Pancreas-preserving management in reinterventions for severe pancreatic fistula after pancreatoduodenectomy: a systematic review

Pancreatic duct occlusion with polychloroprene-based glue for the management of postoperative pancreatic fistula after pancreatoduodenectomy-an outdated approach?

Background

Managing postoperative pancreatic fistula (POPF) presents a formidable challenge after pancreatoduodenectomy. Some centers consider pancreatic duct occlusion (PDO) in reoperations following pancreatoduodenectomy as a pancreas-preserving procedure, aiming to control a severe POPF. The aim of the current study was to evaluate the short- and long-term outcomes of employing PDO for the management of the pancreatic stump during relaparotomy for POPF subsequent to pancreatoduodenectomy.

Methods

Retrospective review of consecutive patients at Oslo University Hospital undergoing pancreatoduodenectomy and PDO during relaparotomy. Pancreatic stump management during relaparotomy consisted of occlusion of the main pancreatic duct with polychloroprene Faxan-Latex, after resecting the dehiscent jejunal loop previously constituting the pancreaticojejunostomy.

Results

Between July 2005 and September 2015, 826 pancreatoduodenectomies were performed. Overall reoperation rate was 13.2% (n = 109). POPF grade B/C developed in 113 (13.7%) patients. PDO during relaparotomy was performed in 17 (2.1%) patients, whereas completion pancreatectomy was performed in 22 (2.7%) patients. Thirteen (76%) of the 17 patients had a persistent POPF after PDO, and the time from PDO until removal of the last abdominal drain was median 35 days. Of the PDO patients, 13 (76%) patients required further drainage procedures (n = 12) or an additional reoperation (n = 1). In-hospital mortality occurred in one patient (5.9%). Five (29%) patients developed new-onset diabetes mellitus, and 16 (94%) patients acquired exocrine pancreatic insufficiency.

Conclusions

PDO is a safe and feasible approach for managing severe POPF during reoperation following pancreatoduodenectomy. A significant proportion of patients experience persistent POPF post-procedure, necessitating supplementary drainage interventions. The findings suggest that it is advisable to explore alternative pancreas-preserving methods before opting for PDO in the management of POPF subsequent to pancreatoduodenectomy.

Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It?

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.

Management of postoperative pancreatic fistula after pancreaticoduodenectomy

A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy

Purpose

This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).

Methods

This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy.

Results

A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months.

Conclusion

Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

A comparison of surgical approaches in the treatment of grade C postoperative pancreatic fistula: A retrospective study

Background

Postoperative 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.

Methods

A 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.

Results

A 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.

Conclusion

Open 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.

Surgical Management of Postoperative Grade C Pancreatic Fistula following Pancreatoduodenectomy

Background

The incidence of Grade C postoperative pancreatic fistula ranges from 2 to 11% depending on the type of pancreatic resection. This complication may frequently require early relaparotomy and the surgical approach remains technically challenging and is still associated with a high mortality. Infectious complications and post-operative hemorrhage are the two most common causes of reoperation.

Summary

The best management of grade C pancreatic fistulas remains controversial and ranges from conservative approaches up to completion pancreatectomy. The choice of the technique depends on the patient's conditions, intraoperative findings, and surgeon's discretion. A pancreas-preserving strategy appears to be attractive, including from simple to more complex procedures such as debridement and drainage, and external wirsungostomy. Completion pancreatectomy should be reserved for selected cases, including stable patients with severe infection complication or hemorrhage after pancreatic fistula who do not respond to pancreas-preserving procedures.

Key Messages

This review describes the current options for management of grade C pancreatic fistula after pancreatoduodenectomy with regard to indication, choice of procedure and outcomes of the different approaches.

Efficacy of laparoscopic-assisted pancreaticoduodenectomy in Vietnamese patients with periampullary of Vater malignancies: A single-institution prospective study

Introduction

Minimally invasive pancreaticoduodenectomy is a technically complex technique, that is being used to treat periampullary malignancy. We provide our experience with laparoscopic-assisted pancreaticoduodenectomy (LAPD) with statistics on the outcomes of periampullary cancer patients.

Material and method

Thirty patients underwent surgery between June 1, 2016 and May 30, 2020, with 21 undergoing classical PD and 9 undergoing pylorus-preserving pancreaticoduodenectomy (PPPD). Prospectively gathered data on surgical outcomes and long-term oncological results are given.

Results

The median operative time was 277.5 min (range, 258.7–330 min), and the median intraoperative estimated blood loss was 319.5 mL (range, 241.2–425 mL). The rate of conversion to OPD, surgical reintervention, and mortality was 20%, 13.3%, and 10% respectively. Cumulative surgery-related morbidity was 33.4%, including bleeding (n = 4), severe POPF (n = 4), biliary fistula (n = 1), DGE (n = 2), and intestinal obstruction (n = 1). Pathologic diagnoses were AoV cancer (n = 23), distal CBD cancer (n = 4), PDAC (n = 2), and AoV NET (n = 1). The mean survival time of the LAPD group was 29.9 months. The long-term survival time of the N0 group was 36.8 months, which was significantly longer than that of the N1 group. The long-term survival times of stages I–B, II-A, and II-B were 36.9, 26.5, and 15.7 months, respectively (p = 0.016).

Conclusion

LAPD has a high rate of conversion to OPD, morbidity, and mortality. However, LPD is feasible technique for highly selected patients. Lymph node metastasis and stage of disease are the risk factors for long-term survival.

•

Most of tumours that develop in the periampullary of the Vater region are malignant.

•

Laparoscopic pancreaticoduodenectomy (LPD) remains the most challenging procedure in laparoscopic surgery with the rate of conversion to OPD, morbility, and mortality was 0–40%, 3.8%–50%, and 1.6%–8%, respectively.

•

In the first 30 cases, LAPD has a high rate of complications, conversion to OPD, and mortality. However, LAPD is feasible method and can provide acceptable oncological results with careful patient selection.

•

Experience, learning curve, and high-volume centre might have influenced the results.

Standardized salvage completion pancreatectomy for grade C postoperative pancreatic fistula after pancreatoduodenectomy (with video)

BACKGROUND

Emergency completion pancreatectomy (CP) after pancreatoduodenectomy (PD) is a technically demanding procedure. We report our experiences with a four-step standardized technique used at our center since 2012.

METHODS

In the first step, the gastrojejunostomy is divided with a stapler to quickly access the pancreatic anastomosis and permit adequate exposure, especially in cases of active bleeding. Second, the bowel loops connected to the pancreatic anastomosis is divided in cases of pancreaticojejunostomy. Third, the pancreatectomy is completed with or without the splenic vessels and spleen conservation according to the local conditions. Finally, the fourth step reconstructs in a Roux-en-Y fashion and ensures drainage.

RESULTS

From January 2012 to December 2019, 450 patients underwent PD at our center. Reintervention for grade C postoperative pancreatic fistula was decided for 30 patients, and CP was performed in 21 patients. The mean intraoperative blood loss and operative duration were relatively low (600 ml and 240 min, respectively). During the perioperative period, three patients died from multiple organ failure, and two patients died intraoperatively from a cataclysmic hemorrhage originating from the superior mesenteric artery.

DISCUSSION

Our standardized procedure appears to be relatively safe, reproducible, and could be particularly useful for young surgeons.

Additional modifications to the Blumgart pancreaticojejunostomy: Results of a propensity score-matched analysis versus Cattel-Warren pancreaticojejunostomy

BACKGROUND

Postoperative pancreatic fistula continues to occur frequently after pancreatoduodenectomy.

METHODS

We have described a modification of the Blumgart pancreaticojejunostomy. The modification of the Blumgart pancreaticojejunostomy was compared to the Cattel-Warren pancreaticojejunostomy in cohorts of patients matched by propensity scores based on factors predictive of clinically relevant postoperative pancreatic fistula, which was the primary endpoint of this study. Based on a noninferiority study design, 95 open pancreatoduodenectomies per group were needed. Feasibility of the modification of the Blumgart pancreaticojejunostomy in robotic pancreatoduodenectomy was also shown. All pancreaticojejunostomies were performed by a single surgeon.

RESULTS

Between October 2011 and May 2019, there were 415 pancreatoduodenectomies with either a Cattel-Warren pancreaticojejunostomy (n = 225) or a modification of the Blumgart pancreaticojejunostomy (n = 190). There was 1 grade C postoperative pancreatic fistula in 190 consecutive modification of the Blumgart pancreaticojejunostomies (0.5%). Logistic regression analysis showed that the rate of clinically relevant postoperative pancreatic fistula was not affected by consecutive case number. After exclusion of robotic pancreatoduodenectomies (the Cattel-Warren pancreaticojejunostomy: 82; modification of the Blumgart pancreaticojejunostomy: 66), 267 open pancreatoduodenectomies were left, among which the matching process identified 109 pairs. The modification of the Blumgart pancreaticojejunostomy was shown to be noninferior to the Cattel-Warren pancreaticojejunostomy with respect to clinically relevant postoperative pancreatic fistula (11.9% vs 22.9%; odds ratio: 0.46 [0.21-0.93]; P = .03), grade B postoperative pancreatic fistula (11.9% vs 18.3%; P = .18), and grade C postoperative pancreatic fistula (0 vs 4.6%; P = .05) as well as to all secondary study endpoints. The modification of the Blumgart pancreaticojejunostomy was feasible in 66 robotic pancreatoduodenectomies. In this subgroup with 1 conversion to open surgery (1.5%), a clinically relevant postoperative pancreatic fistula occurred after 9 procedures (13.6%) with no case of grade C postoperative pancreatic fistula and a 90-day mortality of 3%.

CONCLUSION

The modification of the Blumgart pancreaticojejunostomy described herein is noninferior to the Cattel-Warren pancreaticojejunostomy in open pancreatoduodenectomy. This technique is also feasible in robotic pancreatoduodenectomy.

Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy

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.

Pancreas-preserving management of grade-C pancreatic fistula and a novel bridging technique for repeat pancreaticojejunostomy: An observational study

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.

Salvage Islet Auto Transplantation After Relaparatomy

BACKGROUND

To assess feasibility, safety, and metabolic outcome of islet auto transplantation (IAT) in patients undergoing completion pancreatectomy because of sepsis or bleeding after pancreatic surgery.

METHODS

From November 2008 to October 2016, approximately 22 patients were candidates to salvage IAT during emergency relaparotomy because of postpancreatectomy sepsis (n = 11) or bleeding (n = 11). Feasibility, efficacy, and safety of salvage IAT were compared with those documented in a cohort of 36 patients who were candidate to simultaneous IAT during nonemergency preemptive completion pancreatectomy through the pancreaticoduodenectomy.

RESULTS

The percentage of candidates that received the infusion of islets was significantly lower in salvage IAT than simultaneous IAT (59.1% vs 88.9%, P = 0.008), mainly because of a higher rate of inadequate islet preparations. Even if microbial contamination of islet preparation was significantly higher in candidates to salvage IAT than in those to simultaneous IAT (78.9% vs 20%, P < 0.001), there was no evidence of a higher rate of complications related to the procedure. Median follow-up was 5.45 ± 0.52 years. Four (36%) of 11 patients reached insulin independence, 6 patients (56%) had partial graft function, and 1 patient (9%) had primary graft nonfunction. At the last follow-up visit, median fasting C-peptide was 0.43 (0.19-0.93) ng/mL; median insulin requirement was 0.38 (0.04-0.5) U/kg per day, and median HbA1c was 6.6% (5.9%-8.1%). Overall mortality, in-hospital mortality, metabolic outcome, graft survival, and insulin-free survival after salvage IAT were not different from those documented after simultaneous IAT.

CONCLUSIONS

Our data demonstrate the feasibility, efficacy, and safety of salvage IAT after relaparotomy.