SSAT GI Surgery Debate: Hepatobiliary and Pancreas: Is Post-Pancreatectomy Acute Pancreatitis a Relevant Clinical Entity?

Early prediction of post-pancreatectomy acute pancreatitis after pancreaticoduodenectomy based on serum C-reactive protein

BACKGROUND

Post-pancreatectomy acute pancreatitis (PPAP) is an early acute inflammatory process of the pancreatic remnant that is associated with a series of downstream pancreas-specific complications. This study aimed to investigate the relationship between postoperative serum C-reactive protein (CRP) levels and the occurrence of PPAP after pancreaticoduodenectomy (PD).

METHODS

Consecutive patients who underwent PD between January 1, 2020, and May 31, 2022, were retrospectively analyzed. PPAP was defined according to the International Study Group for Pancreatic Surgery (ISGPS) definitions. A Sankey diagram incorporating Fistula Risk Score (FRS), serum amylase levels, and serum CRP levels was further performed for the early iterative risk stratification of PPAP.

RESULTS

A total of 601 patients were included in the analysis. Postoperative serum hyperamylasemia (POH) was observed in 268 patients (44.6 %), of whom 136 (16.7 %) developed PPAP after PD. Patients with serum CRP >100 mg/L on postoperative day (POD) 2 had a significantly higher incidence of PPAP (27.2 % vs. 2.3 %, p < 0.001). The highest Youden index was achieved with the cut-off value of 100 mg/L, with the area under the curve (AUC) value of 0.754 for predicting PPAP (sensitivity 91.8 %, specificity 59.0 %). Multivariate analysis revealed that body mass index (BMI) ≥24 (OR 2.09), estimated blood loss >200 mL (OR 1.70), and elevated serum CRP levels (OR 13.01) were independent risk factors for PPAP. Notably, patients with both POH and elevated serum CRP levels on POD 2 were classified as the high-risk group, exhibiting a remarkably high PPAP rate of 41.8 %.

CONCLUSIONS

Serum CRP levels on POD 2 are strongly associated with the development of PPAP after PD. This finding has the potential to enable tailored postoperative management and pave the way for the anti-inflammation strategies targeting the early postoperative period.

The proinflammatory status, based on preoperative interleukin-6, predicts postpancreatectomy acute pancreatitis and associated postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND AND AIM

Early predictors of morbidity after pancreaticoduodenectomy (PD) can guide tailored postoperative management. Preoperative inflammatory data in patients who underwent PD remained poorly studied in investigating the clinical significance of predicting postpancreatectomy acute pancreatitis (PPAP) and PPAP-associated postoperative pancreatic fistula (POPF).

METHODS

The clinical data of 467 patients receiving PD between January 2020 and December 2022 were retrospectively reviewed. Preoperative inflammatory data were stratified according to PPAP, and independent risk factors were analyzed. Multivariate logistic regression and subgroup analyses were conducted to compare risk factors of PPAP-associated POPF and non-PPAP-associated POPF.

RESULTS

PPAP occurred in 17.6% of patients. The incidence of other complications increased following PPAP. Among the preoperative inflammatory factors, only interleukin-6 (IL-6) increased (P < 0.001), leading to a higher incidence of PPAP and POPF (P < 0.001; P = 0.002). The area under the curve of IL-6 in predicting PPAP was 0.71 (0.65-0.77; P < 0.001). Abnormal preoperative IL-6 levels (odds ratio [OR]: 5.01; P < 0.001), soft pancreatic texture (OR: 2.15; P = 0.007), and pathology (OR: 2.03; P = 0.012) were independent risk factors for PPAP. The subgroup analysis showed that increased IL-6 (OR: 1.01; P = 0.006) and soft pancreatic texture (OR: 2.05; P = 0.033) resulted in a higher risk of PPAP-associated POPF, while increased IL-8 (OR: 1.01; P = 0.007), older age (OR: 1.05; P = 0.008), and higher body mass index (OR: 1.12; P = 0.021) correlated with non-PPAP-associated POPF.

CONCLUSION

PPAP is common after PD; a high preoperative IL-6 level can predict its occurrence, in addition to associated POPF, which could be due to a preoperative proinflammatory status.

Association of Postoperative Hyperamylasemia With Clinically Relevant Postoperative Pancreatic Fistula in Pancreatoduodenectomy

Background In this study, we aimed to determine the association between postoperative hyperamylasemia (POH) and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). Methodology A prospective observational study of 140 consecutive PDs between March 2020 and March 2022 was conducted. POH was defined as an elevation in serum pancreatic amylase levels above the institutional upper limit of normal on postoperative day (POD) 1 (>100 U/L). CR-POPF was defined as the International Study Group of Pancreatic Surgery Grade B or C POPF. The primary outcome was the rate of CR-POPF in the study population. The trial was prospectively registered with Clinicaltrials.gov (NCT04514198). Results In our study, 93 (66.42%) patients had POH (serum amylase >100 U/L). CR-POPF developed in 48 (34.28%) patients: 40 type B and 8 type C. CR-POPF rate was 43.01% (40/93) in patients with POH compared to 17.02% (8/47) in patients without POH (p = 0.0022). Patients with POH had a mean serum amylase of 422.7 ± 358.21 U/L on POD1 compared to 47.2 ± 20.19 U/L in those without POH (p < 0.001). Serum amylase >100 U/L on POD1 was strongly associated with developing CR-POPF (odds ratio = 3.71; 95% confidence interval = 1.31-10.37) on logistic regression, with a sensitivity and specificity of 83.3% and 42.4%, respectively. Blood loss >350 mL, pancreatic duct size <3 mm, and elevated POD1 serum amylase >100 U/L were predictive of CR-POPF on multivariate analysis (p < 0.001). Conclusions An elevated serum amylase on POD1 may help identify patients at risk for developing POPF following PD.

The effect of perioperative of dexamethasone on postoperative complications after pancreaticoduodenectomy (PANDEX): a study protocol for a pragmatic multicenter randomized controlled trial

BACKGROUND

Pancreaticoduodenectomy (PD) nowadays serves as a standard treatment for patients with disorders of the pancreas, intestine, and bile duct. Although the mortality rate of patients undergoing PD has decreased significantly, postoperative complication rates remain high. Dexamethasone, a synthetic glucocorticoid with potent anti-inflammatory and metabolic effects, has been proven to have a favorable effect on certain complications. However, the role it plays in post-pancreatectomy patients has not been systematically evaluated. The aim of this study is to assess the effect of dexamethasone on postoperative complications after PD.

METHODS

The PANDEX trial is an investigator-initiated, multicentric, prospective, randomized, double-blinded, placebo-control, pragmatic study. The trial is designed to enroll 300 patients who are going to receive elective PD. Patients will be randomized to receive 0.2 mg/kg dexamethasone or saline placebo, administered as an intravenous bolus within 5 min after induction of anesthesia. The primary outcome is the Comprehensive Complication Index (CCI) score within 30 days after the operation. The secondary outcomes include postoperative major complications (Clavien-Dindo≥3), postoperative pancreatic fistula (POPF), post-pancreatectomy acute pancreatitis (PPAP), infection, and unexpected relaparotomy, as well as postoperative length of stay, 30-day mortality, and 90-day mortality.

DISCUSSION

The PANDEX trial is the first randomized controlled trial concerning the effect of dexamethasone on postoperative complications of patients undergoing PD, with the hypothesis that the intraoperative use of dexamethasone can reduce the incidence of postoperative complications and improve short-term outcomes after PD. The results of the present study will guide the perioperative use of dexamethasone and help improve the clinical management of post-pancreatectomy patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05567094. Registered on 30 September 30 2022.

Acute pancreatitis after pancreatoduodenectomy: clinical outcomes and predictive factors analysis according to the International Study Group of Pancreatic Surgery definition

BACKGROUND

Post-pancreatectomy acute pancreatitis (PPAP) is an increasingly described complication after pancreatic resection. No uniform definition criteria were present in the literature until the recent proposal of the International Study Group of Pancreatic Surgery (ISGPS). Aim of this study is to evaluate the clinical significance of the novel ISGPS definition of PPAP.

METHODS

Patients who underwent pancreatoduodenectomy (PD) between 2006 and 2022 were enrolled. PPAP was defined and graded according to the ISGPS criteria.

RESULTS

Among 520 PDs, 120 (23%)patients developed post-operative hyperamylasemia (POH), while PPAP occurred in 63(12.1%) cases. PPAP occurrence related to a higher rate of more severe complications (48-76.1%vs118-25.8%; p < 0.0001), delayed gastric emptying (DGE) (27-42.9%vd114-24.9%; p = 0.003) and post-operative pancreatic fistula (POPF) (57-90.5%vs186-40.8%; p < 0.0001). When stratified for PPAP severity, grade B and C patients more frequently developed major complications (p < 0.0001), POPF (p < 0.0001), DGE (p = 0.02) and post-operative hemorrhage (p < 0.0001) as compared to POH. At the multivariable analysis, soft pancreatic texture (p = 0.01)and a Wirsung diameter ≤3 mm (p = 0.01) were recognized as prognostic factors for PPAP onset, while a pancreatic duct ≤3 mm was the only feature significantly influencing a more severe course of PPAP (p = 0.01).

CONCLUSION

The ISGPS classification is confirmed as a valuable method for a uniform definition and clinical course evaluation. Further studies in a prospective manner are still needed for a further confirmation.

Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort

BACKGROUND

Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).

METHOD

A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF.

RESULTS

Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69-0.83) to identify the onset of CR-POPF.

CONCLUSION

Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.