Pancreatic atrophy relative to external versus internal drainage of the pancreatic duct after pylorus-preserving pancreaticoduodenectomy

Pancreatic volume and endocrine function changes following pancreaticoduodenectomy for peri-ampullary neoplasms: A retrospective single-center study utilizing pancreas volumetry

Backgrounds/Aims

We evaluated long-term pancreatic functional outcomes, including pancreatic volumetry after pancreaticoduodenectomy (PD) for peri-ampullary neoplasm.

Methods

We retrospectively reviewed 353 patients with a 12-month follow-up who underwent elective pancreaticoduodenectomies for peri-ampullary neoplasms at a single university hospital between January 2011 and December 2020. Perioperative and postoperative outcomes, long-term pancreatic endocrine functions, and pancreatic volume changes 12 month postoperatively were evaluated.

Results

The mean age was 65.4 years, and the sex ratio was 1.38. The patients with prediagnosed diabetes mellitus (DM) comprised 31.4%. The peri-ampullary neoplasm origins were: the pancreas (49.0%), common bile duct (27.2%), ampulla of Vater (18.4%), and duodenum (5.4%). The 1-week, and 3-, 6-, and 12-month postoperative proportions of patients with DM diagnosed before surgery combined with new-onset postoperative DM were 39.7%, 42.8%, 43.9%, and 49.6%, respectively. The preoperative and postoperative 1-week, and 3-, 6-, and 12-month mean pancreatic volumes were 82.3, 38.7, 28.1, 24.9, and 25.5 mL, respectively. Univariate risk factor analyses for new-onset DM after PD observed no significant difference between the 'No DM after PD' and 'New-onset DM after PD' groups.

Conclusions

Following PD for peri-ampullary neoplasms, pancreatic endocrine functions and volumes continued to decrease for a minimum of 12 months. The current study did not identify any causal relationship between pancreatic endocrine dysfunction and pancreatic atrophy following PD.

nnU-Net-Based Pancreas Segmentation and Volume Measurement on CT Imaging in Patients with Pancreatic Cancer

RATIONALE AND OBJECTIVES

To develop and validate a deep learning (DL)-based method for pancreas segmentation on CT and automatic measurement of pancreatic volume in pancreatic cancer.

MATERIALS AND METHODS

This retrospective study used 3D nnU-net architecture for fully automated pancreatic segmentation in patients with pancreatic cancer. The study used 851 portal venous phase CT images (499 pancreatic cancer and 352 normal pancreas). This dataset was divided into training (n = 506), internal validation (n = 126), and external test set (n = 219). For the external test set, the pancreas was manually segmented by two abdominal radiologists (R1 and R2) to obtain the ground truth. In addition, the consensus segmentation was obtained using Simultaneous Truth and Performance Level Estimation (STAPLE) algorithm. Segmentation performance was assessed using the Dice similarity coefficient (DSC). Next, the pancreatic volumes determined by automatic segmentation were compared to those determined by manual segmentation by two radiologists.

RESULTS

The DL-based model for pancreatic segmentation showed a mean DSC of 0.764 in the internal validation dataset and DSC of 0.807, 0.805, and 0.803 using R1, R2, and STAPLE as references in the external test dataset. The pancreas parenchymal volume measured by automatic and manual segmentations were similar (DL-based model: 65.5 ± 19.3 cm3 and STAPLE: 65.1 ± 21.4 cm3; p = 0.486). The pancreatic parenchymal volume difference between the DL-based model predictions and the manual segmentation by STAPLE was 0.5 cm3, with correlation coefficients of 0.88.

CONCLUSION

The DL-based model efficiently generates automatic segmentation of the pancreas and measures the pancreatic volume in patients with pancreatic cancer.

Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.

METHODS

The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.

RESULTS

A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.

CONCLUSIONS

Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.

Pancreatic duct stents

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

Early drain removal and late drain removal in patients after pancreatoduodenectomy: A systematic review and meta-analysis

Whether early or late drain removal (EDR/LDR) is better for patients after pancreatic resection remains controversial. We aim to systematically evaluate the safety and efficacy of early or late drain removal in patients who undergo pancreatic resection. We searched seven databases from January 1, 2000, through September 2021, and included randomized controlled trials (RCTs) or observational studies comparing EDR vs. LDR in patients after pancreatic resection. We separately pooled effect estimates across RCTs and observational studies. Finally, we included 4 RCTs with 711 patients and 8 nonRCTs with 7207 patients. Based on the pooled RCT data, compared to LDR, EDR reduced hospital length of stay (LOS) (RR: -2.59, 95% CI: -4.13 to -1.06) and hospital cost (RR: -1022.27, 95% CI: -1990.39 to -54.19). Based on the pooled nonRCT data, EDR may reduce the incidence of all complications (OR: 0.45, 95% CI: 0.32 to 0.63), pancreatic fistula (OR: 0.26, 95% CI: 0.15 to 0.45), wound infection (RR: 0.59, 95% CI: 0.06 to 5.45)), reoperation (OR: 0.62, 95% CI: 0.40 to 0.96) and hospital readmission (OR: 0.57, 95% CI: 0.47 to 0.69). There was an uncertain effect on mortality (OR from pooled nonRCTs: 1.02, 95% CI: 0.41 to 2.53) and delayed gastric emptying (RR from pooled RCTs: 0.76, 95% CI: 0.41 to 1.41). The findings of this meta-analysis suggest that early drain removal is associated with lower hospital cost, is safe and may reduce the incidence of complications compared to late drain removal in patients after pancreaticoduodenectomy.

Atrophy of remnant pancreas after pancreatoduodenectomy: Risk factors and effects on quality of life, nutritional status, and pancreatic function

BACKGROUND

Factors aggravating remnant pancreas atrophy following pancreatoduodenectomy and the effects of atrophy have not been extensively studied. This study aimed to evaluate the clinical factors affecting remnant pancreas atrophy and assess the effects of atrophy on quality of life, nutritional status, and pancreatic exocrine and endocrine functions.

METHODS

Data collected prospectively from 122 patients who completed 12 months of follow-up, including computed tomography and the quality-of-life questionnaire, were analyzed. Pancreas volume was measured using a computed tomography volumetry program. Endocrine and exocrine functions were evaluated.

RESULTS

Malignancy and adjuvant chemoradiotherapy were associated with severity of atrophy. At 12 postoperative months, quality-of-life scores and nutritional indexes were mostly not associated with atrophy, but stool elastase level decreased significantly and incidence of new-onset diabetes mellitus was higher in the severe atrophy group. Postprandial 2-hour blood glucose and glycosylated hemoglobin levels were also higher in this group.

CONCLUSIONS

Remnant pancreas atrophy was more severe in patients with malignant disease who received adjuvant chemoradiotherapy and was associated with pancreatic exocrine and endocrine functions. More careful monitoring and active management of exocrine and endocrine deficiencies are necessary for patients who underwent pancreatoduodenectomy for malignant disease and received chemoradiotherapy.

Effects of pancreatic resection for benign pancreatic neoplasms on pancreatic volume and endocrine function: A long-term computed tomography-based study

BACKGROUND

Pancreatic surgery may result in changes in pancreatic volume and endocrine function. The effects of pancreatic resection for benign neoplasms on pancreatic volume and endocrine function have not been established yet. This study aimed to investigate the long-term results of different pancreatic surgeries for benign pancreatic neoplasms on pancreatic volume and endocrine function.

METHODS

The medical records of 30 patients who underwent pancreaticoduodenectomy (PD) and 30 patients who underwent left-sided pancreatectomy(LP) for benign pancreatic neoplasms between 2005 and 2012 were reviewed. The changes in pancreatic volume after pancreatic surgery were assessed using multi-detector row computed tomography volumetry. Endocrine pancreatic function was evaluated on the basis of fasting glucose level or oral glucose tolerance test result.

RESULTS

The median follow-up duration was 91.3 months (interquartile range, 75.7-119.1 months). Reduction in pancreatic volume after surgery was more pronounced in patients who underwent PD than in those who underwent LP (median percentage of volume reduction, 23.8% vs 5.1%, p < .001). Multivariable analysis of prognostic factors for endocrine insufficiency showed that PD to be significant factor. (HR 3.87, 95% CI 1.12-14.66, p = .037).

CONCLUSIONS

The surgical methods for benign pancreatic neoplasms affect the reduction in pancreatic volume. Furthermore, the methods of pancreatic surgery were associated with the risk of endocrine insufficiency. Further studies with a large number of patients are warranted to evaluate the association between the degree of volume reduction and the development of endocrine insufficiency.

The Prognostic Value of External vs Internal Pancreatic Duct Stents in CR-POPF after Pancreaticoduodenectomy: A Systematic Review and Meta-analysis

BACKGROUND

There is no specific evidence regarding the benefits of external and internal pancreatic duct stents after pancreaticoduodenectomy since pancreatic fistula (grade A) have been redefined with no clinical treatment effect. We aimed to reevaluate the prognostic value of external and internal stents in clinically relevant postoperative pancreatic fistula over pancreaticoduodenectomy.

METHODS

PubMed, Web of Science, EMBASE and the Cochrane Database were specifically searched for pertinent and original articles published before May 2019. The project has been registered in PROSPERO (Registration number: CRD42019137579).

RESULTS

Four randomized controlled trials and six nonrandomized controlled trials with a total of 2101 patients were enrolled in this meta-analysis. The use of an external stent resulted in better performance than the use of an internal stent in terms of pancreatic fistula (grade C) (OR 0.58, P = 0.03) but did not reduce the rate of pancreatic fistula (grade B) (OR 0.99, P = 0.94) in all studies. The meta-analysis of randomized controlled trials found that the use of an external stent approached a level of significance for an increased rate of clinically relevant postoperative pancreatic fistula compared to the use of an internal stent (OR 1.40, P = 0.10) but had no significant effect on pancreatic fistula (grade B) (OR 1.34, P = 0.26) or pancreatic fistula (grade C) (OR 1.68, P = 0.62).

CONCLUSION

Compared with internal stents, the use of external stent might be associated with a lower rate of pancreatic fistula (grade C). More randomized clinical trials are warranted to further explore safety and efficacy of pancreatic duct external stents.

Morphological changes of the pancreas after pancreaticoduodenectomy

The aim of this retrospective study was thus to evaluate postoperative morphological changes in the remnant pancreas after pancreaticoduodenectomy (PD) associated with postoperative pancreatic fistula (POPF). Fifty-one patients subjected to PD were enrolled in the study and allocated into 2 groups according to the presence (n = 16) or absence of POPF (n = 35). A morphological evaluation of the pancreas was conducted for up to a 20 months follow-up on CT scans and compared between groups. No significant differences were observed in morphology between the groups at the different preoperative and PO intervals, regardless of the clinical relevance of the POPF or POPF grade. However, in the overall patient analysis we observed a significant reduction of the entire pancreas over time. In fact, thickness decreased 0.4 mm/month, length 1.2 mm/month and volume 1.17 cm³/month over the PO. The impact of age, POPF, type of anastomosis, surgical technique and PO follow-up (time) was evaluated in a multivariate analysis using the general linear model, but only PO follow-up had a significant influence on the final model (p < 0.001). A significant reduction on pancreatic parenchyma (thickness, length and volume) occurs after PD with no significant differences between patients with or without POPF.

Pancreas volume in health and disease: a systematic review and meta-analysis

The pancreas plays a central role in metabolism and is involved in the pathogenesis of several diseases. Pancreas volume is a holistic quantitative measure of pancreas size but the clinical relevance of pancreas volumetry is poorly understood. Areas covered: The aim was to systematically review studies in adults that used computed tomography or magnetic resonance imaging to measure pancreas volume in health and disease, to determine normal pancreas volume range, and to quantify changes in pancreas volume that are associated with disease. Expert commentary: The normal pancreas volume range in adults is 71-83 cm³, with no statistically significant difference between men and women. Type 2 diabetes and type 1 diabetes are associated with a progressively reduced pancreas volume. Overweight and obesity are associated with a progressively increased pancreas volume. There is a paucity of studies on pancreas volume in the setting of diseases of the exocrine pancreas, which should become a research priority in the future.

New-onset diabetes after pancreatoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Pancreatoduodenectomy may lead to new-onset diabetes mellitus, also known as type 3c diabetes, but the exact risk of this complication is unknown. The aim of this review was to assess the risk of new-onset diabetes mellitus after pancreatoduodenectomy.

METHODS

A literature search was performed in PubMed, Embase (Ovid), and the Cochrane Library for English articles published from March 1993 until March 2017 (PROSPERO registry number: CRD42016039784). Studies reporting on the risk of new-onset diabetes mellitus after pancreatoduodenectomy were included. For meta-analysis, studies were pooled using the random-effects model. All studies were appraised according to the Newcastle-Ottawa Scale.

RESULTS

After screening 1,523 studies, 22 studies involving 1,121 patients were eligible. The mean weighted overall proportion of new-onset diabetes mellitus after pancreatoduodenectomy was 16% (95% confidence interval, 12%-20%). We found no significant difference in risk of new-onset diabetes mellitus when pancreatoduodenectomy was performed for nonmalignant disease after excluding patients with chronic pancreatitis (19% risk; 95% confidence interval, 7%-43%; 6 studies) or for malignant disease (22% risk; 95% confidence interval, 14%-32%; 11 studies), P = .71. Among all patients, 6% (95% confidence interval, 4%-10%) developed insulin-dependent new-onset diabetes mellitus.

CONCLUSION

This systematic review identified a clinically relevant risk of new-onset diabetes mellitus after pancreatoduodenectomy of which patients should be informed preoperatively.

Extended pancreatic transection for secure pancreatic reconstruction during pancreaticoduodenectomy

Backgrounds/Aims

Pancreaticoduodenectomy (PD) is associated with various surgical complications including healing failure of the pancreaticojejunostomy (PJ). This study intended to ensure blood supply to the pancreatic stump through extended pancreatic transection (EPT).

Methods

This study assessed whether EPT reduces PJ-associated complications and whether EPT is harmful on the remnant pancreatic function. The EPT group included 19 patients undergoing PD, pylorus-preserving PD (PPPD) or hepatopancreaticoduodenectomy. The propensity score matched control group included 45 patients who had undergone PPPD. Pancreatic transection was performed at the level of the celiac axis in the EPT group, by which the pancreatic body was additionally removed by 3 cm in length comparing with the conventional pancreatic transection.

Results

A small invagination fissure suspected as the embryonic fusion site was identified at the ventro-caudal edge of the pancreatic body in all patients undergoing EPT. A sizable fissure permitting easy separation of the pancreatic parenchyma was identified in 15 of 19 patients (78.9%). The incidence of significant postoperative pancreatic fistula was significantly lower in the EPT group than in the control group (p=0.047). There was no significant increase in the postoperative de novo diabetes mellitus in EPT group (p=0.60).

Conclusions

The EPT technique contributes to the prevention of major pancreatic fistula without impairing remnant pancreatic function. EPT is feasible for routine clinical application or at least in patients with any known risk of PJ leak.

Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma

Functional and morphological evolution of remnant pancreas after resection for pancreatic adenocarcinoma is investigated.The medical records of 45 patients who had undergone radical resection for pancreatic adenocarcinoma from March 2010 to September 2013 were reviewed retrospectively. There were 34 patients in the pancreaticoduodenectomy (PD) group and 10 patients in the distal pancreatectomy (DP) group. One patient received total pancreatectomy. The endocrine function was measured using the glucose tolerance index (GTI), which was derived by dividing daily maximum serum glucose fluctuation by daily minimum glucose. Remnant pancreas volume (RPV) was estimated by considering pancreas body and tail as a column, and head as an ellipsoid, respectively. The pancreatic atrophic index (PAI) was defined as the ratio of pancreatic duct width to total pancreas width. Representative indices of each patient were compared before and after resection up to 2 years postoperatively.The area under receiver operating characteristic curve of GTI for diagnosing DM was 0.823 (95% confidence interval, 0.699-0.948, P < .001). Overall, GTI increased on postoperative day 1 (POD#1, mean ± standard deviation, 1.79 ± 1.40 vs preoperative, 1.02 ± 1.41; P = .001), and then decreased by day 7 (0.89 ± 1.16 vs POD#1, P < .001). In the PD group, the GTI on POD#14 became lower than preoperative (0.51 ± 0.38 vs 0.96 ± 1.37; P = .03). PAI in the PD group was significantly lower at 1 month postoperatively (0.22 ± 0.12 vs preoperative, 0.38 ± 0.18; P < .001). In the PD group, RPV was significantly lower at 1 month postoperatively (25.3 ± 18.3 cm vs preoperative, 32.4 ± 20.1 cm; P = .02), due to the resolution of pancreatic duct dilatation. RPV of the DP group showed no significant change. GTI was negatively related to RPV preoperatively (r = -0.317, P = .04), but this correlation disappeared postoperatively (r = -0.044, P = .62).Pancreatic endocrine functional deterioration in pancreatic adenocarcinoma patients may in part be due to pancreatic duct obstruction and dilatation caused by the tumor. After resection, this proportion of endocrine insufficiency is corrected.

Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review.

OBJECTIVES

To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/).

MAIN RESULTS

We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice.

AUTHORS' CONCLUSIONS

This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.

Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis

BACKGROUND

Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis. The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy (PD).

METHODS

We searched PubMed, EMBASE, the Cochrane Library and Web of Science databases until the end of December, 2014. Studies comparing outcomes of external vs. internal stent placement in PD were eligible for inclusion. Included literature was extracted and assessed by two independent reviewers.

RESULTS

Seven articles were identified for inclusion: three randomized controlled trials (RCTs) and four observational clinical studies (OCS). The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula (PF) in total [odds ratio (OR) =0.69; 95% confidence interval (CI), 0.48-0.99; P=0.04], PF in soft pancreas (OR =0.30; 95% CI, 0.16-0.56; P=0.0002) and delayed gastric emptying (DGE) (OR =0.58; 95% CI, 0.38-0.89; P=0.01) compared with internal stents. There were no significant differences in other postoperative outcomes between two stenting methods, including postoperative morbidity (OR =0.93; 95% CI, 0.39-2.23; P=0.88), overall mortality (OR =0.70; 95% CI, 0.22-2.25; P=0.55), and intra-abdominal collections (OR =0.67; 95% CI, 0.26-1.71; P=0.40).

CONCLUSIONS

Based upon this meta-analysis, the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE. Due to the limited number of original studies, more RCTs are needed to further support our result and clarify the issue.

Therapeutic effect of trans-drain administration of antibiotics in patients showing intractable pancreatic leak-associated pus drainage after pancreaticoduodenectomy

BACKGROUNDS/AIMS

To cope with intractable pus drainage from persistent pancreatic leak after pancreaticoduodenectomy (PD), we have empirically performed local administration of high-concentration antibiotics cocktail solution into abdominal drains. The purpose of this study was to assess its therapeutic effect in patients showing intractable pus drainage after PD.

METHODS

The study group was 10 patients who underwent trans-drain administration of high-concentration antibiotics cocktail solution. Another 10 patients were selected through propensity score matching for the control group. Their medical records were retrospectively reviewed with focus on comparison of pancreatic fistula (PF)-associated clinical sequences.

RESULTS

Postoperative PF of grade B and C occurred in 7 and 3 patients in the study group and 9 and 1 patient in the control group, respectively (p=0.58). In the study group, a mean of 1.8 sessions of antibiotics cocktail solution (imipenem 500 mg and vancomycin 500 mg dissolved in 20 ml of normal saline) was administered. Two patients showed procedure-associated febrile episodes that were spontaneously controlled within 48 hours. At 2-4 days after the first-session of antibiotics administration, pus-like drain discharge turned to be serous with significantly decreased amount. The study group showed shortened postoperative hospital stay comparing to the control group (25.2±4.6 vs. 31.8±5.6 days, p=0.011). In both groups, no patient received radiological or surgical intervention due to PF-associated complications.

CONCLUSIONS

The results of our study demonstrated that trans-drain administration of antibiotics could be an effective therapeutic option for pancreaticojejunostomy leak-associated infection. Further validation of our result is necessary in large patient populations from multiple centers.

Pathophysiology after pancreaticoduodenectomy

Pancreaticoduodenectomy (PD) will result in removal of important multiorgans in upper intestinal tract and subsequently secondary physiologic change. In the past, surgeons just focused on the safety of surgical procedure; however, PD is regarded as safe and widely applied to treatment of periampullary lesions. Practical issues after PD, such as, effect of duodenectomy, metabolic surgery-like effect, alignment effect of gastrointestinal continuity, and non-alcoholic fatty liver disease were summarized and discussed.

Prevalence analysis of de novo hepatic steatosis following pylorus-preserving pancreaticoduodenectomy

BACKGROUND

Prevalence of hepatic steatosis following pylorus-preserving pancreaticoduodenectomy (PPPD) is high. This study intended to reveal the prevalence and patterns of de novo hepatic steatosis following PPPD.

METHODS

We investigated postoperative de novo hepatic steatosis following PPPD (n = 101) with a control group of bile duct resection (BDR) (n = 54).

RESULTS

At postoperative 1 year, hepatic steatosis occurred in 21 of 82 patients (25.6%) of PPPD group and in 2 of 47 patients (4.3%) of BDR group (p = 0.001). Thereafter, at 2 to 5 years, a high prevalence of hepatic steatosis persisted in the PPPD group, but no further occurrence developed in BDR group. Once steatosis developed, it persisted until the end of the study period or patient death. Five-year cumulative incidence of hepatic steatosis was 26.7% in the PPPD group and 3.7% in BDR group (p < 0.001). Univariate analyses showed that patient sex, age, body mass index, blood lipid profile, recurrence of tumor, and diabetes did not have significant influence on the development of hepatic steatosis following PPPD.

CONCLUSIONS

De novo hepatic steatosis may develop in a not negligible proportion of patients undergone PPPD. Multicenter studies with a high number of patients are needed to elucidate its pathogenesis and to find effective treatment for pancreaticoduodenectomy-associated hepatic steatosis.