Complications after pancreatic resection: diagnosis, prevention and management

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

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.

Tomoelastography and Pancreatic Extracellular Volume Fraction Derived From MRI for Predicting Clinically Relevant Postoperative Pancreatic Fistula

BACKGROUND

Pancreatic stiffness and extracellular volume fraction (ECV) are potential imaging biomarkers for pancreatic fibrosis. Clinically relevant postoperative fistula (CR-POPF) is one of the most severe complications after pancreaticoduodenectomy. Which imaging biomarker performs better for predicting the risk of CR-POPF remains unknown.

PURPOSE

To evaluate the diagnostic performance of ECV and tomoelastography-derived pancreatic stiffness for predicting the risk of CR-POPF in patients undergoing pancreaticoduodenectomy.

STUDY TYPE

Prospective.

POPULATION

Eighty patients who underwent multiparametric pancreatic MRI before pancreaticoduodenectomy, among whom 16 developed CR-POPF and 64 did not.

FIELD STRENGTH/SEQUENCE

3 T/tomoelastography and precontrast and postcontrast T1 mapping of the pancreas.

ASSESSMENT

Pancreatic stiffness was measured on the tomographic c-map, and pancreatic ECV was calculated from precontrast and postcontrast T1 maps. Pancreatic stiffness and ECV were compared with histological fibrosis grading (F0-F3). The optimal cutoff values for predicting CR-POPF were determined, and the correlation between CR-POPF and imaging parameters was evaluated.

STATISTICAL TESTS

The Spearman's rank correlation and multivariate linear regression analysis was conducted. The receiver operating characteristic curve analysis and logistic regression analysis was performed. A double-sided P < 0.05 indicated a statistically significant difference.

RESULTS

Pancreatic stiffness and ECV both showed a significantly positive correlation with histological pancreatic fibrosis (r = 0.73 and 0.56, respectively). Patients with advanced pancreatic fibrosis had significantly higher pancreatic stiffness and ECV compared to those with no/mild fibrosis. Pancreatic stiffness and ECV were also correlated with each other (r = 0.58). Lower pancreatic stiffness (<1.38 m/sec), lower ECV (<0.28), nondilated main pancreatic duct (<3 mm) and pathological diagnosis other than pancreatic ductal adenocarcinoma were associated with higher risk of CR-POPF at univariate analysis, and pancreatic stiffness was independently associated with CR-POPF at multivariate analysis (odds ratio: 18.59, 95% confidence interval: 4.45, 77.69).

DATA CONCLUSION

Pancreatic stiffness and ECV were associated with histological fibrosis grading, and pancreatic stiffness was an independent predictor for CR-POPF.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 5.

Serum amylase on postoperative day 1 is superior to serum lipase in predicting clinically relevant pancreatic fistula after partial pancreaticoduodenectomy

PURPOSE

To compare the predictive value of serum amylase and lipase regarding the occurrence of clinically relevant postoperative pancreatic fistula (cr-POPF) after partial pancreaticoduodenectomy (PD).

METHODS

Data from 228 consecutive patients undergoing PD were obtained from a prospective database. Serum amylase and lipase were measured on postoperative days (PODs) 0-2. Receiver-operating characteristics analysis was performed and cutoff values were tested using logistic regression.

RESULTS

Serum amylase had a larger area under the curve (AUC) on POD1 (AUC 0.89, p <0.001) than serum lipase. For serum amylase POD 1, a cutoff value of 70 U/l showed sensitivity and specificity of 100% and 70% for the diagnosis of cr-POPF. Serum amylase POD 1 > 70 U/l (OR 9.815, 95% CI 3.683-26.152, p < 0.001), drain amylase POD 1 > 300 U/l (OR 2.777, 95% CI 1.071-7.197, p= 0.036), and a small (≤ 3mm) pancreatic duct diameter (OR 3.705, 95% CI 1.426-9.627, p= 0.007) were significant predictors of cr-POPF in the multivariable analysis. Patients were divided into three risk groups based on serum amylase POD 1 and pancreatic duct diameter. This model had a good performance in discriminating cr-POPF (AUC 0.846, 95% CI 0.793-0.898). The sensitivity, specificity, and negative predictive value for the combination of serum amylase POD 1 <70 U/l and pancreatic duct diameter >3 mm were 100%, 70%, and 100%.

CONCLUSION

Serum amylase POD 1 was superior to serum lipase in predicting cr-POPF after PD. The proposed risk prediction model had a sensitivity and negative predictive value of 100%, allowing for early identification of cr-POPF.

Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care

Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.

Physiological stress level and screening for malnutrition as preoperative predictors of postoperative complications in pancreatic surgery: a retrospective study

BACKGROUND

Assessment of 'physiological stress levels' and 'nutritional status' before surgery is important for predicting complications and indirect interventions on the pancreas. The aim of this study was to determine neutrophil-lymphocyte ratio (NLR) and nutritional risk index (NRI) indicators before surgery to predict 90-day complications and mortality in a cohort of patients with complicated chronic pancreatitis and cancer of the head of the pancreas.

METHODS

We evaluated preoperative levels of NLR and NRI among 225 subjects treated at different centres located in three countries. Short-term outcomes included length of hospital stay, postoperative complications, and mortality at 90 days and were appreciated based on NLR and NRI. The level of physiological stress was divided according by the formulas: neutrophil-lymphocyte ratio (NLR) = (neutrophil count, %)/(lymphocyte count, %). The nutritional state of the patients was divided according to the INR: NRI = (1.519 × serum albumin, g/L) + (41.7 × present weight, kg / usual weight, kg)].

RESULTS

All patients were operated. An analysis of the operations performed in three institutions demonstrated mortality in chronic pancreatitis and pancreatic pseudocysts in 1.4%, in chronic pancreatitis and the presence of an inflammatory mass mainly in the pancreatic head in 1.2%, and in cancer of the pancreatic head in 5.9%. The mean preoperative NLR was normal in 33.8% of the patients, the mild physiologic stress level was 54.7%, and the moderate was 11.5% before surgery. 10.2% of patients had a normal nutritional status, 20% had mild, 19.6% had moderate, and 50.2% had severe malnutrition. In a univariate analysis, at the cutoff of NLR ≥ 9.5 (AUC = 0.803) and the cutoff of NRI ≤ 98.5 (AUC = 0.801), increasing the risk of complications was observed (hazard ratio, 2.01; 95% CI, 1.247-3.250, p = 0.006), but at the cutoff of NRI ≤ 83.55 (AUC = 0.81), we observed a survival difference in operated patients (hazard ratio, 2.15; 95% CI, 1.334-3.477, p = 0.0025).

CONCLUSIONS

Our study demonstrated that NLR and NRI were predictors of postoperative complications, but only NRI was a predictor of 90-day mortality in patients after surgery.

Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis

PURPOSE

ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy.

METHODS

A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance.

RESULTS

The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05).

CONCLUSION

This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.

Outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing robotic (RPD) or open pancreaticoduodenectomies (OPD): a propensity score-weighted survival analysis

The purpose of this study was to compare the survival, recurrence, and complication rates in patients with pancreatic ductal adenocarcinoma (PDAC) who underwent robotic pancreaticoduodenectomy (RPD) or open pancreaticoduodenectomy (OPD) and who received adjuvant therapy. The study was a single-center retrospective analysis of consecutive PDAC patients who underwent RPD/OPD. Patient characteristics, tumor findings, neoadjuvant therapy, adjuvant therapies, overall survival (OS) and recurrence-free survival (RFS) were compared between the OPD and RPD cohorts. Cox proportional hazard regression with and without propensity score matching was used to establish the association between predictors and outcomes. One hundred PDAC patients underwent OPD (n = 36) or RPD (n = 64) from 2013 to 2019. Cox proportional hazard models showed that baseline bilirubin (HR 1.6, p = 0.0006) and operative characteristics such as the number of positive lymph nodes (HR 1.1, p = 0.002), lymph node ratio (HR 1.6, p = 0.001), tumor grade (HR 1.7, p = 0.02), and TNM classification (HR 2.3, p = 0.01) were associated with OS. The independent predictors post-intervention associated with mortality were adjuvant therapy (HR 0.4, p = 0.0003), ISGPS complications (HR 2.8, p = 0.02), and 90-day readmission (HR 2, p = 0.004). After adjustment for these predictors, adjuvant therapy, baseline bilirubin, lymph node ratio, and tumor grade remained the main predictors of mortality. Baseline bilirubin, adjuvant therapy, lymph node ratio, and tumor grade were the main determinants of mortality after OPD or RPD. There was no significant difference in OS and RFS after RPD or OPD in PC patients who received adjuvant therapy.

A new fistula risk score using sarcopenic obesity and subcutaneous fat area for predicting postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND/PURPOSE

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy and current predictors of POPF are inadequate. We developed a new fistula score to more accurately predict POPF.

METHODS

We retrospectively reviewed 169 patients who underwent pancreaticoduodenectomy between January 2010 and August 2021 at our institution and examined patients' risk factors according to the occurrence of grade B/C POPF. Muscle and fat were assessed on preoperative computed tomography images and cutoff values were determined by receiver operating characteristic curve analysis.

RESULTS

Grade B/C POPF occurred in 38 (22.5%) patients. Multivariate analysis of patients' risk factors revealed that sarcopenic obesity (odds ratio [OR] 2.94; p = .033), L3 subcutaneous fat area (SFA) ≥ 98.0 cm² (OR 2.69; p = .049), and soft pancreatic texture (OR 27.5; p = .002) were independent risk factors of grade B/C POPF occurrence. In addition, a new fistula risk score based on these factors revealed that 63.6% of patients with high scores developed grade B/C POPF, while those with negligible or low scores did not.

CONCLUSIONS

A new fistula risk scoring system based on sarcopenic obesity, SFA, and pancreatic texture may accurately predict POFP.

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.

Diagnostic performance of magnetic resonance image for malignant intraductal papillary mucinous neoplasms: the importance of size of enhancing mural nodule within cyst

PURPOSE

To investigate the clinical significance of enhancing mural nodules ≥ 5 mm by comparing the diagnostic performance of high-risk stigmata for diagnosing the malignant IPMN between the international consensus guideline (ICG) 2012 and 2017 in pancreatic magnetic resonance image (MRI).

MATERIALS AND METHODS

In this retrospective study, we reviewed preoperative pancreatic MRI with surgically confirmed IPMNs between May 2009 and April 2021. High-risk stigmata, defined by ICG 2012 and ICG 2017, associated with malignant IPMN were evaluated using logistic regression analysis. We calculated and compared the sensitivity and specificity of ICG 2012 and ICG 2017 for diagnosing malignant IPMNs. Receiver-operating characteristic (ROC) curves were used to compare ICG 2012 to ICG 2017.

RESULTS

A total of 73 patients (43 men and 30 women; mean age, 69 years; standard deviation, 8 years) with 34 malignant IPMNs and 39 benign IPMNs were included. Among high-risk stigmata, enhancing mural nodule ≥ 5 mm, and MPD diameter ≥ 10 mm were the significant predictor of malignant IPMN, in multivariate logistic regression (P < 0.001 for all). For the diagnosis of malignant IPMN, the specificity of ICG 2017 for enhancing mural nodules ≥ 5 mm as the high-risk stigmata was significantly higher than that of ICG 2012 (87.2% vs. 64.1%, P = 0.008). However, there was no significant difference in sensitivity between the two guidelines (94.1% vs. 97.1%, P = 1.0). The comparison of the ROC curves showed that the diagnostic performance of ICG 2017 for malignant IPMNs (AUC, 0.91) significantly improved when compared to that of ICG 2012 (AUC, 0.81) (P = 0.01).

CONCLUSION

When applying enhancing mural nodule ≥ 5 mm as a high-risk stigmata, ICG 2017 provided a significantly higher specificity than ICG 2012 without a reduction in sensitivity.

A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading

BACKGROUND

Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade.

METHODS

A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management.

RESULTS

Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C. 96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C.

CONCLUSION

PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.

Delayed gastric emptying following distal pancreatectomy: incidence and predisposing factors

BACKGROUND

Delayed gastric emptying (DGE) following elective distal pancreatectomy (DP) is poorly known. This study aimed to report incidence of DGE following DP, to identify its predisposing factors, and to assess its impact on hospital stay.

METHODS

Patients who had elective DP without additional organ or vascular resection (2012-2017) in two academic hospitals were included. Factors predisposing to DGE, defined according to the International Study Group of Pancreatic Surgery, were identified by multivariate analysis. A systematic review was performed to evaluate DGE incidence following elective DP.

RESULTS

311 elective DPs were performed. Three perioperative mortalities (1.0%) were unrelated to DGE. DGE occurred in 31 (10.0%) patients (grade A = 21, grade B = 7, grade C = 3) with a median hospital stay of 16 (13-22) days versus 10 (7-14) without DGE (p < 0.001). In multivariate analysis, predisposing factors of DGE were age>75 years (OR = 4.32 [1.53-12.19]; p = 0.006), open approach (OR = 2.97 [1.1-8]; p = 0.031) and POPF grade B-C (OR = 2.54 [1.05-6.1]; p = 0.038). The systematic review identified 7 series including 876 patients with an overall 8.1% DGE incidence.

CONCLUSION

DGE complicates around 10% of elective DP. Laparoscopic approach and prevention of POPF should be encouraged to reduce DGE incidence.

[Pancreatic isthmus intersection with preliminary suturing of arteries in this area]

OBJECTIVE

To analyze the early results of pancreatoduodenectomies with different methods of pancreatic isthmus transection.

MATERIAL AND METHODS

There were 82 pancreatoduodenectomies for cancer of pancreatic head or major duodenal papilla for the period 2010-2019. The control group comprised 38 patients with pancreatic isthmus transection and no preliminary suturing of local vessels. The study group consisted of 44 patients who underwent preliminary intersection of pancreatic isthmus vessels. Inclusion/exclusion criteria were used for grouping. We evaluated total intraoperative blood loss and blood loss following pancreatic isthmus transection, incidence and structure of postoperative complications.

RESULTS

Total intraoperative blood loss was 755.12±108.61 vs. 698.45±92.87 ml, respectively (p>0.05). Intraoperative blood loss following pancreatic isthmus transection was 48.21±9.11 vs. 7.83±1.72 ml, respectively (p<0.01). Incidence of postoperative complications and redo surgeries was similar. Postoperative bleeding occurred in 5 (13.15%) patients of the 1^st group (class A - 2.63%; B - 5.26%; C - 5.26%) and 2 (4.54%) patients of the 2^nd group (A - 4.54%; B and C - 0%). There were no significant differences in the incidence of other complications and postoperative mortality.

CONCLUSION

Pre-stitching of arterial vessels of the pancreatic isthmus reduces blood loss following intersection (p<0.01), as well as the incidence of postoperative bleeding class B and C (p<0.05).

An easy-to-use score to predict Clinically Relevant Post-Operative Pancreatic Fistula after distal pancreatectomy

BACKGROUND

Postoperative Pancreatic Fistula (POPF) is a common and serious complication after Distal Pancreatectomy (DP). An effective and accepted score to predict the occurrence of Clinically Relevant (CR-) POPF does not exist.

METHODS

Data regarding 103 consecutive patients undergoing DP from 2015 to 2019 were collected. A multivariate logistic regression was performed, in order to build a simplified score. The accuracy in predicting a categorical outcome was evaluated using the Receiver Operating Characteristic (ROC) curves. Youden's J test was performed to evaluate the performance of a positive score on the POPF occurrence.

RESULTS

33 patients developed a CR-POPF. Based on multivariate analysis results, a 4 points score was created by assigning 1 point if operation time was >4 hours, amylase levels on drains' fluid >500 UI on POD 3, pancreatic thickness >10mm and if the BMI was > 30. The discriminating ability was tested on the ROC curve, showing an area under the curve of 0.83 (CI 95%=0.75 - 0.92). The score threshold was determined at 2 points/4, the highest value according to the Youden index (0.53). The sensitivity is calculated at 82% (CI95% 69-95) and the specificity at 71 (CI95% 61 - 82). A threshold of 3 points/4 allows to reach a specificity of 99% (CI95% 99 - 100).

CONCLUSIONS

An easy to use post-operative score based on operation time, obesity, amylase level on drains on POD3 and pancreatic thickness on preoperative CT seems to predict the risk of developing CR-POPF.

More Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement.

MATERIALS AND METHODS

A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d.

RESULTS

From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional "night" of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention.

CONCLUSIONS

The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.

Neoadjuvant treatment: A window of opportunity for nutritional prehabilitation in patients with pancreatic ductal adenocarcinoma

Patients affected by pancreatic ductal adenocarcinoma (PDAC) frequently present with advanced disease at the time of diagnosis, limiting an upfront surgical approach. Neoadjuvant treatment (NAT) has become the standard of care to downstage non-metastatic locally advanced PDAC. However, this treatment increases the risk of a nutritional status decline, which in turn, may impact therapeutic tolerance, postoperative outcomes, or even prevent the possibility of surgery. Literature on prehabilitation programs on surgical PDAC patients show a reduction of postoperative complications, length of hospital stay, and readmission rate, while data on prehabilitation in NAT patients are scarce and randomized controlled trials are still missing. Particularly, appropriate nutritional management represents an important therapeutic strategy to promote tissue healing and to enhance patient recovery after surgical trauma. In this regard, NAT may represent a new interesting window of opportunity to implement a nutritional prehabilitation program, aiming to increase the PDAC patient's capacity to complete the planned therapy and potentially improve clinical and survival outcomes. Given these perspectives, this review attempts to provide an in-depth view of the nutritional derangements during NAT and nutritional prehabilitation program as well as their impact on PDAC patient outcomes.

Clinical Efficacy of the Preservation of the Hepatic Branch of the Vagus Nerve on Delayed Gastric Emptying After Laparoscopic Pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is a common complication following laparoscopic pancreaticoduodenectomy (LPD), although it remains incompletely understood, and only few studies have investigated the clinical benefits of hepatic branch of the vagus nerve (HBVN) preservation on DGE after LPD until now. We intended to evaluate the effect of preservation of the HBVN during LPD on the incidence of DGE.

METHODS

A total of 274 consecutive LPDs performed at a single center between July 2014 and December 2019 with available videos were retrospectively reviewed. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria, and HBVN condition during the LPD procedure was evaluated through a video review. Risk factors associated with DGE were assessed by performing univariate and multivariate logistic regression analyses. Postoperative outcomes between the HBVN-preserved and HBVN-injury groups were compared before and after propensity score matching (PSM).

RESULTS

One hundred fifty-six (56.93%) patients underwent LPD with HBVN-preserved and 118 (43.07%) with HBVN injury. DGE occurred in 33.2% of patients (n = 91) with grades B and C occurring at 13.9% (n = 38) and 7.7% (n = 21), respectively. Longer operative time, more EIBL, HBVN injury, POPF (grades B and C), postoperative hemorrhage, intra-abdominal infection, and Clavien-Dindo ≥III were identified as risk factors for DGE in the univariate analysis. Then, in the multivariate analysis, HBVN injury and intra-abdominal infection were found to be independent risk factors affecting the incidence of DGE (any grade) or clinically relevant DGE (grades B and C). Furthermore, the prevalence of DGE was significantly higher in the HBVN-injury group than in the HBVN-preserved group before and after PSM analysis (46.61% vs. 23.08%, P<0.001; 42.59% vs. 23.15%, P=0.013).

CONCLUSIONS

HBVN preservation during LPD might be associated with a reduced incidence of DGE as a framework for prospective quality improvement.

Root-Cause Analysis of Mortality Following Pancreatic Resection (CARE Study): A Multicenter Cohort Study

OBJECTIVES

Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate.

BACKGROUND

Despite undeniable progress in pancreatic surgery for over a century, postoperative outcome remain particularly worse and could be further improved.

METHODS

All patients undergoing pancreatectomy between January 2015 and December 2018 and died post-operatively within 90 days after were included. RCA was performed in two stages: the first being the exhaustive collection of data concerning each patient from preoperative to death and the second being blind analysis of files by an independent expert committee. A typical root cause of death was defined with the identification of avoidable death.

RESULTS

Among the 3195 patients operated on in nine participating centers, 140 (4.4%) died within 90 days after surgery. After the exclusion of 39 patients, 101 patients were analyzed. The cause of death was identified in 90% of cases. After RCA, mortality was preventable in 30% of cases, mostly consequently to a preoperative assessment (disease evaluation) or a deficient postoperative management (notably pancreatic fistula and hemorrhage). An inappropriate intraoperative decision was incriminated in 10% of cases. The comparative analysis showed that young age and arterial resection, especially unplanned, were often associated with avoidable mortality.

CONCLUSION

One third of postoperative mortality after pancreatectomy seems to be avoidable, even if the surgery is performed in high volume centers. These data suggest that improving postoperative pancreatectomy outcome requires a multidisciplinary, rigorous and personalized management.

Multiregion whole-exome sequencing of intraductal papillary mucinous neoplasms reveals frequent somatic KLF4 mutations predominantly in low-grade regions

OBJECTIVE

Intraductal papillary mucinous neoplasms (IPMNs) are non-invasive precursor lesions that can progress to invasive pancreatic cancer and are classified as low-grade or high-grade based on the morphology of the neoplastic epithelium. We aimed to compare genetic alterations in low-grade and high-grade regions of the same IPMN in order to identify molecular alterations underlying neoplastic progression.

DESIGN

We performed multiregion whole exome sequencing on tissue samples from 17 IPMNs with both low-grade and high-grade dysplasia (76 IPMN regions, including 49 from low-grade dysplasia and 27 from high-grade dysplasia). We reconstructed the phylogeny for each case, and we assessed mutations in a novel driver gene in an independent cohort of 63 IPMN cyst fluid samples.

RESULTS

Our multiregion whole exome sequencing identified KLF4, a previously unreported genetic driver of IPMN tumorigenesis, with hotspot mutations in one of two codons identified in >50% of the analyzed IPMNs. Mutations in KLF4 were significantly more prevalent in low-grade regions in our sequenced cases. Phylogenetic analyses of whole exome sequencing data demonstrated diverse patterns of IPMN initiation and progression. Hotspot mutations in KLF4 were also identified in an independent cohort of IPMN cyst fluid samples, again with a significantly higher prevalence in low-grade IPMNs.

CONCLUSION

Hotspot mutations in KLF4 occur at high prevalence in IPMNs. Unique among pancreatic driver genes, KLF4 mutations are enriched in low-grade IPMNs. These data highlight distinct molecular features of low-grade and high-grade dysplasia and suggest diverse pathways to high-grade dysplasia via the IPMN pathway.

Role of artificial intelligence in hepatobiliary and pancreatic surgery

Over the past decade, enhanced preoperative imaging and visualization, improved delineation of the complex anatomical structures of the liver and pancreas, and intra-operative technological advances have helped deliver the liver and pancreatic surgery with increased safety and better postoperative outcomes. Artificial intelligence (AI) has a major role to play in 3D visualization, virtual simulation, augmented reality that helps in the training of surgeons and the future delivery of conventional, laparoscopic, and robotic hepatobiliary and pancreatic (HPB) surgery; artificial neural networks and machine learning has the potential to revolutionize individualized patient care during the preoperative imaging, and postoperative surveillance. In this paper, we reviewed the existing evidence and outlined the potential for applying AI in the perioperative care of patients undergoing HPB surgery.

[Postpancreatectomy hemorrhage]

Surgical treatment of pancreatic diseases is always associated with a large number of complications. Postoperative hemorrhage is a specific complication of pancreatic surgery requiring a clear classification and surgical strategy. According to literature data, postoperative hemorrhage occurs in 3-30% of cases. Incidence of hemorrhages depends on intraoperative, anamnestic, histological and postoperative factors. Early postoperative hemorrhage (within 24 hours after surgery) is usually a consequence of technical errors in intraoperative hemostasis, perioperative coagulation disorders. The mechanism of delayed bleeding is more complex and often associated with various arrosive factors: pancreatic fistula, biliary fistula, abscess. Currently, there is no a single treatment algorithm for patients with postpancreatectomy hemorrhage. According to various researchers, contrast-enhanced CT is preferred for diagnosis. In recent years, the role of endovascular hemostasis has significantly increased. This problem requires further study and development of a single treatment and diagnostic algorithm that will reduce mortality in these patients.

Total Amylase Value in Drains After Gastrectomy for Predicting Postoperative Pancreatic Fistula

Objective

Postoperative pancreatic fistula (POPF) is defined using the ratio of the amylase concentration in abdominal drainage fluid to the upper normal range of serum amylase level. However, we hypothesized that the total amylase value in discharge (AVD) on postoperative day (POD) 3 may be more sensitive for predicting grade II or higher severe POPF (sPOPF) and compared the predictive power of the conventional definition of POPF and AVD for sPOPF.

Methods

One hundred fifty-one patients who underwent gastrectomy between October 2011 and February 2013 were analyzed. A drainage tube was placed in all the cases through the stump of the right gastroepiploic vein and the front of the pancreas to the back of the anastomotic site. The drainage volume and amylase concentration in the discharge were examined on POD 1, 3, and 5. AVD was calculated by multiplying the volume by the amylase concentration.

Results

Eight patients (5.3%) developed sPOPF. In univariate analysis, both AVD and the amylase concentration ratio was significantly correlated with sPOPF (P = 0.002 and 0.007, respectively). AVD on POD 3 showed the best predictive performance compared with the amylase concentration ratio on POD 3 (area under the curve 0.876 versus 0.844). Based on the cutoff values calculated from the receiver operating characteristic curves, AVD was more specific than amylase concentration ratio in predicting sPOPF (specificity: 97.6% versus 86.0%; positive predictive value: 62.5% vs. 23.1%).

Conclusion

AVD on POD 3 is a more specific parameter than conventional amylase concentration ratio in predicting sPOPF.

Comprehensive Complication Index or Clavien-Dindo Classification: Which is Better for Evaluating the Severity of Postoperative Complications Following Pancreatectomy?

BACKGROUND

Complications are important indicators of immediate postoperative outcomes. The Clavien-Dindo classification (CDC) is a widely used index for the classification of surgical complications. More recently, the comprehensive complication index (CCI) has also been introduced for classifying postoperative complications. The aim of this study was to compare the relationship of CCI and CDC with clinical or economic parameters.

METHODS

The study prospectively enrolled patients from April 2015 to October 2016. Two hundred and twenty-two patients underwent pancreatectomy during the enrolled period. Complications were ranked according to CDC and CCI indices. After analyzing the correlation between CCI and CDC, the correlations of length of stay (LOS) and cost with CCI and CDC were compared. Finally, differences between the correlation coefficients of CDC and CCI parameters were calculated.

RESULTS

Complications occurred in 211 patients (95.0%). The correlation between CDC and CCI was r = 0.938. (p < 0.001) Compared to the CDC, CCI showed significantly stronger correlations with LOS and cost of complications (LOS: CCI vs. CDC, r = 0.725 vs. r = 0.630, p < 0.001; cost: CCI vs. CDC, r = 0.774 vs. r = 0.723, p < 0.001).

CONCLUSION

CCI is a more accurate classification index, compared to CDC, for evaluating the risk of postoperative complications.

Acute Phase Response and Postprocedural Evaluation of Open and Laparoscopic Cryoablation Procedures in Porcine Pancreases

OBJECTIVES

Cryoablation is a potentially less invasive locoregional ablation modality. Although cryoablation has been used to treat malignancy in various organs, a limited application of this modality in the pancreas has been reported.

METHODS

Acute phase response assessments and postprocedural course evaluations of 2 experimental locoregional ablation methods were conducted. In one method, open and laparoscopic cryoablation of a porcine pancreas using an argon-helium gas-based cryoablation system and monitoring of tissue temperature during the procedure were performed. In the other method, open cryoablation of a porcine pancreas using liquid nitrogen was performed. The animals were evaluated postoperatively.

RESULTS

The size of the cryolesion was larger in the second treatment than in the first. Laparoscopic cryoablation was associated with the formation of an iceball, which possibly affected the surrounding structures. The ablated region was adequately cooled with 10 minutes of freeze/repeat cycles. The area cooled to a temperature of less than -40°C was approximately half the size of the cryolesion in diameter. The swine used for the evaluation of the postprocedural course survived 3 weeks after the procedure with a temporal elevation of the serum lipase level.

CONCLUSIONS

Cryoablation of the pancreas was experimentally practicable without severe complications under direct or laparoscopic vision.

Risk Factors of Lymph Node Metastasis in Patients with Pancreatic Neuroendocrine Tumors (PNETs)

BACKGROUND

The prognostic value of lymph node metastasis in patients with PNETs is controversial. Understanding the effect of lymph node metastasis on prognosis in pancreatic neuroendocrine tumors is helpful for surgery and follow-up. The purposes of this study are to identify predictors of lymph node metastasis among patients with PNETs and determine its prognostic associations.

METHODS

A retrospective analysis of the surveillance, epidemiology, and end results (SEER) database was performed. Patients with PNETs that underwent surgery and pathologic nodal staging were identified. Logistic regression and Cox regression were performed to identify independent predictors and prognostic factors, respectively.

RESULTS

Of 1956 patients (age: 56.8 ± 13.4 years, 53.3% males), 748 (38.2%) had lymph node metastasis. On multivariable analysis, tumor located in pancreas head, distant metastasis, and poorly differentiated, undifferentiated, and unknown differentiated histology grades were three independent risk factors of lymph node metastasis. In the entire cohort, lymph node metastasis indicated a worse overall survival (HR: 1.48, 95% CI: 1.17-1.88, p < 0.001) and disease-specific survival (HR: 1.87, 95% CI: 1.41-2.48, p < 0.001) on multivariable analysis. Lymph node metastasis was associated with worse overall (HR: 1.45, 95% CI: 1.08-1.93, p = 0.012) and disease-specific survival (HR: 2.13, 95% CI: 1.48-3.05, p < 0.001) in patients without distant metastasis on multivariate analysis. Lymph node metastasis was also independently associated with worse disease-specific survival among patients in well differentiation (HR: 2.16, 95% CI: 1.35-3.46, p = 0.001) and moderately differentiation (HR: 2.67, 95% CI: 1.28-5.56, p = 0.009) groups on multivariate analysis.

CONCLUSIONS

Tumor located in pancreas head, distant metastasis, and poorly differentiated, undifferentiated, and unknown differentiated histology grades were three independent risk factors for lymph node metastasis. Lymph node metastasis was an independent prognostic factor of worse OS and DSS in patients with tumor located in pancreas head. Lymph node metastasis was an independent prognostic factor of worse OS and DSS in patients without distant metastasis. Lymph node metastasis was an independent prognostic factor of worse DSS in well differentiation and moderately differentiation groups.

Early Post-Operative Pancreatitis and Systemic Inflammatory Response Assessed by Serum Lipase and IL-6 Predict Pancreatic Fistula

Background

Post-operative pancreatic fistula (POPF) remains a critical complication after pancreatic resection. This prospective pilot study evaluates perioperative markers of pancreatitis and systemic inflammation to predict clinically relevant grade B/C-POPF (CR-POPF).

Methods

All patients undergoing pancreatic resection from December 2017 to April 2019 were prospectively enrolled. Surgical procedures and outcomes were correlated with perioperative blood markers. ROC analysis was performed to assess their predictive value for CR-POPF. Cut-offs were calculated with the Youden index.

Results

In total, 70 patients were analysed (43 pancreatoduodenectomies and 27 distal pancreatectomies). In-hospital/90-d mortality and morbidity were 5.7/7.1% (n = 4/n = 5) and 75.7% (n = 53). Major complications (Clavien–Dindo ≥ 3a) occurred in 28 (40.0%) patients, CR-POPF in 20 (28.6%) patients. Serum lipase (cut-off > 51U/L) and IL-6 (> 56.5 ng/l) on POD3 were significant predictors for CR-POPF (AUC = 0.799, 95%-CI 0.686–0.912 and AUC = 0.784, 95%-CI 0.668–0.900; combined AUC = 0.858, 95%-CI 0.758–0.958; all p < 0.001). Patients with both or one factor(s) above cut-off more frequently developed CR-POPF than cases without (100 vs. 50% vs. 7.5%, p < 0.001). This also applied for overall and severe complications (p = 0.013 and p = 0.009).

Conclusions

Post-operative pancreatitis and inflammatory response are major determinants for development of POPF. A combination of serum lipase and IL-6 on POD3 is a highly significant early predictor of CR-POPF and overall complications, potentially guiding patient management.

Clinical trial registration

The study protocol was registered at clinicaltrials.gov (NCT04294797)

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05768-9) contains supplementary material, which is available to authorized users.

Comparison of surgical outcomes between isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

We aimed to compare the safety and effectiveness of the following procedures after pancreaticoduodenectomy: isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy.

METHODS

We performed a systematic search of the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 January 2020. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated using STATA 12.0 statistical software.

RESULTS

Thirteen studies involving 1942 patients were included in this study. Pooled analysis showed that reoperation rates following isolated pancreaticojejunostomy were lower reoperation than with conventional pancreaticojejunostomy (OR = 0.36, 95% CI: 0.15-0.86, p = 0.02, respectively), and that isolated pancreaticojejunostomy required longer operation time vs conventional pancreaticojejunostomy (WMD = 43.61, 95% CI: 21.64-65.58, P = 0.00). Regarding postoperative pancreatic fistula, clinically-relevant postoperative pancreatic fistula, delayed gastric emptying, clinically-relevant delayed gastric emptying, bile leakage, hemorrhage, reoperation, length of postoperative hospital stay, major complications, overall complications, and mortality, we found no significant differences for either isolated pancreaticojejunostomy versus conventional pancreaticojejunostomy or isolated gastrojejunostomy versus conventional pancreaticojejunostomy.

CONCLUSIONS

This study showed that isolated pancreaticojejunostomy was associated with a lower reoperation rate, but required longer operation time vs conventional pancreaticojejunostomy. Considering the limitations, high-quality randomized controlled trials are required.

Genomic characterization of malignant progression in neoplastic pancreatic cysts

Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) are non-invasive neoplasms that are often observed in association with invasive pancreatic cancers, but their origins and evolutionary relationships are poorly understood. In this study, we analyze 148 samples from IPMNs, MCNs, and small associated invasive carcinomas from 18 patients using whole exome or targeted sequencing. Using evolutionary analyses, we establish that both IPMNs and MCNs are direct precursors to pancreatic cancer. Mutations in SMAD4 and TGFBR2 are frequently restricted to invasive carcinoma, while RNF43 alterations are largely in non-invasive lesions. Genomic analyses suggest an average window of over three years between the development of high-grade dysplasia and pancreatic cancer. Taken together, these data establish non-invasive IPMNs and MCNs as origins of invasive pancreatic cancer, identifying potential drivers of invasion, highlighting the complex clonal dynamics prior to malignant transformation, and providing opportunities for early detection and intervention.

Management of late hemorrhage after pancreatic surgery: treatment strategy and prognosis

Objective

Postpancreatectomy hemorrhage is a life-threatening complication. Hemorrhage occurring >24 hours after the index operation is defined as late hemorrhage. This study was performed to analyze the therapeutic management and prognostic factors of late hemorrhage after pancreatectomy.

Methods

We identified 87 patients with late hemorrhage among 2031 patients who underwent pancreatic surgery from January 2013 to December 2017. The patients’ demographic characteristics, perioperative treatment, hemorrhage details, and prognosis were retrospectively analyzed.

Results

Of the 87 patients, 53 were men. Bleeding occurred at a mean of 8.9 ± 6.0 days postoperatively. Extraluminal and intraluminal hemorrhage occurred in 58 and 29 patients, respectively. The primary intervention was successful in 66 patients, and 16 patients required a secondary intervention. The primary and total recovery rates were 72.4% and 89.7%, respectively. Of the 87 patients, 9 died. Male sex, hemorrhage on a later postoperative day, a significantly decreased hemoglobin level, and pancreatic fistula showed statistical significance as possible risk factors for mortality.

Conclusions

Male sex, hemorrhage on a later postoperative day, a significantly decreased hemoglobin level, and pancreatic fistula are possible risk factors for mortality in patients with late hemorrhage after pancreatectomy. Hemorrhage is a dynamic process, and a secondary intervention may be necessary.

Endoscopic and surgical treatment options for chronic pancreatitis: an imaging perspective

Chronic pancreatitis is a chronic fibro-inflammatory syndrome characterized by chronic pancreatic inflammation leading to fibrosis and scarring. Patients with this multifactorial debilitating illness often require endoscopic or surgical intervention for treatment. Radiologists play a crucial role in pre-therapeutic workup as well as post-treatment imaging of chronic pancreatitis. This review summarizes the most common surgical and endoscopic treatment options that are currently available for chronic pancreatitis, including the implications on imaging.

Propensity score-matched analysis of clinical outcome after enucleation versus regular pancreatectomy in patients with small non-functional pancreatic neuroendocrine tumors

OBJECTIVES

The effectiveness of enucleation in treatment for low-grade (G1, G2) small (≤2 cm) non-functional pancreatic neuroendocrine tumors (sNF-pNETs) remains controversial. This study investigated short- and long-term outcome of enucleation comparing with regular pancreatectomy in patients with sNF-pNETs.

METHODS

The clinical data of patients with sNF-pNETs who underwent surgery in our hospital from January 2000 to December 2017 were retrospectively collected. Short- and long-term outcomes of two operations were analyzed. The propensity score matching (PSM) was performed to reduce potential selection bias.

RESULTS

A total of 123 patients with sNF-pNETs were enrolled with 62 males, 69 G1, and median age was 56.91 ± 10.04 years old. During the follow-up period (mean 87 ± 58.1 months), 9(7.32%) disease progressed (recurrence or metastasis) and 2 died (1.62%), 5-years OS was 100%, 5-years DFS was 91.4%. Both lymph node metastasis (p = 0.117) and pathological grade (p = 0.050) were not prognostic factors for sNF-pNETs. The propensity score-matched cohort comprised 27 patients with enucleation and 44 patients with regular pancreatectomy. Enucleation was noninferior to regular pancreatectomy in terms of DFS, before or after PSM. The surgical duration (P < 0.01) and blood loss (P < 0.01) significantly decreased in enucleation compared with regular pancreatectomy. The other postoperative complications tended to occur in regular pancreatectomy than in enucleation, but no statistically significant difference (all p > 0.05).

CONCLUSION

Enucleation seems to be an effective option for the treatment of sNF-pNETs with a lower total rate of postoperative complications and similar long-term prognosis, compared with regular pancreatectomy.

The Impact of Sarcopenia on Postoperative Course following Pancreatoduodenectomy: Single-Center Experience of 110 Consecutive Cases

BACKGROUND

Despite that mortality following pancreatoduodenectomy (PD) has gradually dropped during the past few decades, the incidence of postoperative complications remains high, ranging from 30-60%. Many studies have been focused on identification of perioperative risk factors for morbidity, and in recent years, sarcopenia has been pointed out as a valid predictor of postoperative complication.

MATERIALS AND METHODS

Perioperative data from 110 consecutive patients who underwent PD were retrieved, and the presence of sarcopenia was assessed by the measurement of Hounsfield unit average calculation on preoperative CT scans. Postoperative complications were graded according to Clavien-Dindo classification, and the morbidity burden was assessed by comprehensive complication index (CCI) calculation.

RESULTS

Sarcopenia was associated with advanced age (72 vs. 66 years; p = 0.014) and lower preoperative albumin levels (3.5 vs. 3.7 g/dL; p = 0.010); it represented an independent risk factor for clinically relevant complications (relative risk: 1.71; p = 0.015) and was related to a higher rate of Grade C postoperative pancreatic fistula (50.0 vs. 11.4%; p = 0.005) and a higher CCI (47.6 vs. 29.6; p = 0.001).

CONCLUSIONS

Sarcopenia represents a valid indicator of increased morbidity risk and may play a central role in preoperative risk stratification, allowing the selection of patients who may benefit from prehabilitation programs.

Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review

INTRODUCTION

In ovarian cancer (OC), survival benefit in case of complete cytoreduction with absence of residual tumor has been clearly demonstrated; however, it often requires extensive surgery. Particularly, pancreatic resection during cytoreduction, may severely impact perioperative morbidity and mortality.

OBJECTIVES

The aim of this systematic review is to evaluate complication rates and related optimal management of ovarian cancer patients undergoing pancreatic resection as part of cytoreductive surgery.

METHODS

Literature was searched for relevant records reporting distal pancreatectomy for advanced ovarian cancer. All cohorts were rated for quality. We focused our analysis on complications related to pancreatic surgical procedures evaluating the following outcomes: pancreatic fistula (PF), abdominal abscess, pancreatitis, iatrogenic diabetes, hemorrhage from splenic vessels and pancreatic-surgery-related mortality.

RESULTS

The most frequent complication reported was PF. Similar rates of PF were reported after hand-sewn (20%) or stapled closure (24%). Continued drainage is the standard treatment, and often, the leak can be managed conservatively and does not require re-intervention. Abdominal abscess is the second most frequent complication and generally follows a non-adequately drained PF and often required re-laparotomy. Pancreatitis is a rare event that could be treated conservatively; however, death can occur in case of necrotic evolution. Cases of post-operative hemorrhage due to splenic vessel bleeding have been described and represent an emergency.

CONCLUSIONS

Knowledge of pancreatic surgery and management of possible complications ought to be present in the oncologic-gynecologic armamentarium. All patients should be referred to specialized, dedicated, tertiary centers in order to reduce, promptly recognize and optimally manage complications.

Intraoperative Fluid Administration and Surgical Outcomes Following Pancreaticoduodenectomy: External Validation at a Tertiary Referral Center

BACKGROUND

While intraoperative fluid overload is associated with higher complication rates following surgery, data for pancreaticoduodenectomy are scarce and heterogeneous. We evaluated multiple prior definitions of restrictive and liberal fluid regimens and analyzed whether these affected surgical outcomes at our tertiary referral center.

METHODS

Studies evaluating different intraoperative fluid regimens on outcomes after pancreatic resections were retrieved. After application of all prior definitions of restrictive and liberal fluid regimens to our patient cohort, relative risks of each outcome were calculated using all reported infusion regimens.

RESULTS

Five hundred and seven pancreaticoduodenectomies were included. Nine different fluid regimens were evaluated. Two regimens utilized absolute volume cutoffs, and the remaining evaluated various infusion rates, ranging from 5 to 15 mL/kg/h. Total volume administration of >5000 mL and >6000 mL was associated with increased complications (RR 1.25 and RR 1.17, respectively) and >6000 mL with increased sepsis (RR 2.14). Conversely, a rate of <5 mL/kg/h was associated with increased risk of postoperative pancreatic fistula (POPF, RR 3.16) and sepsis (RR 3.20), <6.8 mL/kg/h with increased major morbidity (RR 1.64) and sepsis (RR 2.27), and <8.2 mL/kg/h with increased POPF (RR 2.16). No effects were observed on pulmonary complications, surgical site infections, length of stay, or mortality.

CONCLUSIONS

In an uncontrolled setting with no standard intraoperative or postoperative care map, the volume of intraoperative fluid administration appears to have limited impact on early postoperative outcomes following pancreaticoduodenectomy, with adverse outcomes only seen at extreme values.

Clinical significance of preoperative nutritional parameter and patient outcomes after pancreatectomy: A retrospective study at two academic institute

Backgrounds/Aims

Preoperative nutritional status has been reported to influence patient outcomes after pancreatectomy. The Prognostic Nutritional Index (PNI) is a useful parameter to reflect the outcomes of patients undergoing gastrointestinal surgery. Therefore, the relationship between the PNI and clinicopathological factors, surgical data, and postoperative morbidity were retrospectively evaluated at two academic institutes in a cohort study.

Methods

Curative pancreatectomy was performed on 222 patients at the University of Nagasaki between 1995 and March 2015, and 101 at the University of Miyazaki between April 2015and March 2018. The PNI was calculated using preoperative albumin and total cholesterol levels.

Results

The mean PNI in our series was 39.2±5.4 and the prevalence of PNIs less than 40 was observed in 134 patients (44%). The PNI was not significantly different between normal, hard, and fatty architecture of the pancreatic parenchyma. The PNIs were significantly negatively correlated with higher age (p<0.01), but not with gender, co-morbidity, or habits. The PNI was significantly correlated with levels of hemoglobin, prothrombin activity, choline esterase, total protein, albumin and cholesterol (p<0.01), and with postoperative total protein and albumin levels (p<0.05). Although the preoperative PNI tended to be lower in patients with total postoperative complications, no significant differences for each complication were observed.

Conclusions

Although the preoperative PNIs reflect the perioperative nutritional status, its predictive usefulness for postoperative complications could not be significantly confirmed.

Biliary injuries after pancreatic surgery: interventional radiology management

Bile duct injuries are among the most feared complications after pancreatic surgery. Most of these surgical complications are related to iatrogenic injuries and include bile leakage, biliary duct obstruction or stricture and infection. A wide range of Interventional Radiology treatment options are currently available. The options include percutaneous transhepatic cholangiography (PTC), percutaneous transhepatic biliary drainage (PTBD), percutaneous balloon dilatation and stenting, image-guided percutaneous abscess drainage. The purpose of this review is to describe the current evidence in this continuously evolving field.

Evidence Versus Practice in Early Drain Removal After Pancreatectomy

BACKGROUND

Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes.

METHODS

We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5.

RESULTS

Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P < 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P < 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P < 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy.

CONCLUSIONS

Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.

Isolated Roux loop pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-control study

•

Pancreaticojejunostomy is commonly used in the reconstruction after pancreaticoduodenectomy, but the incidence of POPF remains high.

•

There are a number of theoretical advantages to the isolated Roux loop pancreaticojejunostomy reconstruction, mainly related to the physical separation of bile acids and the pancreaticojejunostomy.

•

The use of an isolated Roux loop pancreaticojejunostomy seems to be associated with decrease in the rate of postoperative PF in patients undergoing PD.

Objectives

The aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD).

Methods

Data of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality.

Results

Seventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p =  0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p =  0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p =  0.001).

Conclusions

The use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.

Photodynamic diagnosis of peritoneal metastasis in human pancreatic cancer using 5-aminolevulinic acid during staging laparoscopy

Peritoneal metastasis is an important prognostic factor for pancreatic cancer. The present study evaluated the possibility of diagnosing peritoneal metastasis by a photodynamic diagnosis using 5-aminolevulinic acid (5-ALA-PDD). In vitro, protoporphyrin IX (PpIX) accumulation was examined in the AsPC-1-GFP cell line following 5-ALA hydrochloride administration. In vivo, AsPC-1-GFP cells were injected into the peritoneal cavities of mice. Three weeks later 5-ALA hydrochloride was intraperitoneally administered to the mice. The peritoneal nodules were observed under fluorescence excitation. A total of 34 patients were enrolled in the present study who were clinically diagnosed with pancreatic malignancy. 5-ALA hydrochloride was orally administered to the patients prior to surgery. During the operation the abdominal cavity was observed under white light and fluorescence. In vitro and in vivo, it was confirmed that PpIX-induced red fluorescence. In 9 patients peritoneal nodules suspected to be peritoneal metastasis were observed under white light. In 4 of the 9 patients nodules were detected on the basis of the fluorescence images. Fluorescent nodules were histopathologically diagnosed as metastatic. In the present study it was confirmed that 5-ALA-PDD holds promise for the rapid diagnosis of peritoneal metastasis in patients with pancreatic cancer.

Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists

Abstract

Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis.

Teaching Points

• Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%).

• Multidetector CT is the mainstay technique to investigate suspected complications following PD.

• Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings.

• CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula.

• Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.

Major pancreatic resections: normal postoperative findings and complications

Objectives

(1) To illustrate and describe the main types of pancreatic surgery; (2) to discuss the normal findings after pancreatic surgery; (3) to review the main complications and their radiological findings.

Background

Despite the decreased postoperative mortality, morbidity still remains high resulting in longer hospitalisations and greater costs. Imaging findings following major pancreatic resections can be broadly divided into “normal postoperative alterations” and real complications. The former should regress within a few months whereas complications may be life-threatening and should be promptly identified and treated.

Imaging findings

CT is the most effective postoperative imaging technique. MRI and fluoroscopy are used less often and only in specific cases such as assessing the gastro-intestinal function or the biliary tree. The most common normal postoperative findings are pneumobilia, perivascular cuffing, fluid collections, lymphadenopathy, acute anastomotic oedema and stranding of the peri-pancreatic/mesenteric fat. Imaging depicts the anastomoses and the new postoperative anatomy. It can also demonstrate early and late complications: pancreatic fistula, haemorrhage, delayed gastric emptying, hepatic infarction, acute pancreatitis of the remnant, porto-mesenteric thrombosis, abscess, biliary anastomotic leaks, anastomotic stenosis and local recurrence.

Conclusions

Radiologists should be aware of surgical procedures, postoperative anatomy and normal postoperative imaging findings to better detect complications and recurrent disease.

Teaching Points

• Morbidity after pancreatic resections is high.

• CT is the most effective postoperative imaging technique.

• Imaging depicts the anastomoses and the new postoperative anatomy.

• Pancreatic fistula is the most common complication after partial pancreatic resection.

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.

Postoperative pancreatic fistula-impact on outcome, hospital cost and effects of centralization

BACKGROUND

One of the most serious complications after pancreaticoduodenectomy (PD) is postoperative pancreatic fistula (POPF). This study investigated the incidence of POPF before and after centralization of pancreatic surgery in Southern Sweden and its impact on outcome and health care costs.

METHODS

The local registry comprising all pancreatic resections at Skåne University Hospital, Lund, Sweden, was searched for PDs from 2005 to 2015. The patients were analysed in three groups: low-volume, high-volume and after introduction of an enhanced recovery program. Only the clinically relevant POPF grades B and C (CR-POPF) were investigated.

RESULTS

322 consecutive patients were identified. The annual operation volume increased almost threefold and the postoperative length of stay and total hospital cost decreased concurrently. The incidence of CR-POPF did not decrease over time. The group with CR-POPF had more complications and prolonged length of stay. The cost was 1.5 times higher for patients with CR-POPF and the cost did not decline despite the increase of hospital volume.

CONCLUSION

Centralization of pancreatic surgery did not decrease the rate of CR-POPF nor its subsequent impact on LOS and costs. Further efforts must be made to reduce the incidence of CR-POPF.

The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After

BACKGROUND

In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of the present report is to verify the value of the International Study Group of Pancreatic Fistula definition and grading of postoperative pancreatic fistula and to update the International Study Group of Pancreatic Fistula classification in light of recent evidence that has emerged, as well as to address the lingering controversies about the original definition and grading of postoperative pancreatic fistula.

METHODS

The International Study Group of Pancreatic Fistula reconvened as the International Study Group in Pancreatic Surgery in order to perform a review of the recent literature and consequently to update and revise the grading system of postoperative pancreatic fistula.

RESULTS

Based on the literature since 2005 investigating the validity and clinical use of the original International Study Group of Pancreatic Fistula classification, a clinically relevant postoperative pancreatic fistula is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. Consequently, the former "grade A postoperative pancreatic fistula" is now redefined and called a "biochemical leak," because it has no clinical importance and is no longer referred to a true pancreatic fistula. Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly. In particular, grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula.

CONCLUSION

This new definition and grading system of postoperative pancreatic fistula should lead to a more universally consistent evaluation of operative outcomes after pancreatic operation and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula. Use of this updated classification will also allow for more precise comparisons of surgical quality between surgeons and units who perform pancreatic surgery.

Prognostic Value of Lymph Node Status and Extent of Lymphadenectomy in Pancreatic Neuroendocrine Tumors Confined To and Extending Beyond the Pancreas

BACKGROUND

The impact of lymph node (LN) status and lymphadenectomy (LA) on survival in pancreatic neuroendocrine tumors (pNETs) remains controversial. We evaluated the impact of tumor extension and grade on nodal metastasis and survival.

METHODS

Surgical pNET patients were queried in the Surveillance Epidemiology and End Results (SEER) database (1998-2012, N = 981). Factors associated with LN status were analyzed by logistic regression and by Cox analyses.

RESULTS

For T1-T2 tumors, N status was associated only with tumor size. N status (p = 0.001), grade (p < 0.001), age (p = 0.001), and sex (p = 0.007) predicted overall survival (OS). For T3-T4, grade (p < 0.001), sex (p = 0.004), size (p = 0.013), and age (p = 0.007) but not N status (p = 0.789) predicted OS. For T1-T2, disease-specific survival (DSS; p = 0.003) and OS (p = 0.008) were longer for N0 vs N1, while N0 vs NX had similar OS (p = 0.59) and DSS (p = 0.80). While a difference was seen in DSS for NX vs N1 (p = 0.04), no significant difference in OS was seen (p = 0.08). For T3-T4, N status did not affect DSS (p = 0.365) or OS (p = 0.454). For all T groups and any N status, extended LA (≥10 nodes resected) was not associated with OS.

CONCLUSION

While in T1-T2 pNET N1 status is a predictor of negative OS, similar outcome between NX and N0 supports limited LN resection in selected patients. Extended LA is unlikely to be helpful in T3-T4.