Pancreatoduodenectomy in obese patients: surgery for nonmalignant tumors might be deferred

Preoperative pancreatic radiologic characteristics predict pancreatic-specific complications before pancreaticoduodenectomy: the pancreatic acinar radiologic score

BACKGROUND

High acinar pancreatic contents are associated with a higher rate of postpancreatectomy acute pancreatitis and pancreatic fistula formation (POPF). Predicting acinar contents preoperatively might identify those at high risk of developing postoperative complications.

METHODS

A multivariable analysis was performed to identify radiological factors associated with high pancreatic acinar content at histology in patients undergoing pancreaticoduodenectomy. Clinical and radiological variables identified were used to build a composite score predicting low, moderate, and high acinar pancreatic contents.

RESULTS

Pancreatic density, wirsung caliber, and pancreatic thickness on preoperative CT-scan predicted acinar contents. These three variables predicted low, moderate, and high acinar content in 94 (26%), 122 (33.6%), and 147 (40.5%) patients, respectively. Patients with high radiological acinar scores compared with patients with intermediate-low risk scores were more frequently male (73.4% vs. 54.1%; p = 0.0003), obese (14% vs. 6%; p = 0.01), and had a statistically significant higher rate of pancreatic-specific complications (23.8% vs. 8.33%; p = 0.01), POPF (12.9% vs. 4.63%; p = 0.005) and pancreaticogastrostomy bleeding (10.8% vs. 4.17%; p = 0.01).

CONCLUSION

A simple radiological score combining pancreatic thickness, density, and wirsung caliber at CT scan preoperatively predicts patients with pancreatic parenchyma that are at higher risk of postoperative pancreatic-specific complications.

Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge

Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.

Prediction of postoperative pancreatic fistula and pancreatitis after pancreatoduodenectomy or distal pancreatectomy: A review

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.

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

INTRODUCTION

Conflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC).

METHODS

All patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan-Meier survival analysis.

RESULTS

Of the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC.

CONCLUSIONS

Obesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

Can the Realization of an External Wirsungostomy be an Option for High-Risk Pancreatic Anastomosis After Pancreaticoduodenectomy?

BACKGROUND

Clinically relevant postoperative pancreatic fistula (POPF) occurs in 15-20% of patients after pancreaticoduodenectomy (PD) and reintervention in the setting of Grade C POPF remains associated with a mortality rate of up to 25%. In patients at high risk of POPF, PD with external wirsungostomy (EW) could be a safe alternative that avoids pancreatico-enteric anastomosis while preserving the remnant pancreas.

METHODS

Of the 155 consecutive patients who underwent PD from November 2015 to December 2020, 10 patients were managed using an EW, all with a fistula risk score (FRS) ≥ 7 and BMI ≥30 kg/m², and/or major associated abdominal surgery. The pancreatic duct was cannulated with a polyethylene tube to allow good external drainage of the pancreatic fluid. We retrospectively analyzed postoperative complications and endocrine and exocrine insufficiencies.

RESULTS

The median alternative FRS was 36.9% [22.1-45.2]. There was no postoperative death. The 90-day overall severe complication (grade  ≥3) rate was 30% (n = 3 patients), no patient required reoperation, and 2 hospital readmissions occurred. 3 patients experienced Grade B POPF (30%), managed using image-guided drainage for 2 patients. The external pancreatic drain was removed after a median drainage time of 75 days [63-80]. Two patients presented with late symptoms (> 6 months) warranting interventional management (pancreaticojejunostomy and transgastric drainage). Six patients experienced significant weight loss (> 2 kg) 3 months after surgery. One year after surgery, 4 patients still complained of diarrhea and were treated with transit-delaying drugs. One patient presented new-onset diabetes one year after surgery, and 1 of the 4 patients with preexisting diabetes experienced worsening disease.

CONCLUSION

EW after PD might be a solution to reduce post-operative mortality following PD in high-risk patients.

Laparoscopic versus robotic adrenalectomy in severely obese patients

BACKGROUND

Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m²) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients.

METHODS

This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range).

RESULTS

For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT.

CONCLUSION

There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Delayed gastric emptying after pancreatoduodenectomy: One complication, two different entities

BACKGROUND

Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy associated with a low complication burden but a prolonged hospital stay. The present study aimed to characterize DGE, with a particular focus on its subtypes and related predictors.

METHODS

A 2-center retrospective analysis was performed including consecutive pancreatoduodenectomy over 5 years. Primary delayed gastric emptying (pDGE) and secondary delayed gastric emptying (sDGE) were defined according to the presence of concomitant causing factors. Predictors of DGE, pDGE and sDGE were assessed through logistic regression.

RESULTS

Out of 1,170 patients considered, 188 developed delayed gastric emptying (16.1%). Most DGE (71.8%) were secondary. sDGE resolved later (P = .007), with hospital stay, duration of total parenteral nutrition, and of enteral nutrition being longer than for pDGE (all P < .005). Smoking status, total operative time, indication for surgery other than pancreatic cancer, estimated blood loss, and soft pancreatic texture were independent predictors of DGE. In the subgroup analysis of pDGE, smoking was the only independent predictor, whereas pylorus-preservation was a protective factor. Smoking, indication for surgery, estimated blood loss, soft gland texture, and main pancreatic duct diameter were independent predictors of sDGE.

CONCLUSION

DGE after pancreatoduodenectomy consists of 2 different subtypes. The primary form resolves earlier, and its occurrence might be reduced by pylorus preservation. For the secondary form, clinicians should focus on preventing and treating other trigger complications. The diagnosis of the DGE subtype has critical therapeutic implications and paves the way for further systematic studies.