Continuous irrigation after pancreatectomy: a systematic review

Drainage and irrigation on demand may decrease severe septic complications and mortality in pancreatic resections

PURPOSE

The necessity of routine drain placement in pancreatic resections is controversial. Some randomized controlled trials have shown that the omission of drainage is safe for some patients, whereas reintervention rates and mortality rates are substantial for others. The present study aimed to assess fistula-associated outcomes in the setting of routine drain placement and drain irrigation on demand.

METHODS

Between 01/2017 and 12/2022, perioperative and outcome data from patients who underwent consecutive pancreatoduodenectomies (PD, n = 253) or distal pancreatectomies (DP, n = 72) were prospectively collected in the electronic StuDoQ database and analysed. All patients underwent intraoperative drain placement. Drains were removed starting at postoperative day 2 in PD or at day 5 in DP after testing for amylase concentration. In case of high amylase levels or macroscopically suspicious pancreatic fistulas, drain irrigation was started. Nondrained fluid collections underwent percutaneous radiologic or transluminal endoscopic evacuation.

RESULTS

Clinically relevant pancreatic fistulas were detected in 53 of 325 patients (POPF grade B 16.3%, grade C 1.2%). 43.3% of those had drain irrigation. Additional interventional or endoscopic drainage was necessary in 14 and 5 patients, respectively (overall 5.8%), and were observed in 4.0% of patients with PD and in 12.5% with DP (p = 0.009). Delayed fistula-associated postpancreatectomy haemorrhage (PPH) was present in 1.2% (4/325) of patients. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). The 30-day and in-hospital mortality rates were both 1.5% (5/325), and the rate of fistula-associated mortality was 0.6% (2/325). The overall 90-day mortality rate was 4.5%.

CONCLUSIONS

In pancreatectomies, a standardized drainage protocol including on-demand drain irrigation results in very low fistula-associated morbidity and mortality and an infrequent need for interventional or surgical reintervention as compared to previously published drainage studies.

A retrospective comparative study on the treatment of non-metastatic pancreatic cancer using high-intensity focused ultrasound versus radical surgery

OBJECTIVE

To compare the efficacy and safety of high-intensity focused ultrasound (HIFU) and radical surgery for non-metastatic pancreatic cancer (PC).

MATERIALS AND METHODS

We retrospectively analyzed 89 stage I/II/III PC patients who underwent HIFU (n = 43) or surgery (n = 46) at the Third Xiangya Hospital from January 2020 to December 2021. Pain relief, Karnofsky Performance Scale (KPS), overall survival (OS), treatment-related complications and risk factors for OS were assessed.

RESULTS

There was no significant difference in the pain relief rate at 30 days post-treatment between the two groups. However, compared with the surgery group, the HIFU group showed significantly lower post-treatment VAS scores (p = 0.019). In the surgery group, the KPS at 30 days post-treatment was lower than pretreatment KPS (70 vs 80; p = 0.015). This relationship was reversed in the HIFU group (80 vs 70; p = 0.024). Median OS favored surgery over HIFU (23 vs 10 months; p < 0.001), with a higher 1-year OS rate (69.57% vs 32.6%; p < 0.001). However, there was no significant difference in OS between the two groups for stage III patients (p = 0.177). Complications rated ≥ grade III were 2.33% in the HIFU group and 32.6% in the surgery group. Multivariate analyses showed that age, KPS, and treatment methods were independent prognostic factors for OS.

CONCLUSION

HIFU demonstrates advantages over surgery in terms of early KPS, VAS improvements, and safety for pancreatic cancer; however, long-term outcomes favor surgery. For III-stage disease, HIFU was noninferior to surgery in overall survival.

Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.