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Maino C, Cereda M, Franco PN, Boraschi P, Cannella R, Gianotti LV, Zamboni G, Vernuccio F, Ippolito D. Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon. Eur J Radiol Open 2024; 12:100544. [PMID: 38304573 PMCID: PMC10831502 DOI: 10.1016/j.ejro.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 02/03/2024] Open
Abstract
Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.
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Affiliation(s)
- Cesare Maino
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Marco Cereda
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Paolo Niccolò Franco
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Piero Boraschi
- Radiology Unit, Azienda Ospedaliero-Universitaria Pisana, 56124 Pisa, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Luca Vittorio Gianotti
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
| | - Giulia Zamboni
- Institute of Radiology, Department of Diagnostics and Public Health, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Federica Vernuccio
- University Hospital of Padova, Institute of Radiology, 35128 Padova, Italy
| | - Davide Ippolito
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
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Gaspar AF, Kemp R, Sankarankutty AK, Júnior JRL, Filho JAF, Martone D, Mota GDA, Santos JSD. Clinical outcomes and costs of the use of fibrin sealant in pancreaticojejunal anastomosis after pancreaticoduodenectomy: a retrospective analysis study. Ann Med Surg (Lond) 2021; 67:102531. [PMID: 34276983 PMCID: PMC8267440 DOI: 10.1016/j.amsu.2021.102531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/27/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives The benefits of using a fibrin sealant to reinforce the pancreaticojejunal anastomosis are still contentious, a fact that justifies the study of its effects on clinical outcomes and costs of pancreaticoduodenectomy. Methods Study of 62 consecutive patients submitted to pancreaticoduodenectomy, divided into two groups of 31 patients each: GWS = group with sealant and GWOS = group without sealant that were compared according to demographic, clinical, laboratory aspects, the incidence of postoperative pancreatic fistula (POPF), according to the definition of the International Study Group on Pancreatic Fistula, updated in 2016, and its postoperative complications categorized according to the Clavien classification, as well as hospital costs evaluated by the absorption costing method (with the exception of those related to medications). Results The groups were homogeneous and there were no significant differences in the postoperative clinical course or in the indicators of hospital care between them. Hard texture of pancreatic tissue was the only protective factor against the development of POPF (RR = 0.29 (95%CI:0,12–0,68); p = 0.005). Moreover, hospital costs were higher in GWS than in GWOS (p < 0.0001). Conclusions The use of fibrin sealant to reinforce pancreaticojejunal anastomosis did not improve the clinical and healthcare outcomes and, in addition, increased hospital costs. Pancreaticoduodenectomy is the treatment of choice for resectable tumors of the pancreato-duodenal confluence. Morbidity rates remain high ranging between 30% and 50%. Pancreatic fistula is the most feared post pancreatic surgery complication. Studies on the effects of using fibrin sealant in pancreatic surgery are scarce and controversial.
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Affiliation(s)
- Alberto Facury Gaspar
- Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Corresponding author. Bandeirantes Avenue, 3900, Monte Alegre, Ribeirão Preto city, São Paulo state, Brazil.
| | - Rafael Kemp
- Division of Gastrointestinal Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ajith Kumar Sankarankutty
- Division of Gastrointestinal Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | | | - Daniel Martone
- Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Gustavo de Assis Mota
- Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - José Sebastião dos Santos
- Division of Gastrointestinal Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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Caputo D, Angeletti S, Ciccozzi M, Cartillone M, Cascone C, La Vaccara V, Coppola A, Coppola R. Role of drain amylase levels assay and routinary postoperative day 3 abdominal CT scan in prevention of complications and management of surgical drains after pancreaticoduodenectomy. Updates Surg 2020; 72:727-741. [PMID: 32410161 DOI: 10.1007/s13304-020-00784-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/02/2020] [Indexed: 12/21/2022]
Abstract
To asses drains amylase (DA) cut-offs for the risk of clinically relevant postoperative pancreatic fistula (POPF) and define the optimal timing of drains removal based on daily DA assay and abdominal CT scan finding after pancreatoduodenectomy (PD). Different algorithms able to identify patients at higher risk of POPF and to assess the optimal time for drains removal after PD have been proposed. The most accurate DA cut-offs in the assessment of the risk of clinically relevant POPF were retrospectively identified. Data from a prospective trial for optimal timing of drains removal were analyzed. Then, to validate the cut-offs identified in the first phase, they were applied to the patients enrolled in the prospective trial. Patients with POD1 DA ≥ 666 U/L were at higher risk of clinically relevant POPF (p 0.0001). POD3 DA value ≥ 252 U/L predicted 88% of clinical relevant fistulas. POD3 DA level ≥ 207 U/L was able to predict 68% of biliary fistulas. Patients with abdominal collection ≥ 5 cm, showed a significantly higher rate (60% vs. 23%, p < 0.001) of biliary fistula. Timing of drains removal did not influence complications. Drains amylase levels predict clinically relevant POPF. Drains should be maintained up to POD3; in case of POD1 DA levels < 666 U/L and POD3 DA levels < 252 U/L drains could be removed. In case of POD3 DA levels, ≥ 207 the routine use of abdominal CT scan in the same day could be justified to detect collections ≥ 5 cm and maintain drains beyond the POD3.
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Affiliation(s)
- Damiano Caputo
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico of Rome, Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistic and Molecular Epidemiology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Mariacristina Cartillone
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Chiara Cascone
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Vincenzo La Vaccara
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Alessandro Coppola
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Roberto Coppola
- Department of Surgery, University Campus Bio-Medico of Rome, Via Alvaro del Portillo 200, 00128, Rome, Italy
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Factibilidad y morbimortalidad en doscientos casos consecutivos de pancreaticogastrostomía después de duodenopancreatectomía. Cir Esp 2019; 97:501-509. [DOI: 10.1016/j.ciresp.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/30/2019] [Accepted: 04/06/2019] [Indexed: 12/19/2022]
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Estándares de calidad en la cirugía oncológica pancreática en España. Cir Esp 2018; 96:342-351. [DOI: 10.1016/j.ciresp.2018.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/02/2018] [Accepted: 03/06/2018] [Indexed: 12/18/2022]
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Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review. Int J Surg 2015; 21 Suppl 1:S4-9. [DOI: 10.1016/j.ijsu.2015.04.088] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 02/08/2023]
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Morales Soriano R, Esteve Pérez N, Tejada Gavela S, Cuadrado García Á, Rodríguez Pino JC, Morón Canis JM, Molina Romero X, Muñoz Pérez J, González Argente X. Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy. Cir Esp 2015; 93:509-15. [PMID: 26072690 DOI: 10.1016/j.ciresp.2015.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/12/2015] [Accepted: 04/15/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs.
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Affiliation(s)
- Rafael Morales Soriano
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España.
| | - Neus Esteve Pérez
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - Silvia Tejada Gavela
- Departamento de Biología y Ciencias de la Salud, Universidad de las Islas Baleares, Palma de Mallorca, Baleares, España
| | | | - José Carlos Rodríguez Pino
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - José Miguel Morón Canis
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - Xavier Molina Romero
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - José Muñoz Pérez
- Servicio de Cirugía General y Digestivo, Hospital Son Llátzer, Palma de Mallorca, Baleares, España
| | - Xavier González Argente
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
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Chen YJ, Lai ECH, Lau WY, Chen XP. Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature. Int J Surg 2014; 12:706-11. [PMID: 24851718 DOI: 10.1016/j.ijsu.2014.05.060] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/11/2014] [Accepted: 05/14/2014] [Indexed: 01/15/2023]
Abstract
Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.
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Affiliation(s)
- Yong-jun Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, China.
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Xiao-ping Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
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