Pancreatic fistula rate after pancreatic resection. The importance of definitions

Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients

BACKGROUND

The correlation of the amylase value in drains (AVD) with the development of pancreatic fistula (PF) is still unclear.

AIM

The purpose of this study was to identify within the first postoperative day (POD1) the predictive role of different risks factors, including AVD, in the development of PF.

PATIENTS AND METHODS

We prospectively investigated 137 patients who underwent major pancreatic resections. PF was defined and graded in accordance with the International Study Group on PF.

RESULTS

We considered 101 pancreaticoduodenectomies and 36 distal resections. The overall incidence of PF (A, B, and C grades) was 19.7% and it was 14.8% after pancreaticoduodenectomy and 33.3% after distal resection. All PF occurred in "soft" remnant pancreas. The PF developed in patients with a POD1 median AVD of 10,000 U/L, whereas patients without PF had a median AVD of 1222 U/L (P < 0.001). We established a cut-off of 5000 U/L POD1 AVD for univariate and multivariate analysis. The area under the receiver operating characteristic (ROC) curve was 0.922 (P < 0.001). The predicting risk factors selected in the univariate setting were "soft" pancreas (P = 0.005; odds ratio [OR]: 1.54; 95% CI: 1.32-1.79) and AVD (P < 0.001; OR: 5.66; 95% CI: 3.6-8.7; positive predictive value 59%; negative predictive value 98%), whereas in multivariate analysis the predicting risk factor was the POD1 AVD (P < 0.001; OR: 68.4; 95% CI: 14.8-315). Only 2 PFs were detected with AVD <5000 U/L and both were in pancreatogastric anastomosis (P = 0.053).

CONCLUSIONS

AVD in POD1 > or =5000 U/L is the only significant predictive factor of PF development.

Distal pancreatectomy with splenic preservation revisited

BACKGROUND

Splenic preservation (SP) during distal pancreatectomy can be accomplished by ligating the main splenic artery and vein relying on blood supply from the short gastric vessels. The purpose of this study was to examine the short-term implications of this operation, comparing it to the outcomes following distal pancreatectomy with splenectomy.

METHODS

The records of 259 patients who underwent distal pancreatectomy with and without SP at Massachusetts General Hospital from 1994 to 2004 were reviewed.

RESULTS

A total of 29% of patients underwent SP with this technique. These patients were more likely to be women (74% vs 56%, P = .008) and to have benign disease (93% vs 54%, P < .0001). Their operative times were shorter (2.5 vs 3.1 h, P < .0001), they had less blood loss (300 vs 500 ml, P < .0001) and a shorter duration of stay (6 days [interquartile range, 5 to 7] vs 7 days [interquartile range, 5 to 8], P = .001). SP was not a significant predictor of complications in either univariate (P = .445) or adjusted analysis (P = .543). One patient (1.4%) in the SP group was reoperated for splenic infarction and two patients (1.1%) in the splenectomy group for abscess and hemorrhage. There were 2 (0.8%) postoperative deaths, both in the splenectomy group.

CONCLUSIONS

Splenic preservation relying on blood supply from the short gastric vessels is reliable and safe and does not have a higher incidence of postoperative complications when compared to traditional distal pancreatectomy with splenectomy. The current series validates this approach and provides further evidence of its feasibility and safety.

Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme

OBJECTIVE

The authors sought to validate the ISGPF classification scheme in a large cohort of patients following pancreaticoduodenectomy (PD) in a pancreaticobiliary surgical specialty unit.

SUMMARY BACKGROUND DATA

Definitions of postoperative pancreatic fistula vary widely, precluding accurate comparisons of surgical techniques and experiences. The ISGPF has proposed a classification scheme for pancreatic fistula based on clinical parameters; yet it has not been rigorously tested or validated.

METHODS

: Between October 2001 and 2005, 176 consecutive patients underwent PD with a single drain placed. Pancreatic fistula was defined by ISGPF criteria. Cases were divided into four categories: no fistula; biochemical fistula without clinical sequelae (grade A), fistula requiring any therapeutic intervention (grade B), and fistula with severe clinical sequelae (grade C). Clinical and economic outcomes were analyzed across all grades.

RESULTS

More than two thirds of all patients had no evidence of fistula. Grade A fistulas occurred 15% of the time, grade B 12%, and grade C 3%. All measurable outcomes were equivalent between the no fistula and grade A classes. Conversely, costs, duration of stay, ICU duration, and disposition acuity progressively increased from grade A to C. Resource utilization similarly escalated by grade.

CONCLUSIONS

Biochemical evidence of pancreatic fistula alone has no clinical consequence and does not result in increased resource utilization. Increasing fistula grades have negative clinical and economic impacts on patients and their healthcare resources. These findings validate the ISGPF classification scheme for pancreatic fistula.

Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy

BACKGROUND

Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD.

STUDY DESIGN

Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10(th) postoperative day.

RESULTS

PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1+/-16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5+/-13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present.

CONCLUSIONS

Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.

Predictive factors for complications after pancreaticoduodenectomy

BACKGROUND

Knowledge of the risk factors for complications following pancreaticoduodenectomy (PD) is sparse and there is not a consensus regarding the criteria to define the complications. The objective of this study was to determine the predictive risk factors for this surgery using the international study group definition.

PATIENTS AND METHODS

Between October 1999 and September 2005, data from 295 consecutive patients who underwent a PD in the Eastern Hepatobiliary Surgery Hospital were recorded prospectively. Medical records and specific charts from surgical procedures, histopathology reports, and intensive care units were continually scrutinized. Multivariable logistic regression analyses were used to estimate relative risks and their 95% confidence intervals.

RESULTS

Among 295 patients undergoing PD, 103 (34.9%) experienced at least one complication. Operations by low-volume surgeons (<50 PD surgeries across their lifetime) were followed by more abdominal complications (odds ratio [OR] 45.2). End-to-end pancreaticojejunostomy (PJ) resulted in more complications than end-to-side PJ (OR 2.7). Diabetes mellitus, increased estimated blood loss, and soft gland texture significantly increased the risks of abdominal complications. Systemic morbidity (OR 9.9) was the only independent predictive factor for mortality.

CONCLUSION

High-volume surgeons and end-to-side PJ greatly reduce the risk of abdominal complications in patients undergoing PD. The higher abdominal complications rate in patients with soft gland texture was similar to those found in previous reports. Moreover, PD should be performed with considerable attention in patients with diabetes mellitus.

Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy

OBJECTIVE

To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system.

BACKGROUND

While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center.

METHODS

The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival.

RESULTS

A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P < 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula.

CONCLUSION

This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.

Absorbable mesh reinforcement of a stapled pancreatic transection line reduces the leak rate with distal pancreatectomy

Pancreatic leak remains a significant cause of morbidity after distal pancreatectomy. We report the use of an absorbable mesh to reinforce a stapled pancreatic transection line for distal pancreatectomy. Forty consecutive distal pancreatectomies (33 open and 7 laparoscopic) were performed since the introduction of mesh reinforcement. We utilized an inclusive definition of pancreatic leak to critically evaluate the staple line reinforcement material. In addition, we compared the pancreatic leak rate for this case series with the antecedent 40 cases where mesh reinforcement was not available. In the prospective series there was 1 leak in 29 cases (3.5%) in which mesh reinforcement was utilized, and 4 leaks in 11 cases (36%) when mesh was not utilized (p < 0.005). The 12.5% leak rate for the 40 cases during the prospective period, compared favorably to the 27.5% leak rate for the 40 cases preceding the study period (p = 0.09). Twenty-nine cases receiving mesh compared favorably to the 23 stapled cases in the control series, reducing leak rate from 22 to 3.5% (p = 0.04). Mesh reinforcement of the stapled pancreatic transection line reduced the pancreatic leak rate after distal pancreatectomy. Mesh reinforcement was possible with open or laparoscopic resections. No complications were attributable to the use of absorbable mesh.

Analysis of closure of the pancreatic remnant after distal pancreatic resection

BACKGROUND

The appropriate management of the pancreatic remnant following distal pancreatic resection remains a clinically relevant problem. We carried out a retrospective analysis which focused on this issue and compared the two favored techniques of suture and staple closure.

PATIENTS AND METHODS

Forty-six patients underwent distal pancreatectomy between October 1999 and January 2006. The patients were retrospectively analysed based on the management of the remaining pancreatic gland. Thirty-seven patients had suture and nine patients had staple closure. The morbidity, mortality, incidence of pancreatic fistula, necessity of secondary surgical intervention, and the duration of hospital stay for the two groups were compared. Pancreatic fistula was considered according to the novel international standard definition (ISGPF). In addition, subgroup analysis of patients receiving octreotide was carried out.

RESULTS

Overall, postoperative morbidity due to pancreatic fistula occurred in seven patients (19%) after suture and in one patient (11%) after staple closure (p = 0.54), with no deaths. The number of patients with surgical revision related to pancreatic leakage was two (5%) after suture closure vs no revision after staple closure (p = 0.65). The median number of total hospital days for the suture group was 19 (range 7-78 days) vs 21 (range 12-96 days) for the stapler group (p = 0.21). No significant benefit for the octreotide application could be determined.

CONCLUSION

According to the data, no significant difference for either suture or stapler closure was observed, with the tendency for staple closure to be superior.

Toward zero pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy

BACKGROUND

Postoperative morbidity after pancreaticoduodenectomy has been associated mainly with the development of pancreatic fistula. However, postoperative complications unrelated to pancreatic fistula cannot be disregarded after pancreaticoduodenectomy. The aim of the present study was to investigate the postoperative morbidity in a large series of pancreaticoduodenectomies with pancreaticogastrostomies without pancreatic fistula.

METHODS

The present study analyzed the data from 194 consecutive patients undergoing a pancreaticoduodenectomy with a pancreaticogastrostomy between July 1997 and June 2003 in whom no postoperative pancreatic fistula occurred.

RESULTS

The overall rate of postoperative morbidity was 33.5%. Specific and general complications occurred in 16% and 17.5% of the patients, respectively. An American Society of Anesthesiologists (ASA) score of 3 and blood transfusion were the only independent factors associated with postoperative morbidity.

CONCLUSIONS

Our study found that the overall morbidity after a pancreaticoduodenectomy with a pancreaticogastrostomy still remains high even in the absence of pancreatic fistula and is associated with the preoperative medical condition (ASA score) of the patients and with blood transfusion.

Complications after pancreaticoduodenectomy: the problem of current definitions

Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%-50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.

Implications and cost of pancreatic leak following distal pancreatic resection

OBJECTIVES

Pancreatic stump leak (PL) after elective distal pancreatic resection significantly impacts cost and increases subsequent health care resource utilization. We sought to provide an economic framework for potential interventions aimed at reducing its occurrence.

DESIGN

Retrospective case series and economic evaluation.

SETTING

University-affiliated, tertiary care referral center.

PATIENTS

Sixty-six patients undergoing elective distal pancreatectomy.

MAIN OUTCOME MEASURES

Postoperative complications; hospital and professional costs.

RESULTS

Overall postoperative morbidity occurred in 34 patients (52%) with no deaths. The total number of patients with complications directly related to PL was 22 (33%). The mean +/- SD number of total hospital days for the no-PL group was 5.2 +/- 1.7 days (range, 3-12 days) vs 16.6 +/- 14.6 days (range, 4-49 days) for the PL group (P = .001). The average patient with PL-related problems incurred a total cost that was 2.01 times greater than the average patient in the no-PL group. A decision analytic model developed to evaluate threshold costs showed that a hypothetical intervention designed to reduce the complication rate of distal pancreatectomy by one third would be financially justifiable up to a cost of $1418 per patient.

CONCLUSIONS

Complications derived from PL following distal pancreatectomy double the cost and dramatically increase health care resource utilization. There is an urgent need to develop strategies that reduce the incidence of this common complication. Interventions aimed at decreasing the incidence of PL should take into account this cost differential. We provide an economic model to serve as a guide for developing these technologies.

Implications and cost of pancreatic leak following distal pancreatic resection

OBJECTIVES

Pancreatic stump leak (PL) after elective distal pancreatic resection significantly impacts cost and increases subsequent health care resource utilization. We sought to provide an economic framework for potential interventions aimed at reducing its occurrence.

DESIGN

Retrospective case series and economic evaluation.

SETTING

University-affiliated, tertiary care referral center.

PATIENTS

Sixty-six patients undergoing elective distal pancreatectomy.

MAIN OUTCOME MEASURES

Postoperative complications; hospital and professional costs.

RESULTS

Overall postoperative morbidity occurred in 34 patients (52%) with no deaths. The total number of patients with complications directly related to PL was 22 (33%). The mean +/- SD number of total hospital days for the no-PL group was 5.2 +/- 1.7 days (range, 3-12 days) vs 16.6 +/- 14.6 days (range, 4-49 days) for the PL group (P = .001). The average patient with PL-related problems incurred a total cost that was 2.01 times greater than the average patient in the no-PL group. A decision analytic model developed to evaluate threshold costs showed that a hypothetical intervention designed to reduce the complication rate of distal pancreatectomy by one third would be financially justifiable up to a cost of $1418 per patient.

CONCLUSIONS

Complications derived from PL following distal pancreatectomy double the cost and dramatically increase health care resource utilization. There is an urgent need to develop strategies that reduce the incidence of this common complication. Interventions aimed at decreasing the incidence of PL should take into account this cost differential. We provide an economic model to serve as a guide for developing these technologies.

Central pancreatectomy for benign pancreatic lesions

INTRODUCTION

Traditional resections for pancreatic malignancies include distal pancreatectomy with splenectomy and pancrearicoduodenectomy (PD). Alternative resections for benign pancreatic disease are used to minimize the resection of normal pancreatic and splenic parenchyma. This study describes the use of central pancreatectomy (CP) in 10 patients.

METHODS

A retrospective chart review of all patients undergoing CP between May 1999 and February 2004 was undertaken.

RESULTS

Ten patients (eight female, two male) underwent CP for benign pancreatic disease. Median age was 59 years (range 21-75). Eight patients presented with abdominal pain, two of whom also had weight loss. One patient each presented with hypoglycemia and as an incidental finding. Median operative time was 255 min (range 160-380 min). Proximal pancreatic remnant was stapled in five and oversewn in five. Distal pancreatic remnant was managed with pancreaticojejunostomy in six patients and pancreatjcogastrostomy in four patients. There were no 30-day mortalities. Pancreatic fistula developed in four patients (40%), and all resolved without operative intervention. All patients are alive with no recurrence and no new endocrine or exocrine dysfunction.

CONCLUSION

CP has similar morbidity and mortality rates to traditional pancreatic resections and may offer a lower incidence of diabetes and exocrine insufficiency.

Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies?

Pancreatic anastomotic leak is the single most important factor responsible for the considerable morbidity and mortality associated with pancreaticoduodenectomy. Management of the pancreatic remnant is controversially discussed, reflecting the complexity of anastomosing a pancreas of different textures to the digestive tract. A number of studies evaluating diverse options have often provided conflicting conclusions. This information is confusing particularly to those surgeons outside of large-volume centers with broad experience and to general surgeons who perform pancreatic surgery. A PubMed search with the key words pancreaticoduodenectomy, pancreatic anastomosis, pancreaticojejunostomy, pancreaticogastrostomy, and pancreatic fistula was performed. Major series of pancreatic anastomosis published between 1990 and 2002 were studied from diverse centers worldwide. Their results with regard to pancreatic fistula, morbidity, and mortality were documented. Nine series of pancreaticojejunostomy and seven series of pancreaticogastrostomy were evaluated. Eight comparative studies evaluating the two techniques were also analyzed. A single randomized controlled trial was identified among these comparative studies. Equally good results were observed with the two techniques. Other uncommon methods of management of the pancreatic remnant (duct occlusion and ligation) were also evaluated. Pancreaticojejunostomy followed by pancreaticogastrostomy are the most favored techniques. A duct-to-mucosa anastomosis is preferred over other methods. Fistula rates of less than 5%-10% should be the standard irrespective of the technique used. Unlike in the past, mortality can be reduced even in the event of an anastomotic dehiscence, and this aspect is primarily dependent on a meticulous anastomosis based on sound surgical principles rather than the method per se. Based on the information accumulated, adherence to these specific principles could ensure a safe and reliable pancreatic anastomosis with mimimal morbidity and mortality after pancreaticoduodenectomy, even in the hands of general surgeons operating outside high-volume centers.

Duct-to-mucosa pancreaticogastrostomy is a safe anastomosis following pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula following pancreaticoduodenectomy is relatively common, and remains a major cause of morbidity and mortality. The aim of this study was to evaluate the results of two-layered duct-to-mucosa pancreaticogastrostomy as a method for restoring pancreaticoenteric continuity.

METHODS

Prospectively collected data from 100 consecutive patients who underwent Whipple's pancreaticoduodenectomy for tumour were evaluated. All operations were performed by the same surgeon.

RESULTS

The perioperative 60-day mortality rate was 1.0 per cent. There were no pancreatic fistulas or anastomotic leaks. Sixteen patients had significant complications that delayed discharge from hospital. Twenty-one patients subsequently required empirical pancreatic exocrine supplements.

CONCLUSION

Two-layered duct-to-mucosa pancreaticogastrostomy for restoration of pancreaticoenteric continuity after pancreaticoduodenectomy is associated with a low incidence of complications.

Distal pancreatic resection: technical differences between open and laparoscopic approaches

Open distal pancreatic resection has been performed over the years for management of patients with a variety of pancreatic disorders. However, the technique is usually not performed in the same way by all surgeons. In recent years, the laparoscopic approach has been introduced with all the advantages of a minimally invasive procedure. The primary differences between the open and laparoscopic approaches are the method of access, the method of exposure, and the extent of operative trauma. The clinical advantages of the laparoscopic approach are the reduced length hospitalization, the reduction in postoperative pain, absence of wound-related complications and faster recovery.

Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery

BACKGROUND

The role of somatostatin and its analogues in reducing complications after pancreatic resection is controversial. This is a meta-analysis of the evidence of benefit.

METHODS

A literature search using Medline and ISI Proceedings with exploration of the references identified 22 studies. Of these, ten met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method. Level of significance was set at P < 0.050.

RESULTS

Outcomes for 1918 patients were compared. Somatostatin and its analogues did not reduce the mortality rate after pancreatic surgery (OR 1.17 (0.70 to 1.94); P = 0.545) but did reduce both the total morbidity (OR 0.62 (0.46 to 0.85); P = 0.003) and pancreas-specific complications (OR 0.56 (0.39 to 0.81); P = 0.002). Somatostatin and its analogues reduced the rate of biochemical fistula (OR 0.45 (0.33 to 0.62); P < 0.001) but not the incidence of clinical anastomotic disruption (OR 0.80 (0.44 to 1.45); P = 0.459).

CONCLUSION

Somatostatin and its analogues reduce the incidence of complications after surgery.

Postoperative pancreatic fistula: an international study group (ISGPF) definition

BACKGROUND

Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences.

METHODS

An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easy-to-apply definition of POPF, graded primarily on clinical impact.

RESULTS

A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient's hospital course.

CONCLUSIONS

The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed.

The unsolved problem of fistula after left pancreatectomy: the benefit of cautious drain management

The aim of the study was to identify factors related to the onset of pancreatic fistula and to define the characteristics of the fistula. The study group was composed of 123 patients who underwent left pancreatectomy since 1996. Pancreatic closure was accomplished by a hand-sewn technique (39 patients) or two kinds of mechanical staplers: Proximate (Ethicon Endo-Surgery, Cincinnati, OH) (46 patients) and Endo-GIA (United States Surgical, Norwalk, CT) (38 patients). Fistula was defined as output greater than 5 ml, with amylase x 5, after day 5. In case of fistula, the drain removal was scheduled at a daily output less than 5 ml. Mortality was 0%, morbidity was 48%, and pancreatic fistula rate was 34%. Fistula rate was 38% after hand-sewn closure, 26% after Proximate, and 39% after Endo-GIA (NS). None of the other factors (separate duct ligation, hand-sewn suture in addition to stapler, spleen preservation, use of pledgetted suture, sex, age, and indication for pancreatectomy) proved to be related to a reduction in the onset of fistula. All fistulas healed spontaneously. Mean fistula duration was 36 days; 92.8% of patients with fistula were discharged with drain. The policy of delayed drain removal allowed a low rate of fistula associated morbidity (16%) and of readmission (4.7%). In conclusion, fistula is an unsolved problem of left pancreatectomy. However, a careful drain management allows a good outcome in patients with fistula.

Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy

BACKGROUND

Appropriate closure of the pancreatic remnant after distal pancreatectomy is still debated. A variety of procedures have been recommended to reduce the frequency of pancreatic fistula. This review quantitatively compares the available techniques.

METHODS

Original articles and abstracts published up to the end of June 2004 were searched without language restriction in the Cochrane Controlled Trials Register, Medline and Embase. Three reviewers independently assessed each study's eligibility and quality, and extracted the data. A random effects model was performed using weighted odds ratios.

RESULTS

Only ten of 262 articles could be included, two randomized clinical trials and eight observational studies. Reported postoperative morbidity varied from 13.3 to 64 per cent. The primary outcome measure, pancreatic fistula rate, occurred within the range 0-60.9 per cent. Meta-analysis of the six studies comparing stapler versus hand-sutured closure showed a non-significant combined odds ratio for occurrence of a pancreatic fistula of 0.66 (95 per cent confidence interval 0.35 to 1.26, P = 0.21) in favour of stapler closure.

CONCLUSIONS

The quality and quantity of information extracted from the available trials are insufficient to enable any firm conclusion to be drawn on the optimal surgical technique of pancreatic stump closure; there is a trend in favour of the stapling technique.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

The feasibility and morbidity of distal pancreatectomy in extensive cytoreductive surgery for advanced epithelial ovarian cancer

INTRODUCTION

Pancreatic metastasis of ovarian cancer is extremely rare and its therapeutic approach is not well documented. The objective of this study is to evaluate the feasibility and morbidity of pancreatic resection as a component of extensive cytoreductive surgery in epithelial ovarian cancer (EOC) patients with pancreas metastasis.

METHODS

Between December 2000 and February 2003, 98 EOC patients were treated with primary cytoreduction. Six (6.12%) of these patients had pancreatic tail metastasis and were operated on using the distal pancreatectomy.

RESULTS

Preoperatively, only 1 (16.7%) of the 6 patients had signs of metastasis to the pancreas on computed tomography (CT). Optimal cytoreduction (absent or < or =1 cm macroscopic residual tumor size) was achieved in all patients. In the early postoperative period, there were 4 patients (66.7%) with complications and no perioperative mortality. In 1 patient (16.7%), glucose intolerance as a late complication of pancreatic resection was detected. All patients received six cycles of platinum-based adjuvant chemotherapy following a cytoreductive operation. Mean follow-up was 27 months (range 9-36), and 3 (50%) patients are still alive at the end of the study period. The two-year survival rate was 66.7%.

CONCLUSION

In conclusion, if optimal cytoreduction is foreseen in advanced epithelial ovarian cancer with pancreatic tail metastasis, distal pancreatectomy should be kept in mind. This procedure has acceptable morbidity and seems to be an attribute for survival.