Amylase level after pancreaticoduodenectomy in predicting postoperative pancreatic fistula

Nursing of a patient with multiple primary cancers: A case report and review of literature

BACKGROUND

Although the occurrence of multiple primary cancers (MPC) is not exceedingly common, it is not rare in clinical practice. In recent years, there has been a notable increase in its incidence. The frequent confusion between MPC and tumor metastasis or recurrence often leads to delays in diagnosis and treatment. This study aimed to enhance understanding of MPC, improve diagnostic accuracy, guide precise clinical treatment, and implement a case management nursing model (CMNM) to facilitate quick patient recovery.

CASE SUMMARY

A 61-year-old female patient presented with persistent upper abdominal pain lasting over 2 months. Gastroscopy revealed the presence of both gastric and duodenal cancers. Following a thorough evaluation, the patient underwent pancreaticoduodenectomy, cholecystectomy, and total gastrectomy. Post-surgery, an individualized case management nursing approach was applied, leading to a successful recovery. Three months after the surgery, follow-up examinations showed no signs of recurrence.

CONCLUSION

The CMNM effectively promoted rapid patient recovery, enhanced the quality of orthopedic nursing services, and accelerated postoperative recovery, ultimately leading to increased patient satisfaction with nursing care.

Biochemical Signals of Survival: A Study on Mortality Markers in Coronary Bypass Surgery Patients

BACKGROUND

Coronary bypass surgery remains a cornerstone treatment for advanced coronary artery disease. Identifying reliable predictors of postoperative mortality can significantly enhance patient care and outcomes. This study investigates the prognostic value of preoperative and postoperative amylase levels, creatinine, alanine aminotransferase, and aspartate aminotransferase as mortality markers in coronary bypass surgery patients.

METHODS

We conducted a retrospective analysis of 343 patients who underwent coronary bypass surgery. We compared the preoperative and postoperative biochemical markers (amylase, creatinine, alanine aminotransferase, and aspartate aminotransferase) of patients who died within the first week post-surgery (n = 52) and those who survived (n = 291). Statistical analyses included chi-square tests for categorical variables, t-tests for continuous variables, and receiver operating characteristic analysis for predicting mortality.

RESULTS

No significant difference was observed in the distribution of blood groups between deceased and surviving patients. However, significant differences were noted in gender distribution and mean ages, with higher mortality observed in older and male patients. Preoperative creatinine levels were significantly higher in patients who died compared to survivors. Postoperatively, deceased patients exhibited significantly higher levels of amylase, creatinine, alanine aminotransferase, and aspartate aminotransferase. Receiver operating characteristic analysis revealed that postoperative amylase, creatinine, alanine aminotransferase, and aspartate aminotransferase values were good predictors of mortality, with amylase being the most significant predictor.

CONCLUSION

This study highlights the importance of biochemical markers, particularly amylase, as predictors of mortality in patients undergoing coronary bypass surgery. The findings suggest that monitoring and managing amylase, creatinine, alanine aminotransferase, and aspartate aminotransferase levels pre- and post-surgery could improve patient outcomes. This study lays the groundwork for further research into the mechanistic links between these biochemical markers and patient survival, potentially leading to improved prognostic tools and therapeutic strategies.

Postoperative Day 1 Drain Amylase After Pancreatoduodenectomy: Optimal Level to Predict Pancreatic Fistula

INTRODUCTION

Drain amylase on day 1 (DA-D1) after pancreaticoduodendectomy (PD) to predict occurrence of postoperative pancreatic fistula (POPF) is controversial. In this study, we evaluate the optimal DA-D1 level to predict clinically relevant POPF (CR-POPF).

METHODS

The 2014-2020 NSQIP pancreatectomy-targeted database was queried for patients who underwent elective PD. Perioperative data was extracted to determine development of POPF and CR-POPF per International Study Group of Pancreatic Fistula guidelines. Receiver operative curve (ROC) and Youden's index were used to assess the performance and optimal cutoff for DA-D1 to predict CR-POPF. The DA-D1 value was confirmed with a multivariable logistic regression to determine hazard ratios (HR) for CR-POPF and conditional logistic regression by modified fistula risk score (mFRS) subgroups.

RESULTS

A total of 6,087 patients with complete perioperative data were included. Mean DA-D1 was 2,897 ± 8,636 U/L; median drain duration was 5 days. CR-POPF was documented in 544 (8.9%) patients. DA-D1 ROC for CR-POPF had area under the curve of 0.779 (95%CI 0.759-0.798). Youden's index for the CR-POPF ROC coordinates had 77.6% sensitivity and 66.3% specificity, corresponding to DA-D1 values ≥ 720U/L as an optimal cutoff. CR-POPF was higher for patients with DA-D1 ≥ 720U/L (HR 4.6; p = 0.001). Patients DA-D1 < 720U/L with a negligible, low, intermediate, and high mFRS had respectively 1%, 3%, 4%, and 7% rate of CR-POPF.

CONCLUSION

DA-D1 < 720U/L after elective PD is a clinically useful predictor of CR-POPF. For patients with negligible to intermediate FRS, surgeons should consider utilizing DA-D1 < 720 U/L for removal of a drain on the first postoperative day.

Incidence and risk factors of postoperative acute pancreatitis after pancreaticoduodenectomy: a systematic review and meta-analysis

Background

Postoperative acute pancreatitis (POAP) is a specific complication after pancreatectomy. The acute inflammatory response of the residual pancreas may affect the healing of pancreatoenteric anastomoses, leading to postoperative pancreatic fistulas (POPFs), abdominal infections, and even progressive systemic reactions, conditions that negatively affect patients' prognoses and can cause death. However, to the best of our knowledge, no systematic reviews or meta-analytic studies have assessed the incidence and risk factors of POAP after pancreaticoduodenectomy (PD).

Method

We searched PubMed, Web of Science, Embase, and Cochrane Library databases for relevant literature describing the outcomes of POAP after PD until November 25, 2022, and we used the Newcastle-Ottawa Scale to assess the quality of the studies. Next, we pooled the incidence of POAP and the odds ratios (ORs) and 95% confidence intervals (CIs) of the risk factors using a random-effect meta-analysis. I2 tests were used to assess heterogeneity between the studies.

Results

We analyzed data from 7,164 patients after PD from 23 articles that met the inclusion criteria for this study. The subgroup results of the meta-analysis by different POAP diagnostic criteria showed that the incidences of POAP were 15% (95% CI, 5-38) in the International Study Group for Pancreatic Surgery group, 51% (95% CI, 42-60) in the Connor group, 7% (95% CI, 2-24) in the Atlanta group, and 5% (95% CI, 2-14) in the unclear group. Being a woman [OR (1.37, 95% CI, 1.06-1.77)] or having a soft pancreatic texture [OR (2.56, 95% CI, 1.70-3.86)] were risk factors of POAP after PD.

Conclusion

The results showed that POAP was common after PD, and its incidence varied widely according to different definitions. Large-scale reports are still needed, and surgeons should remain aware of this complication.

Systematic Review Registration

identifier: CRD42022375124.

Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement after Pancreatic Surgery: Technical and Clinical Outcome in 133 Consecutive Patients during a 14-Year Period

(1) Purpose: To retrospectively assess the technical and clinical outcome of patients with symptomatic postoperative fluid collections after pancreatic surgery, treated with CT-guided drainage (CTD). (2) Methods: 133 eligible patients between 2004 and 2017 were included. We defined technical success as the sufficient drainage of the fluid collection(s) and the absence of peri-interventional complications (minor or major according to SIR criteria). Per definition, clinical success was characterized by normalization of specific blood parameters within 30 days after the intervention or a decrease by at least 50% without requiring additional surgical revision. C-reactive protein (CRP), Leukocytes, Interleukin-6, and Dose length product (DLP) for parts of the intervention were determined. (3) Results: 97.0% of 167 interventions were technically successful. Clinical success was achieved in 87.5% of CRP, in 78.4% of Leukocytes, and in 87.5% of Interleukin-6 assessments. The median of successful decrease was 6 days for CRP, 5 days for Leukocytes, and 2 days for Interleukin-6. No surgical revision was necessary in 93.2%. DLP was significantly lower in the second half of the observation period (total DLP: median 621.5 mGy*cm between 2011–2017 vs. median 944.5 mGy*cm between 2004–2010). (4) Conclusions: Technical success rate of CTD was very high and the clinical success rate was fair to good. Given an elderly and multimorbid patient cohort, CTD can have a temporizing effect in the postoperative period after pancreatic surgery. Reducing the radiation dose over time might reflect developments in CT technology and increased experience of interventional radiologists.

Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases)

Background

To explore the application value of free omental wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).

Methods

The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analysed. In total, 86 cases were divided into Group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases were divided into Group B (control group). The incidences of postoperative pancreatic fistula and other complications were compared between the two groups, and univariate and multivariate logistic regression analyses were used to determine the potential risk factors for postoperative pancreatic fistula. Risk factors associated with postoperative overall survival were identified using Cox regression.

Results

The incidences of grade B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in Group A were lower than those in Group B, and the differences were statistically significant (P < 0.05). Group A had an earlier drainage tube extubation time, earlier return to normal diet time and shorter postoperative hospital stay than the control group (P < 0.05). The levels of C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) inflammatory factors 1, 3 and 7 days after surgery also showed significant. Univariate and multivariate logistic regression analyses showed that a body mass index (BMI) ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P < 0.05). Cox regression analysis showed that age ≥ 65 years old, body mass index ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap isolation and modified pancreaticojejunostomy, and malignant postoperative pathology were independent risk factors associated with postoperative overall survival (P < 0.05).

Conclusions

Wrapping and isolating the modified pancreaticojejunostomy with free greater omentum can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and favourably affect prognosis.

Preoperative and intraoperative risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy – systematic review and meta-analysis

Introduction: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication after pancreaticoduodenectomy (PD). It is observed when the amylase activity in the drain fluid exceeds three times the normal upper value. Grades B and C of POPF are considered as clinically relevant. Fistula might originate due to failure of healing of a pancreatic anastomosis or from raw pancreatic surface. Materials and methods: 18 retrospective and prospective studies published between 2015 and 2020 were included in this meta-analysis. Total number of patients was 5836. To investigate potential risk factors associated with the occurrence of POPF, odds ratios (OR) with 95% confidence intervals (CI) were calculated. To compare discontinuous data, mean differences (MD) were calculated. Results: 13 factors were divided into preoperative and intraoperative groups. Male sex, higher BMI, soft pancreatic texture and small pancreatic duct were considered as significant risk factors while vascular resection lowered the risk of development pancreatic fistula. Discussion: It is considered that the development of POPF is associated with intrapancreatic fat. More severe infiltration with fat tissue is responsible for soft texture of the gland, while higher BMI is one of the risk factors of increased pancreatic fat. On the contrary, diabetes is associated with fibrotic pancreas which could lower the risk of developing POPF.