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Chui JN, Ziaziaris WA, Nahm CB, Fuchs T, Sahni S, Lim CSH, Gill AJ, Samra JS, Mittal A. Lipase-to-Amylase Ratio for the Prediction of Clinically Relevant Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy. Pancreas 2024; 53:e579-e587. [PMID: 38696382 DOI: 10.1097/mpa.0000000000002345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Postoperative pancreatic fistula (POPF) represents a leading cause of morbidity and mortality following major pancreatic resections. This study aimed to evaluate the use of postoperative drain fluid lipase-to-amylase ratio (LAR) for the prediction of clinically relevant fistulae (CR-POPF). METHODS Consecutive patients undergoing pancreaticoduodenectomy between 2017 and 2021 at a tertiary centre were retrospectively reviewed. Univariable and multivariable analyses were performed to identify predictors for CR-POPF (ISGPS grade B/C). Receiver operating characteristic (ROC) curve analyses were conducted to evaluate the performance of LAR and determine optimum prediction thresholds. RESULTS Among 130 patients, 28 (21.5%) developed CR-POPF. Variables positively associated with CR-POPF included soft gland texture, acinar cell density, diagnosis other than PDAC or chronic pancreatitis, resection without neoadjuvant therapy, and postoperative drain fluid lipase, amylase, and LAR (all P <0.05). Multivariable regression analysis identified LAR as an independent predictor of CR-POPF ( P <0.05). ROC curve analysis showed that LAR had moderate ability to predict CR-POPF on POD1 (AUC,0.64; 95%CI,0.54-0.74) and excellent ability on POD3 (AUC,0.85; 95%CI,0.78-0.92) and POD 5 (AUC,0.86; 95%CI,0.79-0.92). Optimum thresholds were consistent over PODs 1 to 5 (ratio>2.6) and associated with 92% sensitivity and 46% to 71% specificity. CONCLUSIONS Postoperative drain fluid LAR represents a reliable predictor for the development of CR-POPF. With early prognostication, the postoperative care of patients at risk of developing high-grade fistulas may be optimized.
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Affiliation(s)
| | | | | | | | - Sumit Sahni
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, University of Sydney
| | - Christopher S H Lim
- From the Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital
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Gajda M, Grudzińska E, Szmigiel P, Czopek P, Rusinowski C, Putowski Z, Mrowiec S. Risk Factors of Postoperative Acute Pancreatitis and Its Impact on the Postoperative Course after Pancreaticoduodenectomy-10 Years of Single-Center Experience. Life (Basel) 2023; 13:2344. [PMID: 38137945 PMCID: PMC10744948 DOI: 10.3390/life13122344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/30/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Clinically relevant acute postoperative pancreatitis (CR-PPAP) after pancreaticoduodenectomy (PD) is a complication that may lead to the development of local and systemic consequences. The study aimed to identify risk factors for CR-PPAP and assess the impact of CR-PPAP on the postoperative course after PD. METHODS The study retrospectively analyzed data from 428 consecutive patients who underwent PD at a single center between January 2013 and December 2022. The presence of increased amylase activity in plasma, above the upper limit of normal 48 h after surgery, was checked. CR-PPAP was diagnosed when accompanied by disturbing radiological features and/or symptoms requiring treatment. We investigated the relationship between the occurrence of CR-PPAP and the development of postoperative complications after PD, and possible predictors of CR-PPAP. RESULTS The postoperative follow-up period was 90 days. Of the 428 patients, 18.2% (n = 78) had CR-PPAP. It was associated with increased rates of CR-POPF, delayed gastric emptying, occurrence of intra-abdominal collections, postoperative hemorrhage, peritonitis, and septic shock. Patients who developed CR-PPAP were more often reoperated (37.17% vs. 6.9%, p < 0.0001)) and had increased postoperative mortality (14.1% vs. 5.74%, p < 0.0001). Soft pancreatic parenchyma, intraoperative blood loss, small diameter of the pancreatic duct, and diagnosis of adenocarcinoma papillae Vateri were independent risk factors for CR-PPAP and showed the best performance in predicting CR-PPAP. CONCLUSIONS CR-PPAP is associated with an increased incidence of postoperative complications after PD, worse treatment outcomes, and an increased risk of reoperation and mortality. Pancreatic consistency, intraoperative blood loss, width of the duct of Wirsung, and histopathological diagnosis can be used to assess the risk of CR-PPAP. Amylase activity 48 h after surgery > 161 U/L is highly specific in the diagnosis of CR-PPAP.
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Affiliation(s)
- Magdalena Gajda
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Paweł Szmigiel
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Piotr Czopek
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Cezary Rusinowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Zbigniew Putowski
- Center for Intensive and Perioperative Care, Jagiellonian University, 31-007 Cracow, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
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Vouros D, Bramis K, Alexakis N, Kotsarinis V, Antonakis P, Memos N, Konstadoulakis M, Toutouzas K. Completion Pancreatectomy. Indications and Outcomes: A Systematic Review. Am Surg 2023; 89:6134-6146. [PMID: 37295804 DOI: 10.1177/00031348231183121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND/OBJECTIVE (S) Completion pancreatectomy (C.P.) is one acceptable treatment of choice in clinical scenarios such as management of post-pancreatectomy complications and recurrence in the pancreatic remnant. Studies referring to completion pancreatectomy as a distinct operation are limited, without emphasizing at the operation itself, rather reporting completion pancreatectomy as a possible option for treatment of various diseases. The identification of indications of CP in various pathologies and the clinical outcomes are therefore mandatory. METHODS A systematic literature search was performed in the Pubmed and Scopus Databases (February 2020),guided by the PRISMA protocol, for all studies reporting CP as a surgical procedure with reference at indications for performing it combined with postoperative morbidity and/or mortality. RESULTS Out of 1647 studies, 32 studies from 10 countries with 2775 patients in total, of whom 561 (20.2%) CPs met the inclusion criteria and were included in the analysis. Inclusion year ranged from 1964 to 2018 and were published from 1992 until 2019. 17 studies with a total number of 249 CPs were performed for post-pancreatectomy complications. Mortality rate was 44.5% (111 out of 249). Morbidity rate was (72.6%). 12 studies with 225 CPs were performed for isolated local recurrence after initial resection with a morbidity rate of 21.5% and 0% mortality rate in the early postoperative period. Two studies with a total number of 12 patients reported CP as a treatment option for recurrent neuroendocrine neoplasms. The mortality in those studies was 8% (1/12) and the mean morbidity rate was 58.3% (7/12). Finally, CP for refractory chronic pancreatitis was presented in one study with morbidity and mortality rates of 19% and 0%, respectively. CONCLUSION Completion pancreatectomy is a distinct treatment option for various pathologies. Morbidity and mortality rates depend on the indications of performing CP, the status performance of the patients and whether the operation is performed electively or urgently.
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Affiliation(s)
- Dimitrios Vouros
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
| | - Konstantinos Bramis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Alexakis
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
| | - Vasileios Kotsarinis
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
| | - Pantelis Antonakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Memos
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Manousos Konstadoulakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
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Loos M, König AK, von Winkler N, Mehrabi A, Berchtold C, Müller-Stich BP, Schneider M, Hoffmann K, Kulu Y, Feisst M, Hinz U, Lang M, Goeppert B, Albrecht T, Strobel O, Büchler MW, Hackert T. Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It? Ann Surg 2023; 278:e87-e93. [PMID: 35781509 PMCID: PMC10249602 DOI: 10.1097/sla.0000000000005494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to identify the indications for and report the outcomes of completion pancreatectomy (CPLP) in the postoperative course after pancreatoduodenectomy (PD). BACKGROUND CPLP may be considered or even inevitable for damage control after PD. METHODS A prospectively maintained database of all patients undergoing PD between 2001 and 2019 was searched for patients who underwent CPLP in the postoperative course after PD. Baseline characteristics, perioperative details, and outcomes of CPLP patients were analyzed and specific indications for CPLP were identified. RESULTS A total of 3953 consecutive patients underwent PD during the observation period. CPLP was performed in 120 patients (3%) after a median of 10 days following PD. The main indications for CPLP included postpancreatectomy acute necrotizing pancreatitis [n=47 (39%)] and postoperative pancreatic fistula complicated by hemorrhage [n=41 (34%)] or associated with uncontrollable leakage of the pancreatoenteric anastomosis [n=23 (19%)]. The overall 90-day mortality rate of all 3953 patients was 3.5% and 37% for patients undergoing CPLP. CONCLUSIONS Our finding that only very few patients (3%) need CPLP suggests that conservative, interventional, and organ-preserving surgical measures are the mainstay of complication management after PD. Postpancreatectomy acute necrotizing pancreatitis, uncontrollable postoperative pancreatic fistula, and fistula-associated hemorrhage are highly dangerous and represent the main indications for CPLP after PD.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anna-Katharina König
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Nikolai von Winkler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P. Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Goeppert
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Albrecht
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General Surgery, Vienna University Hospital, Vienna, Austria
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Radulova-Mauersberger O, Oehme F, Missel L, Kahlert C, Welsch T, Weitz J, Distler M. Analysis of predictors for postoperative complications after pancreatectomy--what is new after establishing the definition of postpancreatectomy acute pancreatitis (PPAP)? Langenbecks Arch Surg 2023; 408:79. [PMID: 36746822 PMCID: PMC9902317 DOI: 10.1007/s00423-023-02814-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 01/17/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE We aimed to analyze the predictive value of hyperamylasemia after pancreatectomy for morbidity and for the decision to perform rescue completion pancreatectomy (CP) in a retrospective cohort study. METHODS Data were extracted from a retrospective clinical database. Postoperative hyperamylasemia (POH) and postoperative hyperlipasemia (POHL) were defined by values greater than those accepted as the upper limit at our institution on postoperative day 1 (POD1). The endpoints of the study were the association of POH with postoperative morbidity and the possible predictors for postpancreatectomy acute pancreatitis (PPAP) and severe complications such as the necessity for rescue CP. RESULTS We analyzed 437 patients who underwent pancreaticoduodenectomy over a period of 7 years. Among them, 219 (52.3%) patients had POH and 200 (47.7%) had normal postoperative amylase (non-POH) levels. A soft pancreatic texture (odds ratio [OR] 3.86) and POH on POD1 (OR 8.2) were independent predictors of postoperative pancreatic fistula (POPF), and POH on POD1 (OR 6.38) was an independent predictor of rescue CP. The clinically relevant POPF (49.5% vs. 11.4%, p < 0.001), intraabdominal abscess (38.3% vs. 15.3%, p < 0.001), postoperative hemorrhage (22.8% vs. 5.1%, p < 0.001), major complications (Clavien-Dindo classification > 2) (52.5% vs. 25.6%, p < 0.001), and CP (13% vs. 1.8%, p < 0.001) occurred significantly more often in the POH group than in the non-POH group. CONCLUSION Although POH on POD1 occurs frequently, in addition to other risk factors, it has a predictive value for the development of postoperative morbidity associated with PPAP and CP.
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Affiliation(s)
- O Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - F Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - L Missel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - C Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - T Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - J Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
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Moll X, Fondevila D, García-Arnas F, Pérez JJ, Ielpo B, Sánchez-Velázquez P, Grande L, Jaume S, Radosevic A, Barranco L, Berjano E, Burdio F, Andaluz A. Is occlusion of the main pancreatic duct by thermal ablation really safe? A surgical innovation assessed according to IDEAL recommendations. Int J Hyperthermia 2023; 40:2203888. [PMID: 37126121 DOI: 10.1080/02656736.2023.2203888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
INTRODUCTION Pre-clinical studies suggest that thermal ablation of the main pancreatic duct (TAMPD) is more recommendable than glue for reducing postoperative pancreatic fistula (POPF). Our aims were (1) to analyze the changes in the pancreas of patients after TAMPD and (2) to correlate the clinical findings with those obtained from a study on an animal model. MATERIALS AND METHODS A retrospective early feasibility study of a marketed device for a novel clinical application was carried out on a small number of subjects (n = 8) in whom TAMPD was conducted to manage the pancreatic stump after a pancreatectoduodenectomy (PD). Morphological changes in the remaining pancreas were assessed by computed tomography for 365 days after TAMPD. RESULTS All the patients showed either Grade A or B POPF, which generally resolved within the first 30 days. The duct's maximum diameter significantly increased after TAMPD from 1.5 ± 0.8 mm to 8.6 ± 2.9 mm after 7 days (p = .025) and was then reduced to 2.6 ± 0.8 mm after 365 days PO (p < .0001). The animal model suggests that TAMPD induces dilation of the duct lumen by enzymatic digestion of ablated tissue after a few days and complete exocrine atrophy after a few weeks. CONCLUSIONS TAMPD leads to long-term exocrine pancreatic atrophy by completely occluding the duct. However, the ductal dilatation that occurred soon after TAMPD could even favor POPF, which suggests that TAMPD should be conducted several weeks before PD, ideally by digestive endoscopy.
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Affiliation(s)
- Xavier Moll
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
- Fundació Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Dolors Fondevila
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Félix García-Arnas
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan J Pérez
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Benedetto Ielpo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Patricia Sánchez-Velázquez
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Luis Grande
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Sofía Jaume
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Aleksandar Radosevic
- Division of Hepato-Biliary and Pancreatic Radiology, Department of Radiology, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Luis Barranco
- Division of Endoscopy, Department of Digestive diseases, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Fernando Burdio
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Anna Andaluz
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
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Stoop TF, Fröberg K, Sparrelid E, Del Chiaro M, Ghorbani P. Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy. Langenbecks Arch Surg 2022; 407:3467-3478. [DOI: 10.1007/s00423-022-02708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. However, in-depth literature is scarce and hard to interpret. This study aimed to evaluate the indications, timing and perioperative outcomes of rescue pancreatectomy for severe POPF after PD.
Methods
Retrospective single-centre study from all consecutive patients (2008–2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days).
Results
From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Mortality after early rescue pancreatectomy did not differ significantly compared to late rescue pancreatectomy (13.6% versus 35.3%; p = 0.142). Timing of a rescue pancreatectomy did not change significantly during the study period: 11 (IQR, 8–14) (2008–2012) versus 14 (IQR, 7–33) (2013–2016) versus 8 days (IQR, 6–11) (2017–2020) (p = 0.140). Over time, the mortality in patients with POPF grade C decreased from 43.5% in 2008–2012 to 31.6% in 2013–2016 up to 0% in 2017–2020 (p = 0.014). However, mortality rates after rescue pancreatectomy did not differ significantly: 31.3% (2008–2012) versus 28.6% (2013–2016) versus 0% (2017–2020) (p = 0.104).
Conclusions
Rescue pancreatectomy for severe POPF is associated with high mortality, but an earlier timing might favourably influence the mortality. Hypothetically, this could be of value for pre-existent vulnerable patients. These findings must be carefully interpreted considering the sample sizes and differences among subgroups by patient selection.
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Záruba P, Rousek M, Kočišová T, Havlová K, Ryska M, Pohnán R. A comparison of surgical approaches in the treatment of grade C postoperative pancreatic fistula: A retrospective study. Front Surg 2022; 9:927737. [PMID: 36017512 PMCID: PMC9395924 DOI: 10.3389/fsurg.2022.927737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative pancreatic fistula is one of the most dreaded complications following pancreatic resections with Grade C the most severe. Several possible types of surgical intervention are available but to date, none of them have clearly shown superiority. This study aims to compare different surgical approaches.MethodsA retrospective analysis of patients who underwent revision surgery for postoperative pancreatic fistula between 2008 and 2020 was performed. Three surgical approaches were compared: open drainage; a disconnection of the pancreaticojejunostomy; and salvage total pancreatectomy. The data of nine monitored parameters were collected. Selected parameters were statistically analyzed and compared.ResultsA total of 54 patients were included. Eighteen patients underwent open drainage, 28 had disconnections of the pancreaticojejunostomy and eight had salvage total pancreatectomy. Statistically significant differences were observed in the time of Intensive Care Unit stay, the number of surgical interventions, 90-day mortality, the number of administered blood transfers and treatment costs. Open drainage showed to be superior in each category. The difference in long-term survival also slightly favored simple drainage.ConclusionOpen drainage procedure showed to be superior to other types of interventions in most of the monitored parameters. Disconnection of the pancreaticojejunostomy and a salvage total pancreatectomy had similar results, which correlated with the surgical burden of these interventions.
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The image-based preoperative fistula risk score (preFRS) predicts postoperative pancreatic fistula in patients undergoing pancreatic head resection. Sci Rep 2022; 12:4064. [PMID: 35260701 PMCID: PMC8904506 DOI: 10.1038/s41598-022-07970-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/22/2022] [Indexed: 12/23/2022] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.
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10
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Groen JV, Smits FJ, Koole D, Besselink MG, Busch OR, den Dulk M, van Eijck CHJ, Groot Koerkamp B, van der Harst E, de Hingh IH, Karsten TM, de Meijer VE, Pranger BK, Molenaar IQ, Bonsing BA, van Santvoort HC, Mieog JSD. Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis. Br J Surg 2021; 108:1371-1379. [PMID: 34608941 PMCID: PMC10364904 DOI: 10.1093/bjs/znab273] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy. METHODS This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005-2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines. RESULTS From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel-Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84). CONCLUSION Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- J V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - D Koole
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,Department of Epidemiology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - T M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, the Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - B K Pranger
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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11
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Nießen A, Hackert T. State-of-the-art surgery for pancreatic cancer. Langenbecks Arch Surg 2021; 407:443-450. [PMID: 34751822 PMCID: PMC8933301 DOI: 10.1007/s00423-021-02362-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/14/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The d evelopment of surgical techniques and specialization and specifically complication management in pancreatic surgery have improved surgical outcomes as well as oncological results in pancreatic surgery in recent decades. Historical morbidity and especially mortality rates of up to 80% have decreased to below 5% today. This review summarizes the current state of the art in pancreatic cancer surgery. METHODS The present literature and clinical experience are summarized to give an overview of the present best practice in pancreatic surgery as one of the most advanced surgical disciplines today. RESULTS Based on the available literature, three important aspects contribute to best patient care in pancreatic surgery, namely, surgical progress, interdisciplinary complication management, and multimodal oncological treatment in case of pancreatic cancer. In addition, minimally invasive and robotic procedures are currently fields of development and specific topics of research. CONCLUSION In experienced hands, pancreatic surgery-despite being one of the most challenging fields of surgery-is a safe domain today. The impact of multimodal, especially adjuvant, therapy for oncological indications is well established and evidence-based. New technologies are evolving and will be evaluated with high-evidence studies in the near future.
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Affiliation(s)
- Anna Nießen
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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12
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Chaouch MA, Leon P, Cassese G, Aguilhon C, Khayat S, Panaro F. Total pancreatectomy with intraportal islet autotransplantation for pancreatic malignancies: a literature overview. Expert Opin Biol Ther 2021; 22:491-497. [PMID: 34747305 DOI: 10.1080/14712598.2022.1990261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION 'Brittle Diabetes' (BD) is a life-threatening metabolic complication after total pancreatectomy (TP). More than 500 Intraportal islet autotransplantation (IAT) have been performed to prevent this complication, with almost 70% insulin independence after 3 years. Even when insulin independence was not achieved, IAT successfully prevented severe hypoglycemia. Currently, preliminary results for oncologic situations are promising, but their oncological outcomes are still a matter of debate. AREAS COVERED We performed a bibliographic research of the last 25 years of data. Articles published in English in peer-reviewed journals were retained. In France, auto- and allo-islet transplantation was recently recognized as a valuable treatment for BD by the national health authority. While accepted for benign diseases, the risk of tumor spreading after IAT in oncologic situations is a source of concern. EXPERT OPINION Preliminary results of IAT in oncological situations are very encouraging. So far, there is no evidence of tumor dissemination. In our opinion, to overcome BD TP with IAT for resectable pancreatic malignancies in patients with a higher risk of postoperative pancreatic fistula and extended pancreatic cancers can be safely performed. Diagnosis of malignancy should not be considered as an exclusion criterion for IAT.
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Affiliation(s)
- Mohamed Ali Chaouch
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Piera Leon
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Gianluca Cassese
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France.,Department of Clinical Medicine and Surgery, Federico Ii University, Naples, Italy
| | - Caroline Aguilhon
- Division of Endocrinology, Diabetology and Clinical Nutrition, Montpellier University Hospital, Montpellier, France
| | - Salah Khayat
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Division of HBP Surgery and Transplantation, Department of Surgery, Montpellier University Hospital, Montpellier, France
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13
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Adamu M, Plodeck V, Adam C, Roehnert A, Welsch T, Weitz J, Distler M. Predicting postoperative pancreatic fistula in pancreatic head resections: which score fits all? Langenbecks Arch Surg 2021; 407:175-188. [PMID: 34370113 PMCID: PMC8847178 DOI: 10.1007/s00423-021-02290-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 07/23/2021] [Indexed: 01/08/2023]
Abstract
Purpose Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery. Methods A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested. Results Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p < 0.001). There was no significant prognostic value for the Fujiwara et al. risk score. Histology, pancreatic duct diameter, intraabdominal fat thickness in computed tomography findings, body mass index, and C-reactive protein were independent prognostic factors on multivariate analysis. Conclusion Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.
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Affiliation(s)
- Mariam Adamu
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Verena Plodeck
- Department of Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Claudia Adam
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Anne Roehnert
- Department of Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Juergen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
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14
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Salvia R, Lionetto G, Perri G, Malleo G, Marchegiani G. Total pancreatectomy and pancreatic fistula: friend or foe? Updates Surg 2021; 73:1231-1236. [PMID: 34363601 PMCID: PMC8397676 DOI: 10.1007/s13304-021-01130-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022]
Abstract
Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.
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Affiliation(s)
- Roberto Salvia
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy.
| | - Gabriella Lionetto
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giampaolo Perri
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of Surgery, Dentistry, Gynecology and Pediatrics (DSCOMI), Unit of General and Pancreatic Surgery, University of Verona, G.B. Rossi Hospital, P.Le Scuro 10, 37134, Verona, Italy
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15
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Hempel S, Oehme F, Tahirukaj E, Kolbinger FR, Müssle B, Welsch T, Weitz J, Distler M. More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis. Ann Surg Oncol 2021; 28:8309-8317. [PMID: 34169383 PMCID: PMC8590996 DOI: 10.1245/s10434-021-10292-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/27/2021] [Indexed: 11/24/2022]
Abstract
Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10292-8.
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Affiliation(s)
- Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ermal Tahirukaj
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fiona R Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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16
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Ramouz A, Mehrabi A, Loos M. Acute pancreatitis following major pancreatic resection. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2021.100036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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17
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Permanent Pancreatic Duct Occlusion With Neoprene-based Glue Injection After Pancreatoduodenectomy at High Risk of Pancreatic Fistula: A Prospective Clinical Study. Ann Surg 2020; 270:791-798. [PMID: 31567180 PMCID: PMC6867669 DOI: 10.1097/sla.0000000000003514] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study was to assess safety and efficacy of pancreatic duct occlusion (PDO) with neoprene-based glue in selected patients undergoing pancreatoduodenectomy (PD) at high risk of postoperative pancreatic fistula (POPF).
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18
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Wroński M, Cebulski W, Witkowski B, Guzel T, Karkocha D, Lech G, Słodkowski M. Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy. HPB (Oxford) 2019; 21:1166-1174. [PMID: 30777699 DOI: 10.1016/j.hpb.2019.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/25/2018] [Accepted: 01/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical management of severe pancreatic fistula after pancreatoduodenectomy remains challenging, and carries high mortality. The aim of this retrospective study was to compare different surgical techniques used at relaparotomy for pancreatic fistula after pancreatoduodenectomy, and to identify factors predictive of failure to rescue. METHODS A total of 43 patients after pancreatoduodenectomy developed a pancreatic fistula requiring relaparotomy. The perioperative data and outcomes were reviewed retrospectively. RESULTS Completion pancreatectomy, simple drainage of the pancreatic anastomosis and external wirsungostomy were performed in 17, 16, and 10 cases, respectively. The mortality rate for completion pancreatectomy was 47.1%, compared with 56.3% for simple drainage (p = 0.598) and 50.0% for external wirsungostomy (p = 0.883). Simple drainage was associated with a higher rate of further relaparotomies (56.3%) in comparison with completion pancreatectomy (23.5%, p = 0.055) and external wirsungostomy (0%, p = 0.003). A rescue resection of the pancreatic remnant after failed simple drainage resulted invariably in death. On multivariate analysis, the factors predictive of mortality after relaparotomy for pancreatic fistula were organ failure on the day of reoperation (p = 0.001) and need of further surgical reintervention (p = 0.007). CONCLUSION Timely reintervention and appropriate surgical technique are essential for reducing mortality after reoperation for pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- Marek Wroński
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097, Warsaw, Poland.
| | - Włodzimierz Cebulski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097, Warsaw, Poland
| | - Bartosz Witkowski
- College of Economic Analysis, Division of Probabilistic Methods, Warsaw School of Economics, Al. Niepodległości 162, 02-554, Warsaw, Poland
| | - Tomasz Guzel
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097, Warsaw, Poland
| | - Dominika Karkocha
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097, Warsaw, Poland
| | - Gustaw Lech
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097, Warsaw, Poland
| | - Maciej Słodkowski
- Department of General, Gastroenterological and Oncological Surgery, Medical University of Warsaw, ul. Banacha 1A, 02-097, Warsaw, Poland
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19
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Lessing Y, Pencovich N, Nevo N, Lubezky N, Goykhman Y, Nakache R, Lahat G, Klausner JM, Nachmany I. Early reoperation following pancreaticoduodenectomy: impact on morbidity, mortality, and long-term survival. World J Surg Oncol 2019; 17:26. [PMID: 30704497 PMCID: PMC6357503 DOI: 10.1186/s12957-019-1569-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/23/2019] [Indexed: 02/08/2023] Open
Abstract
Background Reoperation following PD is a surrogate marker for a complex post-operative course and may lead to devastating consequences. We evaluate the indications for early reoperation following PD and analyze its effect on short- and long-term outcome. Methods Four hundred and thirty-three patients that underwent PD between August 2006 and June 2016 were retrospectively analyzed. Results Forty-eight patients (11%; ROp group) underwent 60 reoperations within 60 days from PD. Forty-two patients underwent 1 reoperation, and 6 had up to 6 reoperations. The average time to first reoperation was 10.1 ± 13.4 days. The most common indications were anastomotic leaks (22 operations in 18 patients; 37.5% of ROp), followed by post-pancreatectomy hemorrhage (PPH) (14 reoperations in 12 patients; 25%), and wound complications in 10 (20.8%). Patients with cholangiocarcinoma had the highest reoperation rate (25%) followed by ductal adenocarcinoma (12.3%). Reoperation was associated with increased length of hospital stay and a high post-operative mortality of 18.7%, compared to 2.6% for the non-reoperated group. For those who survived the post-operative period, the overall and disease-free survival were not affected by reoperation. Conclusions Early reoperations following PD carries a dramatically increased mortality rate, but has no impact on long-term survival.
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Affiliation(s)
- Yonatan Lessing
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel.
| | - Niv Pencovich
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Nir Lubezky
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Yaacov Goykhman
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Richard Nakache
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Guy Lahat
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Joseph M Klausner
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
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20
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Nahm CB, Brown KM, Townend PJ, Colvin E, Howell VM, Gill AJ, Connor S, Samra JS, Mittal A. Acinar cell density at the pancreatic resection margin is associated with post-pancreatectomy pancreatitis and the development of postoperative pancreatic fistula. HPB (Oxford) 2018; 20:432-440. [PMID: 29307511 DOI: 10.1016/j.hpb.2017.11.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 11/02/2017] [Accepted: 11/07/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There has been recent evidence supporting post-pancreatectomy pancreatitis as a factor in the development of postoperative pancreatic fistula (POPF). The aims of this study were to evaluate: (i) the correlation of the acinar cell density at the pancreatic resection margin with the intra-operative amylase concentration (IOAC) of peri-pancreatic fluid, postoperative pancreatitis, and POPF; and (ii) the association between postoperative pancreatitis on the first postoperative day and POPF. METHODS Consecutive patients who underwent pancreatic resection between June 2016 and July 2017 were included for analysis. Fluid for IOAC was collected, and amylase concentration was determined in drain fluid on postoperative days 1, 3, and 5. Serum amylase and lipase and urinary trypsinogen-2 concentrations were determined on the first postoperative day. Histology slides of the pancreatic resection margin were scored for acinar cell density. RESULTS Sixty-one patients were included in the analysis. Acinar cell density significantly correlated with IOAC (r = 0.566, p < 0.001), and was significantly associated with postoperative pancreatitis (p < 0.001), and POPF (p = 0.003). Postoperative pancreatitis was significantly associated with the development of POPF (OR 17.81, 95%CI 2.17-145.9, p = 0.001). DISCUSSION The development of POPF may involve a complex interaction between acinar cell density, immediate leakage of pancreatic fluid, and postoperative pancreatitis.
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Affiliation(s)
- Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Sydney Medical School Northern, University of Sydney, NSW 2006, Australia; Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia
| | - Kai M Brown
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Sydney Medical School Northern, University of Sydney, NSW 2006, Australia
| | - Philip J Townend
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Emily Colvin
- Sydney Medical School Northern, University of Sydney, NSW 2006, Australia; Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia
| | - Viive M Howell
- Sydney Medical School Northern, University of Sydney, NSW 2006, Australia; Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia
| | - Anthony J Gill
- Sydney Medical School Northern, University of Sydney, NSW 2006, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Sydney Medical School Northern, University of Sydney, NSW 2006, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Sydney Medical School Northern, University of Sydney, NSW 2006, Australia.
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Zhou YM, Zhou X, Wan T, Xu D, Si XY. An evidence-based approach to the surgical interventions for severe pancreatic fistula after pancreatoduodenectomy. Surgeon 2018; 16:119-124. [DOI: 10.1016/j.surge.2017.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/23/2017] [Accepted: 07/30/2017] [Indexed: 12/19/2022]
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Ma T, Bai X, Chen W, Li G, Lao M, Liang T. Pancreas-preserving management of grade-C pancreatic fistula and a novel bridging technique for repeat pancreaticojejunostomy: An observational study. Int J Surg 2018; 52:243-247. [PMID: 29462737 DOI: 10.1016/j.ijsu.2018.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 01/31/2018] [Accepted: 02/11/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Optimal surgical strategy for grade-C postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is not justified. External wirsungostomy is feasible. However, the subsequent repeat pancreaticojejunostomy (PJ) is challenging. This study aims to introduce our experience of external wirsungostomy for grade-C POPF and a novel technique to do the repeat PJ (re-PJ). MATERIALS AND METHODS From January 1, 2012 to December 31, 2016, all consecutive patients who underwent pancreaticoduodenectomy (PD) with PJ were identified. The clinical data were retrospectively collected and analyzed. RESULTS Out of 325 patients, 11 patients (3.38%) underwent salvage re-laparotomy for grade-C POPF. External wirsungostomy was performed in 10 patients (3.08%). Four patients died of severe complications within 90 days postoperatively or tumor progression before the scheduled re-PJ was performed. Three patients got their external pancreatic drainage tube pulled out accidentally without causing severe consequences. Three patients underwent planned re-PJ after external wirsungostomy, including one with duct-to-mucosa PJ and two with the novel bridging technique. The operative times of the two patients undergoing the novel bridging technique were 120 min, 135 min, respectively, and the length of post-operative hospital stay (LPHS) were 7 d, 5 d, respectively. The operative time and the LPHS of whom underwent duct-to-mucosa PJ were 315 min, 24 d, respectively. There was no major post-operative complication. CONCLUSION External wirsungostomy may be a safe way to preserve the pancreas remnant in grade-C POPF patients. The novel bridging technique may be a simpler alternative to traditional PJ.
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Affiliation(s)
- Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, 88 Jiefang Road, Hangzhou 310009, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, 88 Jiefang Road, Hangzhou 310009, China
| | - Wen Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, 88 Jiefang Road, Hangzhou 310009, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, 88 Jiefang Road, Hangzhou 310009, China
| | - Mengyi Lao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, 88 Jiefang Road, Hangzhou 310009, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang Provincial Key Laboratory of Pancreatic Disease, 88 Jiefang Road, Hangzhou 310009, China.
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Bressan AK, Wahba M, Dixon E, Ball CG. Completion pancreatectomy in the acute management of pancreatic fistula after pancreaticoduodenectomy: a systematic review and qualitative synthesis of the literature. HPB (Oxford) 2018; 20:20-27. [PMID: 28978403 DOI: 10.1016/j.hpb.2017.08.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/26/2017] [Accepted: 08/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula. METHODS A systematic search of PubMed and EMBASE for all studies reporting clinical outcomes for CP in the acute treatment of pancreatic fistula following PD from January 1975 until May 2016. RESULTS Eleven patient-series with a total of 5566 PD and 151 (3%) emergency CP were included. Median time from PD to CP ranged from 6 to 17 days (7 studies), and mean operative time and blood loss - reported in only two studies - were 197 min and 2173 mL respectively. Re-laparotomy following CP was required in 35% of patients. Median hospital length-of-stay varied from 21 to 64 days, and postoperative mortality was 42%. CONCLUSIONS Emergency surgery for postoperative pancreatic fistula should only be considered after expert consultation. CP carries a high risk of mortality, and it is most commonly recommended for a selected subgroup of patients with locally complicated fistula.
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Affiliation(s)
| | - Michael Wahba
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
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Connor S. Defining post-operative pancreatitis as a new pancreatic specific complication following pancreatic resection. HPB (Oxford) 2016; 18:642-51. [PMID: 27485058 PMCID: PMC4972444 DOI: 10.1016/j.hpb.2016.05.006] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/08/2016] [Accepted: 05/17/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Post-operative pancreatic fistula has been well defined. However the underlying aetiology remains poorly understood. The aim of this review was to investigate whether the underlying aetiology for a proportion of patients suffering from post-operative pancreatic fistula was due to post-operative pancreatitis. METHOD A systematic literature review according to the PRISMA guidelines. The date range was from 2005 to 2016. The search strategy included the terms: post-operative pancreatitis, pathophysiology, post-operative pancreatic fistula, pancreaticoduodenectomy, ischaemic pancreatitis, microcirculation and pancreatitis, serum and drain amylase and lipase. The data was summarised without quantitative or qualitative analysis. RESULTS There exists significant physiological, biochemical, clinical and histological evidence in the literature that a proportion of post-operative pancreatic fistula is due to post-operative pancreatitis. A new definition of post-operative pancreatitis based on the presence of biochemical evidence for pancreatic inflammation (urinary trypsinogen-2 >50 ug/L or serum amylase/lipase > upper limit of normal) between post-operative days 0-2. Predicted severity is based on C-reactive protein with a cut-off of 180 mg/L at post-operative day 2. The proposed grading of severity is in line with previous work by international study group of pancreatic surgery. CONCLUSION Post-operative pancreatitis should be recognised as a separate pancreatic specific complication following pancreatic resection. Improved recognition may allow better understanding of potential methods of prevention, treatment and prediction of severity.
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Affiliation(s)
- Saxon Connor
- Correspondence Saxon Connor, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand. Tel: +64 3 3640640. Fax: +64 3 3640352.Department of SurgeryChristchurch HospitalChristchurchNew Zealand
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Horvath P, Beckert S, Nadalin S, Königsrainer A, Königsrainer I. Pancreas-preserving surgical management of grade-C pancreatic fistulas after pancreatic head resection by external wirsungostomy. Langenbecks Arch Surg 2016; 401:457-62. [DOI: 10.1007/s00423-016-1423-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/01/2016] [Indexed: 12/30/2022]
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Vijay A, Noaman I, Mahfouz A, Khawar M, Khalaf H, Elaffandi A. Pancreatico-enteric fistula post pancreatic duct ligation for delayed haemorrhage complicating pancreaticoduodenectomy. Int J Surg Case Rep 2016; 21:29-31. [PMID: 26921533 PMCID: PMC4802135 DOI: 10.1016/j.ijscr.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/31/2016] [Accepted: 02/07/2016] [Indexed: 11/29/2022] Open
Abstract
Delayed post-pancreatectomy haemorrhage in association with pancreatic fistula is a grave complication. Pancreatic duct occlusion may be considered in hemodynamically unstable patients. Spontaneous development of a pancreatico-enteric fistula despite ligation of the pancreatic duct has never been reported to date.
Introduction Pancreatic fistula remains the main cause for postoperative morbidity following pancreaticoduodenectomy. The coincidence of sentinel bleed prior to post pancreatectomy haemorrhage (PPH) and pancreatic fistula is associated with very high mortality. Presentation of case We report a case of pancreaticoduodenectomy complicated by postoperative leak and hematemesis. Severe delayed haemorrhage from the pancreatico-jejunostomy necessitated re-laparotomy and complete disconnection of the pancreatic anastomosis. Hemodynamic instability precluded a pancreatectomy or creation of a new anastomosis. A follow up MRI done 3 weeks after the patient’s discharge demonstrated a fistulous tract causing a communication between both the pancreatic and biliary systems and the enteric loop. Discussion Spontaneous development a pancreatico-enteric fistula despite ligation of the pancreatic duct and complete disconnection of the pancreatic anastomosis has never been reported in literature to date. Conclusion Pancreatic duct occlusion may be considered over a completion pancreatectomy or revisional pancreatic anastomosis in hemodynamically unstable and challenging cases.
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Affiliation(s)
- Adarsh Vijay
- General Surgery, Hamad Medical Corporation, General Surgery, Doha, Qatar
| | - Islam Noaman
- Organ Transplant, Hamad Medical Corporation, General Surgery, Doha, Qatar
| | - Ahmed Mahfouz
- Radiology, Hamad Medical Corporation, General Surgery, Doha, Qatar
| | - Mahwish Khawar
- General Surgery, Hamad Medical Corporation, General Surgery, Doha, Qatar
| | - Hatem Khalaf
- Organ Transplant, Hamad Medical Corporation, General Surgery, Doha, Qatar
| | - Ahmed Elaffandi
- Organ Transplant, Hamad Medical Corporation, General Surgery, Doha, Qatar.
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