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Salman MA, Elewa A, Elsherbiny M, Tourkey M, Emechap EN, Chikukuza S, Salman A. Postoperative pancreatic fistula after pancreaticogastrostomy versus pancreatojejunostomy after pancreatic resection, a comparative systematic review and meta-analysis. World J Surg 2024; 48:1467-1480. [PMID: 38629863 DOI: 10.1002/wjs.12173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/22/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND In patients undergoing pancreaticoduodenectomy (PD), there has been some evidence favoring pancreaticogastrostomy (PG) over pancreatojejunostomy (PJ) in the occurrence of postoperative pancreatic fistulas (POPF) and considering PG as a safer anastomotic technique. However, other publications revealed comparable incidences of POPF attributed to both techniques. The current work attempts to reach a more consolidated conclusion about such an issue. METHODS This is a systematic review and meta-analysis that analyzed the studies comparing PG and PJ during PD in terms of the rate of POPF occurrence. Studies were obtained by searching the Scopus, PubMed Central, and Cochrane Central Register of Controlled Trials databases. RESULTS 35 articles published between 1995 and 2022 presented data from 14,666 patients; 4547 underwent PG and 10,119 underwent PJ. Statistically significant lower rates of POPF (p = 0.044) and clinically relevant CR-POPF (p = 0.043) were shown in the PG group. The post-pancreatectomy hemorrhage (PPH) was significantly higher in the PG group, while no significant difference was found between the two groups in the clinically significant PPH. No statistically significant differences were found regarding the amount of intraoperative blood loss, length of hospital stay, DGE, overall morbidity rates, reoperation rates, or mortality rates. The percentage of male sex in the PG group and the percentage of soft pancreas in the PJ group seem to influence the odds ratio of CR-POPF (p = 0.076 and 0.074, respectively). CONCLUSION The present study emphasizes the superiority of PG over PJ regarding CR-POPF rates. Higher rates of postoperative hemorrhage were associated with PG. Yet, the clinically significant hemorrhage rate was comparable between the two groups.
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Affiliation(s)
- Mohamed AbdAlla Salman
- General Surgery Department, Kasralainy School of Medicine, Cairo University, Giza, Egypt
| | - Ahmed Elewa
- General Surgery Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | | | - Mohamed Tourkey
- General Surgery Department, Great Western Hospital, Swindon, UK
| | | | | | - Ahmed Salman
- Internal Medicine Department, Kasralainy School of Medicine, Cairo University, Giza, Egypt
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Harrison J, Dua MM, Kastrinakis WV, Fagenholz PJ, Fernandez-Del Castillo C, Lillemoe KD, Poultsides GA, Visser BC, Qadan M. "Duct tape:" Management strategies for the pancreatic anastomosis during pancreatoduodenectomy. Surgery 2024:S0039-6060(24)00270-8. [PMID: 38796390 DOI: 10.1016/j.surg.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Jon Harrison
- Section of Hepatobiliary & Pancreatic Surgery, Stanford University Hospital, Palo Alto, CA.
| | - Monica M Dua
- Section of Hepatobiliary & Pancreatic Surgery, Stanford University Hospital, Palo Alto, CA
| | - William V Kastrinakis
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Peter J Fagenholz
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Carlos Fernandez-Del Castillo
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George A Poultsides
- Section of Surgical Oncology, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA
| | - Brendan C Visser
- Section of Hepatobiliary & Pancreatic Surgery, Stanford University Hospital, Palo Alto, CA
| | - Motaz Qadan
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
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3
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Kim J, Hong SS, Kim SH, Hwang HK, Kang CM. Optimal surgical management of unifocal vs. multifocal NF-PNETs: a respective cohort study. World J Surg Oncol 2024; 22:115. [PMID: 38671431 PMCID: PMC11046948 DOI: 10.1186/s12957-024-03383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) represent 1-2% of pancreatic tumors, with recent guidelines recommending active surveillance for non-functioning PNETs (NF-PNETs) smaller than 2 cm. However, the management of multiple NF-PNETs, as well as the influence of tumor number on prognosis, remains under-researched. METHODS This retrospective study analyzed NF-PNET patients who underwent pancreatic resection at Severance Hospital between February 1993 and August 2023, comparing the characteristics of patients diagnosed with multifocal tumors and those with unifocal tumors. A subgroup analysis of overall survival (OS) and recurrence-free survival (RFS) was performed based on multifocality employing the Kaplan-Meier method and the log-rank test. RESULTS Of 187 patients, 169 (90.4%) had unifocal and 18 (9.6%) had multifocal tumors. Multifocal tumors were more likely to be diffusely spread, necessitating more total pancreatectomies (diffuse tumor location: 4.7% in unifocal vs. 38.9% in multifocal cases, p < 0.001; total pancreatectomy: 4.1% in unifocal vs. 33.3% in multifocal cases, p < 0.001). In patients with NF-PNET who underwent the same extent of pancreatic resection, no significant difference in the incidence of complication was observed regardless of multifocality. Moreover, no significant difference in OS was seen between the unifocal and multifocal groups (log-rank test: p = 0.93). However, the multifocal group exhibited a poorer prognosis in terms of RFS compared to the unifocal group (log-rank test: p = 0.004) Hereditary syndrome, tumor grade, size, lymphovascular invasion, and lymph node metastasis were key factors in the recurrence. CONCLUSION This study's findings suggest that the presence of multiple tumors was associated with poorer recurrence-free survival but did not affect long-term survival following surgery. Given the long-term oncologic outcome and quality of life following surgery, resection of tumors over 2 cm is advisable in patients with multifocal PNETs, while a cautious "wait-and-see" approach for smaller tumors (under 2 cm) can minimize the extent of resection and improve the quality of life. In cases with only small multifocal NF-PNETs (< 2 cm), immediate resection may not be crucial, but the higher recurrence rate than that in solitary NF-PNET necessitates intensified surveillance.
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Affiliation(s)
- Juwan Kim
- Department of surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Soo Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Sung Hyun Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Ho Kyong Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of surgery, Yonsei University College of Medicine, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of surgery, Yonsei University College of Medicine, Seoul, Korea.
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.
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Ogawa D, Okabe H, Masuda T, Sugita H. Long-term survivor of giant pancreatic solid pseudopapillary neoplasm with splenic infiltration and lymph node metastasis. BMJ Case Rep 2023; 16:e253554. [PMID: 36731944 PMCID: PMC9896223 DOI: 10.1136/bcr-2022-253554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A man in his 70s with a 10 cm abdominal mass in the tail of the pancreas was diagnosed with pancreatic tail cancer. Distal pancreatectomy with curative intent was performed. Since tumour invasion of the spleen and transverse colon was suspected, pancreatectomy with splenectomy, left adrenalectomy and partial transverse colectomy was performed. Pathological examination of the resected specimen showed a giant pancreatic tumour, and a diagnosis of locally invasive solid pseudopapillary neoplasm (SPN) of the pancreas was made. The patient achieved 8-year survival without any recurrences. We herein report a very rare case of a giant pancreatic SPN with splenic infiltration and lymph node metastasis that was cured by resection.
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Affiliation(s)
- Daisuke Ogawa
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Hirohisa Okabe
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Toshiro Masuda
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Hiroki Sugita
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
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Zavrtanik H, Tomažič A. Is Surgery in Autoimmune Pancreatitis Always a Failure? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020193. [PMID: 36837395 PMCID: PMC9961097 DOI: 10.3390/medicina59020193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/14/2023] [Accepted: 01/15/2023] [Indexed: 01/21/2023]
Abstract
Autoimmune pancreatitis is a rare form of chronic pancreatitis of presumed autoimmune etiology. Due to significant overlap in clinical and imaging characteristics, misdiagnosis as a pancreatic malignancy is common. As a result, a significant number of patients undergo a major pancreatic resection, associated with considerable morbidity, for a disease process that generally responds well to corticosteroid therapy. In the past ten years, important advances have been made in understanding the disease. Several diagnostic criteria have been developed to aid in diagnosis. Despite this, pancreatic resection may still be required in a subset of patients to reliably exclude pancreatic malignancy and establish a definite diagnosis of autoimmune pancreatitis. This article aimed to define the role of surgery in autoimmune pancreatitis, if any. For this purpose, published case series of patients with a diagnosis of autoimmune pancreatitis, based on the histopathological examination of surgical specimens, were reviewed and patients' clinical, radiological and serological details were assessed. At the end, histopathologic examinations of patients who underwent pancreatic resection at our department in the last 10 years were retrospectively reviewed in order to identify patients with autoimmune pancreatitis and assess their clinical characteristics.
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Wang R, Jiang P, Chen Q, Liu S, Jia F, Liu Y. Pancreatic fistula and biliary fistula after laparoscopic pancreatoduodenectomy: 500 patients at a single institution. J Minim Access Surg 2023; 19:28-34. [PMID: 35915533 PMCID: PMC10034801 DOI: 10.4103/jmas.jmas_336_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Pancreatic fistula (PF) and biliary fistula (BF) are two major leakage complications after pancreatoduodenectomy (PD). The aim of this study is to investigate the risk factors of PF and BF after laparoscopic PD (LPD). Materials and Methods We conducted a retrospective analysis of 500 patients who underwent LPD from 1 April 2015 to 31 March 2020. Clinical data from patients were analysed using multivariate logistic regression analysis. Results PF occurred in 86 (17.2%) patients. Univariate and multivariate analysis indicated that the soft texture of the pancreas (P = 0.001) was the independent risk factor for PF. BF occurred in 32 (6.4%) patients. Univariate and multivariate analysis indicated that history of cardiovascular disease (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) were independent risk factors for BF. Conclusion The texture of the pancreas was an independent risk factor for PF after LPD, which was consistent with the literatures. In addition, history of cardiovascular disease, surgical time, pre-operative CA125 and pre-operative total bilirubin were new independent risk factors for BF after LPD. Therefore, patients with high-risk factors of BF should be informed that they are at a high risk for this complication.
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Affiliation(s)
- Ruobing Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Qingmin Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Songyang Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Feng Jia
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
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Crafa F, Vanella S, Noviello A, Lombardi G, Coppola Bottazzi E. Pancreatic Ducts Obliteration With Controlled Injection of Onyx ®: A Proposal of New Onyx ® Pancreatic Ducts Obliteration Scoring System. Surg Innov 2022:15533506221120148. [PMID: 35950220 DOI: 10.1177/15533506221120148] [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: 12/07/2022]
Abstract
BACKGROUND The aim of this study was confirm the efficacy and feasibility of Onyx injection for pancreatic stump management after pancreaticoduodenectomy (PD) and investigate a new Onyx® Pancreatic Ducts Obliteration (OPDO) scoring system of pancreatic duct obliteration (PDOb) in patients with high risk of Post-Operative Pancreatic Fistula (POPF). STUDY DESIGN We enrolled ten patients undergoing PDOb with Onyx® intraoperative controlled injection after elective PD. RESULTS PDOb with Onyx® controlled injection was classified according to the OPDO scoring system in three degrees: complete 5/10 (50%), medium 2/10 (20%) and bad 3/10 (30%). Increased amylase in abdominal drainage was identified in two patients (20%) with a degree II and III, and resolved spontaneously within a week. A "clinically relevant" POPF (CR-POPF) was observed in one patient (10%) with a degree III and none in the patients with degree I and II. DISCUSSION We confirm that intraoperative injection of Onyx® is a valid solution in high-risk POPF patients and our OPDO scoring system allows obtain an intraoperative classification of the degree of PDO to prevent the CR-POPOF; furthermore, it may be suggested that the viscosity of the injected product (Onyx®) reduce parenchymal fibrosis.
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Affiliation(s)
- Francesco Crafa
- Oncological and General Surgery Unit, 90384"St. Giuseppe Moscati" Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Serafino Vanella
- Oncological and General Surgery Unit, 90384"St. Giuseppe Moscati" Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Adele Noviello
- Oncological and General Surgery Unit, 90384"St. Giuseppe Moscati" Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Giulio Lombardi
- Department of Radiology, 90384"St. Giuseppe Moscati" Hospital of National Relevance and High Specialty, Avellino, Italy
| | - Enrico Coppola Bottazzi
- Oncological and General Surgery Unit, 90384"St. Giuseppe Moscati" Hospital of National Relevance and High Specialty, Avellino, Italy
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Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2022; 3:CD013462. [PMID: 35289922 PMCID: PMC8923262 DOI: 10.1002/14651858.cd013462.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. OBJECTIVES To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. SEARCH METHODS We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. MAIN RESULTS We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.
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Affiliation(s)
- Hua Hai
- Department of Operating Room, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziwei Zhang
- Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Wang X, Xu W, Hu X, Yang X, Zhang M. The Prognostic Role of Glycemia in Patients With Pancreatic Carcinoma: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:780909. [PMID: 35223469 PMCID: PMC8866248 DOI: 10.3389/fonc.2022.780909] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022] Open
Abstract
Background Fasting blood glucose and glycated hemoglobin (HbA1c) levels are associated with the risk of pancreatic cancer. Aim To examine the relationship between perioperative glucose and HbA1c levels and prognosis in patients with pancreatic cancer. Methods PubMed, Embase, and the Cochrane Library were queried for potentially eligible studies published up to May 2021. The exposures were perioperative fasting glucose and HbA1c levels. The primary outcome was survival. The secondary outcome was complications. All analyses were performed using the random-effects model. Results Ten studies (48,424 patients) were included. The pre-operative (HR=1.10, 95%CI: 0.89-1.35; I2 = 45.1%, Pheterogeneity=0.078) and postoperative (HR=1.19, 95%CI: 0.92-1.54; I2 = 67.9%, Pheterogeneity=0.001) blood glucose levels were not associated with the survival to pancreatic cancer. Similar results were observed for HbA1c (HR=1.09, 95%CI: 0.75-1.58; I2 = 64.2%, Pheterogeneity=0.039), fasting blood glucose (FBG)/HbA1c (HR=1.16, 95%CI: 0.67-1.68; I2 = 0.0%, Pheterogeneity=0.928), and FBG (HR=1.75, 95%CI: 0.81-3.75; I2 = 79.4%, Pheterogeneity=0.008). Pre-operative blood glucose levels were not associated with postoperative complications (OR=0.90, 95%CI: 0.52-1.56), but postoperative glucose levels were associated with postoperative complications (OR=3.06, 95%CI: 1.88-4.97; I2 = 0.0%, Pheterogeneity=0.619). Conclusion Blood glucose, FBG, and HbA1c levels are not associated with the survival of patients with pancreatic cancer. Postoperative blood glucose levels could predict postoperative complications.
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Affiliation(s)
- Xiaofang Wang
- Department of Clinical Oncology and Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wanfeng Xu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaoru Hu
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xianghong Yang
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mingming Zhang
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, China
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10
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Biesma NC, Te Riele WW, Van Santvoort HC, Molenaar IQ. Pancreatoduodenectomy for distal cholangiocarcinoma 13 years after oesophagectomy with gastric tube reconstruction: report of a case. BMJ Case Rep 2022; 15:e246852. [PMID: 35135799 PMCID: PMC8830154 DOI: 10.1136/bcr-2021-246852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/03/2022] Open
Abstract
Advancements in cancer management have led to improved survival in patients with oesophageal cancer. This has resulted in an increased incidence of second primary malignancies with the pancreas as a common secondary cancer site. Resectable pancreatic and periampullary cancers are treated by pancreatoduodenectomy, including resection of the gastroduodenal artery which provides the blood supply to the gastric conduit in patients who underwent oesophagectomy. A 77-year-old man with a history of distal oesophageal cancer, for which an oesophagectomy with gastric tube reconstruction was performed, presented in the emergency department. Extensive workup showed a lesion suspected for a distal cholangiocarcinoma. Pancreatoduodenectomy was deemed feasible after arterial angiography revealed that the gastric conduit was dominantly vascularised by the right gastric artery. Adequate imaging of the blood supply is essential to determine eligibility for pancreatoduodenectomy in patients with a second primary malignancy in the pancreas or periampullary region after oesophagectomy with gastric tube reconstruction.
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Affiliation(s)
- Nanske C Biesma
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, The Netherlands, Utrecht, The Netherlands
| | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, The Netherlands, Utrecht, The Netherlands
| | - Hjalmar C Van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, The Netherlands, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, The Netherlands, Utrecht, The Netherlands
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11
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Gaspar AF, Kemp R, Sankarankutty AK, Júnior JRL, Filho JAF, Martone D, Mota GDA, Santos JSD. Clinical outcomes and costs of the use of fibrin sealant in pancreaticojejunal anastomosis after pancreaticoduodenectomy: a retrospective analysis study. Ann Med Surg (Lond) 2021; 67:102531. [PMID: 34276983 PMCID: PMC8267440 DOI: 10.1016/j.amsu.2021.102531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/27/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives The benefits of using a fibrin sealant to reinforce the pancreaticojejunal anastomosis are still contentious, a fact that justifies the study of its effects on clinical outcomes and costs of pancreaticoduodenectomy. Methods Study of 62 consecutive patients submitted to pancreaticoduodenectomy, divided into two groups of 31 patients each: GWS = group with sealant and GWOS = group without sealant that were compared according to demographic, clinical, laboratory aspects, the incidence of postoperative pancreatic fistula (POPF), according to the definition of the International Study Group on Pancreatic Fistula, updated in 2016, and its postoperative complications categorized according to the Clavien classification, as well as hospital costs evaluated by the absorption costing method (with the exception of those related to medications). Results The groups were homogeneous and there were no significant differences in the postoperative clinical course or in the indicators of hospital care between them. Hard texture of pancreatic tissue was the only protective factor against the development of POPF (RR = 0.29 (95%CI:0,12–0,68); p = 0.005). Moreover, hospital costs were higher in GWS than in GWOS (p < 0.0001). Conclusions The use of fibrin sealant to reinforce pancreaticojejunal anastomosis did not improve the clinical and healthcare outcomes and, in addition, increased hospital costs. Pancreaticoduodenectomy is the treatment of choice for resectable tumors of the pancreato-duodenal confluence. Morbidity rates remain high ranging between 30% and 50%. Pancreatic fistula is the most feared post pancreatic surgery complication. Studies on the effects of using fibrin sealant in pancreatic surgery are scarce and controversial.
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Affiliation(s)
- Alberto Facury Gaspar
- Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Corresponding author. Bandeirantes Avenue, 3900, Monte Alegre, Ribeirão Preto city, São Paulo state, Brazil.
| | - Rafael Kemp
- Division of Gastrointestinal Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ajith Kumar Sankarankutty
- Division of Gastrointestinal Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | | | - Daniel Martone
- Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Gustavo de Assis Mota
- Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - José Sebastião dos Santos
- Division of Gastrointestinal Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
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12
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Jena SS, Meher D, Ranjan R. Delayed pancreatic fistula: An unaccustomed complication following pancreaticoduodenectomy- a rare case report. Ann Med Surg (Lond) 2021; 66:102460. [PMID: 34150205 PMCID: PMC8193112 DOI: 10.1016/j.amsu.2021.102460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/23/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction and Importance: Post-operative pancreatic fistula is a morbid complication after pancreaticoduodenectomy. Though most of them present in the immediate post-operative period, few case reports have mentioned it even 7 years after index surgery. Here, we report a delayed presentation of pancreatic fistula 6 months after surgery. Case presentation A 57 year old female underwent Whipple's pancreaticoduodenectomy for pancreatic head adenocarcinoma and was discharged with an uneventful post-operative recovery. She presented after 6 months with complaints of abdominal pain and distension which upon evaluation was found to be a pancreatic enzyme rich mutiloculated collection. It was managed with per-cutaneous drain placement. Clinical discussion Pancreatic fistula remained a major cause of morbidity and mortality even after 100 years of its existence. It can be overt fistula which manifest in the immediate post-operative period or occult fistula which manifests long after primary surgery. Various causes of delayed fistula are anastomotic site stricture, previous chemotherapy, infection. The management options available are percutaneous drainage, endoscopic stenting of anastomotic stricture or redoing the anastomosis. Conclusion Pancreatic fistula can have a delayed presentation which can be diagnosed and managed with regular follow up. POPF is a morbid complication following PD. It can be occult and overt. Usually presents in the early post-operative period. Few cases has been described upto 7 years. Variuos management options are available.
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Affiliation(s)
- Suvendu Sekhar Jena
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Dibyasingh Meher
- Department of General Surgery, VMMC and Safdarjung Hospital, New Delhi, India
| | - Rahul Ranjan
- Department of General Surgery, VMMC and Safdarjung Hospital, New Delhi, India
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13
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Kuscher S, Kiehl T, Kronberger IE, Moser P, Maier H, Maier S, Hautz T, Öfner D, Schneeberger S, Troppmair J. Distal Pancreatic Resection with Splenectomy in the Rat: A Pancreatic Fistula Model to Investigate Postsurgical Damage? Eur Surg Res 2021; 62:97-104. [PMID: 34023826 DOI: 10.1159/000515867] [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: 01/28/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a major complication in pancreatic surgery and can cause considerable postoperative morbidity. Advanced surgical-technical approaches to prevent POPF did not yield a substantial improvement. To investigate innovative treatments, experimental animal models of distal pancreatic resection and pancreaticoduodenectomy are of fundamental importance. After a failed attempt to replicate a previously described rat model for pancreatic fistula induction, we proceeded to distal pancreatic resection with splenectomy to provoke pancreatic leakage and generate a suitable animal model. METHODS Distal pancreatic resection with splenectomy was performed in 40 rats. The rats were sacrificed on postoperative day (POD) 1, 2, 4, 6, 8, or 10, and the abdominal cavity was explored. Ascites probes were collected pre- and postoperatively for the detection of pancreas amylase and lipase. Tissue samples from the naïve pancreas (POD 0) and the postoperatively harvested remnant were evaluated histologically. The extent of necrosis was determined, and samples were examined for neutrophil infiltration. TUNEL staining served for the verification of necrosis in distinct cases. Immunohistochemistry of Ki67, von Willebrand factor, and CD68 was performed to evaluate proliferation, blood-vessel sprouting, and macrophage invasion. RESULTS The rats showed no clinical symptoms or severe complications in the postoperative course up to 10 days. Abdominal exploration revealed adhesions in the upper abdomen, but no intra-abdominal fluid accumulations were found. Signs of inflammation and tissue damage were evident at the pancreatic resection margin on histological examination whereas the naïve pancreatic tissue was widely unaffected. Statistically significant differences were seen between the preoperative and postoperative extent of necrosis, the presence of neutrophil infiltrate, and levels of ascitic amylase and lipase. Immunohistochemical staining on Ki67, von Willebrand factor, and CD68 did not reveal any workable results on nonstatistical examination, and it was therefore not considered for further analyses. CONCLUSION Creating a functional animal model of pancreatic fistula that reflects the clinical and pathophysiological impact of pancreatic leakage in humans has not been achieved. Our approach of left pancreatic resection recapitulated inflammation and tissue damage, early events in the development of fistulas, and it could be suitable for the experimental testing of novel targeting methods.
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Affiliation(s)
- Stefanie Kuscher
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Kiehl
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Irmgard Elisabeth Kronberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrizia Moser
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Hans Maier
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Sarah Maier
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Troppmair
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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14
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Kumar S, Chandra A, Madhavan SM, Kumar D, Chauhan S, Pandey A, Masood S. Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience. Indian J Surg Oncol 2021; 12:22-30. [PMID: 33814828 DOI: 10.1007/s13193-020-01195-3] [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: 04/26/2020] [Accepted: 08/19/2020] [Indexed: 01/04/2023] Open
Abstract
Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.
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Affiliation(s)
- Suneed Kumar
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George Medical University, Lucknow, Uttar Pradesh India
| | - Shibumon M Madhavan
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Dinesh Kumar
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Smita Chauhan
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Anshuman Pandey
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Shakeel Masood
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
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15
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Novel Modified Blumgart Technique to Reduce Postoperative Pancreatic Fistula After Pancreaticojejunostomy-Compressed Pancreatic Stump (COMPAS) Anastomosis. J Gastrointest Surg 2021; 25:1082-1086. [PMID: 33511545 DOI: 10.1007/s11605-020-04848-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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16
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Clinical Phase I/II Study: Local Disease Control and Survival in Locally Advanced Pancreatic Cancer Treated with Electrochemotherapy. J Clin Med 2021; 10:jcm10061305. [PMID: 33810058 PMCID: PMC8005134 DOI: 10.3390/jcm10061305] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023] Open
Abstract
Objective. To assess local disease control rates (LDCR) and overall survival (OS) in locally advanced pancreatic cancer (LAPC) treated with electrochemotherapy (ECT). Methods. Electrochemotherapy with bleomycin was performed in 25 LAPC patients who underwent baseline Magnetic Resonance Imaging (MRI) and/or Computed Tomography (CT) and Position Emission Tomography (PET) scans before ECT and 1 and 6 months post ECT. LDCR were assessed using Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and Choi criteria. Needle electrodes with fixed linear (N-30-4B) or fixed hexagonal configurations (N-30-HG or I-40-HG or H-30-ST) or variable geometry (VGD1230 or VGD1240) (IGEA S.p.A., Carpi, Italy) were used to apply electric pulses. Pain evaluation was performed pre-ECT, after 1 month and after 6 months with ECT. Overall survival estimates were calculated by means of a Kaplan-Meier analysis. Results. At 1 month after ECT, 76% of patients were in partial response (PR) and 20% in stable disease (SD). Six months after ECT, 44.0% patients were still in PR and 12.0% in SD. A LDCR of 56.0% was reached six months after ECT: 13 patients treated with fixed geometry had a LDCR of 46.1%, while for the 12 patients treated with variable geometry, the LDCR was 66.7%. The overall survival median value was 11.5 months: for patients treated with fixed geometry the OS was 6 months, while for patients treated with variable geometry it was 12 months. Electrochemotherapy was well-tolerated and abdominal pain was rapidly resolved. Conclusions. Electrochemotherapy obtained good results in terms of LDCR and OS in LAPC. Multiple needle insertion in a variable geometry configuration optimized by pre-treatment planning determined an increase in LDCR and OS compared to a fixed geometry configuration.
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17
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Impact of Neoadjuvant Systemic Therapy on Pancreatic Fistula Rates Following Pancreatectomy: a Population-Based Propensity-Matched Analysis. J Gastrointest Surg 2021; 25:747-756. [PMID: 32253648 DOI: 10.1007/s11605-020-04581-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/23/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) drives morbidity and mortality following pancreatectomy. Use of neoadjuvant chemotherapy (NAC) has recently increased in the treatment of potentially resectable pancreatic ductal adenocarcinoma (PDAC). This study examined the effect of NAC on POPF rates and postoperative outcomes in PDAC. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset was queried to identify PDAC patients who underwent curative-intent pancreatectomies. Propensity score matching was used to stratify patients by receipt of NAC. Postoperative outcomes were compared and logistic regression applied to identify POPF predictors. RESULTS Six thousand eight hundred sixty-three patients met the inclusion criteria; of those, 1908 (27.8%) received NAC and 4955 (72.2%) did not (NNAC). Two thousand sixty-two patients were matched 1:1 from each group. NAC patients had significantly lower POPF rates (9.0% vs. 14.5%; P < 0.001); the majority were categorized as grade A (5.1% vs. 9.5%). Overall 30-day morbidity was lower with NAC (40.4% vs. 49.5%; P < 0.001). Specifically, pneumonia (2.3% vs. 4.1%), organ space infections (7.9% vs. 13.2%), sepsis (5.2% vs. 8.0%), and delayed gastric emptying (10.1% vs. 14.8%) occurred less frequently in the NAC group. Postoperative mortality and unplanned reoperations were similar. On multivariate analysis, receipt of NAC was an independent predictor of decreased POPF rates (HR, 0.73 [0.56-0.94]; P = 0.016). Other factors included gland texture, duct size, male gender, and lower BMI. CONCLUSIONS In this propensity-matched, population-based cohort study of PDAC patients, NAC was associated with lower POPF rates and overall major complications. Those findings suggest a modest protective effect of NAC from POPF.
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18
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Popov AY, Lishchishin VY, Petrovskiy AN, Lishchenko AN, Grigorov SP, Baryshev AG, Porkhanov VA. [Immediate outcomes of pancreatoduodenectomy after different digestive reconstruction procedures]. Khirurgiia (Mosk) 2021:14-19. [PMID: 33570349 DOI: 10.17116/hirurgia202102114] [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: 11/18/2022]
Abstract
OBJECTIVE To study the immediate results of pancreatoduodenectomy depending on digestive reconstruction procedure. MATERIAL AND METHODS We analyzed 242 patients who underwent pancreatoduodenectomy for the period from January 2013 to December 2019. There were 32 combined procedures: 28 (11.6%) with portal vein resection and 8 (3.3%) simultaneous operations (right-sided hemicolectomy - 4, right-sided adrenalectomy - 2, gastrectomy with splenectomy - 2). Pancreatic stump was inserted into the jejunum in 156 (64.5%) patients, into the stomach - in 86 (35.5%) cases. RESULTS Postoperative period was uneventful in 180 (74.4%) patients. Eighty postoperative complications were observed in 62 (25.6%) patients; 221 (91.3%) patients were discharged, 21 (8.7%) patients died. Pancreatic necrosis was the most common postoperative event and provoked 65 (82.5%) various complications (38 (72.1%) in patients with pancreaticojejunostomy and 20 (71.5%) in those with pancreaticogastrostomy). Incidence of complications was similar in both groups. However, pancreaticojejunostomy was followed by severe pancreatic fistula type C in 12 (23.1%) patients, type B in 24 (46.1%) cases. In case of pancreaticogastrostomy, pancreatic fistula type C occurred in 4 (14.3%) cases, type B - in 8 (28.6%) patients. CONCLUSION Pancreatic necrosis was the most common postoperative event after pancreatoduodenectomy. Fewer severe pancreatic fistulae (type C) were recorded after pancreaticogastrostomy although these patients had lower density of the pancreas and unclear pancreatic duct. Choice of pancreatic-digestive anastomosis should be determined by features of pancreatic parenchyma, pancreatic duct diameter. Nevertheless, final decision is a prerogative of surgeon. Pancreaticogastrostomy is especially advisable in minimally invasive PDEs that will simplify inclusion of the pancreas into digestive system and reduce the incidence of complications and mortality.
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Affiliation(s)
- A Yu Popov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - V Ya Lishchishin
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - A N Petrovskiy
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - A N Lishchenko
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - S P Grigorov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - A G Baryshev
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - V A Porkhanov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
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19
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Kumar M, Sonika U, Sachdeva S, Dalal A. Mucin-filled CBD, difficult to manage cholangitis. BMJ Case Rep 2021; 14:14/1/e238363. [PMID: 33431462 PMCID: PMC7802659 DOI: 10.1136/bcr-2020-238363] [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] [Indexed: 01/13/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are mucin-secreting cystic neoplasm of pancreas. They have a malignant potential. They are usually localised to the pancreas but occasionally can involve surrounding structures (1.9%-6.6%), like bile duct and duodenum, and are labelled as IPMN with invasion. Jaundice as a manifestation of IPMN is not common (4.5%). It can present as jaundice as a result of invasion of common bile duct (CBD) resulting in stricture formation or uncommonly as a result of fistulising to CBD with resultant obstruction of CBD by thick mucin secreted by this tumour. As only few cases (around 23) of mucin-filled CBD are reported in the literature. We are presenting our experience in dealing a rare case of obstructive jaundice caused by IPMN fistulising into CBD, highlighting the difficulties faced in managing such case, especially with regards to biliary drainage and what can be the optimum management in such cases.
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Affiliation(s)
- Manish Kumar
- Gastroenterology, GB Pant Hospital, New Delhi, India
| | - Ujjwal Sonika
- Gastroenterology, GB Pant Hospital, New Delhi, India
| | | | - Ashok Dalal
- Gastroenterology, GB Pant Hospital, New Delhi, India
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20
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Sato N, Kimura T, Kenjo A, Kofunato Y, Okada R, Ishigame T, Watanabe J, Marubashi S. Early intra-abdominal infection following pancreaticoduodenectomy:associated factors and clinical impact on surgical outcome. Fukushima J Med Sci 2020; 66:124-132. [PMID: 32963204 PMCID: PMC7790468 DOI: 10.5387/fms.2020-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Early intra-abdominal infection (IAI) following pancreaticoduodenectomy (PD) is an initial event relating to morbidities caused by postoperative pancreatic fistula (POPF). The aims of this study were to determine factors associated with IAI, and to investigate its impact on postoperative outcome. Consecutive patients, 113 in total, who underwent PD at Fukushima Medical University Hospital between January 2012 and September 2017 were included in this retrospective study. IAI was defined by positive bacterial culture from intra-abdominal drainage fluid any time through postoperative day 3 (POD3). Logistic regression analysis was used to identify the relevant factors associated with IAI. The clinical impact of the POD3 infection indicators related to POPF were assessed by multivariate analysis. The incidence of IAI, POPF, and mortality were 36.1%, 36.1%, and 0%, respectively. Independent factors associated with IAI were preoperative biliary drainage (PBD) (OR = 2.91, CI = 1.16-7.33, p = 0.023) and soft pancreas (OR = 8.67, CI = 2.37-31.77, p = 0.001). Among infection markers on POD3, the significant factors for POPF were CRP (OR = 1.18, CI = 1.08-1.30, p < 0.001), IAI (OR = 7,37, CI = 2.53-21.5, p < 0.001), and drain amylase (OR = 1.00, CI = 1.00-1.01, p = 0.001). In conclusion, PBD, soft pancreas, and higher age were associated with IAI. IAI has a significantly negative impact on postoperative outcome.
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Affiliation(s)
- Naoya Sato
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Takashi Kimura
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Akira Kenjo
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Yasuhide Kofunato
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Ryo Okada
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Teruhide Ishigame
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Junichiro Watanabe
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
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21
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Chen JS, Liu G, Li TR, Chen JY, Xu QM, Guo YZ, Li M, Yang L. Pancreatic fistula after pancreaticoduodenectomy: Risk factors and preventive strategies. J Cancer Res Ther 2020; 15:857-863. [PMID: 31436243 DOI: 10.4103/jcrt.jcrt_364_18] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. This study aimed to investigate the risk factors and preventive strategies for POPF after PD. Materials and Methods We retrospectively reviewed 301 consecutive patients who underwent PD at our hospitals between January 2011 and December 2017. We analyzed the pancreatic fistula rate according to the clinical characteristics, pathologic and laboratory findings, and the anastomotic methods and summarized the prevention measures. Results Postoperative morbidities included pancreatic leakage in 10.30% (31/301), delayed gastric emptying in 22.92% (69/301), abdominal infection in 6.98% (21/301), post-PD hemorrhage in 4.65% (14/301), and bile leakage in 4.98% (15/301), and the mortality rate was 2.33% (7/301). POPF was the most prominent factor for preoperative morbidity. Significant risk factors for pancreatic fistula were a soft pancreas, small pancreatic duct, tumor location, and interrupted anastomosis. Of these, soft texture, pancreatic duct <4 mm, and end-to-end anastomosis through hand suture closure were independent risk factors on multivariate analysis, while interrupted anastomosis, internal stent, and somatostatin use were risk factors in the high-risk pancreas subgroup. Conclusions Our study demonstrated that pancreatic fistula is related to a soft texture and small pancreatic duct. The surgeon must consider these risk factors when performing PD. Thus, we propose a risk- and indication-adapted choice of anastomosis or an individualized approach for the pancreatic remnant to reduce the pancreatic fistula rate.
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Affiliation(s)
- Jian-Shu Chen
- Department of Radiology, The 4th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Gang Liu
- Department of Radiology, OASIS International Hospital, Beijing, China
| | - Tian-Ran Li
- Department of Radiology, The 4th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jian-Yu Chen
- Department of Radiology, The 4th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qi-Ming Xu
- Department of Radiology, The 4th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yan-Zhen Guo
- Department of Radiology, The 4th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ming Li
- Department of Radiology, The 4th Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Li Yang
- Department of Radiology, The 1st Medical Center of Chinese PLA General Hospital, Beijing, China
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Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy-a review of modern techniques. Langenbecks Arch Surg 2020; 405:13-22. [PMID: 31975148 PMCID: PMC7036071 DOI: 10.1007/s00423-020-01855-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Background Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods. Purpose The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF. Conclusions Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.
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Affiliation(s)
- Marek Olakowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland.
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
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23
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Cheng Y, He S, Xia J, Ding X, Liu Z, Gong J. Duct-to-mucosa pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Sirong He
- Chongqing Medical University; Department of Immunology, College of Basic Medicine; No. 1 Yixue Road Chongqing China 450000
| | - Jie Xia
- Chongqing Medical University; The Key Laboratory of Molecular Biology on Infectious Diseases; Chongqing China 450000
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
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Gonzalez-Heredia R, Durgam S, Masrur M, Gonzalez-Ciccarelli LF, Gangemi A, Bianco FM, Giulianotti PC. Comparison of Different Techniques of Pancreatic Stump Management in Robot-Assisted Pancreaticoduodenectomy. Gastrointest Tumors 2019; 5:68-76. [PMID: 30976577 DOI: 10.1159/000489777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 04/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background Various technical improvements have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. The aim of this study was to identify the risk factors and incidence of POPF with different types of pancreatic stump management after robot-assisted pancreaticoduodenectomy (RAPD). Materials and Methods This study is a retrospective review of consecutive patients who underwent RAPD at the University of Illinois Hospital and Health Sciences System between September 2007 and January 2016. The cohort was divided based on the type of pancreatic stump management: pancreatic duct occlusion with cyanoacrylate glue (CG), pancreaticojejunostomy (PJ), posterior pancreaticogastrostomy (PPG), and transgastric pancreaticogastrostomy (TPG). Results The cohort included 69 patients: pancreatic duct occlusion with CG (n = 18), PJ (n = 12), PPG (n = 11), and TPG (n = 28). Pancreatic duct diameter < 3 mm and duct occlusion with CG were identified as risk factors for POPF (p < 0.05). The incidence of POPF was lower when TPG and PJ were performed (p < 0.001). Conclusions Reconstruction with PJ and TPG had better results compared to pancreatic duct occlusion with CG and PPG. However, TPG was the technique of choice and showed comparable results to PJ.
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Affiliation(s)
- Raquel Gonzalez-Heredia
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Samarth Durgam
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mario Masrur
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Luis Fernando Gonzalez-Ciccarelli
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Antonio Gangemi
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Pier C Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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25
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Zhang P, Li YL, Qiu XD, Luo J, Shi YF, Sun YL, Su F, Qi ZR, Tan HY. Clinicopathological characteristics and risk factors for recurrence of well-differentiated pancreatic neuroendocrine tumors after radical surgery: a case-control study. World J Surg Oncol 2019; 17:66. [PMID: 30975157 PMCID: PMC6460793 DOI: 10.1186/s12957-019-1606-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/20/2019] [Indexed: 01/18/2023] Open
Abstract
Background Well-differentiated pancreatic neuroendocrine tumors (PanNETs) usually have a good prognosis; however, there are patients that experience recurrence after curative resection. Aim To explore recurrence-related risk factors by analyzing clinicopathological data of PanNETs after radical surgery. Methods Clinical and pathological data from 47 patients with well-differentiated PanNETs at China-Japan Friendship Hospital from January 2012 to March 2016 were analyzed retrospectively. Univariate and multivariate analyses of the risk factors of PanNETs for postoperative recurrence were conducted. Results Among the 47 patients with well-differentiated PanNETs, there were 38 cases with non-functioning tumors, 9 cases with functional tumors (6 insulinomas, 1 gastrinoma, 1 glucagonoma, and 1 VIPomas). There are 17 cases (36.2%) in the pancreatic head, 17 (36.2%) in the body and tail, 9 (19.1%) in the tail, and 4 (8.5%) in the body. The median tumor size was 3.65 (IQR 2–5.5) cm. Fourteen cases (29.8%) were NET G1, and 33 cases (70.2%) were NET G2. In regard to the clinical stage, 9 (19.1%) cases were IA, 14 (29.8%) cases were IB, 7 (14.9%) cases were IIA, 14 (29.8%) cases were IIB, and 3 cases unknown. There were 17 patients who presented with postoperative recurrence. Univariate analysis showed that AJCC TNM staging, Ki67 index, vascular invasion, margin status, and the regional stage of the tumors are related to the recurrence of patients with PanNETs (p < 0.05). The results of multivariate analysis showed that Ki67 index ≥ 10% is an independent risk factor for the postoperative recurrence of PanNETs (p < 0.05). Conclusion The Ki67 index ≥ 10% is an independent risk factor for recurrence in well-differentiated PanNETs after radical surgery, and close surveillance for these patients may be needed.
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Affiliation(s)
- Pan Zhang
- Beijing University of Chinese Medicine, Beijing, China.,Department of Integrative Oncology, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Yuan-Liang Li
- Beijing University of Chinese Medicine, Beijing, China.,Department of Integrative Oncology, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Xu-Dong Qiu
- Beijing University of Chinese Medicine, Beijing, China.,Department of Integrative Oncology, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Jie Luo
- Department of Pathology, China-Japan Friendship Hospital, Beijing, China
| | - Yan-Fen Shi
- Department of Pathology, China-Japan Friendship Hospital, Beijing, China
| | - Yong-Liang Sun
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Fei Su
- Department of Integrative Oncology, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Zhi-Rong Qi
- Department of Integrative Oncology, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Huang-Ying Tan
- Department of Integrative Oncology, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
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26
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Daamen LA, Smits FJ, Besselink MG, Busch OR, Borel Rinkes IH, van Santvoort HC, Molenaar IQ. A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy. HPB (Oxford) 2018; 20:777-785. [PMID: 29773356 DOI: 10.1016/j.hpb.2018.03.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/05/2018] [Accepted: 03/14/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is lacking. This systematic review and meta-analysis aims to provide an online overview of all pancreatic anastomosis techniques and to evaluate the incidence of clinically relevant POPF in randomized controlled trials (RCTs). METHODS A literature search was performed to December 2017. Included were studies giving a detailed description of the pancreatic anastomosis after open pancreatoduodenectomy and RCTs comparing techniques for the incidence of POPF (International Study Group of Pancreatic Surgery [ISGPS] Grade B/C). Meta-analyses were performed using a random-effects model. RESULTS A total of 61 different anastomoses were found and summarized in 19 subgroups (www.pancreatic-anastomosis.com). In 6 RCTs, the POPF rate was 12% after pancreaticogastrostomy (n = 69/555) versus 20% after pancreaticojejunostomy (n = 106/531) (RR0.59; 95%CI 0.35-1.01, P = 0.05). Six RCTs comparing subtypes of pancreaticojejunostomy showed a pooled POPF rate of 10% (n = 109/1057). Duct-to-mucosa and invagination pancreaticojejunostomy showed similar results, respectively 14% (n = 39/278) versus 10% (n = 27/278) (RR1.40, 95%CI 0.47-4.15, P = 0.54). CONCLUSION The proposed online overview can be used as an interactive platform, for uniformity in reporting anastomotic techniques and for educational purposes. The meta-analysis showed no significant difference in POPF rate between pancreatic anastomosis techniques.
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Affiliation(s)
- Lois A Daamen
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Jasmijn Smits
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Inne H Borel Rinkes
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Dept. of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Kuesters S, Chikhladze S, Makowiec F, Sick O, Fichtner-Feigl S, Hopt UT, Wittel UA. Oncological outcome of laparoscopically assisted pancreatoduodenectomy for ductal adenocarcinoma in a retrospective cohort study. Int J Surg 2018; 55:162-166. [PMID: 29807171 DOI: 10.1016/j.ijsu.2018.05.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/12/2018] [Accepted: 05/22/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Laparoscopic resections of the pancreatic head are increasingly performed. Several studies show that they are comparable to open operations in terms of postoperative morbidity. However, since a substantial proportion of pancreatic head resections are necessary for pancreatic adenocarcinoma the oncologic safety and outcome of minimally invasive operations is of interest. In this study we evaluated oncologic outcome and survival after laparoscopically assisted pancreatic head resection for ductal adenocarcinoma. METHODS Perioperative and oncological outcome of sixty-two laparoscopically assisted pancreatic head resections for pancreatic ductal adenocarcinoma performed between 2010 and 2016 was compared to outcome of 278 open resections between 2001 and 2016 in a retrospective study. Data was continuously collected in a prospectively maintained database. RESULTS Operation time was significantly longer in the laparoscopic group (477 vs. 428 min. p < 0.001). Tumor size, lymph node yield and lymph node state and need of portal vein resection were comparable. There was a higher rate of free resection margins in the laparoscopic group (87% vs. 71%, p < 0.01). There was no difference in postoperative mortality and morbidity. Patients with laparoscopic resection stayed in hospital significantly shorter (median 14 vs. 16 days, p < 0.003). Postoperative survival after 5 years was not different in both groups. CONCLUSION Laparoscopically assisted resection of adenocarcinoma of the pancreatic head is equal to open resection concerning oncologic outcome and actuarial survival. However, minimally invasive resection shortened the hospital stay. However, further evaluations with a longer follow up time are needed.
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Affiliation(s)
- Simon Kuesters
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Frank Makowiec
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Olivia Sick
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Ulrich T Hopt
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany.
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28
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Wang SE, Shyr BU, Chen SC, Shyr YM. Robotic distal pancreatectomy: Comparison of spleen-preservation by the Warshaw technique and splenectomy. Int J Med Robot 2018; 14:e1922. [PMID: 29745464 DOI: 10.1002/rcs.1922] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/02/2018] [Accepted: 04/08/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Outcomes after robotic distal pancreatectomy with spleen preservation (RDP-SP) by the Warshaw technique and with splenectomy (RDP-S) were compared. METHODS All the data for patients undergoing robotic distal pancreatectomy (RDP) were prospectively collected. RESULTS A total of 66 patients were included, with 33 in each group. The console time was significantly shorter in the RDP-SP group than in the RDP-S group (165 minutes vs. 220 minutes). The median blood loss was 50 cm3 in the RDP-SP group and 100 cm3 in the RDP-S group. The surgical morbidity was significantly lower in RDP-SP group (18% vs. 58%). Spleen infarction (15%), gastric varices (6%) and perigastric varices (45%) after RDP-SP were not associated with any subsequent complication. Postoperative platelet count and white blood cell (WBC) count were significantly higher in the RDP-S group. CONCLUSIONS Both RDP-SP and RDP-S are feasible in selected patients. RDP-SP is feasible and time-saving. Although gastric/perigastric varices and spleen infarction are not uncommon after RDP-SP, they appear to be clinically irrelevant.
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Affiliation(s)
- Shin-E Wang
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Bor-Uei Shyr
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
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Pancreaticoduodenectomy is justified in a subset of elderly patients with pancreatic ductal adenocarcinoma: A population-based retrospective cohort study of 4,283 patients. Int J Surg 2018; 53:262-268. [DOI: 10.1016/j.ijsu.2018.03.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 02/05/2018] [Accepted: 03/21/2018] [Indexed: 01/16/2023]
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30
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Karim SAM, Abdulla KS, Abdulkarim QH, Rahim FH. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg 2018; 52:383-387. [DOI: 10.1016/j.ijsu.2018.01.041] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/15/2018] [Accepted: 01/27/2018] [Indexed: 12/17/2022]
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31
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Potrc S, Ivanecz A, Pivec V, Marolt U, Rudolf S, Iljevec B, Jagric T. Impact Factors for Perioperative Morbidity and Mortality and Repercussion of Perioperative Morbidity and Long-term Survival in Pancreatic Head Resection. Radiol Oncol 2018. [PMID: 29520206 PMCID: PMC5839082 DOI: 10.1515/raon-2017-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background The focus of the present study was to reveal any impact factors for perioperative morbidity and mortality as well as repercussion of perioperative morbidity on long-term survival in pancreatic head resection. Patients and methods In a retrospective study, clinic-pathological factors of 240 patients after pancreatic head (PD) or total resection were analyzed for correlations with morbidity, 30- and 90-day mortality, and long-term survival. According to Clavien–Dindo classification, all complications with grade II and more were defined as overall complications (OAC). OAC, all surgical (ASC), general (AGC) and some specific types of complications like leaks from the pancreatoenteric anastomosis (PEA) or pancreatic fistula (PF, type A, B and C), leaks from other anastomoses (OL), bleeding (BC) and abscesses (AA) were studied for correlation with clinic-pathological factors. Results In the 9-year period, altogether 240 patients had pancreatic resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase on drains, and pancreatic fistulas B and C correlated significantly with different types of complications. Overall 30- and 90-day mortalities were 5 and 7.9% and decreased to 3.5 and 5% in P2. Conclusions High amylase on drains and higher mean age were independent indicators of morbidity, whereas PL and BC revealed as independent predictor for 30-day mortality, and physical status, OAC and PF C for 90-day mortality.
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Affiliation(s)
- Stojan Potrc
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Vid Pivec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia.,Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Urska Marolt
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Sasa Rudolf
- Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Iljevec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Tomaz Jagric
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
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Yang F, Jin C, Di Y, He H, Hao S, Yao L, Li J, Fu D. Central pancreatectomy with external drainage of monolayer pancreaticojejunostomy for prevention of postoperative pancreatic fistula: A retrospective cohort study. Int J Surg 2018; 51:104-108. [DOI: 10.1016/j.ijsu.2018.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 02/06/2023]
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Sealing with Cyanoacrylate and a Falciform Patch Cannot Prevent Postoperative Pancreatic Fistula. World J Surg 2018; 41:1601-1609. [PMID: 28091745 DOI: 10.1007/s00268-017-3883-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This study aimed to evaluate the effect of a new combined method of covering the pancreatic anastomosis or stump with a cyanoacrylate and a falciform patch (CAFP) on the occurrence of postoperative pancreatic fistula (POPF). METHODS Patients undergoing a pancreaticoduodenectomy (PD) or a distal pancreatectomy (DP) were recruited over a period of 12 months. The pancreaticojejunostomy in PD and the stump in DP were sealed with cyanoacrylate glue and wrapped in a falciform patch. Incidence and severity of POPF and associated postoperative complications were retrospectively compared with historical controls of 750 PD and 336 DP at the same institution and with current data from the literature. RESULTS The new method was applied in 27 PD and 25 DP. The rate of clinically relevant POPF after PD with CAFP was 22.2% compared to 14.4% in historical patients, p = 0.26. The rate of clinically relevant POPF after DP with CAFP was 36% compared to 30% in historical patients, p = 0.65. CONCLUSION Sealing the pancreatic anastomosis or stump with a combination of a cyanoacrylate glue and a falciform patch didn't reduce the rate of POPF after major pancreatic resections.
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Deng Y, Zhao B, Yang M, Li C, Zhang L. Association Between the Incidence of Pancreatic Fistula After Pancreaticoduodenectomy and the Degree of Pancreatic Fibrosis. J Gastrointest Surg 2018; 22:438-443. [PMID: 29330723 PMCID: PMC5838130 DOI: 10.1007/s11605-017-3660-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 12/18/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The objective of this study is to investigate the association between the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) and the degree of pancreatic fibrosis. METHOD Between January 2013 and December 2016, the analysis of the clinical data of 529 cases of pancreaticoduodenectomy patients of our hospital was performed in a retrospective fashion. The univariate analysis and multivariate analysis were done using the Pearson chi-squared test and binary logistic regression analysis model; correlations were analyzed by Spearman rank correlation analysis. The value of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy was evaluated by the area under the receiver operating characteristic (ROC) curve. RESULTS The total incidence of pancreatic fistula after pancreaticoduodenectomy was 28.5% (151/529). Univariate analysis and multivariate analysis showed that BMI ≥ 25 kg/m2, pancreatic duct size ≤ 3 mm, pancreatic CT value< 30, the soft texture of the pancreas (judged during the operation), and the percent of fibrosis of pancreatic lobule ≤ 25% are prognostic factors of pancreatic fistula after pancreaticoduodenectomy (P < 0.05); the pancreatic CT value and the percent of fibrosis of pancreatic lobule in pancreatic fistula group were both lower than those in non-pancreatic fistula group (P < 0.05). Results indicated that there is a negative correlation between the severity of pancreatic fistula and the pancreatic CT value or the percent of fibrosis of pancreatic lobule (r = - 0.297, - 0.342, respectively). The areas under the ROC curve of the percent of fibrosis of pancreatic lobule and the pancreatic CT value were 0.756 and 0.728, respectively. CONCLUSION The degree of pancreatic fibrosis is a prognostic factor which can influence the pancreatic texture and the incidence of pancreatic fistula after pancreaticoduodenectomy. The pancreatic CT value can be used as a quantitative index of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
- Yong Deng
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30, GaoTanYan Street, Chongqing, 400038 People’s Republic of China
| | - Baixiong Zhao
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30, GaoTanYan Street, Chongqing, 400038 People’s Republic of China
| | - Meiwen Yang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30, GaoTanYan Street, Chongqing, 400038 People’s Republic of China
| | - Chuanhong Li
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30, GaoTanYan Street, Chongqing, 400038 People’s Republic of China
| | - Leida Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), No. 30, GaoTanYan Street, Chongqing, 400038 People’s Republic of China
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35
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Fujio A, Usuda M, Ozawa Y, Kamiya K, Nakamura T, Teshima J, Murakami K, Suzuki O, Miyata G, Mochizuki I. A case of gastrointestinal bleeding due to right hepatic artery pseudoaneurysm following total remnant pancreatectomy: A case report. Int J Surg Case Rep 2017; 41:434-437. [PMID: 29546010 PMCID: PMC5702859 DOI: 10.1016/j.ijscr.2017.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 12/19/2022] Open
Abstract
Introduction Pseudoaneurysm is a serious complication after pancreatic surgery, which mainly depends on the presence of a preceding pancreatic fistula. Postpancreatectomy hemorrhage following total pancreatectomy is a rare complication due to the absence of a pancreatic fistula. Here we report an unusual case of massive gastrointestinal bleeding due to right hepatic artery (RHA) pseudoaneurysm following total remnant pancreatectomy. Presentation of case A 75-year-old man was diagnosed with intraductal papillary mucinous carcinoma recurrence following distal pancreatectomy and underwent total remnant pancreatectomy. After discharge, he was readmitted to our hospital with melena because of the diagnosis of gastrointestinal bleeding. Gastrointestinal endoscopy was performed to detect the origin of bleeding, but an obvious bleeding point could not be detected. Abdominal computed tomography demonstrated an expansive growth, which indicated RHA pseudoaneurysm. Emergency angiography revealed gastrointestinal bleeding into the jejunum from the ruptured RHA pseudoaneurysm. Transcatheter arterial embolization was performed; subsequently, bleeding was successfully stopped for a short duration. Because of improvements in his general condition, the patient was discharged. Discussion To date, very few cases have described postpancreatectomy hemorrhage following total remnant pancreatectomy. We suspect that the aneurysm ruptured into the jejunum, possibly because of the scarring and inflammation associated with his two complex surgeries. Conclusion Pseudoaneurysm should be considered when the fragility of blood vessels is suspected, despite no history of anastomotic leak and intra-abdominal abscess. Our case also highlighted that detecting gastrointestinal bleeding is necessary to recognize sentinel bleeding if the origin of bleeding is undetectable.
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Affiliation(s)
- Atsushi Fujio
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Masahiro Usuda
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Yohei Ozawa
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Kurodo Kamiya
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Takanobu Nakamura
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Jin Teshima
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Kazushige Murakami
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - On Suzuki
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Go Miyata
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
| | - Izumi Mochizuki
- Department of Gastroenterological Surgery, Iwate Prefectural Central Hospital, Iwate, 020-0066, Japan.
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Tao L, Yuan C, Ma Z, Jiang B, Xiu D. Surgical resection of a primary tumor improves survival of metastatic pancreatic cancer: a population-based study. Cancer Manag Res 2017; 9:471-479. [PMID: 29056856 PMCID: PMC5635848 DOI: 10.2147/cmar.s145722] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Pancreatic cancer is a lethal disease with a very poor prognosis. This study investigates survival of patients diagnosed with metastatic pancreatic cancer (mPC) based on local treatment of the primary tumor. METHODS Patients diagnosed with stage IV mPC between 2004 and 2013 were identified from the Surveillance, Epidemiology and End Results (SEER) database. Cancer-specific survival (CSS) and overall survival (OS) were examined. CSS and OS were examined by using the Kaplan-Meier method with the log-rank test. Multivariable survival analyses of CSS and OS were conducted using the Cox proportional hazard model. RESULTS A total of 28918 patients with mPC were included in this analysis. There were 467 patients who received surgical resection (1.6%) and 28451 patients who did not (98.4%). Patients who were younger than 70 years (odds ratio [OR]=1.45, 95% CI=1.04-2.03, p=0.03), diagnosed from 2004 to 2008 (OR=1.49, 95% CI=1.25-1.80, p<0.001), female (OR=1.31, 95% CI=1.08-1.58, p<0.001), married (OR=1.56, 95% CI=1.27-1.90, p<0.001), at T3 stage (OR=3.53, 95% CI=1.10-11.37, p=0.035), at N1 stage (OR=2.05, 95% CI=1.68-2.50, p<0.001), presenting histological types other than adenocarcinoma (OR=2.04, 95% CI=1.43-2.94, p<0.001), and with tumor of the pancreatic head (OR=1.90, 95% CI=1.27-2.82, p=0.002) were more likely to be treated with surgical resection. The results of multivariate analysis showed that surgical resection of the primary tumor was associated with CSS (hazard ratio [HR]=0.58, 95% CI=0.52-0.64, p<0.001) and OS (HR=0.59, 95% CI=0.53-0.65, p<0.001) benefits. In addition, not receiving chemotherapy (HR=2.33, 95% CI=2.27-2.39, p<0.001), age >50 years (HR=1.25, 95% CI=1.09-1.42, p=0.001), male (HR=1.121, 95% CI=1.09-1.15, p<0.001), black ethnicity (HR=1.11, 95% CI=1.1-1.15, p<0.001), unmarried (HR=1.20, 95% CI=1.17-1.23, p<0.001), histological type of adenocarcinoma (HR=1.18, 95% CI=1.14-1.22, p<0.001), and primary site other than the pancreatic head (HR=1.08, 95% CI=1.05-1.11, p<0.001) are factors associated with poor survival. CONCLUSION This study reveals that local treatment has the primary benefit of both CSS and OS in patients with mPC. These results may guide the management of this patient population.
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Affiliation(s)
- Lianyuan Tao
- Department of General Surgery, Peking University Third Hospital, Beijing, People's Republic of China
| | - Chunhui Yuan
- Department of General Surgery, Peking University Third Hospital, Beijing, People's Republic of China
| | - Zhaolai Ma
- Department of General Surgery, Peking University Third Hospital, Beijing, People's Republic of China
| | - Bin Jiang
- Department of General Surgery, Peking University Third Hospital, Beijing, People's Republic of China
| | - Dianrong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, People's Republic of China
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Cheng Y, Briarava M, Lai M, Wang X, Tu B, Cheng N, Gong J, Yuan Y, Pilati P, Mocellin S. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2017; 9:CD012257. [PMID: 28898386 PMCID: PMC6483797 DOI: 10.1002/14651858.cd012257.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference. OBJECTIVES To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions. SELECTION CRITERIA We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability. MAIN RESULTS We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data. AUTHORS' CONCLUSIONS There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.
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Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Marta Briarava
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyPadovaItaly
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Xiaomei Wang
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Bing Tu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Yuhong Yuan
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1280 Main Street WestRoom HSC 3N51HamiltonONCanadaL8S 4K1
| | - Pierluigi Pilati
- University of PadovaMeta‐Analysis Unit, Department of Surgery, Oncology and Gastroenterologyvia Giustiniani 2PadovaItaly35128
| | - Simone Mocellin
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyPadovaItaly
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Liao X, Huang K, Huang R, Liu X, Han C, Yu L, Yu T, Yang C, Wang X, Peng T. Genome-scale analysis to identify prognostic markers in patients with early-stage pancreatic ductal adenocarcinoma after pancreaticoduodenectomy. Onco Targets Ther 2017; 10:4493-4506. [PMID: 28979141 PMCID: PMC5602474 DOI: 10.2147/ott.s142557] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Molecular analysis is a promising source of clinically useful prognostic biomarkers. The aim of this investigation was to identify prognostic biomarkers for patients with early-stage pancreatic ductal adenocarcinoma (PDAC) after pancreaticoduodenectomy. METHODS An RNA sequencing dataset of PDAC was obtained from The Cancer Genome Atlas. Survival analysis and weighted gene co-expression network analysis were used to investigate the prognostic markers of early-stage PDAC after pancreaticoduodenectomy. RESULTS Using whole genome expression level screening, we identified 1,238 markers that were related to the prognosis of PDAC after pancreaticoduodenectomy, and identified 9 hub genes (ARHGAP30, HCLS1, CD96, FAM78A, ARHGAP15, SLA2, CD247, GVINP1, and IL16) using the weighted gene co-expression network analysis approach. We also constructed a signature comprising the 9 hub genes and weighted by the regression coefficient derived from a multivariate Cox proportional hazards regression model to divide patients into a high-risk group, with increased risk of death, and a low-risk group, with significantly improved overall survival (adjusted P=0.026, adjusted HR =0.513, 95% CI =0.285-0.924). The prognostic signature of the 9 genes demonstrated good performance for predicting 1-year overall survival (area under the respective receiver operating characteristic curves =0.641). CONCLUSION Our results have provided a new prospect for prognostic biomarkers of PDAC after pancreaticoduodenectomy, and may have a value in clinical application.
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Affiliation(s)
- Xiwen Liao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
| | - Ketuan Huang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
| | - Rui Huang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning
| | - Xiaoguang Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University.,Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang
| | - Chuangye Han
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
| | - Long Yu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University.,Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tingdong Yu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
| | - Chengkun Yang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
| | - Xiangkun Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
| | - Tao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University
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Shamali A, De’Ath HD, Jaber B, Abuawad M, Barbaro S, Hamaday Z, Abu Hilal M. Elderly patients have similar short term outcomes and five-year survival compared to younger patients after pancreaticoduodenectomy. Int J Surg 2017; 45:138-143. [DOI: 10.1016/j.ijsu.2017.07.106] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023]
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Pancreatogastrostomy versus Pancreatojejunostomy: An Up-to-Date Meta-Analysis of RCTs. Int J Surg Oncol 2017; 2017:7526494. [PMID: 28798875 PMCID: PMC5535752 DOI: 10.1155/2017/7526494] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 04/22/2017] [Accepted: 05/14/2017] [Indexed: 12/12/2022] Open
Abstract
Background A meta-analysis was conducted in order to provide an up-to-date comparison of pancreatogastrostomy (PG) and pancreatojejunostomy (PJ), after pancreatoduodenectomy (PD), in terms of clinically significant postoperative pancreatic fistula (POPF) and other postoperative complications. Methods This meta-analysis was conducted according to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic literature search in MEDLINE and Cochrane Central Register of Controlled Clinical Trials was performed. Fixed Effects or Random Effects model was used, based on the Cochran Q test. Results In total, 10 studies (1629 patients) were included. There was no statistical significance between PG and PJ regarding the rate of clinically significant POPF (OR: 0.70, 95%CI: 0.46–1.06). PG was associated with a higher rate of postpancreatoduodenectomy haemorrhage (PPH) (OR: 1.52, 95%CI: 1.08–2.14). There was no difference between the two techniques in terms of clinically significant PPH (OR: 1.35, 95%CI: 0.95–1.93) and clinically significant postoperative delayed gastric emptying (DGE) (OR: 0.98, 95%CI: 0.59–1.63). Discussion There is no difference between the two anastomotic techniques regarding the rate of clinically significant POPF. Given several limitations, more large scale high quality RCTs are required.
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Cesaretti M, Bifulco L, Costi R, Zarzavadjian Le Bian A. Pancreatic resection in the era of laparoscopy: State of Art. A systematic review. Int J Surg 2017; 44:309-316. [PMID: 28689866 DOI: 10.1016/j.ijsu.2017.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/22/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature. DATA SOURCE A systematic review of literature was performed regarding laparoscopic pancreatic resection. RESULTS Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported. CONCLUSIONS Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.
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Affiliation(s)
- Manuela Cesaretti
- Service de Chirurgie Hépatique, Pancréatique et Biliaire, Transplantation Hépatique, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Université Paris Diderot-VII, Clichy, 92110, France; Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Lelio Bifulco
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France
| | - Renato Costi
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Parma, 43100, Italy
| | - Alban Zarzavadjian Le Bian
- Service de Chirurgie Digestive, Hôpital Simone Veil, Eaubonne, 95600, France; Laboratoire d'Ethique Médicale et de Médecine Légale, Université Paris Descartes - V, Paris, 75006, France.
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Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: Single center experience for 34 years. Int J Surg 2017; 42:152-157. [DOI: 10.1016/j.ijsu.2017.03.054] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/06/2017] [Accepted: 03/17/2017] [Indexed: 12/13/2022]
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Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study. Aging Clin Exp Res 2017; 29:35-40. [PMID: 27837458 PMCID: PMC5334406 DOI: 10.1007/s40520-016-0657-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/12/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents the major source of morbidity. Derivative procedures are preferred by pancreatic surgeons, but the optimal management of remnant pancreatic stump remains controversial. AIMS The purpose of this retrospective study is to evaluate the efficacy and safety of pancreatic stump closure in selected elderly patients (>65 years). METHODS Clinical data of 44 PD undergone mechanical closure of the pancreatic stump performed between 2001 and 2014 in two department of general and oncologic surgery were retrospectively collected. Considering the age, patients were divided into two groups: 21 patients of less than 65 years (Group A) and 23 patients of more than 65 years (Group B). RESULTS A soft pancreatic parenchyma with a not-dilated duct (diameter <3 mm) was reported in all the 44 patients. A grade-A PF, which did not required further treatments, developed in 20 cases (45.4%; 13 in group A and 7 in group B; p < 0.05), grade-B in 5 patients (11.4%; 3 in group A and 2 in group B; statistically not significant) and a grade-C PF was observed only in one patient (2.2%; 1 in group A and 0 in group B). DISCUSSION In selected "high risk" elderly patients (>65 years) with soft pancreatic texture, the closure of the pancreatic stump can be a useful tool in the surgical armamentarium with the aim to reduce the incidence of age-related complications. CONCLUSIONS Prospective randomized controlled trial to better evaluate PF risk factors is needed.
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Karaman K, Bal A, Aziret M, Ercan M, Bostanci EB, Akoglu M. Which Suture Material is Optimal for Pancreaticojejunostomy Anastomosis? An In Vitro Study. J INVEST SURG 2016; 30:277-284. [DOI: 10.1080/08941939.2016.1240271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Kerem Karaman
- Department of Gastroenterological Surgery, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ali Bal
- Department of Gastroenterological Surgery, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Mehmet Aziret
- Department of Gastroenterological Surgery, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Metin Ercan
- Department of Gastroenterological Surgery, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Erdal Birol Bostanci
- Department of Gastroenterological Surgery, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Musa Akoglu
- Department of Gastroenterological Surgery, Faculty of Medicine, Sakarya University, Sakarya, Turkey
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Mocellin S, Briarava M, Yuan Y, Pilati P. Anastomosis to stomach versus anastomosis to jejunum for reconstructing the pancreatic stump after pancreatoduodenectomy. Hippokratia 2016. [DOI: 10.1002/14651858.cd012308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Simone Mocellin
- University of Padova; Department of Surgery, Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
- IOV-IRCCS; Istituto Oncologico Veneto; Padova Italy 35100
| | - Marta Briarava
- University of Padova; Department of Surgery, Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
| | - Yuhong Yuan
- McMaster University; Department of Medicine, Division of Gastroenterology; 1280 Main Street West Room HSC 3N51 Hamilton ON Canada L8S 4K1
| | - Pierluigi Pilati
- University of Padova; Meta-Analysis Unit, Department of Surgery, Oncology and Gastroenterology; via Giustiniani 2 Padova Italy 35128
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Kriger AG, Akhtanin EA, Zemskov VM, Gorin DS, Smirnov AV, Berelavichus SV, Kozlova MN, Shishkina NS, Glotov AV. [Risk factors and prevention of postoperative pancreatitis after pancreatectomy]. Khirurgiia (Mosk) 2016:4-10. [PMID: 27459481 DOI: 10.17116/hirurgia201674-10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
AIM to improve the results of pancreatic resections through decrease of postoperative pancreatitis incidence. MATERIAL AND METHODS It was analyzed 207 patients who underwent pancreatic surgery for pancreatic tumor (n=137) or chronic pancreatitis (n=70). 22 risk factors of postoperative pancreatitis were analyzed in 112 patients retrospectively. In prospective study of 95 patients the efficacy of lornoxicam to prevent postoperative pancreatitis was assessed. 68 parameters of immune state were studied to estimate effect of lornoxicam. RESULTS Significant factors were mellow pancreatic parenchyma, tumoral disease, pancreatic duct diameter over 3 mm, pancreatric duct index over 0.2, body mass index over 27 kg/m2. Likelihood of postoperative pancreatitis was 40%, 63%, 74.3% and 88.9% if 2, 3, 4 and 5 factors were combined respectively. Preventive use of lornoxicam reduced significantly incidence of postoperative pancreatitis (p=0.042). Incidence of pancreatic fistula and arrosive bleeding was decreased insignificantly due to small number of observations. CONCLUSION Assessment of significant risk factors and use of medical prevention are available to decrease likelihood of postoperative pancreatitis.
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Affiliation(s)
- A G Kriger
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - E A Akhtanin
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - V M Zemskov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - D S Gorin
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - A V Smirnov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - S V Berelavichus
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - M N Kozlova
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - N S Shishkina
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - A V Glotov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
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