Short-term outcomes and risk factors for pancreatic fistula after pancreatic enucleation: A single-center experience of 142 patients

Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area

Background

Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation.

Methods

Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed.

Results

Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up.

Conclusions

The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.

Minimally invasive enucleation versus open enucleation for benign or low-grade malignant pancreatic neoplasms: Effects on clinical outcomes and quality of life

Introduction

The efficacy and safety of minimally invasive pancreatic enucleation (PE) have rarely been investigated. This study aimed to compare the perioperative and long-term outcomes of minimally invasive enucleation (MIEn) with those of open enucleation (OEn) for benign/low-grade malignant pancreatic neoplasms.

Patients and Methods

Data collected from patients who underwent PE between January 2011 and June 2020 at our centre were analysed.

Results

Forty-two patients who underwent MIEn (10 - robot-assisted and 32 - laparoscopic) and 47 who underwent OEn were included in this study. Compared with the OEn group, the MIEn group showed shorter operation time (147.6 ± 71.3 min vs. 183.1 ± 64.3 min), shorter post-operative hospital stay (11.5 ± 3.9 days vs. 13.4 ± 4.2 days), shorter off-bed activity time (2.9 ± 0.9 days vs. 3.7 ± 1.0 days) and lower estimated blood loss (EBL) (118.5 ± 59.2 mL vs. 153.1 ± 85.0 mL). Overall complication rate (47.6% vs. 55.3%), overall post-operative pancreatic fistula (POPF) rate (40.5% vs. 44.7%) and Grade B + C POPF rate (11.9% vs. 19.1%) were similar in both the groups. For neoplasms located in the proximal pancreas, MIEn showed more favourable perioperative outcomes than OEn. Unlike MIEn for superficial neoplasms, MIEn for neoplasms deeply embedded in the pancreas resulted in a longer operative time and tended to increase EBL and the incidence of complications and POPF. During the follow-up period, no significant differences were observed between these two groups in terms of pancreatic function or quality of life.

Conclusions

Compared to OEn, MIEn is effective and safe for patients with benign or low-grade malignant pancreatic neoplasms. However, MIEn for embedded pancreatic neoplasms is recommended only in experienced centres because of the high rates of complications and POPF.

Pancreatic Enucleation Patients Share the Same Quality of Life as the General Population at Long-Term Follow-Up: A Propensity Score-Matched Analysis

OBJECTIVE

The aim of this study was to assess short- and long-term outcomes including quality of life (QoL) following pancreatic enucleation (PE).

BACKGROUND

PE is deemed to preserve both the endocrine and the exocrine function while ensuring radicality. However, to assess whether this reflects an actual benefit perceived by patients, QoL has to be considered.

METHODS

Data from all consecutive patients undergoing PE from January 2010 to December 2019 were retrospectively analyzed. Surgical outcomes were graded according to the Clavien-Dindo classification, and EORTC-C30 and the EORTC-Pan26 were administered as a cross-sectional assessment of QoL. A control group consisting of healthy individuals from the general population was obtained and matched using the propensity score matching method.

RESULTS

Eighty-one patients underwent PE using the open (59.3%), laparoscopic (27.2%), or robot-assisted (13.5%) approach. Sixty-five (80.2%) patients exhibited functioning/nonfunctioning pancreatic neuroendocrine tumors at final pathology.Surgical morbidity and complications of a Clavien-Dindo grade ≥3 were 48.1% and 16.0%, respectively. In-hospital mortality was 0%. Postoperative pancreatic fistula, post-pancreatectomy hemorrhage, and delayed gastric emptying rates were 21.0%, 9.9%, and 4.9%, respectively.Patients returned the questionnaires after a median of 74.2 months from the index surgery. Postoperative new onset of diabetes mellitus (NODM) was observed in 5 subjects (7.1%), with age being an independent predictor. Seven patients (10.0%) developed postoperative exocrine insufficiency. At the analysis of QoL, all function and symptom scales were comparable between the 2 groups, except for 2 of the EORTC-Pan 26 symptom scales, ("worries for the future" and "body image", P < 0.05).

CONCLUSIONS

Despite being associated with significant postoperative morbidity, PE provides excellent long-term outcomes. The risk of NODM is low and related to patient age, with QoL being comparable to the general population. Such information should drive surgeons to pursue PE whenever properly indicated.

Minimally-invasive versus open pancreatic enucleation: systematic review and metanalysis of short-term outcomes

BACKGROUND

Minimally Invasive Pancreatic Enucleation, either laparoscopic or robot-assisted, is rarely performed. The aim of this study was to offer the current available evidence about the outcomes of minimally invasive pancreatic enucleations and explore the possible advantage of this approach over traditional surgery.

METHODS

PubMed (MEDLINE), Cochrane Library and Embase (ELSEVIER) medical databases were searched for articles published from January 1990 to March 2022. Studies which included more than 10 cases of minimally-invasive pancreatic enucleation were included. Data on the outcomes were synthetized and meta-analyzed when appropriate.

RESULTS

Twenty studies published between 2009 and 2022 with a total of 552 patients were included in the systematic review: three hundred fifty-one patients (63.5%) had a laparoscopic intervention, two hundred and one (36.5%) robot-assisted with a cumulative incidence of conversion rate of 5%. Minimally-invasive surgery was performed in 63% of cases on the body/tail of the Pancreas and in 37% of the cases on the head/uncinate process of the Pancreas. The cumulative post-operative 30 days - mortality rate was 0.2% and the major postoperative morbidity (Clavien-Dindo III-IV-V) 35%. Clinically relevant pancreatic fistula was observed in 17% of the patients. Compared with the standardized open approach (n: 366 patients), mean length of hospital stay was significantly reduced in patients undergoing minimally invasive pancreatic enucleation (2.45 days, p = 0.003) with a favorable trend for post-operative major morbidity (Clavien-Dindo III-IV) (- 24% RR, p: 0.13). Operative time, blood loss and clinically relevant pancreatic fistula rate were comparable between the two groups. One hundred and fourteen robot-assisted enucleations entered in a subgroup analysis with comparable results to open surgery.

CONCLUSION

Minimally-Invasive approach for pancreatic enucleation is safe, feasible and offers short-term clinical outcomes comparable with open surgery. The potential benefit of robotic surgery will need to be verified in further studies.

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula

BACKGROUND

Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN.

METHODS AND PATIENTS

All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF.

RESULTS

From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51 years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20 mm (9-110); 30 mm (20-110) for mucinous cystadenoma and 18 mm (8-33) for NET. The median operative time was 90 mn (30-330), median blood loss was 20 ml (0-800) ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7 days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24 months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3 mm.

CONCLUSION

In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.

Intraoperative Ultrasound Guided Robotic Pancreatic Enucleation, Does a Distance of 3mm Still Matters?

Background: A minimal distance of 3 mm to main pancreatic duct (MPD) was generally considered to be necessary for pancreatic enucleation (PE). This study was designed to report the safety and feasibility of PE for tumors located in 3 mm to MPD Under the intraoperative ultrasound (IOUS) guidance.Methods: The data of patients who received IOUS guided robotic PE from January 2018 to May 2019 in the second department of hepato-pancreato-biliary surgery were reviewed in this study. According to the distance to MPD (less than 3 mm or not), patients were divided in 2 groups, and the short-term operative outcomes were compared.Statistics: Students' t-test and Mann-Whitney U test were used for comparing continuous variables, and Chi-squared test was used for comparing categorical variables.Results: And a total of 56 patients were analyzed, and a minimal distance less than 3 mm between the tumor and pancreatic duct measured by IOUS was found in 12 patients. The tumors and MPD were clearly revealed intraoperatively in all the cases. The operative duration was significantly longer in patients with tumors located in 3 mm from MPD (143.25 ± 40.89 min vs 107.14 ± 37.73 min, t = 2.756, P=.014). There was no significant difference between the rate of post-operative pancreatic fistula and other complications in the different groups (χ² =.924, P=.48).Discussion and conclusion: robotic PE could be safely performed under IOUS guidance for benign or low-grade malignant tumors located less than 3 mm to the MPD.

Laparoscopic clamp-crushing enucleation with a pancreatic duct stent for tumors located close to the main pancreatic duct

The perioperative management and technical details of laparoscopic clamp-crushing enucleation for low-malignant-potential pancreatic neuroendocrine neoplasms (PNENs) located close to the main pancreatic duct (MPD) in the body/tail of the pancreas using a perioperative MPD stent are reported. The procedure was performed in two patients with PNEN (13 and 10 mm in diameter) in the body/tail of the pancreas. A naso-pancreatic stent (NPS) was placed preoperatively in both patients. Resection was performed using Maryland-type bipolar forceps. The surgical duration was 139 and 55 min, and the estimated blood loss was 5 and 0 mL, respectively. One patient was discharged uneventfully on postoperative day (POD) 12. The other patient developed a grade B pancreatic fistula, but was discharged on POD 22. Laparoscopic clamp-crushing enucleation with an NPS might be a viable treatment option for tumors located close to the MPD.

A critical analysis of laparoscopic and open approaches to sporadic pancreatic insulinoma resection in the modern era

BACKGROUND

A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management.

METHODS

Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed.

RESULTS

The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02).

CONCLUSIONS

Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.

Risk factors and prevention of postoperative pancreatic fistula after insulinoma enucleation:a retrospective study from a high-volume center

BACKGROUND/OBJECTIVES

Enucleation is an effective surgical method to treat pancreatic insulinoma, however, the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) is high. We aim to investigate the risk factors for CR-POPF which have not been well characterized and develop effective methods to prevent CR-POPF after enucleation.

METHODS

This retrospective cohort study included 161 patients diagnosed with insulinoma from June 2016 to July 2020 in Peking Union Medical College Hospital. The risk factors for CR-POPF were evaluated and the role of prophylactic pre-operative pancreatic stent to prevent the occurrence of CR-POPF after enucleation of pancreatic insulinoma were explored.

RESULTS

A cohort of 161 insulinoma cases were reviewed. The CT or MRI imaging reports could be tracked in 108 cases. A total of 96 patients underwent surgery, while 81 experienced pancreatic enucleation. Univariate and multivariate analyses showed that the distance from insulinoma to the main pancreatic duct (MPD) ≤2 mm was an independent risk factor for CR-POPF (p = 0.003, OR = 6.011, 95% Cl 1.852-19.512). The pre-operative pancreatic stent substantially reduced the incidence of CR-POPF in patients with tumor located in proximity to (distance ≤2 mm) the MPD (CR-POPF of the stented group vs the non-stented group: 37.5% vs 71.4%, p = 0.028).

CONCLUSIONS

The distance from insulinoma to MPD ≤2 mm is a predictive factor for CR-POPF after enucleation. Pancreatic duct stenting may benefit patients with insulinoma in proximity to the MPD by enabling a lower CR-POPF rate, so it should be considered before the enucleation of the insulinoma in proximity to the MPD (distance ≤2 mm).

Does tumor size influence the outcome of laparoscopic distal pancreatectomy?

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned.

METHODS

Patients who underwent LDP for pancreatic solitary tumors in 1997-2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III).

RESULTS

218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II - 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar - 38.5, 32 and 34% in the group I, II and III.

CONCLUSION

LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.

The Effect of Fibrinogen/Thrombin-Coated Collagen Patch (TachoSil®) Application in Pancreaticojejunostomy for Prevention of Pancreatic Fistula After Pancreaticoduodenectomy: A Randomized Clinical Trial

BACKGROUND

Fibrin sealants and topical glue have been studied to reduce the incidence of postoperative pancreatic fistulas (POPF) after pancreatico-enteric anastomosis, but a definitive innovation is still needed. We aim to evaluate the effectiveness of fibrin sealant patch applied to pancreatico-enteric anastomosis to reduce postoperative complications, including POPF.

METHODS

This study was a single-center, prospective, randomized, phase IV trial involving three pancreaticobiliary surgeons. The primary outcome was POPF; secondary outcomes included complications, drain removal days, hospital stay, readmission rate, and cost. Risk factors for POPF were identified by logistic regression analysis.

RESULTS

A total of 124 patients were enrolled. Biochemical leakage (BL) or POPF occurred in 16 patients (25.8%) in the intervention group and 23 patients (37.1%) in the control group (no statistical significance). Clinically relevant POPF occurred in 4 patients (6.5%) in both the intervention and control groups (p = 1.000). Hospital stay (11.6 days vs. 12.1 days, p = 0.585) and drain removal days (5.7 days vs. 5.3 days, p = 0.281) were not statistically different between two groups. Complication rates were not different between the two groups (p = 0.506); nor were readmission rates (12.9% vs. 11.3%, p = 1.000) or cost ($13,549 vs. $15,038, p = 0.103). In multivariable analysis, age and soft pancreas texture were independent risk factors for BL or POPF in this study. Applying fibrin sealant patch is not a negative risk factor, but the p value may indicate a likelihood of reducing the incidence of BL (p = 0.084).

CONCLUSIONS

Fibrin sealant patches after pancreaticojejunostomy did not reduce the incidence of POPF or other postoperative complications. This study was registered at clinicaltrials.gov (NCT03269955).

Endoscopic placement of pancreatic stent for "Deep" pancreatic enucleations operative technique and preliminary experience at two high-volume centers

BACKGROUND

Pancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of "deep" PE preceded by endoscopic stenting of the MPD.

METHODS

From January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3 weeks before surgery, depending on the participating institute.

RESULTS

Ten patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases.

CONCLUSION

In the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.

Enucleation for branch duct intraductal papillary mucinous neoplasms: a systematic review and meta-analysis

BACKGROUND

The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN and compare it with pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy and central pancreatectomy).

METHODS

A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases.

RESULTS

Sixteen studies were included in the final analysis comprising 991 patients with 293 EN patients and 698 resected patients. EN was most often performed for low grade (77%, 151/197) BD-IPMN's (99%, 251/253) of the pancreatic head (64%, 106/165), with a pooled mean diameter of 21 mm (SD 28 mm). EN was a shorter procedure (MD -115.8 min, CI -142.2 to -89.5 min, P=<0.001) with a lower rate of post-pancreatectomy haemorrhage (EN 1% 2/144, Resection 5% 10/186, RR 0.32, CI 0.11 to 0.94, P = 0.043) and postoperative exocrine and endocrine insufficiency (P = <0.001 and P = 0.003 respectively) than resection.

CONCLUSION

EN for BD-IPMN's appears to be a reasonable alternative to resection in low risk BD-IPMN's, allowing preservation of exocrine and endocrine function with comparable reoperation and recurrence rates to resection. However, surveillance was indicated in these low risk patients based on current published guidelines.

Minimally-invasive versus open enucleation for pancreatic tumours: A propensity-score adjusted analysis

Backgrounds/Aims

This study aims to evaluate the perioperative outcomes of minimally-invasive enucleation (MIEn) of the pancreas versus open enucleation (OEn).

Methods

This is a retrospective review of 20 consecutive patients who underwent pancreatic enucleation at a single institution.

Results

Seven patients underwent MIEn, of which 3 were robotic and 4 were laparoscopic. After propensity-adjusted analysis, the only significant difference was a reduced rate of readmissions within 30 days in the MIEn group versus the OEn group [0 vs 4 (30.8%), p=0.0464]. There were no conversions to open in the MIEn group, and median operation time was similar in both groups. There was no difference in median EBL in both groups, and none of the patients in our series required blood transfusions. The overall morbidity rate was 45.0% and the major complication (Clavien-Dindo>2) rate was 15%; which was similar between both groups. Seven (35%) patients had a Grade B/C POPF, and there was no significant difference between the two groups for this. The MIEn group had a shorter median length of stay compared to OEn [5 days (range, 3–24) vs 8.5 days (range, 5–42)] this was not significant on propensity-adjusted analysis (p=0.3195). There was no post-operative 90-day/in-hospital mortality in all 20 patients.

Conclusions

Our experience demonstrates that MIEn was associated with similar perioperative outcomes and fewer readmissions compared to OEn.

Open and minimally invasive pancreatic neoplasms enucleation: a systematic review

BACKGROUND

Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting. Nowadays, pEN is frequently carried out through a minimally invasive approach either laparoscopic or robotic. Its impact on overall perioperative complications and pancreatic fistula (POPF) is still under evaluation. The scope of our systematic review is to assess pEN's perioperative outcomes and to evaluate the effect of the minimally invasive techniques over POPF and other surgical complications.

METHODS

We performed a systematic literature search (time-frame January 1999-September 2018), considering exclusively those studies which included at least 5 cases of either open or minimally invasive pEN. Data regarding postoperative outcome and POPF were extracted and analyzed. We defined postoperative morbidities by the Clavien-Dindo classification while POPF according to the International Study Group of Pancreatic Fistula (ISGPF) definition.

RESULTS

Sixty-three studies met the criteria selected, accounting for a study population of 2485 patients. 27.7% had a minimally invasive pEN. The overall postoperative morbidity rate was 46.1% with 11.9% rated as severe (Clavien-Dindo ≥ 3). Mortality rate was 0.69%. The minimally invasive approach to pEN led to a statistically significant reduction of both the overall POPF rate (28.7% vs. 45.9%, p < 0.001), and clinically significant B-C POPF (p < 0.027). The postoperative overall morbidity rate was clearly in favor of the minimally invasive approach (27.6% vs. 55.2%, p < 0.001).

CONCLUSIONS

Our review confirms that pEN is a safe and feasible technique for the treatment of small benign or low-grade pancreatic neoplasms and it can be implemented with an acceptable morbidity rate along with low mortality. The minimally invasive approach is gaining widespread acceptance due to its supposed non-inferiority compared with the traditional open approach. In our review, it showed to be even better in terms of POPF incidence rate and short-term postoperative outcome. Still, such data need to be corroborated by randomized clinical trials.

A pancreatic zone at higher risk of fistula after enucleation

Background

To determine predictive factors of postoperative pancreatic fistula (POPF) in patients undergoing enucleation (EN).

Methods

From 2005 to 2017, 47 patients underwent EN and had magnetic resonance imaging available for precise analysis of tumor location. Three pancreatic zones were delimited by the right side of the portal vein and the main pancreatic head duct (zone #3 comprising the lower head parenchyma and the uncinate process).

Results

The mortality and morbidity rates were 0% and 62%, respectively. POPF occurred in 23 patients (49%) and was graded as B or C (severe) in 15 patients (32%). Four patients (8.5%) developed a postoperative hemorrhage, and 5 patients (11%) needed a reintervention. In univariate and multivariate analyses, the pancreatic zone was the unique predictive factor of overall (P = .048) or severe POPF (P = .05). We did not observe any difference in postoperative courses when comparing the EN achieved in zones #1 and #2. We noted a longer operative duration (P = .016), higher overall (P = .017) and severe POPF (P = .01) rates, and longer hospital stays (P = .04) when comparing the EN achieved in zone #3 versus that in zones #1 and #2. Patients who underwent EN in zone #3 had a relative risk of developing a severe POPF of 3.22 compared with patients who underwent EN in the two other pancreatic zones.

Conclusion

Our study identifies the lower head parenchyma and the uncinate process as a high-risk zone of severe POPF after EN. Patients with planned EN in this zone could be selected and benefit from preoperative and/or intraoperative techniques to reduce the severe POPF rate.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1476-5) contains supplementary material, which is available to authorized users.