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Codjia T, Roussel E, Papet E, Pinson J, Monge M, Tortajada P, Tuech JJ, Schwarz L. Can the Realization of an External Wirsungostomy be an Option for High-Risk Pancreatic Anastomosis After Pancreaticoduodenectomy? World J Surg 2023; 47:1533-1539. [PMID: 36884081 DOI: 10.1007/s00268-023-06927-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (POPF) occurs in 15-20% of patients after pancreaticoduodenectomy (PD) and reintervention in the setting of Grade C POPF remains associated with a mortality rate of up to 25%. In patients at high risk of POPF, PD with external wirsungostomy (EW) could be a safe alternative that avoids pancreatico-enteric anastomosis while preserving the remnant pancreas. METHODS Of the 155 consecutive patients who underwent PD from November 2015 to December 2020, 10 patients were managed using an EW, all with a fistula risk score (FRS) ≥ 7 and BMI ≥30 kg/m2, and/or major associated abdominal surgery. The pancreatic duct was cannulated with a polyethylene tube to allow good external drainage of the pancreatic fluid. We retrospectively analyzed postoperative complications and endocrine and exocrine insufficiencies. RESULTS The median alternative FRS was 36.9% [22.1-45.2]. There was no postoperative death. The 90-day overall severe complication (grade ≥3) rate was 30% (n = 3 patients), no patient required reoperation, and 2 hospital readmissions occurred. 3 patients experienced Grade B POPF (30%), managed using image-guided drainage for 2 patients. The external pancreatic drain was removed after a median drainage time of 75 days [63-80]. Two patients presented with late symptoms (> 6 months) warranting interventional management (pancreaticojejunostomy and transgastric drainage). Six patients experienced significant weight loss (> 2 kg) 3 months after surgery. One year after surgery, 4 patients still complained of diarrhea and were treated with transit-delaying drugs. One patient presented new-onset diabetes one year after surgery, and 1 of the 4 patients with preexisting diabetes experienced worsening disease. CONCLUSION EW after PD might be a solution to reduce post-operative mortality following PD in high-risk patients.
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Affiliation(s)
- Tatiana Codjia
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Edouard Roussel
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Eloise Papet
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Matthieu Monge
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Pauline Tortajada
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, UNIROUEN, UMR 1245 INSERM, Normandie ROUEN University, 76000, Rouen, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France.
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, UNIROUEN, UMR 1245 INSERM, Normandie ROUEN University, 76000, Rouen, France.
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Stoop TF, Fröberg K, Sparrelid E, Del Chiaro M, Ghorbani P. Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy. Langenbecks Arch Surg 2022; 407:3467-3478. [DOI: 10.1007/s00423-022-02708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. However, in-depth literature is scarce and hard to interpret. This study aimed to evaluate the indications, timing and perioperative outcomes of rescue pancreatectomy for severe POPF after PD.
Methods
Retrospective single-centre study from all consecutive patients (2008–2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days).
Results
From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Mortality after early rescue pancreatectomy did not differ significantly compared to late rescue pancreatectomy (13.6% versus 35.3%; p = 0.142). Timing of a rescue pancreatectomy did not change significantly during the study period: 11 (IQR, 8–14) (2008–2012) versus 14 (IQR, 7–33) (2013–2016) versus 8 days (IQR, 6–11) (2017–2020) (p = 0.140). Over time, the mortality in patients with POPF grade C decreased from 43.5% in 2008–2012 to 31.6% in 2013–2016 up to 0% in 2017–2020 (p = 0.014). However, mortality rates after rescue pancreatectomy did not differ significantly: 31.3% (2008–2012) versus 28.6% (2013–2016) versus 0% (2017–2020) (p = 0.104).
Conclusions
Rescue pancreatectomy for severe POPF is associated with high mortality, but an earlier timing might favourably influence the mortality. Hypothetically, this could be of value for pre-existent vulnerable patients. These findings must be carefully interpreted considering the sample sizes and differences among subgroups by patient selection.
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Lee SJ, Choi IS, Moon JI. Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy. Ann Surg Treat Res 2022; 103:217-226. [PMID: 36304194 PMCID: PMC9582620 DOI: 10.4174/astr.2022.103.4.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/09/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy. Results A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months. Conclusion Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.
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Affiliation(s)
- Seung Jae Lee
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - In Seok Choi
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Ju Ik Moon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
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Chierici A, Frontali A, Granieri S, Facciorusso A, De' Angelis N, Cotsoglou C. Postoperative morbidity and mortality after pancreatoduodenectomy with pancreatic duct occlusion compared to pancreatic anastomosis: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:1395-1404. [PMID: 35450800 DOI: 10.1016/j.hpb.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/15/2022] [Accepted: 03/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatoduodenectomy is burdened by elevated postoperative morbidity. Pancreatic duct ligation or occlusion have been experimented as an alternative to reduce the insurgence of postoperative pancreatic fistula. The aim of this systematic review and meta-analysis was to compare postoperative mortality and morbidity (pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, pancreatic exocrine insufficiency and diabetes mellitus) between patients undergoing pancreatic anastomosis or pancreatic duct ligation/occlusion after pancreatoduodenectomy. METHODS A systematic review and meta-analysis of 13 studies was conducted following the PRISMA guidelines and the Cochrane protocol (PROSPERO ID: CRD42021249232). RESULTS No difference in postoperative mortality was highlighted. Pancreatic anastomosis was found to be protective considering all-grades pancreatic fistula (RR: 2.38, p = 0.0005), but pancreatic duct occlusion presented a 3-folded reduced risk to develop "grade C" pancreatic fistula (RR: 0.36, p = 0.1186), although not significant. Diabetes mellitus was more often diagnosed after duct occlusion (RR: 1.61, p < 0.0001); no difference was found in terms of pancreatic exocrine insufficiency (RR: 1.19, p = 0.151). CONCLUSION Postoperative mortality is not influenced by the pancreatic reconstruction technique. Pancreatic anastomosis is associated with a reduction in all-grades pancreatic fistula. More high-quality studies are needed to clarify if duct sealing could reduce the prevalence of "grade C" fistula.
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Affiliation(s)
- Andrea Chierici
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy.
| | - Alice Frontali
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Stefano Granieri
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Antonio Facciorusso
- Department of Medical Sciences, Gastroenterology Unit, Ospedali Riuniti di Foggia, Viale Luigi Pinto, 1, 71122, Foggia, Italy
| | - Nicola De' Angelis
- Unit of Digestive Surgery, University of Paris Est, UPEC, Créteil, France
| | - Christian Cotsoglou
- General Surgery Unit, Vimercate Hospital - ASST Brianza, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
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Záruba P, Rousek M, Kočišová T, Havlová K, Ryska M, Pohnán R. A comparison of surgical approaches in the treatment of grade C postoperative pancreatic fistula: A retrospective study. Front Surg 2022; 9:927737. [PMID: 36017512 PMCID: PMC9395924 DOI: 10.3389/fsurg.2022.927737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative pancreatic fistula is one of the most dreaded complications following pancreatic resections with Grade C the most severe. Several possible types of surgical intervention are available but to date, none of them have clearly shown superiority. This study aims to compare different surgical approaches.MethodsA retrospective analysis of patients who underwent revision surgery for postoperative pancreatic fistula between 2008 and 2020 was performed. Three surgical approaches were compared: open drainage; a disconnection of the pancreaticojejunostomy; and salvage total pancreatectomy. The data of nine monitored parameters were collected. Selected parameters were statistically analyzed and compared.ResultsA total of 54 patients were included. Eighteen patients underwent open drainage, 28 had disconnections of the pancreaticojejunostomy and eight had salvage total pancreatectomy. Statistically significant differences were observed in the time of Intensive Care Unit stay, the number of surgical interventions, 90-day mortality, the number of administered blood transfers and treatment costs. Open drainage showed to be superior in each category. The difference in long-term survival also slightly favored simple drainage.ConclusionOpen drainage procedure showed to be superior to other types of interventions in most of the monitored parameters. Disconnection of the pancreaticojejunostomy and a salvage total pancreatectomy had similar results, which correlated with the surgical burden of these interventions.
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Groen JV, Smits FJ, Koole D, Besselink MG, Busch OR, den Dulk M, van Eijck CHJ, Groot Koerkamp B, van der Harst E, de Hingh IH, Karsten TM, de Meijer VE, Pranger BK, Molenaar IQ, Bonsing BA, van Santvoort HC, Mieog JSD. Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis. Br J Surg 2021; 108:1371-1379. [PMID: 34608941 PMCID: PMC10364904 DOI: 10.1093/bjs/znab273] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy. METHODS This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005-2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines. RESULTS From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel-Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84). CONCLUSION Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- J V Groen
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - D Koole
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - O R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - I H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,Department of Epidemiology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - T M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, the Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - B K Pranger
- Department of Surgery, University of Groningen and University Medical Centre Groningen, Groningen, the Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, University Medical Centre Utrecht, and St. Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Traub B, Link KH, Kornmann M. Curing pancreatic cancer. Semin Cancer Biol 2021; 76:232-246. [PMID: 34062264 DOI: 10.1016/j.semcancer.2021.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/14/2022]
Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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Casciani F, Bassi C, Vollmer CM. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021; 170:889-909. [PMID: 33892952 DOI: 10.1016/j.surg.2021.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula. METHODS A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon. RESULTS Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula. CONCLUSION A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, University of Verona, Italy. https://twitter.com/F_Casciani
| | - Claudio Bassi
- Department of Surgery, University of Verona, Italy. https://twitter.com/pennsurgery
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management. Langenbecks Arch Surg 2020; 405:1219-1231. [PMID: 33104886 PMCID: PMC7686010 DOI: 10.1007/s00423-020-02005-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/29/2020] [Indexed: 01/04/2023]
Abstract
Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management. Electronic supplementary material The online version of this article (10.1007/s00423-020-02005-8) contains supplementary material, which is available to authorized users.
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Bardol T, Delicque J, Hermida M, Herrero A, Guiu B, Fabre JM, Souche R. Neck transection level and postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort study of 195 patients. Int J Surg 2020; 82:43-50. [PMID: 32841726 DOI: 10.1016/j.ijsu.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the level of neck transection on clinically relevant postoperative pancreatic fistula (CR-POPF) after standard pancreaticoduodenectomy (PD) with pancreaticojejunostomy. METHOD A total of 195 patients with an early postoperative CT scan were retrospectively analyzed and divided into 2 groups (CR-POPF and No CR-POPF) in order to seek potential risk factors for CR-POPF. We focused our analysis on the relationship between CR-POPF and the level of neck transection, defined by measuring the distance between the left side of the portal vein and the remnant pancreatic stump on the postoperative CT scan. RESULT CR-POPF occurred in 58 out of 195 PD (29.7%); grade B (17%) and grade C (12.7%). The Clavien-Dindo ≥ 3 morbidity rate was 33% (65/195) and the mortality rate was 2.5% (5/195). Multivariate analysis indicated that a 'right-sided' level of neck transection (P = 0.007), a firm pancreatic texture (P = 0.001), and a PD for non-pancreatic ductal adenocarcinoma histology (P = 0.032) were independent risk factors for CR-POPF. A full neck resection with systematic transection ≥7 mm at the left side of the portal vein seems to prevent CR-POPF harboring a protective effect (OR 0.056; 95% CI 0.003 to 0.978; P = 0.039). CONCLUSION Here we further consolidate the concept describing the pancreatic neck as a vascular watershed, showing that a long remnant pancreatic neck could be an independent risk factor for CR-POPF after PD (NCT03850236). TRIAL REGISTRATION NUMBER AND AGENCY The present study was approved by our local ethics committee and was declared on ClinicalTrials.gov (ID: NCT03850236).
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Affiliation(s)
- Thomas Bardol
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France.
| | - Julien Delicque
- Department of Radiology, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Margaux Hermida
- Department of Radiology, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Astrid Herrero
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Boris Guiu
- Department of Radiology, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Jean-Michel Fabre
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Regis Souche
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
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11
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Commentary on "Surgical management and outcome of grade-C pancreatic fistulas after pancreaticoduodenectomy: A retrospective multicenter cohort study". Int J Surg 2019; 70:11-12. [PMID: 31400505 DOI: 10.1016/j.ijsu.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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