1
|
Stoop TF, Bergquist E, Theijse RT, Hempel S, van Dieren S, Sparrelid E, Distler M, Hackert T, Besselink MG, Del Chiaro M, Ghorbani P. Systematic Review and Meta-analysis of the Role of Total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula: Is it a Justifiable Indication? Ann Surg 2023; 278:e702-e711. [PMID: 37161977 PMCID: PMC10481933 DOI: 10.1097/sla.0000000000005895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF). SUMMARY BACKGROUND DATA TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking. METHODS Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥IIIa) on the short-term and quality of life. RESULTS After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR=1.04 [95%CI 0.56-1.93]). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR=0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [±15] vs. 76% [±20]; P =0.857). CONCLUSIONS This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bail-out procedure, the comparable long-term quality of life is reassuring.
Collapse
Affiliation(s)
- Thomas F. Stoop
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Erik Bergquist
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Rutger T. Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G. Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
2
|
Marichez A, Adam JP, Mauriac P, Passand GT, Fernandez B, Laurent C, Chiche L. Preemptive wirsungostomy: a safe fistula for avoiding a dreadful fistula in elective or planned pancreatoduodenectomy. HPB (Oxford) 2023:S1365-182X(23)00121-1. [PMID: 37183127 DOI: 10.1016/j.hpb.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND High-risk pancreatic anastomosis can lead to a high mortality rate after PD due to the development of postoperative pancreatic fistula (POPF). Performing a wirsungostomy by externalizing the pancreatic duct is a poorly known alternative to anastomosis which could reduce the risk of POPF and the associated severe morbidity METHODS: We retrospectively evaluated patients who underwent primary wirsungostomy with PD from January 2007 to December 2021 in our tertiary referral center. Rates of morbidity and mortality with long-term pancreatic functions were studied. RESULTS Sixty patients were included. The median Updated Alternative Fistula Risk Score (ua-FRS) was 52%, with 95% patients in the high-risk ua-FRS category and 88.3% patients with stage D risk of developing POPF according to the classification of the ISGPS. The mortality rate was 3.3%, and overall 90-day postoperative morbidity was 63.7% with 50% of patients developing major complications. Mean follow-up was 29.8 months. Twelve patients (20%) became diabetic and 35 patients (58.3%) had preserved pancreatic endocrine function CONCLUSION: Preemptive wirsungostomy with PD could be an appropriate procedure for patients with high-risk pancreatic anastomosis. The high associated morbidity could be compromised by the low mortality and preservation of endocrine function compared to total pancreatectomy or severe POPF.
Collapse
Affiliation(s)
- Arthur Marichez
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France; Inserm UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion". Bordeaux Institute of Oncology, University of Bordeaux, France
| | - Jean-Philippe Adam
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France
| | - Paul Mauriac
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France
| | - Goudarz T Passand
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France
| | - Benjamin Fernandez
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France
| | - Christophe Laurent
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France
| | - Laurence Chiche
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut-Lévêque Hospital, CHU de Bordeaux, France; Inserm UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion". Bordeaux Institute of Oncology, University of Bordeaux, France.
| |
Collapse
|
3
|
Kazantsev GB, Spitzer AL, Peng PD, Ramirez RM, Chang CK, Tsai S, Aldakkak M, Huyser MR, Dominguez DA. Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy. HPB (Oxford) 2023; 25:124-135. [PMID: 36323594 DOI: 10.1016/j.hpb.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hypothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF. METHODS Review of prospective database of all PD's performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed "high risk" if soft gland and/or small duct were present. RESULTS PJ was performed in 199 (147 "low-risk" and 52 "high-risk") cases, and 110 patients (all "high-risk") had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in "low-risk" versus "high risk" scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively. CONCLUSION Selective use of PG after PD in "high-risk" scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.
Collapse
Affiliation(s)
- George B Kazantsev
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA.
| | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Rene M Ramirez
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed Aldakkak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michelle R Huyser
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA, USA
| | - Dana A Dominguez
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA, USA
| |
Collapse
|
4
|
Prevention and Treatment of Grade C Postoperative Pancreatic Fistula. J Clin Med 2022; 11:jcm11247516. [PMID: 36556131 PMCID: PMC9784648 DOI: 10.3390/jcm11247516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is a troublesome complication after pancreatic surgeries, and grade C POPF is the most serious situation among pancreatic fistulas. At present, the incidence of grade C POPF varies from less than 1% to greater than 9%, with an extremely high postoperative mortality rate of 25.7%. The patients with grade C POPF finally undergo surgery with a poor prognosis after various failed conservative treatments. Although various surgical and perioperative attempts have been made to reduce the incidence of grade C POPF, the rates of this costly complication have not been significantly diminished. Hearteningly, several related studies have found that intra-abdominal infection from intestinal flora could promote the development of grade C POPF, which would help physicians to better prevent this complication. In this review, we briefly introduced the definition and relevant risk factors for grade C POPF. Moreover, this review discusses the two main pathways, direct intestinal juice spillover and bacterial translocation, by which intestinal microbes enter the abdominal cavity. Based on the abovementioned theory, we summarize the operation techniques and perioperative management of grade C POPF and discuss novel methods and surgical treatments to reverse this dilemma.
Collapse
|
5
|
Stoop TF, Fröberg K, Sparrelid E, Del Chiaro M, Ghorbani P. Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy. Langenbecks Arch Surg 2022; 407:3467-3478. [DOI: 10.1007/s00423-022-02708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. However, in-depth literature is scarce and hard to interpret. This study aimed to evaluate the indications, timing and perioperative outcomes of rescue pancreatectomy for severe POPF after PD.
Methods
Retrospective single-centre study from all consecutive patients (2008–2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days).
Results
From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Mortality after early rescue pancreatectomy did not differ significantly compared to late rescue pancreatectomy (13.6% versus 35.3%; p = 0.142). Timing of a rescue pancreatectomy did not change significantly during the study period: 11 (IQR, 8–14) (2008–2012) versus 14 (IQR, 7–33) (2013–2016) versus 8 days (IQR, 6–11) (2017–2020) (p = 0.140). Over time, the mortality in patients with POPF grade C decreased from 43.5% in 2008–2012 to 31.6% in 2013–2016 up to 0% in 2017–2020 (p = 0.014). However, mortality rates after rescue pancreatectomy did not differ significantly: 31.3% (2008–2012) versus 28.6% (2013–2016) versus 0% (2017–2020) (p = 0.104).
Conclusions
Rescue pancreatectomy for severe POPF is associated with high mortality, but an earlier timing might favourably influence the mortality. Hypothetically, this could be of value for pre-existent vulnerable patients. These findings must be carefully interpreted considering the sample sizes and differences among subgroups by patient selection.
Collapse
|
6
|
Feasibility and outcome of spleen and vessel preserving total pancreatectomy (SVPTP) in pancreatic malignancies - a retrospective cohort study. Langenbecks Arch Surg 2022; 407:3457-3465. [PMID: 36169725 DOI: 10.1007/s00423-022-02690-7] [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: 05/23/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Total pancreatectomy (TP) is most commonly performed to avoid postoperative pancreatic fistula (POPF) in patients with high-risk pancreas or to achieve tumor-free resection margins. As part of TP, a simultaneous splenectomy is usually performed primarily for the reason of oncologic radicality. However, the benefit of a simultaneous splenectomy remains unclear. Likewise, the technical feasibility as well as the safety of spleen and vessel preserving total pancreatectomy in pancreatic malignancies has hardly been evaluated. Thus, the aims of the study were to evaluate the feasibility as well as the results of spleen and vessel preserving total pancreatectomy (SVPTP). MATERIAL AND METHODS Patient characteristics, technical feasibility, perioperative data, morbidity, and mortality as well as histopathological results after SVPTP, mainly for pancreatic malignancies, from patient cohorts of two European high-volume-centers for pancreatic surgery were retrospectively analyzed. Mortality was set as the primary outcome and morbidity (complications according to Clavien-Dindo) as the secondary outcome. RESULTS A SVPTP was performed in 92 patients, predominantly with pancreatic adenocarcinoma (78.3%). In all cases, the splenic vessels could be preserved. In 59 patients, the decision to total pancreatectomy was made intraoperatively. Among these, the most common reason for total pancreatectomy was risk of POPF (78%). The 30-day mortality was 2.2%. Major complications (≥ IIIb according to Clavien-Dindo) occurred in 18.5% within 30 postoperative days. There were no complications directly related to the spleen and vascular preservation procedure. A tumor-negative resection margin was achieved in 71.8%. CONCLUSION We could demonstrate the technical feasibility and safety of SVPTP even in patients mainly with pancreatic malignancies. In addition to potential immunologic and oncologic advantages, we believe a major benefit of this procedure is preservation of gastric venous outflow. We consider SVPTP to be indicated in patients at high risk for POPF, in patients with multilocular IPMN, and in cases for extended intrapancreatic cancers.
Collapse
|
7
|
Perri G, Bortolato C, Marchegiani G, Holmberg M, Romandini E, Sturesson C, Bassi C, Sparrelid E, Ghorbani P, Salvia R. Pure biliary leak vs. pancreatic fistula associated: non-identical twins following pancreatoduodenectomy. HPB (Oxford) 2022; 24:1474-1481. [PMID: 35367129 DOI: 10.1016/j.hpb.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary leak (BL) after pancreatoduodenectomy (PD) may have diffrent severity depending on its association with postoperative pancreatic fistula (POPF). METHODS Data of 2715 patients undergoing PD between 2011 and 2020 at two European third-level referral Centers for pancreatic surgery were retrospectively reviewed. These included BL incidences, grading, outcomes, specific treatments, and association with POPF. RESULTS BL occurred in 6% of patients undergoing PD. Among 143 BL patients, 47% had an associated POPF and 53% a pure BL. Major morbidity (64% vs 36%) and mortality (19% vs 4%) were higher in POPF-associated BL group (all P< 0.01). Day of BL onset was similar between groups (POD 2 vs 3; P = 0.2), while BL closure occurred earlier in pure BL (POD 12 vs 23; P < 0.01). Conservative treatment was more frequent (55% vs 15%; P < 0.01), and the rate of percutaneous and/or trans-hepatic drain placement was lower (30% vs 16%; P = 0.04) in pure BL group. Relaparotomy was more common in POPF-associated BL group (42% VS 17%; P < 0.01) but was performed earlier in pure BL (POD 2 vs 10; P = 0.02). CONCLUSIONS Pure BL represents a more benign entity, managed conservatively in half of the cases.
Collapse
Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Cecilia Bortolato
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy; Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy.
| | - Marcus Holmberg
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Elisa Romandini
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Christian Sturesson
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| |
Collapse
|
8
|
Yamamoto M, Zaima M, Yazawa T, Yamamoto H, Harada H, Yamada M, Tani M. Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy. World J Surg Oncol 2022; 20:223. [PMID: 35786384 PMCID: PMC9252026 DOI: 10.1186/s12957-022-02687-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pancreaticojejunal (PJ) anastomosis occasionally fails several months after pancreaticoduodenectomy (PD) with Child reconstruction and can ultimately result in a late-onset complete pancreaticocutaneous fistula (Lc-PF). Since the remnant pancreas is an isolated segment, surgical intervention is necessary to create internal drainage for the pancreatic juice; however, surgery at the previous PJ anastomosis site is technically challenging even for experienced surgeons. Here we describe a simple surgical procedure for Lc-PF, termed redo PJ anastomosis, which was developed at our facility. METHODS: Between January 2008 and December 2020, six consecutive patients with Lc-PF after PD underwent a redo PJ anastomosis, and the short- and long-term clinical outcomes have been evaluated. The abdominal cavity is carefully dissected through a 10-cm midline skin incision, and the PJ anastomosis site is identified using a percutaneous drain through the fistula tract as a guide, along with the main pancreatic duct (MPD) stump on the pancreatic stump. Next, the pancreatic stump is deliberately immobilized from the dorsal plane to prevent injury to the underlying major vessels. After fixing a stent tube to both the MPD and the Roux-limb using two-sided purse-string sutures, the redo PJ anastomosis is completed using single-layer interrupted sutures. Full-thickness pancreatic sutures are deliberately avoided by passing the needle through only two-thirds of the anterior side of the pancreatic stump. RESULTS The redo PJ anastomosis was performed without any intraoperative complications in all cases. The median intraoperative bleeding and operative time were 71 (range 10-137) mL and 123 (range 56-175) min, respectively. Even though a new mild pancreatic fistula developed postoperatively in all cases, it could be conservatively treated within 3 weeks, and no other postoperative complications were recorded. During the median follow-up period of 92 (range 12-112) months, no complications at the redo PJ anastomosis site were observed. CONCLUSIONS This research shows that the redo PJ anastomosis for Lc-PF we developed is a safe, feasible, and technically no demanding procedure with acceptable short- and long-term clinical outcomes. This procedure has the potential to become the preferred treatment strategy for Lc-PF after PD.
Collapse
Affiliation(s)
- Michihiro Yamamoto
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan.
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Tekefumi Yazawa
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Masaki Tani
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| |
Collapse
|
9
|
Giuliani A, Avella P, Segreto AL, Izzo ML, Buondonno A, Coluzzi M, Cappuccio M, Brunese MC, Vaschetti R, Scacchi A, Guerra G, Amato B, Calise F, Rocca A. Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers. Front Surg 2022; 8:804675. [PMID: 34993230 PMCID: PMC8725883 DOI: 10.3389/fsurg.2021.804675] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/25/2021] [Indexed: 12/07/2022] Open
Abstract
Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO. Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months. Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive. Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.
Collapse
Affiliation(s)
- Antonio Giuliani
- Unit of General and Emergency Surgery, AOR "San Carlo", Potenza, Italy.,Unit of Hepatobiliary Surgery and Liver Transplant Centre, "Cardarelli" Hospital, Naples, Italy
| | - Pasquale Avella
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Anna Lucia Segreto
- Department of General Surgery "SS. Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Maria Lucia Izzo
- Unit of General and Emergency Surgery, AOR "San Carlo", Potenza, Italy
| | - Antonio Buondonno
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | | | - Micaela Cappuccio
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Roberto Vaschetti
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Andrea Scacchi
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Germano Guerra
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fulvio Calise
- Unit of Hepatobiliary Surgery and Liver Transplant Centre, "Cardarelli" Hospital, Naples, Italy.,HPB Surgery Unit, Pineta Grande Hospital, Campania, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.,HPB Surgery Unit, Pineta Grande Hospital, Campania, Italy
| |
Collapse
|
10
|
Falconi M. Total pancreatectomy: how, when and why? Updates Surg 2021; 73:1203-1204. [PMID: 34286418 DOI: 10.1007/s13304-021-01134-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Massimo Falconi
- School of Medicine, Vita Salute San Raffaele University, Milan, Italy.
- Division of Pancreatic Surgery, IRCCS Ospedale San Raffaele, Milan, Italy.
| |
Collapse
|