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Cardoso D, Miranda J, de Arimateia Batista Araujo-Filho J, Soares LE, Chagas L, Seidel K, Fonseca GM, Hamdan D, Kalaycioglu B, Chhabra S, Yildirim O, Chakraborty J, Horvat N. Cross-sectional imaging of pancreatic leak: a pictorial review. Abdom Radiol (NY) 2024:10.1007/s00261-024-04401-w. [PMID: 38900317 DOI: 10.1007/s00261-024-04401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024]
Abstract
Pancreatic leaks occur when a disruption in the pancreatic ductal system results in the leakage of pancreatic enzymes such as amylase, lipase, and proteases into the abdominal cavity. While often associated with pancreatic surgical procedures, trauma and necrotizing pancreatitis are also common culprits. Cross-sectional imaging, particularly computed tomography, plays a crucial role in assessing postoperative conditions and identifying both early and late complications, including pancreatic leaks. The presence of fluid accumulation or hemorrhage near an anastomotic site strongly indicates a pancreatic fistula, particularly if the fluid is connected to the pancreatic duct or anastomotic suture line. Pancreatic fistulas are a type of pancreatic leak that carries a high morbidity rate. Early diagnosis and assessment of pancreatic leaks require vigilance and an understanding of its imaging hallmarks to facilitate prompt treatment and improve patient outcomes. Radiologists must maintain vigilance and understand the imaging patterns of pancreatic leaks to enhance diagnostic accuracy. Ongoing improvements in surgical techniques and diagnostic approaches are promising for minimizing the prevalence and adverse effects of pancreatic fistulas. In this pictorial review, our aim is to facilitate for radiologists the comprehension of pancreatic leaks and their essential imaging patterns.
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Affiliation(s)
- Daniel Cardoso
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91-Bela Vista, São Paulo, SP, 01308-050, Brazil.
| | - Joao Miranda
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
- Department of Radiology, University of São Paulo, R. Dr. Ovídio Pires de Campos, 75-Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | | | - Luciana Eltz Soares
- SIDI Radiology at Cardiology Institute of Porto Alegre, Avenida Princesa Isabel 395, Porto Alegre, CEP 90620000, Brazil
| | - Lucia Chagas
- Department of Radiology, Hospital Samaritano, Rua Conselheiro Brotero, 1489-Higienópolis, São Paulo, SP, 01232-010, Brazil
| | - Kamila Seidel
- Departmente of Radiology, Beneficência Portuguesa de São Paulo-Rua Maestro Cardim, 637-Bela Vista, São Paulo, SP, 01323-001, Brazil
| | - Gilton Marques Fonseca
- Department of Gastroenterology, University of São Paulo Medical School, Avenida Doutor Enéas de Carvalho Aguiar, 255, Instituto Central, 9° Andar, Sala 9074-Cerqueira Cesar, São Paulo, SP, 05403-900, Brazil
| | - Dina Hamdan
- Department of Radiology, Mount Sinai Hospital, 1468 Madison Avenue, New York, NY, 10029, USA
| | - Bora Kalaycioglu
- Department of Radiology, The University of Chicago. Billings Hospital, P220, 5841 South Maryland Avenue, MC2026, Chicago, IL, 60637, USA
| | - Shalini Chhabra
- Department of Radiology, Shalini Chhabra, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Onur Yildirim
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Jayasree Chakraborty
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
- Department of Radiology, University of São Paulo, R. Dr. Ovídio Pires de Campos, 75-Cerqueira César, São Paulo, SP, 05403-010, Brazil
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Ramírez-Giraldo C, Conde Monroy D, Arbelaez-Osuna K, Isaza-Restrepo A, Sabogal Olarte JC, Upegui D, Rojas-López S. Evaluation of postoperative pancreatic fistula prediction scales following pancreatoduodenectomies based on magnetic resonance imaging: A diagnostic test study. Pancreatology 2024:S1424-3903(24)00635-5. [PMID: 38824072 DOI: 10.1016/j.pan.2024.05.526] [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: 07/25/2023] [Revised: 04/04/2024] [Accepted: 05/25/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most feared and common complications following pancreatoduodenectomies. This study aims to evaluate the performance of different scales in predicting POPF using magnetic resonance imaging (MRI), including estimation of the pancreatic duct diameter, pancreatic texture, main duct index, relation to the portal vein, and intra-abdominal fat thickness. MATERIALS AND METHODS A retrospective diagnostic test study was designed. Between January 2017 and December 2021, 133 pancreatoduodenectomies were performed at our institution. The performance for predicting overall POPF and clinically relevant POPF (CR-POPF) was evaluated using a receiver operating characteristic (ROC) curve. RESULTS A total of 96 patients were included in the study, of whom 26 patients experienced overall POPF, and 8 patients had CR-POPF. When analyzing the predictive value of each of the different scores applied, the Birmingham score showed the highest performance for predicting overall POPF and CR-POPF with an AUC (area under the curve) of 0.815 (95 % CI 0.725-0.906) and 0.813 (0.679-0.947), respectively. CONCLUSION The Birmingham scale demonstrated the highest predictive performance for POPF. It is a simple scale with only two variables that can be obtained preoperatively using MRI. Based on these results, we recommend its use in patients undergoing pancreatoduodenectomy.
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Affiliation(s)
- Camilo Ramírez-Giraldo
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia; Universidad del Rosario, Bogotá, Colombia; Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia.
| | | | | | - Andrés Isaza-Restrepo
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia; Universidad del Rosario, Bogotá, Colombia; Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | | | - Daniel Upegui
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia
| | - Susana Rojas-López
- Hospital Universitario Mayor - Méderi, Bogotá, Colombia; Universidad del Rosario, Bogotá, Colombia
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Ross S, Sucandy I, Vasanthakumar P, Espeut A, Christodoulou M, Pattilachan TM, Rosemurgy A. Deconstructing the Operative Times of Robotic Pancreaticoduodenectomy. Am Surg 2024:31348241241705. [PMID: 38563300 DOI: 10.1177/00031348241241705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Despite numerous benefits offered, robotic procedures take longer than "open" procedures. With the intent to reduce operative duration, we examined the degree each operative step contributes to operative duration in robotic pancreaticoduodenectomy. MATERIALS AND METHODS With IRB approval, we prospectively followed 88 patients to determine the duration of robotic pancreaticoduodenectomy, and the duration of 12 key steps. Each operative step was regressed against the operation date, from most distant to most recent operation date. Data are presented as median (mean ± SD) for illustrative purposes. RESULTS Patients were 73 (71 ± 10.2) years old; 53% were men. Total time patient spent in the operating room was 471 (488 ± 93.3) minutes. Total operative time was 399 (421 ± 90.7) minutes. Total console time was 293 (297 ± 68.0) minutes. The 3 longest portions of the operation were (1) mobilization of the specimen and specimen extraction; (2) construction of the duodenojejunostomy; and (3) closure. CONCLUSION A third of the operative time is spent off the console. Over half of the steps required more than 20 minutes each to complete. Since robotic operations are associated with shorter LOS and without increased complication rates relative to "open" operations, salutary benefit can be gained by decreasing operative times of robotic procedures. Operative duration is an important metric that needs to be addressed. We need to target the most time-consuming steps, and break them into smaller pieces, to reach optimal efficiency and provide the benefits of decreased operative duration to the patients, hospitals, and providers.
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Affiliation(s)
- Sharona Ross
- Digestive Health Institute, AdventHealth, Tampa, FL, USA
| | | | - Padma Vasanthakumar
- Digestive Health Institute, AdventHealth, Tampa, FL, USA
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Abigail Espeut
- Digestive Health Institute, AdventHealth, Tampa, FL, USA
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Tian XF, Zhang L, Lou WH, Qiu YJ, Zuo D, Wang WP, Dong Y. Application of ultrasound shear wave elastography in pre-operative and quantitative prediction of clinically relevant post-operative pancreatic fistula after pancreatectomy: a prospective study for the investigation of risk evaluation model. Eur Radiol 2023; 33:7866-7876. [PMID: 37368114 DOI: 10.1007/s00330-023-09859-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 03/23/2023] [Accepted: 04/17/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES The aim of this study was to modify recognized clinically relevant post-operative pancreatic fistula (CR-POPF) risk evaluation models with quantitative ultrasound shear wave elastography (SWE) values and identified clinical parameters to improve the objectivity and reliability of the prediction. METHODS Two prospective, successive cohorts were initially designed for the establishment of CR-POPF risk evaluation model and the internal validation. Patients who scheduled to receive pancreatectomy were enrolled. Virtual touch tissue imaging and quantification (VTIQ)-SWE was used to quantify pancreatic stiffness. CR-POPF was diagnosed according to 2016 International Study Group of Pancreatic Fistula standard. Recognized peri-operative risk factors of CR-POPF were analyzed, and the independent variables selected from multivariate logistic regression were used to build the prediction model. RESULTS Finally, the CR-POPF risk evaluation model was built in a group of 143 patients (cohort 1). CR-POPF occurred in 52/143 (36%) patients. Constructed from SWE values and other identified clinical parameters, the model achieved an area under the receiver operating characteristic curve of 0.866, with sensitivity, specificity, and likelihood ratio of 71.2%, 80.2%, and 3.597 in predicting CR-POPF. Decision curve of modified model revealed a better clinical benefit compared to the previous clinical prediction models. The models were then examined via internal validation in a separate collection of 72 patients (cohort 2). CONCLUSIONS Risk evaluation model based on SWE and clinical parameters is a potential non-invasive way to pre-operatively, objectively predict CR-POPF after pancreatectomy. CLINICAL RELEVANCE STATEMENT Our modified model based on ultrasound shear wave elastography may provide an easy access in pre-operative and quantitative evaluating the risk of CR-POPF following pancreatectomy and improve the objectivity and reliability of the prediction compared to previous clinical models. KEY POINTS • Modified prediction model based on ultrasound shear wave elastography (SWE) provides an easy access for clinicians to pre-operatively, objectively evaluate the risk of clinically relevant post-operative pancreatic fistula (CR-POPF) following pancreatectomy. • Prospective study with validation showed that the modified model provides better diagnostic efficacy and clinical benefits compared to previous clinical models in predicting CR-POPF. • Peri-operative management of CR-POPF high-risk patients becomes more possible.
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Affiliation(s)
- Xiao-Fan Tian
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Lei Zhang
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Hui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yi-Jie Qiu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Dan Zuo
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China.
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Søreide K, Hallet J, Jamieson NB, Stättner S. Optimal surgical approach for digestive neuroendocrine neoplasia primaries: Oncological benefits versus short and long-term complications. Best Pract Res Clin Endocrinol Metab 2023; 37:101786. [PMID: 37328324 DOI: 10.1016/j.beem.2023.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The rising incidence and the accumulating prevalence of neuroendocrine neoplasia (NEN) in the population makes this a common, prevalent and a clinically relevant disease group. Surgical resection represents the only potentially curative treatment for digestive NENs. Thus, resection should in principle be considered for all patients with NEN, although taking the patients age, relevant comorbidity, and performance status into account for operability. Patients with insulinomas, NEN of the appendix and rectal NENs are usually cured by surgery alone. However, less than a third of patients are amendable to curative surgery alone at time of diagnosis. Furthermore, recurrence is common and may occur years after primary surgery, hence the long follow-up time recommended in most NENs (>10 years). As many patients with NENs present with locoregional or metastatic disease, there is considerable debate regarding the role of debulking surgery in these settings. However, good long-term survival can be achieved in a considerable proportion of patients, with 50-70% alive up to 10 years after surgery. Location and grade are the main determinants of long-term survival. Here we present considerations to surgery for primary neuroendocrine tumors in the digestive tract.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
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Bannone E, Marchegiani G, Vollmer C, Perri G, Procida G, Corvino G, Peressotti S, Vacca PG, Salvia R, Bassi C. Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy. Ann Surg 2023; 278:e293-e301. [PMID: 35876366 DOI: 10.1097/sla.0000000000005629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether postoperative serum hyperamylasemia (POH), with drain fluid amylase (DFA) and C-reactive protein (CRP), improves the Fistula Risk Score (FRS) accuracy in assessing the risk of a postoperative pancreatic fistula (POPF). SUMMARY BACKGROUND DATA The FRS predicts POPF occurrence using intraoperative predictors with good accuracy but intrinsic limits. METHODS Outcomes of patients who underwent pancreaticoduodenectomies between 2016 and 2021 were evaluated across FRS-risk zones and POH occurrence. POH consists of serum amylase activity greater than the upper limit of normal (52 U/l), persisting within the first 48 hours postoperatively (postoperative day -POD- 1 and 2). RESULTS Out of 905 pancreaticoduodenectomies, some FRS elements, namely soft pancreatic texture (odds ratio (OR) 11.6), pancreatic duct diameter (OR 0.80), high-risk pathologic diagnosis (OR 1.54), but not higher blood loss (OR 0.99), were associated with POH. POH was an independent predictor of POPF, which occurred in 46.8% of POH cases ( P <0.001). Once POH occurs, POPF incidence rises from 3.8% to 42.9%, 22.9% to 41.7%, and 48.9% to 59.2% in patients intraoperatively classified at low, moderate and high FRS risk, respectively. The predictive ability of multivariable models adding POD 1 drain fluid amylase, POD 1-2 POH and POD 3 C-reactive protein to the FRS showed progressively and significantly higher accuracy (AUC FRS=0.82, AUC FRS-DFA=0.85, AUC FRS-DFA-POH=0.87, AUC FRS-DFA-POH-CRP=0.90, DeLong always P <0.05). CONCLUSIONS POPF risk assessment should follow a dynamic process. The stepwise retrieval of early, postoperative biological markers improves clinical risk stratification by increasing the granularity of POPF risk estimates and affords a possible therapeutic window before the actual morbidity of POPF occurs.
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Affiliation(s)
- Elisa Bannone
- 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
| | - Charles Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gaetano Corvino
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Sara Peressotti
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- 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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Bonsdorff A, Sallinen V. Prediction of postoperative pancreatic fistula and pancreatitis after pancreatoduodenectomy or distal pancreatectomy: A review. Scand J Surg 2023:14574969231167781. [PMID: 37083016 DOI: 10.1177/14574969231167781] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND AND OBJECTIVE Postoperative pancreatic fistula (POPF) is the leading cause of morbidity and early mortality in patients undergoing pancreatic resection. In addition, recent studies have identified postoperative acute pancreatitis (POAP) as an independent contributor to morbidity. Most perioperative mitigation strategies experimented for POPF have been shown to be in vain with no consensus on the best perioperative management. Clinical prediction models have been developed with the hope of identifying high POPF risk patients with the leading idea of finding subpopulations possibly benefiting from pre-existing or novel mitigation strategies. The aim of this review was to map out the existing prediction modeling studies to better understand the current stage of POPF prediction modeling, and the methodology behind them. METHODS A narrative review of the existing POPF prediction model studies was performed. Studies published before September 2022 were included. RESULTS While the number of POPF prediction models for pancreatoduodenectomy has increased, none of the currently existing models stand out from the crowd. For distal pancreatectomy, two unique POPF prediction models exist, but due to their freshness, no further external validation or adoption in clinics or research has been reported. There seems to be a lack of adherence to correct methodology or reporting guidelines in most of the studies, which has rendered external validity-if assessed-low. Few of the most recent studies have demonstrated preoperative assessment of pancreatic aspects from computed tomography (CT) scans to provide relatively strong predictors of POPF. CONCLUSIONS Main goal for the future would be to reach a consensus on the most important POPF predictors and prediction model. At their current state, few models have demonstrated adequate transportability and generalizability to be up to the task. Better understanding of POPF pathophysiology and the possible driving force of acute inflammation and POAP might be required before such a prediction model can be accessed.
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Affiliation(s)
- Akseli Bonsdorff
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Departments of Gastroenterological Surgery and Transplantation and Liver Surgery Helsinki University Hospital and University of HelsinkiHaartmaninkatu 400029 Helsinki Finland
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Zhao Z, Zhou L, Han L, Zhou S, Tan Z, Dai R. The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula. Heliyon 2023; 9:e13660. [PMID: 36865459 PMCID: PMC9970899 DOI: 10.1016/j.heliyon.2023.e13660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/13/2023] Open
Abstract
Background The clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF. Methods We retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients' demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF. Results In the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group. Conclusion Of all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.
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Affiliation(s)
- Zhirong Zhao
- College of Medicine, Southwest Jiaotong University, Chengdu, China,General Surgery Center, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China
| | - Lichen Zhou
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China,College of Clinical Medicine Southwest Medical University, Luzhou, Sichuan Province, China
| | - Li Han
- College of Medicine, Southwest Jiaotong University, Chengdu, China,General Surgery Center, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China
| | - Shibo Zhou
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China,College of Clinical Medicine Southwest Medical University, Luzhou, Sichuan Province, China
| | - Zhen Tan
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China
| | - Ruiwu Dai
- College of Medicine, Southwest Jiaotong University, Chengdu, China,General Surgery Center, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China,College of Clinical Medicine Southwest Medical University, Luzhou, Sichuan Province, China,Pancreatic Injury and Repair Key Laboratory of Sichuan Province, General Hospital of Western Theater Command, Chengdu, Sichuan Province, China,Corresponding author. Affiliated Hospital of Southwest Jiaotong University, The General Hospital of Western Theater Command, Chengdu 610031, Sichuan, China.
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Luo D, Li Y, Ji L, Gong X. Novel end-to-side one-layer continuous pancreaticojejunostomy vs. end-to-end invaginated pancreaticojejunostomy in pancreatoduodenectomy: A single-center retrospective study. Front Surg 2023; 9:980056. [PMID: 36684316 PMCID: PMC9852522 DOI: 10.3389/fsurg.2022.980056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/18/2022] [Indexed: 01/09/2023] Open
Abstract
Background and Objective Postoperative pancreatic fistula (POPF) is the most common critical complication after pancreatoduodenectomy (PD) and is the primary reason for increased mortality and morbidity after PD. We aim to investigate the clinical significance of a novel approach, i.e., end-to-side one-layer continuous pancreaticojejunostomy, for patients with PD. Methods The clinical data of 65 patients who underwent pancreatoduodenectomy at the Xiangya Hospital, Central South University, from September 2020 to December 2021 were retrospectively analyzed. Results Forty patients underwent end-to-end invaginated pancreaticojejunostomy, and 25 underwent the novel end-to-side one-layer continuous pancreaticojejunostomy. No significant differences were observed in pancreatic fistula, intraperitoneal infection, intraperitoneal bleeding, reoperation, postoperative hospital stay, or perioperative death between the two groups. However, the novel end-to-side one-layer continuous pancreaticojejunostomy group had significantly shorter operation duration (32.6 ± 5.1 min vs. 8.3 ± 2.2 min, p < 0.001). The incidence of pancreatic fistula in the novel pancreaticojejunostomy group was 12%, including two cases of grade A POPF and only one case of grade B POPF. No cases of grade C POPF occurred. No deaths were observed during the perioperative period. Conclusions The novel anastomosis method leads to a shorter operation duration than the traditional anastomosis method and does not increase postoperative complications. In conclusion, it is a simplified and feasible method for pancreatic anastomosis.
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Affiliation(s)
- Dong Luo
- Department of Hepatopancreatobiliary Surgery II, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yixiong Li
- Department of General Surgery (Pancreatic Surgery), Xiangya Hospital, Central South University, Changsha, China
| | - Liandong Ji
- Department of General Surgery (Pancreatic Surgery), Xiangya Hospital, Central South University, Changsha, China,Correspondence: LianDong Ji Xuejun Gong
| | - Xuejun Gong
- Department of General Surgery (Pancreatic Surgery), Xiangya Hospital, Central South University, Changsha, China,Correspondence: LianDong Ji Xuejun Gong
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Sauseng S, Imamovic A, Kresic J, Niernberger T, Rabl H. Perioperative management of pancreatic excretory function in the context of pancreatic head resections in PDAC patients. Eur Surg 2022. [DOI: 10.1007/s10353-022-00779-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Preoperative NLR and PLR are predictive of clinically relevant postoperative pancreatic fistula. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Development of a prediction model of pancreatic fistula after duodenopancreatectomy and soft pancreas by assessing the preoperative image. Langenbecks Arch Surg 2022; 407:2363-2372. [DOI: 10.1007/s00423-022-02564-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
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Bannone E, Marchegiani G, Perri G, Procida G, Vacca PG, Cattelani A, Salvia R, Bassi C. Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: It is not all about pancreatic fistula. Surgery 2022; 172:715-722. [PMID: 35636983 DOI: 10.1016/j.surg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/16/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association between postoperative serum hyperamylasaemia (POH) and morbidity has been hypothesized but rarely explored once occurring with or without (POH-exclusive) a combined postoperative pancreatic fistula (POPF). METHODS Analysis of patients who consecutively underwent pancreaticoduodenectomy from 2016 to 2020. POH was defined as serum amylase activity greater than the institutional upper limit of normal (52 U/L), persisting within the first 48 hours postoperatively (postoperative day [POD] 1 and 2). RESULTS Among 852 patients, 15.8% developed POH-exclusive. Compared with patients without POH or POPF (64.3%), they showed a significantly higher postoperative burden (Clavien-Dindo ≥II: 52.6% vs 30.8%) with increased rates of bacteraemia (12.6% vs 6%), pleural effusion (13.3% vs 5.3%), postpancreatectomy haemorrhage (13.3% vs 7.5%), postpancreatectomy acute pancreatitis (PPAP) (10.3% vs 0%), and organ site infections (18.5% vs 10.9%; all P < .05). A total of 13.8% experienced POH with POPF leading to the worse outcome. The combined occurrence of POH with POPF led to a shorter median time to morbidity (3 PODs, 95% confidence interval [CI] 2.2-3.7 vs 6 PODs, 95% CI 4.2-8; P < .001) than patients experiencing POPF-exclusive (5.9%). In all, 46.6% of POH patients developed POPF. Body mass index (BMI) (odds ratio [OR] 1.1), male sex (OR 2.1), increased drain fluid amylase on POD 1 (OR 1.001), and increased C-reactive protein (OR 1.01) were independent risk factors for POPF once POH has occurred. CONCLUSION POH has relevant postoperative clinical implications, independently from POPF occurrence. Developing POH with POPF leads to an earlier onset of higher postoperative burdens. Once POH is diagnosed, risk factors for additional POPF could identify patients who may benefit from additional surveillance, specific drains protocols, and preventive strategies.
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Affiliation(s)
- Elisa Bannone
- 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
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Cattelani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- 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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14
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Vilhav C, Fagman JB, Holmberg E, Naredi P, Engström C. C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage. Langenbecks Arch Surg 2022; 407:1949-1959. [PMID: 35306601 PMCID: PMC9399186 DOI: 10.1007/s00423-022-02440-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
Background Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C. Methods Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C. Results High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started. Discussion High postoperative CRP levels are related to an increased risk of PPH C.
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Affiliation(s)
- C Vilhav
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J B Fagman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Holmberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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15
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Yang Y, Fu X, Zhu S, Cai Z, Qiu Y, Mao L. Vater's ampullary carcinoma increases the risk of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. BMC Gastroenterol 2022; 22:51. [PMID: 35125104 PMCID: PMC8818205 DOI: 10.1186/s12876-022-02128-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a frequent complication after pancreaticoduodenectomy (PD). This study aimed to investigate the impact of Vater's ampullary carcinoma (VAC) on clinically relevant POPF (CR-POPF) in patients undergoing PD. METHODS Clinical data were gathered retrospectively from January 2018 to December 2020 for all patients undergoing PD. The univariate and multivariate analysis were used to identify independent risk factors of CR-POPF. A propensity score-matched (PSM) analysis at a ratio of 1:1 was performed to minimize bias from baseline characteristics between VAC and non-VAC groups. Main postoperative complications were compared between the two groups after PSM. RESULTS In 263 patients, 94 (35.7%) patients were diagnosed as VAC. CR-POPF occurred in 99 (37.6%) patients and VAC was identified as an independent risk factor of CR-POPF in multivariate logistic regression analysis (OR = 0.548, 95% CI = 0.327-0.920, P = 0.023). After PSM, there were similar baseline characteristics between the VAC and non-VAC group. Moreover, VAC group had a higher rate of CR-POPF (P = 0.025) and intra-abdominal infection (P = 0.015) compared to the non-VAC group. CONCLUSIONS In patients undergoing PD, VAC increases the risk of CR-POPF and several other postoperative complications.
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Affiliation(s)
- Yifei Yang
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Xu Fu
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Saisai Zhu
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Zhenghua Cai
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Yudong Qiu
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China
| | - Liang Mao
- Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China.
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16
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Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy. J Gastrointest Surg 2022; 26:1967-1981. [PMID: 35546220 PMCID: PMC9489565 DOI: 10.1007/s11605-022-05339-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract. METHODS A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review. RESULTS The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing. CONCLUSIONS This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.
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17
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Cecire J, Adams K, Pham H, Pang T, Burnett D. Pharmacological prevention of post-operative pancreatitis: systematic review and meta-analysis of randomized controlled trials on animal studies. ANZ J Surg 2021; 92:1338-1346. [PMID: 34936178 DOI: 10.1111/ans.17417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a significant complication of pancreatic resection with recent evidence showing a strong association between post-operative pancreatitis and subsequent development of POPF. Incidence and severity of pancreatitis following endoscopic therapy has been effectively reduced with indomethacin prophylaxis, however further agents require evaluation. We present a systematic literature review and meta-analysis of the prophylactic treatment with corticosteroids or n-acetyl cysteine (NAC) of induced pancreatitis in rodent models. METHODS A systematic literature search was conducted using Pubmed, Medline, Embase and Cochrane library to identify eligible randomized control trials (RCT) involving animal models that examined NAC or corticosteroids. The primary outcome was the subsequent effect on serum amylase and IL-6 and the histopathological markers of severity such as pancreatic oedema and necrosis. RESULTS Four RCTs (n = 178) met inclusion criteria examining NAC and eight RCTs (n = 546) examining corticosteroid agents (dexamethasone, hydrocortisone, methylprednisolone). Prophylactic administration of all corticosteroid agents showed a net effect in favour of reducing markers of severity of pancreatitis. NAC showed a significant reduction in severity of amylase and necrosis. CONCLUSION The RCTs examined suggest that prophylactic administration of corticosteroid agents and NAC can reduce the severity of pancreatitis as indicated by histopathologic markers, serum amylase and IL-6 levels.
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Affiliation(s)
- Jack Cecire
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Kristian Adams
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Helen Pham
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Tony Pang
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - David Burnett
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
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18
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Pecorelli N, Mazza M, Guarneri G, Delpini R, Partelli S, Balzano G, Turi S, Meani R, Beretta L, Falconi M. Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program. HPB (Oxford) 2021; 23:1815-1823. [PMID: 33975798 DOI: 10.1016/j.hpb.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). METHODS Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. RESULTS Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08-1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to -2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13-1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73-4.54; p < 0.001). CONCLUSION Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Meani
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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19
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Vasilescu AM, Andriesi Rusu DF, Bradea C, Vlad N, Lupascu-Ursulescu C, Cianga Spiridon IA, Trofin AM, Tarcoveanu E, Lupascu CD. Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology. Life (Basel) 2021; 11:life11111216. [PMID: 34833092 PMCID: PMC8624365 DOI: 10.3390/life11111216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.
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Affiliation(s)
- Alin Mihai Vasilescu
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Delia Florina Andriesi Rusu
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
- Correspondence:
| | - Costel Bradea
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Nutu Vlad
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Corina Lupascu-Ursulescu
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Irene Alexandra Cianga Spiridon
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Ana Maria Trofin
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Eugen Tarcoveanu
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
| | - Cristian Dumitru Lupascu
- First Surgical Clinic, “St. Spiridon” Hospital Iasi, Independentei str, no 1, 700111 Iasi, Romania; (A.M.V.); (C.B.); (N.V.); (A.M.T.); (E.T.); (C.D.L.)
- Faculty of Medicine, ”Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania; (C.L.-U.); (I.A.C.S.)
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20
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Nishio RT, Pacheco-Jr AM, Moricz AD, Silva RA. WHAT FACTORS CONTRIBUTE TO DELAYED GASTRIC EMPTYING AFTER DUODENOPANCREATECTOMY WITH PILORIC PRESERVATION? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2021; 34:e1592. [PMID: 34669882 PMCID: PMC8521836 DOI: 10.1590/0102-672020210002e1592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/28/2021] [Indexed: 12/23/2022]
Abstract
Background: The delay in gastric emptying is the second most frequent complication after duodenopancreatectomy with pyloric preservation, that increases hospitalization time and hospital costs.
Aim: To identify factors that contribute to the appearance the delay in this surgical procedure.
Method: Ninety-five patients were submitted to duodenopancreatectomy with pyloric preservation. After retrospective analysis of the medical records, it was observed that 60 had prolonged hospitalization due to complications. Thus, univariate and multivariate logistic regression were used to analyze predictors of delayed gastric emptying.
Results: Delay was present in 65% (n=39) and pancreatic fistula in 38.3% (n=23). Univariate analysis revealed that the presence of pancreatic complications (pancreatic fistula, p=0.01), other intracavitary complications with the appearance of abdominal collections (p=0.03) and hypoalbuminemia (p=0.06) were responsible, also confirmed by the multivariate analysis. In those who presented delay without a determined cause, it was observed that high levels of total bilirubin (p=0.01) and direct bilirubin (p=0.01) could be related to it.
Conclusion: The delay in gastric emptying in patients undergoing duodenopancreatectomy with pyloric preservation is due to intracavitary complications.
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Affiliation(s)
- Ricardo Tadashi Nishio
- Department of Surgery, Faculty of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | | | - André de Moricz
- Department of Surgery, Faculty of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil
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21
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Privett BJ, Perini MV, Weinberg L, Fink MA, Muralidharan V, Lee E, Starkey G, Jones R, Lin YJ, Nikfarjam M. Reduction in post-operative pancreatic fistula with polyethylene glycol and recombinant human albumin sealant following stapled distal pancreatectomy. ANZ J Surg 2021; 91:2459-2465. [PMID: 34514684 DOI: 10.1111/ans.17181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a significant cause of morbidity in patients undergoing distal pancreatectomy (DP). The use of polyethylene glycol (PEG) and recombinant human albumin sealant gel applied to the transected pancreatic margin in DP may reduce POPF rates and was assessed. METHODS A retrospective single centre cohort study of patient undergoing DP at an Australian high volume tertiary institution between January 2015 and January 2021. Rates of POPF in patients undergoing stapled pancreatic transection with PEG sealant were compared to other methods. RESULTS A total of 54 cases were identified for analysis, with 16 undergoing stapled DP combined with staple line application of PEG (PEG group). Most patients in the control group had stapled DP 92% (35 of 38), with 47% (18 of 38) combined with a reinforcing buttress, with or without the use other glue types. Overall, 28 of 54 (52%) developed a POPF, with a significantly lower rate in the PEG group (3 of 16 vs. 25 of 38 in the Control group; p = 0.003). Clinically significant Grade B/C POPF was lower in the PEG group (0 of 16 vs. 9 of 28 in the Control group; p = 0.045), and patients in the PEG group had a shorter median (range) length of hospital stay (6 [4-14] days vs. 10 [6-41] days p = 0.04). CONCLUSION Stapled DP with the application of PEG and recombinant human albumin sealant to the transection line appears to be associated with a lower rate of clinically significant POPF.
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Affiliation(s)
- Benjamin J Privett
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Marcos V Perini
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.,The University of Melbourne Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Michael A Fink
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | | | - Eunice Lee
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Graham Starkey
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Robert Jones
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Yi-Ju Lin
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- The University of Melbourne Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
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22
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Fields RC. Infection Risk Stratification in Pancreatic Surgery: Look to the Blood. J Am Coll Surg 2021; 232:306-308. [PMID: 33637178 DOI: 10.1016/j.jamcollsurg.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
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23
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Adamu M, Plodeck V, Adam C, Roehnert A, Welsch T, Weitz J, Distler M. Predicting postoperative pancreatic fistula in pancreatic head resections: which score fits all? Langenbecks Arch Surg 2021; 407:175-188. [PMID: 34370113 PMCID: PMC8847178 DOI: 10.1007/s00423-021-02290-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 07/23/2021] [Indexed: 01/08/2023]
Abstract
Purpose Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery. Methods A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested. Results Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p < 0.001). There was no significant prognostic value for the Fujiwara et al. risk score. Histology, pancreatic duct diameter, intraabdominal fat thickness in computed tomography findings, body mass index, and C-reactive protein were independent prognostic factors on multivariate analysis. Conclusion Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.
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Affiliation(s)
- Mariam Adamu
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Verena Plodeck
- Department of Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Claudia Adam
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Anne Roehnert
- Department of Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Juergen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
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24
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Bonaroti JW, Zenati MS, Al-Abbas AI, Rieser CJ, Zureikat AH, Hogg ME, Zeh HJ, Boone BA. Impact of postoperative pancreatic fistula on long-term oncologic outcomes after pancreatic resection. HPB (Oxford) 2021; 23:1269-1276. [PMID: 33526357 PMCID: PMC8282784 DOI: 10.1016/j.hpb.2020.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/02/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The short-term morbidity associated with post-operative pancreatic fistula (POPF) is well established, however data regarding the long-term impact are lacking. We aim to characterize long-term oncologic outcomes of POPF after pancreatic resection through a single institution, retrospective study of pancreatic resections performed for adenocarcinoma from 2009 to 2016. METHODS Kaplan-Meier survival analysis, logistic regression, and multivariate analysis (MVA) were used to evaluate impact of POPF on overall survival (OS), disease free survival (DFS), and receipt of adjuvant chemotherapy (AC). RESULTS 767 patients were included. 82 (10.6%) developed grade B (n = 67) or C (n = 15) POPF. Grade C POPF resulted in decreased OS when compared to no POPF (20.22 vs 26.33 months, p = 0.027) and to grade B POPF (20.22 vs. 26.87 months, p = 0.049). POPF patients were less likely to receive AC than those without POPF (59.5% vs 74.9%, p = 0.003) and grade C POPF were less likely to receive AC than all others (26.7% vs 74.2%, p = 0.0001). CONCLUSION POPF patients are less likely to receive AC and more likely to have delay in time to AC. These factors are exacerbated in grade C POPF and likely contribute to decreased OS. These findings validate the clinical significance of the ISGPF definition of POPF.
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Affiliation(s)
- Jillian W Bonaroti
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Mazen S Zenati
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Amr I Al-Abbas
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Caroline J Rieser
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Melissa E Hogg
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA; Department of Surgery, Northshore University Health System, 2650 Ridge Ave, Room 2539 Walgreen Building, Evanston, IL, 60201, USA
| | - Herbert J Zeh
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA; Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Office E.7102B, Dallas, TX, 75390, USA
| | - Brian A Boone
- Department of Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital F1281, 200 Lothrop Street, Pittsburgh, PA, 15213, USA; Department of Surgery, West Virginia University, PO Box 9238 Health Sciences Center, One Medical Center Drive, Morgantown, WV, 26506, USA.
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25
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Goh BKP, Lee CY, Koh YX, Teo JY, Kam JH, Cheow PC, Chung AYF, Chan CY, Lee SY. Use of Reinforced Staplers Decreases the Rate of Postoperative Pancreatic Fistula Compared to Bare Staplers After Minimally Invasive Distal Pancreatectomies. J Laparoendosc Adv Surg Tech A 2021; 31:1124-1129. [PMID: 33449857 DOI: 10.1089/lap.2020.0754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Postoperative pancreatic fistula (POPF) is the most common and important cause of morbidity after distal pancreatectomy. Various transection and closure techniques of the pancreatic stump have been proposed with no robust evidence unanimously supporting one technique over the other. This study aims to compare the outcomes of minimally invasive distal pancreatectomy (MIDP) performed with reinforced stapler (RS) versus bare stapler (BS) with particular attention to the POPF. Methods: Retrospective review of 90 consecutive elective MIDP performed at a single institution between 2014 and 2019 was performed. The primary outcome was POPF as defined by the latest International Study Group of Pancreatic Fistula classification. MIDP with RS was adopted by two surgeons who subsequently performed all their consecutive surgeries with RS. Results: There were 25 and 65 patients who underwent MIDP with RS and BS, respectively. There were 8 (8.9%) open conversions and 17 (18.9%) patients experienced a POPF. Patients who underwent MIDP with RS had a significantly lower POPF rate (4% versus 24.6%, P = .025), lower major (>grade 2) morbidity rate (4% versus 21.5%, P = .046), and lower readmission rate (4% versus 27.7%, P = .014). On multivariate analysis, only the use of BS and obesity (body mass index ≥27.5) was independently associated with the development of a POPF. Conclusion: MIDP performed with RS was associated with a significantly lower rate of POPF, major morbidity, and readmissions compared to BS. The use of RS was protective against POPF.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chuan-Yaw Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Juinn-Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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26
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Søreide K. Neoadjuvant and Adjuvant Therapy in Operable Pancreatic Cancer: Both Honey and Milk (but No Bread?). Oncol Ther 2021; 9:1-12. [PMID: 33439449 PMCID: PMC8140001 DOI: 10.1007/s40487-020-00136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022] Open
Abstract
Pancreatic cancer has a dismal prognosis. Resection is the best option for cure, supported by multimodal therapy to treat the systemic disease. While adjuvant therapy has become standard in those who are fit and who can tolerate the given regimen, the concept of perioperative (neoadjuvant) therapy is building momentum. The concepts of “borderline” and “locally advanced” have changed the previous dichotomized “resectable/non-resectable” into subcategories for which new algorithms have emerged, with neoadjuvant therapy discussed both for upfront resectable pancreatic cancer, for those deemed borderline resectable, and as “induction or conversion” therapy for locally advanced disease. The purpose of this invited commentary is to discuss some of the changing paradigms in multimodal therapy for operable pancreatic cancer. The PREOPANC trial presented randomized data on the role of neoadjuvant therapy for resectable and borderline cancers, but new questions have emerged. The role of combination therapy in the preoperative setting is discussed in the light of this trial. FOLFIRINOX has emerged as the most potent treatment regimen in the metastatic and adjuvant setting, but with no level I data to support neoadjuvant use yet. Several trials are ongoing to arrive at the best answer.
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Affiliation(s)
- Kjetil Søreide
- -Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Gastrointestinal Translation Research Unit, Stavanger University Hospital, Stavanger, Norway.
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27
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Drozdov ES, Koshel AP, Rodionova OV, Dibina TV, Klokov SS. [Predictors of external pancreatic fistulae after pancreatic resection]. Khirurgiia (Mosk) 2020:107-114. [PMID: 33210516 DOI: 10.17116/hirurgia2020111107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.
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Affiliation(s)
- E S Drozdov
- Siberian State Medical University, Tomsk, Russia.,Tomsk Regional Oncology Hospital, Tomsk, Russia
| | - A P Koshel
- Siberian State Medical University, Tomsk, Russia.,Alperovich Tomsk City Clinical Hospital No. 3, Tomsk, Russia
| | | | | | - S S Klokov
- Siberian State Medical University, Tomsk, Russia.,Zherlov Medical Center, Seversk, Russia
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28
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Nong K, Zhang Y, Liu S, Yang Y, Sun D, Chen X. Analysis of pancreatic fistula risk in patients with laparoscopic pancreatoduodenectomy: what matters. J Int Med Res 2020; 48:300060520943422. [PMID: 33106067 PMCID: PMC7780568 DOI: 10.1177/0300060520943422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To analyse potential risk factors for postoperative pancreatic fistula (POPF). Methods A retrospective study on risk factors for POPF was conducted in patients undergoing laparoscopic pancreatoduodenectomy. Basic characteristics, and preoperative, intraoperative and postoperative patient data were collected and analysed. Results A total of 268 patients were enrolled in this study, including 54 patients with POPF following surgery (POPF incidence, 20.15%). Univariate analysis indicated that patient’s age, body mass index (BMI), preoperative bilirubin level, pancreas texture, and drainage fluid amylase level on day 1 following surgery were associated with POPF. Multiple logistic regression analysis indicated that preoperative bilirubin level ≥170 µmol/l, soft pancreas texture, BMI ≥25, and age ≥65 years were independent risk factors associated with POPF. Conclusions For patients with preoperative bilirubin level ≥170 µmol/l, soft pancreas texture, BMI ≥25 and age ≥65 years, clinically relevant measures should be taken as early as possible for the prophylaxis of POPF.
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Affiliation(s)
- Kate Nong
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yue Zhang
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Shengyong Liu
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yue Yang
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Donglin Sun
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xuemin Chen
- Department of Hepatopancreatobiliary Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
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29
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Bhatti ABH, Jafri RZ, Khan NA. Best achievable results need territorial familiarity: Impact of living donor liver transplant experience on outcomes after pancreaticodoudenectomy. Ann Med Surg (Lond) 2020; 55:213-218. [PMID: 32518644 PMCID: PMC7272504 DOI: 10.1016/j.amsu.2020.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
Background Recently, benchmarks for pancreatic surgery have been proposed. Living donor liver transplantation (LDLT) is thought to have a positive impact on PD outcomes. The objective of the current study was to determine if the proposed benchmark cutoffs are achievable in an LDLT program with low to medium volumes for PD. Methods We retrospectively reviewed patients who underwent PD between 2011 and 2018 (N = 116). Their outcomes were assessed and compared with benchmark cutoffs for pancreatic surgery based on results from high volume centers (HVC) for PD. During the same period, 759 LDLTs were performed in our center. Outcomes were further compared based on whether PD was performed in low volume (≤76/year) (Group 1) or high volume (>76/year) (Group 2) transplant years. Results Out off 20 benchmarks, 15 (75%) were met while 19/20 (95%) were within range reported from HVC-PD. Benchmarks remained within range for biochemical leak (15.5% vs 13%, 1.3–22.7%), grade 4 complications (12.1% vs 5%, (0–14%), hospital mortality (3.8% vs 1.6%, 0–4%) and failure to rescue (24.4% vs 9%, 0–25%). There was a significant reduction in blood transfusion rate (69% vs 39.5%, P = 0.003) in group 2 while patients with at least one complication (45.5% vs 66.7%) (P = 0.04), median hospital stay (9 vs 11, P = 0.004), and median comprehensive complication index (CCI) (0 vs 20.9, P = 0.005) increased. Conclusion Best achievable results for PD can be reproduced in LDLT programs with low to moderate PD volumes. Transition to a high volume transplant center does not confer additional improvement in outcomes. This is the first study to objectively assess impact of living donor liver transplant (LDLT) experience on pancreaticdoudenectomy (PD) outcomes. ∙Even with low to moderate PD volumes, LDLT programs can achieve outcomes comparbale to high volume centers. ∙Transition from low to high annual LDLT volume does not confer any additional improvement in PD outcomes.
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Affiliation(s)
- Abu Bakar H Bhatti
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Roshni Z Jafri
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Nasir A Khan
- Department of Anesthesiology, Shifa International Hospital Islamabad, Pakistan
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