Clinical effect of pancreaticojejunostomy with a long-internal stent during pancreaticoduodenectomy in patients with a main pancreatic duct of small diameter

The methods of prophylaxis of the pancreatic fistula occurrence after pancreato–duodenectomy

Objective. To elaborate the measures system, which permit to reduce the occurrence of pancreatic fistula and other severe complications after performance of pancreato–duodenectomy. Materials and methods. There were analyzed the results of treatment of 327 patients, in whom pancreato–duodenectomy was performed. In accordance to the scheme proposed, using the elaborated scale of risk for the postoperative pancreatic fistula occurrence with estimation of sarcopenia presence and application of certain prophylactic measures 98 patients were operated in period from November 2018 to December 2020 yr. (the main group). Into the control group 229 patients were included, operated on in the clinic from January 2015 to October 2018 yr. without estimation of risk for the pancreatic fistula occurrence and presence of sarcopenia. The method of pancreato–jejunoanastomosis formation was selected by operating surgeon. Results. Postoperative complications have occurred in 94 (41.0%) patients of the control group and in 28 (28.6%) patients of the main group (c 2 = 4.56, p=0.03). Clinically significant postoperative pancreatic fistula of B Degree have occurred in 9 (9.2%) patients of the main group, what was statistically significantly lower, than in the control group, in which postoperative pancreatic fistula of B or C Degree have occurred in 64 (27.9%) patients (c 2 = 11.6, p=0.0007). Lethality was 2.2% in the control group and 1.02% – in the main one. Conclusion. Introduction of the measures system elaborated have permitted to lower the postoperative pancreatic fistula rate statistically significantly from 27.9 to 9.2%, and of other postoperative complications – from 41.0 to 28.6% and lethality from 2.2 to 1.02%.

USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience

Background. Plastic stents have been used to avoid postoperative pancreatic fistula (POPF) following Whipple's Pancreaticoduodenectomy (WPD), but they may cause some stent-related complications. Biodegradable stents have been recently introduced and might be a safe alternative. Here we present our initial experience with their use. Methods. Between March 1, 2020, and September 30, 2020, ten (10) consecutive patients underwent WPD. They all had conventional two-layer pancreaticojejunostomy with the placement of an internal biodegradable stent. They were assessed for technical feasibility, pancreatic leak, and stent-related complications. Results. The use of biodegradable stents was technically feasible in all patients, despite some difficulties in insertion due to stent stiffness and design. After a median follow-up period of 124 days, none of the patients suffered POPF. One patient had a biochemical pancreatic leak with no clinical significance. The median hospital stay was 7 days, and there were no stent-related complications. Conclusion. Biodegradable stents are technically feasible and safe in WPD with good short-term outcomes. They might provide a better alternative to plastic stents and their potential complications. Larger long-term studies are needed to validate efficacy and safety. Few modifications of the stent's design might be needed to facilitate use in open surgery.

Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases)

Background

To explore the application value of free omental wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).

Methods

The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analysed. In total, 86 cases were divided into Group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases were divided into Group B (control group). The incidences of postoperative pancreatic fistula and other complications were compared between the two groups, and univariate and multivariate logistic regression analyses were used to determine the potential risk factors for postoperative pancreatic fistula. Risk factors associated with postoperative overall survival were identified using Cox regression.

Results

The incidences of grade B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in Group A were lower than those in Group B, and the differences were statistically significant (P < 0.05). Group A had an earlier drainage tube extubation time, earlier return to normal diet time and shorter postoperative hospital stay than the control group (P < 0.05). The levels of C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) inflammatory factors 1, 3 and 7 days after surgery also showed significant. Univariate and multivariate logistic regression analyses showed that a body mass index (BMI) ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P < 0.05). Cox regression analysis showed that age ≥ 65 years old, body mass index ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap isolation and modified pancreaticojejunostomy, and malignant postoperative pathology were independent risk factors associated with postoperative overall survival (P < 0.05).

Conclusions

Wrapping and isolating the modified pancreaticojejunostomy with free greater omentum can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and favourably affect prognosis.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ​​obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.

Preoperative Computed Tomography Imaging of the Pancreas Identifying Predictive Factors for the Progression of Grade A, or Biochemical Leak, to Grade B Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy: A Retrospective Study

Background

This retrospective study aimed to identify the predictive factors for the progression of grade A, or early biochemical leak, to grade B postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy using preoperative computed tomography (CT) imaging of the pancreas.

Material/Methods

A total of 156 patients were analyzed retrospectively. Biochemical leakage occurred in 60 patients, who were divided into POPF progression and non-POPF progression groups. Perioperative parameters were collected. Univariate analysis and multivariate logistic regression analysis were done. For the parameters with statistical significance, the area under the curve (AUC) was calculated if possible and the predictive value was assessed.

Results

Univariate analysis showed that main pancreatic duct diameter, postoperative complications (except POPF), prothrombin time (PT) and serum albumin on postoperative day 3, and pancreatic CT value were risk factors of POPF (P<0.05). Multivariate analysis showed that serum albumin and PT on postoperative day 3 and pancreatic CT value were independent risk factors of POPF (P<0.05). Lower postoperative albumin, lower pancreatic CT value, and longer PT were associated with a higher risk of POPF (P<0.05). The AUC of CT value was 0.808. CT value thresholds of 42.5 Hounsfield units (HU) and 41.5 HU were tied for the highest predictive performance, with Youden indices of 0.486 for both, and sensitivity of 79% and 71%, and specificity of 69% and 78%, respectively.

Conclusions

Preoperative laboratory investigations and CT imaging of the pancreas may identify factors associated with early biochemical leakage progressing to grade B POPF following pancreaticoduodenectomy.

Internal stenting across the pancreaticojejunostomy anastomosis and main pancreatic duct after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula is associated with high morbidity and mortality. Studies have reported internal stenting of the pancreaticojejunostomy anastomosis to reduce postoperative pancreatic fistula, but it is still controversial.

MATERIALS AND METHODS

Fifty patients undergoing elective pancreaticoduodenectomy, were included. Patients were divided into 2 groups in randomized fashion; Group A (n-25) without internal stenting across the pancreaticojejunostomy anastomosis and Group B (n-25) with internal stenting of the pancreaticojejunostomy anastomosis. Primary endpoint was the occurrence of postoperative pancreatic fistula.

RESULT

Both the groups were comparable in demographics, co morbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, total 23(46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery on conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p-0.366]. Six patients developed superficial surgical site infection (2 in group A and 4 in group B; p-0.445). The length of hospital stay was comparable in two groups. There was no mortality.

CONCLUSION

Internal stenting of pancreaticojejunostomy anastomosis does not decrease the rate of postoperative pancreatic fistula after pancreaticoduodenectomy.

Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct

BACKGROUND

Soft pancreas with small pancreatic duct is a known risk factor for postoperative pancreatic fistula (POPF). This study demonstrated the safety and feasibility of laparoscopic duct-to-mucosa pancreaticojejunostomy (PJ) and compared perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with soft pancreas and small pancreatic duct.

METHODS

From January 2014 to December 2019, 183 patients underwent LPD and 91 patients underwent OPD by a single surgeon. Data on patients with soft pancreas and combined small pancreatic duct (≤ 2 mm) were retrospectively reviewed. Clinicopathologic characteristics, and perioperative outcomes were compared between LPD and OPD. We evaluated risk factors affecting clinically relevant POPF (CR-POPF). We also correlated calculated risks of POPF and CR-POPF between the two groups.

RESULTS

We compared 62 patients in the LPD group and 34 patients in the OPD group. Perioperative outcomes showed less blood loss, shorter hospital stays, and less postoperative pain score on postoperative day (POD)#1 and #5 in LPD compared with OPD. Postoperative complications showed no differences between LPD and OPD. LPD group showed significantly reduced CR-POPF rates compared to the OPD group (LPD 11.3% vs. OPD 29.4%, p = 0.026). Multivariate analysis identified obesity (BMI ≥ 25), thick pancreas parenchyma and open surgery as independent predicting factors for CR-POPF. The LPD group showed less CR-POPF than the OPD group according to POPF risk groups. This difference was more prominent in a high-risk group.

CONCLUSION

With appropriate laparoscopic technique, LPD is feasible and safe and reduces CR-POPF in soft pancreas with a small pancreatic duct.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.

The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

BACKGROUND

Partial pancreatoduodenectomy is performed for malignant and benign diseases of the pancreatic head region. The procedure is considered highly difficult and highly invasive. Postoperative pancreatic fistula (POPF) is an important complication because of several consequent complications, including intraabdominal haemorrhage, often increasing hospital stays and surgical mortality. Although many kinds of pancreaticojejunostomy aimed at reducing POPF have been examined to date, the technique has not yet been standardized. We devised a new method using double-coated polyglycolic acid felt after pancreaticojejunostomy. The aim of the PLANET-PJ trial is to evaluate the superiority of polyglycolic acid felt reinforcement in preventing POPF after pancreaticojejunostomy in patients undergoing partial pancreatoduodenectomy to previous anastomosis methods.

METHODS

Patients diagnosed with pancreatic or periampullary lesions in whom it is judged that the main pancreatic duct diameter was 3 mm or less on the left side of the portal vein without pancreatic parenchymal atrophy due to obstructive pancreatitis are considered eligible for inclusion. This study is designed as a multicentre randomized phase III trial in Japan and the Republic of Korea. Eligible patients will be centrally randomized to either group A (polyglycolic acid felt reinforcement) or group B (control). In total, 514 patients will be randomized in 31 high-volume centres in Japan and Republic of Korea. The primary endpoint is the incidence of POPF (International Study Group of Pancreatic Surgery grade B/C).

DISCUSSION

The PLANET-PJ trial evaluates the efficacy of a new method using double-coated polyglycolic acid felt reinforcement for preventing POPF after pancreaticojejunostomy. This new method may reduce POPF.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03331718 . University Hospital Medical Information Network Clinical Trials Registry, UMIN000029647. Registered on 30 November 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033874.

Dual-center randomized clinical trial exploring the optimal duration of antimicrobial prophylaxis in patients undergoing pancreaticoduodenectomy following biliary drainage

OBJECTIVES

The aim of this dual-center randomized controlled trial was to determine the optimal duration of antimicrobial prophylaxis in patients treated with pancreaticoduodenectomy (PD) who underwent preoperative biliary drainage (PBD) but were without cholangitis.

BACKGROUND

Some reports showed that PBD in patients undergoing pancreatectomy increased the rate of perioperative complications. However, no clinical trial has evaluated the optimal duration of antimicrobial prophylaxis with a focus on patients who underwent PD following PBD.

METHODS

A total of 82 patients who underwent PD between March 2012 and December 2016 were randomly assigned to either a 1-day group (n = 40), in which cefozopran (CZOP) as antimicrobial prophylaxis was given only on the day of surgery, or a 5-day group (n = 42), in which CZOP was given for 5 consecutive days beginning on the day of surgery. We evaluated the incidence of infectious and other complications after PD.

RESULTS

Outcomes were significantly better in the 1-day group compared with the 5-day group (P < 0.05) in terms of the incidence of overall infectious complications (15% vs 36%, respectively), intra-abdominal abscess (3% vs 21%, respectively), clinically relevant postoperative pancreatic fistula (8% vs 24%, respectively), and Clavien-Dindo grade III-V complications (10% vs 31%, respectively). Duration of postoperative hospital stay was significantly shorter in the 1-day group (10 days vs 15 days, P = 0.018). Anaerobic bacteria and methicillin-resistant cocci were isolated from the drainage fluid only among patients in the 5-day group.

CONCLUSION

Single-day prophylactic use of CZOP is appropriate for patients who undergo PD following PBD without preoperative cholangitis.

Does modified Blumgart anastomosis without intra-pancreatic ductal stenting reduce post-operative pancreatic fistula after pancreaticojejunostomy?

BACKGROUND

Post-operative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). The aim of this study is to retrospectively compare clinically relevant (CR) POPF and other complications after pacreaticojejunostomy (PJ) after modified Kakita (m-Kakita) or modified Blumgart (m-Blumgart) anastomoses without stenting in a single institution.

METHODS

One hundred twenty-eight patients underwent PJ using m-Kakita anastomoses (two interrupted penetrating sutures) between January 2009 and December 2011. One hundred eighteen patients underwent m-Blumgart anastomoses (two transpancreatic/jejunal seromuscular sutures to cover the pancreatic stump with jejunal serosa) between January 2014 and December 2015. Demographics, clinical characteristics, and post-operative mortality and morbidity were retrospectively compared between the two groups.

RESULTS

There were no significant differences in demographics or clinical characteristics between the two groups except operative time. A significantly lower rate of CR-POPF was found in the m-Blumgart group relative to the m-Kakita group (10% vs. 19%, p = 0.038). Univariate and multivariate analyses revealed that the m-Blumgart anastomosis and fistula risk category (Negligible, Low) were independently protective against CR-POPF (p < 0.05).

CONCLUSION

This retrospective single-center study demonstrated that the modified Blumgart method without pancreatic duct stenting was associated with a lower rate of CR-POPF.

Substantial atherosclerotic celiac axis stenosis is a new risk factor for biliary fistula after pancreaticoduodenectomy

BACKGROUND

Biliary fistula (BF) is a major surgical complication that can develop after pancreaticoduodenectomy (PD) whose risk factors remain unclear. Substantial atherosclerotic celiac axis stenosis (SACAS) has not been reported to be one of them.

METHODS

Data from 507 patients undergoing PD between Jan 1, 2013 and Dec 31, 2015 were retrospectively collected. Clinical data from patients with SACAS were studied, and the independent risk factors for BF underwent multivariate logistic regression analysis, including SACAS.

RESULTS

BF occurred in 22 (4.3%) patients, and the incidence of BF was significantly higher in patients with SACAS than in those without it (27.0% vs 2.6%, P < .001). In the univariate analysis, BF was significantly related to SACAS, older age, a higher ASA score, history of coronary disease, greater blood loss and RBC transfusion during surgery, smaller CBD diameter and higher POD 1 BUN level. The multivariate analysis showed that only SACAS (OR 8.91, 95% CI 2.36-33.69, P = .001), older age (OR 1.08, 95% CI 1.01-1.15, P = .028) and smaller preoperative CBD (OR 0.79, 95% CI 0.69-0.92, P = .002) were independent risk factors for postoperative BF.

CONCLUSION

Older age and a smaller preoperative CBD diameter are independent risk factors for BF after PD, which is consistent with the literature. In addition, SACAS is a new independent risk factor for BF. For patients with SACAS, postoperative drainage should be carefully managed to precisely observe the potential for BF.