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Hajibandeh S, Hajibandeh S, Hablus MA, Bari H, Pathanki AM, Ali M, Ahmad J, Marangoni G, Khan S, Lam FT. Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2024; 28:302-314. [PMID: 38522846 PMCID: PMC11341886 DOI: 10.14701/ahbps.24-015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement. Future randomized research is needed to provide stronger evidence.
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Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohammed Abdallah Hablus
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
- Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hassaan Bari
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Adithya Malolan Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Majid Ali
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Jawad Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Gabriele Marangoni
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Saboor Khan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - For Tai Lam
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
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Minimally invasive versus open distal pancreatectomy: a matched analysis using ACS-NSQIP. Surg Endosc 2023; 37:617-623. [PMID: 35705756 DOI: 10.1007/s00464-022-09363-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 05/22/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) is gaining popularity due to improved perioperative outcomes over open distal pancreatectomy (ODP). The purpose of this study is to compare outcomes of MIDP and ODP using patients within a nationwide cohort. METHODS The American College of Surgeons' National Quality Improvement Program (2014-2018) was used to evaluate incidence of post-operative pancreatic fistula (POPF) as well as 30-day composite major morbidity for patients undergoing MIDP vs. ODP. Matching was performed with a Mahalanobis-distance model for demographic characteristics, preoperative risk factors, and benign versus malignant pathology. Outcomes were assessed via weighted multiple logistic regression. RESULTS A total of 3940 patients underwent distal pancreatectomy (1978 MIDP, 1962 ODP). After matching, 2985 patients were included (1978 MIDP, 1007 ODP). The rates of major morbidity (8.65% MIDP vs. 9.76% ODP, p = 0.37) were similar between groups. The MIDP group was found to have significantly decreased length of stay (5.6 vs. 7 days, p ≤ 0.001), but greater rates (12.54% MIDP vs. 9.35% ODP, p = 0.02) of post-operative fistula. CONCLUSIONS When matched for baseline patient characteristics, MIDP was associated with shorter length of hospitalization with similar rates of morbidity compared to ODP. However, MIDP was associated with significantly increased rates of POPF. Further studies are needed to investigate this difference in POPF rate, and determine how to optimize MIDP surgical technique to reduce this risk.
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Moll X, Fondevila D, García-Arnas F, Burdio F, Trujillo M, Irastorza RM, Berjano E, Andaluz A. Comparison of two radiofrequency-based hemostatic devices: saline-linked bipolar vs. cooled-electrode monopolar. Int J Hyperthermia 2022; 39:1397-1407. [DOI: 10.1080/02656736.2022.2140840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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
| | - Fernando Burdio
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Hospital del Mar, Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Macarena Trujillo
- Department of Applied Mathematics, BioMIT, Universitat Politècnica de València, Valencia, Spain
| | - Ramiro M. Irastorza
- Instituto de Física de Líquidos y Sistemas Biológicos (CONICET), La Plata, Argentina
- Departamento de Ingeniería Mecánica, Universidad Tecnológica Nacional, Facultad Regional La Plata, La Plata, Argentina
| | - Enrique Berjano
- Department of Electronic Engineering, BioMIT, Universitat Politècnica de València, Valencia, Spain
| | - Anna Andaluz
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Barcelona, Spain
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Arnold P, Belchos J, Meagher A, Robbins C, Sparks Joplin T, Ortiz D, Ferries I, Hartwell J. Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication. J Surg Res 2022; 280:35-43. [PMID: 35952555 DOI: 10.1016/j.jss.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence. METHODS Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development. RESULTS Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence. CONCLUSIONS Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.
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Affiliation(s)
- Peter Arnold
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana.
| | - Jessica Belchos
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Ashley Meagher
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Christopher Robbins
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Tasha Sparks Joplin
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Damaris Ortiz
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Sidney & Lois Eskenazi Hospital, Indianapolis, Indiana
| | - Ian Ferries
- Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Jennifer Hartwell
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
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Elkomos BE, Elkomos PE, Salem AA, Adly PB. The outcome of bioabsorbable staple line reinforcement versus standard stapler for distal pancreatectomy: A systematic review and meta-analysis. J Minim Access Surg 2022; 18:338-345. [PMID: 35708377 PMCID: PMC9306122 DOI: 10.4103/jmas.jmas_47_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/15/2022] [Accepted: 04/22/2022] [Indexed: 01/08/2023] Open
Abstract
Background and Aim In the era of minimally invasive procedures and as a way to decrease the incidence of post-operative pancreatic fistula (POPF), the use of staplers for distal pancreatectomy (DP) has increased dramatically. Our aim was to investigate whether reinforced staplers decrease the incidence of clinically relevant PF after DP compared with staplers without reinforcement. Methods PubMed, Scopus, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 November 2021, and a systematic review and a meta-analysis were done to detect the outcomes after using reinforced staplers versus standard stapler for DP. Results Seven studies with a total of 681 patients were included. The overall incidence of POPF and the incidence of Grade A POPF after DP are similar for the two groups (overall POPF, risk ratio [RR] = 0.85, 95% confidence interval [CI] = 0.71-1.01, P = 0.06; I2 = 38% and Grade A POPF, RR = 1.15, 95% CI = 0.78-1.69, P = 0.47; I2 = 49%). However, the incidence of clinically significant POPF (Grades B and C) is significantly lower in DP with reinforced staplers than DP with bare staplers (Grades B and C, RR = 0.45, 95% CI = 0.29-0.71, P = 0.0005; I2 = 17%). Nevertheless, the time of the operation, the blood loss during surgical procedure, the hospital stay after the surgery and the thickness of the pancreas are similar for both techniques. Conclusion Although staple line reinforcement after DP failed to prevent biochemical PF, it significantly reduced the rate of clinically relevant POPF in comparison to standard stapling.
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Affiliation(s)
- Beshoy Effat Elkomos
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
| | | | - Amir Ali Salem
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
| | - Philobater Bhgat Adly
- Department of General Surgery, Faculty of Medicine, Ain Shams University Hospital, Cairo, Egypt
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Pueyo-Périz E, Téllez-Marquès C, Radosevic A, Morató O, Visa L, Ilzarbe L, Berjano E, de Vicente E, Poves I, Ielpo B, Grande L, Burdío F, Sánchez-Velázquez P. Radiofrequency-assisted transection of the pancreas vs stapler in distal pancreatectomy: a propensity score matched cohort analysis. Sci Rep 2022; 12:7486. [PMID: 35523857 PMCID: PMC9076639 DOI: 10.1038/s41598-022-11583-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 04/25/2022] [Indexed: 12/20/2022] Open
Abstract
To demonstrate the efficacy of radiofrequency for pancreatic stump closure in reducing the incidence of postoperative pancreatic fistula (POPF) in distal pancreatectomy (DP) compared with mechanical transection methods. Despite all the different techniques of pancreatic stump closure proposed for DP, best practice for avoiding POPF remains an unresolved issue, with an incidence of up to 30% regardless of center volume or surgical expertise. DP was performed in a cohort of patients by applying radiofrequency to stump closure (RF Group) and compared with mechanical closure (Control Group). A propensity score (PS) matched cohort study was carried out to minimize bias from nonrandomized treatment assignment. Cohorts were matched by PS accounting for factors significantly associated with either undergoing RF transection or mechanical closure through logistic regression analysis. The primary end-point was the incidence of clinically relevant POPF (CR-POPF). Of 89 patients included in the whole cohort, 13 case patients from the RF-Group were 1:1 matched to 13 control patients. In both the first independent analysis of unmatched data and subsequent adjustment to the overall propensity score-matched cohort, a higher rate of CR-POPF in the Control Group compared with the RF-Group was detected (25.4% vs 5.3%, p = 0.049 and 53.8% vs 0%; p = 0.016 respectively). The RF Group showed better outcomes in terms of readmission rate (46.2% vs 0%, p = 0.031). No significant differences were observed in terms of mortality, major complications (30.8% vs 0%, p = 0.063) or length of hospital stay (5.7 vs 5.2 days, p = 0.89). Findings suggest that the RF-assisted technique is more efficacious in reducing CR-POPF than mechanical pancreatic stump closure.
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Affiliation(s)
- E Pueyo-Périz
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain.
| | - C Téllez-Marquès
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - A Radosevic
- Department of Radiology, Hospital del Mar, Passeig Maritim 25-29, Barcelona, Spain
| | - O Morató
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - L Visa
- Department of Oncology, Hospital del Mar-IMIM-CIBERONC, Passeig Maritim 25-29, Barcelona, Spain
| | - L Ilzarbe
- Department of Gastroenterology, Hospital del Mar, Passeig Maritim 25-29, Barcelona, Spain
| | - E Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - E de Vicente
- Department of Surgery, Hospital Sanchinarro, Madrid, Spain
| | - I Poves
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - B Ielpo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - L Grande
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - F Burdío
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain
| | - P Sánchez-Velázquez
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, University Hospital del Mar-IMIM (Hospital del Mar Medical Research Institute), Passeig Maritim 25-29, Barcelona, Spain.
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Qu G, Wang D, Xu W, Wu K, Guo W. The Systemic Inflammation-Based Prognostic Score Predicts Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy. Int J Gen Med 2021; 14:787-795. [PMID: 33727855 PMCID: PMC7955733 DOI: 10.2147/ijgm.s299167] [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: 01/06/2021] [Accepted: 02/22/2021] [Indexed: 01/07/2023] Open
Abstract
Background Although many studies have confirmed the correlation between inflammation-based or nutritional markers and postoperative complications in patients undergoing colorectal cancer surgery, their correlation after undergoing pancreaticoduodenectomy (PD) remains unclear. Methods We retrospectively reviewed the clinical data of patients who underwent PD in Beijing Friendship hospital between 2018 and 2020. Univariate analysis, multivariate analysis, and receiver operating characteristic curve (ROC) were performed. We assessed the preoperative modified Glasgow Prognostic Score (mGPS), C-reactive protein/albumin ratio (CAR), C-reactive protein (CRP), postoperative Glasgow Prognostic Score (poGPS), CRP on postoperative day 3 (POD3) and CAR on POD3. The optimal cut-off values were determined by performing logistic regression analysis. Results Of the 172 patients who underwent PD, 74 (43.0%) developed complications, of whom 27 (15.7%) had clinically relevant postoperative pancreatic fistulas (CR-POPF) and 36 (20.9%) had positive drainage fluid cultures. Elevated levels of preoperative mGPS (P<0.001), poGPS (P<0.001), CRP (P<0.001) and CAR on POD3 were associated with postoperative complications. CRP on POD3 (OR=1.028, 95% CI=1.017-1.039, P<0.001) was an independent risk factor associated with postoperative complications in both univariate and multivariate analyses. CAR on POD 3 showed the largest area under the curve (AUC=0.883, P<0.001). Compared with CAR<4.86, CAR ≥4.86 on POD3 was associated with a higher probability of complications (85.5% vs 14.6%, P<0.001), especially CR-POPF (33.3% vs 4.9%, P<0.001), intra-abdominal infection (36.2% vs 10.7%, P<0.001) with a positive drainage fluid culture. Conclusion CAR, an inflammatory response-based marker, can effectively predict early postoperative complications in patients undergone PD.
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Affiliation(s)
- Guangzhen Qu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Dong Wang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Weiyu Xu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Kai Wu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Wei Guo
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
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Luu AM, Braumann C, Uhl W, Janot-Matuschek M, Herzog T. Does autologous fibrin sealant (vivostat ©) reduce the incidence of postoperative pancreatic fistula after distal pancreatectomy? - a matched pairs analysis. Acta Chir Belg 2021; 121:16-22. [PMID: 31433745 DOI: 10.1080/00015458.2019.1658354] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most common complication following distal pancreatectomy. This retrospective study investigated the effects of autologous fibrin sealant (Vivostat©) in reducing the incidence of POPF after distal pancreatectomy. METHODS A matched pairs analysis was performed to compare the incidence of clinically relevant POPF of 41 patients who underwent a distal pancreatectomy with application of autologous fibrin sealant (Vivostat©) with a historical control group. RESULTS Clinically relevant POPF were present in 11 patients in the study group (27%) and in 13 patients in the control group (32%, p = .639). No patient of the study group required emergency angiographic treatment for postoperative hemorrhage due to POPF, whereas three patients were identified in the control group (7%, p = .079). CONCLUSIONS POPF cannot be prevented under treatment with autologous fibrin sealant (Vivostat©). We observed the tendency of a lower rate of postoperative pancreatic hemorrhage due to POPF. However, prospective randomized controlled studies are required.
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Affiliation(s)
- Andreas Minh Luu
- Department of Surgery, Katholisches Klinikum Bochum – St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Chris Braumann
- Department of Surgery, Katholisches Klinikum Bochum – St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, Katholisches Klinikum Bochum – St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Monika Janot-Matuschek
- Department of Surgery, Katholisches Klinikum Bochum – St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Torsten Herzog
- Department of Surgery, Katholisches Klinikum Bochum – St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Zimmitti G, La Mendola R, Manzoni A, Sega V, Malerba V, Treppiedi E, Codignola C, Monfardini L, Garatti M, Rosso E. Investigation of intraoperative factors associated with postoperative pancreatic fistula following laparoscopic left pancreatectomy with stapled closure: a video review-based analysis : Video-review for predictors of pancreatic leak. Surg Endosc 2020; 35:941-954. [PMID: 32914358 DOI: 10.1007/s00464-020-07912-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) remains the most frequent complication, potential precursor of more serious events, and mechanisms behind POPF development are not clear. Primary aim of the current study is to investigate correlations between patients' characteristics, including technical intraoperative data assessed by retrospective video review of laparoscopic DP (L-PD), and development of clinically relevant (CR-)POPF and major complication. METHODS Patients undergoing L-DP whose surgery video was available for review were included in this study. Retrospective video review, performed by two surgeons blinded for postoperative outcomes, was focused on pancreatic neck transection and identification of pancreatic capsule disruption (PCD)/staple line bleeding (SLB). Correlation between clinical, demographic, and intraoperative factors and CR-POPF/major complications and assessment of factors associated with PCD and SLB were investigated. RESULTS Of 41 L-DP performed at our institution (June 2015-June 2020) using a triple-row stapler (EndoGIA™ Reloads with Tri-Staple™), surgery video was available for 38 patients [men/women, 13/25; median age (range) 62 (25-84) years; median BMI (range) 24 (17-42)]. PCD and SLB occurred in 15(39%) and 19(50%) patients and were concomitant in 9(24%). CR-POPF and major complications occurred in 8(21%) and 12(31%) patients, respectively. PCD, SLB, and PCD + SLB rates were significantly higher among patients with CR-POPF, compared to patients without (all p < 0.05). Among patients with PCD, pancreatic thickness at pancreatic transection site was higher (19 mm), compared to non-PCD patients (13 mm, p < 0.001). A directly proportional relation between PCD, CR-POPF, and major complication rate and pancreatic thickness was confirmed by ROC analysis (AUC = 0.949, 0.798, and 0.740, respectively). CONCLUSION PCD and SLB close to the staple line detected by retrospective video-review are intraoperatively detectable indicators of severe pancreatic traumatism and a potential precursors of CR-POPF following L-PD. Given the strict correlation between PCD and pancreatic thickness, alternative techniques to stapled closure for pancreatic transection may be recommended for patients with a thick pancreas and modification in postoperative care may be considered in patients with PCD/SLB.
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Affiliation(s)
- Giuseppe Zimmitti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy.
| | - Roberta La Mendola
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Valentina Sega
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Valentina Malerba
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Elio Treppiedi
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Claudio Codignola
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Lorenzo Monfardini
- Department of Radiology, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Marco Garatti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Edoardo Rosso
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
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Miao Y, Lu Z, Yeo CJ, Vollmer CM, Fernandez-Del Castillo C, Ghaneh P, Halloran CM, Kleeff J, de Rooij T, Werner J, Falconi M, Friess H, Zeh HJ, Izbicki JR, He J, Laukkarinen J, Dejong CH, Lillemoe KD, Conlon K, Takaori K, Gianotti L, Besselink MG, Del Chiaro M, Montorsi M, Tanaka M, Bockhorn M, Adham M, Oláh A, Salvia R, Shrikhande SV, Hackert T, Shimosegawa T, Zureikat AH, Ceyhan GO, Peng Y, Wang G, Huang X, Dervenis C, Bassi C, Neoptolemos JP, Büchler MW. Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2020; 168:72-84. [PMID: 32249092 DOI: 10.1016/j.surg.2020.02.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
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Affiliation(s)
- Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China.
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jörg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Keith D Lillemoe
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Montorsi
- Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, HCL, UCBL1, Lyon, France
| | | | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Güralp O Ceyhan
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Yunpeng Peng
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Guangfu Wang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xumin Huang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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11
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Bashir MU, Kandilis A, Jackson NM, Parikh JA, Jacobs MJ. Distal pancreatectomy outcomes: Perspectives from a community-based teaching institution. Ann Hepatobiliary Pancreat Surg 2020; 24:156-161. [PMID: 32457260 PMCID: PMC7271100 DOI: 10.14701/ahbps.2020.24.2.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 12/14/2022] Open
Abstract
Backgrounds/Aims Distal pancreatic resections are intricate operations with potential for significant morbidity; there is controversy surrounding the appropriate setting regarding surgeon/hospital volume. We report our distal pancreatectomy experience from a community-based teaching hospital. Methods This study includes all patients who underwent laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and malignant lesions between June 2004 and October 2017. Both groups were compared for perioperative characteristics, parenchymal resection technique, and outcomes. Results 138 patients underwent distal pancreatectomy during this time. The distribution of LDP and ODP was 68 and 70 respectively. Operative time (146 vs. 174 min), blood loss (139 vs. 395 ml) and mean length of stay (4.8 vs. 8.0 days) were significantly lower in the laparoscopic group. The 30-day Clavien Grade 2/3 morbidity rate was 13.7% (19/138) and the incidence of Grade B/C pancreatic fistula was 6.5% (9/138), with no difference between ODP and LDP. 30-day mortality was 0.7% (1/138). 61/138 resections had a malignancy on final pathology. ODP mean tumor diameter was greater (6.4 cm vs. 2.9 cm), but there was no significant difference in the mean number of harvested nodes (8.6 vs. 7.4). The cost of hospitalization, including readmissions and surgery was significantly lower for LDP ($7558 vs. $11610). Conclusions This series of distal pancreatectomies indicates a shorter hospital stay, less operative blood loss and reduced cost in the LDP group, and comparable morbidity and oncologic outcomes between LDP and ODP. It highlights the feasibility and safety of these complex surgeries in a community setting.
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Affiliation(s)
- Muhammad Umair Bashir
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Apostolos Kandilis
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Nancy M Jackson
- Department of Research, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Janak A Parikh
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Michael J Jacobs
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
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12
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Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection. J Trauma Acute Care Surg 2020; 87:1289-1300. [PMID: 31765347 DOI: 10.1097/ta.0000000000002495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared with elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP. METHODS A retrospective, single-institution review of all patients undergoing DP from 1999 to 2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analyses were performed using SAS (version 9.4). RESULTS Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17 (44.7%) of 38 TDPs compared with 41 (15.8%) of 260 EDPs (p < 0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (odds ratio, 4.3; 95% confidence interval, 2.10-8.89). Age, sex, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs. elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared with elective DP (odds ratio, 8.6; 95% confidence interval, 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP. CONCLUSION To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic versus elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP. LEVEL OF EVIDENCE Prognostic study, Therapeutic, level III.
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13
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The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection. Ann Surg 2020; 271:1-14. [PMID: 31567509 DOI: 10.1097/sla.0000000000003590] [Citation(s) in RCA: 280] [Impact Index Per Article: 70.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.
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14
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Kauffmann EF, Napoli N, Cacace C, Menonna F, Vistoli F, Amorese G, Boggi U. Resection or repair of large peripancreatic arteries during robotic pancreatectomy. Updates Surg 2020; 72:145-153. [DOI: 10.1007/s13304-020-00715-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
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15
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Shen J, Zhang Y, Hu J, Wei R, Wu H. Albumin difference as a new predictor of pancreatic fistula following distal pancreatectomy: a retrospective study of 211 consecutive patients. Langenbecks Arch Surg 2020; 405:55-62. [PMID: 31900605 DOI: 10.1007/s00423-019-01849-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/11/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The level of albumin declines after surgery, and whether the difference between preoperative and postoperative albumin levels on postoperative day 1 has an effect on the development of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is unclear. Our aim was to evaluate the effect of albumin difference on POPF. METHODS A retrospective analysis of consecutive patients who had undergone DP between January 2016 and October 2018 at a single institution was conducted. Patient demographic data and perioperative data were analysed using univariate and multivariate models. Pancreatic fistula was defined by the 2016 International Study Group of Pancreatic Surgery criteria. All patients were followed for up to 90 days. RESULTS A total of 211 consecutive patients were identified. The POPF rate was 15.64%, and no 90-day mortality was observed. Five predictors were independently associated with POPF: albumin difference (OR 6.60, 95% CI 2.36-18.45, P < 0.001), pancreatic texture (OR 4.15, 95% CI 1.62-10.63, P = 0.003), operative time (OR 3.13, 95% CI 1.19-8.24, P = 0.021), intraoperative fluid transfusion (OR 4.85, 95% CI 1.70-13.79, P = 0.003), and cardiovascular disease (OR 5.38, 95% CI 1.99-14.55, P = 0.001). CONCLUSIONS Although DP can be performed with a low rate of mortality, POPF remains a common complication. Albumin difference is a new, accessible predictor for POPF following DP.
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Affiliation(s)
- Jian Shen
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China
| | - Yushun Zhang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China
| | - Jin Hu
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruozheng Wei
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China.
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16
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Maatman TK, Butler JR, Quigley SN, Loncharich AJ, Crafts T, Ceppa EP, Nakeeb A, Schmidt CM, Zyromski NJ, House MG. Leukocytosis after distal pancreatectomy and splenectomy as a marker of major complication. Am J Surg 2019; 220:354-358. [PMID: 31848020 DOI: 10.1016/j.amjsurg.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to analyze the associations between the degree of postoperative leukocytosis and major morbidity after elective distal pancreatectomy with splenectomy (DPS). METHODS Retrospective review of patients undergoing DPS for pancreatic diseases (2013-2016). Receiver operating characteristic curves, Youden's index, and area under the curve were used to identify ideal lab cut-off values and discriminatory ability of postoperative white blood cell count to detect complications. RESULTS 158 patients underwent DPS. Median age was 57 years (range, 22-90) and 53% of patients were male. POD3 absolute WBC count ≥16 × 109/L or an increase in WBC count ≥9 × 109/L from preoperative baseline was associated with major morbidity after DPS (AUC 0.7 and 0.7, respectively). CONCLUSION Postoperative day three leukocytosis ≥16 × 109/L or an increase in WBC of ≥9 × 109/L from preoperative baseline should raise clinical awareness for major postoperative complication after DPS.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. https://twitter.com/maatman_tom
| | - James R Butler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephen N Quigley
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Trevor Crafts
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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17
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Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group. Ann Surg 2019; 269:143-149. [PMID: 28857813 DOI: 10.1097/sla.0000000000002491] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.
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18
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Chikhladze S, Makowiec F, Küsters S, Riediger H, Sick O, Fichtner-Feigl S, Hopt UT, Wittel UA. The rate of postoperative pancreatic fistula after distal pancreatectomy is independent of the pancreatic stump closure technique - A retrospective analysis of 284 cases. Asian J Surg 2019; 43:227-233. [PMID: 30982560 DOI: 10.1016/j.asjsur.2019.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Many techniques have been developed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy, but POPF rates remain high. The aim of our study was to analyze POPF occurrence after closure of the pancreatic remnant by different operative techniques. METHODS Between 2006 and 2017, 284 patients underwent distal pancreatectomy in our institution. For subgroup analysis the patients were divided into hand-sewn (n = 201) and stapler closure (n = 52) groups. The hand-sewn closure was performed in three different ways (fishmouth-technique, n = 27; interrupted transpancreatic U-suture technique, n = 77; common interrupted suture, n = 97). All other techniques were summarized in a separate group (n = 31). Results were gained by analysis of our prospective pancreatic database. RESULTS The median age was 63 (range 23-88) years. 74 of 284 patients (26%) were operated with spleen preservation (similar rates in subgroups). ASA-classes, median BMI as well as frequencies of malignant diseases, chronic pancreatitis, alcohol and nicotine abuse were also comparable in the subgroups. Neither the rates of overall POPF (fishmouth-technique 30%, common interrupted suture 40%, stapler closure 33% and interrupted U-suture 38%) nor the rates of POPF grades B and C showed significant differences in the subgroups. However is shown to be associated with pancreatic function and parenchymal texture. CONCLUSION In our experience the technique of pancreatic stump closure after distal resection did not influence postoperative pancreatic fistula rate. As a consequence patient specific reasons rather than surgical techniques may be responsible for POPF formation after distal pancreatectomy.
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Affiliation(s)
- S Chikhladze
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany.
| | - F Makowiec
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
| | - S Küsters
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
| | - H Riediger
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
| | - O Sick
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
| | - S Fichtner-Feigl
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
| | - U T Hopt
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
| | - U A Wittel
- Medical Center - University of Freiburg, Center for Surgery, Department of General and Visceral Surgery, Germany
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19
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Abstract
Postoperative pancreatic fistula (POPF) is the most common and also the most threatening complication following distal pancreatectomy. For this reason, morbidity and mortality of this operation remain still high. Over the last two decades, many different studies have been performed aiming to reduce the rate and the severity of POPF. However, effective treatments to prevent or avoid clinically relevant pancreatic fistula are still unclear. In this review, we discuss the current evidence on such a relevant topic.
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Affiliation(s)
- Fabio Ausania
- HPB and Transplant Surgery, Clinic Hospital, Barcelona, Spain -
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20
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Minarich MJ, Schwarz RE. Simplicity and Safety: Minimized Pancreatic Fistula Rate after Distal Pancreatectomy through Pancreas Stump Sutured Fish-Mouth Closure. Am Surg 2018. [DOI: 10.1177/000313481808401127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pancreatic stump leak after distal pancreatectomy (DP) is a major determinant for impaired postoperative recovery. Factors influencing pancreatic fistula (PF) occurrence remain of interest. Prospectively collected data from an academic surgical oncology practice were examined for predictors of PF. Seventy-five of 294 pancreatectomy patients underwent DP (26%). There were 33 men and 42 women, with a median age of 61 years (range: 18–85 years). Underlying conditions included cancer (60%) and benign processes (40%). Resections were comprising open DP (64%), laparoscopic DP (21%), and open multivisceral resections (15%). Of 21 cases with postoperative complications (28%, no death), six were PFs (8%, 2 grade A and 4 grade B). The median length of stay was six days (4–24). The PF rate was 2.0 per cent in 50 patients after sutured fish-mouth closures, but 20 per cent in cases using other techniques including stapling ( P = 0.007); no other variable was linked to PF occurrence. Length of stay was linked to complications, resection extent, malignancy, and transfusions (all at P < 0.02), but not to PF. PF rate after DP in this experience is unaffected by splenic vessel resection but seems to be minimized through a sutured fish-mouth closure technique.
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Affiliation(s)
| | - Roderich E. Schwarz
- Department of Surgery, Indiana University School of Medicine, South Bend, Indiana
- Goshen Center for Cancer Care, Goshen, Indiana
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21
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Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience. PLoS One 2018; 13:e0197553. [PMID: 29897920 PMCID: PMC5999073 DOI: 10.1371/journal.pone.0197553] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 05/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP. Methods We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques. Results 8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02). Conclusion After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.
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Kowalsky SJ, Zenati MS, Dhir M, Schaefer EG, Dopsovic A, Lee KK, Hogg ME, Zeh HJ, Vollmer CM, Zureikat AH. Postoperative narcotic use is associated with development of clinically relevant pancreatic fistulas after distal pancreatectomy. Surgery 2018; 163:747-752. [DOI: 10.1016/j.surg.2017.10.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/02/2017] [Accepted: 10/24/2017] [Indexed: 02/08/2023]
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Volk A, Distler M, Müssle B, Berning M, Hampe J, Brückner S, Weitz J, Welsch T. Reproducibility of preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula. Innov Surg Sci 2018; 3:69-75. [PMID: 31579768 PMCID: PMC6754046 DOI: 10.1515/iss-2017-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/04/2018] [Indexed: 01/08/2023] Open
Abstract
Background A postoperative pancreatic fistula (POPF) is the most common and potentially life-threatening surgical complication in pancreatic surgery. One possible pharmacological treatment could be the endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi to prevent POPF. Promising data reported a significantly reduced rate of clinically relevant POPF. We analyzed the effect of BTX injection in our patients undergoing distal pancreatectomy (DP). Methods A retrospective analysis of patients undergoing DP was performed. Patients with preoperative endoscopic injection of BTX into the sphincter of Oddi were included. The end points were postoperative outcomes including POPF. BTX patients were compared with a historical cohort and matched in a 1:1 ratio using a propensity score analysis. Results A total of 19 patients were treated with endoscopic injection of BTX before open (n=8) or laparoscopic (n=11) DP. The median age of the patients was 67 years and the mean body mass index was 25.9 kg/m2. In median, the intervention was performed 1 day (range, 0–14 days) before the operation. There were no intervention-related complications. The incidence of POPF was not statistically different between the two groups: a clinically relevant POPF grade (B/C) occurred in 32% (BTX) and 42% (control; p=0.737). Likewise, there were no significant differences in postoperative drain fluid amylase levels, morbidity, and mortality. Conclusion The present study could not reproduce the published results of a significant lowering of grade B/C POPF. The explanations could be the timing of BTX injection before surgery and the endoscopic technique of BTX injection. However, the conflicting results after BTX injection in two high-volume centers prompt a randomized controlled multicenter trial with trained endoscopists.
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Affiliation(s)
- Andreas Volk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marco Berning
- Department of Internal Medicine, Section of Gastroenterology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Hampe
- Department of Internal Medicine, Section of Gastroenterology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan Brückner
- Department of Internal Medicine, Section of Gastroenterology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Dresden, Fetscherstraße 74, 01307 Dresden, Germany
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Kawai M, Hirono S, Okada KI, Satoi S, Yanagimoto H, Kon M, Murakami Y, Kondo N, Sho M, Akahori T, Toyama H, Fukumoto T, Fujii T, Matsumoto I, Eguchi H, Ikoma H, Takeda Y, Fujimoto J, Yamaue H. Reinforced staplers for distal pancreatectomy. Langenbecks Arch Surg 2017; 402:1197-1204. [PMID: 29103084 DOI: 10.1007/s00423-017-1634-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 10/13/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE The safety and efficacy of reinforced staplers during distal pancreatectomy (DP) remain controversial because of the small sample size. This multicenter single-arm prospective study aims to evaluate the safety and efficacy of reinforced staplers with bioabsorbable material during DP. METHODS Between October 2014 and August 2015, 121 patients scheduled for DP were enrolled in this study at 11 institutions in Japan. The primary endpoint was the incidence of clinically relevant pancreatic fistula. Protocol treatment was defined as "distal pancreatectomy using reinforced staplers." RESULTS Per-protocol analysis of 105 patients was performed; 16 of the patients were excluded based on discontinuation of protocol treatment criteria. Clinically relevant pancreatic fistula occurred in 13 (12.4%) of 105 patients. The overall morbidity rate was 29.5% (31 of 105 patients) and severe complication (Clavien classification IIIa or more) was 10.5% (11/105). Mortality rate was 0%, although reoperations were performed on two patients (1.9%). Multivariate logistic regression analysis of independent risk factors for clinically relevant pancreatic fistula after DP using reinforced stapler closure was operative time more than 240 min (P = 0.047, odds ratio 5.79), registration numbers less than 10 (P = 0.046, odds ratio 13.01), and staple line hemorrhage (P = 0.003, odds ratio 16.34). CONCLUSION This study confirms the safety of reinforced staplers for pancreatic stump closure during DP. However, the efficacy of reinforced staplers for decreasing clinically relevant pancreatic fistula could not be drawn from this study. TRIAL REGISTRATION This prospective study was registered with ClinicalTrials.gov (NCT02270554) and UMIN Clinical Trial Registry (UMIN000015384).
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Affiliation(s)
- Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | | | - Masanori Kon
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naru Kondo
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ippei Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kindai University, Higashi-osaka, Japan
| | - Hidetoshi Eguchi
- Department of Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yutaka Takeda
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - Jiro Fujimoto
- Department of Hepato-Biliary-Pancreatic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
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Valente R, Lykoudis P, Tamburrino D, Inama M, Passas I, Toumpanakis C, Luong TV, Davidson B, Imber C, Malagò M, Rahman SH, Shankar A, Sharma D, Caplin M, Fusai G. Major postoperative complications after pancreatic resection for P-NETS are not associated to earlier recurrence. Eur J Surg Oncol 2017; 43:2119-2128. [PMID: 28821361 DOI: 10.1016/j.ejso.2017.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The oncological impact of surgical complications has been studied in visceral and pancreatic cancer. AIM To investigate the impact of complications on tumour recurrence after resections for pancreatic neuroendocrine tumours. METHODS We have retrospectively analysed 105 consecutive resections performed at the Royal Free London Hospital from 1998 to 2014, and studied the long-term outcome of nil-minor (<3) versus major (≥3) Clavien-Dindo complications (CD) on disease-free (DFS) and overall survival (OS). RESULTS The series accounted for 41 (39%) pancreaticoduodenectomies, two (1.9%) central, 48 (45.7%) distal pancreatectomies, eight (7.6%) enucleations, four (3.8%) total pancreatectomies. Sixteen (15.2%) were extended to adjacent organs, 13 (12.3%) to minor liver resections. Postoperative complications presented in 43 (40.1%) patients; CD grade 1 or 2 in 23 (21.9%), grades ≥3 in 20 (19%). Among 25 (23.8%) pancreatic fistulas, 14 (13.3%) were grades B or C. Thirty-four (32.4%) patients developed exocrine, and 31 (29.5%) endocrine insufficiency. Seven patients died during a median 27 (0-175) months follow up. Thirty-day mortality was 0.9%. OS was 94.1% at 5 years. Thirty tumours recurred within 11.7 (0.8-141.5) months. DFS was 44% at 5 years. At univariate analysis, high-grade complications were not associated with shorter DFS (p = 0.744). At multivariate analysis, no parameter was independent predictor for DFS or OS. The comparison of nil-minor versus major complications showed no DFS difference (p = 0.253). CONCLUSION From our series, major complications after P-NETs resection are not associated to different disease recurrence; hence do not require different follow up or adjuvant regimens.
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Affiliation(s)
- R Valente
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK; Hepatopancreatobiliary Service, Barts Health NHS Trust, The Royal London Hospital, E1 1BZ, UK.
| | - P Lykoudis
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - D Tamburrino
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - M Inama
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - I Passas
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - C Toumpanakis
- Neuroendocrine Tumour Unit, Royal Free and University College London, NW32QG, UK
| | - T V Luong
- Histopathology Unit, Royal Free and University College London, NW32QG, UK
| | - B Davidson
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - C Imber
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - M Malagò
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - S H Rahman
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - A Shankar
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - D Sharma
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
| | - M Caplin
- Neuroendocrine Tumour Unit, Royal Free and University College London, NW32QG, UK
| | - G Fusai
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery, Royal Free and University College London, NW32QG, UK
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Ikeguchi M, Hanaki T, Endo K, Suzuki K, Nakamura S, Sawata T, Shimizu T. C-Reactive Protein/Albumin Ratio and Prognostic Nutritional Index Are Strong Prognostic Indicators of Survival in Resected Pancreatic Ductal Adenocarcinoma. J Pancreat Cancer 2017. [DOI: 10.1089/crpc.2017.0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Masahide Ikeguchi
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Takehiko Hanaki
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kanenori Endo
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kazunori Suzuki
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Seiichi Nakamura
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Takashi Sawata
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Tetsu Shimizu
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
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Ikeguchi M, Hanaki T, Endo K, Suzuki K, Nakamura S, Sawata T, Shimizu T. C-Reactive Protein/Albumin Ratio and Prognostic Nutritional Index Are Strong Prognostic Indicators of Survival in Resected Pancreatic Ductal Adenocarcinoma. J Pancreat Cancer 2017; 3:31-36. [PMID: 30631838 PMCID: PMC5933481 DOI: 10.1089/pancan.2017.0006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose: We evaluated the clinical importance, such as the occurrence of postoperative pancreatic fistula (POPF) or prognosis, of preoperative serum markers of chronic inflammation, nutrition, and immunity, as well as that of serum tumor markers after curative resection of pancreatic ductal adenocarcinomas (PDACs). Methods: Between 2006 and 2015, 43 patients with PDACs underwent curative resection at Tottori Prefectural Central Hospital. We analyzed which preoperative indicators (i.e., C-reactive protein/albumin ratio [CAR], neutrophil/lymphocyte ratio [NLR], prognostic nutritional index [PNI], carcinoembryonic antigen [CEA], and carbohydrate antigen 19-9 [CA 19-9]) were the most relevant risk factors for occurrence of POPF and poor patient survival. Results: POPF was detected in 8/43 (18.6%) patients. One patient died of pancreatic fistula at 2 months postoperatively. Among nine candidate factors (operative procedure, operation time, tumor stage, preoperative serum amylase, preoperative CAR, NLR, PNI, CEA, and CA 19-9), we did not identify any significant risk factor for the occurrence of POPF. The 5-year overall survival (OS) rate of the 43 patients was 22.4%, and the overall median survival time was 21 months. The multivariate OS analysis demonstrated that high CAR and low PNI were strong preoperative markers of poor prognosis independently of tumor stage. Conclusions: Preoperative CAR and PNI are useful prognostic markers for patients with operable PDACs.
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Affiliation(s)
- Masahide Ikeguchi
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Takehiko Hanaki
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kanenori Endo
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Kazunori Suzuki
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Seiichi Nakamura
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Takashi Sawata
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Tetsu Shimizu
- Department of Surgery, Tottori Prefectural Central Hospital, Tottori, Japan
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Bauman MD, Becerra DG, Kilbane EM, Zyromski NJ, Schmidt CM, Pitt HA, Nakeeb A, House MG, Ceppa EP. Laparoscopic distal pancreatectomy for pancreatic cancer is safe and effective. Surg Endosc 2017. [PMID: 28643065 DOI: 10.1007/s00464-017-5633-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To compare the short-term and oncologic outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP). METHODS Consecutive cases of distal pancreatectomy (DP) (n = 422) were reviewed at a single high-volume institution over a 10-year period (2005-2014). Inclusion criteria consisted of any patient with PDAC by surgical pathology. Ninety-day outcomes were monitored through a prospectively maintained pancreatic resection database. The Social Security Death Index was used for 5-year survival. Two-way statistical analyses were used to compare categories; variance was reported with standard error of the mean; * indicates P value <0.05. RESULTS Seventy-nine patients underwent DP for PDAC. Thirty-three underwent LDP and 46 ODP. There were no statistical differences in demographics, BMI, and ASA classification. Intraoperative and surgical pathology variables were comparable for LDP versus ODP: operative time (3.9 ± 0.2 vs. 4.2 ± 0.2 h), duct size, gland texture, stump closure, tumor size (3.3 ± 0.3 vs. 4.0 ± 0.4 cm), lymph node harvest (14.5 ± 1.1 vs. 17.5 ± 1.2), tumor stage (see table), and negative surgical margins (77 vs. 87%). Patients who underwent LDP experienced lower blood loss (310 ± 68 vs. 597 ± 95 ml; P = 0.016*) and required fewer transfusions (0 vs. 13; P = 0.0008*). Patients who underwent LDP had fewer positive lymph nodes (0.8 ± 0.2 vs. 1.6 ± 0.3; P = 0.04*) and a lower incidence of type C pancreatic fistula (0 vs. 13%; P = 0.03*). Median follow-up for all patients was 11.4 months. Long-term oncologic outcomes revealed similar outcomes including distant or local recurrence (30 vs. 52%; P = 0.05) and median survival (18 vs. 15 months), as well as 1-year (73 vs. 59%), 3-year (22 vs. 21%), and 5-year (20 vs. 15%) survival for LDP and ODP, respectively. CONCLUSIONS The results of this series suggest that LDP is a safe surgical approach that is comparable from an oncologic standpoint to ODP for the management of pancreatic adenocarcinoma.
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Affiliation(s)
- Marita D Bauman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA.
| | - David G Becerra
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - E Molly Kilbane
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Henry A Pitt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
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Teres Ligament Patch Reduces Relevant Morbidity After Distal Pancreatectomy (the DISCOVER Randomized Controlled Trial). Ann Surg 2017; 264:723-730. [PMID: 27455155 DOI: 10.1097/sla.0000000000001913] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the impact of teres ligament covering on pancreatic fistula rate after distal pancreatectomy (DP). BACKGROUND Postoperative pancreatic fistula (POPF) represents the most significant complication after DP. Retrospective studies suggested a benefit of covering the resection margin by a teres ligament patch. METHODS This prospective randomized controlled study (DISCOVER trial) included 152 patients undergoing DP, between October 2010 and July 2014. Patients were randomized to undergo closure of the pancreatic cut margin without (control, n = 76) or with teres ligament coverage (teres, n = 76). The primary endpoint was the rate of POPF, and the secondary endpoints included postoperative morbidity and mortality, length of hospital stay, and readmission rate. RESULTS Both groups were comparable regarding epidemiology (age, sex, body mass index), operative parameters (operation time [OP] time, blood loss, method of pancreas transection, additional operative procedures), and histopathological findings. Overall inhospital mortality was 0.6% (1/152 patients). In the group of patients with teres ligament patch, the rate of reoperations (1.3% vs 13.0%; P = 0.009), and also the rate of readmission (13.1 vs 31.5%; P = 0.011) were significantly lower. Clinically relevant POPF rate (grade B/C) was 32.9% (control) versus 22.4% (teres, P = 0.20). Multivariable analysis showed teres ligament coverage to be a protective factor for clinically relevant POPF (P = 0.0146). CONCLUSIONS Coverage of the pancreatic remnant after DP is associated with less reinterventions, reoperations, and need for readmission. Although the overall fistula rate is not reduced by the coverage procedure, it should be considered as a valid measure for complication prevention due to its clinical benefit.
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Comparison of surgical outcomes of three different stump closure techniques during distal pancreatectomy. Pancreatology 2017; 17:497-503. [PMID: 28411019 DOI: 10.1016/j.pan.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/11/2017] [Accepted: 04/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND To find the appropriate method of pancreatic transection during distal pancreatectomy (DP), we retrospectively compared post-operative complications including postoperative pancreatic fistula (POPF) according to the different types of pancreatic transection. METHODS This study included 169 patients who underwent pancreatic transection using an ultrasonic activated device (USAD) with transfixion of the pancreatic duct (DP-TF group, n = 89), USAD followed by pancreaticogastrostomy (DP-PG group, n = 44), and a reinforced linear tristapler (DP-ST, n = 36). RESULTS Overall and POPF-related complications in DP-PG group, and delayed gastric emptying (DGE) in DP-ST group were significantly lower than DP-TF group. There were no significant difference in overall complication, length of hospitalization and operative costs between DP-PG and DP-ST groups. Operative time was significantly longer in DP-PG group than others. CONCLUSION Both DP-PG and DP-ST are associated with better surgical outcomes. Regarding ease of surgical technique, shorter operative times, and similar medical costs, DP with a reinforced linear tristapler is a good choice during DP.
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A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review. Am J Gastroenterol 2017; 112:537-554. [PMID: 28139655 PMCID: PMC5659272 DOI: 10.1038/ajg.2016.610] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/01/2016] [Indexed: 12/11/2022]
Abstract
In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.
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32
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Attempts to prevent postoperative pancreatic fistula after distal pancreatectomy. Surg Today 2016; 47:416-424. [DOI: 10.1007/s00595-016-1367-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023]
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33
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Burdío F, Dorcaratto D, Hernandez L, Andaluz A, Moll X, Quesada R, Poves I, Grande L, Cáceres M, Berjano E. Radiofrequency-induced heating versus mechanical stapler for pancreatic stump closure: in vivo comparative study. Int J Hyperthermia 2016; 32:272-80. [PMID: 26821683 DOI: 10.3109/02656736.2015.1136845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The aim of this study was to assess the capacity of two methods of surgical pancreatic stump closure in terms of reducing the risk of pancreatic fistula formation (POPF): radiofrequency-induced heating versus mechanical stapler. MATERIALS AND METHODS Sixteen pigs underwent a laparoscopic transection of the neck of the pancreas. Pancreatic anastomosis was always avoided in order to work with an experimental model prone to POPF. Pancreatic stump closure was conducted either by stapler (ST group, n = 8) or radiofrequency energy (RF group, n = 8). Both groups were compared for incidence of POPF and histopathological alterations of the pancreatic remnant. RESULTS Six animals (75%) in the ST group and one (14%) in the RF group were diagnosed with POPF (p = 0.019). One animal in the RF group and three animals in the ST group had a pseudocyst in close contact with both pancreas stumps. On day 30 post-operation (PO), almost complete atrophy of the exocrine distal pancreas was observed when the main pancreatic duct was efficiently sealed. CONCLUSIONS Our findings suggest that RF-induced heating is more effective at closing the pancreatic stump than mechanical stapler and leads to the complete atrophy of the distal remnant pancreas.
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Affiliation(s)
- Fernando Burdío
- a Department of Surgery , Hospital del Mar , Barcelona , Spain
| | - Dimitri Dorcaratto
- b Department of Surgery , St Vincent's University Hospital , Dublin , Ireland
| | | | - Anna Andaluz
- c Departament de Medicina i Cirurgia Animals , Facultat de Veterinària, Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - Xavier Moll
- c Departament de Medicina i Cirurgia Animals , Facultat de Veterinària, Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - Rita Quesada
- d Fundación Instituto Mar de Investigaciones Médicas , Barcelona , Spain
| | - Ignasi Poves
- a Department of Surgery , Hospital del Mar , Barcelona , Spain
| | - Luis Grande
- a Department of Surgery , Hospital del Mar , Barcelona , Spain
| | | | - Enrique Berjano
- f Biomedical Synergy, Electronic Engineering Department, Universitat Politècnica de València , Valencia , Spain
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Beane JD, House MG, Pitt SC, Kilbane EM, Hall BL, Parmar AD, Riall TS, Pitt HA. Distal pancreatectomy with celiac axis resection: what are the added risks? HPB (Oxford) 2015; 17. [PMID: 26201994 PMCID: PMC4557651 DOI: 10.1111/hpb.12453] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Reported series of a distal pancreatectomy with celiac axis resection (DP-CAR) are either small or not adequately controlled. The aim of this analysis was to report a multicentre series of modified Appleby procedures with a comparison group to determine the relative operative risk. METHODS Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project. Over 14 months, 822 patients underwent a distal pancreatectomy at 43 institutions. Twenty of these patients (2.4%) also underwent a celiac axis resection. DP-CAR patients were matched by age, gender, BMI, serum albumin, ASA class, gland texture, duct size and pathology to 172 patients undergoing DP alone. RESULTS The majority of DP and DP-CAR patients had adenocarcinomas (61% and 60%). The median operative time for a DP alone was shorter than for a DP-CAR (207 versus 276 min, P < 0.01). Post-operative acute kidney injury (1% versus 10%, P < 0.03) and 30-day mortality were higher after a DP-CAR (1% versus 10%, P < 0.03). CONCLUSION A distal pancreatectomy with celiac axis resection is associated with increased operative time, post-operative acute kidney injury and a 10% operative mortality. The decision to offer a modified Appleby procedure for a body of pancreas tumour should be made with full disclosure of the increased risks.
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Affiliation(s)
- Joal D Beane
- Department of Surgery, Indiana University School of MedicineIndianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of MedicineIndianapolis, IN, USA
| | - Susan C Pitt
- Washington University School of MedicineSt. Louis, MO, USA
| | - E Molly Kilbane
- Department of Surgery, Indiana University School of MedicineIndianapolis, IN, USA
| | - Bruce L Hall
- Washington University School of MedicineSt. Louis, MO, USA
| | | | | | - Henry A Pitt
- Temple University School of MedicinePhiladelphia, PA, USA
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