Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

Safety and effectiveness of minimally invasive central pancreatectomy versus open central pancreatectomy: a systematic review and meta-analysis

BACKGROUND

Central pancreatectomy is a surgical procedure for benign and low-grade malignant tumors which located in the neck and proximal body of the pancreas that facilitates the preservation of pancreatic endocrine and exocrine functions but has a high morbidity rate, especially postoperative pancreatic fistula (POPF). The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness between minimally invasive central pancreatectomy (MICP) and open central pancreatectomy (OCP) basing on perioperative outcomes.

METHODS

An extensive literature search to compare MICP and OCP was conducted from October 2003 to October 2023 on PubMed, Medline, Embase, Web of Science, and the Cochrane Library. Fixed-effect models or random effects were selected based on heterogeneity, and pooled odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 10 studies with a total of 510 patients were included. There was no significant difference in POPF between MICP and OCP (OR = 0.95; 95% CI [0.64, 1.43]; P = 0.82), whereas intraoperative blood loss (MD = - 125.13; 95% CI [- 194.77, -55.49]; P < 0.001) and length of hospital stay (MD = - 2.86; 95% CI [- 5.00, - 0.72]; P = 0.009) were in favor of MICP compared to OCP, and there was a strong trend toward a lower intraoperative transfusion rate in MICP than in OCP (MD = 0.34; 95% CI [0.11, 1.00]; P = 0.05). There was no significant difference in other outcomes between the two groups.

CONCLUSION

MICP was as safe and effective as OCP and had less intraoperative blood loss and a shorter length of hospital stay. However, further studies are needed to confirm the results.

International consensus guidelines on robotic pancreatic surgery in 2023

Background

With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS.

Methods

World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline.

Results

After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence.

Conclusions

The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

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

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

Continuous irrigation after pancreatectomy: a systematic review

PURPOSE

Prevention and management of postoperative pancreatic fistula (POPF) after pancreatic resections is still an unresolved issue. Continuous irrigation of the peripancreatic area is frequently used to treat necrotizing pancreatitis, but its use after elective pancreatic surgery is not well-known. With this systematic review, we sought to evaluate the current knowledge and expertise regarding the use of continuous irrigation in the surgical area to prevent or treat POPF after elective pancreatic resections.

METHODS

A systematic search of the literature was conducted according to the PRISMA 2020 guidelines, screening the databases of Pubmed, Scopus, Web of Science, and Ovid MEDLINE. Because of the heterogeneity of the included articles, a statistical inference could not be performed and the literature was reviewed only descriptively. The study was pre-registered online (OSF Registry).

RESULTS

Nine studies were included. Three studies provided data regarding the prophylactic use of continuous irrigation after distal and limited pancreatectomies. Here, patients after irrigation showed a lower rate of clinically relevant POPF, related complications, lengths of stay, and mortality. Six other papers reported the use of local lavage to treat clinically relevant POPF and subsequent fluid collections, with successful outcomes.

CONCLUSION

In the current literature, only a few publications are focused on the use of continuous irrigation after pancreatic resection to prevent or manage POPF. The included studies showed promising results, and this technique may be useful in patients at high risk of POPF. Further investigations and randomized trials are needed.

The Practice of Pancreatoduodenectomy in India: A Nation-Wide Survey

Introduction The way pancreatoduodenectomy (PD) is performed can vary a lot around the world, and there is no agreed-upon standard approach. To learn more about how PD is practised in India, a survey was conducted among Indian surgeons to gather information about their current practices. Methods A survey was created and shared with surgeons in India who practice pancreatic surgery. It had 33 questions that aimed to capture information about different aspects of PD practice. These questions covered topics such as the surgeons' education and experience, how they evaluated patients before surgery, what they considered during the operation, and how they managed patients after surgery. Results A total of 129 surgeons were sent the survey, and 110 of them completed it. The results showed that 40.9% of the surgeons had less than five years of experience, and 36.4% of them performed more than 15 PDs in a year. When deciding whether to perform preoperative biliary drainage, 60% of surgeons based their decision on the level of bilirubin in the patient's blood, while the rest considered other specific indications. The majority of surgeons (72.7%) looked at the trend of albumin levels to assess the patient's nutritional status before surgery. Venous infiltration was seen as a reason for neoadjuvant therapy by 76.4% of the participants, whereas 95.5% considered upfront surgery in cases of venous abutment. When it came to the type of PD, 40% preferred classical PD, 40.9% preferred pylorus-resecting PD (PRPD), and the rest chose pylorus-preserving PD (PPPD). Pancreatojejunostomy (PJ) was the preferred method for 77.3% of surgeons, while 6.3% preferred pancreatogastrostomy (PG). About 65.5% of surgeons used octreotide selectively during the operation when the duct diameter was small. Nearly all surgeons (94.5%) preferred to secure feeding access during PD, and all of them placed intraperitoneal drains. As for postoperative care, 37.3% of surgeons attempted early oral feeding within 48 hours, while 28.2% preferred to wait at least 48 hours before initiating oral feeds. Conclusions The survey revealed significant differences in how PD is practised among surgeons in India, highlighting the heterogeneity in their approaches and preferences.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most frequent and potentially life-threatening complications following pancreatic surgery. Fibrin sealants have been used in some centres to reduce POPF rate. However, the use of fibrin sealant during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2020.

OBJECTIVES

To evaluate the benefits and harms of fibrin sealant use for the prevention of POPF (grade B or C) in people undergoing pancreatic surgery compared to no fibrin sealant use.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 09 March 2023, together with reference checking, citation searching, and contacting study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 RCTs, randomising 1989 participants, comparing fibrin sealant use versus no fibrin sealant use for different locations: stump closure reinforcement (eight trials), pancreatic anastomosis reinforcement (five trials), or main pancreatic duct occlusion (two trials). Six RCTs were carried out in single centres; two in dual centres; and six in multiple centres. One RCT was conducted in Australia; one in Austria; two in France; three in Italy; one in Japan; two in the Netherlands; two in South Korea; and two in the USA. The mean age of the participants ranged from 50.0 years to 66.5 years. All RCTs were at high risk of bias. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included eight RCTs involving 1119 participants: 559 were randomised to the fibrin sealant group and 560 to the control group after distal pancreatectomy. Fibrin sealant use may result in little to no difference in the rate of POPF (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.73 to 1.21; 5 studies, 1002 participants; low-certainty evidence) and overall postoperative morbidity (RR 1.20, 95% CI 0.98 to 1.48; 4 studies, 893 participants; low-certainty evidence). After fibrin sealant use, approximately 199 people (155 to 256 people) out of 1000 developed POPF compared with 212 people out of 1000 when no fibrin sealant was used. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto odds ratio (OR) 0.39, 95% CI 0.12 to 1.29; 7 studies, 1051 participants; very low-certainty evidence) and total length of hospital stay (mean difference (MD) 0.99 days, 95% CI -1.83 to 3.82; 2 studies, 371 participants; very low-certainty evidence). Fibrin sealant use may reduce the reoperation rate slightly (RR 0.40, 95% CI 0.18 to 0.90; 3 studies, 623 participants; low-certainty evidence). Serious adverse events were reported in five studies (732 participants), and there were no serious adverse events related to fibrin sealant use (low-certainty evidence). The studies did not report quality of life or cost-effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included five RCTs involving 519 participants: 248 were randomised to the fibrin sealant group and 271 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF (RR 1.34, 95% CI 0.72 to 2.48; 3 studies, 323 participants; very low-certainty evidence), postoperative mortality (Peto OR 0.24, 95% CI 0.05 to 1.06; 5 studies, 517 participants; very low-certainty evidence), reoperation rate (RR 0.74, 95% CI 0.33 to 1.66; 3 studies, 323 participants; very low-certainty evidence), and total hospital cost (MD -1489.00 US dollars, 95% CI -3256.08 to 278.08; 1 study, 124 participants; very low-certainty evidence). After fibrin sealant use, approximately 130 people (70 to 240 people) out of 1000 developed POPF compared with 97 people out of 1000 when no fibrin sealant was used. Fibrin sealant use may result in little to no difference both in overall postoperative morbidity (RR 1.02, 95% CI 0.87 to 1.19; 4 studies, 447 participants; low-certainty evidence) and in total length of hospital stay (MD -0.33 days, 95% CI -2.30 to 1.63; 4 studies, 447 participants; low-certainty evidence). Serious adverse events were reported in two studies (194 participants), and there were no serious adverse events related to fibrin sealant use (very low-certainty evidence). The studies did not report quality of life. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two RCTs involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto OR 1.41, 95% CI 0.63 to 3.13; 2 studies, 351 participants; very low-certainty evidence), overall postoperative morbidity (RR 1.16, 95% CI 0.67 to 2.02; 2 studies, 351 participants; very low-certainty evidence), and reoperation rate (RR 0.85, 95% CI 0.52 to 1.41; 2 studies, 351 participants; very low-certainty evidence). Fibrin sealant use may result in little to no difference in the total length of hospital stay (median 16 to 17 days versus 17 days; 2 studies, 351 participants; low-certainty evidence). Serious adverse events were reported in one study (169 participants; low-certainty evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report POPF, quality of life, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealant use may result in little to no difference in the rate of POPF in people undergoing distal pancreatectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF in people undergoing pancreaticoduodenectomy. The effect of fibrin sealant use on postoperative mortality is uncertain in people undergoing either distal pancreatectomy or pancreaticoduodenectomy.

Hot topics in pancreatic cancer management

Pancreatic ductal adenocarcinoma (PDAC) is a sneaky and lethal disease burdened by poor prognosis. PDAC is often detected too late to be successfully cured, and it has been estimated that it will be a leading cause of cancer-related deaths in the near future. During the last decade, multimodal treatments involving surgery, chemotherapy and radiotherapy have contributed to improving the prognosis of this disease; however, long-term results are still not satisfactory. Postoperative morbidity and mortality rates remain high, and systemic treatments are burdened by toxicity in both neoadjuvant and adjuvant settings. Advancements in technologies, targeted therapies, immunotherapy and PDAC microenvironment modulation strategies may represent useful potential weapons in the future. Nevertheless, in the fight against this dreadful disease, there is an urgent need for new, cheap and user-friendly tools for early detection. In this field, promising results have been found in nanotechnologies and “omics” analyses that search for new biomarkers to be used in primary and secondary prevention. However, there are many issues that need to be solved before considering these tools in daily clinical practice. This editorial reported the state of the art of pancreatic cancer management.

Effects of ketorolac on complications and postoperative pancreatic fistula in patients undergoing pancreatectomy

BACKGROUND

There are conflicting data on the risk of postoperative pancreatic fistula (POPF) associated with postoperative NSAID use. The primary objective of this multi-center retrospective study was to assess the relationship between ketorolac use and POPF. The secondary objective was to assess for effect of ketorolac use on overall complication rate.

METHODS

Retrospective chart review of patients undergoing pancreatectomy from January 1, 2005-January 1, 2016 was performed. Data on patient factors (age, sex, comorbidities, previous surgical history etc.), operative factors (surgical procedure, estimated blood loss, pathology etc.), and outcomes (morbidities, mortality, readmission, POPF) were collected. The cohort was compared based on ketorolac use.

RESULTS

The study included 464 patients. Ninety-eight (21%) patients received ketorolac during the study period. Ninety-six (21%) patients were diagnosed with POPF within 30 days. There was a significant association between ketorolac use and clinically relevant POPF (21.4 vs. 12.7%) (p = 0.04, 95% CI [1.76, 1.04-2.97]). There was no significant difference in overall morbidity or mortality between the groups.

DISCUSSION

Though there was no overall increase in morbidity, there was a significant association between POPF and ketorolac use. The use of ketorolac after pancreatectomy should be judicious.

Prospective cohort study on short-term outcomes of 3D-laparoscopic pancreaticoduodenectomy with stented pancreaticogastrostomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy, either laparoscopic or robotic, is a high-risk procedure with demanding learning curve. The aim of this prospective cohort study was to evaluate short-term clinical and oncologic outcomes of 3D-laparoscopic pancreaticoduodenectomy (3dLPD) with stented pancreaticogastrostomy (sPG) and Roux-en-Y gastroenterostomy (ryGES).

METHODS

Between March 2016 and July 2021, 347 consecutive patients underwent 3dLPD for confirmed or suspected pancreatic or periampullary tumors. Pancreatic duct diameter measured 3 mm or less in 221 (64%) and pancreatic texture was soft in 191 (55%) patients. Simultaneous resection of the superior mesenteric or portal vein was performed in 52 (15%) patients.

RESULTS

Postoperative complications were observed in 189 (54%) patients, with severe complications (Clavien-Dindo grade > 2) in 68 (20%) including 4 (1.2%) deaths. Clinically relevant pancreatic fistula (cPOPF) occurred in 88 (25%), hemorrhage in 25 (7%), and bile leakage in 10 (3%) patients. Clinical pancreatic fistula was strongly associated with soft pancreatic texture and small pancreatic duct diameter (p < 0.001) and managed by endoscopic trans-gastric drainage in 34 (38.6%) patients, reoperation in 12 (13.6%), and ICU admission in 11 (12.5%). The remaining 31 (35%) patients with cPOPF were managed without invasive intervention. Median length of hospital stay after surgery was 13 (range 5-112; IQR 8-18) days. In pancreatic adenocarcinoma (PDAC) the R0-resection rate was 66/186 (36%), R1-indirect 95/186 (51%), and R1-direct 25 (13%). Median number of locoregional lymph nodes retrieved in PDAC was 21 (IQR 15-28). R0-resection rate for malignancy other than PDAC was 78/86 (91%) with a median of 16 (IQR 12-22) locoregional lymph nodes retrieved.

CONCLUSION

3dLPD with sPG and ryGES is associated with 1.2% mortality and 25% cPOPF. About two-third of patients with cPOPF were managed with some type of invasive intervention, whereas the intraoperatively placed drains sufficed in one-third of patients.

CLINICAL TRIAL REGISTRY

Clinicaltrials.gov NCT02671357.

Pancreatico-Gastrostomy: A Modified Two-Layered Technique

Introduction: Pancreato-duodenal resections are commonly done for periampullary carcinomas. The outcome of the procedure is decided by pancreato-enterostomy. Pancreato-jejunostomy (PJ) has been employed largely as pancreato-enterostomy. Recently, there has been a renewed interest in pancreato-gastrostomy (PG). The debate continues on the choice of reconstruction.

Methods: A hundred cases of periampullary carcinoma were subjected to modified pancreatico-gastrostomy. The pancreatico-gastrectomy was evaluated by drain fluid amylase done on days 1, 3, and 5 post-operatively and clinical findings. The leaks were classified according to the International Study Group of Pancreatic Fistula (ISGPF) classification of biochemical leaks, postoperative pancreatic fistula (POPF) B and POPF C. The leaks were evaluated against pancreatic factors like duct diameter, consistency of the pancreas, the thickness of the pancreatic neck, and duct location. 

Observations: Eighty percent of patients had no leaks. The biochemical leak was seen in 10% of cases. POPF B and C were observed at 5% each. Mortality was 3%. The diameter of the pancreatic duct of more than 3 mm and the firm consistency of the pancreas were favourable factors in the outcome of the anastomosis.

Conclusion: A modified pancreatico-gastrostomy technique appears to be technically feasible and safe. The leak rates and mortality appear to be low. We need a higher number of patients to confirm the efficacy of this modified pancreatico-enterostomy.

Establishment and Application of a Novel Difficulty Scoring System for da Vinci Robotic Pancreatoduodenectomy

Background

Robotic pancreatoduodenectomy (RPD) technology is developing rapidly, but there is still a lack of a specific and objective difficulty evaluation system in the field of application and training of RPD surgery.

Methods

The clinical data of patients who underwent RPD in our hospital from November 2014 to October 2020 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were used to determine the predictors of operation difficulty and convert into a scoring system.

Results

A total of 72 patients were enrolled in the group. According to the operation time (25%), intraoperative blood loss (25%), conversion to laparotomy, and major complications, the difficulty of operation was divided into low difficulty (0–2 points) and high difficulty (3–4 points). The multivariate logistic regression model included the thickness of mesenteric tissue (P1) (P = 0.035), the thickness of the abdominal wall (B1) (P = 0.017), and the preoperative albumin (P = 0.032), and the nomogram was established. AUC = 0.773 (0.645–0.901).

Conclusions

The RPD difficulty evaluation system based on the specific anatomical relationship between da Vinci’s laparoscopic robotic arm and tissues/organs in the operation area can be used as a predictive tool to evaluate the surgical difficulty of patients before operation and guide clinical practice.

C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage

Background

Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C.

Methods

Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C.

Results

High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started.

Discussion

High postoperative CRP levels are related to an increased risk of PPH C.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Prophylactic abdominal drainage for pancreatic surgery

BACKGROUND

The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. This is the third update of a previously published Cochrane Review to address the uncertain benifits of prophylactic abdominal drainage in pancreatic surgery.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal.

SEARCH METHODS

In this updated review, we re-searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and the Chinese Biomedical Literature Database (CBM) on 08 February 2021.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We identified a total of nine RCTs with 1892 participants. Drain use versus no drain use We included four RCTs with 1110 participants, randomised to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. Low-certainty evidence suggests that drain use may reduce 90-day mortality (RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants). Compared with no drain use, low-certainty evidence suggests that drain use may result in little to no difference in 30-day mortality (RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants), wound infection rate (RR 0.98, 95% CI 0.68 to 1.41; four studies, 1055 participants), length of hospital stay (MD -0.14 days, 95% CI -0.79 to 0.51; three studies, 876 participants), the need for additional open procedures for postoperative complications (RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants), and quality of life (105 points versus 104 points; measured with the pancreas-specific quality of life questionnaire (scale 0 to 144, higher values indicating a better quality of life); one study, 399 participants). There was one drain-related complication in the drainage group (0.2%). Moderate-certainty evidence suggests that drain use probably resulted in little to no difference in morbidity (RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants). The evidence was very uncertain about the effect of drain use on intra-abdominal infection rate (RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-certainty evidence), and the need for additional radiological interventions for postoperative complications (RR 0.87, 95% CI 0.40 to 1.87; three studies, 660 participants; very low-certainty evidence). Active versus passive drain We included two RCTs involving 383 participants, randomised to the active drain group (N = 194) and the passive drain group (N = 189) after pancreatic surgery. Compared with a passive drain, the evidence was very uncertain about the effect of an active drain on 30-day mortality (RR 1.23, 95% CI 0.30 to 5.06; two studies, 382 participants; very low-certainty evidence), intra-abdominal infection rate (RR 0.87, 95% CI 0.21 to 3.66; two studies, 321 participants; very low-certainty evidence), wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; two studies, 321 participants; very low-certainty evidence), morbidity (RR 0.97, 95% CI 0.53 to 1.77; two studies, 382 participants; very low-certainty evidence), length of hospital stay (MD -0.79 days, 95% CI -2.63 to 1.04; two studies, 321 participants; very low-certainty evidence), and the need for additional open procedures for postoperative complications (RR 0.44, 95% CI 0.11 to 1.83; two studies, 321 participants; very low-certainty evidence). There was no drain-related complication in either group. Early versus late drain removal We included three RCTs involving 399 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 200) and the late drain removal group (N = 199) after pancreatic surgery. Compared to late drain removal, the evidence was very uncertain about the effect of early drain removal on 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; three studies, 399 participants; very low-certainty evidence), wound infection rate (RR 1.32, 95% CI 0.45 to 3.85; two studies, 285 participants; very low-certainty evidence), hospital costs (SMD -0.22, 95% CI -0.59 to 0.14; two studies, 258 participants; very low-certainty evidence), the need for additional open procedures for postoperative complications (RR 0.77, 95% CI 0.28 to 2.10; three studies, 399 participants; very low-certainty evidence), and the need for additional radiological procedures for postoperative complications (RR 1.00, 95% CI 0.21 to 4.79; one study, 144 participants; very low-certainty evidence). We found that early drain removal may reduce intra-abdominal infection rate (RR 0.44, 95% CI 0.22 to 0.89; two studies, 285 participants; very low-certainty evidence), morbidity (RR 0.49, 95% CI 0.30 to 0.81; two studies, 258 participants; very low-certainty evidence), and length of hospital stay (MD -2.20 days, 95% CI -3.52 to -0.87; three studies, 399 participants; very low-certainty evidence), but the evidence was very uncertain. None of the studies reported on drain-related complications.

AUTHORS' CONCLUSIONS

Compared with no drain use, it is unclear whether routine drain use has any effect on mortality at 30 days or postoperative complications after pancreatic surgery. Compared with no drain use, low-certainty evidence suggests that routine drain use may reduce mortality at 90 days. Compared with a passive drain, the evidence is very uncertain about the effect of an active drain on mortality at 30 days or postoperative complications. Compared with late drain removal, early drain removal may reduce intra-abdominal infection rate, morbidity, and length of hospital stay for people with low risk of postoperative pancreatic fistula, but the evidence is very uncertain.

What is the pancreatic duct size limit for a safe duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy? A retrospective study

Backgrounds/Aims

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a dreadful complication. Duct-to-mucosa pancreaticojejunostomy (DTMPJ) is a commonly performed anastomosis after PD. This study aims to evaluate whether there is a size limit of pancreatic duct below which POPF rate increases significantly after DTMPJ.

Methods

A retrospective study was performed from a database with prospectively collected data on consecutive patients undergoing DTMPJ.

Results

Between the years 2003 and 2019, a total of 288 patients with DTMPJ were recruited. POPF occurred in 56.3% of the patients, of which 43.8% were biochemical leak, 8.7% were grade B, and 1.4% were grade C. Overall operative morbidity was 51.4%, of which 19.1% were major complications. Five patients (1.7%) died within 90 days of operation. Patients with grade B/C POPF had significantly soft pancreas (p < 0.001), smaller duct size (p = 0.031), and a diagnosis of carcinoma of the pancreas (p = 0.027). When a clinically significant POPF rate was analysed based on the pancreatic duct diameter, pancreatic duct size ≤ 1 mm had the highest POPF rate (35.7%). There was a significant difference in POPF rate between adjacent ductal diameter ≤ 1 mm and > 1 mm to 2 mm (35.7% vs 13.3%; p = 0.040). Multivariable analysis showed that for the soft pancreas, pancreatic duct diameter ≤ 1 mm was the only significant predictive factor for POPF (p = 0.027).

Conclusions

DTMPJ can be safely performed for pancreatic duct > 1 mm without significantly increased POPF risk.

Clinical impact of the new "twin U-stitch method" of pancreaticogastrostomy in pancreaticoduodenectomy

PURPOSE

The optimal pancreaticogastrostomy (PG) method for reducing pancreatic fistula (PF) incidence remains unclear. This retrospective review aimed to evaluate the clinical impact of the "twin U-stitch method" and compared it with the conventional invagination method.

METHODS

Data of 183 consecutive patients who underwent PG after pancreaticoduodenectomy (PD) between January 2015 and November 2020 were evaluated. PF incidence was compared between patients who experienced twin U-stitch PG (twin U-stitch group) and those who experienced conventional invagination PG (conventional PG group).

RESULTS

The twin U-stitch and conventional PG methods were performed in 97 and 86 patients, respectively. The time required for twin U-stitch PG was shorter than conventional PG (9.3 min vs 20.0 min, P < 0.001). The twin U-stitch group showed a lower incidence of PF than the conventional PG group (8% vs. 19%, P = 0.038). Multivariate analysis confirmed that twin U-stitch PG was significantly correlated with a decreased risk of PF (odds ratio, 0.23; P = 0.006), independent of the texture of the pancreas. Subgroup analysis of patients with soft-textured pancreas showed that the median drain amylase levels in the twin U-stitch group on postoperative days (POD) 1 and 3 were significantly lower than those in the conventional PG group (POD 1: 1,335 vs. 5,991 U/L, P < 0.001; POD 3: 212 vs. 518, P = 0.001).

CONCLUSION

The twin U-stitch method was simple and preferable to the conventional method for preventing PF in patients with PD.

Retrospective Comparative Analysis of POPF Using Fistula Risk Score According to Pancreaticoenterostomy Method

Background

The aim of this study is to examine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is the better reconstructive method to reduce postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the fistula risk.

Methods

An institutional database was reviewed for patients undergoing PD between January 2008 and August 2019. A total of 159 patients were stratified into 4 groups according to the Clinical Risk Score-Pancreatic Fistula. POPF according to 4 risk groups was compared between PJ and PG.

Results

Of the 159 patients, 82 underwent PG (51.6%) and 77 underwent PJ (48.4%) reconstruction. POPF rate was 17.1% (n = 14) in the PG group and 12.9% (n = 10) in the PJ group (P = 0.51). POPF rates were not different in intermediate, low, and negligible risks between 2 reconstructive methods. In the high-risk group (n = 47), there were 4 POPFs (22.2%) in PJ group and 9 (31.0%) in the PG group, respectively (P = 0.74).

Conclusion

In PD, there was no superior method of reconstruction with regard to POPF, even in high-risk glands.

A randomised, multicentre trial of somatostatin to prevent clinically relevant postoperative pancreatic fistula in intermediate-risk patients after pancreaticoduodenectomy

BACKGROUND

Prophylactic somatostatin to reduce the incidence of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy remains controversial. We assessed the preventive efficacy of somatostatin on clinically relevant postoperative pancreatic fistula in intermediate-risk patients who underwent pancreaticoduodenectomy at pancreatic centres in China.

METHODS

In this multicentre, prospective, randomised controlled trial, we used the updated postoperative pancreatic fistula classification criteria and cases were confirmed by an independent data monitoring committee to improve comparability between centres. The primary endpoint was the rate of clinically relevant postoperative pancreatic fistula within 30 days after pancreaticoduodenectomy.

RESULTS

Eligible patients (randomised, n = 205; final analysis, n = 199) were randomised to receive postoperative intravenous somatostatin (250 μg/h over 120 h; n = 99) or conventional therapy (n = 100). The primary endpoint was significantly lower in the somatostatin vs control group (n = 13 vs n = 25; 13% vs 25%, P = 0.032). There were no significant differences for biochemical leak (P = 0.289), biliary fistula (P = 0.986), abdominal infection (P = 0.829), chylous fistula (P = 0.748), late postoperative haemorrhage (P = 0.237), mean length of hospital stay (P = 0.512), medical costs (P = 0.917), reoperation rate (P > 0.99), or 30 days' readmission rate (P = 0.361). The somatostatin group had a higher rate of delayed gastric emptying vs control (n = 33 vs n = 21; 33% vs 21%, P = 0.050).

CONCLUSIONS

Prophylactic somatostatin treatment reduced clinically relevant postoperative pancreatic fistula in intermediate-risk patients after pancreaticoduodenectomy.

TRIAL REGISTRATION

NCT03349424.

[Surgery for periampullary pancreatic cancer]

Periampulläre Neoplasien sind eine heterogene Gruppe verschiedener Tumorentitäten der periampullären Region, von denen das Pankreasadenokarzinom mit 60–70 % am häufigsten ist. Wie typisch für Pankreaskarzinome zeichnen sich periampulläre Pankreaskarzinome durch ein aggressives Wachstum und eine frühe systemische Progression aus. Aufgrund ihrer besonderen Lage in unmittelbarer Nähe zur Papilla Vateri treten Symptome in eher früherem Tumorstadium auf, sodass die Therapiemöglichkeiten und Prognose insgesamt günstiger sind als bei Pankreaskarzinomen anderer Lokalisation. Trotzdem unterscheiden sich die Therapieprinzipien bei periampullären Pankreaskarzinomen nicht wesentlich von den Standards bei Pankreaskarzinomen anderer Lokalisation. Ein potenziell kurativer Therapieansatz beim nichtmetastasierten periampullären Pankreaskarzinom ist multimodal und besteht aus der Durchführung einer partiellen Duodenopankreatektomie als radikale onkologische Resektion in Kombination mit einer systemischen, meist adjuvant verabreichten Chemotherapie. Bei Patienten mit günstigen prognostischen Faktoren kann hierdurch ein Langzeitüberleben erzielt werden. Zudem wurden mit der Weiterentwicklung der Chirurgie und Systemtherapie auch potenziell kurative Therapiekonzepte für fortgeschrittene, früher irresektable Tumoren etabliert, welche nun nach Durchführung einer neoadjuvanten Therapie oft einer Resektion zugeführt werden können. In diesem Beitrag werden die aktuellen chirurgischen Prinzipien der radikalen onkologischen Resektion periampullärer Pankreaskarzinome im Kontext der multimodalen Therapie dargestellt und ein Ausblick auf mögliche künftige Entwicklungen der Therapie gegeben.

Modified Technique for Wirsung-Pancreatogastric Anastomosis after Pancreatoduodenectomy: A Single Center Experience and Systematic Review of the Literature

BACKGROUND

The mortality rate following pancreaticoduodenectomy (PD) has been decreasing over the past few years; nonetheless, the morbidity rate remains elevated. The most common complications after PD are post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) syndrome. The issue as to which is the best reconstruction method for the treatment of the pancreatic remnant after PD is still a matter of debate. The aim of this study was to retrospectively analyze the morbidity rate in 100 consecutive PD reconstructed with Wirsung-Pancreato-Gastro-Anastomosis (WPGA), performed by a single surgeon applying a personal modification of the pancreatic reconstruction technique.

METHODS

During an 8-year period (May 2012 to March 2020), 100 consecutive patients underwent PD reconstructed with WPGA. The series included 57 males and 43 females (M/F 1.32), with a mean age of 68 (range 41-86) years. The 90-day morbidity and mortality were retrospectively analyzed. Additionally, a systematic review was conducted, comparing our technique with the existing literature on the topic.

RESULTS

We observed eight cases of clinically relevant POPF (8%), three cases of "primary" DGE (3%) and four patients suffering "secondary" DGE. The surgical morbidity and mortality rate were 26% and 6%, respectively. The median hospital stay was 13.6 days. The systematic review of the literature confirmed the originality of our modified technique for Wirsung-Pancreato-Gastro-Anastomosis.

CONCLUSIONS

Our modified double-layer WPGA is associated with a very low incidence of POPF and DGE. Also, the technique avoids the risk of acute hemorrhage of the pancreatic parenchyma.

Pancreatoduodenectomy within 2 weeks after endoscopic retrograde cholangio-pancreatography increases the risk of organ/space surgical site infections: a 5-year retrospective cohort study in a high-volume centre

BACKGROUND

Organ/space surgical site infections (OSSI) after pancreaticoduodenectomy (PD) are not rare events. The role of diagnosis and treatment for pancreatic and biliary diseases with an endoscopic retrograde cholangio-pancreatography (ERCP) procedure is currently controversial. However, the ERCP procedure might play a role in surgical outcomes after PD.

METHODS

We conducted a retrospective cohort study for patients who underwent PD in the First Affiliated Hospital with the Nanjing Medical University from 1st September 2012 to 31st January 2018. The relationship between ERCP exposure and OSSI after PD was analyzed by univariate and forward stepwise multivariate logistic regression model.

RESULTS

Of the 1,365 patients who underwent PD, 136 developed OSSI (10.0%). We found that ERCP exposure before PD (EEBPD) was significantly associated with an increased incidence rate of post-operative pancreas fistula (POPF) [24.2% (23/95) vs. 14.9% (189/1,270), risk ratio (RR) =1.63, 95% confidence interval (CI), 1.11-2.38, P=0.015]. Hypertension, a higher level of preoperative low-density lipoprotein (LDL) and creatinine (Cr) were associated with elevated risks of post-operative OSSI [adjusted odds ratio (Adj-OR) (95% CI) were 1.59 (1.09-2.32), 1.70 (1.16-2.51), 1.99 (1.36-2.92)], whereas a preoperatively higher level of aspartate aminotransferase (AST) would decrease the risk [Adj-OR (95% CI), 0.62 (0.42-0.91)]. Remarkably, EEBPD would significantly increase and more than double the OSSI risk [Adj-OR (95% CI), 2.56 (1.46-4.47)] especially if it was within 14 days before surgery (Spearman =-0.698, P<0.001).

CONCLUSIONS

ERCP, as an independent risk factor, significantly increased the risk of post-operative OSSI after PD if it is performed within 14 days prior to surgery. Our findings would assist clinical decision-making, and improve OSSI control and prevention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Modified "Blumgart-Type" Suture for Wirsung-Pancreaticogastrostomy: Technique and Results of a Pilot Study

INTRODUCTION

Postoperative pancreatic fistula (POPF) represents the principal determinant of morbidity and mortality after pancreaticoduodenectomy. Since 1994 we have been performing pancreaticogastrostomy with duct-to-mucosa anastomosis (Wirsung-pancreaticogastric anastomosis [WPGA]), but postoperative morbidity, although limited, was still a concern. An original pancreas-transfixing suture technique, named "Blumgart's anastomosis" (BA), has shown efficacy at reducing fistula rates from pancreaticojejunostomy. Few cohort studies have shown that WPGA with pancreas-transfixing stitches may help reduce the rate of POPF. We designed a novel "Blumgart-type" modification of WPGA (B-WPGA) aiming at harnessing the full potential of the Blumgart design.

METHODS

A prospective development study was designed around the application of B-WPGA after pancreaticoduodenectomy for primary periampullary tumors. It focused on describing the early iterations of this technique and on assessing the rate of POPF and delayed post-pancreatectomy hemorrhage (DPH) (primary outcomes), along with other perioperative outcomes. Technically, after mobilizing the pancreatic remnant for a few centimeters, the Wirsung duct is cannulated. A lozenge of seromuscular layer is excised from the posterior gastric wall, matching the shape and size of the pancreas's cut surface. Two to four transparenchymal pancreatic-to-gastric submucosa U stitches with 4/0 Gore-Tex are positioned cranially and caudally to the Wirsung duct, respectively, mounted on soft clamps, and tied onto the gastric serosa only after duct-to-mucosa anastomosis. Postoperative follow-up was standardized by protocol and included a pancreatic enzyme check on the drain output.

RESULTS

From February 2018 to June 2019, in 15 continuous cases, B-WPGA was performed after pancreaticoduodenectomy. Indications for pancreaticoduodenectomy were mainly ampulla of Vater and pancreatic head adenocarcinomas. There was no operative mortality and no pancreatic anastomosis-related morbidity. Two events (13%) of transiently elevated amylase in the drain fluid, not matching the definition of POPF, were identified in patients with a soft pancreas on postoperative day 2. No DPHs were recorded after a minimum follow-up of 18.6 months.

DISCUSSION/CONCLUSION

The principles of BA may be safely applied to the WPGA model. B-WPGA allows (1) gentle compression and closure of the small secondary ducts in the pancreatic remnant; (2) partial invagination of the pancreatic body in the gastric wall, with the pancreatic cut surface protected by the gastric submucosa; and (3) prevention of parenchymal fractures, as the pancreaticogastric stitches are tied onto the gastric serosa. Despite the limited number of cases in this study, the absence of mortality and anastomosis-related complications supports further reproduction of this technical variant. Larger studies are necessary to determine its efficacy.

Preoperative Predictors for 90-Day Mortality after Pancreaticoduodenectomy in Patients with Adenocarcinoma of the Ampulla of Vater: A Single-Centre Retrospective Cohort Study

Background

The standard treatment for ampullary adenocarcinoma is pancreaticoduodenectomy. Identification of preoperative risk factors might help the clinician to select patients fit for resection and potentially decrease morbidity and mortality after PD. We conducted a cohort study to determine the preoperative factors related to 90-day severe morbidity and mortality after PD.

Methods

We conducted a retrospective cohort study in patients with a diagnosis of ampullary adenocarcinoma who underwent an open PD between January 2010 and December 2019 at our tertiary centre.

Results

Independent preoperative predictors of mortality were the albumin-bilirubin (ALBI) grade 3 (OR: 21.7; CI 95: 2.1–226.9; p=0.01) and the estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m² (OR: 17.7; CI 95: 1.8–172.6; p=0.013). The eGFR <90 mL/min/1.73 m² (OR = 6.6; CI 95: 1.9–23.4; p=0.003) and prothrombin time (OR = 1.5; CI 95; 1.1–2.1; p=0.005) were independent predictors for severe morbidity.

Conclusion

These findings suggest that baseline renal function measured by the eGFR and liver function categorized with the ALBI grading are predictors of severe morbidity and mortality. Thus, they should be considered when selecting patients for PD or the use of neoadjuvant treatments. Further research is warranted.

[Immediate outcomes of pancreatoduodenectomy after different digestive reconstruction procedures]

OBJECTIVE

To study the immediate results of pancreatoduodenectomy depending on digestive reconstruction procedure.

MATERIAL AND METHODS

We analyzed 242 patients who underwent pancreatoduodenectomy for the period from January 2013 to December 2019. There were 32 combined procedures: 28 (11.6%) with portal vein resection and 8 (3.3%) simultaneous operations (right-sided hemicolectomy - 4, right-sided adrenalectomy - 2, gastrectomy with splenectomy - 2). Pancreatic stump was inserted into the jejunum in 156 (64.5%) patients, into the stomach - in 86 (35.5%) cases.

RESULTS

Postoperative period was uneventful in 180 (74.4%) patients. Eighty postoperative complications were observed in 62 (25.6%) patients; 221 (91.3%) patients were discharged, 21 (8.7%) patients died. Pancreatic necrosis was the most common postoperative event and provoked 65 (82.5%) various complications (38 (72.1%) in patients with pancreaticojejunostomy and 20 (71.5%) in those with pancreaticogastrostomy). Incidence of complications was similar in both groups. However, pancreaticojejunostomy was followed by severe pancreatic fistula type C in 12 (23.1%) patients, type B in 24 (46.1%) cases. In case of pancreaticogastrostomy, pancreatic fistula type C occurred in 4 (14.3%) cases, type B - in 8 (28.6%) patients.

CONCLUSION

Pancreatic necrosis was the most common postoperative event after pancreatoduodenectomy. Fewer severe pancreatic fistulae (type C) were recorded after pancreaticogastrostomy although these patients had lower density of the pancreas and unclear pancreatic duct. Choice of pancreatic-digestive anastomosis should be determined by features of pancreatic parenchyma, pancreatic duct diameter. Nevertheless, final decision is a prerogative of surgeon. Pancreaticogastrostomy is especially advisable in minimally invasive PDEs that will simplify inclusion of the pancreas into digestive system and reduce the incidence of complications and mortality.

Early vs Late Readmissions in Pancreaticoduodenectomy Patients: Recognizing Comprehensive Episodic Cost to Help Guide Bundled Payment Plans and Hospital Resource Allocation

INTRODUCTION

Previous studies on readmission cost in pancreaticoduodenectomy patients use estimated cost data and do not delineate etiology or cost differences between early and late readmissions. We sought to identify relationships between postoperative complication type and readmission timing and cost in pancreaticoduodenectomy patients.

METHODS

Hospital cost data from date of discharge to postoperative day 90 were merged with 2008-2018 NSQIP data. Early readmission was within 30 days of surgery, and late readmission was 30 to 90 days from surgery. Regression analyses for readmission controlled for patient comorbidities, complications, and surgeon.

RESULTS

Of 230 patients included, 58 (25%) were readmitted. The mean early and late readmission costs were $18,365 ± $20,262 and $24,965 ± $34,435, respectively. Early readmission was associated with index stay deep vein thrombosis (p < 0.01), delayed gastric emptying (p < 0.01), and grade B pancreatic fistula (p < 0.01). High-cost early readmission had long hospital stays or invasive procedures. Common late readmission diagnoses were grade B pancreatic fistula requiring drainage (n = 5, 14%), failure to thrive (n = 4, 14%), and bowel obstruction requiring operation (n = 3, 11%). High-cost late readmissions were associated with chronic complications requiring reoperation.

CONCLUSION

Early and late readmissions following pancreaticoduodenectomy differ in both etiology and cost. Early readmission and cost are driven by common complications requiring percutaneous intervention while late readmission and cost are driven by chronic complications and reoperation. Late readmissions are frequent and a significant source of resource utilization. Negotiations of bundled care payment plans should account for significant late readmission resource utilization.

Predictive Factors for Postoperative Pancreatic Fistula-A Swedish Nationwide Register-Based Study

BACKGROUND

A serious complication after pancreatoduodenectomy (PD) is postoperative pancreatic fistula (POPF). The aim of this study was to analyse the incidence and predictive factors for POPF by using a large nationwide cohort.

METHODS

Data from the Swedish National Registry for Pancreatic and Periampullary Cancer for all patients undergoing a PD from 2010 until 30th June 2018 were collected. The material was analysed in two groups, no POPF and clinically relevant (grade B and C) POPF.

RESULTS

A total of 2503 patients underwent PD, of which 245 (10%) developed POPF. Patients with POPF had significantly more overall complications (Clavien Dindo ≥3a, 75% vs. 21%, p < 0.001) and longer hospital stay (median 23 [16-35] vs. 11 [8-15], p < 0.001) than patients without POPF. The risk of POPF was higher with increased BMI (OR 1.08, p < 0.001). Preoperative presence of diabetes (OR 0.52, p = 0.012) and preoperative biliary drainage (OR 0.34, p < 0.001) reduced the risk of POPF. Reconstruction with pancreaticojejunostomy caused a more than two folded increase in POPF compared with pancreaticogastrostomy (OR 2.41, p < 0.001). Weight gain ≥2 kg on postoperative day 1 was also a risk factor (OR 1.76, p < 0.001).

CONCLUSION

A high BMI, a pancreaticojejunostomy and postoperative weight gain were risk factors for developing POPF. Diabetes or preoperative biliary drainage was protective.

The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula

Pancreatic fistula has been the defining complication and challenge of pancreatic surgery. Better awareness and mitigation of postoperative pancreatic fistulas has led to significant improvements in morbidity and mortality of pancreatic surgery. The definition and management of pancreatic fistulas has sequentially progressed over the last three decades; the literature ranges from retrospective, observational studies to prospective multicenter randomized controlled trials. The landmark literature contributions driving the perioperative management of pancreatic fistulas are detailed in this article.

The 1-year outcomes after pancreaticogastrostomy using vertical versus horizontal mattress suturing for gastric wrapping

PURPOSE

To investigate the differences in nutritional status 1 year after pancreaticogastrostomy (PG) using vertical suturing (VS) vs. twin square horizontal mattress (HMS) suturing in patients undergoing pancreaticoduodenectomy (PD).

METHODS

The subjects of this study were 134 patients who underwent PD, followed by PG, which was closed by VS in 52 and by HMS in 82. We evaluated the peri- and postoperative factors, nutritional parameters, diameter of the remnant main pancreatic duct, and glucose intolerance 1 year postoperatively.

RESULTS

Forty-five (87%) patients from the VS group and 75 (91%) patients from the HMS group survived for more than 1 year. The incidences of intraabdominal abscess and pancreatic fistula were significantly lower in the HMS group than in the VS group (19.2% vs. 6.6% and19.2% vs. 2.6%, respectively). There were no significant changes in the total protein, serum albumin, and HbA1c levels 1 year postoperatively. The postoperative expansion ratio of the main pancreatic duct diameter was significantly smaller in the HMS group than in the VS group. The strongest risk factor for body weight loss 1 year postoperatively was a non-soft pancreas texture.

CONCLUSION

HMS was superior to VS for preventing early postoperative complications and did not affect pancreatic function.

Comparative long-term outcomes for pancreatic volume change, nutritional status, and incidence of new-onset diabetes between pancreatogastrostomy and pancreatojejunostomy after pancreaticoduodenectomy

Background

The difference in volume change in a pancreatic remnant according to the type of pancreaticoenterostomy after pancreaticoduodenectomy (PD) for long-term follow-up is unknown. Also, there are few studies that evaluate the difference in general nutritional status and pancreatic endocrine function, including new-onset diabetes mellitus (NODM) depending on the type of pancreaticoenterostomy. This study aimed to compare serial pancreatic volume changes in pancreatic remnants between pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) after PD and to evaluate the difference in general nutritional status and incidence of NODM between PG and PJ.

Methods

This study enrolled 115 patients who had survived for more than 3 years after PD. They were divided into the PG group and the PJ group. Their clinicopathologic factors were collected and analyzed. We calculated serial pancreas volume and pancreatic duct size precisely from preoperative stage to 5 years after surgery by image-processing software specifically designed for navigation and visualization of multimodality and multidimensional images. Consecutive changes of albumin and body mass index (BMI) as related to general nutritional status were compared between the PG and PJ groups. To evaluate the incidence and risk factors of NODM following PD, subgroup analysis was performed in 88 patients who did not have diabetes preoperatively.

Results

Most patient demographics were not significantly different between the PG group (n=45) and PJ group (n=70). There was no significant difference in volume reduction between the groups from postoperative 1 month to 5 years (PG group -18.21±14.66 mL versus PJ group -14.43±13.05 mL, P=0.209). But there was a significant difference in increased pancreatic duct size between the groups from postoperative 1 month to 5 years (PG group 1.66±2.20 mm versus PJ group 0.54±1.54 mm, P=0.007). There was no significant difference in the increase of total serum albumin between the groups for 5 years after surgery (PG group 0.51±0.47 g/dL, 14.3% versus PJ group 0.42±0.60 g/dL, 11.3%, P=0.437). There was also no significant difference in BMI decrease between the groups (PG group -1.13±3.12, -4.9% versus PJ group -1.97±2.01, -8.7%, P=0.206). On the whole, NODM was diagnosed in 19 patients out of the 88 patients (21.6%) who did not have DM preoperatively. The incidence of NODM was not significantly different between the groups (PG group 21.6% versus PJ group 21.5%, P=0.995). In addition, pancreaticoenterostomy was not an independent risk factor for NODM by logistic regression analysis (odds ratio, 0.997, 95% CI: 0.356-0.2.788, P=0.995). No other risk factors for NODM were found.

Conclusions

PG and PJ following PD induced similar pancreatic volume reduction during long-term follow-up. There was no difference in general nutritional status or incidence of NODM between the groups after PD.

Prospective study on predictability of complications by pancreatic surgeons

PURPOSE

We evaluated the intuition of expert pancreatic surgeons, in predicting the associated risk of pancreatic resection and compared this "intuition" to actual operative follow-up. The objective was to avoid major complications following pancreatic resection, which remains a challenge.

METHODS

From January 2015 to February 2018, all patients who were 18 years old or more undergoing a pancreatic resection (pancreaticoduodenectomy [PD], distal pancreatectomy [DP], or central pancreatectomy [CP]) for pancreatic lesions were included. Preoperatively and postoperatively, all surgeons completed a form assessing the expected potential occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF: grade B or C), postoperative hemorrhage, and length of stay.

RESULTS

Preoperative intuition was assessed for 101 patients for 52 PD, 44 DP, and 5 CP cases. Overall mortality and morbidity rates were 6.9% (n = 7) and 67.3% (n = 68), respectively, and 38 patients (37.6%) developed a POPF, including 27 (26.7%) CR-POPF. Concordance between preoperative intuition of CR-POPF occurrence and reality was minimal, with a Cohen's kappa coefficient (κ) of 0.175 (P value = 0.009), and the same result was obtained between postoperative intuition and reality (κ = 0.351; P < 0.001). When the pancreatic parenchyma was hard, surgeons predicted the absence of CR-POPF with a negative predictive value of 91.3%. However, they were not able to predict the occurrence of CR-POPF when the pancreas was soft (positive predictive value 48%).

CONCLUSIONS

This study assessed for the first time the surgeon's intuition in pancreatic surgery, and demonstrated that pancreatic surgeons cannot accurately assess outcomes except when the pancreatic parenchyma is hard.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019).

SELECTION CRITERIA

We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

A Novel Way of Preventing Postoperative Pancreatic Fistula by Directly Injecting Profibrogenic Materials into the Pancreatic Parenchyma

This paper aims to validate if intrapancreatic injection of penicillin G can enhance hardness and suture holding capacity (SHC) of the pancreas through prompting the fibrosis process. Soft pancreatic texture is constantly mentioned as one of the most contributory predictors of postoperative pancreatic fistula (POPF). Soft pancreas has poor SHC and higher incidence of parenchymal tearing, frequently leading to POPF. From a library of 114 antibiotic compounds, we identified that penicillin G substantially enhanced pancreatic hardness and SHC in experimental mice. Specifically, we injected penicillin G directly into the pancreas. On determined dates, we measured the pancreatic hardness and SHC, respectively, and performed molecular and histological examinations for estimation of the degree of fibrosis. The intrapancreatic injection of penicillin G activated human pancreatic stellate cells (HPSCs) to produce various fibrotic materials such as transforming growth factor-β1 (TGF-β1) and metalloproteinases-2. The pancreatic hardness and SHC were increased to the maximum at the second day after injection and then it gradually subsided demonstrating its reversibility. Pretreatment of mice with SB431542, an inhibitor of the TGF-β1 receptor, before injecting penicillin G intrapancreatically, significantly abrogated the increase of both pancreatic hardness and SHC caused by penicillin G. This suggested that penicillin G promotes pancreatic fibrosis through the TGF-β1 signaling pathway. Intrapancreatic injection of penicillin G promotes pancreatic hardness and SHC by enhancing pancreatic fibrosis. We thus think that penicillin G could be utilized to prevent and minimize POPF, after validating its actual effectiveness and safety by further studies.

Pancreaticogastrostomy as reconstruction choice in pancreatic trauma surgery: Case report and review of the literature

INTRODUCTION

Due to its retroperitoneal location and its proximity to major vascular structures and other organs, isolated pancreatic injuries are rare. The optimal management for pancreatic injuries of grades III and IV, where a main ductal transection is present, remains controversial. Isolated complete traumatic transection of the pancreatic neck is uncommon, but this condition is associated with some peculiar technical aspects that allow more conservative treatments.

PRESENTATION OF THE CASE

A closed abdominal blunt trauma in a young patient underwent emergency surgery for suspect hemoperitoneum. Intraoperatively evidence of complete traumatic transection of the pancreatic neck treated with pancreas tissue debridement, suture of the cephalic stump and pancreaticogastrostomy reconstruction.

DISCUSSION

Preservation of pancreatic volume and avoidance of adjacent organ resection is associated with lesser mortality and morbidity rate. The advantages of conservative treatments are related to reductions in the postoperative exocrine and endocrine insufficiencies.

CONCLUSION

In selected cases of complete neck transection with preserved pancreatic parenchyma in a stable patient, parenchymal-sparing interventions should be considered. Pancreaticogastrostomy offers an easier to learn and faster technique also suited for less experienced surgeons.

Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes

This review aims to outline the most up-to-date knowledge of pancreatic adenocarcinoma risk, diagnostics, treatment and outcomes, while identifying gaps that aim to stimulate further research in this understudied malignancy. Pancreatic adenocarcinoma is a lethal condition with a rising incidence, predicted to become the second leading cause of cancer death in some regions. It often presents at an advanced stage, which contributes to poor five-year survival rates of 2%-9%, ranking firmly last amongst all cancer sites in terms of prognostic outcomes for patients. Better understanding of the risk factors and symptoms associated with this disease is essential to inform both health professionals and the general population of potential preventive and/or early detection measures. The identification of high-risk patients who could benefit from screening to detect pre-malignant conditions such as pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms is urgently required, however an acceptable screening test has yet to be identified. The management of pancreatic adenocarcinoma is evolving, with the introduction of new surgical techniques and medical therapies such as laparoscopic techniques and neo-adjuvant chemoradiotherapy, however this has only led to modest improvements in outcomes. The identification of novel biomarkers is desirable to move towards a precision medicine era, where pancreatic cancer therapy can be tailored to the individual patient, while unnecessary treatments that have negative consequences on quality of life could be prevented for others. Research efforts must also focus on the development of new agents and delivery systems. Overall, considerable progress is required to reduce the burden associated with pancreatic cancer. Recent, renewed efforts to fund large consortia and research into pancreatic adenocarcinoma are welcomed, but further streams will be necessary to facilitate the momentum needed to bring breakthroughs seen for other cancer sites.

Outcome of 150 Consecutive Blumgart's Pancreaticojejunostomy After Pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is the most feared complication after pancreaticoduodenectomy (PD) that leads to intra-abdominal abscess, sepsis, or bleeding and remains the single most important source of morbidity and mortality after PD. To minimize this dreaded complication, various surgical techniques and modifications of pancreaticoenteric reconstruction have been proposed. However, still POPF does occur even in experienced hands. We herein describe the outcome of 150 post PD patients who underwent duct-to-mucosa (DM) pancreaticojejunostomy (PJ) using a special technique, Blumgart's "through & through" U transpancreatic sutures. The technique is described in detail. Postoperative octreotide and metoclopramide were used in all patients for 3 days. An enhanced recovery (ERAS) protocol was followed in a subset of patients. All patients were ASA grade 1 and had adenocarcinoma of the periampullary region/pancreatic head and underwent standard pylorus resecting PD after due optimization. Eighty-eight (58.7%) patients had pancreatic duct < 3 mm and pancreatic texture was soft to very soft in 112 (74.6%) patients. There was only one International Study Group of Pancreatic Surgery (ISGPS) grade C POPF with concomitant hemorrhage. Five patients developed ISGPS grade B and two grade C, delayed gastric emptying (DGE). There was no 30-day mortality. The average length of hospital stay was 7.3 ± 4.2 days with a median of 6 days in the ERAS subset of patients. Blumgart's "through & through" DMPJ technique is very helpful in reducing the POPF and other complications even in high-risk pancreas (i.e., soft with a small pancreatic duct) and is easy to learn and perform.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

Prophylactic abdominal drainage for pancreatic surgery

BACKGROUND

The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal.

SEARCH METHODS

For the last version of this review, we searched CENTRAL (2016, Issue 8), and MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database (CBM) to 28 August 2016). For this updated review, we searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2016 to 15 November 2017.

SELECTION CRITERIA

We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled studies that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

We identified six studies (1384 participants). Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model.

MAIN RESULTS

Drain use versus no drain useWe included four studies with 1110 participants, who were randomized to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. There was little or no difference in mortality at 30 days between groups (1.5% with drains versus 2.3% with no drains; RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants; moderate-quality evidence). Drain use probably slightly reduced mortality at 90 days (0.8% versus 4.2%; RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants; moderate-quality evidence). We were uncertain whether drain use reduced intra-abdominal infection (7.9% versus 8.2%; RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-quality evidence), or additional radiological interventions for postoperative complications (10.9% versus 12.1%; RR 0.87, 95% CI 0.79 to 2.23; three studies, 660 participants; very low-quality evidence). Drain use may lead to similar amount of wound infection (9.8% versus 9.9%; RR 0.98 , 95% CI 0.68 to 1.41; four studies, 1055 participants; low-quality evidence), and additional open procedures for postoperative complications (9.4% versus 7.1%; RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants; low-quality evidence) when compared with no drain use. There was little or no difference in morbidity (61.7% versus 59.7%; RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants; moderate-quality evidence), or length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies, 711 participants; moderate-quality evidence) between groups. There was one drain-related complication in the drainage group (0.2%). Health-related quality of life was measured with the pancreas-specific quality-of-life questionnaire (FACT-PA; a scale of 0 to 144 with higher values indicating a better quality of life). Drain use may lead to similar quality of life scores, measured at 30 days after pancreatic surgery, when compared with no drain use (105 points versus 104 points; one study, 399 participants; low-quality evidence). Hospital costs and pain were not reported in any of the studies.Type of drainWe included one trial involving 160 participants, who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. An active drain may lead to similar mortality at 30 days (1.2% with active drain versus 0% with passive drain; low-quality evidence), and morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15; low-quality evidence) when compared with a passive drain. We were uncertain whether an active drain decreased intra-abdominal infection (0% versus 2.6%; very low-quality evidence), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05; very low-quality evidence), or the number of additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29; very low-quality evidence). Active drain may reduce length of hospital stay slightly (MD -1.90 days, 95% CI -3.67 to -0.13; one study; low-quality evidence; 14.1% decrease of an 'average' length of hospital stay). Additional radiological interventions, pain, and quality of life were not reported in the study.Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula, who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no mortality in either group. Early drain removal may slightly reduce morbidity (38.6% with early drain removal versus 61.4% with late drain removal; RR 0.63, 95% CI 0.43 to 0.93; low-quality evidence), length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; low-quality evidence; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (MD -EUR 2069.00, 95% CI -3872.26 to -265.74; low-quality evidence; 17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33, 95% CI 0.01 to 8.01; one study; very low-quality evidence). Intra-abdominal infection, wound infection, additional radiological interventions, pain, and quality of life were not reported in the study.

AUTHORS' CONCLUSIONS

It was unclear whether routine abdominal drainage had any effect on the reduction of mortality at 30 days, or postoperative complications after pancreatic surgery. Moderate-quality evidence suggested that routine abdominal drainage probably slightly reduced mortality at 90 days. Low-quality evidence suggested that use of an active drain compared to the use of a passive drain may slightly reduce the length of hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.

Modified end-to-side double-layer open pancreaticogastrostomy after Whipple procedure: surgical tips for a safe anastomosis

Pancreatic fistula (PF) remains the Achilles' heel of pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) appears to be associated with a lower risk of postoperative leak according to recent evidence. We started to fashion PG, especially in soft pancreas, modifying the original technique described by Bassi. At our institution, 105 PD procedures were carried out from January 2011 to December 2016; pancreatic-enteric continuity was restored by PG in 35 cases. Superior mesenteric/portal vein resection/reconstruction was necessary in three patients. A total of 34/35 patients underwent PG with an open anterior gastrostomy approach. Briefly, our double-layer PG anastomosis (illustrated by a video) starts with a posterior row of interrupted absorbable 4/0 monofilament sutures including the gastric serosa and the pancreatic capsule. It is essential to mobilize the left pancreas for 4-5 cm and to shape the posterior gastrostomy shorter than the pancreatic stump. After a wide anterior auxiliary gastrostomy the pancreas is invaginated into the stomach and an interrupted row of sutures between the posterior gastric wall (full-thickness) and the body of the pancreatic stump is fashioned. The anterior gastrostomy is closed with an absorbable running suture. Finally, a further layer of sutures is applied over the posterior suture line between the gastric serosa and the pancreatic capsule. The 90-day postoperative mortality was nihil. No biliary leakage was detected and the overall PF rate was 11.4% (4/35) according to the ISGPF study group. Only one patient suffered a grade B PF (in this case, PG was carried out only through a posterior gastrostomy), whereas three patients had a minor (grade A) PF. Our modified PG proved to be safe and easy to perform, while it carried excellent outcomes even in the setting of soft pancreas. Despite the limited number of cases, such modified PG appears promising, particularly for pancreatic remnants at higher risk of PF.

Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference.

OBJECTIVES

To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability.

MAIN RESULTS

We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data.

AUTHORS' CONCLUSIONS

There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.