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Gaballah AH, Kazi IA, Zaheer A, Liu PS, Badawy M, Moshiri M, Ibrahim MK, Soliman M, Kimchi E, Elsayes KM. Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications. Radiographics 2024; 44:e230061. [PMID: 38060424 DOI: 10.1148/rg.230061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.
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Affiliation(s)
- Ayman H Gaballah
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Irfan A Kazi
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Atif Zaheer
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Peter S Liu
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mohamed Badawy
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mariam Moshiri
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Mohamed K Ibrahim
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Moataz Soliman
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Eric Kimchi
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
| | - Khaled M Elsayes
- From the Department of Diagnostic Imaging, The University of Texas Southwestern Medical Center, 201 Inwood Rd, Dallas, TX 75390 (A.H.G.); Departments of Radiology (I.A.K.) and Surgery (E.K.), University of Missouri, Columbia, Mo; Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Md (A.Z.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (P.S.L.); Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (M.B., K.M.E.); Department of Radiology, Vanderbilt University Medical Center, Nashville, Tenn (M.M.); Department of Radiology, Mayo Clinic, Rochester, Minn (M.K.I.); and Department of Radiology, Northwestern University, Chicago, Ill (M.S.)
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2
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Paulino J, Mansinho H. Recent Developments in the Treatment of Pancreatic Cancer. ACTA MEDICA PORT 2023; 36:670-678. [PMID: 37788655 DOI: 10.20344/amp.19957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/22/2023] [Indexed: 10/05/2023]
Abstract
Pancreatic duct adenocarcinoma is currently the sixth-leading cause of cancer death worldwide and the fourth in Europe, with a continuous increase in annual lethality in Portugal during the last two decades. Surgical en-bloc resection of the tumor with microscopic-negative margins and an adequate lymphadenectomy is the only possibility of long-term survival. As this type of cancer is a systemic disease, there is a high rate of recurrence even after curative resection, turning systemic therapy the core of its management, mostly based on chemotherapy. Neoadjuvant strategies for nonmetastatic disease showed significant improvement in overall survival compared with upfront surgery, namely in borderline resectable disease. Moreover, these strategies provided downstaging in several situations allowing R0 resections. Under these new oncologic strategies, several recent surgical issues were introduced, namely more aggressive vascular resections and even tumor resections in oligometastatic disease. This review revisits the state-of-the-art of surgical and oncological interventions in pancreatic duct adenocarcinoma and highlights recent advances in the field aiming to achieve higher survival rates.
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Affiliation(s)
- Jorge Paulino
- General Surgery Department. Hospital da Luz. Lisboa. Portugal
| | - Hélder Mansinho
- Oncology Department. Hospital Garcia de Orta. Almada. Portugal
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Frigerio I, Capelli G, Chiminazzo V, Spolverato G, Lorenzoni G, Mancini S, Giardino A, Regi P, Girelli R, Butturini G. Hepatic Artery Anomalies in Pancreaticoduodenectomy: Outcomes from a High-Volume Center. Dig Surg 2023; 40:196-204. [PMID: 37699375 DOI: 10.1159/000533619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 07/20/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Hepatic artery anomalies (HAA) may have an impact on surgical and oncological outcomes of patients undergoing pancreaticoduodenectomy (PD). METHODS Patients who underwent PD at our institution between July 2015 and January 2020 were retrospectively reviewed and classified into two groups: group 1, with presence of HAA, and group 2, with no HAA. A weighted logistic regression model was employed to assess the association between HAA and postoperative complications, and to assess the association between HAA and R status in patients with pancreatic cancer. RESULTS 502 patients were considered for analysis, with 75 (15%) of them in group 1. They had either an accessory (n = 28, 40.8%) or replaced (n = 26, 36.6%) right hepatic artery. Most patients underwent surgery for a malignancy (n = 451; 90%); among them, vascular resection was performed in 69 cases (15%). The presence of a HAA was reported at preoperative imaging only in 4 cases (5%) and the aberrant vessel was preserved in 72% of patients. At weighted multivariable logistic regression analysis, HAA were not associated to higher odds of morbidity (odds ratio [OR]: 0.753, 95% confidence interval [CI]: 0.543-1.043) nor to R1 status in case of pancreatic cancer (OR: 1.583, 95% CI: 0.979-2.561). CONCLUSION At our institution, the presence of HAA does not have an impact on postoperative outcomes or affects oncological clearance after PD. Hospitals', surgeons', volume and systematic review of preoperative imaging are all factors that help reduce possible adverse events.
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Affiliation(s)
- Isabella Frigerio
- Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Italy,
| | - Giulia Capelli
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
- Department of Surgery, ASST Bergamo Est, Seriate, Italy
| | - Valentina Chiminazzo
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
| | - Gaya Spolverato
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
| | - Silvia Mancini
- Department of General Surgery, Madonna della Navicella Hospital, Venice, Italy
| | | | - Paolo Regi
- Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Roberto Girelli
- Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Giovanni Butturini
- Pancreatic Surgical Unit, Pederzoli Hospital, Peschiera del Garda, Italy
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Stitzel HJ, Hue JJ, Elshami M, McCaulley L, Hoehn RS, Rothermel LD, Ammori JB, Hardacre JM, Winter JM, Ocuin LM. Assessing the use of Extended Venous Thromboembolism Prophylaxis on the Rates of Venous Thromboembolism and Postpancreatectomy Hemorrhage Following Pancreatectomy for Malignancy. Ann Surg 2023; 278:e80-e86. [PMID: 35797622 DOI: 10.1097/sla.0000000000005483] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare rates of venous thromboembolism (VTE) and postpancreatectomy hemorrhage (PPH) in patients with pancreatic or periampullary malignancy preimplementation and postimplementation of routine extended VTE prophylaxis. BACKGROUND Guidelines recommend up to 28 days of VTE prophylaxis following major abdominal cancer operations. There is a paucity of data examining rates of VTE and PPH in patients who receive extended VTE prophylaxis following pancreatectomy. METHODS Single-institution analysis of patients who underwent pancreatectomy for malignancy (2004-2021). VTE and PPH rates within 90 days of discharge were compared based on receipt of extended VTE prophylaxis with enoxaparin. RESULTS A total of 478 patients were included. Twenty-two (4.6%) patients developed a postoperative VTE, 12 (2.5%) of which occurred postdischarge. Twenty-five (5.2%) patients experienced PPH, 13 (2.7%) of which occurred postdischarge. There was no associated difference in the development of postdischarge VTE between patients who received extended VTE prophylaxis and those who did not (2.3% vs 2.8%, P =0.99). There was no associated difference in the rate of postdischarge PPH between patients who received extended VTE prophylaxis and those who did not (3.4% vs 1.9%, P =0.43). In the subset of patients on antiplatelet agents, the addition of enoxaparin did not appear to be associated with higher VTE (3.9 vs. 0%, P =0.31) or PPH (3.0 vs. 4.5%, P =0.64) rates. CONCLUSIONS Extended VTE prophylaxis following pancreatectomy for malignancy was not associated with differences in postdischarge VTE and PPH rates. These data suggest extended VTE prophylaxis is safe but may not be necessary for all patients following pancreatectomy.
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Affiliation(s)
- Henry J Stitzel
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jonathan J Hue
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mohamedraed Elshami
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lauren McCaulley
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Richard S Hoehn
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Luke D Rothermel
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lee M Ocuin
- Division of Surgical Oncology, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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5
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Thobie A, Robin F, Menahem B, Lubrano J, Boudjema K, Alves A, Dejardin O, Sulpice L. Influence of Hemorrhagic Complications of Pancreatoduodenectomy in Patients with Cancer on Short- and Long-Term Mortality. J Clin Med 2023; 12:jcm12082852. [PMID: 37109189 PMCID: PMC10143756 DOI: 10.3390/jcm12082852] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND With a mortality rate of up to 30%, post-pancreatectomy hemorrhage (PPH) remains a serious complication after pancreatoduodenectomy (PD) for cancer. Little is known about the long-term survival of patients after PPH. This retrospective study aimed to evaluate the impact of PPH on long-term survival after PD. METHODS The study included 830 patients (PPH, n = 101; non-PPH, n = 729) from two centers, who underwent PD for oncological indications. PPH was defined as any bleeding event occurring within 90 days after surgery. A flexible parametric survival model was used to determine the evolution of the risk of death over time. RESULTS At postoperative day 90, PPH significantly increased the mortality rate (PPH vs. non-PPH: 19.8% vs. 3.7%, p < 0.0001) and severe postoperative complication rate (85.1% vs. 14.1%, p < 0.0001), and decreased median survival (18.6 months vs. 30.1 months, p = 0.0001). PPH was associated with an increased mortality risk until the sixth postoperative month. After this 6-month period, PPH had no more influence on mortality. CONCLUSIONS PPH had a negative impact on the short-term overall survival beyond postoperative day 90 and up to six months after PD. However, compared to non-PPH patients, this adverse event had no impact on mortality after a 6-month period.
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Affiliation(s)
- Alexandre Thobie
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
| | - Fabien Robin
- Department of Digestive Surgery, University Hospital of Rennes, 35000 Rennes, France
| | - Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
| | - Jean Lubrano
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
| | - Karim Boudjema
- Department of Digestive Surgery, University Hospital of Rennes, 35000 Rennes, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, CS 30001, CEDEX 9, 14033 Caen, France
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
| | - Olivier Dejardin
- "ANTICIPE" U1086 INSERM, Team Ligue Contre le Cancer, Centre François Baclesse, University of Caen Normandy, 14000 Caen, France
- Department of Clinical Research, University Hospital of Caen, 14000 Caen, France
| | - Laurent Sulpice
- Department of Digestive Surgery, University Hospital of Rennes, 35000 Rennes, France
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Kobayashi K, Inoue Y, Omiya K, Sato S, Kato T, Oba A, Ono Y, Sato T, Ito H, Matsueda K, Saiura A, Takahashi Y. Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies. Pancreatology 2023; 23:235-244. [PMID: 36764874 DOI: 10.1016/j.pan.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/19/2022] [Accepted: 01/10/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND/OBJECTIVES This study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center. METHODS This retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage. RESULTS Of 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups. CONCLUSIONS Standardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.
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Affiliation(s)
- Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Kojiro Omiya
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shoki Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Ultrasound, Interventional Radiology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary and Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Nour HM, Peristeri DV, Ahsan A, Shafique S, Khan PM, Sajid MS. Regional vessels wrapping following pancreaticoduodenectomy reduces the risk of post-operative extra-luminal bleeding. A systematic review. Ann Med Surg (Lond) 2022; 82:104618. [PMID: 36268446 PMCID: PMC9577535 DOI: 10.1016/j.amsu.2022.104618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background Post-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether wrapping of regional vessels with omentum or falciform/teres ligament following pancreaticoduodenectomy reduces the risk of extra-luminal bleeding. Materials and method Standard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) and any type of comparative trial were shortlisted according to the inclusion criteria. The summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software. Result Two RCTs and 5 retrospective studies on 4100 patients undergoing pancreaticoduodenectomy were found suitable for this meta-analysis. There were 1404 patients in the wrapping-group (WG) and 2696 patients in the no-wrapping group (NWG). In the random effects model analysis, the incidence of extra-luminal haemorrhage was statistically lower in WG [odds ratio 0.51, 95%, CI (0.31, 0.85), Z = 2.59, P = 0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant. Conclusion The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres) following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting a greater number of patients are required to validate these findings as this study presents the combined data of two RCTs and 5 retrospective studies. Post pancreaticoduodenectomy haemorrhage can be mortality and morbidity increasing complication. The aim is to assess the effectiveness of regional vessels wrapping in decreasing post operative bleeding. Two RCTs and five retrospective studies were used to obtain the submitted data. Regional vessels wrapping was associated with reduced bleeding post pancreaticoduodenectomy.
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8
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Maccabe TA, Robertson HF, Skipworth J, Rees J, Roberts K, Pathak S. A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading. HPB (Oxford) 2022; 24:1110-1118. [PMID: 35101359 DOI: 10.1016/j.hpb.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Thomas A Maccabe
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK.
| | - Harry F Robertson
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - James Skipworth
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - Jonathan Rees
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - Keith Roberts
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK; Department of Pancreatic Surgery, University Hospitals Birmingham, UK
| | - Samir Pathak
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
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9
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Clancy TE, Baker EH, Maegawa FA, Raoof M, Winslow E, House MG. AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery. HPB (Oxford) 2022; 24:575-585. [PMID: 35063354 DOI: 10.1016/j.hpb.2021.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided. METHODS Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines. RESULTS Levels of evidence and strength of recommendations are presented. DISCUSSION While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.
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10
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Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery. Curr Oncol 2022; 29:2472-2482. [PMID: 35448175 PMCID: PMC9025466 DOI: 10.3390/curroncol29040201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/26/2022] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: To report and compare the results of endovascular and open surgical treatment for erosion bleeding of visceral arteries following pancreatitis and pancreatic surgery. Materials and Methods: This retrospective study included 65 consecutive patients (46 males, mean age 63 ± 14 years) presenting with visceral artery erosions between January 2011 and December 2020. Endpoints were technical success, freedom from reintervention, stent-graft-related complications, and 30-day and one-year mortality. Results: The causes of erosion bleeding included complications of surgical treatment for the pancreas and upper gastrointestinal tract (75%), pancreatitis (19%), and spontaneous bleeding (6%). Pancreatectomy was performed in 34 (52%) patients, representing 2% of all pancreatectomy procedures (n = 1645) performed in our hospital during the study period. A total of 37 (57%) patients underwent endovascular treatment (EVT), and 28 (43%) patients had open surgery (OS) as a primary treatment. Eight of 37 (22%) patients in the EVT group underwent stent-graft treatment of the eroded vessels and 28 (78%) coil embolization. Six (9%) patients underwent reintervention with no significant differences between EVT and OS groups (11% vs. 7%, p = 0.692). Postoperative morbidity and complications in 52% of all patients were higher in the OS group than in the EVT group (41% vs. 68%, p = 0.029). The in-hospital 30-days mortality rate for all patients was 25%, and it was higher in the OS group than in the EVT group (14% vs. 39%, p = 0.017). Conclusions: An endovascular-first strategy for treating visceral arteries erosions may be preferred to reduce the complications associated with open surgery if patients are hemodynamically stable and have no anastomotic insufficiency. Endovascular treatment may be associated with better in-hospital survival when compared to primary open surgery. Further studies are required to identify the optimal approach.
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11
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Nguyen LT, Do DH, Van Nguyen H, Nguyen KT, Nguyen CD. Lymph Node Characteristics and Short-Term Outcomes for Resectable Pancreatic Ductal Adenocarcinoma in Vietnam: A Retrospective Single-Center Study. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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12
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Russell TB, Aroori S. Procedure‐specific morbidity of pancreatoduodenectomy: a systematic review of incidence and risk factors. ANZ J Surg 2022; 92:1347-1355. [DOI: 10.1111/ans.17473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 12/16/2022]
Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery University Hospitals Plymouth NHS Trust Plymouth UK
| | - Somaiah Aroori
- Department of HPB Surgery University Hospitals Plymouth NHS Trust Plymouth UK
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13
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Chierici A, Intotero M, Granieri S, Paleino S, Flocchini G, Germini A, Cotsoglou C. Timely synergic surgical and radiological aggressiveness improves perioperative mortality after hemorrhagic complication in Whipple procedure. Hepatobiliary Pancreat Dis Int 2021; 20:387-390. [PMID: 33358611 DOI: 10.1016/j.hbpd.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/26/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Andrea Chierici
- General Surgery Unit, University of Milan, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy
| | - Marcello Intotero
- Radiodiagnostic Unit, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy
| | - Stefano Granieri
- General Surgery Unit, University of Milan, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy
| | - Sissi Paleino
- General Surgery Unit, University of Milan, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy
| | - Giovanni Flocchini
- General Surgery Unit, University of Milan, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy
| | - Alessandro Germini
- General Surgery Unit, University of Milan, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy
| | - Christian Cotsoglou
- General Surgery Unit, University of Milan, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871 Vimercate, Italy.
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14
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Salvia R, Andrianello S, Ciprani D, Deiro G, Malleo G, Paiella S, Casetti L, Landoni L, Tuveri M, Esposito A, Marchegiani G, Bassi C. Pancreatic surgery is a safe teaching model for tutoring residents in the setting of a high-volume academic hospital: a retrospective analysis of surgical and pathological outcomes. HPB (Oxford) 2021; 23:520-527. [PMID: 32859493 DOI: 10.1016/j.hpb.2020.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Academic hospitals must train future surgeons, but whether residents could negatively affect the outcomes of major procedures is a matter of concern. The aim of this study is to assess if pancreatic surgery is a safe teaching model. METHODS Outcomes of 1230 major pancreatic resections performed at a high-volume pancreatic teaching hospital between 2015 and 2018 were compared according to the first surgeon type, attending vs resident. RESULTS Residents performed a selection of 132 (16%) pancreaticoduodenectomies (PD) and 46 (11%) distal pancreatectomies (DP). For PD, pancreatic fistula (25% vs 0, p < 0.001), biliary fistula (7.1% vs 3.5%, p = 0.04) and operative time (400 vs 390 min, p < 0.001) were lower for residents but post-pancreatectomy hemorrhage was higher (20.5% vs 13% p = 0.024). For DP, pancreatic fistula rate was lower for residents (31.7% vs 17.5% p = 0.046). There was no difference in terms of lymph nodes retrieval both for PDs and DPs, while the R1 resections were more frequent among PDs performed by attending surgeons (31.5% vs 15.7%, p = 0.023). CONCLUSION The active participation of residents does not negatively affect outcomes of major pancreatic resections in a high-volume center. By means of case selection and continuous tutoring, pancreatic surgery represents a safe and valid teaching model.
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Affiliation(s)
- Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Debora Ciprani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giacomo Deiro
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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15
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Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system. Eur Radiol 2021; 31:6879-6888. [PMID: 33665718 DOI: 10.1007/s00330-021-07788-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/30/2021] [Accepted: 02/15/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Clinically significant pancreatic fistula (POPF) has been established as a well-known risk factor for late and severe postpancreatectomy hemorrhage after pancreaticoduodenectomy (PD) (postpancreatectomy pancreatic fistula-associated hemorrhage [PPFH]). Our aim was to assess whether contrast-enhanced CT scan after PD is an effective tool for early prediction of PPFH. METHODS From a prospectively acquired database, all consecutive patients who underwent PD between January 2013 and May 2019 were identified; within this database, all patients who were evaluated, for clinical suspicion of POPF, with at least one contrast-enhanced CT scan examination, were enrolled in this retrospective study. The selected CT findings included perianastomotic fluid collections and air bubbles; pancreaticojejunostomy (PJ) was analyzed in terms of dehiscence and defect. RESULTS One hundred seventy-eight out of 953 PD patients (18.7%) suffered from clinically significant POPF; after exclusions, 166 patients were enrolled. Among this subset, 33 patients (19.9%) had at least one PPFH episode. In multivariable analysis, PPFH was associated with postoperative CT evidence of fluid collections (p = 0.046), air bubbles (p = 0.046), and posterior PJ defect (p < 0.001). Based on these findings, a practical 4-point prediction score was developed (AUC: 0.904, Se: 76%, Sp: 93.8%): patients with a score ≥ 3 demonstrated a significantly higher risk of PPFH development (OR = 45.6, 95% CI: 13.0-159.3). CONCLUSIONS Postoperative CT scan permits early stratification of PPFH risk, thus providing an actual aid for patients' management. KEY POINTS • Postpancreatectomy hemorrhage (PPH) is a dramatic, clinically unpredictable occurrence. • After pancreaticoduodenectomy (PD), early identification of posterior pancreaticojejunostomy defect, perianastomotic air bubbles, and retroperitoneal fluid collections enables effective PPH risk stratification by means of a practical CT-based 4-point scoring system. • CT scan after PD allows a paradigm shift in the management PPH, from a conventional "wait and see" approach, to a more proactive one that relies on early anticipation and timely prevention.
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16
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Ferraro V, Tedeschi M, Laera L, Ammendola M, Riccelli U, Silvestris N, Fiorentino A, Surico G, Inchingolo R, Decembrino F, de Angelis N, Memeo R. The Role of Laparoscopic Surgery in Localized Pancreatic Neuroendocrine Tumours. Curr Treat Options Oncol 2021; 22:27. [PMID: 33641016 DOI: 10.1007/s11864-021-00824-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 02/05/2023]
Abstract
Pancreatic neuroendocrine tumours (PNETs) are a rare and heterogeneous group of tumours with various clinical manifestations and biological behaviours. They represent approximately 2-4% of all pancreatic tumours, with an incidence of 2-3 cases per million people. PNETs are classified clinically as non-functional or functional, and pancreatic resection is recommended for lesions greater than 2 cm. The surgical approach can involve "typical" and "atypical" resections depending on the number, size and location of the tumour. Typical resections include pancreaticoduodenectomy, distal pancreatectomy enucleation and, rarely, total pancreatectomy. Atypical resections comprise central pancreatectomies or enucleations. Minimally invasive pancreatic resection has been proven to be technically feasible and safe in high-volume and specialized centres with highly skilled laparoscopic surgeons, with consolidated benefits for patients in the postoperative course. However, open and minimally invasive pancreatic surgery remains to have a high rate of complications; there is no specific technical contraindication to minimally invasive pancreatic surgery, but an appropriate patient selection is crucial to obtain satisfactory clinical and oncological outcomes.
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Affiliation(s)
- Valentina Ferraro
- Hepato-Pancreato-Biliary Surgery Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy.
| | - Michele Tedeschi
- Hepato-Pancreato-Biliary Surgery Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Letizia Laera
- Medical Oncology Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Michele Ammendola
- Department of Health Sciences, General Surgery, Magna Græcia University, Medicine School of Germaneto, Catanzaro, Italy
| | - Umberto Riccelli
- Department of Reconstructive Surgery, "Pugliese Ciaccio" Hospital, Catanzaro, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, IRCCS Cancer Institute "Giovanni Paolo II", Bari, Italy
| | - Alba Fiorentino
- Radiotherapy Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Giammarco Surico
- Medical Oncology Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Francesco Decembrino
- Gastroenterology and Endoscopy Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Nicola de Angelis
- Minimally invasive and Robotic Gastrointestinal Surgery, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Hepato-Pancreato-Biliary Surgery Unit, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
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17
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Hufkens AS, van Cleven S, Abreu de Carvalho L, Vanlander A, Berrevoet F. Evaluation of an enhanced recovery program for outcome improvement after pancreaticoduodenectomy: A retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2020.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Khuri S, Mansour S, Obeid A, Azzam A, Borzellino G, Kluger Y. Postpancreatoduodenectomy Hemorrhage: Association between the Causes and the Severity of the Bleeding. Visc Med 2020; 37:171-179. [PMID: 34250074 DOI: 10.1159/000509894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023] Open
Abstract
Introduction Of the complications following pancreatoduodenectomy (PD), postpancreatoduodenectomy hemorrhage (PPH) is the least common, but severe forms can be life-threatening without urgent treatment. While early PPH is mostly related to surgical hemostasis, late PPH is more likely due to complex physiopathological pathways secondary to different etiologies. The understanding of such etiologies could therefore be of great interest to help guide the treatment of severe, potentially life-threatening, late PPH cases. Objective The aim of this retrospective study was to assess the causes of PPH as a complication and explore a possible association between the causes and the severity of late PPH. Methods A retrospective study was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted for PD were reviewed, and all patients with PPH were included. The timing, cause, and severity of PPH as well as other information were collected. A statistical analysis on the possible association between cause and severity of late PPH was performed. Results A total of 347 patients underwent PD, 18 of whom (5.18%) developed PPH. Early PPH was reported in 1 patient (5.6%) with severe bleeding from the gastric staple line. Late PPH was reported in 17 patients (94.4%). The most common causes of late PPH were bleeding from a vascular pseudoaneurysm (PSA) reported in 6 patients, 1 with mild and 5 with severe hemorrhage, and bleeding from a gastroenteric anastomosis marginal ulcer reported in 6 patients, all with mild hemorrhage. No etiology was found in 5 patients with mild hemorrhage. A significant association was found between the severity of late hemorrhage and vascular PSA as the cause of the bleeding (p = 0.001). All PSA bleeding occurred in cases complicated by a postoperative pancreatic fistula (POPF), with a significant statistical association (p < 0.001). Conclusions The most common cause of PPH was bleeding from a vascular PSA; the majority of these cases involved severe bleeding with late presentation, and all were associated with a POPF formation. In such cases, early detection by computed tomography angiography is mandatory, thereby promoting urgent treatment by angiography of vascular bleeding complications following PD.
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Affiliation(s)
- Safi Khuri
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.,HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
| | - Subhi Mansour
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Amir Obeid
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ameer Azzam
- Emergency Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.,HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel
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19
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Funamizu N, Omura K, Takada Y, Ozaki T, Mishima K, Igarashi K, Wakabayashi G. Geriatric Nutritional Risk Index Less Than 92 Is a Predictor for Late Postpancreatectomy Hemorrhage Following Pancreatoduodenectomy: A Retrospective Cohort Study. Cancers (Basel) 2020; 12:cancers12102779. [PMID: 32998260 PMCID: PMC7600944 DOI: 10.3390/cancers12102779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/25/2020] [Indexed: 01/06/2023] Open
Abstract
Simple Summary The definite risk factor of postpancreatectomy hemorrhage (PPH) is still unknown in spite of a lethal complication of pancreatoduodenectomy (PD). In this study, we evaluated whether GNRI is a reliable marker for PPH following PD. The present study retrospectively evaluated 121 patients treated with PD at Ageo Central General Hospital in Japan. Ten patients had developed PPH. Among them, the patients were divided into bleeding group (n = 10) and non-bleeding group (n = 111). The bleeding group had significantly low geriatric nutritional risk index (GNRI) values compared to those in the non-bleeding group (p = 0.001). The cut-off value of GNRI was determined by 92 accounting for a sensitivity 80.0%, specificity 82.9% using receiver operating characteristic curve analysis. A GNRI of <92 was statistically identified as an independently risk factor of PPH risk following PD. Abstract Postpancreatectomy hemorrhage (PPH) is the most lethal complication of pancreatoduodenectomy (PD). The main risk factor for PPH is the development of a postoperative pancreatic fistula (POPF). Recent evidence shows that the geriatric nutritional risk index (GNRI) may be predictive indicator for POPF. In this study, we aimed to evaluate whether GNRI is a reliable predictive marker for PPH following PD. The present study retrospectively evaluated 121 patients treated with PD at Ageo Central General Hospital in Japan between January 2015 and March 2020. We investigated the potential of age, gender, body mass index, serum albumin, American Society of Anesthesiologists classification (ASA), diabetes mellitus and smoking status, time taken for the operation, estimated blood loss, and postoperative complications (POPF, bile leak, and surgical site infections) to predict the risk of PPH following PD using univariate and multivariate analyses. Ten patients had developed PPH with an incidence of 8.3%. Among them, the patients were divided into bleeding group (n = 10) and non-bleeding group (n = 111). The bleeding group had significantly lower GNRI values than those in the non-bleeding group (p = 0.001). We determined that the cut-off value of GNRI was 92 accounting for a sensitivity 80.0%, specificity 82.9%, and likelihood ratio of 4.6 using receiver operating characteristic curve analysis. A GNRI of <92 was statistically associated with PPH in both univariate (p < 0.001) and multivariate analysis (p = 0.01). Therefore, we could identify that a GNRI < 92 was an independently potential predictor of PPH risk following PD. We should alert surgeons if patients have low level GNRI before PD.
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Affiliation(s)
- Naotake Funamizu
- Department of Surgery, Ageo Central General Hospital, Saitama Prefecture, Ageo, Saitama 362-8588, Japan; (K.O.); (T.O.); (K.M.); (K.I.); (G.W.)
- Department of HBP Surgery, Ehime University, Ehime Prefecture, Matsuyama 791-0295, Japan;
- Correspondence: ; Tel.: +81-48-773-1111 (ext. 8625)
| | - Kenji Omura
- Department of Surgery, Ageo Central General Hospital, Saitama Prefecture, Ageo, Saitama 362-8588, Japan; (K.O.); (T.O.); (K.M.); (K.I.); (G.W.)
| | - Yasutsugu Takada
- Department of HBP Surgery, Ehime University, Ehime Prefecture, Matsuyama 791-0295, Japan;
| | - Takahiro Ozaki
- Department of Surgery, Ageo Central General Hospital, Saitama Prefecture, Ageo, Saitama 362-8588, Japan; (K.O.); (T.O.); (K.M.); (K.I.); (G.W.)
| | - Kohei Mishima
- Department of Surgery, Ageo Central General Hospital, Saitama Prefecture, Ageo, Saitama 362-8588, Japan; (K.O.); (T.O.); (K.M.); (K.I.); (G.W.)
| | - Kazuharu Igarashi
- Department of Surgery, Ageo Central General Hospital, Saitama Prefecture, Ageo, Saitama 362-8588, Japan; (K.O.); (T.O.); (K.M.); (K.I.); (G.W.)
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama Prefecture, Ageo, Saitama 362-8588, Japan; (K.O.); (T.O.); (K.M.); (K.I.); (G.W.)
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20
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Xu J, Zhang A, Tang B, Tian X, Ma Y, Song J, Qiao J, Wei J, Chen J, Yang Y. Modification of a new subclassification of Grade B postoperative pancreatic fistula: A bicenter retrospective cohort study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 29:641-648. [PMID: 32506811 DOI: 10.1002/jhbp.780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/17/2020] [Accepted: 05/03/2020] [Indexed: 12/16/2022]
Abstract
AIM To propose a modified subclassification of grade B postoperative pancreatic fistula (POPF) based on management approaches in Chinese patients. METHODS Data of consecutive pancreatoduodenectomy at two hospitals in China from 2013 to 2018 were collected, and outcomes were compared across different groups of POPF. Subclassification of B-POPF was made based on intervention to B1: non-interventional subclass and B2: interventional subclass. RESULTS A total of 142 of 522 patients had biochemical leaks (BLs) (27.2%), and POPFs developed in 106 of 522 patients (20.3%), with 81 B-POPFs (15.5%) and 25 C-POPFs (4.8%). BL did not differ from the non-fistula condition in almost all outcomes. The differences of outcomes among the non-fistula/BL, B-POPF and C-POPF groups were significant. The prevalence of subclass B1 and B2 was 56.8% (46/81) and 43.2% (35/81), respectively. Compared to the B1 group, patients in the B2 group had worse outcomes, such as post-pancreatectomy hemorrhage (15.2% vs 34.3%, P = .045), biliary fistula (13.0% vs 34.3%, P = .023), postoperative hospital stay (32 vs 39 days, P = .011), and cost ($US28 601.0 vs $US39 314.5, P < .001). CONCLUSION The recently reported B-POPF subclassification method was modified in Chinese patients according to the intervention, and is more practical, simpler and fits Chinese patients.
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Affiliation(s)
- Jingyong Xu
- Department of General Surgery, Peking University First Hospital, Beijing, China.,Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Aoran Zhang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Bingjun Tang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Jinghai Song
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiangchun Qiao
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Junmin Wei
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jian Chen
- Department of General Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
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21
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Computed tomographic angiography for diagnosis of post-pancreatoduodenectomy hemorrhage. Hepatobiliary Pancreat Dis Int 2019; 18:598-600. [PMID: 31320268 DOI: 10.1016/j.hbpd.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/01/2019] [Indexed: 02/05/2023]
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Laparoscopic Spleen-Preserving Distal Pancreatectomy (LSPDP) versus Open Spleen-Preserving Distal Pancreatectomy (OSPDP): A Comparative Study. Can J Gastroenterol Hepatol 2019; 2019:9367868. [PMID: 31355163 PMCID: PMC6633873 DOI: 10.1155/2019/9367868] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/01/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To compare outcomes between laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and open spleen-preserving distal pancreatectomy (OSPDP) for treatment of benign and low-grade malignant tumors of the pancreas and evaluate feasibility and safety of LSPDP. METHODS The clinical data of 53 cases of LSPDP and 44 cases of OSPDP performed between January 2008 and August 2018 were retrospectively analyzed. The clinical outcomes between the two groups were compared. RESULTS There was no significant difference in preoperative data between the two groups. However, the LSPDP group had statistically significant shorter operative time (145.3±55.9 versus 184.7±33.5, P=0.03) and lesser intraoperative blood loss (150.6±180.8 versus 253.5±76.2, P=0.03) than that of the OSPDP group. Moreover, the LSPDP group also had statistically significant earlier passing of first flatus (2.2±1.4 versus 3.1±1.9, P=0.01), earlier diet intake (2.3±1.8 versus 3.4±2.0, P=0.01), and shorter hospital stay (6.2±7.2 versus 8.8±9.3, 0.04) than that of the OSPDP group. However, postoperative pancreatic fistula (P=0.64) and total postoperative complications (P=0.59) were not significantly different between the groups. The rate of pancreatic fistula and total postoperative complications occurred in 62.5% and 64.5%, respectively, in LSPDP group and, similarly, 70% and 70.0%, respectively, in OSPDP group. CONCLUSION This study confirms that LSPDP is safe, feasible, and superior to OSPDP in terms of operative time, intraoperative blood loss, hospital stay, and postoperative recovery. Hence, it is worth popularizing LSPDP for benign and low-grade malignant tumors of the pancreas.
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Laparoscopic Spleen-Preserving Distal Pancreatectomy (LSPDP) with Preservation of Splenic Vessels: An Inferior-Posterior Approach. Gastroenterol Res Pract 2018; 2018:1683719. [PMID: 30298089 PMCID: PMC6157179 DOI: 10.1155/2018/1683719] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/15/2018] [Accepted: 08/07/2018] [Indexed: 01/08/2023] Open
Abstract
Objective To summarize the operation experience of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with preservation of splenic vessels by an inferior-posterior dissection of the pancreatic body and evaluate its feasibility. Methods Patients undergoing LSPDS at Ningbo Li Huili Hospital and Ningbo Li Huili Eastern Hospital from January 2014 to April 2017 were recruited in this study and were analyzed retrospectively. They were divided into two groups based on the surgical approach: the inferior-posterior approach group and the other approach group. We sought to compare outcomes of the two groups. Results The LSPDP procedure was completed successfully in 49 cases, and 48 patients had their splenic artery and vein preserved, including 26 cases in the inferior-posterior approach group and 22 cases in the other approach group. There were no significant differences between the two groups with respect to age (p = 0.18), sex (p = 0.56), preoperative diabetes (p = 1.00), ASA grading (p = 1.00), tumor size (p = 0.91), intraoperative blood loss (t = −0.01, p = 0.99), hospital stay (t = −0.02, p = 0.98), and pancreatic fistula rates (p = 1.00). Patients undergoing LSPDP by the inferior-posterior approach had a shorter operative time (t = −4.13, p < 0.001) than the other approach group. Conclusions LSPDS by the inferior-posterior approach associated with shorter operative time is safe and feasible.
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