A cost analysis of somatostatin use in the prevention of pancreatic fistula after pancreatectomy

Pre-, peri- and post-operative factors for the development of pancreatic fistula after pancreatic surgery

BACKGROUND

The most hazardous complication to pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures.

METHODS

Systematic literature search using the English PubMed literature up to April 2019, with emphasis on the past 5 years.

RESULTS

Several risk scores have been developed but none are perfect in predicting POPF risk. A conceptual framework of factors that contribute to the pathophysiology of pancreatic fistulae is still developing but incomplete. Recognized factors include those related to the patient, the pathology and the perioperative care. Interventions such as use of drains, stents and various drugs to mediate risk is still debated. Emerging data suggest that both the microbiome and the inflammation in the post-operative phase may play important roles in risk for POPF. Available risk scores allow for stratification of risk and mitigation strategies tailored to reduce this. However, accurate estimation of risk remains a challenge and mechanisms are only partially understood.

CONCLUSIONS

The pathophysiology of POPF remains poorly understood. Current models only partially explain risks or associated mechanisms. Novel areas of investigation need to be explored for better prediction.

The effect of somatostatin analogues on postoperative outcomes following pancreatic surgery: A meta-analysis

Background

Leakage from the pancreatic stump is a leading cause of morbidity following pancreatic surgery. It is essential to evaluate the effect of somatostatin analogues (SAs) following pancreatic surgery by analyzing all recent clinical trials.

Data sources

We performed a literature search in the Medline, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science databases up to May 29, 2016. Publication bias was assessed with Egger’s test. Study quality was assessed using the Jadad Composite Scale.

Conclusions

Twelve clinical trials involving 1703 patients from Jan 1st, 2000 to May 29th, 2016 were included in the study. With improvements in surgical management and peri-operative patient care, prophylactic use of somatostatin and its analogues reduced the overall incidence of pancreatic fistulas (RR 0.72, 95% CI 0.55–0.94; p = 0.02) and decreased the post-operative hospital stay after pancreatic surgery (the weighted mean difference was -1.06, 95% CI-1/88 to -0.23; p = 0.01). Other post-operative outcomes did not change significantly with the use of somatostatin analogues.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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