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Uijterwijk BA, Lemmers DH, Fusai GK, Groot Koerkamp B, Koek S, Zerbi A, Sparrelid E, Boggi U, Luyer M, Ielpo B, Salvia R, Goh BKP, Kazemier G, Björnsson B, Serradilla-Martín M, Mazzola M, Mavroeidis VK, Sánchez-Cabús S, Pessaux P, White S, Alseidi A, Valle RD, Korkolis D, Bolm LR, Soonawalla Z, Roberts KJ, Vladimirov M, Mazzotta A, Kleeff J, Suarez Muñoz MA, Besselink MG, Hilal MA. Different Periampullary Types and Subtypes Leading to Different Perioperative Outcomes of Pancreatoduodenectomy: Reality and Not a Myth; An International Multicenter Cohort Study. Cancers (Basel) 2024; 16:899. [PMID: 38473260 DOI: 10.3390/cancers16050899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/23/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
This international multicenter cohort study included 30 centers. Patients with duodenal adenocarcinoma (DAC), intestinal-type (AmpIT) and pancreatobiliary-type (AmpPB) ampullary adenocarcinoma, distal cholangiocarcinoma (dCCA), and pancreatic ductal adenocarcinoma (PDAC) were included. The primary outcome was 30-day or in-hospital mortality, and secondary outcomes were major morbidity (Clavien-Dindo 3b≥), clinically relevant post-operative pancreatic fistula (CR-POPF), and length of hospital stay (LOS). Results: Overall, 3622 patients were included in the study (370 DAC, 811 AmpIT, 895 AmpPB, 1083 dCCA, and 463 PDAC). Mortality rates were comparable between DAC, AmpIT, AmpPB, and dCCA (ranging from 3.7% to 5.9%), while lower for PDAC (1.5%, p = 0.013). Major morbidity rate was the lowest in PDAC (4.4%) and the highest for DAC (19.9%, p < 0.001). The highest rates of CR-POPF were observed in DAC (27.3%), AmpIT (25.5%), and dCCA (27.6%), which were significantly higher compared to AmpPB (18.5%, p = 0.001) and PDAC (8.3%, p < 0.001). The shortest LOS was found in PDAC (11 d vs. 14-15 d, p < 0.001). Discussion: In conclusion, this study shows significant variations in perioperative mortality, post-operative complications, and hospital stay among different periampullary cancers, and between the ampullary subtypes. Further research should assess the biological characteristics and tissue reactions associated with each type of periampullary cancer, including subtypes, in order to improve patient management and personalized treatment.
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Affiliation(s)
- Bas A Uijterwijk
- Department of Surgery, Fondazione Poliambulanza, 25124 Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1012 Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 Amsterdam, The Netherlands
| | - Daniël H Lemmers
- Department of Surgery, Fondazione Poliambulanza, 25124 Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1012 Amsterdam, The Netherlands
- Cancer Center Amsterdam, 1081 Amsterdam, The Netherlands
| | - Giuseppe Kito Fusai
- Department of Surgery, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | | | - Sharnice Koek
- Department of Surgery, Fiona Stanley Hospital, Murdoch, WA 6150, Australia
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, 171 64 Solna, Sweden
| | - Ugo Boggi
- Department of Surgery, Pisa University Hospital, 56100 Pisa, Italy
| | - Misha Luyer
- Department of Surgery, Catharina Hospital Eindhoven, 5623 Eindhoven, The Netherlands
| | - Benedetto Ielpo
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
| | - Roberto Salvia
- Department of Surgery, University Hospital of Verona, 37126 Verona, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobilliary and Transplant Surgery, National Cancer Centre, Singapore General Hospital, Singapore 168583, Singapore
- Surgery Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, Location VUmc, 1007 Amsterdam, The Netherlands
| | - Bergthor Björnsson
- Department of Surgery in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, 581 83 Linköping, Sweden
| | | | - Michele Mazzola
- Division of Oncologic and Mini-Invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Vasileios K Mavroeidis
- Department of Academic Surgery, The Royal Marsden Hospital, London SW3 6JJ, UK
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals, NHS Foundation Trust, Oxford OX3 9DU, UK
| | | | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Nouvel Hôpital Civil (NHC), 67000 Strasbourg, France
| | - Steven White
- Department of Surgery, Newcastle Upon Tyne Hospitals, NHS Foundation Trust, Newcastle Upon Tyne NE3 3HD, UK
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason, Seattle, WA 98101, USA
| | | | - Dimitris Korkolis
- Department of Surgery, Hellenic Anticancer Hospital 'Saint Savvas', 115 22 Athens, Greece
| | - Louisa R Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
| | - Zahir Soonawalla
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals, NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Keith J Roberts
- Faculty of Medicine, University of Birmingham, Birmingham B15 2TT, UK
| | - Miljana Vladimirov
- Department of Surgery Hospital Nuremberg, PMU Nürnberg, 90419 Nürnberg, Germany
| | - Alessandro Mazzotta
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014 Paris, France
| | - Jorg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, 06108 Halle (Saale), Germany
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1012 Amsterdam, The Netherlands
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Chui JN, Sahni S, Samra JS, Mittal A. Postoperative pancreatitis and pancreatic fistulae: a review of current evidence. HPB (Oxford) 2023; 25:1011-1021. [PMID: 37301633 DOI: 10.1016/j.hpb.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies. METHODS A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset. RESULTS A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury. CONCLUSIONS The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.
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Affiliation(s)
- Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
| | - Sumit Sahni
- Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia; School of Medicine, The University of Notre Dame, Sydney, Australia.
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Zhou H, Wu X. Application of Simplified Duct-to-Mucosa Pancreaticojejunostomy for Nondilated Pancreatic Duct in Laparoscopic Pancreatic Surgery. Surg Laparosc Endosc Percutan Tech 2023; 33:219-223. [PMID: 37010359 PMCID: PMC10234321 DOI: 10.1097/sle.0000000000001084] [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: 06/27/2021] [Accepted: 06/17/2022] [Indexed: 04/04/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the feasibility of simplified duct-to-mucosa pancreaticojejunostomy in a nondilated pancreatic duct in laparoscopic surgery. MATERIALS AND METHODS The data of 19 patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and 2 patients who underwent laparoscopic central pancreatectomy were retrospectively analyzed. RESULTS All patients underwent pure laparoscopic surgery successfully with simplified duct-to-mucosa pancreaticojejunostomy. The operation time of LPD was 365.11±41.56 minutes, the time of pancreaticojejunostomy was 28.39±12.58 minutes, and postoperative hospitalization time was 14.16±6.88 days on average. Postoperative complications occurred in 3 patients of LPD, including 2 cases of class B postoperative pancreatic fistula and 1 case of gastroparesis followed by gastrointestinal anastomotic perforation. The operative time of laparoscopic central pancreatectomy was 191.00±12.73 minutes, the time of pancreaticojejunostomy 36.00±5.66 minutes, and the postoperative hospitalization time 12.5±0.71 days on average. CONCLUSIONS The described technique is a simple and safe reconstruction procedure and suitable for patients with nondilated pancreatic duct.
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Hassan RA, Zidan A, Jabir MA, Abdelshafy M, Abdallah M, Taha AM. Risk factors predicting the development of a pancreatic fistula following pancreaticoduodenectomy: A retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zhou H, Yu S, Wu X, Li X. Application of purse string suture pancreaticojejunostomy for undilated pancreatic duct in total laparoscopic pancreaticoduodenectomy. BMC Surg 2022; 22:195. [PMID: 35590306 PMCID: PMC9118586 DOI: 10.1186/s12893-022-01640-w] [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: 02/18/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background To investigate the feasibility of purse string suture pancreaticojejunostomy in complete laparoscopic pancreaticoduodenectomy for patients with an undilated pancreatic duct. Methods We retrospectively reviewed a database of 113 patients with undilated pancreatic ducts who had undergone laparoscopic pancreaticoduodenectomy (LPD) with purse string suture pancreaticojejunostomy to analyze the perioperative outcomes. Results One hundred thirteen patients underwent successful LPD. The surgery time was 353 ± 41 min, the time required for pancreaticojejunostomy was 27 ± 5 min, and the hospital stay after surgery was 16 ± 8 days. Fifteen patients suffered postoperative complications, including twelve patients with pancreatic fistula, one with bile leakage, one with gastroparesis (complicated with abdominal infection), and one with abdominal bleeding. No perioperative death occurred. Conclusions Purse string suture pancreaticojejunostomy is safe and feasible for patients with an undilated pancreatic duct. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01640-w.
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Affiliation(s)
- Haihua Zhou
- Department of Hepatobiliary Surgery, The Affiliated Jinhua Hospital of Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Shian Yu
- Department of Hepatobiliary Surgery, The Affiliated Jinhua Hospital of Zhejiang University School of Medicine, Jinhua, Zhejiang, China.
| | - Xiaokang Wu
- Department of Hepatobiliary Surgery, The Affiliated Jinhua Hospital of Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Xuemin Li
- Department of Hepatobiliary Surgery, The Affiliated Jinhua Hospital of Zhejiang University School of Medicine, Jinhua, Zhejiang, China
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Gierek M, Merkel K, Ochała-Gierek G, Niemiec P, Szyluk K, Kuśnierz K. Which Suture to Choose in Hepato-Pancreatic-Biliary Surgery? Assessment of the Influence of Pancreatic Juice and Bile on the Resistance of Suturing Materials—In Vitro Research. Biomedicines 2022; 10:biomedicines10051053. [PMID: 35625790 PMCID: PMC9139064 DOI: 10.3390/biomedicines10051053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: The choice of appropriate surgical suture during operation is of great significance. Currently, there are no objective studies regarding the resistance of commonly used sutures in biliary tract surgery. (2) Methods: This fact leads one to conduct research concerning the resistance of the sutures (Polydioxanone, Poliglecaprone, Poliglactin 910, and their analogues coated with antibacterial triclosan) in the environment of sterile and contaminated bile and pancreatic juice. Tensile strength was tested at days 0, 7, 14, 21, and 28 of research. The study was performed in in vitro conditions for 28 days. (3) Results: Pancreatic juice and bile has a significant influence on the tensile strength of each suture. (4) Conclusions: The study indicated that sutures made of polydioxanone had the best qualities during the entire experiment.
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Affiliation(s)
- Marcin Gierek
- Center for Burns Treatment im. Dr Sakiel, ul. Jana Pawła II 2, 41-100 Siemianowice Śląskie, Poland
- Correspondence: (M.G.); (K.M.); Tel.: +48-6-6070-7704 (M.G.); +48-6-9834-2856 (K.M.)
| | - Katarzyna Merkel
- Institute of Materials Engineering, Faculty of Science and Technology, University of Silesia, ul. 75. Pułku Piechoty, 41-500 Chorzów, Poland
- Correspondence: (M.G.); (K.M.); Tel.: +48-6-6070-7704 (M.G.); +48-6-9834-2856 (K.M.)
| | - Gabriela Ochała-Gierek
- Dermatology Department, City Hospital in Sosnowiec, ul. Zegadłowicza 3, 41-200 Sosnowiec, Poland;
| | - Paweł Niemiec
- Department of Biochemistry and Medical Genetics, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
| | - Karol Szyluk
- Department of Physiotherapy, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
- Department of Orthopaedic and Trauma Surgery, District Hospital of Orthopaedics and Trauma Surgery, 41-940 Piekary Śląskie, Poland
| | - Katarzyna Kuśnierz
- Department of Gastrointestinal Surgery, Medical University of Silesia in Katowice, ul. Medyków 14, 40-752 Katowice, Poland;
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Utsumi M, Aoki H, Nagahisa S, Nishimura S, Une Y, Kimura Y, Taniguchi F, Arata T, Katsuda K, Tanakaya K. Preoperative Nutritional Assessment Using the Controlling Nutritional Status Score to Predict Pancreatic Fistula After Pancreaticoduodenectomy. In Vivo 2021; 34:1931-1939. [PMID: 32606165 DOI: 10.21873/invivo.11990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023]
Abstract
Backgound: This study aimed to determine the usefulness of the Controlling Nutritional Status (CONUT) scorescore for predicting postoperative pancreatic fistula (POPF). PATIENTS AND METHODS Data from 108 consecutive pancreaticoduodenectomy cases performed at the Surgery Department of Iwakuni Clinical Center, from April 2008 to May 2018, were included. Preoperative patient data and postoperative complication data were collected. RESULTS Of the 108 patients (male=65; female=43; mean age=70 years), 41 (37.9%) had indication for pancreaticoduodenectomy due to pancreatic carcinoma. Grade B or higher POPF was diagnosed in 32 patients (29.6%). In the multivariate analysis, body mass index ≥22 kg/m2 [odds ratio (OR)=5.24; p=0.005], CONUT score ≥4 (OR=3.28; p=0.042), non-pancreatic carcinoma (OR=47.17; p=0.001), and a low computed tomographic contrast attenuation value (late/early ratio) (OR=4.39; p=0.029) were independent risk factors for POPF. CONCLUSION Patients with high CONUT score are at high risk for POPF. Preoperative nutritional intervention such as immunonutrition might help reduce the POPF risk in these patients.
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Affiliation(s)
- Masashi Utsumi
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Seichi Nagahisa
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Seitaro Nishimura
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuta Une
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuji Kimura
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Takashi Arata
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Koh Katsuda
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, Yamaguchi, Japan
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Zhang JY, Huang J, Zhao SY, Liu X, Xiong ZC, Yang ZY. Risk Factors and a New Prediction Model for Pancreatic Fistula After Pancreaticoduodenectomy. Risk Manag Healthc Policy 2021; 14:1897-1906. [PMID: 34007227 PMCID: PMC8121671 DOI: 10.2147/rmhp.s305332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/15/2021] [Indexed: 01/03/2023] Open
Abstract
Aim In order to find the risk factors of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the latest definition and grading system of International Study Group of Pancreatic Surgery (ISGPS) (version 2016) and propose a nomogram for predicting POPF. Methods We conducted a retrospective analysis of 232 successive cases of PD performed at our hospital by the same operator from August 2012 to June 2020. POPF was diagnosed in accordance with the latest definition of pancreatic fistula from the ISGPS. The risk factors of POPF were analyzed by univariate and multivariate logistic regression analysis. A nomogram model to predict the risk of POPF was constructed based on significant factors. Results There were 18 cases of POPF, accounting for 7.8% of the total. Among them, 17 cases were classified into ISGPF grade B and 1 case was classified into ISGPF grade C. In addition, 35 cases were classified into biochemical leak. Univariate and multivariate analysis showed that hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Based on significant factors, a nomogram is plotted to predict the risk of POPF. The C-index of this nomogram to assess prediction accuracy was 0.916 (P < 0.001) indicating good prediction performance. Conclusion Hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Meanwhile, a nomogram for predicting POPF with good test performance and discriminatory capacity was constituted.
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Affiliation(s)
- Jia-Yu Zhang
- Graduate School of Peking Union Medical College, Beijing, 100730, People's Republic of China.,Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Jia Huang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Su-Ya Zhao
- Beijing University of Chinese Medicine, Beijing, 100029, People's Republic of China
| | - Xin Liu
- Graduate School of Tianjin Medical University, Tianjin, 300041, People's Republic of China
| | - Zhen-Cheng Xiong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, 100029, People's Republic of China
| | - Zhi-Ying Yang
- Graduate School of Peking Union Medical College, Beijing, 100730, People's Republic of China.,Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
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Wei Z, Huang L, Cui L, Zhu X. Mannose: Good player and assister in pharmacotherapy. Biomed Pharmacother 2020; 129:110420. [DOI: 10.1016/j.biopha.2020.110420] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/07/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022] Open
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Wu J, Zhang G, Yao X, Xiang Y, Lin R, Yang Y, Zhang X. Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas. Expert Rev Gastroenterol Hepatol 2020; 14:527-537. [PMID: 32567383 DOI: 10.1080/17474124.2020.1775582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear. AREAS COVERED This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications. EXPERT OPINION No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.
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Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Guofeng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xuewen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
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Ke ZX, Xiong JX, Hu J, Chen HY, Li Q, Li YQ. Risk Factors and Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy: Single-center Experience. Curr Med Sci 2019; 39:1009-1018. [DOI: 10.1007/s11596-019-2136-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 09/03/2019] [Indexed: 12/19/2022]
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Persaud A, Kakked G, Ahmed A, Shulik O, Ahlawat S. Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy. J Surg Res 2019; 241:95-102. [PMID: 31018171 DOI: 10.1016/j.jss.2019.03.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD. MATERIALS AND METHODS The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay. RESULTS A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014. CONCLUSIONS Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.
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Affiliation(s)
- Alana Persaud
- Division of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey.
| | - Gaurav Kakked
- Division of Medicine, Mount Sinai West, New York, New York
| | - Ahmed Ahmed
- Division of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Oleg Shulik
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sushil Ahlawat
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, New Jersey
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Fiorentini G, Tamburrino D, Belfiori G, Crippa S, Partelli S, Falconi M. Which is the best pancreatic anastomosis? MINERVA CHIR 2019; 74:241-252. [PMID: 30665292 DOI: 10.23736/s0026-4733.19.07997-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Postoperative pancreatic fistula is responsible for most of the complications following pancreaticoduodenectomy and several surgical techniques and strategies to prevent it have been suggested. None of these was ever proved to be the safest. Aim of this review is to present existing evidence on the best pancreatic anastomosis.
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Affiliation(s)
- Guido Fiorentini
- Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Giulio Belfiori
- Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy
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14
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Wu T, Guo Y, Bi J, Liu S, Guo Y, Bao S. Modified duct-to-mucosa versus conventional pancreaticoenterostomy for pancreaticoduodenectomy: a retrospective cohort study based on propensity score matching analysis. World J Surg Oncol 2019; 17:5. [PMID: 30611270 PMCID: PMC6320616 DOI: 10.1186/s12957-018-1557-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/27/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common neopathy after pancreatoduodenectomy (PD). An ideal pancreaticoenterostomy (PE) which can effectively reduce the incidence of CR-POPF and its potential neopathy is needed. We aimed to assess the efficacy of our modified duct-to-mucosa PE in the PD. METHOD From January 2011 to December 2017, 233 consecutive patients with PD were retrospectively included from Shenzhen People's Hospital. After propensity score matching (PSM), there were 82 patients in both the modified duct-to-mucosa PE group (group A) and the conventional end-to-side inserting PE group (group B), respectively. The clinical course and the incidence of postoperative neopathy were compared between groups. Logistic regression method was utilized to analyze the association between PE approach and CR-POPF. RESULTS The PE time was shorter in group A (9.3 ± 1.8 min vs. 21.5 ± 2.8 min, P < 0.001). The group A had significantly lower incidence of severe neopathy (Clavien-Dindo grade > II) [7.3% (5/82) vs. 17.1% (14/82), P = 0.028] and incidence of CR-POPF [1.2% (1/82) vs. 19.5% (12/82), P < 0.001] than the group B. Our modified duct-to-mucosa PE technique was associated with a reduced risk for CR-POPF (OR, 0.11 [95% CI, 0.02-0.57]; P = 0.009) as compared with the conventional end-to-side inserting PE. CONCLUSION Compared with conventional end-to-side inserting PE, our modified duct-to-mucosa PE technique can effectively reduce the incidences of postoperative neopathy and CR-POPF. TRIAL REGISTRATION Researchregistry3877 . Registered 24 March 2018. Retrospectively registered.
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Affiliation(s)
- Tianchong Wu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Yuehua Guo
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Jiangang Bi
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Shuwang Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Yusheng Guo
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Shiyun Bao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China.
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El Shobary M, El Nakeeb A, Sultan A, Ali MAEW, El Dosoky M, Shehta A, Ezzat H, Elsabbagh AM. Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy-Does It Affect the Surgical Outcomes? A Propensity Score-Matched Study. Surg Innov 2018; 26:201-208. [PMID: 30419788 DOI: 10.1177/1553350618812322] [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: 11/16/2022]
Abstract
BACKGROUND There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. PATIENTS AND METHOD This is a propensity score-matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. RESULTS The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas. CONCLUSION Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.
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Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, Lesurtel M, Clavien PA. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford) 2018; 20:992-1003. [PMID: 29807807 DOI: 10.1016/j.hpb.2018.04.003] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/09/2018] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive. METHODS A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition. RESULTS 122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT. CONCLUSION The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel A Schneider
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, University of Lyon, Lyon, France
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
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Andrianello S, Marchegiani G, Malleo G, Allegrini V, Pulvirenti A, Giardino A, Butturini G, Girelli R, Salvia R, Bassi C. Polyester sutures for pancreaticojejunostomy protect against postoperative pancreatic fistula: a case-control, risk-adjusted analysis. HPB (Oxford) 2018; 20:977-983. [PMID: 29853432 DOI: 10.1016/j.hpb.2018.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/17/2018] [Accepted: 04/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is wide variability in the use of suture material for pancreatic anastomosis after pancreaticoduodenectomy (PD). This study evaluates the role of suture material on clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticojejunostomy (PJ) in a risk-adjusted setting. METHODS A retrospective study comparing (polyester) PE with polydioxanone (PDO) in 520 PDs. Patients were matched for risk for CR-POPF according to the fistula risk score (FRS) with the propensity score. RESULTS The matched PE and PDO groups consisted of 232 patients. The incidence of CR-POPF was lower for PE group (11.6 vs. 22%, p<0.01), with a lower rate of grade B (10.3 vs. 15.5%, p<0.01) and C (1.3 vs. 6.5%, p<0.01). After stratifying by fistula risk zone, PE suture remained associated with a reduced incidence of CR-POPF (9.4 vs. 15.6% low-, p = 0.04; 15.6 vs. 28.1% intermediate-, p = 0.02; 16.7 vs. 83.3% high-risk zone, p<0.01, respectively). Multivariable analysis demonstrated that pancreatic texture, preoperative diagnosis, FRS and the use of PE sutures were independent predictors of CR-POPF. CONCLUSIONS In the setting of a case-control matched for risk analysis, the use of PE suture for PJ is associated with a significant reduction of CR-POPF.
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Affiliation(s)
- Stefano Andrianello
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy
| | - Giovanni Marchegiani
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy
| | - Giuseppe Malleo
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy
| | - Valentina Allegrini
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy
| | - Alessandra Pulvirenti
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy
| | - Alessandro Giardino
- Department of Hepato-Pancreatico-Biliary Surgery - Casa di Cura Pederzoli, Peschiera del Garda, Italy
| | - Giovanni Butturini
- Department of Hepato-Pancreatico-Biliary Surgery - Casa di Cura Pederzoli, Peschiera del Garda, Italy
| | - Roberto Girelli
- Department of Hepato-Pancreatico-Biliary Surgery - Casa di Cura Pederzoli, Peschiera del Garda, Italy
| | - Roberto Salvia
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy.
| | - Claudio Bassi
- Department of Surgery and Oncology, General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital, Italy
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Winer LK, Dhar VK, Wima K, Lee TC, Morris MC, Shah SA, Ahmad SA, Patel SH. Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:1743-1751. [PMID: 29869090 DOI: 10.1007/s11605-018-3813-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Our goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHODS Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance. RESULTS POPF was identified in 17.3% of patients (n = 18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p = 0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03-1.55, p = 0.03). CONCLUSION High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.
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Affiliation(s)
- Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA
| | - Sameer H Patel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Section of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way (ML 0558), Cincinnati, OH, 45267-0558, USA.
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Ke Z, Cui J, Hu N, Yang Z, Chen H, Hu J, Wang C, Wu H, Nie X, Xiong J. Risk factors for postoperative pancreatic fistula: Analysis of 170 consecutive cases of pancreaticoduodenectomy based on the updated ISGPS classification and grading system. Medicine (Baltimore) 2018; 97:e12151. [PMID: 30170457 PMCID: PMC6392812 DOI: 10.1097/md.0000000000012151] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This study was designed to analyze the risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).Between September 2015 and August 2017, 170 successive patients underwent a radical PD in the Department of Pancreatic Surgery, Union Hospital, Wuhan. We carried out a retrospective study of these cases and the prospective conditions, which might be related to POPF, were examined with univariate and multivariate analysis. POPF was defined as a drain output of any measurable volume of fluid with an amylase level more than 3 times the upper limit of serum amylase activity on postoperative day 3, accompanied by a clinically relevant condition according to the 2016 update of the International Study Group for Pancreatic Surgery (ISGPS) definition. In our study, the POPF was just referred to as grade B and grade C pancreatic fistula in accordance with the ISGPS consensus, because the former grade A pancreatic fistula is now redefined as a biochemical leak, namely no-POPF, which has no clinical impact and needs no other special therapy.Pancreatic fistula occurred in 44 (25.9%) patients after PD, with a mean length of hospital stay of 24.98 ± 14.30 days. Thirty-six patients (21.2%) developed grade B pancreatic fistula, and 8 patients (4.7%) had grade C pancreatic fistula. Among patients with grade C pancreatic fistula, 4 patients died, 3 patients were operated on again, and 3 patients developed multiple organ failure.Univariate analysis showed a significantly important association between POPF and the following factors: pancreas texture (soft vs hard: 39.1% vs 10.3%, P < .0001) and fasting blood glucose level (<108.0 mg/dL vs ≥108.0 mg/dL: 32.5% vs 12.5%, P = .005). Multivariate logistic regression analysis identified 2 independent factors related to POPF: soft pancreas texture and fasting blood glucose level <108.0 mg/dL.A soft pancreas and a fasting blood glucose level of <108.0 mg/dL are risk factors for the development of a POPF.
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Affiliation(s)
- Zunxiang Ke
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Jing Cui
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Nianqi Hu
- Department of Clinical Laboratory, Wuhan Puai Hospital, Huazhong University of Science and Technology
| | - Zhiyong Yang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Hengyu Chen
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Jin Hu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Xiuquan Nie
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiongxin Xiong
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
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Liu CZ, Zhu JK, Xu Q, Liu FY, Wang YD, Zhu M. Application of pancreaticojejunostomy with one-layer suture in pancreaticoduodenectomy: A retrospective cohort study. Int J Surg 2018; 56:68-72. [PMID: 29890300 DOI: 10.1016/j.ijsu.2018.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/14/2018] [Accepted: 06/06/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most common critical complication after pancreaticoduodenectomy (PD) and a primary reason for increased mortality and morbidity after PD. To perform a safe pancreaticojejunostomy (PJ), a fast and simple technique of duct-to-mucosa PJ with one-layer suture was devised at our institution. MATERIALS AND METHODS We conducted a retrospective analysis of 81 successive cases of PD performed at our hospital from March 2012 to August 2016. Data of perioperative parameters were collected for all PD cases. RESULTS A total of 17 (21.0%) cases of morbidity occurred after PD, including 5 (6.1%) cases of POPF (grade A), 8 (9.8%) cases of delayed gastric emptying, 1 (1.2%) case of abdominal infection, and 3 (3.7%) cases of incision infection. The median operative time for the PJ was 7 min. No mortality or relaparotomy was observed. CONCLUSION Our technique could significantly reduce the incidence of POPF and other complications after PD and may be a promising technique for pancreaticoenteric anastomosis.
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Affiliation(s)
- Chong Zhong Liu
- Department of General Surgery, Qilu Hospital of Shan Dong University, NO 107 West Wenhua Road, Jinan, 250012, China.
| | - Jian Kang Zhu
- Department of General Surgery, Qilu Hospital of Shan Dong University, NO 107 West Wenhua Road, Jinan, 250012, China.
| | - Qianqian Xu
- Department of Organ Transplantation, Qilu Hospital of Shan Dong University, NO 107 West Wenhua Road, Jinan, 250012, China.
| | - Feng Yue Liu
- Department of General Surgery, Qilu Hospital of Shan Dong University, NO 107 West Wenhua Road, Jinan, 250012, China.
| | - Ya Dong Wang
- Department of General Surgery, Qilu Hospital of Shan Dong University, NO 107 West Wenhua Road, Jinan, 250012, China.
| | - Min Zhu
- Department of General Surgery, Qilu Hospital of Shan Dong University, NO 107 West Wenhua Road, Jinan, 250012, China.
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Polyester Preserves the Highest Breaking Point After Prolonged Incubation in Pancreatic Juice. J Gastrointest Surg 2018; 22:444-450. [PMID: 28861698 DOI: 10.1007/s11605-017-3558-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 08/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of suture materials on the development of pancreatic fistula after pancreaticoduodenectomy remains unclear. Thus, their choice among pancreatic surgeons is still mostly experience-based. Aim of the present study is to assess what is the best suture material to be used for pancreaticojejunostomy. MATERIALS AND METHODS The force needed to reach the breaking point of five widely used suture materials (polypropylene, polyester, polydioxanone, silk, and polyglactin 910) has been determined through a digital precision dynamometer at baseline and after 5 and 20 days of incubation in pancreatic juice, bile, or a mixture of both. RESULTS Regardless of the condition, polyglactin 910 has retained only 10% of its baseline force. Silk has maintained almost 90% of its initial force showing a very low baseline value of force. In pancreatic juice, polypropylene has lost less force compared to polyester (0.25 vs. 0.93 N; p = 0.03) and polydioxanone (0.25 vs. 3.67 N; p = 0.04). Polyester and polydioxanone have showed similar values of force. However, polydioxanone has lost a significant amount of force in pancreatic juice when compared to polyester (0.93 vs. 3.67 N; p = 0.03). Polyester has showed the highest value of force needed to reach the breaking point after 20 days of incubation in pancreatic juice. CONCLUSIONS After incubation in pancreaticobiliary secretions, polyglactin 910 loses almost all its force. Polypropylene preserves its characteristic, but polydioxanone and polyester show absolute higher breaking points, with polyester retaining the highest value of force needed to reach its breaking point after incubation in pancreatic juice.
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Barreto SG, Shukla PJ. Different types of pancreatico-enteric anastomosis. Transl Gastroenterol Hepatol 2017; 2:89. [PMID: 29264427 DOI: 10.21037/tgh.2017.11.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/03/2017] [Indexed: 12/15/2022] Open
Abstract
The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.
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Affiliation(s)
- Savio George Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park SA, Australia
| | - Parul J Shukla
- Department of Surgery, Weill Cornell Medical College & New York Presbyterian Hospital, New York, USA
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Kennedy GT, McMillan MT, Maggino L, Sprys MH, Vollmer CM. Surgical experience and the practice of pancreatoduodenectomy. Surgery 2017; 162:812-822. [DOI: 10.1016/j.surg.2017.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/13/2017] [Accepted: 06/25/2017] [Indexed: 01/10/2023]
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24
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Marchegiani G, Ballarin R, Malleo G, Andrianello S, Allegrini V, Pulvirenti A, Paini M, Secchettin E, Boriero F, Di Benedetto F, Bassi C, Salvia R. Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula. World J Surg 2017; 41:2876-2883. [DOI: 10.1007/s00268-017-4073-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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25
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Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, Yeo CJ, Fernandez-delCastillo C, Dervenis C, Halloran C, Gouma DJ, Radenkovic D, Asbun HJ, Neoptolemos JP, Izbicki JR, Lillemoe KD, Conlon KC, Fernandez-Cruz L, Montorsi M, Bockhorn M, Adham M, Charnley R, Carter R, Hackert T, Hartwig W, Miao Y, Sarr M, Bassi C, Büchler MW. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2017; 161:1221-1234. [PMID: 28027816 DOI: 10.1016/j.surg.2016.11.021] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/02/2016] [Accepted: 11/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis. METHODS An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy. RESULTS There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies. CONCLUSION Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.
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Affiliation(s)
- Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
| | - Masillamany Sivasanker
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, Technische Universitat Munchen, Munich, Germany
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Abe Fingerhut
- Department of Digestive Surgery, University Hospital of Graz, Austria
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Christoper Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dejan Radenkovic
- First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Horacio J Asbun
- Department of General Surgery, Mayo Clinic, Jacksonville, FL
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin C Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Laureano Fernandez-Cruz
- Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Milan, Italy
| | - Max Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hopital Edouard Herriot, HCL, UCBL1, Lyon, France
| | - Richard Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Ross Carter
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Werner Hartwig
- Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany
| | - Yi Miao
- Pancreas Center, Nanjing Medical University, Nanjing, P.R. China
| | - Michael Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University Hospital Trust of Verona, Verona, Italy
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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The influence of fellowship training on the practice of pancreatoduodenectomy. HPB (Oxford) 2016; 18:965-978. [PMID: 28029534 PMCID: PMC5144550 DOI: 10.1016/j.hpb.2016.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/13/2016] [Accepted: 09/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND There has been a proliferation of gastrointestinal surgical fellowships; however, little is known regarding their association with surgical volume and management approaches. METHODS Surveys were distributed to members of GI surgical societies. Responses were evaluated to define relationships between fellowship training and surgical practice with pancreatoduodenectomy (PD). RESULTS Surveys were completed by 889 surgeons, 84.1% of whom had completed fellowship training. Fellowship completion was associated with a primarily HPB or surgical oncology-focused practice (p < 0.001), and greater median annual PD volume (p = 0.030). Transplant and HPB fellowship-trained respondents were more likely to have high-volume (≥20) annual practice (p = 0.005 and 0.029, respectively). Regarding putative fistula mitigation strategies, HPB-trained surgeons were more likely to use stents, biologic sealants, and autologous tissue patches (p = 0.007, <0.001 and 0.001, respectively). Surgical oncology trainees reported greater autologous patch use (p = 0.003). HPB fellowship-trained surgeons were less likely to routinely use intraperitoneal drainage (p = 0.036) but more likely to utilize early (POD ≤ 3) drain amylase values to guide removal (p < 0.001). Finally, HPB fellowship-trained surgeons were more likely to use the Fistula Risk Score in their practice (29 vs. 21%, p = 0.008). CONCLUSION Fellowship training correlated with significant differences in surgeon experience, operative approach, and use of available fistula mitigation strategies for PD.
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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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Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol 2016; 22:7797-805. [PMID: 27678363 PMCID: PMC5016380 DOI: 10.3748/wjg.v22.i34.7797] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 06/28/2016] [Accepted: 07/31/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy. METHODS We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from March 2012 to October 2015. Pancreatic fistula was diagnosed in strict accordance with the definition of pancreatic fistula from the International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis. RESULTS A total of 269 (49.9%) cases of pancreatic fistula occurred after pancreaticoduodenectomy, including 71 (13.17%) cases of grade A pancreatic fistula, 178 (33.02%) cases of grade B, and 20 (3.71%) cases of grade C. Univariate analysis showed no significant correlation between postoperative pancreatic fistula (POPF) and the following factors: age, hypertension, alcohol consumption, smoking, history of upper abdominal surgery, preoperative jaundice management, preoperative bilirubin, preoperative albumin, pancreatic duct drainage, intraoperative blood loss, operative time, intraoperative blood transfusion, Braun anastomosis, and pancreaticoduodenectomy (with or without pylorus preservation). Conversely, a significant correlation was observed between POPF and the following factors: gender (male vs female: 54.23% vs 42.35%, P = 0.008), diabetes (non-diabetic vs diabetic: 51.61% vs 39.19%, P = 0.047), body mass index (BMI) (≤ 25 vs > 25: 46.94% vs 57.82%, P = 0.024), blood glucose level (≤ 6.0 mmol/L vs > 6.0 mmol/L: 54.75% vs 41.14%, P = 0.002), pancreaticojejunal anastomosis technique (pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis vs pancreatic-jejunum single-layer mucosa-to-mucosa anastomosis: 57.54% vs 35.46%, P = 0.000), diameter of the pancreatic duct (≤ 3 mm vs > 3 mm: 57.81% vs 38.36%, P = 0.000), and pancreatic texture (soft vs hard: 56.72% vs 29.93%, P = 0.000). Multivariate logistic regression analysis showed that gender (male), BMI > 25, pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis, pancreatic duct diameter ≤ 3 mm, and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy. CONCLUSION Gender (male), BMI > 25, pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis, pancreatic duct diameter ≤ 3 mm, and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.
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