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Mastalier B, Cauni V, Tihon C, Septimiu Petrutescu M, Ghita B, Popescu V, Andras D, Radu IM, Vlasceanu VG, Floroiu MF, Draghici C, Botezatu C, Cretoiu D, Varlas VN, Lazar AM. Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score. J Clin Med 2023; 12:6193. [PMID: 37834836 PMCID: PMC10573877 DOI: 10.3390/jcm12196193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/07/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.
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Affiliation(s)
- Bogdan Mastalier
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Victor Cauni
- Urology Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania;
| | - Constantin Tihon
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Septimiu Petrutescu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Bogdan Ghita
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Valentin Popescu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dan Andras
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Ion Mircea Radu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Vasile Gabriel Vlasceanu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Florian Floroiu
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Draghici
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Botezatu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dragos Cretoiu
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Genetics, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of Obstetrics and Gynaecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
- Department of Obstetrics and Gynaecology, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania
| | - Angela Madalina Lazar
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
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Wu S, Wu H, Xu G, Zhao Y, Xue F, Dong S, Han L, Wang Z, Wu Z. Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System. Front Surg 2022; 9:916486. [PMID: 35860201 PMCID: PMC9289243 DOI: 10.3389/fsurg.2022.916486] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background The definition and grading system of post-pancreatectomy acute pancreatitis (PPAP) has recently been proposed by ISGPS. This study aimed to put this definition and classification into practice and investigate the potential risk factors and clinical impacts of PPAP. Methods Demographic and perioperative data of consecutive patients who underwent pancreaticoduodenectomy (PD) from January 2019 to July 2021 were collected and analyzed retrospectively. The diagnostic criteria of PPAP published by ISGPS, consisting of biochemical, radiologic, and clinical parameters, were adopted. The risk factors were analyzed by univariate and multivariate analyses. Results A total of 298 patients were enrolled in this study, and the total incidence of PPAP was 52.4% (150 patients). Stratified by clinical impacts of PPAP, the incidences of grades B and C PPAP were 48.9% and 3.5%, respectively. PPAP after PD was significantly associated with pancreatic fistula and other unfavorable complications. Soft pancreatic texture (OR 3.0) and CRP ≥ 180 mg/L (OR 3.6) were the independent predictors of PPAP, AUC 0.613. Stratified by the grade of PPAP, soft pancreatic texture (OR 2.7) and CRP ≥ 180 mg/L (OR 3.4) were the independent predictors of grade B PPAP, and soft pancreatic texture (OR 19.3), operation duration >360 min (OR 13.8), and the pancreatic anastomosis by using conventional duct to mucosa methods (OR 10.4) were the independent predictors of grade C PPAP. PPAP complicated with pancreatic fistula significantly increased the severe complications and mortality compared to only PPAP occurrence. Conclusion PPAP was not an uncommon complication after PD and was associated with unfavorable clinical outcomes, especially since it was complicated with pancreatic fistula. Soft pancreatic texture and CRP ≥ 180 mg/L were the independent predictors of PPAP. Higher-volume multicenter and prospective studies are strongly needed.
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Affiliation(s)
- Shuai Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hanxue Wu
- Department of Physiology and Pathophysiology, School of Basic Medicine, Xi’an Jiaotong University, Xi’an, China
| | - Guiping Xu
- Department of Radiology, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yaling Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Feng Xue
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shunbin Dong
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Liang Han
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Correspondence: Zheng Wu
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Alekyan BG, Lusnikov VP, Varava AB, Kriger AG. [Endovascular treatment of arterial bleeding after pancreatic surgery]. Khirurgiia (Mosk) 2021:76-83. [PMID: 34363449 DOI: 10.17116/hirurgia202108176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreatic surgery is complex and associated with a risk of complications including bleeding. Bleeding after pancreatic surgery is rare, but characterized by high mortality. This review is devoted to classification, diagnosis and treatment strategies for bleeding after pancreatic surgery. Methods and results of endovascular surgery are of special attention.
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Affiliation(s)
- B G Alekyan
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - V P Lusnikov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A B Varava
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Uchida Y, Masui T, Hashida K, Machimoto T, Nakano K, Yogo A, Sato A, Nagai K, Anazawa T, Takaori K, Uemoto S. Impact of vascular abnormality on contrast-enhanced CT and high C-reactive protein levels on postoperative pancreatic hemorrhage after pancreaticoduodenectomy: A multi-institutional, retrospective analysis of 590 consecutive cases. Pancreatology 2021; 21:263-268. [PMID: 33339724 DOI: 10.1016/j.pan.2020.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/26/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: This study aimed to elucidate the efficacy of CT findings and perioperative characteristics to predict post-pancreatectomy hemorrhage (PPH): a critical complication after pancreaticoduodenectomy. METHODS The records of 590 consecutive patients who underwent pancreaticoduodenectomy at three institutes between 2012 and 2018 were included. The presence of a vascular wall abnormality or ascites with high density (vascular abnormality) on postoperative day (POD) 5-10 contrast-enhanced CT (early CT), perioperative characteristics, and any PPH or pseudoaneurysm formation (PPH events) were analyzed through a multivariate analysis. RESULTS PPH events occurred in 48 out of 590 patients (8%). The vascular abnormality on early CT and the C-reactive protein (CRP) value on POD 3 were independent risk factors for PPH events after POD5 (vascular abnormality: odds ratio 6.42, p = 0.001; CRP on POD 3: odds ratio 1.17, p = 0.016). The sensitivity of vascular abnormality for PPH events was 24% (7/29), and the positive predictive value was 30% (7/23). The combination of vascular abnormality and a high CRP value (≥15.5 mg/dL) on postoperative day 3 had a higher positive predictive value of 64% (7/11) than the vascular abnormality alone. None of the seven PPH events that occurred more than one month after surgery were foreseen via early CT. CONCLUSION The combination of vascular abnormality and high CRP value was associated with increasing risk of PPH events after pancreaticoduodenectomy, but the low sensitivity of early CT must be noted as an important shortcoming. The normal findings on early CT could not eliminate the risk of late PPH.
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Affiliation(s)
- Yuichiro Uchida
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan; Department of Surgery, Fujita Medical University, Japan
| | - Toshihiko Masui
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan.
| | - Kazuki Hashida
- Department of Surgery, Kurashiki Central Hospital, Japan
| | | | - Kenzo Nakano
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Akitada Yogo
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Asahi Sato
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Kazuyuki Nagai
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Takayuki Anazawa
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Kyoichi Takaori
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepato-biliary-pancreatic Surgery and Transplantation, Kyoto University, Japan
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Uchida Y, Masui T, Nakano K, Yogo A, Yoh T, Nagai K, Anazawa T, Takaori K, Uemoto S. Combination of postoperative C-reactive protein value and computed tomography imaging can predict severe pancreatic fistula after pancreatoduodenectomy. HPB (Oxford) 2020; 22:282-288. [PMID: 31416787 DOI: 10.1016/j.hpb.2019.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent management after pancreatoduodenectomy recommends either omission of prophylactic drainage or early removal. This potentially makes the diagnosis of postoperative pancreatic fistula (POPF) difficult because the diagnosis is based on the amylase value of drain effluent. The aim of this study was to determine if severe POPF could be predicted independent of drainage information. METHODS Records of consecutive patients who underwent pancreatoduodenectomy between 2012 and 2018 were included for further analysis. The presence of a peripancreatic collection (PC) on routine postoperative (day7) computed tomography (early CT) and perioperative characteristics were analyzed. RESULTS PC appeared in 82/211 patients (39%) and was associated with clinically relevant POPF (p < 0.001). The C-reactive protein (CRP) on postoperative day5 was a good predictor of severe POPF (needing interventional therapy or Grade C) (area under the receiver operating characteristics curve, 0.802; 95% confidence interval, 0.702-0.875). Presence of a PC and a high CRP value were independent risk factors for severe POPF following multivariate analysis. The combination of CRP<5.0 mg/dL on postoperative day 5 and the absence of a PC had 98% negative predictive value. CONCLUSION The combination of CRP measurement and PC evaluation by early CT was useful in predicting severe POPF after pancreatoduodenectomy.
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Affiliation(s)
- Yuichiro Uchida
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Toshihiko Masui
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan.
| | - Kenzo Nakano
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Akitada Yogo
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Tomoaki Yoh
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Kazuyuki Nagai
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Takayuki Anazawa
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Kyoichi Takaori
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepatobiliarypancreatic Surgery and Transplantation, Kyoto University, Japan
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Biondetti P, Fumarola EM, Ierardi AM, Carrafiello G. Bleeding complications after pancreatic surgery: interventional radiology management. Gland Surg 2019; 8:150-163. [PMID: 31183325 DOI: 10.21037/gs.2019.01.06] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.
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Affiliation(s)
- Pierpaolo Biondetti
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Enrico Maria Fumarola
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
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