In Patients with a Soft Pancreas, a Thick Parenchyma, a Small Duct, and Fatty Infiltration Are Significant Risks for Pancreatic Fistula After Pancreaticoduodenectomy

Impact of pancreatic ductal occlusion on postoperative outcomes in pancreatic head cancer patients undergoing neoadjuvant therapy

BACKGROUND

Pancreatic ductal occlusion can accompany pancreatic head cancer, leading to pancreatic exocrine insufficiency (PEI) and adverse effects on nutritional status and postoperative outcomes. We investigated its impact on nutritional status, body composition, and postoperative outcomes in patients with pancreatic head cancer undergoing neoadjuvant therapy (NAT).

METHODS

We analyzed 136 patients with pancreatic head cancer who underwent NAT prior to intended pancreaticoduodenectomy (PD) between 2015 and 2022. Nutritional and anthropometric indices (body mass index [BMI], albumin, prognostic nutritional index [PNI], Glasgow prognostic score, psoas muscle index, subcutaneous adipose tissue index [SATI], and visceral adipose tissue index) and postoperative outcomes were compared between the occlusion (n = 78) and non-occlusion (n = 58) groups, in which 61 and 44 patients, respectively, ultimately underwent PD.

RESULTS

The occlusion group showed significantly lower post-NAT BMI, PNI, and SATI (p = 0.011, 0.005, and 0.015, respectively) in the PD cohort. The occlusion group showed significantly larger main pancreatic duct, smaller pancreatic parenchyma, and greater duct-parenchymal ratio (p < 0.001), and these morphological parameters significantly correlating with post-NAT nutritional and anthropometric indices. Postoperative 3-year survival and recurrence-free survival (RFS) rates were significantly poorer (p = 0.004 and 0.013) with pancreatic ductal occlusion, also identified as an independent postoperative risk factor for overall survival (hazard ratio [HR]: 2.31, 95% confidence interval [CI] 1.08-4.94, p = 0.030) and RFS (HR: 2.03, 95% CI 1.10-3.72, p = 0.023), in multivariate analysis.

CONCLUSIONS

Pancreatic ductal occlusion may be linked to poorer postoperative outcomes due to PEI-related malnutrition.

Risk factors of textbook outcome in laparoscopic pancreatoduodenectomy: results from a prospective high-volume center study

OBJECTIVE

Achieving textbook outcome (TO) implies a smooth recovery post-operation without specified composite complications. This study aimed to evaluate TO in laparoscopic pancreaticoduodenectomy (LPD) and identify independent risk factors associated with achieving TO.

METHODS

We conducted a retrospective analysis of data from a randomized controlled trial on LPD at West China Hospital (ChiCTR1900026653). Patients were categorized into the TO and non-TO groups. Perioperative variables were compared between these groups. Multivariate logistic regression was utilized to identify the risk factors.

RESULTS

A total of 200 consecutive patients undergoing LPD were included in this study. TO was achieved in 82.5% (n = 165) of the patients. Female patients (OR: 2.877, 95% CI: 1.219-6.790; P = 0.016) and those with a hard pancreatic texture (OR: 2.435, 95% CI: 1.018-5.827; P = 0.046) were associated with an increased likelihood of achieving TO.

CONCLUSIONS

TO can be achieved in more than 80% of patients in a high-volume LPD center. Independent risk factors associated with achieving TO included gender (male) and pancreatic texture (soft).

A Comparison of Preoperative Predictive Scoring Systems for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy Based on a Single-Center Analysis

Background: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is associated with major postoperative morbidity and mortality. Several scoring systems have been described to stratify patients into risk groups according to the risk of POPF. The aim of this study was to compare scoring systems in patients who underwent a PD. Methods: A total of 196 patients undergoing PD from July 2019 to June 2022 were identified from a prospectively maintained database of the University Hospital Ghent. After performing a literature search, four validated, solely preoperative risk scores and the intraoperative Fistula Risk Score (FRS) were included in our analysis. Furthermore, we eliminated the variable blood loss (BL) from the FRS and created an additional score. Univariate and multivariate analyses were performed for all risk factors, followed by a ROC analysis for the six scoring systems. Results: All scores showed strong prognostic stratification for developing POPF (p < 0.001). FRS showed the best predictive accuracy in general (AUC 0.862). FRS without BL presented the best prognostic value of the scores that included solely preoperative variables (AUC 0.783). Soft pancreatic texture, male gender, and diameter of the Wirsung duct were independent prognostic factors on multivariate analysis. Conclusions: Although all predictive scoring systems stratify patients accurately by risk of POPF, preoperative risk stratification could improve clinical decision-making and implement preventive strategies for high-risk patients. Therefore, the preoperative use of the FRS without BL is a potential alternative.

Extracellular volume fraction derived from dual-energy CT: a potential predictor for acute pancreatitis after pancreatoduodenectomy

OBJECTIVES

To investigate the value of extracellular volume (ECV) fraction and fat fraction (FF) derived from dual- energy CT (DECT) for predicting postpancreatectomy acute pancreatitis (PPAP) after pancreatoduodenectomy (PD).

METHODS

This retrospective study included patients who underwent DECT and PD between April 2022 and September 2022. PPAP was determined according to the International Study Group for Pancreatic Surgery (ISGPS) definition. Iodine concentration (IC) and FF of the pancreatic parenchyma were measured on preoperative DECT. The ECV fraction was calculated from iodine map images of the equilibrium phase. The independent predictors for PPAP were assessed by univariate and multivariable logistic regression analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS

Sixty-nine patients were retrospectively enrolled (median age, 60 years; interquartile range, 55-70 years; 47 men). Of these, nine patients (13.0%) developed PPAP. These patients had lower portal venous phase IC, equilibrium phase IC, FF, and ECV fraction, and higher pancreatic parenchymal-to-portal venous phase IC ratio and pancreatic parenchymal-to-equilibrium phase IC ratio, compared with patients without PPAP. After multivariable analysis, ECV fraction was independently associated with PPAP (odd ratio [OR], 0.87; 95% confidence interval [CI]: 0.79, 0.96; p < 0.001), with an area under the curve (AUC) of 0.839 (sensitivity 100.0%, specificity 58.3%).

CONCLUSIONS

A lower ECV fraction is independently associated with the occurrence of PPAP after PD. ECV fraction may serve as a potential predictor for PPAP after PD.

CLINICAL RELEVANCE STATEMENT

DECT-derived ECV fraction of pancreatic parenchyma is a promising biomarker for surgeons to preoperatively identify patients with higher risk for postpancreatectomy acute pancreatitis after PD and offer selective perioperative management.

KEY POINTS

PPAP is a complication of pancreatic surgery, early identification of higher-risk patients allows for risk mitigation. Lower DECT-derived ECV fraction was independently associated with the occurrence of PPAP after PD. DECT aids in preoperative PAPP risk stratification, allowing for appropriate treatment to minimize complications.

Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy

OBJECTIVE

Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF).

METHODS

Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C).

RESULTS

A total of 204 patients met inclusion criteria. Median PTP was 5.8 cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8 cm or PNT > 1.3 cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008).

CONCLUSIONS

Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.

Evaluation of pancreatic chymotrypsin activity for on-site prediction of clinically relevant postoperative pancreatic fistula

OBJECTIVES

Although the risk of complications due to postoperative pancreatic fistula (POPF) have been evaluated based on the amylase level in drained ascitic fluid, this method has much room for improvement regarding diagnostic accuracy and facility of the measurement. This study aimed to investigate the clinical value of measuring pancreatic chymotrypsin activity for rapid and accurate prediction of POPF after pancreaticoduodenectomy.

METHODS

In 52 consecutive patients undergoing pancreaticoduodenectomy, the chymotrypsin activity in pancreatic juice was measured by calculating the increase in fluorescence intensity during the first 5 min after activation with an enzyme-activatable fluorophore. The predictive value for clinically relevant POPF (CR-POPF) was compared between this technique and the conventional method based on the amylase level.

RESULTS

According to receiver operating characteristic analyses, pancreatic chymotrypsin activity on postoperative day (POD) 3 measured with a multiplate reader had the highest predictive value for CR-POPF (area under the curve [AUC], 0.752; P < 0.001), yielding 77.8 % sensitivity and 68.8 % specificity. The AUC and sensitivity/specificity of the amylase level in ascitic fluid on POD 3 were 0.695 (P = 0.053) and 77.8 %/41.2 %, respectively. Multivariable analysis identified high pancreatic chymotrypsin activity on POD 3 as an independent risk factor for CR-POPF. Measurement of pancreatic chymotrypsin activity with a prototype portable fluorescence photometer could significantly predict CR-POPF (AUC, 0.731; P = 0.010).

CONCLUSION

Measurement of pancreatic chymotrypsin activity enabled accurate and rapid prediction of CR-POPF after pancreaticoduodenectomy. This can help surgeons to implement appropriate drain management at the patient's bedside without delay.

Prevalence of and risk factors for surgical site infections after pancreaticoduodenectomy: a systematic review and meta-analysis

Background

Surgical site infections (SSIs) are one of the most common complications after pancreaticoduodenectomy (PD); however, the global prevalence and risk factors for SSIs after PD remain unknown.

Objectives

To investigate the prevalence of and risk factors for SSIs after PD.

Methods

The PubMed, Embase, Cochrane Library, Web of Science, and Science Direct databases were systematically searched from inception to 1 December 2022. Observational studies reporting adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of risk factors for SSIs in patients undergoing PD were included. Two independent reviewers in teams performed data extraction, risk of bias assessment, and level of evidence analysis. The pooled results were estimated using a random-effects model. The I 2 statistic and Q χ 2 statistic were used to assess heterogeneity. Funnel plots, Egger's regression test, and the trim-and-fill method were used to determine publication bias. The primary outcomes were identifying risk factors for SSIs after PD. The secondary outcomes were the pooled prevalence rates of SSIs.

Results

A total of 98 704 patients from 45 studies were included, and 80% of the studies were considered high quality. The estimated pooled prevalence of SSIs was 23% (0.19-0.27, I 2=97%). The prevalence of SSIs was found to be higher in Japan and lower in USA. Preoperative biliary stenting, higher body mass index (BMI), longer operation time, postoperative pancreatic fistula, soft pancreatic texture, perioperative blood transfusion, and cardiac disease were identified as significant risk factors for the development of SSIs after PD. Additionally, broad-spectrum antibiotics were a significant protective factor against SSIs. Subgroup analysis and sensitivity analysis showed that the results were robust.

Conclusion and relevance

The prevalence of SSIs remains high and varies widely among regions. It is necessary to take effective preventive measures and carry out more prospective studies to further verify these results.

A modified Blumgart anastomosis with a simple and practicable procedure after laparoscopic pancreaticoduodenectomy: our center's experience

BACKGROUND

Laparoscopic pancreaticoduodenectomy(LPD) has become the goal of lots of minimally invasive surgical centers in recent years. Postoperative pancreatic fistula(POPF) is still the barrier to attaining the above goal. Thus, improving anastomosis techniques to reduce the rate of POPF has been a hotspot of surgery. Blumgart pancreaticojejunostomy is considered one of the best anastomosis procedures, with low rates of POPF. However, the original Blumgart pancreaticojejunostomy method is not easy for laparoscopic operation. In consequence, we modified a Blumgart pancreaticojejunostomy technique with a simple and practicable procedure and applied to LPD.

METHODS

We collected and retrospectively analyzed the perioperative clinical data of patients who underwent modified Blumgart anastomosis from February 2017 to September 2022. The above patients included 53 cases in open pancreaticojejunostomy(OPD) and 58 cases in LPD. After propensity score matching, 44 cases were included for comparison in each group.

RESULTS

After propensity score matching, the average time for pancreaticojejunostomy was about 30 min in the LPD group. The Clinically relevant POPF(CR-POPF) rate was 9.1%. The length of postoperative hospitalization was 13.1 days. Compared with the OPD group, The CR-POPF rate in the LPD group are not significant differences. But the postoperative length of hospital stay was significantly shorter in the LPD group. Besides, there were no other severely postoperative complications between two groups.

CONCLUSION

The modified Blumgart anastomosis technique applied to LPD in our Center not only has simple and convenient properties but also low rate of CR-POPF. And this method may be a good choice for surgeons to begin to carry out LPD.

Pancreatic steatosis and metabolic pancreatic disease: a new entity?

Overweight and obesity are some of the most important health challenges. Many diseases are related to these metabolic disorders, and, among them, the pancreatic fat accumulation, also called "pancreatic steatosis" or "nonalcoholic fatty pancreas", seems to have an emerging role in different conditions. There are different method to evaluate the fat content in the pancreas, such as histology, different imaging techniques and endoscopic ultrasound, but there is no gold standard for the correct diagnosis and for the identification of "inter/intralobular" and "intra-acinar" pancreatic fat. However, the fat storage in the pancreas is linked to chronic inflammation and to several conditions, such as acute and chronic pancreatitis, type 2 diabetes mellitus and pancreatic cancer. In addition, pancreatic fat accumulation has also been demonstrated to play a role in surgical outcome after pancreatectomy, in particular for the development of postoperative pancreatic fistula. Different possible therapeutic approaches have been proposed, but there is still a lack of evidence. The aim of this review is to report the current evidence about the relationship between the obesity, the pancreatic fat accumulation and its potential role in pancreatic diseases.

A novel prediction model of pancreatic fistula after pancreaticoduodenectomy using only preoperative markers

BACKGROUND

Since clinically relevant postoperative pancreatic fistula (CR-POPF) can cause intra-abdominal hemorrhage and abscesses, leading to surgery-related deaths after pancreaticoduodenectomy (PD), its preoperative prediction is important to develop strategies for surgical procedures and perioperative management. This study aimed to establish a novel prediction model for CR-POPF using preoperative markers.

METHODS

On a training set of 180 patients who underwent PD at the Yamaguchi University Hospital, a combination of CR-POPF predictors were explored using the leave-one-out method with a unique discrete Bayes classifier. This predictive model was confirmed using a validation set of 366 patients who underwent PD at the Osaka University Hospital.

RESULTS

In the training set, CR-POPF occurred in 60 (33%)　of 180 patients and 130 (36%)　of 366 patients in the validation set using selected markers. In patients with pancreatic ductal adenocarcinoma (PDAC), the main pancreatic duct (MPD) index showed the highest prognostic performance and could differentiate CR-POPF with 87% sensitivity and 81% specificity among 84 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index-based model for 130 PDAC samples were 93% and 87%, respectively. In patients with non-PDAC, the MPD index/body mass index (BMI) combination showed the highest prognostic performance and could differentiate CR-POPF with 84% sensitivity and 57% specificity among 96 patients in the training set. In the validation set, the sensitivity and specificity of the MPD index/BMI-based model for 236 non-PDAC samples were 85% and 53%, respectively.

CONCLUSION

We developed a novel prediction model for pancreatic fistulas after PD using only preoperative markers. The MPD index and MPD index/BMI combination will be useful for CR-POPF assessment in PDAC and non-PDAC samples, respectively.

Quantitative imaging predicts pancreatic fatty infiltration on routine CT examination

PURPOSE

The purpose of this study was to assess the performance of quantitative computed tomography (CT) imaging for detecting pancreatic fatty infiltration, using the results of histopathological analysis as reference.

MATERIALS AND METHODS

Sixty patients who underwent pancreatic surgery for a pancreatic tumor between 2016 and 2019 were retrospectively included. There were 33 women and 27 men with a mean age of 56 ± 12 (SD) years (age range: 18-79 years). Patients with dilatation of the main pancreatic duct, chronic pancreatitis, or preoperative treatment were excluded to prevent any bias in the radiological-pathological correlation. Pancreatic fatty infiltration was recorded at pathology. Pancreatic surface lobularity, pancreatic attenuation, visceral fat area, and subcutaneous fat area were derived from preoperative CT images. The performance for the prediction of fatty infiltration was assessed using area under receiver operating characteristic curve (AUC) and backward binary logistic regression analysis. Results were validated in a separate cohort of 34 patients (17 women; mean age, 50 ± 14 [SD] years; age range: 18-73).

RESULTS

A total of 28/60 (47%) and 17/34 (50%) patients had pancreatic fatty infiltration in the derivation and validation cohorts, respectively. In the derivation cohort, patients with pancreatic fatty infiltration had a significantly higher PSL (P < 0.001) and a lower pancreatic attenuation on both precontrast and portal venous phase images (P = 0.011 and 0.003, respectively), and higher subcutaneous fat area and visceral fat area (P = 0.010 and 0.007, respectively). Multivariable analysis identified pancreatic surface lobularity > 7.6 and pancreatic attenuation on portal venous phase images < 83.5 Hounsfield units as independently associated with fatty infiltration. The combination of these variables resulted in an AUC of 0.85 (95% CI: 0.74-0.95) and 0.83 (95% CI: 0.67-0.99) in the derivation and validation cohorts, respectively.

CONCLUSION

CT-based quantitative imaging accurately predicts pancreatic fatty infiltration.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Textbook outcome as a composite outcome measure in laparoscopic pancreaticoduodenectomy: a multicenter retrospective cohort study

BACKGROUND

Textbook outcome (TO) is a composite outcome measure for surgical quality assessment. The aim of this study was to assess TO following laparoscopic pancreaticoduodenectomy (LPD), identify factors independently associated with achieving TO, and analyze hospital variations regarding the TO after case-mix adjustment.

METHODS

This multicenter cohort study retrospectively analyzed 1029 consecutive patients undergoing LPD at 16 high-volume pancreatic centers in China from January 2010 to August 2016. The percentage of patients achieving TO was calculated. Preoperative and intraoperative variables were compared between the TO and non-TO groups. Multivariate logistic regression was performed to identify factors independently associated with achieving TO. Hospital variations regarding the TO were analyzed by the observed/expected TO ratio after case-mix adjustment. Differences in expected TO rates between different types of hospitals were analyzed using the one-way analysis of variance test.

RESULTS

TO was achieved in 68.9% ( n =709) of 1029 patients undergoing LPD, ranging from 46.4 to 85.0% between different hospitals. Dilated pancreatic duct (>3 mm) was associated with the increased probability of achieving TO [odds ratio (OR): 1.564; P =0.001], whereas advanced age (≥75 years) and concomitant cardiovascular disease were associated with a lower likelihood of achieving TO (OR: 0.545; P =0.037 and OR: 0.614; P =0.006, respectively). The observed/expected TO ratio varied from 0.62 to 1.22 after case-mix adjustment between different hospitals, but no significant hospital variations were observed. Hospital volume, the surgeon's experience with open pancreaticoduodenectomy and minimally invasive surgery, and surpassing the LPD learning curve were significantly correlated with expected TO rates.

CONCLUSION

TO was achieved by less than 70% of patients following LPD. Dilated pancreatic ducts, advanced age, and concomitant cardiovascular disease were independently associated with achieving TO. No significant hospital variations were observed after case-mix adjustment.

The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula

Background

The clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF.

Methods

We retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients' demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF.

Results

In the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group.

Conclusion

Of all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.

Surgical outcome and prognosis of pediatric solid-pseudopapillary neoplasm

BACKGROUND

The aim of this study was to clarify the characteristics and outcomes of pediatric patients with solid pseudopapillary neoplasms (SPNs) who underwent pancreatectomy.

METHODS

Pediatric patients with SPNs who underwent pancreatectomy at our institution between 1995 and 2020 were included in the study.

RESULTS

During the period under review, 12 patients underwent pancreatectomy for SPNs (median age: 10 years; range: 6-15 years). The surgical procedures included pancreatoduodenectomy (n = 2; 16.6%), distal pancreatectomy (n = 3; 25%), and enucleation (n = 7; 58.3%). The most common postoperative complication was postoperative pancreatic fistula (n = 6; 50%). Patients who underwent enucleation tended to have higher postoperative complication rates compared with those who underwent other procedures. All patients were alive without recurrence at the end of the study period.

CONCLUSIONS

SPN is associated with a good prognosis, regardless of the surgical procedure. If surgeons select enucleation for pediatric SPNs, they should bear in mind that it is associated with a higher complication rate.

Impact of pancreatic fat infiltration on postoperative pancreatic fistula occurrence in patients undergoing invagination pancreaticojejunostomy

BACKGROUND

No studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ).

METHODS

The medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF.

RESULTS

Of 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas.

CONCLUSIONS

Pancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.

Systemic therapy and perioperative management improve the prognosis of pancreatic ductal adenocarcinoma: A retrospective cohort study of 2000 consecutive cases

OBJECTIVE

This study aimed to explore patterns of the treatment strategies of pancreatic ductal adenocarcinoma based on 2000 consecutive cases of a prospective database since 2012 to obtain new insights for future directions.

METHODS

Among 2000 patients enrolled in this study, 210 patients were excluded, and 710, 521, and 559 patients were treated between 2012 and 2015 (group 1), between 2016 and 2017 (group 2), and between 2018 and 2019 (group 3), respectively. Patient clinicopathologic and biological factors, and perioperative outcomes were used to assess the prognostic factors.

RESULTS

The median survival for all patients with pancreatic ductal adenocarcinoma was 21.7 months (1-year survival, 75.0%; 2-year survival, 43.7%; 5-year survival, 19.7%). Group 3 had a better survival outcome than groups 1 and 2 (median survival time: 23 versus 20.5 and 21.1 months). The proportion of patients younger than 65 gradually increased over time, as did the use of systemic chemotherapy and postoperative adjuvant radiotherapy. The tendency for early diagnosis (lower CA19-9 and CEA levels, smaller size, and earlier N stage), use of chemotherapy and radiotherapy, early recovery (lesser hospital stay and Clavien-Dindo grade <3), absence of abdominal pain, younger age, length of operation ≤3 h, and pathological factors (absence of lymphovascular invasion, peripancreatic fat infiltration and neural invasion, higher differentiation) were related to patients' survival. Multivariable analysis for prognosis revealed that tumor biological factors (increased preoperative serum CA19-9 level, tumor size, tumor differentiation, N stage, and presence of lymphovascular invasion and neural invasion), chemotherapy, radiotherapy, abdomen pain, operation period, length of stay, and length of operation correlated with patients' survival.

CONCLUSIONS

Systemic therapy, including chemotherapy and radiotherapy, has gradually improved the prognosis after operative resection for pancreatic ductal adenocarcinoma. Neoadjuvant therapy is also beneficial to improve the prognosis to a certain extent. The enhanced recovery after surgery (ERAS) policies and the specific assessment of postoperative pancreatic fistula (POPF) risk may be related to reduced hospital stays and the reduction of serious complications. These advancements show that the concept of systemic therapy has been accepted and actively applied by Chinese medical institutions.

Pancreatic juice outflow in pancreatojejunostomy monitoring with the inter-anastomosis drainage tube; a retrospective observational study

BACKGROUND

Pancreatic fistula remains the biggest problem in pancreatic surgery. We have previously reported a new pancreatojejunostomy method using an inter-anastomosis drainage (IAD) suction tube with Blumgart anastomosis for drainage of the pancreatic juice leaking from the branched pancreatic ducts. This study aimed to evaluate the postoperative outcomes of our novel method, in pancreatojejunostomy and investigate the nature of the inter-anastomosis space between jejunal wall and pancreas parenchyma.

METHODS

This retrospectively study consist of 282 pancreatoduodenectomy cases, including 86 reconstructions via the Blumgart method plus IAD (B + IAD group) and 196 cases reconstructed using the Blumgart method alone (B group). Postoperative outcomes and the amylase value and the volume of the drainage fluids were compared between the two groups. The IAD tube was placed to collect amylase-rich fluid from the inter-anastomosis space during operative procedure between the jejunal wall and pancreatic stump.

RESULTS

The daily IAD drainage volume and the amylase level was significantly higher in patients with a soft pancreas (vs hard pancreas; 16.5 vs. 10.0 mL/day, p = 0.012; 90,900 vs. 1634 IU/L, p < 0.001, respectively). The mean amylase value of IAD collection in 86 cases of B + IAD group was 63,100 IU/L. The incidence of clinically relevant pancreatic fistula grade B and C (23.2% vs. 23.0%, p = 0.55) and the hospital stay was similar between the groups (median 17 vs. 18 days, p = 0.55). In 176 patients with soft pancreas, the incidence of pancreatic fistula grade B and C (33.3% vs. 35.3%, p = 0.67) and the hospital stay was also similar between the groups (median 22.5 vs. 21 days, p = 0.81).

CONCLUSIONS

Positive effect of the IAD method observed in the pilot cases was not reproduced in the current study. IAD tube objectively demonstrated the existence of amylase-rich discharge at the anastomosis site, and countermeasures to eliminate this liquid are highly desired for preventing pancreatic fistula, especially in patients with soft pancreatic texture. Trial registration Retrospectively registered.

Day of surgery and mortality after pancreatoduodenectomy: A retrospective analysis of 29 270 surgical cases of pancreatic head cancer from Japan

BACKGROUND/PURPOSE

The day of the week can impact medical treatment outcomes; however, few large-scale, disease-specific studies have focused on the association between the day of the week and mortality in patients after pancreatoduodenectomy for pancreatic head cancer.

METHODS

Data were obtained from the National Clinical Database. Twenty-two clinical variables were adopted for hierarchal logistic regression modeling to determine adjusted odds ratios (ORs) for surgical mortality after elective pancreatoduodenectomy.

RESULTS

The 30-day mortality and surgical mortality rates were 1.0% and 1.7%, respectively (n = 29 720). Surgeries were performed the least on Fridays (13.4%) compared with other weekdays. Crude rates of severe postoperative complications (mean, 14.1%; range, 13.5%-14.8%) and pancreatic fistulas (mean, 10.0%; range, 9.6%-10.3%) remained stable throughout the week. Unadjusted/adjusted ORs did not significantly differ between Friday and Monday (0.868, 95% CI: 0.636-1.173, P = .365, and 0.928, 95% CI: 0.668-1.287, P = .653, respectively), and results were similar for the remaining weekdays. Nineteen independent factors were associated with surgical mortality.

CONCLUSIONS

The rate of perioperative mortality for elective pancreatoduodenectomy is low in Japan, with no evidence of disparities in surgical mortality rates between weekdays.

Pancreatico-Gastrostomy: A Modified Two-Layered Technique

Introduction: Pancreato-duodenal resections are commonly done for periampullary carcinomas. The outcome of the procedure is decided by pancreato-enterostomy. Pancreato-jejunostomy (PJ) has been employed largely as pancreato-enterostomy. Recently, there has been a renewed interest in pancreato-gastrostomy (PG). The debate continues on the choice of reconstruction.

Methods: A hundred cases of periampullary carcinoma were subjected to modified pancreatico-gastrostomy. The pancreatico-gastrectomy was evaluated by drain fluid amylase done on days 1, 3, and 5 post-operatively and clinical findings. The leaks were classified according to the International Study Group of Pancreatic Fistula (ISGPF) classification of biochemical leaks, postoperative pancreatic fistula (POPF) B and POPF C. The leaks were evaluated against pancreatic factors like duct diameter, consistency of the pancreas, the thickness of the pancreatic neck, and duct location. 

Observations: Eighty percent of patients had no leaks. The biochemical leak was seen in 10% of cases. POPF B and C were observed at 5% each. Mortality was 3%. The diameter of the pancreatic duct of more than 3 mm and the firm consistency of the pancreas were favourable factors in the outcome of the anastomosis.

Conclusion: A modified pancreatico-gastrostomy technique appears to be technically feasible and safe. The leak rates and mortality appear to be low. We need a higher number of patients to confirm the efficacy of this modified pancreatico-enterostomy.

Incidence of postoperative pancreatic fistula after using a defined pancreaticojejunostomy technique for laparoscopic pancreaticoduodenectomy: A prospective multicenter study on 1033 patients

OBJECTIVE

This prospective multicenter study aimed to study the incidence of postoperative pancreatice fistula using a defined technique of pancreaticojejunostomy (PJ) in laparoscopic pancreaticoduodenectomy (LPD).

BACKGROUND

PJ is a technically challenging and time-consuming procedure in LPD. Up to now, only a few small sample size studies have been reported on various PJ techniques in LPD, none of which has widely been accepted by surgeons.

METHODS

This prospective study enrolled consecutive patients who underwent LPD using a defined technique of PJ at four institutions in China between January 2017 and December 2020.

RESULTS

Of 1045 patients, after excluding 12 patients (1.2%) due to conversion to open surgery, 1033 patients were analysed. The males comprised of 57.12% (590/1033), and females 42.88% (443/1033), with a mean age of 59.00 years. The mean ± s.d. operation time was (270.2 ± 101.8) min. The median time for PJ was 24min (IQR = 20.0-30.0). The overall incidence of postoperative pancreatic fistula was 12.6%, including 67 patients (6.5%) with Grade A biochemical leak, 50 patients (4.8%) with Grade B, and 13 patients (1.3%) with Grade C pancreatic fistulas. The overall incidence of major complications (Clavien-Dindo score ≥3) was 6.3% and the 30-day mortality was 2.8%.

CONCLUSION

The pancreaticojejunostomy technique for LPD was safe, simple and reproduceable with favorable clinical outcomes. However, further validations using high-quality RCTs are still required to confirm the findings of this study.

The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck.

METHODS

The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film.

RESULTS

Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF.

CONCLUSION

Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.

Dual-Energy CT Iodine Concentration to Evaluate Postoperative Pancreatic Fistula after Pancreatoduodenectomy

Background Pancreatic fibrosis and fatty infiltration are associated with postoperative pancreatic fistula (POPF), but accurate preoperative assessment remains a challenge. Iodine concentration (IC) and fat fraction derived from dual-energy CT (DECT) may reflect the amount of fibrosis and steatosis, potentially enabling the preoperative prediction of POPF. Purpose To identify multiphasic DECT-derived IC and fat fraction that improve the prediction of POPF risks compared with contrast-enhanced CT attenuation values and to evaluate the underlying histopathologic changes. Materials and Methods This retrospective study included patients who underwent pancreatoduodenectomy and DECT (including pancreatic parenchymal, portal venous, and delayed phase scanning) between January 2020 and December 2020. The relationships of the quantitative DECT-derived IC and fat fraction, along with CT attenuation values from enhanced images with POPF risk, were analyzed with logistic regression analysis. The predictive performance of the IC was compared with that of the CT values. The histopathologic underpinnings of IC were evaluated with multivariable linear regression analysis. Results A total of 107 patients (median age, 65 years; interquartile range, 57-70 years; 56 men) were included. Of these, 23 (21%) had POPF. The pancreatic parenchymal-to-portal venous phase IC ratio (adjusted odds ratio [OR], 13; 95% CI: 2, 162; P < .001) was an independent predictor of POPF occurrence. The accuracy of the pancreatic parenchymal-to-portal venous phase IC ratio in predicting POPF was higher than that of the CT value ratio in the same phases (78% vs 65%, P < .001). The pancreatic parenchymal-to-portal venous phase IC ratio was independently associated with pancreatic fibrosis (β = -1.04; 95% CI: -0.44, -1.64; P = .001). Conclusion A higher pancreatic parenchymal-to-portal venous phase IC ratio was associated with less histologic fibrosis and greater risk of POPF. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee and Yoon in this issue.

The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy

Background

The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the ¹³C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF.

Method

A total of 80 patients who underwent ¹³C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between ¹³C-trioctanoin absorption and PF incidence.

Results

Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the ¹³C-trioctanoin breath test value (Aa% dose/h) increased (odd’s ratio: 1.082, 95% confidence interval: 1.007–1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53).

Conclusions

Favorable preoperative fat absorption evaluated using the ¹³C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

Reinforced duct-mucosa anastomosis (REDMA). New alternative after cephalic duodepancreatectomy

INTRODUCTION

Of the possible complications after a cephalic duodenopancreatectomy (CPD), the clinically relevant postoperative pancreatic fistula (PPF) is the most important, especially in patients with pancreas of a soft consistency. The main objective of this work is to analyze the different postsurgical complications, with special emphasis on the rate of PPF on soft pancreas with a risk of moderate/high PPF, and its incidence between the two different types of sutures used by our group (classic vs reinforced duct-mucosa anastomosis [REDMA]).

METHODS

Retrospective observational study, between January 2017 and March 2020, of patients undergoing CPD in our unit after applying the inclusion and exclusion criteria. Analysis of preoperative, intraoperative factors and postoperative complications observed during follow-up.

RESULTS

Sample of 34 patients; 67.6% (n = 23) of them under the classic protocol and 32.4% (n = 11) with REDMA. The only post-surgical complication in which we obtained statistical repercussion, without differences between cases and controls in terms of the risk of FPP, in favor of the REDMA anastomosis is that of FPP. Thanks to this surgical innovation, both the complications from stage IIIb, according to the Clavien-Dindo classification, and the mean hospital stay have also been reduced with statistical significance.

CONCLUSIONS

When REDMA reduces the rate of PPF in patients with moderate/high surgical risk of it, we consider it to be a useful alternative to consider in the reconstruction of transit after CPD.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ​​obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.

Impact of a 7.5-Fr Pancreatic Stent for Preventing Pancreatic Fistula after Pancreaticoduodenectomy

INTRODUCTION

Pancreatic duct stents are widely used to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD); however, small stents may cause adverse effects, such as occlusion. Recently, we have tried placing a 7.5-Fr pancreatic duct stent to achieve more effective exocrine output from the pancreas; however, the association between pancreatic duct stent size and POPF remains unknown.

METHODS

Sixty-five patients with soft pancreatic texture who underwent PD were retrospectively analyzed. After dividing the pancreas, a pancreatic duct stent (stent size 4.0 in 29 patients, 5.0 in 18, and 7.5 Fr in 18) was placed in the main pancreatic duct.

RESULTS

Twenty-five of 65 patients with soft pancreatic texture (38.5%) developed POPF. POPF became less frequent as the pancreatic duct stent size increased (p = 0.003). The factors associated with POPF development were a 7.5-Fr pancreatic duct stent (p = 0.005), 5.0-Fr pancreatic duct stent (p = 0.031), and male sex (p = 0.008). Pancreatic duct stent size and pancreatic duct diameter did not differ between the POPF and non-POPF groups.

DISCUSSION/CONCLUSIONS

In patients with a soft pancreas, the placement of a 7.5-Fr pancreatic duct stent may reduce the incidence of POPF.

Estimation of pancreatic fibrosis and prediction of postoperative pancreatic fistula using extracellular volume fraction in multiphasic contrast-enhanced CT

OBJECTIVE

To investigate the diagnostic performance of the extracellular volume (ECV) fraction in multiphasic contrast-enhanced computed tomography (CE-CT) for estimating histologic pancreatic fibrosis and predicting postoperative pancreatic fistula (POPF).

METHODS

Eighty-five patients (49 men; mean age, 69 years) who underwent multiphasic CE-CT followed by pancreaticoduodenectomy with pancreaticojejunal anastomosis between January 2012 and December 2018 were retrospectively included. The ECV fraction was calculated from absolute enhancements of the pancreas and aorta between the precontrast and equilibrium-phase images, followed by comparisons among histologic pancreatic fibrosis grades (F0‒F3). The diagnostic performance of the ECV fraction in advanced fibrosis (F2‒F3) was evaluated using receiver operating characteristic curve analysis. Multivariate logistic regression analysis was used to evaluate the associations of the risk of POPF development with patient characteristics, histologic findings, and CT imaging parameters.

RESULTS

The mean ECV fraction of the pancreas was 34.4% ± 9.5, with an excellent intrareader agreement of 0.811 and a moderate positive correlation with pancreatic fibrosis (r = 0.476; p < 0.001). The mean ECV fraction in advanced fibrosis was significantly higher than that in no/mild fibrosis (44.4% ± 10.8 vs. 31.7% ± 6.7; p < 0.001), and the area under the receiver operating characteristic curve for the diagnosis of advanced fibrosis was 0.837. Twenty-two patients (25.9%) developed clinically relevant POPF. Multivariate logistic regression analysis demonstrated that the ECV fraction was a significant predictor of POPF.

CONCLUSIONS

The ECV fraction can offer quantitative information for assessing pancreatic fibrosis and POPF after pancreaticojejunal anastomosis.

KEY POINTS

• There was a moderate positive correlation of the extracellular volume (ECV) fraction of the pancreas in contrast-enhanced CT with the histologic grade of pancreatic fibrosis (r = 0.476; p < 0.001). • The ECV fraction was higher in advanced fibrosis (F2‒F3) than in no/mild fibrosis (F0‒F1) (p < 0.001), with an AUC of 0.837 for detecting advanced fibrosis. • The ECV fraction was an independent risk factor for predicting subclinical (odds ratio, 0.81) and clinical (odds ratio, 0.80) postoperative pancreatic fistula.

A preserved pancreatic exocrine function after pancreatectomy may be a crucial cause of pancreatic fistula: paradoxical results of the 13C-trioctanoin breath test in the perioperative period

PURPOSE

The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy.

METHODS

The subjects were 96 patients who underwent a ¹³C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test.

RESULTS

The preoperative level of ¹³C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, ¹³C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a ¹³C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001).

CONCLUSION

PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) can be associated with severe postoperative morbidity. This study aims to develop a preoperative POPF risk calculator that can be easily implemented in clinical routine.

METHODS

Patients undergoing PD were identified from a prospectively-maintained database. A total of 11 preoperative baseline and CT-based radiological parameters were used in a binominal logistic regression model. Parameters remaining predictive for grade B/C POPF were entered into the risk calculator and diagnostic accuracy measures and ROC curves were calculated for a training and a test patient cohort. The risk calculator was transformed into a simple nomogram.

RESULTS

A total of 242 patients undergoing PD in the period from 2012 to 2018 were included. CT-imaging-based maximum main pancreatic duct (MPD) diameter (p = 0.047), CT-imaging-based pancreatic gland diameter at the anticipated resection margin (p = 0.002) and gender (p = 0.058) were the parameters most predictive for grade B/C POPF. Based on these parameters, a risk calculator was developed to identify patients at high risk of developing grade B/C POPF. In a training cohort of PD patients this risk calculator was associated with an AUC of 0.808 (95%CI 0.726-0.874) and an AUC of 0.756 (95%CI 0.669-0-830) in the independent test cohort. A nomogram applicable as a visual risk scale for quick assessment of POPF grade B/C risk was developed.

CONCLUSION

The preoperative POPF risk calculator provides a simple tool to stratify patients planned for PD according to the risk of developing postoperative grade B/C POPF. The nomogram visual risk scale can be easily integrated into clinical routine and may be a valuable model to select patients for POPF-preventive therapy or as a stratification tool for clinical trials.

Clinical Application of a Modified Double Purse-String Continuous Suture Technique for Pancreaticojejunostomy: Reliable for Laparoscopic Surgery and Small Size Main Pancreatic Duct

Background

The technical challenge of pancreatojejunostomy (PJ) is the greatest barrier for surgeons to complete pancreatoduodenectomy (PD). The authors present an easy-to-master PJ anastomosis technique with limited technical requirements. This technique uses two layers of sutures and double purse-string sutures to complete the entire anastomosis. This anastomosis technique has achieved good results in laparoscopic surgery (LS) and small size main pancreatic duct (MPD).

Methods

From February 2015 to August 2020, 63 patients who met the surgical indications underwent a modified double purse-string continuous suture pancreaticojejunostomy technique in our center. We collected patient demographic characteristics and perioperative outcomes and analyzed these data.

Results

A total of 63 patients underwent PD using our new anastomosis technique. Thirty-eight patients underwent LS, and 26 patients had a small MPD (<3 mm). The median operative time (OT) was 270 min, and the median estimated blood loss (EBL) was 200 ml. Ten patients had grade B postoperative pancreatic fistula (POPF), while no patients had grade C POPF. No 90-day mortality was observed. There were significant differences in the OT and postoperative hospital stay (PHS) among groups with different surgical procedures, while there were no significant differences among groups with different MPD sizes. Neither the surgical procedure nor the MPD size affected early postoperative complications.

Conclusion

This new technique can not only reduce the incidence of POPF but also is reliable for LS and surgeries with small size MPD. Therefore, this technique is worthy of clinical promotion and application in the future.

Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct

BACKGROUND

Soft pancreas with small pancreatic duct is a known risk factor for postoperative pancreatic fistula (POPF). This study demonstrated the safety and feasibility of laparoscopic duct-to-mucosa pancreaticojejunostomy (PJ) and compared perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with soft pancreas and small pancreatic duct.

METHODS

From January 2014 to December 2019, 183 patients underwent LPD and 91 patients underwent OPD by a single surgeon. Data on patients with soft pancreas and combined small pancreatic duct (≤ 2 mm) were retrospectively reviewed. Clinicopathologic characteristics, and perioperative outcomes were compared between LPD and OPD. We evaluated risk factors affecting clinically relevant POPF (CR-POPF). We also correlated calculated risks of POPF and CR-POPF between the two groups.

RESULTS

We compared 62 patients in the LPD group and 34 patients in the OPD group. Perioperative outcomes showed less blood loss, shorter hospital stays, and less postoperative pain score on postoperative day (POD)#1 and #5 in LPD compared with OPD. Postoperative complications showed no differences between LPD and OPD. LPD group showed significantly reduced CR-POPF rates compared to the OPD group (LPD 11.3% vs. OPD 29.4%, p = 0.026). Multivariate analysis identified obesity (BMI ≥ 25), thick pancreas parenchyma and open surgery as independent predicting factors for CR-POPF. The LPD group showed less CR-POPF than the OPD group according to POPF risk groups. This difference was more prominent in a high-risk group.

CONCLUSION

With appropriate laparoscopic technique, LPD is feasible and safe and reduces CR-POPF in soft pancreas with a small pancreatic duct.

Intraoperative amylase level of pancreatic juice as a simple predictor of pancreatic fistula after pancreaticoduodenectomy

INTRODUCTION

A soft remnant texture of the pancreas is commonly accepted as a risk factor for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). However, its assessment is subjective. The aim of this study was to evaluate the significance of intraoperative amylase level of the pancreatic juice as a risk factor of POPF after PD.

METHOD

This study included 75 patients who underwent PD between November 2014 and April 2020 at Jikei University Hospital. We investigated the relationship between pancreatic texture, intraoperative amylase level of pancreatic juice, results of the pathological evaluations, and the incidence of POPF.

RESULTS

Twenty-three patients (31%) developed POPF. The significant predictors of POPF were non-ductal adenocarcinoma (p < 0.01), soft pancreatic remnant (p < 0.01), high intraoperative blood loss (p < 0.01), high intraoperative amylase level of pancreatic juice (p < 0.01), and low pancreatic fibrosis (p < 0.01). Multivariate analysis revealed that the significant independent predictors of POPF were high intraoperative blood loss (p < 0.01) and high intraoperative amylase level of pancreatic juice (p = 0.02). Receiver operating characteristic (ROC) analysis showed that the cut-off value for the intraoperative amylase level of pancreatic juice was 2.17 × 10⁵ IU/L (area under the curve = 0.726, sensitivity = 95.7%, and specificity = 50.0%) CONCLUSIONS: The intraoperative amylase level of pancreatic juice is a reliable objective predictor for POPF after PD.

A deep pancreas is a novel predictor of pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct

BACKGROUND

We investigated the risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.

METHODS

We investigated a total of 354 patients who underwent pancreaticoduodenectomy. The diameter of the main pancreatic duct, the shortest distance from the body surface to the pancreas (the pancreatic depth), and the computed tomography attenuation index (the difference between the pancreatic and splenic computed tomography attenuation) were measured in preoperative computed tomography.

RESULTS

One hundred eighty-one (51.1%) patients had a nondilated main pancreatic duct, and 50 (27.6%) of the 181 patients with a nondilated main pancreatic duct developed a clinically relevant postoperative pancreatic fistula. Univariate analyses revealed that the calculated body mass index (≥21.8 kg/m²) (P = .004), deep pancreas (pancreatic depth ≥51.2 mm) (P = .001), and low computed tomography attenuation index (≤-3.8 Hounsfield units) (P = .02) were significant risk factors for clinically relevant postoperative pancreatic fistula. The multivariate logistic regression analysis revealed that deep pancreas (odds ratio 2.370; 95% confidence interval 1.0019-5.590; P = .049) was an independent risk factor for clinically relevant postoperative pancreatic fistula. Among patients with a nondilated main pancreatic duct, deep pancreas (in comparison to patients without deep pancreas) was associated with male sex (72.7% vs 54.9%; P = .016), higher body mass index (22.5 kg/m² vs 19.6 kg/m²; P < .001), a history of diabetes mellitus (24.5% vs 8.5%; P = .006), a lower computed tomography attenuation index (-9.6 Hounsfield units vs -4.6 Hounsfield units; P = .007), a longer operative time (454 minutes vs 420 minutes; P = .007), and a higher volume of intraoperative blood loss (723 mL vs 500 mL; P < .001), respectively.

CONCLUSION

Deep pancreas may be an important parameter associated with significant risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.

Reinforced duct-mucosa anastomosis (REDMA). New alternative after cephalic duodepancreatectomy

INTRODUCTION

Of the possible complications after a cephalic duodenopancreatectomy (CPD), the clinically relevant postoperative pancreatic fistula (PPF) is the most important, especially in patients with pancreas of a soft consistency. The main objective of this work is to analyze the different postsurgical complications, with special emphasis on the rate of PPF on soft pancreas with a risk of moderate/high PPF, and its incidence between the two different types of sutures used by our group (classic vs reinforced duct-mucosa anastomosis [REDMA]).

METHODS

Retrospective observational study, between January 2017 and March 2020, of patients undergoing CPD in our unit after applying the inclusion and exclusion criteria. Analysis of preoperative, intraoperative factors and postoperative complications observed during follow-up.

RESULTS

Sample of 34 patients; 67.6% (n = 23) of them under the classic protocol and 32.4% (n = 11) with REDMA. The only post-surgical complication in which we obtained statistical repercussion, without differences between cases and controls in terms of the risk of FPP, in favor of the REDMA anastomosis is that of FPP. Thanks to this surgical innovation, both the complications from stage IIIb, according to the Clavien-Dindo classification, and the mean hospital stay have also been reduced with statistical significance.

CONCLUSIONS

When REDMA reduces the rate of PPF in patients with moderate/high surgical risk of it, we consider it to be a useful alternative to consider in the reconstruction of transit after CPD.

Relation of computed tomography features of the pancreatic tissue and development of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic density and steatosis detected in pre-operative computed tomography (CT) may be a risk factor for PF development after pancreatoduodenectomy (PD). There is insufficient data available on the relationship between PF and atherosclerosis in pancreatic vasculature of pancreatitis. This study aims to investigate whether PF development in patients undergoing PD can be predicted by preoperative CT findings.

MATERIAL-METHOD

Pancreas and spleen densities were measured on non-contrast CT images and pancreatic index (PI) was calculated to detect pancreatic steatosis. Pancreatic density and Wirsung diameter (WD) were measured on portal venous phase. Pancreatic fistulae were identified as biochemical leak (BL), grade B and grade C using ISGPF classification. The findings were compared between the fistula and non-fistula groups and ISGPF subgroups.

RESULTS

Of 148 patients, PF was detected on 31 (20.9%). In PF group, mean pancreatic density and PI were significantly lower than non-PF group, while pancreatic steatosis was detected at a higher rate. The WD was significantly narrower in the PF group. No significant relationship was found between the development of PF and the findings of atherosclerosis in the CT and SMA or acute pancreatitis. There was no significant difference between the PF subgroups for pancreas density.

CONCLUSION

In preoperative CT examinations, measuring the pancreatic density, PI index and WD can be used as a noninvasive quantitative method to predict the possibility of postoperative PF development.

[Contrast-enhanced computed tomography in evaluation of pancreatic stump volume in pancreaticoduodenectomy]

OBJECTIVE

To analyze the role of contrast-enhanced computed tomography in evaluation of pancreatic stump volume for prediction of significant pancreatic fistula.

MATERIAL AND METHODS

A retrospective analysis enrolled 99 patients. Patients were divided into 2 groups depending on the course of postoperative period and development of clinically significant pancreatic fistula. The first group included 24 patients (25%) with clinically significant postoperative pancreatic fistula. The second group included 75 patients (75%) without postoperative complications. Pancreatic structure, pancreatic parenchyma thickness (mm), pancreatic duct diameter (mm) and volume of pancreatic stump (cm³) were preoperatively analyzed considering contrast-enhanced computed tomography data.

RESULTS

The risk of postoperative pancreatic fistula is 10 times higher in case of soft structure of the pancreas, 1,7 times higher in decrease of pancreatic duct diameter, 9,3 times higher in increased volume of residual pancreatic parenchyma, 8.6 times higher in increase of pancreatic parenchyma thickness.

CONCLUSION

Contrast-enhanced computed tomography is valuable for preoperative evaluation of the volume of residual pancreatic parenchyma and identification of patients with high risk of postoperative pancreatic fistula.

Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy

BACKGROUND

Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon's hand.

METHODS

Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT.

RESULTS

In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (1.5%). According to multivariate analysis, a high pancreas-visceral fat CT value ratio (p = 0.002), serrated-type contour (p = 0.02) and no history of chemoradiotherapy (p = 0.019) were identified as independent risk factors for POPF grade B/C. Even in patients with soft pancreas, the incidence of POPF grade B/C was 0% (0/57) in patients with a pancreas-visceral fat CT value ratio of less than - 0.4 and smooth-type contour, whereas the incidence was markedly high (45.0%, 9/20) in patients with a pancreas-visceral fat CT value ratio of - 0.4 or greater and serrated-type contour, indicating that patients with soft pancreas should be categorized into POPF high-risk and low-risk groups according to preoperative CT scan results.

CONCLUSIONS

The pancreas-visceral fat CT value ratio and serrated-type pancreas are useful markers to preoperatively identify true POPF high-risk groups in patients undergoing PD, regardless of the pancreatic texture judged intraoperatively.

Fibroblasts as a Biological Marker for Curative Resection in Pancreatic Ductal Adenocarcinoma

Achievement of microscopic tumor clearance (R0) after pancreatic ductal adenocarcinoma (PDAC) surgery is determined by cancer biology rather than operative technique. Fibroblasts are known to play pro-cancer roles; however, a small subset was recently found to play anti-cancer roles. Therefore, we hypothesized that intratumor fibroblasts contribute to curative resection and a better survival of PDAC. Utilizing a large, publicly available PDAC cohort, we found that fibroblast composition was associated with R0 curative resection. A high amount of fibroblasts in PDACs was significantly associated with a higher amount of mature vessels, but not with blood angiogenesis. A high amount of fibroblasts was also associated with a higher infiltration of anti-cancer immune cells, such as CD8+ T-cells and dendritic cells, together with higher inflammatory signaling, including IL2/STAT5 and IL6/JAK/STAT3 signaling. Further, the fibroblast composition was inversely associated with cancer cell composition in the bulk tumor, along with an inverse association with proliferative characteristics, such as MYC signaling and glycolysis. The patients with high-fibroblast PDACs showed an improved prognosis. In conclusion, we found that PDACs with high fibroblasts were associated with a higher R0 resection rate, resulting in a better prognosis. These findings may be due to less aggressive biology with a higher vascularity and anti-cancer immunity, and a low cancer cell component.

Pancreatic Fat and Body Composition Measurements by Computed Tomography are Associated with Pancreatic Fistula After Pancreatectomy

OBJECTIVES

Postoperative pancreatic fistula (POPF) is the most threatening complication after pancreatectomy. This study aimed to directly assess pancreatic fatty infiltration with preoperative computed tomography (CT) imaging and to investigate whether a preoperative analysis of patient variables, including CT characteristics and clinical factors, can predict POPF.

METHODS

We enrolled 150 consecutive patients who underwent curative pancreatectomy. Radiographic factors, including pancreatic fat volume, were measured using preoperative CT imaging and the predictive factors were explored using univariate and multivariate analyses.

RESULTS

POPF developed in 30 patients (20.0%). The ratio of pancreatic fat (RPF) ≥ 4.83% was associated with a risk of POPF, high body mass index (BMI), and obese body habitus. Patients with POPF were significantly more likely to have high BMI (≥ 25 kg/m²), obese body habitus, and an RPF ≥ 4.83% than patients without POPF. In the multivariate analysis, visceral fat area/skeletal muscle index (VFA/SMI) ≥ 1.94 (odds ratio [OR] 4.28, 95% confidence interval [CI] 1.43-12.9, p = 0.0095) was the sole independent predictive factor for POPF. For patients with a soft pancreas, VFA/SMI ≥ 1.94 (OR 5.67, 95% CI 2.05-15.7, p = 0.0008) was again the sole independent predictive factor for POPF.

CONCLUSION

Preoperative CT images can examine pancreatic fatty infiltration, and patients who had POPF were significantly associated with a high RPF. Among several parameters, VFA/SMI was the only independent predictive factor for clinically relevant POPF. Preoperative evaluation of these body composition variables and the pancreatic configuration could be useful for predicting POPF.

Pancreatic ultrasound elastography is not useful to predict the risk of pancreatic fistulas after pancreatic resection

The clinical usefulness of pancreatic elastography (PE) in the assessment of the pancreatic texture before pancreatic resection still remains uncertain. The aims are: to evaluate the value of pancreatic stiffness in both healthy volunteers and patients affected by pancreatic tumor; to evaluate the ability of PE in predicting clinically relevant postoperative pancreatic fistula (CR-POPF). Pancreatic stiffness of healthy subjects was compared with those of pancreatic tumors measuring shear wave velocity (SWV). In the last group, the ability of preoperative SWV in predicting CR-POPF was evaluated using linear regression. Ninety subjects were consecutively enrolled. No difference was found in SWV in the two groups (1.33 ± 0.31 vs 1.26 ± 0.30, p = 0.337). Multivariate analyses showed that male gender was associated with a softer pancreas (OR 0.74, CI 0.55-0.98, p = 0.035). In the 45 patients suitable for a secondary endpoint, the presence of soft pancreas assessed by surgeon's palpation (OR 61.21; CI 2.14- > 1000; p = 0.016) and preoperative risk score (OR 1.72; CI 1.01-2.96; p = 0.049) was predictors of CR-POPF. SWV showed a trend in predicting CR-POPF. The pancreatic stiffness far to the pancreatic neoplasm is the same as healthy controls. SWV showed a trend in predicting CR-POPF but the clinical utility is limited.

HYAL-1-induced autophagy facilitates pancreatic fistula for patients who underwent pancreaticoduodenectomy

The main mechanism of hyaluronidase 1(HYAL-1) in the development of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) was unknown. In this study, a comprehensive inventory of pre-, intra-, and postoperative clinical and biological data of two cohorts (62 pancreatic cancer [PCa] and 111 pancreatic ductal adenocarcinoma [PDAC]) which could induce POPF were retrospectively analyzed. Then, a total of 7644 genes correlated with HYAL-1 was predicted in PDAC tissues and the enriched pathway, kinase targets and biological process of those correlated genes were evaluated. Finally, a mouse pancreatic fistula (PF) model was first built and in vitro studies were performed to investigate the effects of HYAL-1 on PF progression. Our data indicated that preoperative serum HYAL-1 level, pancreatic fibrosis score, and pancreatic duct size were valuable factors for detecting POPF of Grade B and C. The serum HYAL-1 level of 2.07 mg/ml and pancreatic fibrosis score of 2.5 were proposed as the cutoff values for indicating POPF. The bioinformatic analysis and in vitro and in vivo studies demonstrated that HYAL-1 facilitates pancreatic acinar cell autophagy via the dephosphorylation of adenosine 5'-monophosphate-activated protein kinase (AMPK) and signal transducers and activators of transcription 3 (STAT3) signaling pathways, which exacerbate pancreatic secretion and inflammation. In summary, the preoperative serum HYAL-1 was a significant predictor for POPF in patients who underwent PD. Tumor-induced HYAL-1 is one of core risk in accelerating PF and then promoting pancreatic secretion and acute inflammation response through the AMPK and STAT3-induced autophagy.

Measurement of Pancreatic Fat Fraction by CT Histogram Analysis to Predict Pancreatic Fistula after Pancreaticoduodenectomy

Objective

To evaluate the effectiveness of computed tomography (CT) Hounsfield unit histogram analysis (HUHA) in postoperative pancreatic fistula (PF) prediction.

Materials and Methods

Fifty-four patients (33 males and 21 females; mean age, 65.6 years; age range, 37–89 years) who had undergone preoperative CT and pancreaticoduodenectomy were included in this retrospective study. Two radiologists measured mean CT Hounsfield unit (CTHU) values by drawing regions of interest (ROIs) at the level of the pancreaticojejunostomy site on preoperative pre-contrast images. The HUHA values were arbitrarily divided into three categories, comprising HUHA-A ≤ 0 HU, 0 HU < HUHA-B < 30 HU, and HUHA-C ≥ 30 HU. Each HUHA value within the ROI was calculated as a percentage of the entire area using commercial 3-dimensional analysis software. Pancreas texture was evaluated as soft or hard by manual palpation.

Results

Fifteen patients (27.8%) had clinically relevant PFs. The PF group had significantly higher HUHA-A (p < 0.01) and significantly lower mean CTHU (p < 0.01) values than those of the non-PF group. The HUHA-A value had a moderately strong correlation with PF occurrence (r = 0.60, p < 0.01), whereas the mean CTHU had a weak negative correlation with PF occurrence (r = −0.27, p < 0.01). The HUHA-A and mean CTHU areas under the curve (AUCs) for predicting PF occurrence were 0.86 and 0.65, respectively, with significant difference (p < 0.01). The HUHA-A and mean CTHU AUCs for predicting pancreatic softness were 0.86 and 0.64, respectively, with significant difference (p < 0.01).

Conclusion

The HUHA-A values on preoperative pre-contrast CT images demonstrate a strong correlation with PF occurrence.

Significance of bile culture surveillance for postoperative management of pancreatoduodenectomy

Background

The management of infectious complications is important in pancreatoduodenectomy (PD). We sought to determine the significance of preoperative surveillance bile culture in perioperative management of PD.

Methods

This study enrolled 69 patients who underwent PD for malignant tumors at a single institute between 2014 and 2017. Surveillance bile culture was performed before or during surgery. Correlations between the incidence of infectious postoperative complications and clinicopathological parameters, including bile cultures, were evaluated.

Results

Preoperative positive bile culture was confirmed in 28 of 51 patients (55%). Bile culture was positive in 27 of 30 cases (90%) with preoperative biliary drainage, and 1 of 21 cases (5%) without drainage (p < 0.01). Preoperative isolated microorganisms in bile were consistent with those detected in surgical sites in 11 of 27 cases (41%). Cases with positive multi-drug-resistant bacteria in preoperative bile culture showed significantly higher incisional SSI after PD (p = 0.01). The risk factors for the incidence of organ/space SSI were soft pancreatic texture (p = 0.01) and smoking history (p = 0.02) by multivariate analysis. Preoperative positive bile culture was neither associated with organ/space SSI nor overall postoperative complications.

Conclusions

Preoperative surveillance bile culture is useful for the management of wound infection, prediction of causative pathogens for infectious complications, and the selection of perioperative antibiotic prophylaxis.

Novel single-layer continuous suture of pancreaticojejunostomy for robotic pancreaticoduodenectomy

BACKGROUND

The best technique for pancreatic anastomosis after pancreaticoduodenectomy (PD) remains controversial, and the procedure for robotic PD (RPD) has not been previously reported. This study aimed to evaluate the safety and feasibility of a novel technique of pancreaticojejunostomy (PJ) for RPD.

METHODS

The demographics and perioperative outcomes of a consecutive series of RPD patients who underwent single-layer continuous suture (SCS) for PJ between September 2018 and November 2018 were analyzed.

RESULTS

Thirty patients were included in the study. Twenty patients had a soft pancreas, and 15 patients had a small main pancreatic duct (MPD) (<3 mm). The mean operative time was 234.1 min, the mean duration of PJ was 14.9 min, and the median estimated blood loss was 100.0 ml. No patients required conversion to laparotomy. Postoperative pancreatic fistula (POPF) included seven cases of Grade A and two cases of Grade B. No case of Grade C POPF occurred. The mean postoperative hospital stay was 12.3 days. No 90-day readmission or mortality was observed. Neither pancreatic texture nor MPD size affected the perioperative outcomes.

CONCLUSIONS

Single-layer continuous suture is easy to perform and is associated with favorable clinical outcomes, regardless of the pancreatic duct size and texture.

Evaluation of preoperative risk factors for postpancreatectomy hemorrhage

Purpose

To investigate the risk factors for post-pancreatectomy hemorrhage (PPH).

Methods

The incidence, outcome, and risk factors for PPH were evaluated in 1169 patients who underwent pancreatectomy.

Results

The incidence and mortality rates of PPH were 3% and 11% in all pancreatectomies, 4% and 11% in pancreatoduodenectomy, 1% and 20% in distal pancreatectomy, and 3% and 0% in total pancreatectomy, respectively. Male sex [odds ratio (OR) 2.32], body mass index (BMI) ≥ 25 kg/m² (OR 3.70), absence of diabetes mellitus (DM; HbA1c ≤ 6.2%; OR 3.62), and pancreatoduodenectomy (OR 3.06) were risk factors for PPH after all pancreatectomies. The PPH incidence was 0%, 1%, 2%, 6%, and 20% in patients with risk scores of 0 (n = 65), 1 (n = 325), 2 (n = 455), 3 (n = 299), and 4 (n = 25), respectively. The differences between risk-score groups 0–2 (2%) and 3–4 (7%) were significant (P < 0.05, OR 4.7). In patients who had undergone pancreatoduodenectomy, postoperative pancreatic fistula (POPF; OR 31.7) and absence of DM (OR 3.45) were risk factors for PPH. There was no significant association between POPF and PPH after distal pancreatectomy (P = 0.28). The incidence of POPF post-pancreatoduodenectomy was 20%. BMI ≥ 25 kg/m² (OR 3.17), serum albumin < 3.5 g/dl (OR 1.77), absence of DM (OR 1.75), distal extrahepatic bile duct carcinoma (OR 4.05), and carcinoma of the papilla of Vater (OR 5.19) were risk factors for POPF post-pancreatoduodenectomy.

Conclusion

Our study clarified the preoperative risk factors for PPH and recommends using a risk scoring system that includes “absence of DM” for predicting PPH.

Electronic supplementary material

The online version of this article (10.1007/s00423-019-01830-w) contains supplementary material, which is available to authorized users.

Malnutrition, frailty, and sarcopenia in pancreatic cancer patients: assessments and interventions for the pancreatic surgeon

The objective of this article is to review the available literature examining the impact of malnutrition, frailty, and sarcopenia on surgical morbidity among pancreatic cancer patients. We examine definitions used to diagnose and quantify these conditions and review the differences between them with regards to preoperative assessment and postoperative outcomes. The most relevant scoring systems are summarized. Lastly, we summarize current knowledge regarding effectiveness of specific interventions aimed at malnutrition, frailty, and sarcopenia for patients undergoing pancreatic cancer surgery.