of Pancreatic Surgery [ISGPS] Grade B/C). Meta-analyses were performed using a random-effects model.

RESULTS

A total of 61 different anastomoses were found and summarized in 19 subgroups (www.pancreatic-anastomosis.com). In 6 RCTs, the POPF rate was 12% after pancreaticogastrostomy (n = 69/555) versus 20% after pancreaticojejunostomy (n = 106/531) (RR0.59; 95%CI 0.35-1.01, P = 0.05). Six RCTs comparing subtypes of pancreaticojejunostomy showed a pooled POPF rate of 10% (n = 109/1057). Duct-to-mucosa and invagination pancreaticojejunostomy showed similar results, respectively 14% (n = 39/278) versus 10% (n = 27/278) (RR1.40, 95%CI 0.47-4.15, P = 0.54).

CONCLUSION

The proposed online overview can be used as an interactive platform, for uniformity in reporting anastomotic techniques and for educational purposes. The meta-analysis showed no significant difference in POPF rate between pancreatic anastomosis techniques.

Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality

Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).

Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses.

Results: Invagination patients had higher serum albumin (p < 0.01) and lower body mass index (p < 0.01), were less likely to have a preoperative biliary stent (p < 0.01), and were more likely to have a soft gland (p < 0.01). PJ anastomosis type was not associated with morbidity but was associated with mortality (duct-to-mucosa vs. invagination, odds ratio = 0.22, p < 0.01). Among patients who developed a clinically relevant pancreatic fistula, none of the 119 duct-to-mucosa, compared with 5 of 21 invagination, patients died (p < 0.01).

Conclusion: Patients who undergo a PJ by duct-to-mucosa or invagination differ with respect to preoperative and intraoperative variables. When an invagination PJ leaks, there may be a greater influence on mortality than when a duct-to-mucosa PJ leaks.

32 Consecutive Cases of Whipple's Operation with Single-Layer End to Side Dunking Pancreatojejunostomy Without Any Pancreatic Fistula: Our Institutional Experience

The aim of this paper is to study the outcome of single-layer end to side dunking pancreatojejunostomy technique in 32 patients of malignant pancreatic disease undergoing Whipple's surgery in a tertiary care oncology centre in India. From January 2013 to January 2016, 32 consecutive patients who underwent pancreatoduodenectomy for malignant diseases were analysed retrospectively. All the patients underwent standard Whipple's operation. Pancreatojejunostomy was established in a single-layer end to side dunking manner with PDS 4-0. Various patient data, i.e. preoperative symptoms and demography, intra-operative time, blood loss and need of blood transfusion, postoperative hospital stay and complications, were noted. Mean operative time was 3.5 h approximately. Mean blood loss was 328 ml approx (range 150-600 ml). Postoperative delayed gastric emptying was observed in 8 (25%) patients. Three (9.4%) patients developed superficial surgical site infection. Mean hospital stay was 16.5 days (range 13-20 days). There were no pancreatic leak or fistula and no perioperative mortality. It is a feasible technique. It achieved zero leak rates, zero mortality and minimal morbidity without compromising any oncologic principles.

Acinar cell density at the pancreatic resection margin is associated with post-pancreatectomy pancreatitis and the development of postoperative pancreatic fistula

BACKGROUND

There has been recent evidence supporting post-pancreatectomy pancreatitis as a factor in the development of postoperative pancreatic fistula (POPF). The aims of this study were to evaluate: (i) the correlation of the acinar cell density at the pancreatic resection margin with the intra-operative amylase concentration (IOAC) of peri-pancreatic fluid, postoperative pancreatitis, and POPF; and (ii) the association between postoperative pancreatitis on the first postoperative day and POPF.

METHODS

Consecutive patients who underwent pancreatic resection between June 2016 and July 2017 were included for analysis. Fluid for IOAC was collected, and amylase concentration was determined in drain fluid on postoperative days 1, 3, and 5. Serum amylase and lipase and urinary trypsinogen-2 concentrations were determined on the first postoperative day. Histology slides of the pancreatic resection margin were scored for acinar cell density.

RESULTS

Sixty-one patients were included in the analysis. Acinar cell density significantly correlated with IOAC (r = 0.566, p < 0.001), and was significantly associated with postoperative pancreatitis (p < 0.001), and POPF (p = 0.003). Postoperative pancreatitis was significantly associated with the development of POPF (OR 17.81, 95%CI 2.17-145.9, p = 0.001).

DISCUSSION

The development of POPF may involve a complex interaction between acinar cell density, immediate leakage of pancreatic fluid, and postoperative pancreatitis.

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.

Use and acceptance of the International Study Group for Pancreatic Fistula (ISGPF) definition and criteria in the surgical literature

BACKGROUND

The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has not be quantified. The aim of this study was to determine the uptake of the ISGPF definition and evaluate its use in the surgical literature.

METHODS

A sample of primary studies, review articles, and textbooks were identified through screening of literature searches. Included citations were assessed for their definition of POPF and use of the ISGPF criteria.

RESULTS

From 2006 to 2009, 6%-63% of primary papers were compliant with the ISGPF definition compared to 84%-98% from 2010 onwards. Of the primary studies compliant with the ISGPF criteria, 36% focused on grade B and C fistula and 15% did not report grade A fistula. 88% of European papers used the criteria compared to 77% and 72% of Asian and North American papers, respectively (p = 0.033). 46% of review articles and textbooks did not define POPF. Among those that defined POPF, 74% cited the ISGPF definition exclusively while 26% mentioned other definitions.

CONCLUSION

The ISGPF criteria have been widely adopted and accepted as the standard for defining POPF, although the utility of grade A fistulas is questionable.

Modifications in the International Study Group for Pancreatic Surgery (ISGPS) definition of postoperative pancreatic fistula

Postoperative pancreatic fistula (POPF) remains the major postoperative cause of morbidity and mortality following pancreatic surgery. Since 2005, the International Study Group of Pancreatic Fistula (ISGPF) definition and classification has been adopted worldwide allowing the comparison among different surgical approaches and mitigation strategies. Over the last 11 years, several limitations have emerged from clinical practice and in 2016 the International Study Group for Pancreatic Surgery (ISGPS) updated the POPF definition and grading system. Objectives of this review article were to summarize modifications in the updated ISGPS definition and to illustrate their clinical impact.

The pancreatic juice length in the stent tube as the predicting factor of clinical relevant postoperative pancreatic fistula after pancreaticoduodenectomy

Several risk factors for pancreatic fistula had been widely reported, but there was no research focusing on the exocrine output of remnant gland.During the study period of January 2015 to September 2016, 82 patients accepted pancreaticoduodenectomy (PD, end-to-end dunking pancreaticojejunostomy with internal stent tube). All the data were collected, including preoperative medical status, operative course, final pathology, gland texture, pancreatic duct diameter, size of the stent, length of pancreatic juice in the stent tube, width of the pancreatic stump, diameter of the jejunum and the status of postoperative pancreatic fistula (POPF). POPF was defined according to International Study Group of Pancreatic Fistula criteria.The diameter of pancreatic duct in the POPF group was significantly smaller than that in the group without POPF (1.99 vs 2.90 mm, P = .000). The length of pancreatic juice in the stent tube in the POPF group was significantly longer than that in the group without POPF (18.04 vs 6.92 cm, P = .014). There were more pancreatic ductal adenocarcinoma cases and hard glands in the group without POPF. The length of pancreatic juice in the clinically relevant postoperative pancreatic fistula (CR-POPF) group was significantly longer than that in the grade A group (32.4 vs 9.21 cm, P = .000). Multivariate analysis identified gland texture and length of pancreatic juice as independent predictors for pancreatic fistula. Multivariate analysis also identified the length of pancreatic juice as an independent predictor for CR-POPF.The length of pancreatic juice in the stent tube might be a useful predictive factor of POPF after PD, especially for CR-POPF.

Laparoscopic distal resection of the pancreas. Can be all resections of body and tail of the pancreas called the same?

Introduction

Distal resection of the pancreas is a routine procedure in high-volume centres. However, the volume of this procedure can vary. This variation plays a very important role in laparoscopic approach of pancreatic surgery and can be a real challenge if the anatomical situation is underestimated.

Aim of the study

To present our experience in minimally invasive treatment of the pancreatic tumours and to discuss different approaches to different anatomical situations.

Material and methods

We performed a retrospective analysis of patients, who underwent laparoscopic pancreas resection for pancreatic cancer in our hospital since 2014 to 2016 February. According to extension of operation, patients were divided into two groups: distal pancreatectomy and left hemipancreatectomy for cases that required preparation of the portal vein. Demographic characteristics, and operative and postoperative data were compared between both groups.

Results

Out of 16 patients, distal pancreatectomy was performed for 7 (43.8%) and left hemipancreatectomy for 9 (56.2%) patients. For 1 (14.3%) laparoscopic distal pancreatectomy and for 2 (22.2%) laparoscopic left hemipancreatectomy patients surgical conversion to laparotomy was performed. The average operation time was 205 (195–245) min for distal pancreatectomy and 412.5 (280–520) min for left hemipancreatectomy group (p = 0.001), blood loss 125 (20–250) ml and 250 (50–1800) ml accordingly (p = 0.138). Totally postoperative fistula occurred in 7 (43.8%) cases; out of them, 5 (71.4%) patients were from the left hemipancreatectomy group.

Conclusions

Laparoscopic left hemipancreatectomy is more complicated than distal pancreatectomy. Extension and technique selection of distal resection of the pancreas depends on the Yonsei criteria and tumour relation to the portal vein.

Factors associated with prolonged hospitalization in patients undergoing pancreatoduodenectomy

BACKGROUND

Complex surgeries such as a pancreatoduodenectomy (PD) traditionally have long hospital stays (LOS).

METHODS

Patients who underwent elective PD at our institution from 8/2011-6/2015 were retrospectively examined. Interquartile ranges were calculated from LOS. Patient were compared between the highest quartile and the remainder of the cohort.

RESULTS

492 patients had a median LOS of 9 days, with 106 (22%) admitted for >14 days. Characteristics associated with prolong hospitalization include age (p = 0.004) and preoperative albumin <3.5 (p = 0.007). Significant intra-operative measures associated with prolonged LOS were blood loss (EBL, p = 0.004) and increased operative time (p = 0.008). Any complication extended hospitalizations (p < 0.001). Patients in the top quartile were less likely to be discharged home (p < 0.0001) and more likely to be readmitted (p < 0.0001).

CONCLUSION

Older patients with hypoalbuminemia are at higher risk of prolonged LOS following PD as well as high EBL, operative time, and surgical complications. Focused efforts to counsel and optimize patients pre-operatively and minimize intra-operative complications may shorten hospital stays.

Drainage fluid and serum amylase levels accurately predict development of postoperative pancreatic fistula

AIM

To investigate potential biomarkers for predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).

METHODS

We prospectively recruited 83 patients to this study. All patients underwent PD (Child’s procedure) at the Division of Hepatobiliary and Pancreas Surgery at the First Bethune Hospital of Jilin University between June 2011 and April 2015. Data pertaining to demographic variables, clinical characteristics, texture of pancreas, surgical approach, histopathological results, white blood cell count, amylase and choline levels in the serum, pancreatic/gastric drainage fluid, and choline and amylase levels in abdominal drainage fluid were included in the analysis. Potential correlations between these parameters and postoperative complications such as, POPF, acute pancreatitis, hemorrhage, delayed gastric emptying, and biliary fistula, were assessed.

RESULTS

Twenty-eight out of the 83 (33.7%) patients developed POPF. The severity of POPF was classified as Grade A in 8 (28%) patients, grade B in 16 (58%), and grade C in 4 (14%), according to the pancreatic fistula criteria. On univariate and multivariate logistic regression analyses, higher amylase level in the abdominal drainage fluid on postoperative day (POD)1 and higher serum amylase levels on POD4 showed a significant correlation with POPF (P < 0.05). On receiver operating characteristic curve analysis, amylase cut-off level of 2365.5 U/L in the abdominal drainage fluid was associated with a 78.6% sensitivity and 80% specificity [area under the curve (AUC): 0.844; P = 0.009]. A cut-off serum amylase level of 44.2 U/L was associated with a 78.6% sensitivity and 70.9% specificity (AUC: 0.784; P = 0.05).

CONCLUSION

Amylase level in the abdominal drainage fluid on POD1 and serum amylase level on POD4 represent novel biomarkers associated with POPF development.

Neoadjuvant Therapy of Pancreatic Cancer: Definitions and Benefits

The standard treatment of resectable pancreatic cancer is surgery followed by adjuvant chemotherapy. Due to the complication rate of pancreatic surgery and the high rate of primary irresectability, neoadjuvant concepts are increasingly used for pancreatic cancer. Neoadjuvant therapy is better tolerated than adjuvant and might decrease the surgical complication rate from pancreatic surgery. In contrast to neoadjuvant chemoradiation, the nutritional status improves during neoadjuvant chemotherapy. Also, the survival of patients who develop postoperative complications after neoadjuvant therapy is comparable to those without complications whereas the survival of patients who underwent upfront surgery and then develop surgical complications is impaired. Moreover, large data base analyses suggest a down-sizing effect and improvement of overall survival by neoadjuvant therapy. Neoadjuvant chemotherapy appears to be equally efficient in converting irresectable in resectable disease and more efficient with regard to systemic tumor progression and overall survival compared to neoadjuvant chemoradiation therapy. Despite these convincing findings from mostly small phase II trials, neoadjuvant therapy has not yet proven superiority over upfront surgery in randomized trials.

Over-the-scope clip closure for treatment of post-pancreaticogastrostomy pancreatic fistula: A case series

BACKGROUND AND AIM

The over-the-scope clip (OTSC) system is a recently developed endoscopic device. In the last few years, it has been successfully used for severe bleeding or deep wall lesions, or perforations of the gastrointestinal (GI) tract. We hereby report a series of patients with post-pancreaticogastrostomy pancreatic fistula in whom OTSC were used as endoscopic treatment.

METHODS

From January 2012 to July 2015, we prospectively collected data on cases of postoperative pancreatic fistula. These patients underwent pancreaticoduodenectomy in a high-volume center of hepatobiliopancreatic surgery. After conservative management, OTSC closure was done by single skilled operators in anesthesiologist-assisted deep sedation.

RESULTS

A total of seven patients were enrolled. According to the International Study Group of Pancreatic Surgery criteria, we observed grade B postoperative pancreatic fistula in all cases. All patients were treated with 12/6 t-type OTSC. In two cases, a second clip was successfully applied to a second site adjacent to the original closure site. In all cases, subsequent fluoroscopy showed no contrastographic spreading through the wall. There were no complications related to the procedure itself, not from the endoscopy point of view, nor from the anesthesiological perspective. There were no device malfunctions. Further clinical and endoscopic evaluation was made 8 weeks later and showed no fistula or anastomotic defect recurrence. No patients required additional endoscopic or interventional procedures.

CONCLUSION

In consideration of clinical and technical success, OTSC placement in POPF seems to be effective, safe and technically relatively easy to carry out.

Intra-Operative Amylase Concentration in Peri-Pancreatic Fluid Predicts Pancreatic Fistula After Distal Pancreatectomy

Post-operative pancreatic fistula (POPF) is a potentially severe complication following distal pancreatectomy. The aim of this study was to assess the predictive value of intra-operative amylase concentration (IOAC) in peri-pancreatic fluid after distal pancreatectomy for the diagnosis of POPF. Consecutive patients who underwent a distal pancreatectomy between November 2014 and September 2016 were included in the analysis. IOAC was measured, followed by drain fluid analysis for amylase on post-operative days (PODs) 1, 3, and 5. Receiver operator characteristic (ROC) analysis was performed to evaluate the discriminative capacity of IOAC as a predictor of POPF. IOAC was measured after distal pancreatectomy in 26 patients. The IOAC correlated significantly with (i) PODs 1, 3, and 5 drain amylase (p < 0.01); (ii) the development of POPF (p < 0.01); and (iii) the Clavien-Dindo grade of surgical complications (p = 0.02). Eighty-three percent of patients with an IOAC > 1000 experienced a post-operative complication (OR 18.3, 95% CI 2.51-103, p < 0.01). ROC curve analysis confirmed the predictive relationship of IOAC and POPF as an excellent test with an area under the curve of 0.92 (95% CI 0.81-0.99, p < 0.01). Measurement of IOAC allows early and accurate categorization of patients at risk for POPF in distal pancreatectomy.

Pancreatic fistula risk for pancreatoduodenectomy: an international survey of surgeon perception

INTRODUCTION

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a morbid complication following pancreatoduodenectomy (PD). It is unclear how pancreatic surgeons perceive risk for this complication, and the implications thereof.

METHODS

A web-based survey was distributed to members of 22 international GI surgical societies. CR-POPF risk factors were categorized as follows: (i) patient factors, (ii) pancreatic gland characteristics, (iii) intraoperative variables, (iv) perioperative mitigation techniques, or (v) institutional features.

RESULTS

Surveys were completed by 897 surgeons worldwide. The most commonly cited contributors to CR-POPF risk were gland characteristics (90.7%), while patient and intraoperative factors were selected 71.2 and 69.3% of the time, respectively. Conversely, institutional features (31.7%) and perioperative mitigation techniques (21.3%) were rarely recognized. Eighty percent of surgeons use drain amylase concentration to guide drain removal decision-making; however, only 45.2% of surgeon remove drains early based upon drain amylase values. When evaluating clinical scenarios, surgeons were able to identify both negligible and high risk scenarios but struggled to differentiate between low and moderate CR-POPF risk.

CONCLUSION

This international study analyzed how surgeons discern CR-POPF risk for PD. There was considerable variability in surgeons' perceptions of risk, which may have an adverse effect on the clinical use of risk adjustment measures.

Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation

OBJECTIVE

To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.

BACKGROUND

Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk.

METHODS

This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance.

RESULTS

There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment.

CONCLUSIONS

This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

Anatomo-radiological patterns of pancreatic vascularization, with surgical implications: Clinical and anatomical study

The pancreas receives multiple arterial sources that should be considered in patients undergoing pancreatic surgery. The aim of this study is to describe pancreatic vascularization and to explore the anatomical basis of postoperative complications. Ten specimens from unembalmed cadavers, including the retroperitoneal vessels and organs and spleen, were injected with acrylic resins to obtain vascular casts. Thirty computed tomography angiographies (CTA) of subjects with no pancreatic pathology (mean age 70.9 years) were also analyzed. A paucivascular area at the neck of the pancreas was apparent in all vascular casts. At CTA: (1) the transverse pancreatic artery, the only artery running from the cervicocephalic to the somatocaudal segment, was visible in 76.9% of cases; (2) the splenic artery was suprapancreatic in 66.7% and intrapancreatic with a tortuous course in 33.3%; (3) the posterior superior pancreaticoduodenal artery was visible in 100% of cases, the anterior superior pancreatico-duodenal artery in 92.6%, the anterior inferior pancreaticoduodenal artery in 73.1%, the posterior inferior pancreaticoduodenal artery in 86.4%, the dorsal pancreatic artery in 65.4%, the great pancreatic artery in 73.1%, and the pancreatic arteries to the body and caudal pancreatic arteries in 96.2%. Our study demonstrated great individual variability of the pancreatic vasculature, which can be explored by CTA and could be relevant to surgical procedures. Clin. Anat. 30:614-624, 2017. © 2017 Wiley Periodicals, Inc.

Postoperative pancreatic fistula-impact on outcome, hospital cost and effects of centralization

BACKGROUND

One of the most serious complications after pancreaticoduodenectomy (PD) is postoperative pancreatic fistula (POPF). This study investigated the incidence of POPF before and after centralization of pancreatic surgery in Southern Sweden and its impact on outcome and health care costs.

METHODS

The local registry comprising all pancreatic resections at Skåne University Hospital, Lund, Sweden, was searched for PDs from 2005 to 2015. The patients were analysed in three groups: low-volume, high-volume and after introduction of an enhanced recovery program. Only the clinically relevant POPF grades B and C (CR-POPF) were investigated.

RESULTS

322 consecutive patients were identified. The annual operation volume increased almost threefold and the postoperative length of stay and total hospital cost decreased concurrently. The incidence of CR-POPF did not decrease over time. The group with CR-POPF had more complications and prolonged length of stay. The cost was 1.5 times higher for patients with CR-POPF and the cost did not decline despite the increase of hospital volume.

CONCLUSION

Centralization of pancreatic surgery did not decrease the rate of CR-POPF nor its subsequent impact on LOS and costs. Further efforts must be made to reduce the incidence of CR-POPF.

The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After

BACKGROUND

In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of the present report is to verify the value of the International Study Group of Pancreatic Fistula definition and grading of postoperative pancreatic fistula and to update the International Study Group of Pancreatic Fistula classification in light of recent evidence that has emerged, as well as to address the lingering controversies about the original definition and grading of postoperative pancreatic fistula.

METHODS

The International Study Group of Pancreatic Fistula reconvened as the International Study Group in Pancreatic Surgery in order to perform a review of the recent literature and consequently to update and revise the grading system of postoperative pancreatic fistula.

RESULTS

Based on the literature since 2005 investigating the validity and clinical use of the original International Study Group of Pancreatic Fistula classification, a clinically relevant postoperative pancreatic fistula is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. Consequently, the former "grade A postoperative pancreatic fistula" is now redefined and called a "biochemical leak," because it has no clinical importance and is no longer referred to a true pancreatic fistula. Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly. In particular, grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula.

CONCLUSION

This new definition and grading system of postoperative pancreatic fistula should lead to a more universally consistent evaluation of operative outcomes after pancreatic operation and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula. Use of this updated classification will also allow for more precise comparisons of surgical quality between surgeons and units who perform pancreatic surgery.

Impact of intra-abdominal absorbable sutures on surgical site infection in gastrointestinal and hepato-biliary-pancreatic surgery: results of a multicenter, randomized, prospective, phase II clinical trial

BACKGROUND

The use of absorbable sutures in wound closure has been shown to reduce the incidence of surgical site infection (SSI); however, there is no evidence that the intra-abdominal use of absorbable rather than silk sutures reduces the incidence of SSI after gastrointestinal surgery. We report the findings of a phase II trial, designed to evaluate the impact of the intra-abdominal use of absorbable sutures on the incidence of SSI.

METHODS

At 19 Japanese hospitals, 1147 patients undergoing elective gastrectomy, colorectal surgery, hepatectomy, or pancreaticoduodenectomy (PD) were randomly assigned to absorbable or silk intra-abdominal suture groups. The primary efficacy endpoint was the incidence of SSI. The secondary efficacy endpoints were the locations of SSI, time to resolution of SSI, length of hospital stay, and the incidence of bile leakage in hepatectomy and pancreatic fistula.

RESULTS

The incidence of SSI was 11.3%, 15.5%, 11.3%, and 36.9% after gastrectomy, colorectal surgery, hepatectomy, and PD, respectively. The incidence of SSI was higher in the absorbable suture group than in the silk suture group for all the surgical procedures, but the difference was not significant.

CONCLUSION

The intra-abdominal use of absorbable sutures did not have enough of an effect on the reduction of SSI in this phase II trial to justify the planning of a large-scale phase III trial.

Meta-analysis of invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: An update

OBJECTIVE

Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic review comparing the safety and efficacy of the two PJ techniques. Here, we added new evidence and updated our previous conclusion.

METHODS

We systematically searched multiple databases and included randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination techniques of PJ. The quality of evidence was assessed using Jadad score, and reporting bias was evaluated using funnel plots. Meta-analysis was performed using a random-effects model. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The primary outcome was pancreatic fistula, and the secondary outcomes included mortality, reoperation, morbidity and postoperative hospital stay. Trial sequential analysis was performed to calculate the required information size.

RESULTS

Seven RCTs with 850 participants were included. No significant difference was detected in the rates of pancreatic fistula (RR 0.98, 95% CI 0.63 to 1.53), mortality (RR 0.94, 95% CI 0.40 to 2.18), reoperation (RR 1.23, 95% CI 0.69 to 2.20) and morbidity (RR 0.98, 95% CI 0.82 to 1.16) between the two groups. However, patients who underwent duct-to-mucosa PJ had a significantly shorter postoperative hospital stay (mean difference -2.80, 95% CI -5.08 to -0.52). Trial sequential analysis showed that another 279 participants were needed for conclusive results.

CONCLUSIONS

Given the current evidence, duct-to-mucosa PJ did not decrease the rates of pancreatic fistula and other adverse events as compared to invagination PJ; however, it did reduce postoperative hospital stay. Further RCTs are needed.

Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review

BACKGROUND

Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.

METHODS

A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.

RESULTS

A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.

CONCLUSIONS

Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.

Perioperative application of somatostatin analogs for pancreatic surgery-current status in Germany

BACKGROUND

The most common major complication after pancreatic resection is the postoperative pancreatic fistula (POPF). Somatostatin analogs can reduce POPF, but the use of somatostatin analogs is still controversial. The aim of this study was to assess treatment algorithms for pancreatic surgery in Germany with a special focus on the application of somatostatin analogs.

METHODS

A questionnaire evaluating the perioperative management-especially the use of somatostatin analogs-and postoperative complications after pancreatic surgery was developed and sent to 209 German hospitals performing >12 pancreatoduodenectomies per year (the requirement for certification as a pancreas center). Statistical analysis was carried out using SPSS 21.

RESULTS

The final response rate was 77 % (160/209), 14.5 % of hospitals never, 37 % always, and 45 % occasionally apply somatostatin analogs after pancreatic surgery. A (standard) drug of choice was defined in 64 % of hospitals. When standard and occasional usage was analyzed, it appeared that hospitals favored somatostatin (69 %) > sandostatin (50 %) > pasireotide (5 %). A relation between the usage of the different somatostatin analogs and morbidity (POPF) or mortality (84 and 16 % of hospitals reported <5 and 5-10 %, respectively) was not seen. Eighty-seven percent of hospitals were interested in participating in future studies analyzing somatostatin use.

CONCLUSION

This is the first national survey in Germany evaluating the perioperative application of somatostatin analogs for pancreatic surgery. Despite controversial results in the literature, the majority of German pancreas surgeons apply somatostatin analogs perioperatively. The ideal drug to reduce POPF is still unclear. This uncertainty has aroused significant interest and prompted surgeons to participate in future studies in order to elucidate this issue.

Is total pancreatectomy as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy? A single center, prospective, observational study

BACKGROUND

Total pancreatectomy is actually considered a viable option in selected patients even if large comparative studies between partial versus total pancreatectomy are not currently available. Our aim was to evaluate whether total pancreatectomy can be considered as feasible, safe, efficacious, and cost-effective as pancreaticoduodenectomy.

METHODS

A single center, prospective, observational trial, regarding postoperative outcomes, long-term results, and cost-effectiveness, in a tertiary referral center was conducted, comparing consecutive patients who underwent elective total pancreatectomy and/or pancreaticoduodenectomy.

RESULTS

Seventy-three consecutive elective total pancreatectomies and 184 pancreaticoduodenectomies were compared. There were no significant differences regarding postoperative outcomes and overall survival. The quality of life, evaluated in 119 patients according to the EQ-5D-5L questionnaire, showed that there were no significant differences regarding the five items considered. The mean EQ-5D-5L score was similar in the two procedures (total pancreatectomy = 0.872, range 0.345-1.000; pancreaticoduodenectomy = 0.832, range 0.393-1.000; P = 0.320). The impact of diabetes according to the Problem Areas in Diabetes (PAID) questionnaire did not show any significant differences except for question 13 (total pancreatectomy = 0.60; pancreaticoduodenectomy = 0.19; P = 0.022). The cost-effectiveness analysis suggested that the quality-adjusted life year was not significantly different between the two procedures (total pancreatectomy = 0.910, range 0.345-1.000; pancreaticoduodenectomy = 0.910, range -0.393-1.000; P = 0.320).

CONCLUSIONS

From this study, it seems reasonable to suggest that total pancreatectomy can be considered as safe, feasible, and efficacious as PD and acceptable in terms of cost-effectiveness.

Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy.

METHODS

From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00.

RESULTS

No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group.

CONCLUSION

Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.

Pancreaticoureteral Fistula: A Rare Complication of Chronic Pancreatitis

Context:

Chronic pancreatitis is an inflammatory condition that may result in progressive parenchymal damage and fibrosis which can ultimately lead to destruction of pancreatic tissue. Fistulas to the pleura, peritoneum, pericardium, and peripancreatic organs may form as a complications of pancreatitis. This case report describes an exceedingly rare complication, pancreaticoureteral fistula (PUF). Only two additional cases of PUF have been reported. However, they evolved following traumatic injury to the ureter or pancreatic duct. No published reports describe PUF as a complication of pancreatitis.

Case Report:

A 69-year-old Hispanic female with a past medical history of cholecystectomy, pancreatic pseudocyst, and recurrent episodes of pancreatitis presented with severe, sharp, and constant abdominal pain. Upon imaging, a fistulous tract was visualized between the left renal pelvis (at the level of an upper pole calyx) and the pancreatic duct and a ureteral stent was placed to facilitate fistula closure. Following the procedure, the patient attained symptomatic relief and oral intake was resumed. A left retrograde pyelogram was repeated 2 months after the initial stent placement and demonstrating no evidence of a persistent fistulous tract.

Conclusion:

Due to PUF's unclear etiology and possible variance of presentation, it is important for physicians to keep this rare complication of pancreatitis in mind, especially, when evaluating a patient with recurrent pancreatitis, urinary symptoms and abnormal imaging within the urinary collecting system and pancreas.

Dunking pancreaticojejunostomy versus duct-to-mucosa anastomosis

Following the resectional aspect of pancreaticoduodenectomy, three anastomoses are used to reestablish gastrointestinal continuity. The pancreatic-enteric anastomosis is by far the most problematic, and has been considered by many the Achilles heel of the pancreaticoduodenal resection. Multiple clinical trials have been published focusing on improving outcomes of the pancreatic-enteric anastomosis, including elements such as the use of prophylactic octreotide, the use of sealants, stenting of the pancreatic duct, and surgical technique. There are two widely used methods to accomplish an end-to-side pancreaticojejunostomy (PJ) after pancreaticoduodenectomy: either invagination PJ or duct-to-mucosa PJ. Two prospective randomized trials have evaluated these techniques, the first a trial by Bassi and co-authors, and the second a trial by Berger et al. In this article we will focus on our current technique for both invagination pancreaticojejunostomy and duct-to-mucosa pancreaticojejunostomy, recognizing that careful surgical technique, surgeon experience, and surgical volume are factors that are important in yielding the best outcomes.

Pancreaticopericardial Fistula: A Case Report and Literature Review

Purpose. Pancreaticopericardial fistula (PPF) is an extremely rare complication of acute or chronic pancreatitis. This paper presents a rare case of PPF and provides systematic review of existing cases from 1970 to 2014. Methods. A PubMed search using key words was performed for all the cases of PPF from January 1970 to December 2014. Fourteen cases were included in the study. The cases were reviewed for demographic characteristics, diagnostic modalities, and treatment. Descriptive analysis of these variables was performed. Results. Median age was 43 years. 78% were known alcoholics and 73.3% had chronic pancreatitis. Dyspnea was present in 78%. Cardiac tamponade was present in 53%; 75% of patients had known chronic pancreatitis (RR = 0.74). Surgery was associated with best treatment outcomes and 50% of patients who underwent endoscopic treatment survived. Conclusion. PPF is a rare disease. This paper indicates that acute cardiac tamponade in patients with history of alcoholism and chronic pancreatitis could be a sign of an existing pancreaticopericardial fistula and early surgical intervention could be life-saving.

Postoperative biological and clinical outcomes following uncomplicated pancreaticoduodenectomy

Backgrounds/Aims

The aim of this study was to describe clinical and biological changes in a group of patients who underwent pancreaticoduodenectomy (PD) without any complication during the postoperative period. These changes reflect the "natural history" of PD, and a deviation should be considered as a warning sign.

Methods

Between January 2000 and December 2009, 131 patients underwent PD. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. Postoperative variables were validated using an external prospective database of 158 patients.

Results

The mean postoperative length of hospital stay was 20.3±4 days. The mean number of days until removal of nasogastric tube was 6.3±1.6 days. The maximal fall in hemoglobin level occurred on day 3 and began to increase after postoperative day (POD) 5, in patients with or without transfusions. The white blood cell count increased on POD 1 and persisted until POD 7. There was a marked rise in aminotransferase levels at POD 3. The peak was significantly higher in patients with hepatic pedicle occlusion (866±236 IU/L versus 146±48 IU/L; p<0.001). For both γ-glutamyl transpeptidase and alkaline phosphatase, there was a fall on POD1, which persisted until POD 5, followed with a stabilization. Bilirubin decreased progressively from POD 1 onwards.

Conclusions

This study facilitates a standardized biological and clinical pathway of follow-up. Patients who do not follow this recovery indicator could be at risk of complications and additional exams should be made to prevent consequences of such complications.

Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis

PURPOSE

Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results.

METHODS

A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals.

RESULTS

Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results.

CONCLUSIONS

The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.

Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis

PURPOSE

Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results.

METHODS

A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals.

RESULTS

Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results.

CONCLUSIONS

The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.

The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy

INTRODUCTION

International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas (POPF) are the greatest contributor to major morbidity and mortality following pancreatoduodenectomy (PD); however, their infrequent occurrence has hindered deeper analysis. This study sought to develop a predictive algorithm, which could facilitate effective management of this challenging complication.

METHODS

Data were accrued from 4301 PDs worldwide. Demographics, postoperative management, and microbiological characteristics of grade C POPFs were evaluated. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) preoperative and intraoperative variables were compared between grade C POPFs and a 639-case sample of non-grade C POPFs. Risk factors for grade C POPF formation were identified using regression analysis.

RESULTS

Grade C POPFs developed in 79 patients (1.8 %). Deaths (90 days) occurred in 2.0 % (N = 88) of the overall series, with 35 % (N = 25) occurring in the presence of a grade C POPF. Reoperations occurred 72.2 % of the time. The rates of single- and multi-system organ failure were 28.2 and 39.7 %, respectively. Mortality rates escalated with pulmonary, renal, and neurologic organ failure, but they were unaffected by reoperation(s). The median number of complications incurred was four (IQR: 2-5), and the median duration of hospital stay was 32 (IQR: 21-54) days. Warning signs for impending grade C POPFs most often presented on postoperative day (POD) 6. Adjuvant chemotherapy might have benefited 55.7 % of grade C POPF patients, yet it was delayed in 25.6 % and never delivered in 67.4 % of these patients. Predictive models for grade C POPF occurrence based on preoperative factors alone and preoperative and intraoperative factors yielded areas under the receiver operating characteristic curve of 0.73 and 0.84 (both P < 0.000001), respectively.

CONCLUSION

This global study represents the largest analysis of grade C POPFs following PD. It describes the severe burden that grade C POPFs incur on patients, with high rates of reoperation and infection, while also potentially worsening overall survival by causing death and delay/omission of adjuvant therapy. Additionally, aggressive clinical management for these POPFs did not improve or worsen 90-day mortality. Predictive tools developed through these data may provide value in managing this difficult complication.

Impact of postoperative complications on clinical and economic consequences in pancreatic surgery

Purpose

Patients who develop complications consume a disproportionately large share of available resources in surgery; therefore the attention of healthcare funders focuses on the economic impact of complications. The main objective of this work was to assess the clinical and economic impact of postoperative complications in pancreatic surgery, and furthermore to assess risk factors for increased costs.

Methods

In all, 161 consecutive patients underwent pancreatic resection. The costs of the treatment were determined and analyzed.

Results

The overall morbidity rate was 53.4%, and the in-hospital mortality rate was 3.7%. The median of costs for all patients without complication was 3,963 Euro, whereas the median of costs for patients with at least one complication was significantly increased at 10,670 Euro (P < 0.001). In multivariate analysis American Society of Anesthesiologists ≥ 3 (P = 0.006), multivisceral resection (P < 0.001) and any complication (P < 0.001) were independently associated with increased costs.

Conclusion

Postoperative complications are associated with an increase in mortality, length of hospital stay, and hospital costs. The treatment costs increase with the severity of the postoperative complications. Those factors that are known to increase the treatment costs in pancreatic resection should be considered when planning patients for surgery.

Salvage Completion Pancreatectomies as Damage Control for Post-pancreatic Surgery Complications: A Single-Center Retrospective Analysis

BACKGROUND

Post-pancreatic surgical morbidity is frequent but often manageable by less invasive means than re-operation. Yet, some complications can become hazardous and life threatening. Herein, the results of a completion pancreatectomy (CP) to cope with severe post-operative pancreatic fistulas (POPF) and bleeding complications after major pancreatic resections for suspected pancreatic malignancy are presented.

METHODS

CPs to treat severe post-pancreatic index-surgery complications between January 2002 and January 2012 were selected out of a prospective database. Indications for CP as well as perioperative data were prospectively collected and retrospectively assessed.

RESULTS

In 20 of 521 Kausch-Whipple Resections (3.8%), a CP was necessary to treat post-index surgery morbidity. Indications included insufficiency of the pancreaticojejunal anastomosis with resulting POPF in 14 (70.0%) patients, severe bleeding complications in 6 (30.0%) patients, and a severe portal vein thrombosis in 1 (5.0%) patient. In 7 (35.0%) of the 20 patients, the course was complicated by remnant pancreatitis. Eleven (55.0%) of the 20 patients died during the hospital stay. Median time to re-operation did not significantly differ between survivors and in-hospital deaths (10.0 vs. 8.0 days; p = 0.732). Median hospital stay of the surviving patients was 31.0 (range 10-113) days. Re-operations following CPs were necessary in 5 (55.6%) of the 9 patients who survived and in 9 (81.8%) out of 11 patients who died.

CONCLUSIONS

Post-pancreatic resection complications can become hazardous and result in severely ill patients requiring maximum therapy. CP in these cases has a high mortality but serves as an ultima ratio to cope with deleterious complications.

Postoperative pancreatic fistula: We need to redefine grades B and C

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most important complication after pancreatic surgery. In 2005, the International Study Group of Pancreatic Surgery (ISGPS) introduced a standardized POPF definition with severity grading from A to C. In recent years, interventional drainage (ID) has become the standard of care for symptomatic postoperative fluid collections or undrained POPF. From the original definition, it is unclear whether ID is categorized as POPF grade B or C. Therefore, international authors shift ID between grades B and C. The aim of the study was to analyze patients with ID (proposed new grade B) versus patients who underwent reoperation (grade C) for POPF.

METHODS

Between 2005 and 2013, all patients undergoing pancreatic resection were analyzed regarding POPF grade A-C. Demographic data, type of operation, postoperative complications, therapies and outcome were examined with focus on ID versus reoperation.

RESULTS

Of the 2,955 patients included, 403 developed POPF (13.6%). Among all POPF, 11% were grade A, 17% grade B (clinically symptomatic without ID), and 72% grade C. These patients underwent either ID (n = 165) or reoperation (n = 123). Patients with ID had an average hospital stay of 33 days and POPF-associated mortality of 0%. This was strikingly different from patients undergoing reoperation with a hospital stay of 47 days and POPF-associated mortality of 37% (P < .0001).

CONCLUSION

After 10 years of the ISGPS classification, there is a clear-cut outcome difference between patients undergoing POPF-associated ID or reoperation. We propose assigning all patients undergoing ID as POPF grade B. Patients undergoing reoperation should definitely remain within category C.

Cytoreductive Surgery for Pancreatic Cancer Improves Overall Outcome of Gemcitabine-Based Chemotherapy

OBJECTIVES

Pancreatoduodenectomy is feasible also in patients with locally advanced pancreatic adenocarcinoma (PA) nowadays. Data on risk and survival analysis of palliative pancreatic resections followed by gemcitabine-based chemotherapy (Cx) are limited.

METHODS

Between 2000 and 2009, a total of 45 patients had primary cytoreductive surgery (cS) (pancreaticoduodenectomy or total pancreatectomy) followed by gemcitabine-based Cx (cS + Cx) for advanced PA. We matched 1:1 the cS + Cx group with 45 contemporaneous patients who primarily started palliative gemcitabine-based Cx for age, sex, performance status, and body mass index. Overall, survival was evaluated.

RESULTS

Local R0 and R1 resection in metastatic patients was achieved in 27% and 27%, respectively. The R2 resection status without distant metastasis resulted in 33%, whereas 13% showed a local R2 status with additional metastasis (M1). Median overall survival was 10.4 months after cytoreductive pancreatic surgery and consecutive gemcitabine-based Cx versus 7.2 months after upfront gemcitabine-based Cx (P = 0.009). Median survival for R0/M1 patients was 14.4 months and 11.0 months for R2/M0 patients, whereas the median survival for R1/M1 and for R2/M1 patients was 7.3 months and 6.1 months, respectively.

CONCLUSIONS

Individual patients with advanced PA had a significantly longer overall survival after palliative pancreaticoduodenectomy followed by Cx than patients in a matched control group who underwent primarily palliative Cx.

Clinical impact of preoperative acute pancreatitis in patients who undergo pancreaticoduodenectomy for periampullary tumors

AIM

To investigate the impact of preoperative acute pancreatitis (PAP) on the surgical management of periampullary tumors.

METHODS

Fifty-eight patients with periampullary tumors and PAP were retrospectively analyzed. Thirty-four patients who underwent pancreaticoduodenectomy (PD) and 4 patients who underwent total pancreatectomy were compared with a control group of 145 patients without PAP during the same period.

RESULTS

The preoperative waiting time was significantly shorter for the concomitant PAP patients who underwent a resection (22.4 d vs 54.6 d, P < 0.001) compared to those who did not. The presence of PAP significantly increased the rate of severe complications (Clavien grade 3 or higher) (17.6% vs 4.8%, P = 0.019) and lengthened the hospital stay (19.5 d vs 14.5 d, P = 0.006). A multivariate logistic regression analysis revealed that PAP was an independent risk factor for postoperative pancreatic fistula (OR = 2.91; 95%CI: 1.10-7.68; P = 0.032) and severe complications (OR = 4.70; 95%CI: 1.48-14.96; P = 0.009) after PD. There was no perioperative mortality.

CONCLUSION

PAP significantly increases the incidence of severe complications and lengthens the hospital stay following PD. PD could be safely performed in highly selective patients with PAP.