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Rajagopalan A, Aroori S, Russell TB, Labib PL, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Croagh D. Five-year recurrence/survival after pancreatoduodenectomy for pancreatic adenocarcinoma: does pre-existing diabetes matter? Results from the Recurrence After Whipple's (RAW) study. HPB (Oxford) 2024; 26:981-989. [PMID: 38755085 DOI: 10.1016/j.hpb.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/27/2024] [Accepted: 04/19/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Diabetes mellitus (DM) has a complex relationship with pancreatic cancer. This study examines the impact of preoperative DM, both recent-onset and pre-existing, on long-term outcomes following pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). METHODS Data were extracted from the Recurrence After Whipple's (RAW) study, a multi-centre cohort of PD for pancreatic head malignancy (2012-2015). Recurrence and five-year survival rates of patients with DM were compared to those without, and subgroup analysis performed to compare patients with recent-onset DM (less than one year) to patients with established DM. RESULTS Out of 758 patients included, 187 (24.7%) had DM, of whom, 47 of the 187 (25.1%) had recent-onset DM. There was no difference in the rate of postoperative pancreatic fistula (DM: 5.9% vs no DM 9.8%; p = 0.11), five-year survival (DM: 24.1% vs no DM: 22.9%; p = 0.77) or five-year recurrence (DM: 71.7% vs no DM: 67.4%; p = 0.32). There was also no difference between patients with recent-onset DM and patients with established DM in postoperative outcomes, recurrence, or survival. CONCLUSION We found no difference in five-year recurrence and survival between diabetic patients and those without diabetes. Patients with pre-existing DM should be evaluated for PD on a comparable basis to non-diabetic patients.
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Affiliation(s)
| | | | | | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Mavroeidis VK, Knapton J, Saffioti F, Morganstein DL. Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team. World J Diabetes 2024; 15:598-605. [PMID: 38680702 PMCID: PMC11045411 DOI: 10.4239/wjd.v15.i4.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/30/2024] [Accepted: 03/01/2024] [Indexed: 04/11/2024] Open
Abstract
Pancreatic surgery units undertake several complex operations, albeit with considerable morbidity and mortality, as is the case for the management of complicated acute pancreatitis or chronic pancreatitis. The centralisation of pancreatic surgery services, with the development of designated large-volume centres, has contributed to significantly improved outcomes. In this editorial, we discuss the complex associations between diabetes mellitus (DM) and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis, highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services. Type 3c pancreatogenic DM, refers to DM developing in the setting of exocrine pancreatic disease, and its identification and management can be challenging, while the glycaemic control of such patients may affect their course of treatment and outcome. Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period. The incidence of new onset diabetes after pancreatic resection is widely variable in the literature, and depends on the type and extent of pancreatic resection, as is the case with pancreatic parenchymal loss in the context of severe pancreatitis. Early involvement of a specialist diabetes team is essential to ensure a holistic management. In the current era, large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery, with inclusion of provisions for optimisation of the perioperative glycaemic control, to improve outcomes. While various guidelines are available to aid perioperative management of DM, auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement. The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined, a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis. Therefore, pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams. With the ongoing accumulation of evidence, it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.
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Affiliation(s)
- Vasileios K Mavroeidis
- Department of HPB Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS2 8HW, United Kingdom
- Department of Gastrointestinal Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, United Kingdom
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Jennifer Knapton
- Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Francesca Saffioti
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
- UCL Institute for Liver and Digestive Health, University College London, London NW3 2PF, United Kingdom
| | - Daniel L Morganstein
- Department of Endocrinology, Chelsea and Westminster Hospital NHS Foundation Trust, London SW10 9NH, United Kingdom
- Department of Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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Wijma AG, Driessens H, Nijkamp MW, Hoogwater FJH, van Dijk PR, Klaase JM. Impact of Preoperative Diabetes Mellitus on Postoperative Outcomes in Elective Pancreatic Surgery and Its Implications for Prehabilitation Practice. Pancreas 2024; 53:e274-e279. [PMID: 38277400 DOI: 10.1097/mpa.0000000000002300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
OBJECTIVES Patients with pancreatic disease(s) have a high risk of developing diabetes mellitus (DM). Diabetes mellitus is associated with adverse postoperative outcomes. This study aimed to investigate the prevalence and effects of DM on postoperative outcomes in pancreatic surgery. METHODS Subgroup analysis of a prospective cohort study conducted at an academic hospital. Patients undergoing pancreatoduodenectomy between January 2019 and November 2022 were included and screened for DM preoperatively using glycated hemoglobin (HbA1c). New-onset DM was diagnosed based on HbA1c ≥ 6.5% (48 mmol/mol). Postoperative outcomes were compared between patients with and without DM. RESULTS From 117 patients, 29 (24.8%) were given a diagnosis of DM, and of those, 5 (17.2%) were diagnosed with new-onset DM, and 15 (51.8%) displayed poorly controlled preoperative DM (HbA 1c ≥ 7% [53 mmol/mol]). The incidence of surgical site infections (48.3% vs 27.3% in the non-DM group; P = 0.04) was higher for patients with DM. This association remained significant after adjusting for confounders (odds ratio, 2.60 [95% confidence interval, 1.03-6.66]; P = 0.04). CONCLUSIONS One-quarter of the patients scheduled for pancreatoduodenectomy had DM; over half of them had poor glycemic control. The association between DM status and surgical site infections revealed in this study emphasizes the importance of adequate preoperative glycemic control.
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Affiliation(s)
- Allard G Wijma
- From the Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery
| | - Heleen Driessens
- From the Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery
| | - Maarten W Nijkamp
- From the Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery
| | - Frederik J H Hoogwater
- From the Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery
| | - Peter R van Dijk
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joost M Klaase
- From the Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery
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4
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Huang YL, Tian XF, Qiu YJ, Lou WH, Jung EM, Dong Y, Wang HZ, Wang WP. Preoperative ultrasound radiomics for predicting clinically relevant postoperative pancreatic fistula after pancreatectomy. Clin Hemorheol Microcirc 2024; 86:313-326. [PMID: 37927251 DOI: 10.3233/ch-231955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To evaluate the efficacy of the radiomics model based on preoperative B-mode ultrasound (BMUS) and shear wave elastography (SWE) for predicting the occurrence of clinically relevant-postoperative pancreatic fistula (CR-POPF). METHODS Patients who were scheduled to undergo pancreatectomy were prospectively enrolled and received ultrasound assessment within one week before surgery. The risk factors of POPF (grades B and grades C) were analyzed. Preoperative BMUS images, SWE values of pancreatic lesions and surrounding parenchyma were used to build preoperative prediction radiomics models. Radiomic signatures were extracted and constructed using a minimal Redundancy Maximal Relevance (mRMR) algorithm and an L1 penalized logistic regression. A combined model was built using multivariate regression which incorporated radiomics signatures and clinical data. RESULTS From January 2020 to November 2021, a total of 147 patients (85 distal pancreatectomies and 62 pancreaticoduodenectomies) were enrolled. During the three-week follow-up after pancreatectomy, the incidence rates of grade B/C POPF were 28.6% (42/147). Radiomic signatures constructed from BMUS of pancreas parenchymal regions (panRS) achieved an area under the receiver operating characteristic curve (AUC) of 0.75, accuracy of 68.7%, sensitivity of 85.7 %, and specificity of 61.9 % in preoperative noninvasive prediction of CR-POPF. The AUC of the radiomics model increased to 0.81 when panRS was used for the prediction of CR-POPF after pancreaticoduodenectomy. CONCLUSIONS Radiomics model based on ultrasound images was potentially useful for predicting CR-POPF. Patients with high-risk factors should be closely monitored when postoperation.
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Affiliation(s)
- Yun-Lin Huang
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Fan Tian
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Jie Qiu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Hui Lou
- Department of Pancreas Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ernst-Michael Jung
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Yi Dong
- Department of Ultrasound, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Han-Zhang Wang
- Precision Health Institute, GE Healthcare China, Shanghai, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
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Ekström E, Fagher K, Tingstedt B, Rystedt J, Nilsson J, Löndahl M, Andersson B. Hyperglycemia and insulin infusion in pancreatoduodenectomy: a prospective cohort study on feasibility and impact on complications. Int J Surg 2023; 109:3770-3777. [PMID: 37720940 PMCID: PMC10720831 DOI: 10.1097/js9.0000000000000714] [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: 04/13/2023] [Accepted: 08/13/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Hyperglycemia is a risk factor for postoperative complications but its impact on outcome after pancreatoduodenectomy (PD) is scarcely studied. This prospective cohort study aimed to assess the effect of continuous insulin infusion on postoperative complications and blood glucose, as well as to evaluate the impact of hyperglycemia on complications, after PD. MATERIALS AND METHODS One hundred patients planned for PD at Skåne University Hospital, Sweden were prospectively included for perioperative continuous insulin infusion and a historic cohort of 100 patients was included retrospectively. Median blood glucose levels were calculated and data on complications were analyzed and compared between the historic cohort and the intervention group as well as between normo- and hyperglycemic patients. RESULTS Median glucose levels were significantly lower in the intervention group compared to the historic cohort up to 30 days postoperatively (median glucose 8.5 mmol/l (interquartile range 6.4-11) vs. 9.1 mmol/l (interquartile range 6.8-17) ( P =0.007)). No significant differences in complication rates were recorded between these two groups. The incidence of complications classified as Clavien ≥3 was higher in hyperglycemic patients (100 vs. 27%, P =0.024). Among hyperglycemic patients the prevalence of preoperative diabetes was higher compared to normoglycemic patients (52 vs.12%, P <0.001). In patients with a known diagnosis of diabetes, a trend, although not statistically significant, towards a lower incidence of postoperative pancreatic fistula grade B and C, as well as postpancreatectomy hemorrhage grade B and C, was seen compared to those without preoperative diabetes (6.8 vs. 14%, P =0.231 and 2.3 vs. 7.0%, P =0.238, respectively). CONCLUSION Insulin infusion in the early postoperative phase after PD is feasible in a non-ICU setting and significantly decreased blood glucose levels. The influence on complications was limited. Preoperative diabetes was a significant predictor of postoperative hyperglycemia and was associated with a lower incidence of clinically significant postoperative pancreatic fistula.
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Affiliation(s)
- Eva Ekström
- Department of Surgery, Skåne University Hospital
- Department of Clinical Sciences, Surgery, Lund University
| | - Katarina Fagher
- Department of Clinical Sciences, Surgery, Lund University
- Department of Endocrinology Skåne University Hospital
| | - Bobby Tingstedt
- Department of Surgery, Skåne University Hospital
- Department of Clinical Sciences, Surgery, Lund University
| | - Jenny Rystedt
- Department of Surgery, Skåne University Hospital
- Department of Clinical Sciences, Surgery, Lund University
| | - Johan Nilsson
- Department of Cardiothoracic Surgery, Skåne University Hospital
- Department of Translational Medicine, Lund University, Lund, Sweden
| | - Magnus Löndahl
- Department of Clinical Sciences, Surgery, Lund University
- Department of Endocrinology Skåne University Hospital
| | - Bodil Andersson
- Department of Surgery, Skåne University Hospital
- Department of Clinical Sciences, Surgery, Lund University
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Zhang B, Yuan Q, Li S, Xu Z, Chen X, Li L, Shang D. Risk factors of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29757. [PMID: 35776984 PMCID: PMC9239615 DOI: 10.1097/md.0000000000029757] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common and troublesome complication after pancreatoduodenectomy (PD). We conducted a systematic review and meta-analysis to identify the risk factors of CR-POPF after PD. METHODS We searched PubMed, EMBASE, and Cochrane Library databases for studies related to risk factors of CR-POPF after PD. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were extracted from the included studies, then a meta-analysis was conducted. If necessary, sensitivity analysis would be performed by changing the effect model or excluding 1 study at a time. Publication bias was assessed by funnel plot and Begg test and Egger test. RESULTS A total of 27 studies with 24,740 patients were included, and CR-POPF occurred in 3843 patients (incidence = 17%, 95% CI: 16%-19%). Male (OR = 1.56, 95% CI: 1.42-1.70), body mass index >25 kg/m2 (OR = 1.98, 95% CI: 1.23-3.18), pancreatic duct diameter <3 mm (OR = 1.87, 95% CI: 1.66-2.12), soft pancreatic texture (OR = 3.49, 95% CI: 2.61-4.67), and blood transfusion (OR = 3.10, 95% CI: 2.01-4.77) can significantly increase the risk of CR-POPF. Pancreatic adenocarcinoma (OR = 0.54, 95% CI: 0.47-0.61), vascular resection (OR = 0.57, 95% CI: 0.39-0.83), and preoperative chemoradiotherapy (OR = 0.68, 95% CI: 0.57-0.81) can significantly decrease the factor of CR-POPF. Diabetes mellitus was not statistically associated with CR-POPF (OR = 0.66, 95% CI: 0.40-1.08). However, the analysis of body mass index, pancreatic texture, and diabetes mellitus had a high heterogeneity, then sensitivity analysis was performed, and the result after sensitivity analysis showed diabetes mellitus can significantly decrease the risk of CR-POPF. There was no significant publication bias in this meta-analysis. CONCLUSIONS The current review assessed the effects of different factors on CR-POPF. This can provide a basis for the prevention and management of CR-POPF. Effective interventions targeting the above risk factors should be investigated in future studies for decreasing the occurrence of CR-POPF.
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Affiliation(s)
- Biao Zhang
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Qihang Yuan
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Shuang Li
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Zhaohui Xu
- Department of Hernia and Colorectal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xu Chen
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Lunxu Li
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Dong Shang
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
- *Correspondence: Dong Shang, Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Xigang District, Dalian 116011, Liaoning, China ()
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Marchegiani G, Crippa S, Perri G, Rancoita PMV, Caravati A, Belfiori G, Dall'Olio T, Aleotti F, Partelli S, Bassi C, Falconi M, Salvia R. Surgery for Intraductal Papillary Mucinous Neoplasms of the Pancreas: Preoperative Factors Tipping the Scale of Decision-Making. Ann Surg Oncol 2022; 29:3206-3214. [PMID: 35072863 PMCID: PMC8989932 DOI: 10.1245/s10434-022-11326-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/27/2021] [Indexed: 12/14/2022]
Abstract
Background Decision-making in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas depends on scaling the risk of malignancy with the surgical burden of a pancreatectomy. This study aimed to develop a preoperative, disease-specific tool to predict surgical morbidity for IPMNs. Methods Based on preoperative variables of resected IPMNs at two high-volume institutions, classification tree analysis was applied to derive a predictive model identifying the risk factors for major morbidity (Clavien–Dindo ≥3) and postoperative pancreatic insufficiency. Results Among 524 patients, 289 (55.2%) underwent pancreaticoduodenectomy (PD), 144 (27.5%) underwent distal pancreatectomy (DP), and 91 (17.4%) underwent total pancreatectomy (TP) for main-duct (18.7%), branch-duct (12.6%), or mixed-type (68.7%) IPMN. For 98 (18.7%) of the patients, major morbidity developed. The classification tree distinguished different probabilities of major complications based on the type of surgery (area under the surve [AUC] 0.70; 95% confidence interval [CI], 0.63–0.77). Among the DP patients, the presence of preoperative diabetes identified two risk classes with respective probabilities of 5% and 25% for the development of major morbidity, whereas among the PD/TP patients, three different classes with respective probabilities of 15%, 20%, and 36% were identified according to age and body mass index (BMI). Overall, history of diabetes, age, and cyst size segregated three different risk classes for new-onset/worsening diabetes. Conclusions In presumed IPMNs, the disease-specific risk of major morbidity and pancreatic insufficiency can be determined in the preoperative setting and used to personalize the possible surgical indication. Age and overweight status in case of PD/TP and diabetes in case of DP tip the scale toward less aggressive clinical management in the absence of features suggestive for malignancy. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-11326-5.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy.
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Paola M V Rancoita
- University Centre of Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Tommaso Dall'Olio
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Università degli Studi di Verona, Verona, Italy
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8
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Wiseman JT, Chakedis J, Beal EW, Paredes A, McElhany A, Fang A, Manilchuk A, Ellison C, Van Buren G, Pawlik TM, Schmidt CR, Fisher WE, Dillhoff M. Hemoglobin A1c Is a Predictor of New Insulin Dependence After Partial Pancreatectomy: A Multi-Institutional Analysis. J Gastrointest Surg 2021; 25:3119-3129. [PMID: 33948858 DOI: 10.1007/s11605-021-05014-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic diseases have long been associated with impaired glucose control. This study sought to identify the incidence of new insulin-dependent diabetes mellitus (IDDM) after pancreatectomy and the predictive accuracy of hemoglobin A1c (HbA1c) or blood glucose. METHODS Patients who underwent partial pancreatectomy and had preoperative HbA1c available at two academic institutions were assessed for new IDDM on discharge in relation to complication rates and survival. RESULTS Of the 267 patients analyzed, 67% had abnormal HbA1c levels prior to surgery (mean 6.8%, glucose 135 mg/dL). Two hundred eight (77.9%) were not insulin-dependent prior to surgery, and 35 (16.8%) developed new IDDM after resection. On multivariable regression, increasing HbA1c and preoperative glucose were the only significant predictors for new IDDM. Optimal predictive cutoffs (HbA1c of 6.25% and glucose of 121 mg/dL) were determined in a discovery group (n = 143) and confirmed in a validation group (n = 124) with a diagnostic sensitivity of 72.7% and specificity of 84.8%. Patients with new IDDM after resection had higher rates of severe complications (OR 3.39), increased TPN at discharge (OR 4.32), and increased rates of discharge to nursing facilities (OR 2.57) (all P < 0.05). New IDDM was also associated with a decreased cancer-specific survival. CONCLUSION Preoperative HbA1c ≥ 6.25% and blood glucose ≥ 121 mg/dL can accurately identify patients at increased risk of IDDM. These diagnostics may help identify patients in a preoperative setting that may benefit from interventions such as diabetes education or enhanced glucose control preoperatively.
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Affiliation(s)
- Jason T Wiseman
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - Jeffery Chakedis
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - Eliza W Beal
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - Anghela Paredes
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - Amy McElhany
- Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - Andrew Fang
- Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - Andrei Manilchuk
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - Christopher Ellison
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - George Van Buren
- Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - Carl R Schmidt
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA
| | - William E Fisher
- Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Arthur G. James Cancer Hospital and Solove Research Institute, 395 W. 12th Avenue, Suite 670, Columbus, OH, 43210-1267, USA.
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9
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Endo Y, Kitago M, Shinoda M, Yagi H, Abe Y, Oshima G, Hori S, Yokose T, Abe K, Takemura R, Ishi R, Kitagawa Y. Clinical Impact of Portal Vein Distance on Computed Tomography for Postoperative Pancreatic Fistula after Pancreatoduodenectomy. World J Surg 2021; 45:2200-2209. [PMID: 33791854 DOI: 10.1007/s00268-021-06076-6] [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: 03/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pancreatic fistulas remain a significant concern after pancreatectomy owing to the associated high risk of mortality and high costs. It is not possible to perform preoperative risk stratification for all patients. This study aimed to evaluate the usefulness of the measurement of portal vein (PV) distance as a predictive indicator of pancreatic fistula development after pancreatoduodenectomy and compare it with the usefulness of other indicators such as body mass index (BMI), and abdominal fat area. METHODS Patient characteristics, preoperative laboratory data, radiographic findings, and their association with pancreatic fistula development after pancreatoduodenectomy were analyzed for 157 patients who underwent resection during 2011-2017. Clinically relevant postoperative pancreatic fistulas (CR-POPF) were defined as Grade B or C fistulas based on the International Study Group of Pancreatic Surgery (ISGPS) 2016 consensus. RESULTS CR-POPF developed in 38 patients (24.2%). Multivariate logistic regression indicated that PV distance and BMI were potential candidates for predictive models for pancreatic fistula development, and small pancreatic duct diameter, diabetes mellitus development, and pathology of non-pancreatic cancers were independent factors for CR-POPF. When comparing the two risk models (PV distance- and BMI-based models), the PV distance-derived risk model was compatible to the BMI-based stratification models (area under the curve 0.831 vs. 0.830). CONCLUSIONS PV distance was confirmed to be a useful risk predictor for CR-POPF. This research highlighted the efficacy of abdominal thickness measurement, which is simple and easily applicable in the clinical setting.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Go Oshima
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Takahiro Yokose
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Kodai Abe
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryo Takemura
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryota Ishi
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
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10
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Yu AHK, Chan ACY. Pre‐operative diabetes mellitus does not worsen survival and post‐operative outcomes in
C
hinese patients undergoing resection for pancreatic adenocarcinoma. SURGICAL PRACTICE 2020. [DOI: 10.1111/1744-1633.12453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Adrian H. K. Yu
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery University of Hong Kong Hong Kong China
| | - Albert C. Y. Chan
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery University of Hong Kong Hong Kong China
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11
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Müssle B, Oehme F, Schade S, Sommer M, Bogner A, Hempel S, Pochhammer J, Kahlert C, Distler M, Weitz J, Welsch T. Drain Amylase or Lipase for the Detection of POPF-Adding Evidence to an Ongoing Discussion. J Clin Med 2019; 9:jcm9010007. [PMID: 31861508 PMCID: PMC7019284 DOI: 10.3390/jcm9010007] [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: 10/15/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 01/08/2023] Open
Abstract
Objectives: A postoperative pancreatic fistula (POPF) is defined as a threefold increase in the amylase concentration in abdominal drains on or after the third postoperative day (POD). However, additional lipase fluid analysis is widely used despite lacking evidence. In this study, drain amylase and lipase levels were compared regarding their value in detecting POPF. Methods: We conducted a retrospective study including all patients who underwent pancreatic resections at our center between 2005 and 2016. Drain fluid analysis was performed from day 2 to 5. Results: 990 patients were included in the analysis. Overall, 333 (34%) patients developed a POPF. The median amylase and lipase concentrations at POD 3 in cases with POPF were 11.55 µmol/(s·L) (≈13 ×-fold increase) and 39 µmol/(s·L) (≈39 ×-fold increase), respectively. Seven patients with subsequent POPF (2%) were missed with amylase analysis on POD 3, but detected using 3-fold lipase analysis. The false-positive rate of lipase was 51/424 = 12%. A cutoff lipase value at POD 3 of > 4.88 yielded a specificity of 94% and a sensitivity of 89% for development of a POPF. Increased body mass index turned out as risk factor for the development of POPF in a multivariable model. Conclusions: Threefold-elevated lipase concentration may be used as an indicator of a POPF. However, the additional detection of POPF using simultaneous lipase analysis is marginal. Therefore, assessment of lipase concentration does not provide added clinical value and only results in extra costs.
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Affiliation(s)
- Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Stephanie Schade
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Marian Sommer
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Sebastian Hempel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Julius Pochhammer
- Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (B.M.); (F.O.); (S.S.); (M.S.); (A.B.); (S.H.); (C.K.); (M.D.); (J.W.)
- Correspondence: ; Tel.: +49-(0)351-458-18283
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12
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Yang F, Jin C, Li J, Di Y, Zhang J, Fu D. Clinical significance of drain fluid culture after pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:508-517. [PMID: 30328297 DOI: 10.1002/jhbp.589] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The mechanism of infected postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD) is undefined. Drain amylase has been used to predict POPF, whereas little data are available about the value of drain fluid culture. The aim was to investigate the incidence, risk factors and association with surgical outcomes of positive drainage culture (PDC) after PD. METHODS A single-center retrospective analysis was conducted of prospectively collected data from patients who underwent PD between January 2005 and December 2015. Drain fluid samples were obtained for microbiological analysis after surgery. Risk factors for PDC were evaluated, and its influence on surgical outcomes was explored. RESULTS Of 768 patients, 261 (34%) had PDC during the postoperative period. Among them, a total of 434 isolates were yielded. One hundred and seven (24.7%) were Gram-positive, 283 (65.2%) Gram-negative, and 44 (10.1%) fungi. Multivariate analysis revealed that body mass index (BMI) ≥25 kg/m2 , preoperative chemoradiation and intra-operative red blood cell transfusion were independent risk factors for PDC. PDC was associated with higher incidences of complications including POPF, major complications and reoperation, but with no correlation between the day of PDC and complications. BMI ≥25 kg/m2 , early PDC (≤3 days), main pancreatic duct <3 mm, and soft pancreas were revealed as independent predictors for POPF. There was a correlation between type of microorganisms and complications. CONCLUSION Considering the correlation between PDC and postoperative complications, preventive measures are crucial to improve outcomes after PD. Whether antibiotic treatment for early PDC will alter the clinical course of POPF needs further evaluation.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Yang Di
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Jing Zhang
- Department of Nursing, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
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13
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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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14
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Rozich NS, Landmann A, Butler CS, Bonds MM, Fischer LE, Postier RG, Morris KT. Tobacco Smoking Associated With Increased Anastomotic Disruption Following Pancreaticoduodenectomy. J Surg Res 2018; 233:199-206. [PMID: 30502248 DOI: 10.1016/j.jss.2018.07.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/19/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effect of cigarette smoking on postoperative morbidity following pancreaticoduodenectomy (PD) for cancer is unclear. We hypothesize that smoking is associated with higher morbidity following PD. METHODS A retrospective review of patients undergoing PD for cancer from 2010 to 2016 at a single institution was performed. Patients who had never smoked were compared to current or past-smokers with at least 1 pack-year history. Univariate and multivariable analyses were performed. RESULTS Two hundred fifty-two patients met inclusion criteria. On univariate analysis, there was a significant difference between smokers and never-smokers in age at diagnosis (65.5 versus 68.6 y, P = 0.013) and fistula rate (28.5% versus 16.2%, P = 0.024). Male sex was significantly associated with fistula rate compared with female sex (15.5% versus 7.1%, P = 0.023). Comparing males and females separately, smoking correlated with higher fistula development only in the male cohort (22.5% versus 5.8%, P = 0.016 in men and 7.3% versus 9.1%, P = 1.00 in women). On multivariable analysis, current and past smoking was independently predictive of developing a fistula: odds ratio of 2.038 (P = 0.030). For current and past-smokers, male sex was an independent risk factor for developing a fistula: odds ratio 2.817 (P = 0.022). There were no other significant differences between groups in rates of postoperative complications. CONCLUSIONS Smoking status is independently predictive of postoperative pancreatic fistula following PD for cancer. Among smokers, male sex is an independent risk factor for fistula. Further studies are needed to determine if smoking cessation before surgery decreases this risk, and if so, the optimal duration of cessation.
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Affiliation(s)
- Noah S Rozich
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma.
| | - Alessandra Landmann
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Casey S Butler
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Morgan M Bonds
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Laura E Fischer
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Russell G Postier
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | - Katherine T Morris
- Department of Surgery, University of Oklahoma Medical Center, Oklahoma City, Oklahoma
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15
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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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16
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Potrc S, Ivanecz A, Pivec V, Marolt U, Rudolf S, Iljevec B, Jagric T. Impact Factors for Perioperative Morbidity and Mortality and Repercussion of Perioperative Morbidity and Long-term Survival in Pancreatic Head Resection. Radiol Oncol 2018. [PMID: 29520206 PMCID: PMC5839082 DOI: 10.1515/raon-2017-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background The focus of the present study was to reveal any impact factors for perioperative morbidity and mortality as well as repercussion of perioperative morbidity on long-term survival in pancreatic head resection. Patients and methods In a retrospective study, clinic-pathological factors of 240 patients after pancreatic head (PD) or total resection were analyzed for correlations with morbidity, 30- and 90-day mortality, and long-term survival. According to Clavien–Dindo classification, all complications with grade II and more were defined as overall complications (OAC). OAC, all surgical (ASC), general (AGC) and some specific types of complications like leaks from the pancreatoenteric anastomosis (PEA) or pancreatic fistula (PF, type A, B and C), leaks from other anastomoses (OL), bleeding (BC) and abscesses (AA) were studied for correlation with clinic-pathological factors. Results In the 9-year period, altogether 240 patients had pancreatic resection. The incidence of OAC was 37.1%, ASC 29.2% and AGC 15.8%. ASC presented themselves as PL, OL, BC and AA in 19% (of 208 PD), 5.8%, 5.8%, and 2.5% respectively. Age, ASA score, amylase on drains, and pancreatic fistulas B and C correlated significantly with different types of complications. Overall 30- and 90-day mortalities were 5 and 7.9% and decreased to 3.5 and 5% in P2. Conclusions High amylase on drains and higher mean age were independent indicators of morbidity, whereas PL and BC revealed as independent predictor for 30-day mortality, and physical status, OAC and PF C for 90-day mortality.
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Affiliation(s)
- Stojan Potrc
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Vid Pivec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia.,Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Urska Marolt
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Sasa Rudolf
- Department of Radiology, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Iljevec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Tomaz Jagric
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
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17
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Impact of body constitution on complications following pancreaticoduodenectomy: A retrospective cohort study. Int J Surg 2017; 48:116-121. [PMID: 29054738 DOI: 10.1016/j.ijsu.2017.10.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/05/2017] [Accepted: 10/07/2017] [Indexed: 12/12/2022]
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18
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Lv X, Qiao W, Leng Y, Wu L, Zhou Y. Impact of diabetes mellitus on clinical outcomes of pancreatic cancer after surgical resection: A systematic review and meta-analysis. PLoS One 2017; 12:e0171370. [PMID: 28158300 PMCID: PMC5291503 DOI: 10.1371/journal.pone.0171370] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 01/18/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Diabetes mellitus (DM) is a risk factor for pancreatic cancer but its impact on postoperative outcomes and long-term survival after cancer resection remains controversial. A meta-analysis of published studies was conducted to address this issue. METHODS An extensive electronic search of four databases was performed for relevant articles. Data were processed for meta-analysis using Review Manager version 5.1. RESULTS Seventeen observational studies involving 5407 patients were subjected to the analysis. Overall morbidity or any type of complications and mortality were comparable between diabetic and non-diabetic subjects. Overall DM has a significant negative impact on survival (risk ratio [RR], 1.24, 95% confidence interval [CI], 1.05-1.45; P = 0.01). Stratification by the type of DM revealed that new-onset DM (<2 years duration, RR, 1.54, 95% CI, 1.24-1.91; P <0.001) but not long-standing DM (≥2 years duration, RR, 1.74, 95% CI, 0.86-3.52; P = 0.12) was associated with reduced survival. CONCLUSIONS Diabetes mellitus does not affect perioperative outcomes in patients undergoing surgery for pancreatic cancer. However, new-onset DM confers a negative impact on survival of pancreatic cancer in patients undergoing surgical resection.
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Affiliation(s)
- Xinghua Lv
- Department of Anaesthesiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Wenhui Qiao
- Department of Anaesthesiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Yufang Leng
- Department of Anaesthesiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Lupeng Wu
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
| | - Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
- * E-mail:
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19
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Costi R, De Pastena M, Malleo G, Marchegiani G, Butturini G, Violi V, Salvia R, Bassi C. Poor Results of Pancreatoduodenectomy in High-Risk Patients with Endoscopic Stent and Bile Colonization are Associated with E. coli, Diabetes and Advanced Age. J Gastrointest Surg 2016; 20:1359-67. [PMID: 27170172 DOI: 10.1007/s11605-016-3158-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/22/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic stenting has spread as bridge management before pancreatoduedenectomy (PD) to resolve jaundice, but its role is nowadays challenged as it is reported to increase morbidity. Although bile sampling is increasingly performed, its clinical role is unclear. The objective of the study is to assess bile colonization's impact on outcome. METHODS Results of pancreatoduodenectomy after endoscopic stenting are analyzed in 61 high-risk patients presenting bacterial bile colonization. The impact of 11 demographic, clinical, infectious, and laboratory parameters and outcome, including pancreatic leakage, morbidity, and mortality, is analyzed. RESULTS All stented patients present bacterial bile colonization and PD mortality approaches 10 %. The presence of E. coli in the bile is significantly related to poor outcome, including 23.5 % mortality (p = 0.034), whereas age (≥70 years) and diabetes present borderline results (p < 0.070 and p < 0.066, respectively). E. coli (p = 0.002) and age (p = 0.017) are also related to grade C pancreatic fistula. CONCLUSIONS In high-risk patients undergoing PD, bile colonization inevitably occurs after endoscopic stenting and is a major risk factor of poor outcome, reaching its maximum in the case of E. coli colonization and elderly patients, where the indication to stent and/or to perform PD should be accurately evaluated. E. coli-targeted antibiotic prophylaxis should be administered.
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Affiliation(s)
- Renato Costi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia. .,Service de Chirurgie Digestive et Cancérologique, Hôpital Lariboisière, AP-HP, Université Paris 7 "Diderot", Paris, France. .,Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia.
| | - Matteo De Pastena
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giuseppe Malleo
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Marchegiani
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Giovanni Butturini
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia.,Unità Operativa di Chirurgia del Pancreas, Casa di Cura "Pederzoli", Peschiera sul Garda, Verona, Italia
| | - Vincenzo Violi
- Dipartimento di Scienze Chirurgiche, Università degli Studi di Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Via Gramsci 14, 43100, Parma, Italia
| | - Roberto Salvia
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
| | - Claudio Bassi
- Dipartimento di Chirurgia Generale B, Istituto del Pancreas, Policlinico "G.B. Rossi", Università degli Studi di Verona, Verona, Italia
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Kunstman JW, Healy JM, Araya DA, Salem RR. Effects of preoperative long-term glycemic control on operative outcomes following pancreaticoduodenectomy. Am J Surg 2015; 209:1053-62. [DOI: 10.1016/j.amjsurg.2014.06.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 12/18/2022]
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Preoperative diabetes as a protective factor for pancreatic fistula after pancreaticoduodenectomy: a meta-analysis. Hepatobiliary Pancreat Dis Int 2015; 14:132-8. [PMID: 25865684 DOI: 10.1016/s1499-3872(15)60330-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The role of diabetes mellitus (DM) in pancreatic fistula (PF) or clinical relevant PF (CR-PF) after pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) is unclear. We conducted a meta-analysis to investigate the relationship between DM and PF or CR-PF. DATA SOURCES Embase, MEDLINE and Cochrane databases were searched systematically for relevant articles from January 2005 to June 2013. The selected studies that examined clinical risk factors of PF or CR-PF were included. We created pooled estimates for our outcomes using the random-effects model. RESULTS Sixteen observational clinical studies were included. Pooling of PF rates from ten studies revealed that DM was associated with a decreased risk of PF (P=0.01). CR-PF rates from 8 studies showed no significant difference between DM and control group (P=0.14). CONCLUSIONS DM is not a risk factor for PF in patients undergoing PD or PPPD. On the contrary, patients without DM are at a higher risk of PF because the pancreases in these patients have more fatty tissue and the pancreas is soft.
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Paye F, Micelli Lupinacci R, Bachellier P, Boher JM, Delpero JR. Distal pancreatectomy for pancreatic carcinoma in the era of multimodal treatment. Br J Surg 2014; 102:229-36. [PMID: 25533421 DOI: 10.1002/bjs.9708] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent publications have suggested improvements in the outcome of distal pancreatectomy (DP) for cancer, but the series were small and heterogeneous. The aim of the present study was to assess perioperative and long-term outcomes of DP for pancreatic adenocarcinoma in the era of multimodal treatment in a major European country. METHODS This was a nationwide study of all patients undergoing DP for pancreatic adenocarcinoma between 2004 and 2009 in 28 centres in France. Postoperative and long-term outcomes were assessed retrospectively and outcome predictors were explored by multivariable analysis. RESULTS A total of 278 patients were enrolled. Multivisceral resections were performed in 58 patients (20·9 per cent), venous resections in 33 (11·9 per cent) and arterial resections in 11 (4·0 per cent). Neoadjuvant chemoradiotherapy was used in 20 patients. Postoperative complications occurred in 96 patients (34·5 per cent) and pancreatic fistulas developed in 76 (27·3 per cent). The postoperative 90-day mortality rate was 5·0 per cent. In univariable analysis, multivisceral resection was the only factor associated with postoperative morbidity (P = 0·048). Age 65 years or less, body mass index of at least 30 kg/m(2) and absence of preoperative chemoradiotherapy were associated with an increased risk of pancreatic fistula in multivariable analysis. Overall survival rates at 3 and 5 years were 44·9 and 29·5 per cent respectively. In multivariable analysis, only the presence of lymph node metastases was associated with poorer overall survival. CONCLUSION Postoperative morbidity and mortality associated with pancreatic fistula remain considerable after DP, but both short- and long-term survival have improved markedly.
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Affiliation(s)
- F Paye
- Department of Digestive Surgery, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France; Université Pierre et Marie Curie Paris 06, Paris, France
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Pancreatico-duodenectomy and postoperative pancreatic fistula: risk factors and technical considerations in a specialized HPB center. Updates Surg 2014; 66:145-50. [DOI: 10.1007/s13304-014-0253-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 04/05/2014] [Indexed: 12/19/2022]
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The impact of perioperative blood glucose levels on pancreatic cancer prognosis and surgical outcomes: an evidence-based review. Pancreas 2013; 42:1210-7. [PMID: 24152946 DOI: 10.1097/mpa.0b013e3182a6db8e] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although diabetes mellitus (DM) and pancreatic cancer (PC) are intricately linked, a comprehensive review addressing the impact of DM on PC prognosis and surgical outcomes is lacking. PubMed search was performed (1980-2012) using keywords "pancreatic cancer", "diabetes mellitus", "glucose intolerance", "pancreatic resection", "prognosis", and "post-operative outcomes". The search results were analyzed to determine the strength of association between DM and PC and to assess the impact of DM on PC prognosis and postoperative outcomes. Thirty-one studies involving 38,777 patients were identified. Patients with non-insulin-dependent DM have 1.5-2 fold increased relative risk of developing PC. Non-insulin-dependent DM is identified in 25.7% of patients with PC compared to 10.4% age-matched controls (95% confidence interval, 1.5-4.7; P < 0.0001). Patients with PC are more likely to have a diagnosis of new-onset DM than age-matched controls (14.7% vs 2.7%; P < 0.0001). Patients with PC with DM have a significantly lower overall survival than those without DM (14.4 vs 21.7 months; P < 0.001). The presence of DM significantly increases overall postoperative complication rates (45.6% vs 35.6%; P < 0.008). Patients with new-onset non-insulin-dependent DM are at a higher risk of developing PC and have a worse long-term survival and a higher rate of postoperative complications.
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